1. H. Emama M.D.

2. (Radiation Therapy) By: H. Emami Assistant professor of Radiation Oncology, Isfahan University of Medical Sciences, Isfahan, IRAN.

3. Superficial tumors TUR (standard) Interavesical therapy Or Radical Cystectomy Or Bladder preserving Low grade, Low stage Observation High grade, High stage, Multifocal CIS Multifocal Tumors Tumor associated with CIS If rapidly recur

4. Muscle invasion (T2) Radical Cystectomy (standard) + CT CT + Radical Cystectomy if nodes are Negative (NCCN) category 1 Chemoradiation + CT CT + Chemoradiation Partial Cystectomy + CT CT + Partial Cystectomy (NCCN) Bladder Preservation

5. Muscle invasion (T2) TURBT Chemo-radiation (40 - 45 Gy) Cystoscopic Evaluation Consolidation Chemo-radiation (64 – 66 Gy) Radical Cystectomy CRIn-CR Recurrence

6. Perivesical fat invasion (T3) CT + Chemoradiation CT + Radical Cystectomy (NCCN) category 1 Pre-op. Chemoradiation + Cystectomy + Post op. Chemotherapy

7. Adjacent organ (s) involvement(T4a) CT + Chemoradiation CT + Radical Cystectomy in selected patient Involvement of pelvic or Abdominal wall (T4b) Chemoradiation Palliative therapy Radiation therapy Chemotherapy

8. T2 T3 Selected T4a Pre-op. Chemoradiation or Chemotherapy (for down staging) Post op. Chemoradiation (In high risk patients) Residue Positive LN(s) (Chemoradiation Therapy) Node negative No New Bladder

9. 1)-5000 cGy to the whole pelvis. 2)-Lateral boost to the bladder (1000 cGy). 3)-Cystectomy (4 to 6 week later). 1)-4500-5000 cGy to the whole pelvis + bladder boost Total dose 6400-6600 cGy + Cisplatin, Carboplatin, Paclitaxel, 5FU, Gemcitabine (low dose )(33mg/m 2 twice weekly) Mytomycin-C + 5FU (NCCN) 2)- Two course MCV, then Chemoradiation Pre-op. Radiation therapy Or Chemoradiation (for down staging) Chemoradiation therapy (for bladder preservation) (Radiation Therapy)

10. Bone metastasis Hematuria Lung and Liver Met. Chemotherapy 3000 CGY in 10 fractions. 4000 CGY in 20 fractions. 1000 cGy in one fraction. 1000 cGy every 3-4 week for 3 times 600 cGy every week for 5 weeks (Palliative Therapy)

11. 1)-Convential (180-200 cGy/day) (Total 6400 cGy) 2)-Hyper fractionation (100 cGy X 3 times/day) (total 8400 cGy) 1000 cGy in one fraction 2100 cGy in 3 fractions 3)-Hypo fractionation 3500 cGy in 10 fractions 600 cGy weekly (total 3000 cGy 600 cGy weekly (total 3600 cGy) (Radiation Therapy Schedule)

12. (Radiation Therapy Techniques) Anterior-posterior portal Right lateral portal

13. Box Tech. (whole pelvis) Box Tech. (Bladder) (Radiation Therapy Techniques)

14. Two Lateral Arc Technique Three Field Arrangement (Radiation Therapy Techniques)

15. -External beam radiation is rarely appropriate for patients with recurrent Ta and T1 tumor or diffuse Tis. -simulate and treat patients with bladder empty. -use multiple fields from high-energy linear accelerator beams. -Treat the whole bladder with or without pelvic lymph nodes with 45-50 Gy and then boost the bladder tumor to total dose of 64-66 Gy. -Consider low-dose pre-operative radiation prior to segmental resection for invasive tumors. (Radiation Therapy)