CT-Guided Online Adaptive Hypofractionated Radiotherapy for Primary Bladder Cancer: A Report of Two Cases

Trimodality treatment for bladder cancer, consisting of maximal transurethral resection of the tumor followed by concurrent chemoradiotherapy, is an attractive management option with curative and organ-sparing intent. However, such treatment can be associated with acute toxicities related to the large treatment margins required due to daily variation in bladder filling, with resultant bladder, bowel, and rectal toxicity. Adaptive radiation, which accounts for inter-fraction variations in bladder size, allows the confident delivery of radiation to bladder cancer with smaller margins, with the potential to reduce toxicities without the associated risk of compromising the target coverage. Herein, we present a case series of two patients with primary bladder cancer who were treated with computed tomography (CT)-based online adaptive hypofractionated radiotherapy using the Ethos system (Varian Medical Systems, Palo Alto, CA, USA). The first is an 83-year-old male with a remote history of prostate cancer treated with radiotherapy, who received adaptive radiotherapy as a means of decreasing the required margin size and optimizing planning based on adjacent bowel to reduce the risk of re-irradiation. The second patient is a 78-year-old male with node-positive bladder cancer, which necessitated whole pelvis radiotherapy, who underwent adaptive treatment (25 fractions) as a means of sparing cumulative dose to the bowel while ensuring suitable target coverage. In both cases, the clinical target volume consisted of the entire bladder (± nodes) with a planning target volume expansion of 7 mm. During treatment, daily cone-beam CT scans were acquired and used to generate adapted plans. These plans were compared to the original plans, with attention to target coverage and dose to organs at risk. For all 45 fractions, the adaptive plan was selected, primarily as a means of improving target coverage. This case series demonstrates that the adaptive Ethos system effectively delivers treatment for primary bladder cancer. Further data are needed for clinical toxicity outcomes and the efficacy of this approach.