European Urology Oncology

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European Urology Oncology High-precision Bladder Cancer Irradiation in the Elderly: Clinical Results for a Plan-of- the-day Integrated Boost Technique with Image Guidance Using Lipiodol Markers Alexander J.W. Beulens, Peter-Paul van der Toorn, Michel J. de Wildt, Wout A. Scheepens European Urology Oncology DOI: 10.1016/j.euo.2018.08.012 Copyright © 2018 European Association of Urology Terms and Conditions

Fig. 1 Coronal and axial images of the treatment procedure. (A) Automatic bone registration (purple, planning computed tomography [CT]; green, cone-beam CT [CBCT]). (B) Plan selection based on bladder volume at CBCT. (C) Manual registration of the gross tumour volume (GTV) using Lipiodol markers. (D) Target coverage verification [2]. European Urology Oncology DOI: (10.1016/j.euo.2018.08.012) Copyright © 2018 European Association of Urology Terms and Conditions

Fig. 2 Coronal views of (A,D) a library planning methodology, (B,E) a planned dose, and (C,F) an accumulated dose distribution using a single plan over five fractions. The actual dose delivered was recomputed using cone-beam computed tomography data for five fractions with increasing bladder volumes for which plan 1 (empty bladder) up to plan 5 (full bladder) were selected during treatment. The accumulated dose using the library planning methodology projected for (A) a full and (D) an empty bladder shows good agreement with the intended planned dose. Single plan delivery results in (C) an excessive dose to the small bowel and/or (F) underdosing of the target [2]. European Urology Oncology DOI: (10.1016/j.euo.2018.08.012) Copyright © 2018 European Association of Urology Terms and Conditions

Fig. 3 Number of grade ≥2 (A) genitourinary and (B) gastrointestinal toxicities scored using the Radiation Therapy Oncology Group toxicity scoring system directly after radiation therapy and during follow-up. European Urology Oncology DOI: (10.1016/j.euo.2018.08.012) Copyright © 2018 European Association of Urology Terms and Conditions

Fig. 4 Example of the difference in radiation dosage for one patient using (A) conventional planning and (B) radiotherapy planning using the Lipiodol technique. Conventional planning delivers 59.8Gy in 26 fractions, whereas the healthy bladder receives a lower dosage of 46Gy in 23 fractions using Lipiodol. The tumour (blue line in B) does receive the therapeutic dose of 59.8Gy in 23 fractions. European Urology Oncology DOI: (10.1016/j.euo.2018.08.012) Copyright © 2018 European Association of Urology Terms and Conditions

Fig. 5 Kaplan-Meier survival curves. (A) Overall survival (median 29 mo, maximum 84 mo). (B) Urothelial cell carcinoma (UCC)-specific survival (median 77 mo). European Urology Oncology DOI: (10.1016/j.euo.2018.08.012) Copyright © 2018 European Association of Urology Terms and Conditions