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Radiation therapy for Early Stage Prostate Cancer

Radiation therapy for Early Stage Prostate Cancer. John A. Kalapurakal MD Professor, Radiation Oncology Northwestern University Medical School Chicago, IL. ARS. ? 1-B.

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Radiation therapy for Early Stage Prostate Cancer

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  1. Radiation therapy for Early Stage Prostate Cancer John A. Kalapurakal MD Professor, Radiation Oncology Northwestern University Medical School Chicago, IL

  2. ARS ?1-B

  3. It is estimated that 217,730 men will be diagnosed with and 32,050 men will die of cancer of the prostate in 2010 (SEER DATA)

  4. Anatomy

  5. Risk stratification of Prostate Cancer • Low risk T1c-T2a and PSA<10 and Gleason score <6 • Intermediate risk T2b-T2c or PSA 10-20 or Gleason score 7 • High risk T3-T4 or PSA >20 or Gleason score 8-10

  6. Low-risk Prostate Cancer • External beam RT: (x-rays, protons) • 70.2Gy-79.2Gy in 39-45 sessions (5 treatments/week, 8-9 weeks) • 3D Conformal, Intensity Modulated RT, Protons • Brachytherapy: I-125 (Iodine), Pd-103 (Palladium) • 144Gy in single session

  7. Intermediate-risk Prostate Cancer • External beam RT: (x-rays, protons) • 75.6-79.2Gy in 42 sessions (5 treatments/week, 8-9 weeks) • 3D Conformal, Intensity Modulated RT (IMRT), Protons • External beam RT + Short term Hormone therapy (6-8 months) • External beam RT + Brachytherapy: I-125 (Iodine), Pd-103 (Palladium) • 45 Gy in 25 sessions (5 weeks) + brachytherapy (seeds, HDR)

  8. Image Guided RT (IGRT) • ALL MODERN RT DELIVERY SHOULD BE IGRT • Improve accuracy of treatment • Track daily position of the prostate before delivering RT • Fiducial markers (x-rays), ultrasound scans, electromagnetic tracking, CT scans (cone beam CT, fiducials), endorectal balloon (x-rays, CT scan)

  9. 3D conformal versus IMRT versus Protons

  10. Prostate Seed Implantation: Indications, Techniques and Outcomes

  11. Post Implant CT scan dosimetry

  12. Long-term results: Brachytherapy alone (Low-risk) and RT+Brachytherapy in intermediate-risk Prostate Cancer IJROBP2010 IJROBP 2007

  13. Higher RT dose (79.2Gy) resulted in higher PSA control in low and intermediate-risk prostate cancer without any increase in toxicity Low risk Intermediate-risk JCO 2010

  14. Harvard Study: Adding 6 months of hormones to RT improved survival in intermediate-risk and high-risk disease Intermediate-risk High-risk IJROBP 2010

  15. MD Anderson Study: Higher RT dose (78 Gy) for intermediate-risk patients resulted in better PSA control and cancer–specific survival IJROBP 2010

  16. Low-intermediate risk Prostate Cancer: RTOG 94-08 Study • T1b-T2b, PSA <20 • RT: 66.6Gy + 4 months of hormone therapy • 1979 patients randomized • Overall survival significantly better RT+ hormones (51% vs. 4%) • PSA control significantly higher with RT+ hormones in low and intermediate risk patients • Subset analysis: survival benefit mainly for higher GS and PSA • Final results awaited • IJROBP 2009

  17. Radiation-related Side Effects • Likely • Increased urinary frequency, burning and urgency • Increased bowel frequency, burning and urgency • Fatigue • Less likely • Rectal bleeding, urinary bleeding • Chronic bowel/bladder symptoms • Temporary blockage of urination requiring a catheter • Rare but serious • Permanent Rectal and Bladder injury requiring surgery

  18. Hormone-related Side Effects

  19. Conclusions – RT for Early Prostate Cancer • Best Results: Higher tumor RT doses with improved technology treatments (Brachytherapy, IMRT, Proton therapy) • Role of hormone therapy with RT in low and intermediate-risk patients remains to be defined • Stereotactic Body Radiotherapy (SBRT): Cyberknife, Linear Accelerator, Tomotherapy • Role of hypofractionated RT (70 Gy in 28 fractions, 50Gy in 5 fractions) ? • Role of protons • PATIENT’S CHOICE: Surveillance vs. Surgery vs. Radiation* vs. Seeds

  20. Radiation therapy for Early Stage Prostate Cancer John A. Kalapurakal MD Professor, Radiation Oncology Northwestern University Medical School Chicago, IL

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