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“ Comparison between existing brachytherapy techniques”

“ Comparison between existing brachytherapy techniques”. 2012 November 23 th , Mallorca, Spain Janusz Skowronek, MD, PhD, Ass. Prof. Brachytherapy Department, Greater Poland Cancer Centre, Poznań, Poland; www.wco.pl/zb.

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“ Comparison between existing brachytherapy techniques”

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  1. “Comparison between existing brachytherapy techniques” 2012 November 23th, Mallorca, Spain Janusz Skowronek, MD, PhD, Ass. Prof. Brachytherapy Department, Greater Poland Cancer Centre, Poznań, Poland; www.wco.pl/zb

  2. Permanent LDR brachytherapy and temporary HDR brachytherapy are competitive techniques for clinically localized prostate radiotherapy. PDR – where are you?

  3. Mark K. Buyyounouski et al. A survey of current clinical practice in permanent and temporary prostate brachytherapy: 2010 update. Brachytherapy 11 (2012) 299 - 305 Years of respondents’ experience with LDR and HDR brachytherapy. LDR = low-dose-rate; HDR = high-dose-rate.

  4. USA 2004 – 81850 pts (seeds) http://www.rtanswers.org/statistics/aboutradiationtherapy.aspx

  5. Patterns of care for brachytherapy in Europe: Updated results 2002 - 2007FerranGuedea, Jack Venselaar, Peter Hoskin, Taran Paulsen Hellebust, DidierPeiffert, Bradley Londres, Montse Ventura, Jean-Jacques Mazeron, Erik Van Limbergen, Richard Pötter, Gyorgy Kovacs Radiotherapy and Oncology 97 (2010) 514–520 Prostate cancer Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Monaco, TheNetherlands, Norway, Portugal, Spain, Sweden, Switzerland, United Kingdom Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia, Slovenia. Albania, Armenia, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Georgia, Israel, Macedonia, Moldova, Montenegro, Romania, Serbia, Turkey

  6. NCCN brachytherapy guidelines - brachytherapy LDR • Permanent low-dose rate (LDR) brachytherapy as monotherapy is indicated for patients with low-risk cancers. • For intermediate-risk cancers consider combining brachytherapy with EBRT (40-50 Gy) ± 4-6 mo neoadjuvant/concomittant/adjuvant ADT. • Patients with high-risk cancers may be treated with a combination of EBRT (40-50 Gy) and brachytherapy ± 4-6 mo neoadjuvant/concomitant/adjuvant ADT. • Patients with a very large prostate or very small prostate, symptoms of bladder outlet obstruction (high IPSS), or a previous transurethral resection of the prostate (TURP) are more difficult to implant and may sufler increased risk of side effects. • Neoadjuvant androgen deprivation therapy may be used to shrink the prostate to an acceptable size.

  7. NCCN brachytherapy guidelines - brachytherapy • Post-implant dosimetry should be performer to dokument the quality of the implant. • The recommended prescribed doses for LDR monotherapy are 145 Gy for 125-Iodine and 125 Gy for 103-Palladium. • The corresponding boost dose after 40-50 Gy EBRT are 110 Gy and 90-100 Gy, respectively. HDR • High-dose rate (HDR) brachytherapy can be used in combination with EBRT (40-50 Gy) instead of LDR. • Commonly used boost regiment include 9.5-10.5 Gy x 2 fractions, 5.5-7.5 Gy x 3 fractions, and 4.0-6.0 Gy x 4 fractions.

  8. Brachytherapy dose inhomogeneity Differential dose volume histograms (dDVH) for 125I, 103Pd and 192Ir from average patient-derived data . Note that for the 192Ir HDR brachytherapy DVH, the dose scale is ‘percent dose’ because different dose fraction sizes can be prescribed. Note how heterogeneous and ‘hot’ these DVH are, particularly for 125I and 103Pd. Christopher R. King. LDR vs. HDR brachytherapy for localized prostate cancer:the view from radiobiological models. Brachytherapy 1 (2002) 219–226

  9. HDR „Virtual planning”

  10. HDR „Real-time planning”

  11. LDR „Real-time planning”

  12. HDR 23

  13. HDR

  14. LDR

  15. Seeds LDR brachytherapyAdvantages over HDR • Large worldwide clinical experience and long-term data available, • Patient and MD convenience, • High patient turnover in OR, • Ideal for patients with pre-existing ED or comorbidities precluding prolonged bedrest, • Ideal for patients with AUA scores of <12.

  16. Seeds LDR brachytherapyDisadvantages over HDR • Dosimetric uncertainties regarding final seeds distribution and dosimetry(gland swelling, seeds migration, clumping), • No accurate post-implant plan in the OR since individual seed position identificationis not yet possible, • Dosimetry is performed after patient leaves the OR, • Real implant dosimetry varies with time from procedure (“cold implants” untilprostate edema subsides, seeds migration/clumping may add to dose inhomogeneity over effective treatment time (6 months for I-125).

  17. Seeds LDR brachytherapyDisadvantages over HDR • Operator-dependent and patient volume-dependent to maintain expertise • Longer resolution of urinary symptoms Acute urinary toxicity “The Dribbler” Popular beer bar near Seattle Prostate Institute Courtesy of John Blasko

  18. Seeds LDR brachytherapyDisadvantages over HDR • Less likely to preserve erectile function

  19. Seeds LDR brachytherapyBottom line • Both HDR and LDR work well in properly selected patients, • The differences in toxicity are minimal and the outcome is excellent with both, • No matter what you chose, get good at it! • If you like golf, tennis or dinner with family, go for seeds!

  20. Seeds LDR brachytherapyBottom line • If you have time to spare, • or you are an obsessive-compulsive type of guy • and a few millimeters or a few lost seeds would give you nightmares or heartburn, go for HDR

  21. Seeds LDR brachytherapyBottom line • In the end, what physicists or vendors try to convince you regarding precision, accuracy and sophistication with new HDR or LDR brachy extravaganza, take it with a grain of salt… It may not be clinically relevant after all.

  22. Conclusions At present, the available clinical datawith these two techniques suggests that they are equally effective, stage for stage, in providing high tumor control rates.

  23. Conclusions Will be a randomized trial be conducted comparingthese two forms of brachytherapy?

  24. Conclusions Will be a randomized trial be conducted comparingthese two forms of brachytherapy?

  25. Our choice… Thankyou

  26. Real problem! Radicalprostatectomy Nerve sparing prostatectomy Conventional 3-D Laparoscopic or externalbeam prostatectomy Robotic surgery IMRT Proton Conformal external beam IGRT Dose escalation Hypofractionation High-dose conformal Brachytherapy High dose rate Low dose rate Brachytherapy/externalbeam HIFU RITA Any of the above with androgen deprivation Cryotherapy

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