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Prostate Radiotherapy A-Z

Prostate Radiotherapy A-Z. Dr Hamid Reza Dehghan Manshadi Radiation Oncologist Shahid Beheshti University of Medical Sciences. Staging. Clinical ( cT ) T0 No evidence of primary tumor T1 Clinically inapparent tumor neither palpable nor visible by imaging

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Prostate Radiotherapy A-Z

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  1. Prostate Radiotherapy A-Z • Dr Hamid Reza DehghanManshadi Radiation Oncologist • ShahidBeheshtiUniversity of Medical Sciences

  2. Staging • Clinical (cT) • T0 No evidence of primary tumor • T1 Clinically inapparent tumor neither palpable nor visible by imaging • T1a Tumor incidental histologic finding in 5 percent or less of tissue resected • T1b Tumor incidental histologic finding in more than 5 percent of tissue resected • T1c Tumor identified by needle biopsy (eg, because of elevated PSA) • T2 Tumor confined within prostate* • T2a Tumor involves one-half of one lobe or less • T2b Tumor involves more than one-half of one lobe but not both lobes • T2c Tumor involves both lobes • T3 Tumor extends through the prostate capsule• • T3a Extracapsular extension (unilateral or bilateral) • T3b Tumor invades seminal vesicle(s) • T4 Tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall • Distant metastasis (M)§ • M0 No distant metastasis • M1 Distant metastasis • M1a Nonregional lymph node(s) • M1b Bone(s) • M1c Other site(s) with or without bone disease

  3. TNM anatomic stage prognostic groups for prostate cancer* • Stage (T) (N) (M) PSA Gleason • I T1a-c N0 M0 PSA <10 Gleason ≤6 • T2a N0 M0 PSA <10 Gleason ≤6 • T1-2a N0 M0 PSA X Gleason X • IIA T1a-c N0 M0 PSA <20 Gleason 7 • T1a-c N0 M0 PSA ≥10<20 Gleason ≤6 • T2a N0 M0 PSA <20 Gleason ≤7 • T2b N0 M0 PSA <20 Gleason ≤7 • T2b N0 M0 PSA X Gleason X • IIB T2c N0 M0 Any PSA Any Gleason • T1-2 N0 M0 PSA ≥20 Any Gleason • T1-2 N0 M0 Any PSA Gleason ≥8 • III T3a-b N0 M0 Any PSA Any Gleason • IV T4 N0 M0 Any PSA Any Gleason • Any T N1 M0 Any PSA Any Gleason • Any T Any N M1 Any PSA Any Gleason

  4. Risk stratification • • Low risk — Clinical stage T1c or T2a AND a serum PSA <10 ng/mL AND a biopsy Gleason score ≤6 (anatomic stage prognostic group I) •  • Intermediate risk — Clinical stage T2b OR a serum PSA between 10 and 20 ng/mL OR a biopsy Gleason score 7 (anatomic stage prognostic group IIA) • • High risk — Clinical stage T2c disease OR a serum PSA >20 ng/mL, OR a biopsy Gleason score ≥8 (anatomic stage prognostic group IIB)

  5. Treatment shedules • RADICAL PROSTATECTOMY • Indications : T1,/T2 some T3 • Side Effects : Urinary incontinence, Impotence • EBRT : • Indications : T1/T4 • Conformal, 3D , IMRT • Brachytherapy : • LDR (Seeds) • HDR (Ir 192)

  6. Indications

  7. Treatment optionsfor localized prostate cancer The Urologist’ s point of view by country ? by hospital? by specialty ? Differences in patients: age (biologic), condition, QL--issues… Differences: individual patient: Anatomy,, erectile function… Patient selection / Education Cure potentials, Treatment Options

  8. Equivalence between BT / EBT and Radical Prostatectomy BT advantages : PTV = CTV • - Real dose escalation (144 Gy) • - Fast treatment (/ERT) • - Low impotency rate (<RP and ERT) • - Low rectitis rate (/RTE) • - Low urinary complications (/RP)

  9. Practical advantages of temporaryHDR prostate brachytherapy • Radioprotection • – no free live sources • – no risk of source loss • – no radioprotection issues after discharge • Cheap: utilises existing HDR source and equipment In some centers may be outpatient procedure

  10. Physical advantages of temporaryHDR prostate brachytherapy • • Brachytherapyenables localized high dose with reduced dose to critical normal tissues – rectum, bladder, small bowel • • Uses volume definition after implant; can be customised to individual volume with no organ movement. • Can implant larger volume than permanent implant with certain dose delivery including extracapsular region and seminal vesicles

  11. HDR implant: volume definition

  12. HDR implant: biological advantage2Gy EQD

  13. Selection Criteria for Using HDR Brachytherapy in Patients With Prostate Cancer • Inclusion criteria • Tumor stages T1-T3b Tumor • invasion of • bladder neck • Any Gleason score • Any PSA level • Prostate volume ≤60-80 cc • Possible exclusion criteria • Distant metastases • Life expectancy <5 y • Substantial urinary obstruction • Inability to implant entire prostate • Patient unfit for anesthesia • TURP within previous 6 mo • Rectum-prostate distance <5 mm

  14. Indications and Patient selection for HDR-Brachytherapy(GEC- ESTRO) Recommendations • HDR As Boost To EBRT: • Stage >=T2B or, PSA>10 or GS>=7(intermediate/ Highrisk • HDR As Monotherapy: • Stage =<T2a and PSA=< 10 and GS=<7 (low risk • HDR As Salvage (up To 76 Gy) • No Mts, Biopsy confirmation, PSA relapse, Antianrogen resistance or intolerance

  15. Indications for HDR prostatebrachytherapy BOOST

  16. CTV criteriaGEC ESTRO guidelines • • CTV1: whole gland defined by capsule – Margin around capsule may be added 3 –5 mm • • CTV2: peripheral zone • • CTV3: GTV • • PTV = CTV

  17. OAR criteriaGEC ESTRO guidelines • • Urethral dose <10Gy per fraction • • Rectal dose <6Gy per fraction

  18. Intermediate risk prostate cancerExternal beam +HDR boost • – Highest overall BED • – Includes advantages of regional irradiation by external beam • – Includes advantages of conformality with HDR including extracapsular and seminal vesicle areas • – Optimal therapeutic ratio • – Dose delivery reliable

  19. Dose and Fractions • HDR Boost :PTV= CTV1 • 45Gy EBRT + 2 implants (10.5 Gy*2) •  BED >94-100 • HDR Monotherapy : PTV=CTV1 • 2 implants , 2* 9.5 Gy/implant total 38 Gy in 2 weeks BED =100 Gy • HDR Salvage : • 4 implants * 6 Gy = 24 Gy in 12 weeks

  20. Results • HDR Boost : • Late toxicity : Rectum • EBRT (76 Gy ) EBRT+HDRBoost(86Gy) • Grade 0 81% 96% • Grade 1 6.7% 1.3% • Grade 2 12.5% (Bleeding) 2.7 % • Grade 3 0.4% -- • Bladder • Grade 0 91% 90% • Grade 1 1.3% 1.8% • Grade 2 8.5% 8.5% • Grade 3 -- -- • EBRT + Boost : Less Failure, Less Toxicity

  21. LONG-TERM COMPLICATIONS ? • Brachy(a)RRPXRT • Urethritis 5% N/A 3% • Stricture 6% 5% 6% • Incontinence <1% 5 (b) - 30 (c) % 1% • Rectal/proctitis 5% N/A 9% • Impotence: • < 60 10% 25% d • 60 – 70 20% 35% d vs. 70% (e) 30% • > 70 40% 50% d • (a) No pre-implant TURP • (b) Center of excellence • (c) Population studies • (d) Nerve sparing • (e) Non-nerve sparing

  22. Target Volume Delineation

  23. HDR Monotherapy forLocalised Prostate Cancer • HDR brachytherapy is an established technique enabling high dose delivery to prostate gland • HDR brachytherapy has potential advantages especially for more advanced prostate cancer – Physical implant flexibility – Biological advantage of large fractions

  24. HDR Monotherapy for Localised Prostate Cancer Conclusions • HDR monotherapy is feasible and can deliver 4 fractions over 3 days with one implant procedure • Acute toxicity is limited to transient urinary disturbance, returning to baseline at 12 weeks • Early biochemical results for advanced disease are encouraging. • Further dose escalation is possible or necessary

  25. Post operative follow up • Foley catheter removed on Day 2 • No residual pain • Recommandations/information • Acute effects • Irritation syndrome • Retentionnal syndrome • Radiation hazards

  26. HDR Monotherapy: • OS; 98.9% ,PSA Specific control :100%, Biochemical control : 97.2% • GU Toxicity GI Toxicity • Grade0 34% 96.4% • Grade 1 52% 3.6% • Grade 2 3.3% -- • Grade 3 9.8% --

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