Focal Brachytherapy
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Focal Brachytherapy UK experience. Prof Stephen Langley. Professor of Urology St Luke’s Cancer Centre, Guildford, UK PGMS, University of Surrey. Is there a problem?. Prostate Cancer Focality. 13-38% cancer are unifocal.

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Prof stephen langley

Focal Brachytherapy

UK experience

Prof Stephen Langley

Professor of Urology

St Luke’s Cancer Centre, Guildford, UK

PGMS, University of Surrey


Is there a problem

Is there a problem?


Prostate cancer focality

Prostate Cancer Focality

  • 13-38% cancer are unifocal.

  • Of multifocal tumours, in 97% the Gleason grade of the index tumour was the same as the grade of the overall cancer.

  • PFS relates to index tumour volume not secondary tumour Stamey, Urology 2002

  • Multifocal tumours, 80% of the total volume arises from the index lesion.

  • 512/1832 (28%) of RP patients ECE was evident with 92% of extensions from the index lesion.

  • In low risk PAC, 28% unifocal lesions with 1% showing EPE.

Arora et al, Cancer 2004

Ohori et al, J Urol 2006


Prof stephen langley

Prostate Cancer Focality

  • Multiple studies have suggested that non-index lesions have little if any clinical significance

Noguci et al, J Urol 2003

Karavitakis et al, Nat Rev Clin Onc 2011

Mouraviev et al, BJUInt 2011


Ideal for focal therapy

Ideal for Focal Therapy:

BXT

Eggener et al, J Urol 2007, 178 2260

  • Tumour-cidal activity throughout target zone

  • Real-time monitoring

  • Minimal-access approach to gland

  • Minimal collateral effects outside treatment focus

  • Cost effective

  • Allows re-treatment or subsequent whole gland radical treatment


Terminology focal bxt

Terminology: Focal BXT

  • CTV:Whole gland plus 3mm margin

  • F-GTV:Gross visible/detectable tumour

  • F-CTV:F-GTV + clinically insignificant disease

  • F-PTV :F-CTV + planning margin to allow for uncertainties in treatment delivery

Focal

Ultra-Focal


Imaging

Imaging

Preferred Imaging modality, mpMRI

  • T1/T2, Diff weighting, DCE

  • For 0.5ml tumourNPV 95%, PPV 77%

    Sens. 90%, Spec. 88%

Villers A, et al.J Urol 2006; 176:


Dosimetric effects of focal bxt

Dosimetric Effects of Focal BXT


Male urethra

Male Urethra


Prof stephen langley

Urethral Planning


Prof stephen langley

N=21

Clinical & MRI staging T1c-T2a

PSA<10, Vol <75cc

Unilateral Gleason ≤3+4

No core <50% cancer

<25% cores involved

>20 Biopsy cores taken

Real-time technique, loose seeds

Ultra-focal approach, using mpMRI & biopsy map

Mean Vol R 34% (20-48)

Uniform seed distribution

F-PTV 145Gy, no CT

PSA FU-(Phoenix), MRI & Biopsy 1-2yrs


Prof stephen langley

  • IPSS change similar to whole gland toxicity

  • Little change in potency IIEF 19-20 throughout

  • No incontinence: ICS

  • No rectal toxicity

Mean IPSS


Prof stephen langley

  • 6 patients biopsied: whole gland

  • N=5: no cancer

  • N=1: 1mm Gleason 3+3

    contralateral base to that implanted.

    Patient on Active Surveillance

Mean PSA

Yrs


Prof stephen langley

A Prospective Stage 2S Clinical Trial Evaluating Hemi-Ablative (LDR) Brachytherapy for Localised Prostate Cancer

Hemi-Ablative Prostate Brachytherapy (HAPpy)

1o Objectives

  • To determine if focal brachytherapy shows improved rates of toxicity compared to whole-gland LDR brachytherapy.

  • To determine if focal brachytherapy is associated with similar local disease control rates as whole-gland LDR brachytherapy for low and intermediate prostate cancer.


Prof stephen langley

A Prospective Stage 2S Clinical Trial Evaluating Hemi-Ablative (LDR) Brachytherapy for Localised Prostate Cancer

2o Objectives

  • To histologically assess the untreated prostate at 2-years post hemi-ablative treatment.

  • To determine the clinical validity of mp-MRI to predict the presence of recurrent prostate cancer on TTB biopsies.

  • To assess the value of serum PSA & urinary EN2 in predicting clinical outcome


Prof stephen langley

A Prospective Stage 2S Clinical Trial Evaluating Hemi-Ablative (LDR) Brachytherapy for Localised Prostate Cancer

  • Patient Eligibility

  • TRUS Bx (if taken): unilateral disease only

  • mp-MRI

  • Targeted template biopsy (TTB):

    • unilateral disease only, &

    • Gleason < 7 (either 3+4 or 4+3)

  • Stage T1-T2b N0 M0

  • Serum PSA < 15

  • Prostate volume < 50cc

  • Life expectancy > 10 years

  • No previous radiation therapy

  • No previous hormone treatment


  • Prof stephen langley

    A Prospective Stage 2S Clinical Trial Evaluating Hemi-Ablative (LDR) Brachytherapy for Localised Prostate Cancer


    Prof stephen langley

    Sponsor: NHS R&D RSCH

    LREC: Approved Jan 2013


    Prof stephen langley

    F

    Brachytherapy

    Brachytherapy

    • Simple clinic U/S (H , W , L3).

    • Nomogram calculation of seed requirement.

    • Preloaded stranded seeds implanted peripherally.

    • Real-time planning.

    • Loose seeds implanted centrally.

    • 4thD: Average 40 min per implant.


    Prof stephen langley

    F

    Brachytherapy

    Stranded seed, 1cm spacing

    Loose seed, variable spacing

    CTV

    FPTV

    PTV

    FCTV


    Prof stephen langley

    A Prospective Stage 2S Clinical Trial Evaluating Hemi-Ablative (LDR) Brachytherapy for Localised Prostate Cancer

    Follow up

    • Day 0 CT

    • PSA, EN2, MHI:

      3, 6 ,9, 12, 18, 24m

    • 24m mpMRI

    • 24m TTB of untreated side

    • Standard follow up


    To date

    To date ….


    Prof stephen langley

    Financial Disclosures


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