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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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slide1

Focal Brachytherapy

UK experience

Prof Stephen Langley

Professor of Urology

St Luke’s Cancer Centre, Guildford, UK

PGMS, University of Surrey

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

slide4

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 tumour NPV 95%, PPV 77%

Sens. 90%, Spec. 88%

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

slide13
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

slide15
IPSS change similar to whole gland toxicity
  • Little change in potency IIEF 19-20 throughout
  • No incontinence: ICS
  • No rectal toxicity

Mean IPSS

slide16

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

slide17
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.
slide18
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
slide19
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
slide20
A Prospective Stage 2S Clinical Trial Evaluating Hemi-Ablative (LDR) Brachytherapy for Localised Prostate Cancer
slide21

Sponsor: NHS R&D RSCH

LREC: Approved Jan 2013

slide22

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.
slide23

F

Brachytherapy

Stranded seed, 1cm spacing

Loose seed, variable spacing

CTV

FPTV

PTV

FCTV

slide24
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
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