Prostate radiotherapy a z
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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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Prostate radiotherapy a z

Prostate Radiotherapy A-Z

  • Dr Hamid Reza DehghanManshadi

    Radiation Oncologist

  • ShahidBeheshtiUniversity of Medical Sciences


Staging

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


Prostate radiotherapy a z

  • 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


Risk stratification

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)


Treatment shedules

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)


Indications

Indications


Treatment options for localized prostate cancer

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


Equivalence between bt ebt and radical prostatectomy

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)


Practical advantages of temporary hdr prostate brachytherapy

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


Physical advantages of temporary hdr prostate brachytherapy

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


Hdr implant volume definition

HDR implant: volume definition


Hdr implant biological advantage 2gy eqd

HDR implant: biological advantage2Gy EQD


Selection criteria for using hdr brachytherapy in patients with prostate cancer

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


Indications and patient selection for hdr brachytherapy gec estro recommendations

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


Indications for hdr prostate brachytherapy boost

Indications for HDR prostatebrachytherapy BOOST


Ctv criteria gec estro guidelines

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


Oar criteria gec estro guidelines

OAR criteriaGEC ESTRO guidelines

  • • Urethral dose <10Gy per fraction

  • • Rectal dose <6Gy per fraction


Intermediate risk prostate cancer external beam hdr boost

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


Dose and fractions

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


Results

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


Long term complications

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


Target volume delineation

Target Volume Delineation


Hdr monotherapy for localised prostate cancer

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


Hdr monotherapy for localised prostate cancer conclusions

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


Post operative follow up

Post operative follow up

  • Foley catheter removed on Day 2

  • No residual pain

  • Recommandations/information

  • Acute effects

  • Irritation syndrome

  • Retentionnal syndrome

  • Radiation hazards


Prostate radiotherapy a z

  • 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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