Prostate radiotherapy a z
Download
1 / 39

Prostate Radiotherapy A-Z - PowerPoint PPT Presentation


  • 90 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Prostate Radiotherapy A-Z' - varden


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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


  • 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)



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




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



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


  • 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% --


ad