The benefit of a preplanning procedure - view from oncologist. Dorota Kazberuk November, 2014 Otwock

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1 The benefit of a preplanning procedure - view from oncologist Dorota Kazberuk November, 2014 Otwock

2 Brachytherapy is supreme tool in prostate cancer management with a wide range of options in every risk group HDR BRACHYTHERAPY

3 Recommendations

4 GEC/ESTRO-EAU recommendations Patient selection criteria for a curative combined TEMPORARY BT and EBRT treatment Inclusion criteria Stages T1b T3b Any Gleason score Any ipsa without distant metastases Exclusion criteria Volume>60 cm3 TURP within 6 months Infiltration of the external sphincter of the bladder neck Significant urinary obstructive symptoms Pubic arch interference Rectum-prostate distance on TRUS<5 mm Lithotomy position or anaesthesia not possible

5 GEC/ESTRO-EAU recommendations HDR monotherapy 34 Gy in 4 fractions Gy in 4 fractions Gy in 3 fractions. 26 Gy in 2 fractions. Long term outcome data are not yet available from these cohorts and it is recommended that this treatment is not undertaken outside a formal study.

6 GEC/ESTRO-EAU recommendations TEMPORARY BT and EBRT treatment

7 European Association of Urology states that transperineal BT alone qualification criteria are: clinical stage between T1c and T2a, without nodal involvment or metastases, six or less Gleason score diagnosed with sufficient number of random biopsies, initial PSA level of 10 ng/ml or less, no more than 50% of biopsy cores with cancer, prostate volume of less than 50 cm 3 and good IPSS (< 20 fair tolerance; < 9 good tolerance).

8 Recommendations

9 Selection criteria for a curative combined HDRBT and external beam treatment The indications for HDRBT in dose escalation schedules with external beam are wide ranging with all patients having localized disease eligible for this technique. Inclusion criteria Stages T1b T3b Any Gleason score Any PSA level Exclusion criteria TURP within 3 6 months Maximum urinary flow rate (Qmax) <10 ml/s IPSS > 20 Pubic arch interference Lithotomy position or anaesthesia not possible Rectal fistula

10 Selection criteria for a curative combined HDRBT and external beam treatment GEC/ESTRO recommendations Patient selection criteria for a curative combined TEMPORARY BT and EBRT treatment. Inclusion criteria Stages T1b T3b Any Gleason score Any ipsa without distant metastases Exclusion criteria Volume>60 cm3 TURP within 6 months Infiltration of the external sphincter of the bladder neck Significant urinary obstructive symptoms Pubic arch interference Rectum-prostate distance on TRUS<5 mm Lithotomy position or anaesthesia not possible GEC/ESTRO recommendations. An update Patient selection criteria for a curative combined HDRBT and external beam treatment. Inclusion criteria Stages T1b T3b Any Gleason score Any PSA level Exclusion criteria TURP within 3 6 months Maximum urinary flow rate (Qmax) <10 ml/s IPSS > 20 Pubic arch interference Lithotomy position or anaesthesia not possible Rectal fistula

11 Selection criteria for a curative combined HDRBT and external beam treatment GEC/ESTRO recommendations Patient selection criteria for a curative combined TEMPORARY BT and EBRT treatment. Inclusion criteria Stages T1b T3b Any Gleason score Any ipsa without distant metastases Exclusion criteria Volume>60 cm3 TURP within 6 months Infiltration of the external sphincter of the bladder neck Significant urinary obstructive symptoms Pubic arch interference Rectum-prostate distance on TRUS<5 mm Lithotomy position or anaesthesia not possible GEC/ESTRO recommendations. An update Patient selection criteria for a curative combined HDRBT and external beam treatment. Inclusion criteria Stages T1b T3b Any Gleason score Any PSA level Exclusion criteria TURP within 3 6 months Maximum urinary flow rate (Qmax) <10 ml/s IPSS > 20 Pubic arch interference Lithotomy position or anaesthesia not possible Rectal fistula

12 GEC/ESTRO recommendations. An update. HDRBT boost with external beam EBRT 45 Gy in 25 fractions over 5 weeks. 46 Gy in 23 fractions over 4.5 weeks Gy in 13 fractions over 2.5 weeks Gy in 15 fractions over 3 weeks. Low α/β - value HDR brachytherapy 15 Gy in 3 fractions Gy in 2 fractions Gy in 1 fraction.

13 GEC/ESTRO recommendations. An update. HDRBT boost with external beam EBRT 45 Gy in 25 fractions over 5 weeks. 46 Gy in 23 fractions over 4.5 weeks Gy in 13 fractions over 2.5 weeks Gy in 15 fractions over 3 weeks. Low α/β - value HDR brachytherapy 15 Gy in 3 fractions Gy in 2 fractions Gy in 1 fraction.

14 Recommendations

15 ABS Selection criteria Czynnik rokowniczy BRT zalecana, rokowanie dobre BRT opcjonalna, rokowanie dość dobre BRT w trakcie badań klinicznych, rokowanie złe PSA (ng/ml) < >20 skala Gleasona Stopień T T1c T2a T2b T2c T3 IPSS >20 Objętość prostaty < >60 (cm 3 ) Qmin (ml/s) > <10 Objętość >200 rezydualna (cm 3 ) TURP + +

16 Risk categories and treatment options according to NCCN Risk category Life expectancy Treatment recommendation Very low: T1c; Gleason score 6; PSA < 10 ng/ml; < 3 positive biopsy cores; 50% cancer in each core; PSAD * < 0.15 ng/ml/g Low: T1-T2a; Gleason score 6; PSA < 10 ng/ml < 20 years active surveillance 20 years < 10 years active surveillance active surveillance or radiotherapy (3DCRT/IMRT + IGRT or BT) or RP ± pelvic lymph node dissection 10 years active surveillance or radiotherapy (3DCRT/IMRT + IGRT or BT) or RP ± pelvic lymph node dissection Intermediate: T2b-T2c; Gleason score 7; PSA = ng/ml < 10 years active surveillance or radiotherapy (3DCRT/IMRT + IGRT ± BT boost) ± short-term ADT (4-6 months) High: T3a; Gleason score 8-10; PSA > 20 ng/ml Very high: T3b If 5 years and asymptomatic and if complication as hydronephrosis or dissemination are expected within 5 years RT or ADT may be considered If 5 years and asymptomatic and if complication as hydronephrosis or dissemination are expected within 5 years RT or ADT may be considered 10 years radiotherapy (3DCRT/IMRT + IGRT ± BT boost) ± short-term ADT (4-6 months) or RP ± pelvic lymph node dissection radiotherapy (3DCRT/IMRT + IGRT ) + long-term ADT (2-3 years) or radiotherapy (3DCRT/IMRT + IGRT + BT boost) ± short-term ADT (4-6 months) or RP + pelvic lymph node dissection radiotherapy (3DCRT/IMRT + IGRT ) + long-term ADT (2-3 years) or radiotherapy (3DCRT/IMRT + IGRT + BT boost) ± short-term ADT (4-6 months) or RP + pelvic lymph node dissection or long-term ADT (2-3 years)

17 Recommendations comparison for GEC/ ESTRO and ABS MONOTHERAPY GEC/ESTRO ABS HDR-BT investigational standard LDR-BT standard standard BOOST HDR-BT standard standard LDR-BT Not stated standard SALVAGE HDR-BT investigational Limited LDR-BR Not stated Not stated

18 HDR brachytherapy procedure The transperineal technique is performer under spinal anesthesia. Transrectal ultrasound is essencial for quidance of the applicators into the prostate in an appropriate pattern. A stepper unit is required with a cradle for the ultrasound probe. A template mounted on the stepper and calibrated and calibrated so that positions in the template correspond precisely to the dispayed on the ultrasound image will be required. Applicators compatible with the HDR afterloader are available in different forms, steel or flexible plastic tubing.

19 HDR brachytherapy procedure Procedure can be broken down into a number individual steps as follows: Patient setup Pre-planing? Catheter insertion Catheter fixation Post-implant imaging Outlining and dosimetry Quality assurance Treatment delivery

20 Pre-planning vs. real-time Choosing one or the other is a matter of: Departmental resources Site-specific logistics Experience Personal preferences

21 Advantages Better image quality ( base and apex, capsula, urethtra) Prostate and OAR volume Provides guidance for approach, data on number of needles required Avoid central column to spare urethra Cover target laterally Conform to posterior border (spare rectum) to get experience

22 Disadvantages Organ/ target, OaR motion Planning time, procedure time Prostate volume and deformation Catheters deviation

23 Better image quality ( capsula, urethtra)??

24 Better image quality ( capsula, urethtra)

25 Better image quality ( capsula, urethtra)

26 Organ motion

27 Prostate volume

28 Prostate volume

29 Catheters deviation

30 Catheters deviation

31 Pre-planning vs. real-time Advantages Better image quality ( base and apex, capsula, urethtra) Prostate and OAR volume Provides guidance for approach, data on number of needles required Avoid central column to spare urethra Cover target laterally Disadvantages Organ/ target, OaR motion Planning time, procedure time Prostate volume and deformation Catheters deviation Conform to posterior border (spare rectum) to get experience

32 Conclusions Pre-planning in HDR brachytherapy treatment is a valid procedure expecialy to identify the target and OaR. It may help to get experience but it may be problematic.

33 Thank You..