Content. Acknowledgments. Prostate brachy LDR Prostate brachy HDR. Use of permanent seeds and HDR in prostate: Current practice and advances

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IRIMED Use of permanent seeds and HDR in prostate: Current practice and advances Content

Politecnico La Fe. Valencia. Spain perez_jos@gva.

SWIFT y Oncentra Prostate Elekta 2 Acknowledgments Francoise Lliso Vicente Carmona Jose

Cs-131 T 1/2 60 d 17 d 9,7 d Sources E 27 kev 23 kev 29 kev DISCUSSION Typical dose Time

1 IRIMED Use of permanent seeds and HDR in prostate: Current practice and advances Content Prostate brachy LDR Prostate brachy HDR Jose Perez-Calatayud Hospital Universitario y Politecnico La Fe. Valencia. Spain perez_jos@gva.es 1 Practical overview of this well established techniques, aspects well solved, cautions and required improvements. LDR: SPOT y OncentraProstate Elekta, strands S06 Ibt-Bebig, SeedSelectron Elekta HDR: SWIFT y Oncentra Prostate Elekta 2 Acknowledgments Francoise Lliso Vicente Carmona Jose Gimeno Mar Adria Nuria Carrasco 3 Initial dose rate I-125 Pd-103 Cs-131 I-125 Pd-103 Cs-131 T 1/2 60 d 17 d 9,7 d Sources E 27 kev 23 kev 29 kev DISCUSSION Typical dose Time 90% dose Gy 197 d 125 Gy 56 d Gy 32 d Energy Initial dose rate $$$ Effectivity 4 Procedure TRUS based INTRAOPERATIVE procedure US 3D Procedure TRUS transversal or longitudinal?? 5 6 1

Prostata LDR BASE Contouring Interobservador REFERENCE Training& consensus Societal Recommendations

isodose 150% CTV (prostate+3mm excp rectum/bladder) : V100 95%, D90>100%, V150 50% Rectum: D2cc 145

1cc<200 Gy Urethra: D10<150%, D30<130% Function of the contoured To be reported in postplan: urethra

1cc, V100 Uretra: D10, D0.1cc, D30, D5 Probe postplan?

Societal Recommendations ABS Davis Jan-Feb 2012 Brachyther.

V30 (%) Function of the contoured urethra volume TRUS Contouring Inverse planning Interactive planning

2 Prostata LDR BASE Contouring Interobservador REFERENCE Training& consensus Societal Recommendations ESTRO-EAU-EORTC Salembier 2007 RO, AAPM TG-137 Nath Gy (I-125) 125 Gy (Pd-103) GTV: Within isodose 150% CTV (prostate+3mm excp rectum/bladder) : V100 95%, D90>100%, V150 50% Rectum: D2cc 145 Gy, D0.1cc<200 Gy Urethra: D10<150%, D30<130% Function of the contoured To be reported in postplan: urethra volume(typically 7- CTV-P y CTV-PM: D90, V100,V150, 8 mm diameteralongctv) V200, D100 Recto: D2cc, D0.1cc, V100 Uretra: D10, D0.1cc, D30, D5 Probe postplan? Polo PROBATE-GEC-ESTRO 2010 RO Interactive planning or dynamic calculation RECOMMENDED APEX 7 8 Societal Recommendations ABS Davis Jan-Feb 2012 Brachyther. Procedure Aceptable D Gy (I-125) Ideal: Urethra V150<5% y V125<30% Rectum: V100<1cc Typical activity mci To be reported in postplan: Prostate: D90, V100,V150 Rectum: V100 (cc) Urethra: V150 (cc) V5 (%) V30 (%) Function of the contoured urethra volume TRUS Contouring Inverse planning Interactive planning Needles Implantation Guided by TPS TPS proposed needles and seeds Manual adjustement Probe postplan? Seed reevaluation Coverage (edema) Seeds deliver Report Actualize contours Dynamic calculation 9 10 Prostate LDR Inverse planning (pre-insertion) Insertion guided, interactive planning Stranded Loosed Good prediction Base definition/ first seed center Higher difficulty in strands when 160 Gy 12 2

seeds vs needles 14 Delivering method Seed

Procedure complexity 15 Stranded vs loosed

3 To check coverage because edema Final evaluation To consider deformation due insertion + edema Problems in some TPS with the coordinate system Deviations seeds vs needles 14 Delivering method Seed configuration Manual Afterloader Skill Procedure complexity 15 Stranded vs loosed 16 Seed configuration Stranded vs loosed Seeds RAKR Needles number & trauma Accesibility in small prostates Seeds protagonism Hot spots volumes Gy 160 Gy Courtesy Bradley Peters 0,553 U 0,611 U 0,435 mci 0,481 mci

Post-plan All Recomendations Post-plan 1 moth

Post-plan Recomended CT-MR CT T1 T2 20 prostate CT Pat 1

Hoskin et al RO 2012 Pat 2 Pat 3 De Barbandere.

Cortesy Marisol De Brabandere 22 Interobserver De

Hoskin et al RO 2012 23% 2% --- 18% 7% 6% 17% 2% 16% CT

Brabandere Contouring seeds fusion Guidelines and

automated fusion software need to be implemented 23

4 Post-plan All Recomendations Post-plan 1 moth RecomendedCT-MR, Acepted CT. Post-plan Recomended CT-MR CT T1 T2 20 prostate CT Pat 1 SAG AXIAL prostate T2 SAG AXIAL De Barbandere. Hoskin et al RO 2012 Pat 2 Pat 3 De Barbandere. Hoskin et al RO 2012 Cortesy Marisol De Brabandere 21 Cortesy Marisol De Brabandere 22 Interobserver De Barbandere. Hoskin et al RO % 2% % 7% 6% 17% 2% 16% CT Mean 3 patients T1+T2 CT+T2 Cortesy Marisol De Brabandere Contouring seeds fusion Guidelines and training in contouring together with incorporation of automated fusion software need to be implemented 23 Increase of dose from 145 Gy to 160 Gy Urethra: Keeping 150% de 145 Gy : 218 Gy 135% Rectum: Decrease 100% as possible Strand SeedSelectron To increase the class Keeping needles & seeds 24 4

Prostate HDR 2013 Prostate HDR Imaging Recomended TRUS intraoperative Some Hospitals: CT unique or in a 2nd fx

HDR TRUS Inverse planning TPS provides dwell times Manual adjustments TRUS intraoperative procedure Needles

positions Insertion according experience Less practical IP in virtual Higer optimization degree than seeds

ABS min 14 Prostate HDR Needles Vectors Trauma Time Conformation V overdose Set of 477 cases H La Fe (Jan 12 -

5 Prostate HDR 2013 Prostate HDR Imaging Recomended TRUS intraoperative Some Hospitals: CT unique or in a 2nd fx Convinient the use of gold markers to adjust needles in the 2nd fx due to edema (using SV) 26 Prostate HDR TRUS Inverse planning TPS provides dwell times Manual adjustments TRUS intraoperative procedure Needles Implantation Activation definition Treatment Contouring Needle reconstruction Report Prostate HDR Needles positions Insertion according experience Less practical IP in virtual Higer optimization degree than seeds Avoid recontouring Urethra in base, ref and apex Reference plane Apex plane Prostate HDR Needles number ABS min 14 Prostate HDR Needles Vectors Trauma Time Conformation V overdose Set of 477 cases H La Fe (Jan 12 - Feb18) Plastic vs Metallic GEC/ESTRO ABS Both Image quality Bladder impact Guide Reconstruction $ Plastic Metallic

Prostate HDR Contouring GEC/ESTRO - CTV 3 mm margin

Prostate HDR Needles reconstruction Use free length

31 32 Prostate HDR Activation Prostate HDR Optimization

Fe: A anterior valley isallowed, the 120% shouldbe out

Manual adjustementfor lobes, grandposterior volume and

2005 Uretra < 120% Prostate HDR Recommendations

6 Prostate HDR Contouring GEC/ESTRO - CTV 3 mm margin added to prostate, with exception rectum and bladder Prostate HDR Needles reconstruction Use free length Urethra diameter ie8 mm? Prostate HDR Activation Prostate HDR Optimization Inverse (HIPO) + manual La Fe: 1 mm outsidectv 33 La Fe: A anterior valley isallowed, the 120% shouldbe out from urethra. Manual adjustementfor lobes, grandposterior volume and rectum(85%) 34 Prostate HDR Recommendations GEC/ESTRO 2005 Uretra < 120% Prostate HDR Recommendations Aplication GEC/ESTRO 2013 H La Fe ABS 2012 Adopt RecCTV fromgec/estro No OAR CTV D % V % ResultsH La Fe 10 lastpts 15 Gy GEC/ESTRO 2013 Rectum Urethra D 2cc 75 Gy EQD 2 EBRT + BT D 0,1cc 120 Gy EQD 2 D GyEQD 2 D GyEQD

7 Prostate HDR Interobserver Prostate Advances and research AAPM-ESTRO TG-192 In progress D2cc rectum 5 ORT after consensus Prostate Advances and research Interstitial Rotating Shield BT: 153 Gd PROSTATA EUCLIDEAN Robot AAPM-ESTRO TG-192 In progress R. Moerland (UMCU Utrech) Comprehensive Brachytherapy Book Adams et al, Med Phys 41, (2014) CORTESIA M. RIVARD Hybrid Imaging: Example of mp-mr und 3D- U/S (Biology + Morphology) Tracking CORTESIA D. BALTAS Computer - Integrated Interventional Radiation Oncology Systems (CIIROS) 41 Sana Klinikum Offenbach Prof. Dr. D. Baltas 4 April 2018 Mar

Time-resolved dose verification Cortesy Kari Tanderup vs HDR TPS +/- 1mm Dose rate [mgy/s] In

20) Permanent I-125 HDR Ir-192 or Co-60 Agreement on the level of: pulse / applicator / dwell

against HDR Conclusions Dosimetry (optimization) Migration, local & distance Dose variation due

seeds Procedure duration $ IOP TRUS based LDR/HDR BT prostate procedure well established.

8 Time-resolved dose verification Cortesy Kari Tanderup vs HDR TPS +/- 1mm Dose rate [mgy/s] In vivo meas. (pulse no. 20) Permanent I-125 HDR Ir-192 or Co-60 Agreement on the level of: pulse / applicator / dwell position Time [s] 145 Gy o 160 Gy 13,5 Gy /app 2 app 2 week interval Decrease of LDR against HDR Conclusions Dosimetry (optimization) Migration, local & distance Dose variation due edema Uncertainties (deliver, calcifications, ) Radiation protection after implant Handling seeds Procedure duration $ IOP TRUS based LDR/HDR BT prostate procedure well established. Major current issue that require efforts: contouring interobserver. Important advances: multimodal images, tracking and in vivo dosimetry. Trend towards HDR. 45 Thank you perez_jos@gva.es 47 8

Recent proceedings in Brachytherapy Physics

Recent proceedings in Brachytherapy Physics Frank-André Siebert UKSH, Campus Kiel, Germany Clinic of Radiotherapy Dept. Medical Physics Physical characteristics of brachytherapy (Courtesy Luc Beaulieu,