Prostate gold seed fiducial implantation by radiation oncologists: A report on feasibility Poster No.: R-0006 Congress: Type: Authors: Keywords: DOI: 2014 CSM Scientific Exhibit C. Jayaratne, A. Brown, A. Tan; DOUGLAS/AU Genital / Reproductive system male, Ultrasound, Radiation therapy / Oncology, Toxicity 10.1594/ranzcr2014/R-0006 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply RANZCR/AIR/ACPSEM's endorsement, sponsorship or recommendation of the third party, information, product or service. RANZCR/AIR/ ACPSEM is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold RANZCR/AIR/ACPSEM harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies,.ppt slideshows,.doc documents and any other multimedia files are not available in the pdf version of presentations. Page 1 of 7
Aim The flagship indication for image-guided radiation therapy is in the treatment of prostate cancer with external beam radiotherapy 1. At most centres, a Urologist or Radiologist experienced in transrectal ultrasound guided prostate biopsy performs the FM insertion. The Townsville Cancer Centre is a regional centre treating about 150 prostate cancer patients per year. Here, patients have prostate gold seen fiducials implanted by one of two radiation oncologists prior to radiotherapy. This report is a quality assurance audit to report on the success of the implementation of the gold seed program. Methods and materials Transrectal ultrasound was used to guide periprostatic nerve block and insertion of the fiducial markers. The aim was to insert 3 markers into the prostate capsule at the right apex, right base and left mid zone. At the time of simulation, or at a subsequent follow up appointment, patients were presented with a short questionnaire regarding the insertion and any complications the patient experienced. The questions were designed to determine whether any toxicities experienced were CTCAE grade 1-2 or 3-4, relating to infection, urinary difficulties, rectal bleeding, haematuria and pain. Prior to de-identification of data, demographic information was collected on each of the patients, including the patient's age, TNM stage, Gleason score, use of hormone therapy prior to FM insertion, and history of prior transurethral resection of the prostate (TURP). The date of fiducial marker insertion and the Radiation Oncologist performing the procedure was also collected. The quality of the implant was analysed, with an implant deemed to be of good quality if all implanted seeds were inside the prostate capsule as outlined on the planning CT scan. Note was made if any seeds went missing on the verification images taken daily during the course of treatment. 127 patients were given questionnaires regarding their experience of the fiducial marker implantation, which asked about complications and pain experienced. 101 returned the questionnaire and were analysed. We compared our results with the literature and examined for factors influencing the rate of complication or the quality of the implant. Page 2 of 7
Results Seed placement In three patients, only 2 seeds were intentionally implanted as previous TURP and/or a small gland volume resulted in scarcity of tissue for adequately spaced seed placement. In 10 patients, one (5 patients) or two (5 patients) of the implanted seeds were deemed to be outside the prostatic capsule. Figure 1 is an example of one our patients that had an extraprostatic gold seed. Seed loss In 95 patients (94.1%), all implanted seeds remained in situ for the entire treatment course. Altogether, 7 seeds implanted within the prostate capsule were subsequently lost. In 5 patients, 1 seed was lost and 1 patient lost 2 seeds. Procedural complications Complications were reported at a rate of 19.8% for haematuria and 7.9% had rectal bleeding. All reported cases of haematuria and rectal bleeding were Grade 1, requiring no treatment. Five patients (5%) reported difficulty passing urine, however there were no cases of urinary retention requiring catheterization. No cases of post procedural infections were reported. Grade 3 and 4 complications were absent and no patients required hospitalisation for implant-related toxicities. Most patients (72.3%) reported no complications, while 22.8% had 1 complication and 5% had 2 complications. There was no difference in the proportion of patients with any of the complications after seed implantation between the two doctors (p=0.771, Fisher's exact test, two sided). Comparison to existing published data on complication rates from Transrectal ultrasound guided proste biopsy and gold seed insertion are shown in Figure 2 and Figure 3, respectively. Images for this section: Page 3 of 7
Fig. 1: Gold seed placed outside the prostate capsule Page 4 of 7
Fig. 2: Table comparing complication rates from TRUS prostate needle biopsy Fig. 3: Table comparing complication rates following fiducial marker insertion Page 5 of 7
Conclusion This is the first report of the toxicity and outcome of fiducial marker implantation by radiation oncologists, a skill acquired in order to allow an image guided radiotherapy program in our regional cancer centre. Toxicity is consistent with published data and highlights that while minor complications such as haematuria and rectal bleeding are relatively common, significant complications requiring medical intervention are rare. We believe prostatic fiducial marker insertion is one that can be safely and efficiently performed by Radiation Oncologists with a short period of training. Personal information Chanaka Mahesh Jayaratne Radiation Oncology Registrar (non-accredited) Townsville Cancer Centre The Townsville Hospital Queensland References 1. Hayden A, Martin J, Kneebone et al A. Australian & New Zealand Faculty of Radiation Oncology Genito-Urinary Group: 2010 consensus guidelines for definitive external beam radiotherapy for prostate carcinoma. J Med Imag Rad Oncol. 2010 Dec 28;54(6):513-25. 2. Ecke TH, Gunia S, Bartel P, Hallmann S, Koch S, Ruttloff J. Complications and risk factors of transrectal ultrasound guided needle biopsies of the prostate evaluated by questionnaire. Urol Oncol. 2008;26(5):474-8. 3. Lee G, Attar K, Laniado M, Karim O. Safety and detailed patterns of morbidity of transrectal ultrasound guided needle biopsy of prostate in a urologist-led unit. Int Urol Nephrol. 2006 Page 6 of 7
Jan;38(2):281-5. 4. Raaijmakers R, Kirkels WJ, Roobol MJ, Wildhagen MF, Schroder FH. Complication Rates And Risk Factors Of 5802 Transrectal Ultrasound-Guided Sextant Biopsies Of The Prostate Within A Population-Based Screening Program. Urology. 2002;60(02):826-30. 5. Peyromaure M, Ravery V, Messas A, Toublanc M, Boccon-Gibod L, Boccon-Gibod L. Pain and morbidity of an extensive prostate 10-biopsy protocol: a prospective study in 289 patients. J Urol. 2002 Jan;167(1):218-21. 6. Djavan B, Waldert M, Zlotta A, et al. Safety and morbidity of first and repeat transrectal ultrasound guided prostate needle biopsies: results of a prospective European prostate cancer detection study. J Urol. 2001 Sep;166(3):856-60. 7. Gill S, Li J, Thomas J, et al. Patient-reported complications from fiducial marker implantation for prostate image-guided radiotherapy. Br J Radiol. 2012 Jul;85:1011-7. 8. Igdem S, Akpinar H, Alço G, Agaçayak F, Turkan S, Okkan S. Implantation of fiducial markers for image guidance in prostate radiotherapy: patient-reported toxicity. Br J Radiol. 2009 Dec;82(983):941-5. 9. Langenhuijsen JF, van Lin ENJT, Kiemeney LA, et al. Ultrasound-guided transrectal implantation of gold markers for prostate localization during external beam radiotherapy: complication rate and risk factors. Int J Radiat Oncol Biol Phys. 2007 Nov;69(3):671-6. Page 7 of 7