CLINICAL WORKSHOP IMAGE-GUIDED HDR BRACHYTHERAPY OF PROSTATE CANCER Klinikum Offenbach Nucletron April 27 th 28 th, 2014
History HDR Protocols for Boost and Monotherapy, Results, Logistics and Practical Issues
GEC / ESTRO recommendations on temporary brachytherapy for localised prostate cancer
GEC / ESTRO recommendations Advantage of temporary afterloading brachytherapy: accurate postitioning of the source by first implanting non-active guide needles possibility to choose the source postitions over the lenght of needle no target movement during radiation
GEC / ESTRO recommendations Contraindications - regional and/or distant metastatic disease - interval to TURP < 6 month - large prostatic volume defect after a previous TURP - general contraindications - anatomical abnormalities
Patient selection - clinical stage T1-T3b (TRUS, DRE, MRI) - N0 M0 (CT, MRI, Bone scan) - no severe co-morbidity - no pubic arch interference - Uroflow > 15 ml/s - Prostate volume < 70 ccm
GEC / ESTRO recommendations
GEC / ESTRO recommendations 6 to 12 core biopsy
GEC / / ESTRO recommendations recommandations The clinical team: radiotherapist medical physicist urologist
HDR Brachytherapy in Offenbach HDR - MONOTHERAPY HDR BOOST to EBRT HDR - SALVAGE
HDR-Brachytherapy of Prostate Cancer - History -
History 1. Prostate Brachytherapy in 1996 BOOST + EBRT
History from 2001: Prostate Brachytherapy MONOTHERAPY
History from 2002: Prostate Brachytherapy BOOST + EBRT
History 250 200 150 100 50 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 transrectal transperineal Mono transperineal Kombi > 2500 Patients since 1996
HDR-Brachytherapy in Offenbach HDR boost to EBRT
History BOOST to EBRT Clinical stage T2c or PSA > 10.0 or Gleason 7b (4+3)
BOOST to EBRT Since 1996: transrectal HDR 4 X 5-7 Gy + EBRT 39,6 45 Gy 1450 Patients transperineal HDR 3 x 7,0 Gy + EBRT 45 Gy 258 Patients HDR 2 x 10,5 Gy + EBRT 45 Gy 88 Patients
BOOST to EBRT Protocols: 1 fraction / implant: Dinges: 2 implants (9 Gy per implant) + 45 Gy EBRT Martinez: 2 implants (11.5 Gy per implant) + 46 Gy EBRT Galalae: 2 implants (15 Gy per implant) + 50 Gy EBRT Offenbach: 2 implants (10,5 Gy per implant) + 45 Gy EBRT multiple fractions / implant Rodriguez: Pellizzon: Linares: 2 implants (2 x 6 Gy per implant) + 36 Gy EBRT 2 implants (2 x 6 Gy per implant) + 45 Gy EBRT 1 implant (4 x 5.5 Gy per implant) + 45 Gy EBRT
Athens History - Conference HDR BOOST + EBRT 46 Gy at 2 Gy * Dose Gy # Fxs Total D Gy BED α/β 1.5 % Dose D 2Gy 9.5 2 19 247 57 106 10.5 2 21 275 61 118 11.5 2 23 307 65 131 *45 Gy at 1.8 Gy
History GEC / ESTRO recommandations Different target and treatment philosophies: CTV 1 prostate capsule CTV 2 peripheral zone CTV 3 visible tumor
History GEC / ESTRO recommandations EBRT BTfx Gy/fx Target Borghede et. al. 50 2 15 Tumor volume CTV3 Dinges et. al. 45 2 10 Prostate capsule CTV1 Kovács et. al. 40/50 2 15 Peripheral zone CTV2 Mate et. al. 50.4 4 3-4 Prostate capsule CTV1 Offenbach 45 2 10.5 Prostate capsule CTV1
Boost History EBRT in Offenbach ADT Androgen Deprivation Therapy 9 month 3 month neoadjuvant
BOOST to EBRT Androgen Deprivation Therapy Huggins
BOOST to EBRT LHRH-Agonists -continuously- LH Testosteron flare up Ø pulsatile Anti-androgens
BOOST to EBRT Zelefsky 2008: We observed a benefit for ADT in high-risk patients who received higher doses. Int. J. Radiation Oncology Biol. Phys. Vol.71 No 4 1028-33, 2008
Boost/EBRT History Results Galalae et. al. Vargas et. al. Offenbach Cases 611 197 543 OS 85 % 92% 73.3 % CSS 96 % 98 % 91,9 % BC 77 % 78.4 % 76.2 % DFS 67 % 84.8 % 76.8 % OS= overall survival, CSS = cause specific survival, BC = biochemical control (5-year), DFS = disease-free survival Galalae et. al.; Int. J. Radiation Oncology Biol. Phys. 58, 1048-1055 Vargas et. al.; Int. J. Radiation Oncology Biol. Phys. 66, 416-423
Boost/EBRT Toxicity urogenital (%) gastrointestinal (%) CTC akut chronic akut chronic I 67 16 28 11 II 28 6 7 8 III 5 6 0 0 IV 0 0 0 (1)
HDR-Brachytherapy in Offenbach Monotherapy
HDR Monotherapy Clinical stage < T2c and PSA < 10.0 and Gleason 7a (3+4)
HDR Monotherapy Since 2001: transperineal HDR 4 x 9,5 Gy 1 implant (4 x 9.5 Gy) 2 implants (2 x 9.5 Gy per implant) 577 Patients HDR 3 x 11,5 Gy 114 Patients
HDR Monotherapy Protocols: Martinez 1 implant 2 days 4x9.5 Gy 38 Gy Rodriguez 2 implants 1 day 6x7 Gy 42 Gy Gustafson 1 implant 2 days 4x9.5 Gy 38 Gy 2 implants 1 day 6x7 Gy 42 Gy Offenbach 3 Implants 1 day 3x11.5 Gy 34.5 Gy Int J Radiat Oncol Biol Phys 2000; 47:343-352. International Brachytherapy Meeting, Santa Fe, 2002 Int J Radiat Oncol Biol Phys 2003; 57, Suppl, Abstract 176, p230-231.
Athens - Conference HDR MONOTHERAPY OPTIONS Dose Gy # Fxs Total D Gy BED α/β 1.5 % Dose D 2Gy 9.5 4 38 278 100 120 11 3 33 275 100 118 14 2 28 289 100 124
HDR Monotherapy Toxicity akut urogenital (%) 60 50 40 30 20 10 0 G0 GI GII GIII GIV 1 Implant 2 Implants
HDR Monotherapy 3 patients with rectal ulceration 1 patient with rectal and urethral fistula, definitive Colo- and Urostomie 1 patient with urethro-prostatic fistula Severe chronic toxicity only in patients with CT Planning and 4 fractions with 1 implant
HDR-Brachytherapy in Offenbach Results / Studies
HDR-Brachytherapy Summary Since 1996: 2527 Patients Transrectal HDR 4 X 5-7 Gy + EBRT 39,6 45 Gy 1450 Patients Tarnsperineal HDR 4 x 9,5 Gy HDR 3 x 11,5 Gy 577 Patients 114 Patients HDR 3 x 7,0 Gy + EBRT 45 Gy 258 Patients HDR 2 x 10,5 Gy + EBRT 45 Gy 88 Patients Salvage: HDR 4 x 6,0 Gy 40 Patients
PSA-level Distribution 70,0 60,0 50,0 % 40,0 30,0 20,0 10,0 0,0 PSA < 5 PSA 5-10 PSA 10-20 PSA > 20 PSA >100 3% of Patients with PSA <4 ng/ml at the time of Diagnosis!!!
Clinical Stage Distribution 40 % 35 30 25 20 15 10 5 0 T1c T2a T2b T2c T3a low intermediate high
Questionaire History Since 2007 87 Questions: - QLQ 30 - IPSS - IIEF
Sexual History Activity - without ADT 52,8 % sexual Activivty 47,2 % no sexual Activivty Nearly 50% have no sexual activity (median age: 71 years)
Sexual History Activity - with ADT 20 % sexual Activivty
IPSS History 72 patients - QLQ 30 - IPSS - IIEF - Incomplete emptying - Frequency - Intermittency - Urgency - Weak stream - Straining - Nocturia 0-5 points / question
IPSS IPSS - total score 0 35 points score symptomatic 0 7 mildly symptomatic 8 19 moderatly symptomatic 20 35 severely symptomatic
IPSS History pretreatment - IPSS Posttreatment - IPSS 24 patients (mildly) 37 patients (mildly) 10 patients (moderatly) 03 patients (severely) 01 patients (mildly) 32 patients (moderatly) 23 patients (moderatly) 08 patients (severely) 00 patients (mildly) 03 patients (severely) 01 patients (moderatly) 02 patients (severely)
IPSS History - Seed Wylie et. al. 2007 median
IPSS History - Seed?
HDR-Brachytherapy of Prostate Cancer - Logistics -
Saddle block or spinal anaesthesia
Lithotomy position
Preparing the system
Fixation of the probe and template on the stepper
Fixation needles
Treatment catheters
Theater I 1. Patient 3. Patient Spinal-Anaesthesia A Imobilization N Acquisition: U+P Contouring: R Implantation: U+P Acquisition: U+P Contouring: R Final Plan: P+(R) Treatment delivery Spinal-Anaesthesia A Imobilization N Acquisition: U + P Contouring: R Implantation: U+P Theater II 2. Patient 4. Patient Spinal-Anaesthesia A Imobilization N Acquisition: U + P Contouring: R Implantation: U+P Acquisition: U+P Contouring: R Final Plan: P+(R) Treatment delivery Spinal-Anaesthesia A
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