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ECCLU 2011 - A. Widmark - Prostate cancer: All the truth about local treatment options T1-T2 - Radiotherapy
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ECCLU 2011 - A. Widmark - Prostate cancer: All the truth about local treatment options T1-T2 - Radiotherapy

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  • VIG (Vinblastin, Ifosfamid, Galliumnitrat Obj Resp 67% hos M1 41% df STATUS 5/27 dfs 22-56 MÅN Einhorn -94 ASCO
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    • 1. All the truth about local treatment options T1-T2 RADIOTHERAPY Anders Widmark, Professor, Senior Consultant Department of Radiation Sciences, ONCOLOLGY, Umeå University Hospital Paid Consultant, sanofi-aventis, part time Advisory boards: Astellas, Roche and Janssen European School of Oncology Educational Cancer Convention Lugano (ECCLU): What is New and What is True in Genito-Urinary Oncology? 12-14 May 2011, Lugano, Switzerland ECCLU 2011
    • 2. Philosophy : Risk adapted Treatment with EBRT - Decrease side-effects in low risk tumor – Increase treatment in aggressive tumors Technical Development Dose-escalation, Results IGRT, IMRT 3D-CRT Margins, MRI, CT New techniques to decrease rectal toxicity Combination of hormones SPCG-7/SFUO-3 Hormones vs. Hormones + EBRT Side-effects Overview ECCLU 2011
    • 3. Historical Radiotherapy of PC Onk klin, NUS, A W 0002 ECCLU 2011
    • 4. Dosescalation 65Gy -> 70Gy -> 78 Gy HDR + EBRT IGRT Improved Precision, Tighter Margins Image Guided RadioTherapy IMRT Concave forms, Tighter Marigins Intensity Modulated RadioTherapy MRI Improved Target Deliniation, Established Technical Improvments ECCLU 2011
    • 5. Why EBRT Dose-escalation ?
      • Biopsy Data
      • Local control influence outcome SPCG-7/SFUO-3
      Onk. AW 0103
      • Improvement in technique
        • CT-Based 3D-CRT
        • Decreased margins -> side-effects
        • IGRT
      ECCLU 2011
    • 6. ALL 393 664 843 301 202 104 GETUG 306 Viani et al IJROBP 2009
    • 7. Low Risk Inter M Risk High Risk Viani et al IJROBP 2009
    • 8. Viani et al IJROBP 2009
    • 9. Viani et al IJROBP 2009
    • 10.  
    • 11.  
    • 12. MD anderson Trial Kuban et al Röda 2008 ECCLU 2011 78% 39% 78% 59%
    • 13. Rand Trial 70 vs. 78 Gy, MDA Onk. AW 0101
      • Metastases ALL
      • Pre PSA > 10
      +13% p=0,035 Pollack et al JCO 2002 Kuban et al 2008 Kuban et al 2008 P=0.059 +4% ECCLU 2011
    • 14. Onk. AW 0308 PROT 05 Update 8.9 y. Zietman et al JCO 2010
    • 15. Onk. AW 0308 32.4% 17.4% PROT 05 Update 8.9 y. Zietman et al JCO 2010
    • 16. Onk. AW 0308 28.2% 7.1% 42.1% 30.4% PROT 05 Update 8.9 y. Zietman et al JCO 2010 Low Risk InterMed. Risk
    • 17. Side –Effects Dose –Escalation MRC RT01 Trial , Syndikus at al IJROBP 2009 ECCLU 2011
    • 18.
      • ASTRO 2001
      Onk. AW 0111 Dansande prostata: mätning av prostata rörlighet med MRI ECCLU 2011
    • 19. BeamCath for IGRT Prostata cancer Onk. AW 9809 CT-bild ECCLU 2011
    • 20. Digital Bildframställning “Portal Vision” BeamCath, med markörer som visar urinröret
      • 1:a uppläggning Vid Behandling
      Onk, NUS, A W 0504 ECCLU 2011 Strålfältet Strålfältet
    • 21. Prostate EBRT IGRT Onk klin, NUS, A W 0002 7 mm ECCLU 2011
    • 22. “ Picture verified” radioterapi (IGRT) Röntgenrör Detektor ECCLU 2011
    • 23. Dose plan ECCLU 2011
    • 24. Rectum and dose distribution
    • 25. Rectum dose volume histograms QUANTEC objectives
    • 26. GPS in Prostate Calypso, Micropos ECCLU 2011
    • 27. MR/CT
    • 28. MR-Bild Onk klin, NUS, A W 9602 ECCLU 2011
    • 29. Prostate MRI Cancer (S Johansson) Axial Coronal ECCLU 2011
    • 30. Umeå Trial 1 A randomized Trial Extern Beam RT v.s. Deferred Treatment in Localized Prostate Cancer Inclusion Criteria < 75 years T1b-T2, pN0, G1-G2, M0 Inclusion within 3 mo. from diagnosis Surgical staging (obturator) Bonescan, Pulm X-ray No previous treatment ECCLU 2011
    • 31. Umeå Trial 1 Inklusion 1986- 1996 > 20 års FU Rand studie, Sweden, Denmark, Norway WW v.s. RT Patienter 107 107 ECCLU 2011
    • 32. HYPO-fractionation alpha/beta value in PC HYPO-RT-PC -Study Fractionation schedule under development Yeho Lukka B&R
    • 33. Onk. AW 0609 Hypofractionationated treatments ECCLU 2011
    • 34. SCANDINAVIAN HYPO-Fractionation study NUS Onk. AW 0402 Intermediate Risk Patients Conv: 2 Gy x 39 = 78 Gy R HYPO: 6.1 Gy x 7 = 42,7 Gy
      • 15 centers, Sweden and Denmark
      • Canada might Join
      • 440/ 800 patients Included
      ECCLU 2011
    • 35. Blood in Stools With Smaller margins ECCLU 2011
    • 36. Treatment Effect are improving What about Side-effects? ECCLU 2011
    • 37. Biverkningar - Funding ECCLU 2011
    • 38. N 603 292 306 - Age 59 69 65 - PSA 6.7 9.1 5.8 Side-Effects - Sexual ECCLU 2011
    • 39. Side-Effects - URIN - Funding ECCLU 2011
    • 40. Side-Efects – Bowel - Vitality ECCLU 2011
    • 41. Intestinal Symptoms EBRT Fig. 2 ECCLU 2011
    • 42. Rectal leakage - When? Q31 ECCLU 2011
    • 43. Localized PC! Local Cure is Achivable ! Improve Techniques to Decrease Rectal Toxicity!! ECCLU 2011
    • 44. Prada et al Brachytherapy , 2007, 2009 ECCLU 2011
    • 45. Principal of the No-HARM study Needel operated Hyaluronic Acid for Rectal Move HA 10% 50% 70% 10% 70% 50% ECCLU 2011
    • 46. ECCLU 2011
    • 47. ECCLU 2011 Before RT 20 treatments ./40 G
    • 48. ECCLU 2011
    • 49. ECCLU 2011
    • 50. Rectal fixation probe! ECCLU 2011
    • 51. Rectal fixation probe! ECCLU 2011
    • 52. Hydrodissection of the space between rectum and prostate ECCLU 2011 Pro-Space: Novel Biodegradable Inflatable Balloon System
    • 53. BLADDER PENIS RECTUM ECCLU 2011 Pro-Space: Novel Biodegradable Inflatable Balloon System
    • 54. Lymph Node treatment? ECCLU 2011
    • 55. Lymph Node treatment, IMRT? ECCLU 2011
    • 56. Lymph Node treatment, VMAT? ECCLU 2011
    • 57. Lymph Node treatment? RTOG 0924 And PIVOTAL RT + HORMONES vs RT + HORMONES + Lymph Node Iradiation ECCLU 2011
    • 58.
      • RTOG 8610 RT 2 må.+2 må./RT
      Randomised Studies Radiation v.s. Radiation + Hormones
      • Umeå 2 RT Kir. Kastration + RT
      • EORTC/Bolla RT RT/samtidigt + Adj.3 år
      • RTOG 8531 RT RT + Adj. LHRH 2 år
      • Lavendiere RT 2 må. +2 m/RT 2 +2 må/RT+6må Adj.LHRH
      Is anyone doing RT 78 Gy vs Hormones + RT 78 Gy In intermediate risk PC? ECCLU 2011
    • 59. - Funding PSA recurrence-free survival T1b-T2, PSA < 50; Grad I-II (“SPCG-4 population”) Combination (n=69) Antiandrogen (n=64) HR 0.10 (0.04, 0.24); p>0.0001 ECCLU 2011
    • 60. - Funding Prostate Cancer specific survival T1b-T2, PSA < 50; Grad I-II (“SPCG-4 population”) Combination (n=69) Antiandrogen (n=64) HR 0.21 (0.04, 1.00); p<0.03 ECCLU 2011
    • 61. - Funding Overall survival T1b-T2, PSA < 50; Grad I-II (“SPCG-4 population”) Combination (n=69) Antiandrogen (n=64) HR 0.69 (0.34, 1.39); p<0.30 ECCLU 2011
    • 62.  
    • 63.  
    • 64.  
    • 65.  
    • 66. RT 70 Gy + 6 m. ADT Intermediate risk No/mild comorbidity Moderate/ severe comor
    • 67. RT 70 Gy + 6 m. ADT High Risk No/mild comorbidity Moderate/ severe comor
    • 68. Summary Localised PC! Local Cure is ”Achivable (-ed)” New Radiotherapy Tecniques To further Decrease Rectal Toxicity!! ECCLU 2011
    • 69. Conclusions Radiotherapy Local Cure is Achivable!! Dose escalation ! IGRT, IMRT Improved precision - smaller margins Less Rectal Toxicity? HYPO - Shorter Treatment time? Low Doctor time Low Cost treatment ECCLU 2011
    • 70. Thank You! ECCLU 2011
    • 71. Tack! Frågor ? ECCLU 2011
    • 72. A Randomized Trial Comparing Antiandrogens With Or Without Radiotherapy In The Treatment Of Locally Advanced Prostate Cancer: Survival and Qol Outcome A. Widmark , O. Klepp, P. Fransson, J. Damber, A. Angelsen, A. Solberg, J. Lund, M. Hoyer, F Wiklund, S.D. Fosså On Behalf of SPCG-7/SFUO-3 Study Group Scandinavian Prostate Cancer Group and Swedish Association of Urological Oncology ASTRO, 2008, Plenary Session, The Lancet ECCLU 2011
    • 73. Cumulative incidence of PSA Recurrence 74.7 % (69.6 - 79.8) 71.1 (66.3-75.9) 25.9 % (19.3 - 32.6) p<0.00001 Combination 17.6 % (13.6-21.5) Why this huge benefit? Local control is important? Seeding of cancer cells? Abscopla effect? Vaccination/immunstimulation? ECCLU 2011
    • 74. Cumulative incidence of Prostate Cancer mortality 11.9% (7.4 -16.5) p=0.00003 23.9% (18.4 - 29.4) 9.9 (7.1-5.9) 6.3 % (3.9-8.6) ASTRO, 2008, Plenary Session ECCLU 2011
    • 75. Cumulative incidence of Prostate Cancer mortality 9.9 (7.1-5.9) 6.3 % (3.9-8.6) ASTRO, 2008, Plenary Session ECCLU 2011 SPCG-4

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