Prostate Cancer G Bauman

Achieving the Acheivable: Prostate Glenn Bauman, MD Associate Professor and Chair, Department of Oncology London Regional Cancer Program University of Western Ontario A Cancer Care Ontario Partner

Objectives • We’re we’ve been • What we’ve learned • What we should do • Where we should go • External beam • Brachytherapy • Postoperative radiotherapy • Related issues A Cancer Care Ontario Partner

The Future is a Moving Target… A Cancer Care Ontario Partner

Where we’ve been… A Cancer Care Ontario Partner

What we’ve learned…. JCO 23:2005 A Cancer Care Ontario Partner

What we’ve learned…. Risk stratification • Low risk • T1-T2; PSA<10; Gleason<6 • (% cores or PSA velocity*) • Intermediate risk • T1/T2; PSA<20; Gleason <7; not otherwise low risk • (% cores or PSA velocity*) • High risk • PSA >20 or T3 or Gleason >8; >50% cores positive or PSA velocity >2ng/ml/yr upstages* A Cancer Care Ontario Partner

What we’ve learned… A Cancer Care Ontario Partner

EBXRT: Current Standard: 3D - conformal A Cancer Care Ontario Partner

CT simulation • Simple immobilization sufficient • Patient instructions for bladder/rectum filling • Minimize iatrogenic perturbations • Flag “outliers” (rectal volume or CSA) Contouring conventions (prostate + OAR) • Modality dependent • Apex and base definition • Seminal vesicles and nodes • Wall vs. solid OAR A Cancer Care Ontario Partner

A Cancer Care Ontario Partner

Sample patient data: Marker Motion (Ant/Post, Sup/Inf) from Weekly Port Film 1.5 Urethrogram 1 Post/Ant direction (cm) 22-Aug 31-Jul 12-Aug 17-Jul 7-Aug 28-Aug 12-Jul Urethrogram 12-Jul 12-Aug 0.5 31-Jul 7-Aug 22-Aug 28-Aug 17-Jul Urethrogram 0 12-Aug 22-Aug Prostate Left 31-Jul Prostate Right 7-Aug 12-Jul 28-Aug -0.5 Apex 17-Jul -1 -3.5 -3 -2.5 -2 -1.5 -1 -0.5 0 Sup/Inf direction (cm) A Cancer Care Ontario Partner

Penile Bulb: anatomic marker A Cancer Care Ontario Partner

60 * CT * 50 MR * 3DUS ^3) * 40 olum (cm * * 30 e 20 V 10 0 1 2 3 4 5 6 7 8 9 10 Patient number A Cancer Care Ontario Partner

GTV Delineation: Summary Technique Advantages Limitations CT Available/simple contouring (base/apex) CT+ markers Apex; IG Invasive/base delineation CT+ contrast Apex; base Systemic error 2D TRUS Contouring easy “not fuseable” 3D Ext US “fuseable”, IG inter-observer error MRI “fuseable” Availability; not Rx A Cancer Care Ontario Partner

Planning: One approach CTSIM Prep • BM prior • 500cc fluids • no urethrogram CTSIM; if large rectal volume rectal tube or bathroom and reCT Persistent large rectal volume or Hypofx: IGXRT OARs and GTVs PTVs generated; +/- pelvic fields 1cm margin; 0.7mm post if IGXRT 95% isodose coverage of PTV; 73Gy/35 SIB class solution or 3DCRT plan (IMRT if dose constraints not met) A Cancer Care Ontario Partner

Planning: One approach 73Gy/35 fraction Phase I: 75-77Gy BED 50Gy/25 Phase II: SIB selected based on23Gy/10 % overlaps 25 Gy AP/PA 25 Gy R/L LAT 10 Gy AP/PA 10 Gy R/L LAT 3 Gy/R/L LAT A Cancer Care Ontario Partner

EBXRT Minimum Standards • Every patient planned • 3D dose distribution and DVH • PTV and OAR DVH constraint based • Choose a class solution and stick with it • 4-6 field 3DCRT • Motionmanagement strategy • Minimum dose BED > 74 Gy • PTV margins 1.0cm; 0.5-0.7 posterior A Cancer Care Ontario Partner

DVH Recommendations: PROFIT • Wall volumes; dosimetric definition • Rectal and Bladder wall: D50<53Gy and D30<71Gy DVH Recommendations: RTOG P0126 • lumen volumes; anatomic definition A Cancer Care Ontario Partner

30 40 50 60 70 80 Anatomic Effects of variation of “Dosimetric” contouring on rectal DVH 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0 20 40 60 80 100 A Cancer Care Ontario Partner

Clinical Data Supporting Conformal XRT (www.cancercare.on.ccopgi.on) A Cancer Care Ontario Partner

Pollack IJROBP In Press A Cancer Care Ontario Partner

Future Trend: IMRT A Cancer Care Ontario Partner

MSKCC 81Gy; IMRT A Cancer Care Ontario Partner

Future Trend: 4D Adaptive RT “If you can’t see it, you can’t hit it. If you can’t hit it, you can’t cure it” H.E. Johns or W. Powers “If it’s moving, you can’t hit it. If you can’t hit it, you can’t cure it” J. Battista A Cancer Care Ontario Partner

Inter-fraction variability in dose to organ at risk (rectum) A Cancer Care Ontario Partner

TCP NTCP 5.9 A Cancer Care Ontario Partner

Strategy: Tracking fiducial markers A Cancer Care Ontario Partner

Strategy: Daily U/S localization A Cancer Care Ontario Partner

Strategy: Daily CT localization A Cancer Care Ontario Partner

Future Trend: BTV Definition CT, MRI,US fCT, PET/SPECT, Tumour Cells fMRI Hypoxia Proliferation Composite target A Cancer Care Ontario Partner

Dawson, Lancet Oncol, 7 2006 A Cancer Care Ontario Partner

Future Trend: Target definition IJROBP 67(2) 2007 347-355 IJROBP 63(4) 2005 1262-1269 A Cancer Care Ontario Partner

Future trend: IMRT for Nodal XRT A Cancer Care Ontario Partner

Future trend: Hypofractionation Tumor Control Probability (%) Iso-late-complications * Fowler J, et al. Int J Radiat Oncol Biol Phys 2003;56:1093-1104. Ontario Partner A Cancer Care

Standards: Prostate I125 • Prostate Volume < 50 cc • Clinical Stage T1c or T2a • PSA < 10 • Gleason Score < 6 • No Nodal or distant metastases • No previous TURP A Cancer Care Ontario Partner

Standards: Prostate I125 • Ultrasound Volume Study • Pubic Arch Interference Assessment • Pre-plan: 145Gy to periphery of prostate • Ordering I-125 seeds and calibration • Needle loading • Ultrasound guided Implantation • CT post-planning A Cancer Care Ontario Partner

IJRBOP 67(2): 2007 327-333; IJRBOP 67(2): 2007 334-341 A Cancer Care Ontario Partner

Future trends: dose painting Requirements: • biological imaging and multi-modality fusion • improved stereotaxis (robotic assisted?) • patient selection A Cancer Care Ontario Partner

Future Trend A Cancer Care Ontario Partner

Future trends: HDR Prostate Brachytherapy • int - high risk prostate cancer • Utilizes temporary catheters; u/s guidance; perineal template • Iridium 192 delivers dose in minutes • Usually combined with EBXRT (4-5 weeks) • Invasive, hospitalization overnight • 1-3 fractions A Cancer Care Ontario Partner

Postoperative/Salvage Radiation Postoperative: • 3 RCT supporting adjuvant radiation • pT3 or margin positive Salvage • Case series only (Stephenson, JAMA) • Margin positive, PSA < 2.0, post RP kinetics CTSIM; 60-66Gy/30=33; 3DCRT A Cancer Care Ontario Partner

Candidates •Margin positive •Seminal vesicle inv •Extracapsular ext A Cancer Care Ontario Partner

Future trend: GTV definition A Cancer Care Ontario Partner

Future trends: BTV (again!) A Cancer Care Ontario Partner

RADICALS randomised comparisons: Flow diagram Radical prostatectomy All Groups Assess need for RT Immediate RT group Uncertain group Immediate RT RANDOMISE Immediately after surgery RANDOMISE Immediately after surgery Monitor on trial RT + no AD RT + short AD RT + long AD Trial follow-up Deferred RT group (Monitored off trial, now PSA rising) Deferred RT At rising PSA RANDOMISE RT + no AD RT + short AD RT + long AD Trial follow-up Time Outcome measures A Cancer Care Ontario Partner

What is needed? • Common prep, contouring and DVH conventions • Multi-modality GTV definition (U/S or MRI) • IMRT enabled planning and LINACS • Efficient IMRT class solutions and QA/QC • Image guidance requirements: • CL-PTV: repeat CTSIM and dosimetry capacity • CT: CB or MVCT Unit • U/S: US at LINAC and CTSIM • Seed: Marker placement (radiology) • RT training: image interpretation; action levels; correction A Cancer Care Ontario Partner

What else is needed – long term? • Better predictors of toxicity/common databases • Biological and functional multi-modality imaging • Complete ongoing RCT • Dose escalation and hypofractionation • New RCT • Multimodality (LDR/HDR/CTX/Sx) • A new paradigm? • “Prostate Lumpectomy” + regional XRT • Patient decision aids • EPR enabled follow-up A Cancer Care Ontario Partner

Changes in CaP XRT • 66-70Gy • BED > 74 Gy • BED >78Gy • 4 field; blocks • 4-6 fields; 3DCRT • IGXRT • Fluoroscopic • CTSIM • IMRT • DRE • Risk stratified, bDFS • 3D CRT • IGXRT • Multi-modal • LDR • HDR • BTV optimization • Hypofx (Part I) • Dose escalation • Prostate SRT • Models • Hypofx (Part II) • Gating • MLC • dMLC • Multi-modal imaging • TPS • EPI/US/CBCT/MVCT • Real time IGXRT • CTS • MR SIM/CT-US SIM • Multi-modal TPS • RVS • BTV TPS • Fiducials A Cancer Care Ontario Partner

http://www.youtube.com/watch?v=LQqq3e03EBQ A Cancer Care Ontario Partner

Thank You! A Cancer Care Ontario Partner

Prostate Cancer G Bauman

by fondas vak on Mar 13, 2010

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