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Achieving the
     Acheivable:
      Prostate
       Glenn Bauman, MD
 Associate Professor and Chair,
    Department of On...
Objectives
• We’re we’ve been
• What we’ve learned
• What we should do
• Where we should go
  • External beam
  • Brachyth...
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*)
• Inter...
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 iatrogen...
A Cancer Care Ontario Partner
A Cancer Care Ontario Partner
Sample patient data: Marker Motion (Ant/Post, Sup/Inf) from
                                                      Weekly P...
Penile Bulb: anatomic marker




                       A Cancer Care Ontario Partner
A Cancer Care Ontario Partner
60   *
                                    CT         *
               50                   MR                 *
         ...
GTV Delineation: Summary
Technique        Advantages         Limitations

CT               Available/simple   contouring (...
Planning: One approach
                          CTSIM Prep
                           • BM prior
                        ...
Planning: One approach
                               73Gy/35 fraction
                                  Phase I:
        ...
EBXRT Minimum Standards

• Every   patient planned
 • 3D dose distribution and DVH
 • PTV and OAR DVH constraint based

• ...
DVH Recommendations: PROFIT
• Wall volumes; dosimetric definition
• Rectal and Bladder wall: D50<53Gy and D30<71Gy

DVH Re...
30 40 50 60 70 80


     Anatomic
                                             Effects of
                                ...
Clinical Data Supporting Conformal XRT




(www.cancercare.on.ccopgi.on)



                                    A Cancer C...
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 ...
Inter-fraction
variability in dose to
    organ at risk
       (rectum)




                         A Cancer Care Ontario...
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
A Cancer Care Ontario Partner
Future Trend: BTV Definition

CT, MRI,US                 fCT, PET/SPECT,
Tumour Cells               fMRI Hypoxia



      ...
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
                              ...
Future trend: IMRT for Nodal XRT




                          A Cancer Care Ontario Partner
Future trend: Hypofractionation
Tumor Control Probability (%)




                                      Iso-late-complicat...
Standards: Prostate I125

• Prostate Volume < 50 cc
• Clinical Stage T1c or T2a
• PSA < 10
• Gleason Score < 6
• No Nodal ...
Standards: Prostate I125
• Ultrasound Volume Study
• Pubic Arch Interference Assessment
• Pre-plan: 145Gy to periphery of ...
IJRBOP 67(2): 2007 327-333; IJRBOP 67(2): 2007 334-341


                                               A Cancer Care Onta...
Future trends: dose painting




 Requirements:
 • biological imaging and multi-modality fusion
 • improved stereotaxis (r...
Future Trend




               A Cancer Care Ontario Partner
Future trends: HDR Prostate Brachytherapy
•   int - high risk prostate
    cancer
•   Utilizes temporary
    catheters; u/...
Postoperative/Salvage Radiation


Postoperative:
• 3 RCT supporting adjuvant radiation
• pT3 or margin positive
Salvage
• ...
Candidates
•Margin positive
•Seminal vesicle inv
•Extracapsular ext




    A Cancer Care Ontario Partner
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              ...
What is needed?
• Common prep, contouring and DVH conventions
• Multi-modality GTV definition (U/S or MRI)
• IMRT enabled ...
What else is needed – long term?
• Better predictors of toxicity/common databases
• Biological and functional multi-modali...
Changes in CaP XRT
• 66-70Gy            •   BED > 74 Gy             •   BED >78Gy
• 4 field; blocks    •   4-6 fields; 3DC...
http://www.youtube.com/watch?v=LQqq3e03EBQ




                                  A Cancer Care Ontario Partner
Thank You!




             A Cancer Care Ontario Partner
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Prostate Cancer G Bauman

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Transcript of "Prostate Cancer G Bauman"

  1. 1. 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
  2. 2. 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
  3. 3. The Future is a Moving Target… A Cancer Care Ontario Partner
  4. 4. Where we’ve been… A Cancer Care Ontario Partner
  5. 5. What we’ve learned…. JCO 23:2005 A Cancer Care Ontario Partner
  6. 6. 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
  7. 7. What we’ve learned… A Cancer Care Ontario Partner
  8. 8. EBXRT: Current Standard: 3D - conformal A Cancer Care Ontario Partner
  9. 9. 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
  10. 10. A Cancer Care Ontario Partner
  11. 11. A Cancer Care Ontario Partner
  12. 12. 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
  13. 13. Penile Bulb: anatomic marker A Cancer Care Ontario Partner
  14. 14. A Cancer Care Ontario Partner
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. Clinical Data Supporting Conformal XRT (www.cancercare.on.ccopgi.on) A Cancer Care Ontario Partner
  23. 23. A Cancer Care Ontario Partner
  24. 24. Pollack IJROBP In Press A Cancer Care Ontario Partner
  25. 25. Future Trend: IMRT A Cancer Care Ontario Partner
  26. 26. MSKCC 81Gy; IMRT A Cancer Care Ontario Partner
  27. 27. 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
  28. 28. Inter-fraction variability in dose to organ at risk (rectum) A Cancer Care Ontario Partner
  29. 29. TCP NTCP 5.9 A Cancer Care Ontario Partner
  30. 30. Strategy: Tracking fiducial markers A Cancer Care Ontario Partner
  31. 31. Strategy: Daily U/S localization A Cancer Care Ontario Partner
  32. 32. Strategy: Daily CT localization A Cancer Care Ontario Partner
  33. 33. A Cancer Care Ontario Partner
  34. 34. Future Trend: BTV Definition CT, MRI,US fCT, PET/SPECT, Tumour Cells fMRI Hypoxia Proliferation Composite target A Cancer Care Ontario Partner
  35. 35. Dawson, Lancet Oncol, 7 2006 A Cancer Care Ontario Partner
  36. 36. Future Trend: Target definition IJROBP 67(2) 2007 347-355 IJROBP 63(4) 2005 1262-1269 A Cancer Care Ontario Partner
  37. 37. Future trend: IMRT for Nodal XRT A Cancer Care Ontario Partner
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. IJRBOP 67(2): 2007 327-333; IJRBOP 67(2): 2007 334-341 A Cancer Care Ontario Partner
  42. 42. Future trends: dose painting Requirements: • biological imaging and multi-modality fusion • improved stereotaxis (robotic assisted?) • patient selection A Cancer Care Ontario Partner
  43. 43. Future Trend A Cancer Care Ontario Partner
  44. 44. 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
  45. 45. 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
  46. 46. Candidates •Margin positive •Seminal vesicle inv •Extracapsular ext A Cancer Care Ontario Partner
  47. 47. A Cancer Care Ontario Partner
  48. 48. Future trend: GTV definition A Cancer Care Ontario Partner
  49. 49. Future trends: BTV (again!) A Cancer Care Ontario Partner
  50. 50. 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
  51. 51. 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
  52. 52. 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
  53. 53. 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
  54. 54. http://www.youtube.com/watch?v=LQqq3e03EBQ A Cancer Care Ontario Partner
  55. 55. Thank You! A Cancer Care Ontario Partner
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