0
Acute Toxicity for
      Prostatectomy Patients receiving
                  y                  g
     Intensity Modulated ...
Introduction
          Radical Prostatectomy
                              y
               Effective treatment for patien...
Post-
     Post-Operative Radiotherapy
          Treatment Volume & Technique
                                   q
       ...
Side effects from Radiotherapy

          Gastrointestinal (GI)
            Proctitis
            Loose bowel movement
   ...
Advancement of Technology
          New consensus guideline for prostate bed
                           g           p
    ...
The need to change
          Treatment technique
                          q
               Conformal 4 field box




    ...
Objectives
          To describe the development of an Intensity
                                  p                   y
 ...
Method
          50 patients accrued to prospective trial
             p                   p p




V. Kong, PMH Conference
Process Flowchart
                             Patient Education Sess o
                              at e t ducat o Sessi...
Process Flowchart
                             Patient Education Sess o
                              at e t ducat o Sessi...
CT Simulation
          Full bladder and empty rectum
                             py
          Pelvic vacuum immobilizati...
Process Flowchart
                             Patient Education Sess o
                              at e t ducat o Sessi...
Clinical Target Volume



      Inferior CTV (ICTV)                  Superior CTV (SCTV)




                            W...
Planning Target Volume
          Planning Target Volume (PTV) Margin (mm)
                 g    g          (   )    g (   ...
Organ at Risk (OAR)
          Rectal Wall (RW)
                      (    )
          Bladder Wall (BW)
          Penile B...
Process Flowchart
                             Patient Education Sess o
                              at e t ducat o Sessi...
IMRT
          7 field step-and-shoot distribution
                     p
          Dose fractionation
               66Gy...
IMRT
            Treatment planning objectives
                      p      g j
            1.     Avoid irradiating rectu...
IMRT
          Posterior Rectal Wall (pRW)
                                (p  )




                                     ...
IMRT
            Treatment planning objectives
                      p      g j
            1. Avoid irradiating rectum ci...
IMRT
            Treatment planning objectives
                      p      g j
            1. Avoid irradiating rectum ci...
Dose Constraints

            Organs at Risk        Metric    Dose (Gy)
                  Rectal Wall     1 cm3      ≤ 66 ...
Monitoring Side Effect
          Acute Toxicity Scoring
                       y       g
               Common Terminology...
V. Kong, PMH Conference
Monitoring Side Effect
          Acute Toxicity Scoring
                       y       g
               Common Terminology...
Is IMRT better?
          Comparison with 4FB technique
             p                      q
               23 patients w...
Result
          Mean PTV V95 = 95.2% (SD = 2.1)
                               (        )
                    20
        ...
Result
                          64.0
                                                                        Patient A
  ...
Result
                          Patient A   Patient B




                                                  62.7 Gy
     ...
Result
          Acute GI Toxicity
                          y
             Score        Diarrhea   Proctitis     GI
     ...
Result
          Acute GI Toxicity
                          y
             Score        Diarrhea   Proctitis     GI
     ...
Result
          Acute GU Toxicity
                          y
      Score        Frequency    Haematuria   Cystitis   Spa...
Result
          Acute GU Toxicity
                          y
      Score        Frequency    Haematuria   Cystitis   Spa...
Result
          Comparison of Dose to Rectal Wall
             p
                   100
                                 ...
Result
          Comparison of Dose to Bladder Wall
             p
                   100
                                ...
Result
          Comparison of Acute GI/GU Toxicity Score ≥ 2
             p                             y
              5...
Conclusion
          Avoidance of circumferential irradiation of rectum
          to 55Gy with minimal compromise of PTV c...
Acknowledgment
          Dr. Kirsty Wiltshire
                   y
          Dr. William Chu
          Clinical Trial Co o...
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Prostate Imrt

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Transcript of "Prostate Imrt"

  1. 1. Acute Toxicity for Prostatectomy Patients receiving y g Intensity Modulated Radiotherapy V. Kong, T. Craig, A. Bayley, R. Bristow, C. Catton, P. Chung, M. Gospodarowicz, M. Milosevic, P. Warde, C. Ménard
  2. 2. Introduction Radical Prostatectomy y Effective treatment for patients with favorable prognostic factors Intent of Post-Operative Radiotherapy Reduces local recurrence rate for high risk patients Used as either adjuvant or salvage therapy V. Kong, PMH Conference
  3. 3. Post- Post-Operative Radiotherapy Treatment Volume & Technique q Defined using bony landmark 4 Field Box V. Kong, PMH Conference
  4. 4. Side effects from Radiotherapy Gastrointestinal (GI) Proctitis Loose bowel movement or diarrhea Genitourinary ( ) y (GU) Urinary incontinence Increased frequency Pain/Burning senation V. Kong, PMH Conference
  5. 5. Advancement of Technology New consensus guideline for prostate bed g p Clinical Target Volume (CTV) definition Increase volume? -> Increase toxicity? V. Kong, PMH Conference
  6. 6. The need to change Treatment technique q Conformal 4 field box 62.7 Gy 55.0 Gy V. Kong, PMH Conference
  7. 7. Objectives To describe the development of an Intensity p y Modulated Radiotherapy (IMRT) technique for the Prostate Bed To T report th clinical dosimetric characteristics of t the li i l d i t i h t i ti f the new technique To report acute GI and GU toxicity outcomes To compare results with a historical cohort treated by 4 field box technique (4FB) V. Kong, PMH Conference
  8. 8. Method 50 patients accrued to prospective trial p p p V. Kong, PMH Conference
  9. 9. Process Flowchart Patient Education Sess o at e t ducat o Session CT Simulation Delineation of Regions of Interest (ROI) Generation of IMRT Distribution Treatment V. Kong, PMH Conference
  10. 10. Process Flowchart Patient Education Sess o at e t ducat o Session CT Simulation Delineation of Regions of Interest (ROI) Generation of IMRT Distribution Treatment V. Kong, PMH Conference
  11. 11. CT Simulation Full bladder and empty rectum py Pelvic vacuum immobilization device V. Kong, PMH Conference
  12. 12. Process Flowchart Patient Education Sess o at e t ducat o Session CT Simulation Delineation of Regions of Interest (ROI) Generation of IMRT Distribution Treatment V. Kong, PMH Conference
  13. 13. Clinical Target Volume Inferior CTV (ICTV) Superior CTV (SCTV) Wiltshire et al. IJROBP 2007 69(4); 1090-1099 V. Kong, PMH Conference
  14. 14. Planning Target Volume Planning Target Volume (PTV) Margin (mm) g g ( ) g ( ) Online guidance using soft tissue/surgical clip Chu, 2007 AP SI RL SCTV 14 13 7 ICTV 10 11 5 V. Kong, PMH Conference
  15. 15. Organ at Risk (OAR) Rectal Wall (RW) ( ) Bladder Wall (BW) Penile Bulb (PB) Femur V. Kong, PMH Conference
  16. 16. Process Flowchart Patient Education Sess o at e t ducat o Session CT Simulation Delineation of Regions of Interest (ROI) Generation of IMRT Distribution Treatment V. Kong, PMH Conference
  17. 17. IMRT 7 field step-and-shoot distribution p Dose fractionation 66Gy in 33 fractions y V. Kong, PMH Conference
  18. 18. IMRT Treatment planning objectives p g j 1. Avoid irradiating rectum circumferentially to 55 Gy V. Kong, PMH Conference
  19. 19. IMRT Posterior Rectal Wall (pRW) (p ) 62.7 62 7 Gy 55.0 Gy V. Kong, PMH Conference
  20. 20. IMRT Treatment planning objectives p g j 1. Avoid irradiating rectum circumferentially to 55 Gy 2. PTV D99 ≥ 54 Gy V. Kong, PMH Conference
  21. 21. IMRT Treatment planning objectives p g j 1. Avoid irradiating rectum circumferentially to 55 Gy 2. PTV D99 ≥ 54 Gy 3. Maximize % of PTV receiving 95% of prescription dose – V95 i ti d V. Kong, PMH Conference
  22. 22. Dose Constraints Organs at Risk Metric Dose (Gy) Rectal Wall 1 cm3 ≤ 66 0 66.0 Bladder Wall 2 cm3 ≤ 67.3 Penile Bulb 0.5 cm3 ≤ 66.0 Femur 1 cm3 ≤ 55.0 V. Kong, PMH Conference
  23. 23. Monitoring Side Effect Acute Toxicity Scoring y g Common Terminology Criteria Adverse Events (CTCAE) v3.0 V. Kong, PMH Conference
  24. 24. V. Kong, PMH Conference
  25. 25. Monitoring Side Effect Acute Toxicity Scoring y g Common Terminology Criteria Adverse Events (CTCAE) v3.0 GI GU Diarrhea Frequency Proctitis Haematuria Cystitis Spasm V. Kong, PMH Conference
  26. 26. Is IMRT better? Comparison with 4FB technique p q 23 patients with acute toxicity scored using CTCAE v3.0 Dose to Rectal Wall and Bladder Wall Acute GI/GU toxicity V. Kong, PMH Conference
  27. 27. Result Mean PTV V95 = 95.2% (SD = 2.1) ( ) 20 18 16 14 Number 12 of 10 Patients 8 6 4 2 0 90 92 94 96 98 100 PTV V95 (%) V. Kong, PMH Conference
  28. 28. Result 64.0 Patient A 62.0 60.0 PTV D99 58.0 (Gy) 56.0 54.0 2 R = 0.8514 Patient B 52.0 90.0 92.0 94.0 96.0 98.0 100.0 PTV V95 (%) Mean PTV D99 = 57.8 Gy ( y (Range: 53.4 – 62.9 Gy) g y) V. Kong, PMH Conference
  29. 29. Result Patient A Patient B 62.7 Gy 55.0 Gy V. Kong, PMH Conference
  30. 30. Result Acute GI Toxicity y Score Diarrhea Proctitis GI 0 19 (38%) 17 (34%) 10 (20%) 1 25 (50%) 23 (46%) 27 (54%) 2 6 (12%) 13 (20%) 13 (26%) 3 0 0 0 V. Kong, PMH Conference
  31. 31. Result Acute GI Toxicity y Score Diarrhea Proctitis GI 0 19 (38%) 17 (34%) 10 (20%) 1 25 (50%) 23 (46%) 27 (54%) 2 6 (12%) 13 (20%) 13 (26%) 3 0 0 0 V. Kong, PMH Conference
  32. 32. Result Acute GU Toxicity y Score Frequency Haematuria Cystitis Spasms GU 0 19 (38%) 45 (90%) 39 (78%) 27 (54%) 14 (28%) 1 24 (48%) 5 (10%) 10 (20%) 20 (40%) 28 (56%) 2 5 (10%) 0 1 (2%) 3 (6%) 6 (12%) 3 2 (4%) 0 0 0 2 (4%) V. Kong, PMH Conference
  33. 33. Result Acute GU Toxicity y Score Frequency Haematuria Cystitis Spasms GU 0 19 (38%) 45 (90%) 39 (78%) 27 (54%) 14 (28%) 1 24 (48%) 5 (10%) 10 (20%) 20 (40%) 28 (56%) 2 5 (10%) 0 1 (2%) 3 (6%) 6 (12%) 3 2 (4%) 0 0 0 2 (4%) V. Kong, PMH Conference
  34. 34. Result Comparison of Dose to Rectal Wall p 100 4FB IMRT 80 Normalized 60 Volume (%) 40 20 0 0 1000 2000 3000 4000 5000 6000 7000 Dose (cGy) V. Kong, PMH Conference
  35. 35. Result Comparison of Dose to Bladder Wall p 100 4FB IMRT 80 Normalized 60 Volume (%) 40 20 0 0 1000 2000 3000 4000 5000 6000 7000 Dose (Gy) V. Kong, PMH Conference
  36. 36. Result Comparison of Acute GI/GU Toxicity Score ≥ 2 p y 50 IMRT 4FB 40 Number 30 of Patient 20 (%) 10 0 GI GU G and GI a d GU C Square value = 5 Chi Squa e a ue 5.21 & 9 , d = 1, p < 0 05 9.77, df , 0.05 V. Kong, PMH Conference
  37. 37. Conclusion Avoidance of circumferential irradiation of rectum to 55Gy with minimal compromise of PTV coverage is achievable with IMRT The use of IMRT reduces acute GI/GU toxicity rate when compared with the 4FB technique Ongoing investigation to determine if improved dosimetry to OARs translates to improved late toxicity and biochemical control V. Kong, PMH Conference
  38. 38. Acknowledgment Dr. Kirsty Wiltshire y Dr. William Chu Clinical Trial Co ordinators Co-ordinators Debbie Tsuji Bernadeth Lao V. Kong, PMH Conference
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