All the truth about  local treatment options T1-T2 RADIOTHERAPY Anders Widmark, Professor,  Senior Consultant Department o...
Philosophy : Risk adapted Treatment with EBRT - Decrease side-effects in low risk tumor  – Increase treatment in aggressiv...
Historical Radiotherapy of PC Onk klin, NUS, A W 0002 ECCLU 2011
Dosescalation  65Gy -> 70Gy ->  78 Gy   HDR + EBRT  IGRT Improved Precision, Tighter Margins Image Guided RadioTherapy IMR...
Why EBRT Dose-escalation  ? <ul><li>Biopsy Data </li></ul><ul><li>Local control influence outcome SPCG-7/SFUO-3 </li></ul>...
ALL 393 664 843 301 202 104 GETUG  306 Viani et al IJROBP 2009
Low Risk Inter M Risk High Risk Viani et al IJROBP 2009
Viani et al IJROBP 2009
Viani et al IJROBP 2009
 
 
MD anderson Trial  Kuban et al Röda 2008  ECCLU 2011 78% 39% 78% 59%
Rand Trial 70 vs. 78 Gy,  MDA Onk. AW 0101 <ul><li>Metastases ALL </li></ul><ul><li>Pre PSA > 10 </li></ul>+13% p=0,035 Po...
Onk. AW 0308 PROT 05  Update 8.9 y. Zietman et al JCO 2010
Onk. AW 0308 32.4% 17.4% PROT 05  Update 8.9 y. Zietman et al JCO 2010
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
Side –Effects Dose –Escalation  MRC RT01 Trial ,  Syndikus at al IJROBP 2009 ECCLU 2011
<ul><li>ASTRO 2001 </li></ul>Onk. AW 0111 Dansande prostata: mätning av prostata rörlighet med MRI ECCLU 2011
BeamCath for IGRT   Prostata cancer  Onk. AW 9809 CT-bild ECCLU 2011
Digital Bildframställning “Portal Vision”  BeamCath, med markörer som visar urinröret <ul><li>1:a uppläggning Vid Behandli...
Prostate EBRT IGRT  Onk klin, NUS, A W 0002 7 mm ECCLU 2011
“ Picture verified” radioterapi (IGRT) Röntgenrör Detektor ECCLU 2011
Dose plan  ECCLU 2011
Rectum and dose distribution
Rectum dose volume histograms QUANTEC objectives
GPS in Prostate   Calypso, Micropos ECCLU 2011
MR/CT
MR-Bild Onk klin, NUS, A W 9602 ECCLU 2011
Prostate MRI  Cancer   (S Johansson) Axial Coronal ECCLU 2011
Umeå Trial 1 A randomized Trial Extern Beam RT v.s. Deferred Treatment in Localized Prostate Cancer Inclusion Criteria <  ...
Umeå Trial 1 Inklusion 1986- 1996 > 20 års FU Rand studie, Sweden, Denmark, Norway WW  v.s.  RT  Patienter 107 107 ECCLU 2...
HYPO-fractionation alpha/beta value in PC  HYPO-RT-PC -Study   Fractionation schedule  under development Yeho Lukka B&R
Onk. AW 0609 Hypofractionationated   treatments ECCLU 2011
SCANDINAVIAN HYPO-Fractionation study NUS Onk. AW 0402 Intermediate Risk Patients Conv:  2 Gy x 39  = 78 Gy R HYPO:   6.1 ...
Blood in Stools With Smaller margins ECCLU 2011
Treatment Effect are improving What about Side-effects? ECCLU 2011
Biverkningar - Funding ECCLU 2011
N 603 292 306 - Age 59 69 65 - PSA 6.7 9.1 5.8 Side-Effects - Sexual ECCLU 2011
Side-Effects - URIN - Funding ECCLU 2011
Side-Efects – Bowel - Vitality ECCLU 2011
Intestinal Symptoms EBRT Fig. 2 ECCLU 2011
Rectal leakage - When? Q31 ECCLU 2011
Localized PC! Local Cure is Achivable ! Improve Techniques to  Decrease Rectal Toxicity!! ECCLU 2011
Prada et al Brachytherapy , 2007, 2009 ECCLU 2011
Principal of the No-HARM study Needel operated Hyaluronic Acid for Rectal Move HA 10% 50% 70% 10% 70% 50% ECCLU 2011
ECCLU 2011
ECCLU 2011 Before  RT 20 treatments ./40 G
ECCLU 2011
ECCLU 2011
Rectal fixation probe! ECCLU 2011
Rectal fixation probe! ECCLU 2011
Hydrodissection of the space  between rectum and prostate ECCLU 2011 Pro-Space: Novel Biodegradable Inflatable Balloon Sys...
BLADDER PENIS RECTUM ECCLU 2011 Pro-Space: Novel Biodegradable Inflatable Balloon System
Lymph Node treatment? ECCLU 2011
Lymph Node treatment, IMRT? ECCLU 2011
Lymph Node treatment, VMAT? ECCLU 2011
Lymph Node treatment? RTOG 0924 And PIVOTAL RT + HORMONES vs  RT + HORMONES + Lymph Node Iradiation ECCLU 2011
<ul><li>RTOG 8610 RT    2 må.+2 må./RT  </li></ul>Randomised Studies Radiation v.s. Radiation + Hormones   <ul><li>Umeå 2 ...
- Funding PSA recurrence-free survival T1b-T2, PSA  <  50; Grad I-II  (“SPCG-4 population”) Combination (n=69) Antiandroge...
- Funding Prostate Cancer specific survival   T1b-T2, PSA  <  50; Grad I-II  (“SPCG-4 population”) Combination (n=69) Anti...
- Funding Overall survival   T1b-T2, PSA  <  50; Grad I-II  (“SPCG-4 population”)   Combination (n=69) Antiandrogen (n=64)...
 
 
 
 
RT 70 Gy  +  6 m. ADT  Intermediate risk  No/mild comorbidity Moderate/ severe comor
RT 70 Gy  +  6 m. ADT  High Risk No/mild comorbidity Moderate/ severe comor
Summary Localised PC! Local Cure is ”Achivable (-ed)” New Radiotherapy Tecniques  To further  Decrease Rectal Toxicity!! E...
Conclusions Radiotherapy  Local Cure is Achivable!!  Dose escalation ! IGRT, IMRT Improved precision - smaller margins Les...
Thank You! ECCLU 2011
Tack!  Frågor ? ECCLU 2011
A Randomized Trial Comparing Antiandrogens  With Or Without Radiotherapy In The Treatment Of Locally Advanced Prostate Can...
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 ...
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 % (...
Cumulative incidence of  Prostate Cancer mortality 9.9  (7.1-5.9) 6.3 % (3.9-8.6) ASTRO, 2008, Plenary Session ECCLU 2011 ...
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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

    1. 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. 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. 3. Historical Radiotherapy of PC Onk klin, NUS, A W 0002 ECCLU 2011
    4. 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. 5. Why EBRT Dose-escalation ? <ul><li>Biopsy Data </li></ul><ul><li>Local control influence outcome SPCG-7/SFUO-3 </li></ul>Onk. AW 0103 <ul><li>Improvement in technique </li></ul><ul><ul><li>CT-Based 3D-CRT </li></ul></ul><ul><ul><li>Decreased margins -> side-effects </li></ul></ul><ul><ul><li>IGRT </li></ul></ul>ECCLU 2011
    6. 6. ALL 393 664 843 301 202 104 GETUG 306 Viani et al IJROBP 2009
    7. 7. Low Risk Inter M Risk High Risk Viani et al IJROBP 2009
    8. 8. Viani et al IJROBP 2009
    9. 9. Viani et al IJROBP 2009
    10. 12. MD anderson Trial Kuban et al Röda 2008 ECCLU 2011 78% 39% 78% 59%
    11. 13. Rand Trial 70 vs. 78 Gy, MDA Onk. AW 0101 <ul><li>Metastases ALL </li></ul><ul><li>Pre PSA > 10 </li></ul>+13% p=0,035 Pollack et al JCO 2002 Kuban et al 2008 Kuban et al 2008 P=0.059 +4% ECCLU 2011
    12. 14. Onk. AW 0308 PROT 05 Update 8.9 y. Zietman et al JCO 2010
    13. 15. Onk. AW 0308 32.4% 17.4% PROT 05 Update 8.9 y. Zietman et al JCO 2010
    14. 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
    15. 17. Side –Effects Dose –Escalation MRC RT01 Trial , Syndikus at al IJROBP 2009 ECCLU 2011
    16. 18. <ul><li>ASTRO 2001 </li></ul>Onk. AW 0111 Dansande prostata: mätning av prostata rörlighet med MRI ECCLU 2011
    17. 19. BeamCath for IGRT Prostata cancer Onk. AW 9809 CT-bild ECCLU 2011
    18. 20. Digital Bildframställning “Portal Vision” BeamCath, med markörer som visar urinröret <ul><li>1:a uppläggning Vid Behandling </li></ul>Onk, NUS, A W 0504 ECCLU 2011 Strålfältet Strålfältet
    19. 21. Prostate EBRT IGRT Onk klin, NUS, A W 0002 7 mm ECCLU 2011
    20. 22. “ Picture verified” radioterapi (IGRT) Röntgenrör Detektor ECCLU 2011
    21. 23. Dose plan ECCLU 2011
    22. 24. Rectum and dose distribution
    23. 25. Rectum dose volume histograms QUANTEC objectives
    24. 26. GPS in Prostate Calypso, Micropos ECCLU 2011
    25. 27. MR/CT
    26. 28. MR-Bild Onk klin, NUS, A W 9602 ECCLU 2011
    27. 29. Prostate MRI Cancer (S Johansson) Axial Coronal ECCLU 2011
    28. 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
    29. 31. Umeå Trial 1 Inklusion 1986- 1996 > 20 års FU Rand studie, Sweden, Denmark, Norway WW v.s. RT Patienter 107 107 ECCLU 2011
    30. 32. HYPO-fractionation alpha/beta value in PC HYPO-RT-PC -Study Fractionation schedule under development Yeho Lukka B&R
    31. 33. Onk. AW 0609 Hypofractionationated treatments ECCLU 2011
    32. 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 <ul><li>15 centers, Sweden and Denmark </li></ul><ul><li>Canada might Join </li></ul><ul><li>440/ 800 patients Included </li></ul>ECCLU 2011
    33. 35. Blood in Stools With Smaller margins ECCLU 2011
    34. 36. Treatment Effect are improving What about Side-effects? ECCLU 2011
    35. 37. Biverkningar - Funding ECCLU 2011
    36. 38. N 603 292 306 - Age 59 69 65 - PSA 6.7 9.1 5.8 Side-Effects - Sexual ECCLU 2011
    37. 39. Side-Effects - URIN - Funding ECCLU 2011
    38. 40. Side-Efects – Bowel - Vitality ECCLU 2011
    39. 41. Intestinal Symptoms EBRT Fig. 2 ECCLU 2011
    40. 42. Rectal leakage - When? Q31 ECCLU 2011
    41. 43. Localized PC! Local Cure is Achivable ! Improve Techniques to Decrease Rectal Toxicity!! ECCLU 2011
    42. 44. Prada et al Brachytherapy , 2007, 2009 ECCLU 2011
    43. 45. Principal of the No-HARM study Needel operated Hyaluronic Acid for Rectal Move HA 10% 50% 70% 10% 70% 50% ECCLU 2011
    44. 46. ECCLU 2011
    45. 47. ECCLU 2011 Before RT 20 treatments ./40 G
    46. 48. ECCLU 2011
    47. 49. ECCLU 2011
    48. 50. Rectal fixation probe! ECCLU 2011
    49. 51. Rectal fixation probe! ECCLU 2011
    50. 52. Hydrodissection of the space between rectum and prostate ECCLU 2011 Pro-Space: Novel Biodegradable Inflatable Balloon System
    51. 53. BLADDER PENIS RECTUM ECCLU 2011 Pro-Space: Novel Biodegradable Inflatable Balloon System
    52. 54. Lymph Node treatment? ECCLU 2011
    53. 55. Lymph Node treatment, IMRT? ECCLU 2011
    54. 56. Lymph Node treatment, VMAT? ECCLU 2011
    55. 57. Lymph Node treatment? RTOG 0924 And PIVOTAL RT + HORMONES vs RT + HORMONES + Lymph Node Iradiation ECCLU 2011
    56. 58. <ul><li>RTOG 8610 RT 2 må.+2 må./RT </li></ul>Randomised Studies Radiation v.s. Radiation + Hormones <ul><li>Umeå 2 RT Kir. Kastration + RT </li></ul><ul><li>EORTC/Bolla RT RT/samtidigt + Adj.3 år </li></ul><ul><li>RTOG 8531 RT RT + Adj. LHRH 2 år </li></ul><ul><li>Lavendiere RT 2 må. +2 m/RT 2 +2 må/RT+6må Adj.LHRH </li></ul>Is anyone doing RT 78 Gy vs Hormones + RT 78 Gy In intermediate risk PC? ECCLU 2011
    57. 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
    58. 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
    59. 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
    60. 66. RT 70 Gy + 6 m. ADT Intermediate risk No/mild comorbidity Moderate/ severe comor
    61. 67. RT 70 Gy + 6 m. ADT High Risk No/mild comorbidity Moderate/ severe comor
    62. 68. Summary Localised PC! Local Cure is ”Achivable (-ed)” New Radiotherapy Tecniques To further Decrease Rectal Toxicity!! ECCLU 2011
    63. 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
    64. 70. Thank You! ECCLU 2011
    65. 71. Tack! Frågor ? ECCLU 2011
    66. 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
    67. 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
    68. 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
    69. 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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