MCO 2011 - Slide 2 - A. Horwich - Local treatment: Radiotherapy

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MCO 2011 - Slide 2 - A. Horwich - Local treatment: Radiotherapy

  1. 1. RT for LocalisedProstate Cancer<br />Alan Horwich<br />Institute of Cancer Research and Royal Marsden Hospital, Sutton, Surrey, UK<br />
  2. 2. CASE 1<br />72 years, WHO 0<br />Oncologic problem:<br /><ul><li> prostate adenoCA</li></ul>PSA 15.1 ng/ml, Gleason 7(3+4), 6/10 cores positive,T1c (DRE)<br /><ul><li>Bone scan -ve
  3. 3. MRI T2 Seminal vesicles - ve Nodes –veT2 N0 M0</li></ul>Management options<br />1. Surveillance<br /> Prostatectomy<br /> External Beam RT or Brachytherapy<br />2. Role of adjuvant hormone therapy<br />
  4. 4. CASE 2 <br />56 years, WHO 0, top manager of multinational<br />Oncologic problem: cT3 (DRE)<br /><ul><li> prostate adenoCa PSA 17.3 ng/ml,
  5. 5. Gleason 9 (4+5), 9/9 cores ,
  6. 6. MRI =SV invasion bone scan –ve
  7. 7. T3b N0 M0</li></ul>Management options<br />1. Surveillance<br /> Prostatectomy<br /> External Beam RT or Brachytherapy<br />2. Role of adjuvant hormone therapy<br />
  8. 8. Outline of Talk<br />Why choose RT?<br />Outcomes<br />Current developments in external beam radiotherapy<br />
  9. 9. Active surveillance as a treatment option<br />Aim<br />To select patients that will benefit from treatment.<br />Who?<br />Suitable for radical treatment<br />Low volume cancer<br />Low grade (gleason score 3+4=7)<br />How?<br />Regular PSA/clinical assessment<br />Repeat biopsy<br />MRI<br />
  10. 10. Active surveillance is not watchful waiting <br />
  11. 11. Early outcomes of active surveillance for localised prostate cancerHardie et al. BJU Int (2005) 95:956-60<br />Predictive factors<br />Initial PSA<br />F/T PSA(16%)<br />PSA Density (0.18ng/ml/ml)<br />PSA Velocity (Ing/ml/yr)<br />(PSA DT)<br />T Stage<br />% core involvement <br />Max. core involvement(20%)<br />Outcome: treatment-free survival<br />
  12. 12. Is there any evidence that one treatment is better than another?<br />No randomised trials….<br />
  13. 13. Outcome according to nomograms:<br />Example: T1c,PSA 15.1 ng/ml, Gleason 7(3+4)<br />Note: Nomograms have 10% error<br /> Radical Prostatectomy ~50% salvage by RT<br />
  14. 14. --Estimated prostate-specific antigen outcome for low-risk patients stratified by treatment modality<br />D'Amico, A. V. et al. JAMA 1998;280:969-974.<br />Copyright restrictions may apply.<br />
  15. 15. Disadvantages of treatments<br />Radical Prostatectomy<br />Sexual function<br />Incontinence<br />Major surgery<br />Incomplete resection<br />Brachytherapy<br />Urinary dysfunction<br />Surgical procedure<br />Radical Radiotherapy<br />Length of treatment<br />Bowel dysfunction<br />Sexual dysfunction(<RP)<br />[second malignancy]<br />
  16. 16. Ferrer et al IJROBP 72 p421-32 2008<br />Updated; Pardo et al 2010 JCO 28 p4687-95<br />Longutidinal study of 614 patients<br />Black line: Rad Prostectomy, Dotted line: Brachy therapy , Grey line: EBRT<br />
  17. 17. Improving Radiotherapy<br />Dose matters..<br />
  18. 18. Phase III randomised controlled trials of dose escalation in prostate cancer: PSA control<br />
  19. 19. Phase III randomised controlled trials of dose escalation in prostate cancer: PSA control<br />
  20. 20. Achieving radiotherapy dose escalation without increasing toxicity<br />Minimising normal tissue irradiation<br />Intensity Modulated Radiotherapy<br />Image guided radiotherapy<br />
  21. 21. Inverse Plan<br />
  22. 22. Achieving radiotherapy dose escalation without increasing toxicity<br />Minimising normal tissue irradiation<br />Intensity Modulated Radiotherapy<br />Image guided radiotherapy<br />
  23. 23. Full rectum<br />Empty rectum<br />Prostate movements<br />
  24. 24. IGRT : Gold grain fiducial markers<br />
  25. 25. On line correction with intrafraction motion<br />McNair IJROBP 2008 71(1) 41-50<br />Right- Left<br />3mm<br />Ant-Post<br />3.6mm<br />Sup-Inf<br />3.4mm<br />
  26. 26. Achieving radiotherapy dose escalation without increasing toxicity<br />Minimising normal tissue irradiation<br />Intensity Modulated Radiotherapy<br />Image guided radiotherapy<br />Maximising therapeutic ration<br />Hypo-fractionation<br />
  27. 27. Achieving radiotherapy dose escalation without increasing toxicity<br />Minimising normal tissue irradiation<br />Intensity Modulated Radiotherapy<br />Image guided radiotherapy<br />Maximising therapeutic ration<br />Hypo-fractionation<br />Tumour boosting<br />Intra-prostatic boost<br />‘stereotactic radiotherapy’<br />
  28. 28. Singh Rad Oncol 2007 2 1-6<br />DCE MRI , guided biopsy and planning scan with fiducials<br />N=4<br />75.6Gy (42 F) to prostate 94.5 Gy to 2subtargets<br />
  29. 29. Achieving radiotherapy dose escalation without increasing toxicity<br />Minimising normal tissue irradiation<br />Intensity Modulated Radiotherapy<br />Image guided radiotherapy<br />Maximising therapeutic ration<br />Hypofractionation<br />Tumour boosting<br />Intra-prostatic boost<br />‘stereotactic radiotherapy’<br />Prediction – treatment individualisation<br />
  30. 30. A predictive marker for benefit of Dose Escalation ? Osteopontin Expression<br />Patients treated at RMH in phase 3 trials of dose escalation<br />Morgan NCIC Conf 2009<br />64Gy<br />74Gy<br />74Gy<br />64Gy<br />HR 1.41 (0.53-3.76) P = 0.49<br />HR 0.42 (0.26-0.7) p = 0.001<br />
  31. 31. Summary<br />Organ confined prostate cancer has a good prognosis independent of primary treatment option<br />Active surveillance is a reasonable option for many patients<br />For those with higher risk of progression or wishing treatment there is no good evidence that any option is superior (in terms of survival) than any other.<br />Choice may be made on consideration of efficiency, toxicities and patient preference.<br />

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