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ECCLU 2011 - A. Widmark - Prostate cancer: All the truth about local treatment options T1-T2 - Radiotherapy
This document summarizes key points about radiotherapy options for early stage prostate cancer treatment. It discusses dose escalation studies showing improved outcomes with higher radiation doses. New techniques like IMRT and IGRT have improved precision and reduced side effects. Ongoing studies are further exploring dose escalation and hypofractionated regimens, as well as combining radiotherapy with hormone therapy or novel techniques to reduce rectal toxicity.
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ECCLU 2011 - A. Widmark - Prostate cancer: All the truth about local treatment options T1-T2 - Radiotherapy
- 1. All the truthabout 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. Philosophy : Riskadapted 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. Historical Radiotherapy ofPC Onk klin, NUS, A W 0002 ECCLU 2011
- 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. Why EBRT Dose-escalation ? Biopsy Data Local control influence outcome SPCG-7/SFUO-3 Onk. AW 0103 Improvement in technique CT-Based 3D-CRT Decreased margins -> side-effects IGRT ECCLU 2011
- 6. ALL 393 664843 301 202 104 GETUG 306 Viani et al IJROBP 2009
- 7. Low Risk InterM Risk High Risk Viani et al IJROBP 2009
- 8. Viani et alIJROBP 2009
- 9. Viani et alIJROBP 2009
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- 12. MD anderson Trial Kuban et al Röda 2008 ECCLU 2011 78% 39% 78% 59%
- 13. Rand Trial 70vs. 78 Gy, MDA Onk. AW 0101 Metastases ALL Pre PSA > 10 +13% p=0,035 Pollack et al JCO 2002 Kuban et al 2008 Kuban et al 2008 P=0.059 +4% ECCLU 2011
- 14. Onk. AW 0308PROT 05 Update 8.9 y. Zietman et al JCO 2010
- 15. Onk. AW 030832.4% 17.4% PROT 05 Update 8.9 y. Zietman et al JCO 2010
- 16. Onk. AW 030828.2% 7.1% 42.1% 30.4% PROT 05 Update 8.9 y. Zietman et al JCO 2010 Low Risk InterMed. Risk
- 17. Side –Effects Dose–Escalation MRC RT01 Trial , Syndikus at al IJROBP 2009 ECCLU 2011
- 18. ASTRO 2001 Onk.AW 0111 Dansande prostata: mätning av prostata rörlighet med MRI ECCLU 2011
- 19. BeamCath for IGRT Prostata cancer Onk. AW 9809 CT-bild ECCLU 2011
- 20. Digital Bildframställning “PortalVision” BeamCath, med markörer som visar urinröret 1:a uppläggning Vid Behandling Onk, NUS, A W 0504 ECCLU 2011 Strålfältet Strålfältet
- 21. Prostate EBRT IGRT Onk klin, NUS, A W 0002 7 mm ECCLU 2011
- 22. “ Picture verified”radioterapi (IGRT) Röntgenrör Detektor ECCLU 2011
- 23. Dose plan ECCLU 2011
- 24. Rectum and dosedistribution
- 25. Rectum dose volumehistograms QUANTEC objectives
- 26. GPS in Prostate Calypso, Micropos ECCLU 2011
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- 28. MR-Bild Onk klin,NUS, A W 9602 ECCLU 2011
- 29. Prostate MRI Cancer (S Johansson) Axial Coronal ECCLU 2011
- 30. Umeå Trial 1A 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
- 31. Umeå Trial 1Inklusion 1986- 1996 > 20 års FU Rand studie, Sweden, Denmark, Norway WW v.s. RT Patienter 107 107 ECCLU 2011
- 32. HYPO-fractionation alpha/beta valuein PC HYPO-RT-PC -Study Fractionation schedule under development Yeho Lukka B&R
- 33. Onk. AW 0609Hypofractionationated treatments ECCLU 2011
- 34. SCANDINAVIAN HYPO-Fractionation studyNUS Onk. AW 0402 Intermediate Risk Patients Conv: 2 Gy x 39 = 78 Gy R HYPO: 6.1 Gy x 7 = 42,7 Gy 15 centers, Sweden and Denmark Canada might Join 440/ 800 patients Included ECCLU 2011
- 35. Blood in StoolsWith Smaller margins ECCLU 2011
- 36. Treatment Effect areimproving What about Side-effects? ECCLU 2011
- 37. Biverkningar - FundingECCLU 2011
- 38. N 603 292306 - Age 59 69 65 - PSA 6.7 9.1 5.8 Side-Effects - Sexual ECCLU 2011
- 39. Side-Effects - URIN- Funding ECCLU 2011
- 40. Side-Efects – Bowel- Vitality ECCLU 2011
- 41. Intestinal Symptoms EBRTFig. 2 ECCLU 2011
- 42. Rectal leakage -When? Q31 ECCLU 2011
- 43. Localized PC! LocalCure is Achivable ! Improve Techniques to Decrease Rectal Toxicity!! ECCLU 2011
- 44. Prada et alBrachytherapy , 2007, 2009 ECCLU 2011
- 45. Principal of theNo-HARM study Needel operated Hyaluronic Acid for Rectal Move HA 10% 50% 70% 10% 70% 50% ECCLU 2011
- 46.
- 47. ECCLU 2011 Before RT 20 treatments ./40 G
- 48.
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- 50. Rectal fixation probe!ECCLU 2011
- 51. Rectal fixation probe!ECCLU 2011
- 52. Hydrodissection of thespace between rectum and prostate ECCLU 2011 Pro-Space: Novel Biodegradable Inflatable Balloon System
- 53. BLADDER PENIS RECTUMECCLU 2011 Pro-Space: Novel Biodegradable Inflatable Balloon System
- 54. Lymph Node treatment?ECCLU 2011
- 55. Lymph Node treatment,IMRT? ECCLU 2011
- 56. Lymph Node treatment,VMAT? ECCLU 2011
- 57. Lymph Node treatment?RTOG 0924 And PIVOTAL RT + HORMONES vs RT + HORMONES + Lymph Node Iradiation ECCLU 2011
- 58. RTOG 8610 RT 2 må.+2 må./RT Randomised Studies Radiation v.s. Radiation + Hormones Umeå 2 RT Kir. Kastration + RT EORTC/Bolla RT RT/samtidigt + Adj.3 år RTOG 8531 RT RT + Adj. LHRH 2 år Lavendiere RT 2 må. +2 m/RT 2 +2 må/RT+6må Adj.LHRH Is anyone doing RT 78 Gy vs Hormones + RT 78 Gy In intermediate risk PC? ECCLU 2011
- 59. - Funding PSArecurrence-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
- 60. - Funding ProstateCancer 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
- 61. - Funding Overallsurvival 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
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- 63.
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- 66. RT 70 Gy + 6 m. ADT Intermediate risk No/mild comorbidity Moderate/ severe comor
- 67. RT 70 Gy + 6 m. ADT High Risk No/mild comorbidity Moderate/ severe comor
- 68. Summary Localised PC!Local Cure is ”Achivable (-ed)” New Radiotherapy Tecniques To further Decrease Rectal Toxicity!! ECCLU 2011
- 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
- 70. Thank You! ECCLU2011
- 71. Tack! Frågor? ECCLU 2011
- 72. A Randomized TrialComparing 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
- 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
- 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
- 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