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Lisbon June 22nd 2013

Prostate Cancer Pitfalls and Controversies in Diagnosis and Therapy in 2013 Radiotherapy of prostate cancer: recent developments and results Carlo Greco


Radical Ultra-High Dose Hypofractionated IGRT Salvage Post-Prostatectomy Radiation Therapy for Recurrent Disease


Hypo-fractionated Radiotherapy in Prostate Cancer

Assuming an ι/β ratio 1.5 for prostate cancer


Moderate hypofractionation 70 Gy @ 2.5 Gy in 28 fractions


Tools to reduce the risk of treatment-induced toxicity with extreme hypofractionated RT


Transperineal injection of gel spacer


Beacon transponders: Calypso Platform Overview Optical System with 3 Infrared Cameras

4D Electromagnetic Array

4D Tracking Station

Implanted Beacon速 Electromagnetic Transponders

4D Console


Beacon Transponders Wireless Miniature Beacons

• Accurate, quantitative guidance for prostate localization • Continuous, real-time tracking Actual size: ~8.5 mm


Beacon transponder implant

Same technique and equipment as a prostate biopsy procedure or as the implant of other radiopaque markers


Identify Beacon transponders in treatment planning 4—14 Days post implant


Continuous tracking of the beacons facilitates ensures that the beam stays on target


Reduction in patient-reported acute morbidity in prostate cancer patients treated with 81-Gy Intensity-modulated radiotherapy using reduced planning target volume margins and electromagnetic tracking: Assessing the Impact of Margin reduction study Sandler HM et al Urology. 2010 May;75(5):1004-8

AIM study • • • •

64 Patients treated with implanted beacons assessed Nominal 3-mm margins and electromagnetic real-time tracking Expanded Prostate Cancer Index Composite (EPIC) questionnaires Overall, AIM Study patients showed fewer GI & GU problems post treatment than in the comparator cohort.


University of Pisa Experience hypofractionated (2.5 Gy x 28= 70 Gy) median FU 21.3 months (range 18- 24 months)


PSA response in patients with > 18 months FU treated with Beacon transponder technology and 3 mm margins


Hypofractionation vs Robotic Surgery


Extreme hypo-fractionations for organ-confined low and intermediate risk prostate cancer

Urethral-sparing phase I/II study 9 Gy x 5 fractions 45 Gy in 10 days For α/β ratio 1.5 predicted normalized BED > 250 Gy (86 Gy 1.8 – 2.0 Gy ~ 190 Gy)


MRI- CT Fusion for Prostate delineation and organ at risk sparingg


Apical Region between 12-15 mm from the penile bulb

GU Diaphragm


Urethral-sparing in Ultra High-Dose IGRT


CBCT Matching < 1mm repositiong accuracy


Flattened VS Flattening Filter Free (FFF) Photon Beam: a comparison of BOT for a 9 Gy session

6 FFF 6 MV

10 FFF 6 MV

Energy

BOT (min)

MU

6X

9.1

5510

6 FFF

3.2

4520

10 FFF

1.6

3830


Salvage Post-Prostatectomy Radiation Therapy for Recurrent Disease


This large systematic review provides Level 2a evidence for initiating Salvage RT at the lowest possible PSA


Rising PSA (5 ng/mL at PET) post-radical EBRT (80 Gy to prostate and seminal vesicles) in MAB


Int. J. Radiation Oncology Biol. Phys., Vol. 79, No. 4, pp. 1151â&#x20AC;&#x201C;1157, 2011


MSKCC and the University of Pisa are running a joint study to compare efficacy and toxicity of SD-IGRT vs. Hypofractionation 24 Gy SD vs. 27 Gy (9 Gy x 3) Target accrual 200 patients as of April 2013 > 140 patients randomized and treated


High-dose IGRT for oligometastatic prostate carcinoma 24 Gy SD-IGRT

Choline PET showed complete metabolic response at 3 months Patient still bNED at 2.5 yrs with NO androgen deprivation .



Radiotherapy of prostate cancer: recent developments and results