Brachytherapy in Carcinoma Prostatearoi.org/wp-content/uploads/2018/11/10.-Dr.-D-N-Sharma.pdf · LP...
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Brachytherapy in Carcinoma Prostate
Dr. D.N. SharmaProfessor
Department of Radiation Oncology
All India Institute of Medical Sciences, New Delhi
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Magnitude of the problem
• Prostate cancer relatively uncommon
• Life expectancy : 65 yrs
• Low awareness
• No PSA screening
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Incidence
• Third commonest cancer in most PBCRs
• Incidence is rising : ?apparent ?real
• AAR: 7.1 per lakh population
• Majority present in locally advanced/metastatic
stages
• Sizeable number of patients do come in early stages
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Brachytherapy for Carcinoma
Prostate
• As monotherapy : for low risk patients
• As Boost : for intermediate and high risk pts
• As salvage therapy : for recurrent cases
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Why Brachytherapy ?
• Conformal treatment
• Short course therapy
• Excellent local control
• Better quality of life
• Preservation of sexual function
• Cost effective
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Types of Brachytherapy
• High dose Rate (HDR) Brachytherapy
• Low dose Rate (LDR) Brachytherapy or
Seed Brachytherapy
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HDR Brachytherapy: Indications
Monotherapy
• Low- and intermediate risk
Boost (combined with EBRT)
• any T with N0 M0
• any PSA
• any Gleason-Score
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HDR Brachytherapy: Absolute contraindications
1. Preexisting rectal fistula,
2. Medically unsuited for anesthesia, and
3. No proof of malignancy.
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Patient Preparation
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ProcedureTEMPLATE
USG with TRUS probe 10
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Let the Foley's be high up to avoid balloon rupture
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LP Needle to Decide the Position of Template
12
Template fixation
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TRUS Imaging
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Needle insertion using USG guidance
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Phantom Trials to Streamline Workflow Logistics
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Prostate Steps contd..
� Needle insertion as per preplan
� Repeat 3D USG with Urethral contrast
� Catheter reconstruction and contouring
� Final plan and evaluation
� Connect for treatment
� Implant removal
� Bladder irrigation for hemostasis
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Dosimetry
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Pre-implant & Post Implant Care
• Antibiotic on the morning of implant
• Complete bowel preparation with PEGLEC the day prior
• Part preparation
• Post procedure Anti inflammatory, antibiotics & alpha
blockers
• Bladder irrigation with normal saline till hematuria subsides
• Foleys out the next day
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Initial Results of HDR Brachytherapy in Prostate Cancer:
AIIMS Experience
DN Sharma, KP Haresh
Department of Radiation Oncology,
All India Institute of Medical Sciences, New Delhi
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AIMS & OBJECTIVES
�To assess
1.Feasibility of combining Brachytherapy boost
after EBRT (IMRT)
2. To compare dosimetric parameters for PTV
between IMRT & Brachytherapy arm
3. To compare dosimetric parameters for OAR
(bladder & rectum)
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EBRT BY IMRT 45 GY/25#/5
WEEKS
BOOST BY IMRT 29 GY/15 #/3
WEEKS
BOOST BY HDR BRACHYTHERAPY
19GY/2 #
EBRT BY IMRT 45 GY/25#/5 WEEKS
RANDOMIZATION
Neoadjuvant HT 2 months
Adjuvant HT:Intermediate risk: 6 monthsHigh risk: 2 – 3 years
Conc -
HT
Treatment schema
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RESULTS� Total: 30 patients: Median follow up: 8.5 months
� Median age: 68 years: Stage distribution:T2b -T3b
� Median Gleason: 7 (Range 6-8)
� Mean S.PSA :34.9ng/ml
� Intermediate risk – 9 (30%) High risk – 21 (70%)
� The median prostate volume: 49.2mL(26.2-63.5)
� The major symptoms of acute GU toxicity were dysuria, increase in urinary
frequency or nocturia
� The major symptoms of acute GI toxicity were diarrhea and tenesmus
� T
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BOOST PHASE BRACHY ARM
IMRT ARM
p
EQD2 for 95% of PTV (a/b: 1.5Gy) 45.7Gy 28.4Gy 0.001
EQD2 for Dmean to PTV (a/b: 1.5Gy) 46.5Gy 29.3Gy 0.001
EQD2 for Dmean of Rectum 7.4Gy 13.5Gy 0.001
EQD2 for 33% of Rectum 6.8Gy 17.4Gy 0.001
EQD2 for Dmean of Bladder 5.4Gy 12.8Gy 0.001
EQD2 for 1cc of Bladder 16.7Gy 27.9Gy 0.001
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Toxicity Symptoms Arm 1 (%) Arm 2 (%) P
Acute
genitourinary
≥ grade 2
Dysuria 33 40 0.591
Frequency 40 46 0.279
Hematuria 6 0 0.264
Acute
gastrointestinal
≥ grade 2
Diarrhea 20 33 0.137
Tenesmus 6 13 0.345
Any late genitourinary ≥ grade 2 33 46 0.280
Any late gastrointestinal ≥ grade 2 6 20 0.139
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QLQ PR-25 subscales
(differences between
arms)
Mean difference (Arm 1*) Mean difference (Arm 2#) P
Urinary scale 1 month 11.3 -7.8 0.072
Urinary scale 3 months 22 9.1 0.157
Urinary scale 6 months 29.4 19.1 0.121
Bowel scale 1 month -9.5 -32.6 0.001
Bowel scale 3 months -1.4 -21 0.005
Bowel scale 6 months 2.1 -8.9 0.018
Treatment related scale 1
month
-8.5 -19.9 0.160
Treatment related scale 3
months
-5.2 -8.3 0.580
Treatment related scale 6
months
20 -20 0.941
Sexual scale 1 month 4.4 8.2 0.196
Sexual scale 3 months 10.2 11.8 0.818
Sexual scale 6 months 11.9 15.2 0.55629
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Study Conclusion
�HDR BT produced a more conformal plan & provides
higher mean dose to prostate
�Doses to the OAR are lower than IMRT
�Brachytherapy is effective in achieving dose
escalation
�No difference in bladder & bowel toxicity
�QOL (bowel symptom scale) better in brachytherapy
�Longer follow-up is needed to evaluate the efficacy
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Seed Brachytherapy in Carcinoma Prostate
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Permanent prostate implant
• Mainly monotherapy
• May be used as boost
• Salvage of recurrent tumors
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Brief history• 1917: Young HH used Radium-226 implants thru bladder, urethra,
rectum
• 1970s: Whitmore and Hilaris, retropubic implantation of I-125
• 1980s: Holm and Pederson, transrectal ultrasonography guided I-125 implantation
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Patient selection
I-125/Pb-103 Mono-therapy:
• cT1 ~ T2b
• PSA < 10
• GS: 2 - 6
• T1-T2 / GS < 7 / PSA < 10,
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Relative contraindications
• Severe urinary irritative/obstructive symptomatology
• Extensive TURP defect
• Substantial median lobe hyperplasia
• Prostate dimensions larger than the grid (>60 mm in width & >50mm
in height)
• Severe pubic arch interference
• Gross seminal vesicle involvement
• Prior pelvic radiotherapy
• Inflammatory bowel disease
• Pathologic involvement of pelvic lymph nodes
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Implant procedure
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STEPS:
Planning-TRUS guided volume study—computer preplan
Brachytherapy procedure-TRUS guided trans perineal needle-..
peripheral loading..
seeds placed along the tract from base to apex.
Post implant evaluation-by CT scan
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Aim to keep UV5<150% and UV30<125% in the preplan
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Acute Symptoms
• Dysuria (often)
• Hematuria (common)
• Perineal hematoma (significant < 3 % )
• Obstruction (5-12%)
• Perineal Pain (< 5%)
• Diarrhea (< 10%)
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Delayed Complications
• Chronic cystitis (3-7 %)
• Incontinence (1% for non-TURP, 25-42% for TURP)
• Rectal ulceration (< 1 %)
• Urethral necrosis (< 1 %)
• Erectile dysfunction (> 70y/o, 20-25%; < 70y/o, 10-15%)
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Conclusion
• Brachytherapy is an important treatment for
carcinoma prostate
• Can be used for monotherapy for low risk
patients and boost for intermediate/high risk
patients
• Provides excellent local control
• Preservation of sexual function