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PO-1021: Permanent brachytherapy as salvage therapy for locally recurrent prostate cancer after external beam irradiation
ESTRO 33, 2014 González1, F. Pino Sorroche3, F. Suárez Novo4, F. Guedea Edo1 Institut Català d'Oncologia, Radiation Oncology, L'Hospitalet de Llobregat, Spain 2 Universitá degli Studi di Palermo, Radiation Oncology, Palermo, Italy 3 Institut Català d'Oncologia, Physics, L'Hospitalet de Llobregat, Spain 4 Hospital de Bellvitge, Urology, L'Hospitalet de Llobregat, Spain 1
Purpose/Objective: To evaluate long-term outcomes of patients (pts) treated with permanent seed brachytherapy (BT) as monotherapy for low-risk prostate cancer (PCa), in terms of survival and toxicity. Materials and Methods: Retrospective study of 700 pts treated with transperineal, ultrasound-guided I-125 seed BT (145 Gy) between January 2000 and July 2012. Median age was 64.8 years (range 35-79). Distribution by Gleason score (GS) was as follows: < 7 (684 pts; 97.7%); 7 (13 pts; 1.9%); and 8 (3 pts; 0.4%). The initial prostate-specific antigen (iPSA) level was ≤ 10 ng/mL in 664 pts (94.4%), and > 10 in 32 pts (4.6%). TNM staging was as follows: T2a (685 pts; 97.8%) and T2b-T2c (15 pts; 2.2%). Eighty-five pts (12.1%) received hormonal treatment (HT). Overall survival (OS), cause-specific survival (CSS), disease-free survival (DFS), and biochemical relapse-free survival (BRFS) at 5 and 10 years were calculated. Results: Median follow-up was 63 month (range, 6-164). At 5- and 10years follow up, respectively, OS was 94% (95% confidence interval [CI] 92-96) and 84% (95% CI, 78-90); CSS was 100% and 97% (95% CI, 95-99); DFS was 95% (95% CI, 93-97) and 86% (CI 80-92); and BRFS was 95% (95% CI, 93-97) and 85% (95% CI, 79-91). Grade 2 and 3 acute rectal toxicity was 2.3% (n=16) and 1.4 %( n=10), respectively. Grade 2 and 3 genitourinary (GU) acute toxicity was 22.6% (n=158) and 6.9% (n=48). Urinary catheters were inserted in 59 pts (8.4%) and Cistocath devices in 30 pts (4.3%). Seventeen pts (2.4%) required a transurethral resection of the prostate. Late grade 2 and 3 rectal toxicity was 1% (n=7) and 1.5% (n=11), respectively, with late grade 2 and 3 GU toxicity rates of 6.2% (n=44) and 3.2% (n=23). Only 3 pts died due to disease progression. One patient died from treatment-related toxicity. Conclusions: Long-term results presented here are in line with those reported in the literature and provide further support for the use of permanent seed BT to treat low-risk PCa. PO-1021 Permanent brachytherapy as salvage therapy for locally recurrent prostate cancer after external beam irradiation A. Vavassori1, R. Spoto1, F. Gherardi1, C. Fodor1, F. Cattani2, S. Comi2, B.A. Jereczek-Fossa1, D. Zerini1, R. Lazzari1, R. Orecchia1 1 European Institute of Oncology, Radiotherapy, Milan, Italy 2 European Institute of Oncology, Medical Physics, Milan, Italy Purpose/Objective: To estimate the incidence of acute and late toxicity and to evaluate the biochemical outcome after transperineal ultrasoundguided permanent prostate brachytherapy (PPB) for local failure after initial external beam radiotherapy for prostate cancer. Materials and Methods: Between August 2000 and April 2012 22 patients underwent salvage PPB using 125I for intraprostatic recurrence after external beam radiotherapy. The median patient age was 71 years (range, 52-81). According to NCCN 2013, the risk group distribution at initial diagnosis was as follows: low risk 3 patients (13.6%), intermediate risk 7 patients (31.8%) and high risk 12 patients (54.5%). The median time from first treatment until salvage brachytherapy was 46 months (range, 24-111 months). The median PSA-doubling time was 8.4 months. All patients were treated using a perioperative treatment planning with dedicated hardware and software. Total re-irradiation dose was 145 Gy. Prior to PPB 13 patients were treated with androgen-deprivation therapy. Urinary symptoms (International Prostatic Symptom Score, IPSS) and uroflowmetry were evaluated before treatment: the median IPSS was 4 and the median maximum flow rate was 14 ml/sec. Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer criteria and Houston-Phoenix definition were used for toxicity and biochemical failure evaluation, respectively. Results: The median follow-up was 43.6 months (range, 16.9-105). Four patients developed acute urinary retention. Eight patients developed mild urinary urge incontinence and 14 patients developed G2 urinary toxicity. Only 3 patients developed G2 rectal toxicity. At last follow-up 11 patients (50%) are alive with biochemical failure, 4 of whom with metastatic disease, and 3 patients (13.6%) died with metastatic disease. Four patients (18.2%) are alive without biochemical failure and 3 patients (13.6%) died for other causes without evidence of disease. The biochemical control rate using risk category at first
S153 diagnosis was 33.3%, 42.8%, and 33.3% in patients with low, intermediate and high risk prostate cancer, respectively. Conclusions: Salvage PPB after irradiation is feasible with relatively low urinary and rectal morbidity. No patient had a clear evidence of intraprostatic recurrence. These early results are comparable with literature. Further experience and longer follow-up are needed to evaluate the role of PPB in the treatment of local recurrences. PO-1022 Dosimetry modelling for focal high dose rate prostate brachytherapy J. Mason1, B. Al-Qaisieh1, D.I. Thwaites2, P. Bownes1, A. Henry3 1 St James Institute of Oncology, Department of Medical Physics, Leeds, United Kingdom 2 University of Sydney, Institute of Medical Physics School of Physics, Sydney, Australia 3 St James Institute of Oncology, Clinical Oncology, Leeds, United Kingdom Purpose/Objective: To assess the dosimetric impact of focal high-doserate (HDR) brachytherapy for localized prostate cancer by comparing standard whole gland (STD), hemi-gland (HEMI) and ultra-focal (UF) treatment plans. Plan robustness to source position errors was also assessed. Materials and Methods: Nine patients were selected for this retrospective planning study according to clinical data, template biopsy and multi parametric MRI. MRI T2 and Diffusion images were manipulated to match a typical treatment planning setup for trans-rectal ultrasound based HDR implant. Tumour volumes were delineated based on MRI imaging and template biopsy results. For each patient STD, HEMI and UF plans were produced using the target definitions for low dose rate focal therapy from a recent consensus report (ref 1), with a 3mm margin applied to the prostate or hemi-prostate in STD or HEMI plans. For UF plans a 6mm margin was applied to the visible tumour to create an FPTV. Treatment plans assumed a single fraction monotherapy treatment with prescription dose 19Gy (ref 2). Systematic shifts across all source positions of 1mm-4mm were applied separately in each anatomical direction to assess plan robustness. Results: Mean total-reference air kerma values were 0.726 cGy@1m, 0.513 cGy@1m and 0.215 cGy@1m for STD, HEMI and UF plans respectively. The target V100 was similar and above 98% for all plans. Mean D90 was 20.5Gy for prostate in STD plans, 22.3Gy for hemi-prostate in HEMI plans and 23.2Gy for F-PTV in UF plans. Mean urethra D10 was 20.1Gy, 19.8Gy and 9.2Gy in STD, HEMI and UF plans respectively. Mean D2cc of the rectum was 12.6Gy, 9.9Gy and 4.6Gy in STD, HEMI and UF plans respectively. Plan robustness analysis showed that focal therapy plans were more sensitive to source position errors. For example for 2mm systematic source position shifts, for STD plans prostate D90 was reduced by up to 2% with the largest reduction due to an anterior shift, for HEMI plans hemi-prostate D90 was reduced by up to 4.7% with the largest reduction due to an anterior shift and for UF plans F-PTV D90 was reduced by up to 11.5% with the largest reductions due to a left or right shift. Conclusions: Hemi-gland and ultra focal treatment options can achieve higher D90 values compared to standard whole gland treatments with reduced dose to organs at risk. Focal therapy treatment plans are more sensitive to systematic source position errors than standard whole gland treatments. References (1) Langley S, et al. Report of a consensus meeting on focal low dose rate brachytherapy for prostate cancer. BJU Int. 2012 Feb;109 Suppl 1:716. (2) Prada P, et al. High-dose-rate interstitial brachytherapy as monotherapy in one fraction....... Brachytherapy 2012(11) 105-110.
PO-1023 Impact of catheter displacements on inverse planning simulated annealing G. Reynés-Llompart1, F. Pino1, I. Modolell1, I. Sancho1, J. Pera1, C. Picón1 1 Institut Català d'Oncologia, Física i protecció radiologica, Barcelona, Spain Purpose/Objective: Previous studies have shown the good performance of inverse planning simulated annealing (IPSA, NucletronTM) algorithm
Purpose/Objective: To evaluate long-term outcomes of patients (pts) treated with permanent seed brachytherapy (BT) as monotherapy for low-risk prostate cancer (PCa), in terms of survival and toxicity. Materials and Methods: Retrospective study of 700 pts treated with transperineal, ultrasound-guided I-125 seed BT (145 Gy) between January 2000 and July 2012. Median age was 64.8 years (range 35-79). Distribution by Gleason score (GS) was as follows: < 7 (684 pts; 97.7%); 7 (13 pts; 1.9%); and 8 (3 pts; 0.4%). The initial prostate-specific antigen (iPSA) level was ≤ 10 ng/mL in 664 pts (94.4%), and > 10 in 32 pts (4.6%). TNM staging was as follows: T2a (685 pts; 97.8%) and T2b-T2c (15 pts; 2.2%). Eighty-five pts (12.1%) received hormonal treatment (HT). Overall survival (OS), cause-specific survival (CSS), disease-free survival (DFS), and biochemical relapse-free survival (BRFS) at 5 and 10 years were calculated. Results: Median follow-up was 63 month (range, 6-164). At 5- and 10years follow up, respectively, OS was 94% (95% confidence interval [CI] 92-96) and 84% (95% CI, 78-90); CSS was 100% and 97% (95% CI, 95-99); DFS was 95% (95% CI, 93-97) and 86% (CI 80-92); and BRFS was 95% (95% CI, 93-97) and 85% (95% CI, 79-91). Grade 2 and 3 acute rectal toxicity was 2.3% (n=16) and 1.4 %( n=10), respectively. Grade 2 and 3 genitourinary (GU) acute toxicity was 22.6% (n=158) and 6.9% (n=48). Urinary catheters were inserted in 59 pts (8.4%) and Cistocath devices in 30 pts (4.3%). Seventeen pts (2.4%) required a transurethral resection of the prostate. Late grade 2 and 3 rectal toxicity was 1% (n=7) and 1.5% (n=11), respectively, with late grade 2 and 3 GU toxicity rates of 6.2% (n=44) and 3.2% (n=23). Only 3 pts died due to disease progression. One patient died from treatment-related toxicity. Conclusions: Long-term results presented here are in line with those reported in the literature and provide further support for the use of permanent seed BT to treat low-risk PCa. PO-1021 Permanent brachytherapy as salvage therapy for locally recurrent prostate cancer after external beam irradiation A. Vavassori1, R. Spoto1, F. Gherardi1, C. Fodor1, F. Cattani2, S. Comi2, B.A. Jereczek-Fossa1, D. Zerini1, R. Lazzari1, R. Orecchia1 1 European Institute of Oncology, Radiotherapy, Milan, Italy 2 European Institute of Oncology, Medical Physics, Milan, Italy Purpose/Objective: To estimate the incidence of acute and late toxicity and to evaluate the biochemical outcome after transperineal ultrasoundguided permanent prostate brachytherapy (PPB) for local failure after initial external beam radiotherapy for prostate cancer. Materials and Methods: Between August 2000 and April 2012 22 patients underwent salvage PPB using 125I for intraprostatic recurrence after external beam radiotherapy. The median patient age was 71 years (range, 52-81). According to NCCN 2013, the risk group distribution at initial diagnosis was as follows: low risk 3 patients (13.6%), intermediate risk 7 patients (31.8%) and high risk 12 patients (54.5%). The median time from first treatment until salvage brachytherapy was 46 months (range, 24-111 months). The median PSA-doubling time was 8.4 months. All patients were treated using a perioperative treatment planning with dedicated hardware and software. Total re-irradiation dose was 145 Gy. Prior to PPB 13 patients were treated with androgen-deprivation therapy. Urinary symptoms (International Prostatic Symptom Score, IPSS) and uroflowmetry were evaluated before treatment: the median IPSS was 4 and the median maximum flow rate was 14 ml/sec. Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer criteria and Houston-Phoenix definition were used for toxicity and biochemical failure evaluation, respectively. Results: The median follow-up was 43.6 months (range, 16.9-105). Four patients developed acute urinary retention. Eight patients developed mild urinary urge incontinence and 14 patients developed G2 urinary toxicity. Only 3 patients developed G2 rectal toxicity. At last follow-up 11 patients (50%) are alive with biochemical failure, 4 of whom with metastatic disease, and 3 patients (13.6%) died with metastatic disease. Four patients (18.2%) are alive without biochemical failure and 3 patients (13.6%) died for other causes without evidence of disease. The biochemical control rate using risk category at first
S153 diagnosis was 33.3%, 42.8%, and 33.3% in patients with low, intermediate and high risk prostate cancer, respectively. Conclusions: Salvage PPB after irradiation is feasible with relatively low urinary and rectal morbidity. No patient had a clear evidence of intraprostatic recurrence. These early results are comparable with literature. Further experience and longer follow-up are needed to evaluate the role of PPB in the treatment of local recurrences. PO-1022 Dosimetry modelling for focal high dose rate prostate brachytherapy J. Mason1, B. Al-Qaisieh1, D.I. Thwaites2, P. Bownes1, A. Henry3 1 St James Institute of Oncology, Department of Medical Physics, Leeds, United Kingdom 2 University of Sydney, Institute of Medical Physics School of Physics, Sydney, Australia 3 St James Institute of Oncology, Clinical Oncology, Leeds, United Kingdom Purpose/Objective: To assess the dosimetric impact of focal high-doserate (HDR) brachytherapy for localized prostate cancer by comparing standard whole gland (STD), hemi-gland (HEMI) and ultra-focal (UF) treatment plans. Plan robustness to source position errors was also assessed. Materials and Methods: Nine patients were selected for this retrospective planning study according to clinical data, template biopsy and multi parametric MRI. MRI T2 and Diffusion images were manipulated to match a typical treatment planning setup for trans-rectal ultrasound based HDR implant. Tumour volumes were delineated based on MRI imaging and template biopsy results. For each patient STD, HEMI and UF plans were produced using the target definitions for low dose rate focal therapy from a recent consensus report (ref 1), with a 3mm margin applied to the prostate or hemi-prostate in STD or HEMI plans. For UF plans a 6mm margin was applied to the visible tumour to create an FPTV. Treatment plans assumed a single fraction monotherapy treatment with prescription dose 19Gy (ref 2). Systematic shifts across all source positions of 1mm-4mm were applied separately in each anatomical direction to assess plan robustness. Results: Mean total-reference air kerma values were 0.726 cGy@1m, 0.513 cGy@1m and 0.215 cGy@1m for STD, HEMI and UF plans respectively. The target V100 was similar and above 98% for all plans. Mean D90 was 20.5Gy for prostate in STD plans, 22.3Gy for hemi-prostate in HEMI plans and 23.2Gy for F-PTV in UF plans. Mean urethra D10 was 20.1Gy, 19.8Gy and 9.2Gy in STD, HEMI and UF plans respectively. Mean D2cc of the rectum was 12.6Gy, 9.9Gy and 4.6Gy in STD, HEMI and UF plans respectively. Plan robustness analysis showed that focal therapy plans were more sensitive to source position errors. For example for 2mm systematic source position shifts, for STD plans prostate D90 was reduced by up to 2% with the largest reduction due to an anterior shift, for HEMI plans hemi-prostate D90 was reduced by up to 4.7% with the largest reduction due to an anterior shift and for UF plans F-PTV D90 was reduced by up to 11.5% with the largest reductions due to a left or right shift. Conclusions: Hemi-gland and ultra focal treatment options can achieve higher D90 values compared to standard whole gland treatments with reduced dose to organs at risk. Focal therapy treatment plans are more sensitive to systematic source position errors than standard whole gland treatments. References (1) Langley S, et al. Report of a consensus meeting on focal low dose rate brachytherapy for prostate cancer. BJU Int. 2012 Feb;109 Suppl 1:716. (2) Prada P, et al. High-dose-rate interstitial brachytherapy as monotherapy in one fraction....... Brachytherapy 2012(11) 105-110.
PO-1023 Impact of catheter displacements on inverse planning simulated annealing G. Reynés-Llompart1, F. Pino1, I. Modolell1, I. Sancho1, J. Pera1, C. Picón1 1 Institut Català d'Oncologia, Física i protecció radiologica, Barcelona, Spain Purpose/Objective: Previous studies have shown the good performance of inverse planning simulated annealing (IPSA, NucletronTM) algorithm