9. bRFS in pts with favorable tumors
(T1-T2A, bGS< 6, iPSA< 10 ng/ml)
Kupelian PA, JCO 2002
10. bRFS in pts with unfavorable tumors
(T2b-T2c, bGS> 6, iPSA>10 ng/ml)
Kupelian PA, JCO 2002
11. Long-Term Functional Outcomes after
Treatment for Localized Prostate Cancer
The Prostate Cancer Outcomes Study (PCOS), comprised 1655 men in
whom localized prostate cancer had been diagnosed between the ages of
55 and 74 years and who had undergone either surgery (1164 men) or
radiotherapy (491 men).
Functional status was assessed at baseline and at 2, 5, and 15 years after
diagnosis
• Urinary Incontinence: worse with surgery at 2 and 5 years
but the same by 15 years
• Erectile Dysfunction: worse with surgery at 2 and 5 years
but the same by 15 years
• Bowel Urgency: worse with radiation at 2 and 5 years' but
by 15 years' the same
N Engl J Med 2013; 368:436-445
24. Σςσαιοποιημένερ μελέηερ πος δείσνοςν ηο όθελορ από ηην
αύξηζη ηηρ δόζηρ (συπίρ IMRT και οπμονοθεπαπεία)
RCT N Comparison Result
Pollack
(MDA)
2007 update
301 70Gy/35 vs. 78Gy/39 59% vs. 78% bPFS at
5 years
Zietman
2005
393 70.2Gy vs. 79.2Gy (proton boost) 61% vs. 80% bPFS at
5 years
Peeters
(Dutch)
2006
664 68Gy/34 vs. 78Gy/39 54% vs. 64% FFF at 5
years
Dearnaley
(RTO1)
2007
843 64Gy/32 vs. 74Gy/37 60% vs. 71% bPFS at
5 years
Hoskin
(Mt Vernon)
2007
220 55Gy/20 vs. 35.75Gy/13 + HDR 8.5Gy x 2 64% vs. 80% bPFS at
5 years
bPFS=biochemical progression free survival FFF= freedom from failure
25. Low Risk
T1-2, GS ≤6, PSA ≤10
Memorial Sloan Kettering Cancer Center
IMRT Dose Escalation
Zelefsky MJ, Chan H, et. Al. Journal of Urology Vol. 176, 1415-1419, Oct 2006
26. Intermediate Risk
Memorial Sloan Kettering Cancer Center
IMRT Dose Escalation
Zelefsky MJ, Chan H, et. Al. Journal of Urology Vol. 176, 1415-1419, Oct 2006
T1-2, GS 6, PSA > 10
T1-2, GS >6, PSA 10
T3, GS 6, PSA 10
27. High Risk
GS >6, PSA >10
Memorial Sloan Kettering Cancer Center
IMRT Dose Escalation
Zelefsky MJ, Chan H, et. Al. Journal of Urology Vol. 176, 1415-1419, Oct 2006
28. Improving the Results of Radiotherapy
Dose escalation– increasing the dose of
radiation by 10% can increase local control
by 20% (level 1 evidence)
3D Conformal, IMRT, HDR Brachytherapy boost
Combination treatment with radiotherapy and
androgen suppression
48. • Conventional or Hypofractionated High Dose
Intensity Modulated Radiotherapy for Prostate
Cancer
• Hypothesis: hypofractionated radiotherapy
schedules for localised prostate cancer will
improve the therapeutic ratio by either:
a) Improving tumour control
b) Reducing normal tissue side effects
CHHiP Trial
55. SBRT
cheaper but more toxic
than IMRT
for Prostate Cancer
The study results were published online March 10 in
theJournal of Clinical Oncology.
58. CT scan is obtained at the time of the Simulation
Fiducials may be inserted
before this step. CT images are
then imported into the
treatment planning computer
60. IMRT (intensity
modulated
radiation therapy)
using 7 different
beams to target the
prostate
The computer can
determine the optimal
number of beams to
deliver the radiation
dose to hit the target and
avoid other structures
63. There is significant movement of the
prostate gland based on daily gas in rectum
Planned target
Rectal gas
No Rectal gas
Planned target,
missed badly if
rectal gas pushes
the prostate
forward
65. After IMRT was established then IGRT
(image guided) was introduced
67. Lower Risk of Side Effects with Image Guided IMRT
compared to IMRT
68. Is there ever a need for
radiation after a man
has already had his
prostate removed
PostOp Radiation (Adjuvant Therapy) if the
pathology report from the surgery raises the concern:
“was the cancer completely removed?”
Salvage Radiation
70. NCCN Advice on PostOp Radiation
RP (radical prostatectomy) PLND (pelvic lymph node dissection) RT (radiation
therapy) ADT (androgen deprivation therapy e.g. Lupron)
71. Adverse Features
1.Positive Surgical Margins
2.Invasion into the Seminal Vesicles
3.Extracapsular Extension
4.Detectable PSA (after surgery the PSA
should fall to undetectable by a few weeks)
72. Impact of Path Reporting Positive
Surgical Margins
Risk Group + Margins - Margins
Low risk 5.1% 0.4%
Intermediate 17% 6.5%
High 43% 21.5%
Odds of a PSA Relapse
J Urol. 2010;183(1):145.
73. PostOp Radiation…does it work?
SWOG 8794 Trial path (425 men) = extraprostatic extension after surgery
10 Year PSA Cure Rate (seminal vesicle)
Surgery Only 12%
Surgery Plus Radiation 36%
EORTC (1005 men)
5 Year Cure Rate if Positive Margins
Surgery Only 49%
Surgery Plus Radiation 78%
German Study (Wiegel, 268 men)
5 Year Cure Rate all T3
Surgery Only 54%
Surgery Plus Radiation 72%
76. Is it Better to Treat PostOp for High Risk
Features or to Wait and Treat later if the
PSA starts rising (salvage)?
8 Year Specific Survival by Group and Therapy
Immediate RT Delayed
Positive Margins 91% 67%
Extra-capsular Spread 92% 75%
Gleason 7 88% 72%
Node Metastases 88% 68%
Role of postoperative radiotherapy after pelvic lymphadenectomy and
radical retropubic prostatectomy: a single institute experience of 415
patients
Cozzarini. IJROBP 2004;59:674
78. Salvage Radiation: if months or years
after surgery the PSA blood tests
starts rising again
79. Salvage Radiation…does it work?
Depends…
Original Pathology
What was the Gleason?
Where the surgical margins clear?
Did the cancer involve the seminal vesicles or lymph
nodes?
Was there extra-capsular spread?
How long ago was the surgery?
How fast is the PSA rising (doubling time)?
How high the did PSA get before deciding to try
radiation?
How high a dose of radiation will be used?
83. Does Salvage Radiation Improve Survival?
Mayo (2657) No improvement in 10 y mortality
(70% versus 69%)
Hopkins (635) Improved cancer mortality at 10
years 86% versus 62%
Duke (519) All cause mortality at 11 years was
reduced by 47%
J Urol. 2009;182(6):2708
JAMA. 2008;299(23):2760.