prostate brachytherapy master-class part...

Mira Keyes MD FRCPCClinical Professor Radiation Oncology Department of Surgery UBCHead, BCCA prostate Brachytherapy Program BC Cancer, Vancouver Centre, Canada

Prostate Brachytherapy Master-class Part II

Quality Assurance in prostate Brachytherapy

Quality: A high level of value or excellenceUndetectable PSA (cure) No/minimal side effect Quality is easy to conceptualize, but difficult to quantitate

NRC recommendations INDIVIDUAL

Inadequate training Incorrect seed placement Observed poor placement of seeds and no corrective actions taken

PROGRAM STRUCTURE Inadequate procedures in the program Poor management oversight of program and

contractors No peer review process Lack of safety culture

4

QA makes a big difference in outcomes

13212010896847260483624120time since implant (months)

1.0

0.8

0.6

0.4

0.2

0.0

pro

po

rtio

n f

ree

of

recu

rren

ce

1500 pts 10 y bNED 93%22% QA

All QA

All QA

4

Zlefsky IJROBP 67:2007J. Morris Urology 2009

Merrick Brachytherapy 2010K.A. Hinnen IJROBP 2010

No QA

QA codes must be calibrated at and for each institutions

No shared experience of prostate contouring Different treatment planning algorithmsDifferent target coverage goals

Most important: a well developed functioning organized system with safeguards built in

Work flow, check points, for various teams and tasks, automated system so mistakes are reduced to a minimum

IT

Administrative support Limited hierarchy

Culture of safety

Uniform treatment policy, planning, one seed supplier

Permanent staffUniformity

Training and Mentorship

Keyes at al Brachytherapy Vol 12 2013 SYSTEMATIC DATA COLLECTION AND OUTCOMES

Pre vs. Intraoperative planningNo ideals system, if it works for you, use it !

Pre vs. Intraoperative planningMount Sinai NY

Intraoperative real time Pre-planning Exact volume and size

Can be fast and efficient

Based on activity per volume table

MICK applicator more flexible

Volume and size can be different

Very fast and efficient

Based on exact plan

Stranded seeds more flexible?

Pre vs. Intraoperative planningMount Sinai NY

Intraoperative Pre-planning Embolization

Intraoperative dose

Many extra seeds needed

No embolization issues

Intraoperative dose is uncertain

Seed order accurate

797 i-125 implant: mount sinai Mount Sinai797 I-125 patients

1990 - 2002

Nomograms

Peripheral Needle /seed Placement

Interior Needle /Seed Placement

Completed Implant

Low risk- 55%pts

BEDOptimal LDR dose? Multi institutional analysis 6 large institutions4000 pts; Low, intermediate and high dose

BED:low dose: 200 Gy

Intermediate risk-30% pts

High risk-14% ptsStone at al IJROBP 2007

D90 >180Gy

643 Selected ptsbNED: 97% & 93%medD90 197Gy100% D90 >180Gy

All 1006 ptsbNED 95 & 95%medD90 151Gy6% D90 >180Gy

Mount SinaiKao at al. IJROBP 2008

BCCAMorris at al. J Urology 2009

Intraoperative

Mick Applicator Dose to cover the

margins is generated form the inside the prostate

Dose is pushed out

Implants must be hot to achieve this

D90>180Gy

Preplan

Stranded seedsDose at margins form

seeds placed at the prostate periphery and peri-prostatic tissues

Dose for margins is planned

D90 150Gy is adequateImplants are not too hot

Intraoperative Preplan

Reinforce the QA feedback and understanding your own planning process

Optimal planning geometry

Bowel prep good imagePt positionBase where do you want your seedsApex - Length/ Saggital imageNumber of slices lengthx2 +1sliceSymmetry D rowHost 1.5 or 2 row

US volume study

Saggital

BCCA marginsAnt - 3 mmLat - 5 mm Post - 0 mmInf - 0-5 mm?

CTV = prostate expanded at base and apex + SV basePTV= CTV+ margins

ECE Partin tablesLow risk 20-50%Intermediate Risk- 20-60%High Risk 16-57%

Why do you add margins?Extra Capsular Extension

Mid and posterior prostate (50-60%)

Risk factors:PSA >10, GS =7, CS=T2bTwo risk factors ECE50% pts>4mm >20% pts

Davis at al. Cancer. 1999Bin at al. J. Cancer 2003Chao KK. At IJROBP 2006

I125 Dose decreases by 20 Gy/mm.

Seminal Vesicles involvement

1

15

27

58

0

1020

3040

5060

no risk f 1 risk f 2 risk f 3 risk f

risk factor cathegory

22

%

Risk factors:PSA >10GS =7CS =T2b

344 RP William BeaumontSV involved - 15 % ptsMedian length - 1 cm

Kestin LL at al IJROBP 2002 vol 54 22

1. Symmetry Left to Right2. Peri-uretral sparing3. Margins and SV covered4. High seed density in post

zones5. PTV/CTV ratio > 1.66. Generous margins7. Minimize # needles 8. Extra capsular seed ~30%

Planning Goals V100 - >98%V150 55-65%V200 - ~20%D90 - 120%UD50 ~120%

PTV

July 1998 pt #1

Pt# 4000 Nov 2011

Pt# 2 July 1998

Evolution of planning

Pt# ~6500Dec 2017

Mixed activity seeds activity

High Activity Implants1. Reduces number of needles trauma cost conformity dose homogeneity

2. Rectal dose and fistulas?

Low Activity1. More robust2. Less concern with

misplacement3. Prostate is in the seed

cloud4. Higher

Homogeneity Number of needles Trauma cost

High Activity Seeds? no consensus I-125 - 0.42U 0.84U

Solution mixed activity implants ?

Mixed activity seedsChoice of seed strength depends on technique and extra-prostatic seeds ( BCCA low activity).

Different seed activities have trade-offs between high and low activity

HDR brachytherapy dwell times at each position can be varied to optimize the dose distribution, can LDR achieve the same without having to plan seeds in risky locations ( rectum, urethra)?

Dosimetric study (Nick Chung PhD) 1. High activity 0.6U. 2. Mixed activity 0.4U, 0.6U or 0.9U3. Standard BCCA plans

Plan reconstruction is the process of finding the best correspondence between the preplan and post-plan.

1. ProblemIdentify the different activity seeds

Conclusions1. Method for reducing needle counts and covering the ASQ than high activity implants.

2. Urethral doses increased significantly, primarily as a consequence of higher activity seeds in the anterior base

2. Problem: Pre-implant quality assurance of mixed-activity needles is the subject of ongoing research

Catheter to prostate apex

Check the base image with every needle

Dual images may be helpful

1

Sagittal images2.

1. Needle to mid prostate2. Than to final plane Less gland rotation

3

Needles close to rectumAdjust the template

Use sagittal images

Do not over-crowd seeds in front of the rectum on pre-plan

4 RECTUM

Post implant dosimetry and contouring

Urethra is not a small space

37

Apex

Mid gland

Base

NY contouring conferance: 15 participants > 500 cases eachEach contoured same 8 cases.

(slides from J. Crook)

38

MRI-CT fusionMore accurate dosimetryLabor intensive (VariSeed )(MIM better)More expensiveMay not be available

MR Sequence

3 mm slice/0 gapTE/TR =90/4500 echo time/repetition timeETL 10 echo train lengthFOV 18-20Matrix 320 x 224band width 31 Hz4 NEX (# of excitations)T2 FSE (or FRFSE) fast spin echoCone down on prostate

do not scan entire pelvis

40

What if I cant get an MRI?1. Use all the information you have

Pre-implant TRUS (length, width, height)

2. Use bladder contrast in your CT scan! 1.5 mls in 30mls pre-CT scan

Amys technique

US CT fusion

Joe Buccis technique

Suboptimal post-implant dosimetry

Low risk- 55%pts

BEDOptimal tumoricidal dose? Multi institutional analysis 6 large institutions4000 pts; Low, intermediate and high dose

BED:low dose: 200 Gy

Intermediate risk-30% pts

High risk-14% ptsStone at al IJROBP 2007

144GYCase

Age 57T2aGS 3+3=6LMM core +IPSS 2AS

V100: 59%D90: 70 Gy

Implant I - D90 70 Gy

144 Gy

Initial Implant day 30 CT

New seeds

Previously implanted seeds

1. Additional seeds were keyed in with 5 mm space between, to the cold areas of on post-implant CT (colour change).2. Composite isodose lines were observed on each CT image 3. Avoid 145-Gy isodose overlap between the reimplant and the initial implant.

Avoid any subsequent dragging of the seeds inferiorly to avoid creating overlap of the dose from the first and second implants.

144GY

Implant I - D90 70 Gy Re-implant II - D90 144 Gy

Dose: add up dose form both implants The net effect: alter the dose rate or increase in the overall treatment time. Jan 2018 FU

urethral stricture and has to self catheterizePSA < 0.02

Dosimetry: V100

50 60 70 80 90 100

V100 1stImplant (%)

V100 2ndImplant (%)

V100 1st Implant Mean: 78.2 %

V100 2nd Implant Mean: 93.7 %V100 90%

Chart2

937

7029

971

8315

8116

7918

7027

7620

8213

8015

5936

7321

8211

8112

8112

866

6031

837

6821

807

7410

6418

V100 1st Implant (%)

V100 2nd Implant (%)

Baseline

IDBCCA IDDate of BirthDate of DiagnosisAge at DiagnosisImplant LocationASCENDEInitial PSAT StagePrimary GleasonSecondary GleasonGleason TotalCores PositiveTotal CoresLocation of CoresNeoadjuvant HTErectile Potency BaselineBaseline IPSSDate First ImplantDate Second ImplantTime to ReimplantDate of Last Follow-upTime from Reimplant to last Follow upBiochemical FailureBiochemical Failure CategoryTime to failure or last follow upMetastatic DiseaseMost Recent PSAToxicity

1000488626-Feb-449-Mar-0056.03VCC3.9T2a33636LA, LM, LBnonormal1-Aug-003-Oct-0063.0831-Jan-1312.33031-Jan-130.02

2010630724-Sep-5128-Mar-0149.51VCC7T2a33636LM, LA, RByesnormal24-Jan-0223-Apr-0289.0516-Jul-1412.23016-Jul-140.01Self-catheter, TURP

4011614911-Nov-251-Oct-0175.89VCC7.8T2a43728LB, LMM, LAyesnormal18-Jul-023-Sep-0247.022-Oct-1210.0802-Oct-120.03

5011930928-Jul-503-Dec-0151.35VCC2.9T2a33623RM, RBnonormal19-Feb-0228-May-0297.9711-Jul-075.12011-Jul-070.04

6020513714-Dec-4320-Feb-0460.19VCC5T1c34718LByesimpotent30-Jul-025-Nov-0298.0028-Oct-052.98028-Oct-050.01

702077651-Apr-4015-Apr-0262.04VCC6.6T1c34746LA, LMM, LML, LByesnormal5-Sep-0229-Oct-0253.6128-May-085.58028-May-080.09IPSS 18

8030301021-Nov-3328-Jan-0369.19VICC8.8T1c336211L,Ryesnormal28-Aug-0327-Nov-0391.0027-Jul-106.66027-Jul-100.01radiation proctitis

9030320719-Mar-4430-Jan-0358.87VCCyes5.4T1c45999RB, RMM, RML,RA, LB, LMM, LML, LA, MPZyesnormal22-Apr-0422-Jun-0461.0024-Jul-1410.08024-Jul-140.04

10040985615-Oct-3312-May-0975.57CSIyes6.7T1c45928LB, LMyesimpotent2-Jun-101-Sep-1091.0014-Jul-143.86014-Jul-140.03

11042316024-Oct-4628-Jul-0457.76CSI5.04T2c43766LA, LB, LM, RA, RB, RMyesimpotent10-Feb-0526-Apr-0575.0028-Mar-148.9207-Apr-10107-Apr-1003-May-13

12050140328-May-276-Dec-0477.53VCCyes18T2c45968LA, LMM, RA, RM,RMM, RByesnormal8-Nov-0522-Dec-0543.928-Jan-137.0508-Jan-130.01

13050302729-May-3629-Dec-0468.59VICC3.2T2a34777L,Ryesimpotent20-Sep-053-Jan-06104.925-May-148.3305-May-140.02

1405235184-Sep-3719-Oct-0568.12VCC8.1T2a34728RA, RBnonormal2-Mar-0618-Apr-0647.424-Sep-148.3822-Aug-11122-Aug-11third implant R seminal vesicle, urinary and rectal incontinence

15060037427-Feb-4720-Dec-0558.81VCC5.8T2c33666L, Rno23-Mar-066-Jun-0674.9916-Nov-126.45016-Nov-120.02

1606012691-Jun-334-Oct-0572.34VCC3.5T2c34758RA, RB, LB, LMM, LMLno6-Apr-068-Jun-0662.965-Jun-136.9905-Jun-130.01

17061309916-Apr-419-Jun-0665.15VICC6.3T1c347412L, Rnopartial2-Nov-0612-Dec-0639.8631-Mar-147.30031-Mar-140.02

18070492519-Feb-3012-Dec-0676.81CSI3.04T2c43722yes12-Mar-0916-Jun-0996.0417-Jul-145.08017-Jul-140.1

19072358222-May-4217-Sep-0765.32VCC13.9Tx336210RML, LByesnormal7-Oct-0818-Dec-0872.0822-Oct-134.84022-Oct-130.12

2008107452-Apr-5230-Apr-0856.08CSI4.39T2a34728LM, LTyespartial4-Dec-0816-Jun-09193.4611-Aug-145.15011-Aug-140.1hematospermia

21081315722-Jun-3427-May-0873.93VICC7.3T2a43746L, Ryes20-Apr-0918-Aug-09119.7919-Jun-144.83019-Jun-140.1

22090595725-Feb-3518-Feb-0973.98VCC7.1T2b43728RMM, RMLnonormal18-Jun-0915-Sep-0988.8226-Sep-145.0317-May-11117-May-1113-Jun-11

23090700716-Oct-3427-Feb-0974.37CSI9.17T2a437311RA, LB, LMyesnormal7-Oct-0919-May-10223.9913-Jan-143.65013-Jan-140.12

24093036921-Nov-4023-Nov-0969.00CSI6.4T2a34778LB, LM, LA, LT, RM, RA, RTno24-Mar-1016-Jun-1084.1130-Jun-144.04030-Jun-140.1

2511100605-Feb-3729-Apr-1174.23VCC13T2a34768RB, RMM, RML, RA, LM, LAnoimpotent19-Jul-1130-Aug-1142.3930-Apr-142.6709-Aug-12109-Aug-12

26111400916-Apr-3910-Jun-1172.15CSI9.4T2b43748Ryes5-Jul-1214-Nov-12131.935-Dec-120.0605-Dec-12perioperative mortality (Dec 5, 2012)

2711153558-Oct-4117-Jun-1169.69VCC1.1T2b347512RAM, RAL, RMM, RML, RBLnopartial29-Sep-116-Dec-1167.5818-Jul-142.61018-Jul-140.03

28111893520-Oct-5118-Jul-1159.74CSI7.43T1c34788R, Lyesnormal1-Feb-123-May-1292.0813-Jun-142.11013-Jun-141.69

2912078632-Apr-4720-Mar-1264.97VCC14T2a347510RMM, LB, LMM, RBM, LBMnonormal31-May-1212-Jul-1242.0011-Mar-141.66011-Mar-140.17

30122740711-Mar-5723-Aug-1255.45VCC12.7T2c347612RM, LB, LM, LAnonormal24-Jan-1319-Feb-1325.8528-May-130.27028-May-13

3113181046-Jul-5327-May-1359.89VICC10T1c347720LMM, LML, LA, LA, TZnonormal24-Oct-1323-Jan-1491.0810-Jul-140.46010-Jul-140.89

32895133220-May-367-Jun-0266.05VICC11T2a336713R, Lyespartial3-Jul-037-Oct-0395.8814-Jul-062.77014-Jul-060.08

33922702824-Sep-4321-Jun-0157.74FVCC7.5T2a336110LMyesnormal12-Feb-0214-May-0291.002-Jul-1412.1302-Jul-140.04radiation proctitis, plasma coagulation June 2009

613

Baseline Characteristics

Number of Patients32

Age

Median66

Range50 -76

PSA

200

Gleason

83

Clinical Stage

T1c8

T2a14

T2b3

T2c6

Missing1

Risk Category

Low6

Intermediate23

High3

Prostate Volume

Median35.8

Range21.7 - 61.4

Neoadjuvant ADT

Yes19

No13

Location

VCC17

CSI8

VICC6

FVCC1

Time

20001

20010

20026

20032

20041

20053

20064

20070

20082

20094

20102

20112

20123

20132

Baseline

Dosimetry

First ImplantSecond Implant

IDBCCA IDD90V100%V150%V200%SeedsRectum V50Rectum V100Rectum V150D50 UrethraV150 (%)Cold AreaCT/US RatioD90V100(%)V150%V200%CT/US RatioSeedsRectum V50Rectum V100Rectum V150D50 UrethraV150 (%)

10004886

2010630791.2865926103104.59260241152340

4011614989.183368.51111210117.99863261321410

50119309127.8988057110

60205137105.69343131172130136.11007730

7020776585.38244221242461116.99567311512161

8030301066.6704621924170125.397783911661241.7

9030320784.880318881930115.89555161012151

10040985670119.097542283

11042316059.75930121121940114.89564311322460

12050140376.374331468194192.7843112781630

13050302776.265238991400

14052351867.4683214113305099.1894518142

15060037483.38253281051810113.19378511304570

16060126989.1833291081900100.19047141222210

170613099105.8926238150

18070492587.979301087115.59759251071300

190723582112.39656251272110

20081074570.4733613118600111.59460251512200

21081315782.96421876101095.882271196900

22090595785.1813591371300121.09771331632100

23090700762.876522694119.396592411763110

240930369118.297632777144.7100875385400

25111006012097632113350092.50131.49882561411720

26111400972.874431788500

27111535574.77032999263077.61142.39987451333350137.140

28111893587.8866133781520

29120786388.5813611156625082.90105.59347191704182104.71

301227407113.99559301272040116.10

31131810469.680603149174135.53890.48758281245380

32895133276.2816226721310105.793734788

33922702849.86036138830103101.79141121152450

Urinary Toxicity

IDBCCA IDBaseline (1st Implant)Date First ImplantBaseline IPSS (second implant)Date Second Implant6 weeks3 months6 months1 year18 months2 years30 months3 years42 months4 years54 months5 years6 years7 years8 years9 years10 years

100048861-Aug-003-Oct-00

2010630724-Jan-0223-Apr-02

40116149218-Jul-02263-Sep-0213878325

5011930919-Feb-023128-May-023222138

60205137930-Jul-02185-Nov-0229152295

7020776595-Sep-022629-Oct-02232318131718

80303010228-Aug-03927-Nov-0314717

9030320722-Apr-0422-Jun-04

1004098562-Jun-101-Sep-103

1104231602610-Feb-0526-Apr-05203415212423221424

1205014038-Nov-0522-Dec-05

130503027320-Sep-05153-Jan-06365695425

1405235182-Mar-0618-Apr-06145143182022

1506003741523-Mar-06276-Jun-06282412

160601269126-Apr-068-Jun-06111136874

17061309902-Nov-0612-Dec-061594473843

18070492512-Mar-091016-Jun-096434511

19072358207-Oct-081718-Dec-08187512115

20081074594-Dec-083116-Jun-094211867

210813157320-Apr-092918-Aug-0927

220905957418-Jun-091715-Sep-091314

23090700757-Oct-091319-May-1098423

240930369424-Mar-101216-Jun-10536331

2511100601219-Jul-1130-Aug-1129147

26111400945-Jul-121514-Nov-12

271115355629-Sep-116-Dec-11111

28111893561-Feb-12163-May-12272515

291207863131-May-1212-Jul-121376

301227407024-Jan-1319-Feb-1312

311318104124-Oct-13823-Jan-14109

32895133263-Jul-03107-Oct-0313

339227028412-Feb-0214-May-02244834312

Sheet1

First ImplantSecond Implant

IDD90V100%V150%V200%SeedsRectum V50Rectum V100Rectum V150D50 UrethraV150 (%)Cold AreaCT/US RatioD90V100(%)V150%V200%CT/US RatioSeedsRectum V50Rectum V100Rectum V150D50 UrethraV150 (%)

1

291.2865926103104.59260241152340

489.183368.51111210117.99863261321410

5127.8988057110

6105.69343131172130136.11007730

785.38244221242461116.99567311512161

866.6704621924170125.397783911661241.7

984.880318881930115.89555161012151

1070119.097542283

1159.75930121121940114.89564311322460

1276.374331468194192.7843112781630

1376.265238991400

1467.4683214113305099.1894518142

1583.38253281051810113.19378511304570

1689.1833291081900100.19047141222210

17105.8926238150

1887.979301087115.59759251071300

19112.39656251272110

2070.4733613118600111.59460251512200

2182.96421876101095.882271196900

2285.1813591371300121.09771331632100

2362.876522694119.396592411763110

24118.297632777144.7100875385400

2512097632113350092.50131.49882561411720

2672.874431788500

2774.77032999263077.61142.39987451333350137.140

2887.8866133781520

2988.5813611156625082.90105.59347191704182104.71

30113.99559301272040116.10

3169.680603149174135.53890.48758281245380

3276.2816226721310105.793734788

3349.86036138830103101.79141121152450

V100

IDV100%V200% Increase

24973100

6937100

27702999

2597198

4831598

22811697

18791897

8702797

23762096

7821395

9801595

11593695

20732194

15821193

29811293

32811293

286692

33603191

1683790

14682189

3180787

12741084

21641882

V100



V200

218311

1214-212Mean13.0681818182Range-3 - 36

3313-11229.954545454511 - 56

169514

98816

1414418

2911819

226-224

2326-224

20131225

18101525

48.517.526

3131-328

6131730

722931

11121931

2292433

8211839

2793645

32262147

15282351

24272653

25213556

IDV200%

V200



V150

V150%ChangeV150%

21627

33031

36541

321345

361147

321547

312455

60058

52759

302959

59160

362460

362763

303464

442367

353671

621173

433477

532578

463278

631982

632487

325587

V150

V150% 1st Implant

V150% 2nd Implant

D90

IDD90

24118.226.5144.7

2774.767.6142.3

6105.630.5136.1

2512011.4131.4

866.658.7125.3

2285.135.9121

2362.856.5119.3

489.128.8117.9

785.331.6116.9

984.831115.8

1887.927.6115.5

1159.755.1114.8

1583.329.8113.1

2070.441.1111.5

3276.229.5105.7

2988.517105.5

291.213.3104.5

3349.851.9101.7

1689.111100.1

1467.431.799.1

2182.912.995.8

1276.316.492.7

3169.620.890.4

D90

D90 1st Implant

D90 2nd Implant

Time to Reimplant

IDBCCA IDDate of BirthDate of DiagnosisAge at DiagnosisImplant LocationASCENDEInitial PSAT StagePrimary GleasonSecondary GleasonGleason TotalCores PositiveTotal CoresLocation of CoresNeoadjuvant HTErectile Potency BaselineBaseline IPSSDate First ImplantDate Second ImplantTime to ReimplantDate of Last Follow-upTime from Reimplant to last Follow upBiochemical FailureMetastatic DiseaseMost Recent PSAToxicity

30122740711-Mar-5723-Aug-1255.45VCC12.7T2c347612RM, LB, LM, LAnonormal24-Jan-1319-Feb-1325.8528-May-130.27

17061309916-Apr-419-Jun-0665.15VICC6.3T1c347412L, Rnopartial2-Nov-0612-Dec-0639.8631-Mar-147.300.02

2912078632-Apr-4720-Mar-1264.97VCC14T2a347510RMM, LB, LMM, RBM, LBMnonormal31-May-1212-Jul-1242.0011-Mar-141.660.17

2511100605-Feb-3729-Apr-1174.23VCC13T2a34768RB, RMM, RML, RA, LM, LAnoimpotent19-Jul-1130-Aug-1142.3930-Apr-142.6709-Aug-12

12050140328-May-276-Dec-0477.53VCCyes18T2c45968LA, LMM, RA, RM,RMM, RByesnormal8-Nov-0522-Dec-0543.928-Jan-137.050.01

4011614911-Nov-251-Oct-0175.89VCC7.8T2a43728LB, LMM, LAyesnormal18-Jul-023-Sep-0247.022-Oct-1210.080.03

1405235184-Sep-3719-Oct-0568.12VCC8.1T2a34728RA, RBnonormal2-Mar-0618-Apr-0647.424-Sep-148.3822-Aug-11third implant R seminal vesicle, urinary and rectal incontinence

702077651-Apr-4015-Apr-0262.04VCC6.6T1c34746LA, LMM, LML, LByesnormal5-Sep-0229-Oct-0253.6128-May-085.580.09IPSS 18

9030320719-Mar-4430-Jan-0358.87VCCyes5.4T1c45999RB, RMM, RML,RA, LB, LMM, LML, LA, MPZyesnormal22-Apr-0422-Jun-0461.0024-Jul-1410.080.04

1606012691-Jun-334-Oct-0572.34VCC3.5T2c34758RA, RB, LB, LMM, LMLno6-Apr-068-Jun-0662.965-Jun-136.990.01

1000488626-Feb-449-Mar-0056.03VCC3.9T2a33636LA, LM, LBnonormal1-Aug-003-Oct-0063.0831-Jan-1312.330.02

2711153558-Oct-4117-Jun-1169.69VCC1.1T2b347512RAM, RAL, RMM, RML, RBLnopartial29-Sep-116-Dec-1167.5818-Jul-142.610.03

19072358222-May-4217-Sep-0765.32VCC13.9Tx336210RML, LByesnormal7-Oct-0818-Dec-0872.0822-Oct-134.840.12

15060037427-Feb-4720-Dec-0558.81VCC5.8T2c33666L, Rno23-Mar-066-Jun-0674.9916-Nov-126.450.02

11042316024-Oct-4628-Jul-0457.76CSI5.04T2c43766LA, LB, LM, RA, RB, RMyesimpotent10-Feb-0526-Apr-0575.0028-Mar-148.9207-Apr-1003-May-13

24093036921-Nov-4023-Nov-0969.00CSI6.4T2a34778LB, LM, LA, LT, RM, RA, RTno24-Mar-1016-Jun-1084.1130-Jun-144.040.1

22090595725-Feb-3518-Feb-0973.98VCC7.1T2b43728RMM, RMLnonormal18-Jun-0915-Sep-0988.8226-Sep-145.0317-May-1113-Jun-11

2010630724-Sep-5128-Mar-0149.51VCC7T2a33636LM, LA, RByesnormal24-Jan-0223-Apr-0289.0516-Jul-1412.230.01Self-catheter, TURP

8030301021-Nov-3328-Jan-0369.19VICC8.8T1c336211L,Ryesnormal28-Aug-0327-Nov-0391.0027-Jul-106.660.01radiation proctitis

33922702824-Sep-4321-Jun-0157.74FVCC7.5T2a336110LMyesnormal12-Feb-0214-May-0291.002-Jul-1412.130.04radiation proctitis, plasma coagulation June 2009

10040985615-Oct-3312-May-0975.57CSIyes6.7T1c45928LB, LMyesimpotent2-Jun-101-Sep-1091.0014-Jul-143.860.03

3113181046-Jul-5327-May-1359.89VICC10T1c347720LMM, LML, LA, LA, TZnonormal24-Oct-1323-Jan-1491.0810-Jul-140.460.89

28111893520-Oct-5118-Jul-1159.74CSI7.43T1c34788R, Lyesnormal1-Feb-123-May-1292.0813-Jun-142.111.69

32895133220-May-367-Jun-0266.05VICC11T2a336713R, Lyespartial3-Jul-037-Oct-0395.8814-Jul-062.770.08

18070492519-Feb-3012-Dec-0676.81CSI3.04T2c43722yes12-Mar-0916-Jun-0996.0417-Jul-145.080.1

5011930928-Jul-503-Dec-0151.35VCC2.9T2a33623RM, RBnonormal19-Feb-0228-May-0297.9711-Jul-075.120.04

6020513714-Dec-4320-Feb-0460.19VCC5T1c34718LByesimpotent30-Jul-025-Nov-0298.0028-Oct-052.980.01

13050302729-May-3629-Dec-0468.59VICC3.2T2a34777L,Ryesimpotent20-Sep-053-Jan-06104.925-May-148.330.02

21081315722-Jun-3427-May-0873.93VICC7.3T2a43746L, Ryes20-Apr-0918-Aug-09119.7919-Jun-144.830.1

26111400916-Apr-3910-Jun-1172.15CSI9.4T2b43748Ryes5-Jul-1214-Nov-12131.935-Dec-120.06perioperative mortality (Dec 5, 2012)

2008107452-Apr-5230-Apr-0856.08CSI4.39T2a34728LM, LTyespartial4-Dec-0816-Jun-09193.4611-Aug-145.150.1hematospermia

23090700716-Oct-3427-Feb-0974.37CSI9.17T2a437311RA, LB, LMyesnormal7-Oct-0919-May-10223.9913-Jan-143.650.12

Days to Reimplant

< 301

30 - 607

60-9010

90-12011

>1203

D90 First Implant

D90 2nd Implant

Seeds

SeedsSeeds

1031151299

11113221

110

117

1241512720

9211624

8810113

708313

11213220

687810

99

11314229

10513025

10812214

150

8710720

127

11815133

769620

13716326

9411723

77858

1331418

88

9913334

78

15617014

127

124

728816

8811527

1st Implant

Median99

Range68 - 156

2nd Implant

Seeds Added

Median20

Range8 - 34

Sheet4

ID-30236121824303642485460728496108120

1

2

422613878325

5313222138

691829152295

7926232318131718

82914717

9

103

1126203415212423221424

12

13315365695425

14145143182022

151527282412

1612111136874

1701594473843

18106434511

19017187512115

209314211867

2132927

224171314

2351398423

24412536331

251229147

26415

276111

28616272515

2911376

30012

3118109

3261013

334244834312

1. Age 2. Comorbidities3. ADT4. Never done for boost

pts5. D90/V1006. Rectal dose7. Pathology

tumour location GS

Who to re-implant?

32 replants ( 2-3 per year/~400)

Salvage LDR vs. salvage HDR

LDR Salvage AUR 33%Late Gr3 - 27% (strictures)

Dose related Med 154 vs.134GyPSA failure 20%

Present practicePartial gland salvage MRI based

May 2007Jan 201420 centers, 92 analyzed Med follow up of 54 moMed age 70 Med EBRT dose 74GyPSA

Up to 70% of PSA failures after radiation are due to local recurrenceand these patients could benefit from potentially curative salvage

1. Conformal dose 2. Dose tightly controlled 3. Low / ratio of

HDR for salvage?

? Dose? Volume? Toxicity? Outcomes

N dose Gr3 bNED FU

UCLA 21 36Gy/6 14% 89% 2y

Chan 52 32Gy/4 - 68%

Wojcieszek 83 - - 67%

Sunnybrook 6 27Gy/2 - -

Eligibility Criteria1. Life expectancy >10 years2. Previous EBRT dose up to 78Gy/39 fractions, 81 Gy/45 fractions or 70

Gy/28 fractions3. > 3 year interval since EBRT 4. No late toxicity from prior EBRT > grade 25. Rising PSA < 10 ng/ml 6. PSA DT > 6 months 7. Negative staging with CT scan of the abdomen/pelvis and bone

scan 8. Radiographic evidence of MRI dominant intraprostatic lesion (DIL) as

only area of recurrence (i.e unifocal recurrence) and corresponding to site of original disease

9. Biopsy confirmation of DIL with pathology review by BCCA GU pathologist (TB)

10.ECOG performance status 0-1 prior to registration11. IPSS < 16, or adequate voiding study (post void residual < 100cc and

peak flow rate > 10 cc/second).12.No prior trans urethral prostatic resection

Dose: 13.5Gyx2Urethral Dmax < 115%

Rectal D1cc < 6Gy, D0.1cc

Thank you

One of the symptoms of an approaching nervous breakdown is the belief that ones work is terribly important. Bertrand Russell

Slide Number 1Slide Number 2NRC recommendations QA makes a big difference in outcomesSlide Number 5Slide Number 6Slide Number 7Pre vs. Intraoperative planningMount Sinai NYPre vs. Intraoperative planningMount Sinai NY797 i-125 implant: mount sinaiPeripheral Needle /seed PlacementInterior Needle /Seed PlacementCompleted ImplantSlide Number 14Slide Number 15Slide Number 16Slide Number 17Slide Number 18US volume studySlide Number 20Why do you add margins?Extra Capsular ExtensionSeminal Vesicles involvementSlide Number 23July 1998 pt #1Slide Number 25Slide Number 26Mixed activity seedsSlide Number 28Slide Number 29Slide Number 30Slide Number 31Slide Number 32Slide Number 33Slide Number 34Slide Number 35Slide Number 36Slide Number 37MRI-CT fusionMR SequenceWhat if I cant get an MRI?Slide Number 41Slide Number 42Slide Number 43Slide Number 44Slide Number 45Slide Number 46Slide Number 47Slide Number 48Slide Number 49Slide Number 50Slide Number 51Dosimetry: V100Who to re-implant?Slide Number 54Slide Number 55Slide Number 56Slide Number 57Slide Number 58Slide Number 59

prostate brachytherapy master-class part...

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