World Congress of Brachytherapy 10-12 May, 2012 - Estro-events.org

S12 World Congress of Brachytherapy 2012
204 patients were identified as having a high risk anatomic prostate
gland (50cc, or history of prior TURP). 46 patients were
identified as having ultrasound prostate volume of ≤20 cc at the time
of the implant (median, 17.8cc, range 6.7cc20cc; lower quartile,
6.7cc15.5cc). 121 patients were identified as having ultrasound
prostate volume of ≥50 cc at the time of the implant (median, 61cc,
range 50cc116cc; upper quartile 74cc116cc). 37 patients were
identified as having a history of a prior TURP. In the standard risk
group there were 443 patients, the median ultrasound prostate
volume was 32.8cc (range, 20.249.8).
Neoadjuvant hormone therapy was not routinely recommended unless
the initial ultrasound prostate volume suggested significant pubic arch
interference or the patient's Gleason score and or prostate specific
antigen placed the patient in either intermediate or high risk
categories. Patients received HDR brachytherapy as a boost either
before or after 4500 cGy of external beam radiotherapy (3D conformal
until 2006 and IMRT thereafter). Boost brachytherapy doses ranged
from 1600 1900 cGy, given in 23 fractions, with the most common
fractionation schedule being 950 cGy in two daily fractions given on
the same day as the implant with a minimum 6 hours interval between
fractions.
: The dosimetric findings are as follows:
Patient
Group
D90 V100 V150 D5 rectum D5 urethra
50cc Median106.2% 95.1% 18.2% 55.4% 109.7%
N=121 Range 95117% 9099% 3.335% 3771% 103121%
TURP Median 107.8% 94.7% 19.3% 54.2% 107.8%
N=37 Range 102.5117% 87.9100% 5.332% 3474% 101121%
Standard Median 107.5% 95.5% 18% 51% 110%
N=443 Range 94117% 83100% 336.5% 2473% 97122%
*High risk groups in bold
With a median of 5.1 years, there have been nine grade II urethral
strictures (CTCAE v.3) for the entire cohort. Four of these occurred in
the anatomic high risk group and five occurred in the standard risk
group. There was one grade II incontinence in the high risk group and
one grade I incontinence in the standard risk group. There was only
one grade II or higher toxicities found in the high risk group as well as
only a single grade II gastrointestinal toxicity in the standard group.
: In our experience, cases traditional deemed as
unsuitable for prostate brachytherapy (50cc, prior TURP) are
well managed with HDR brachytherapy with the expectation of
excellent dosimetric coverage acceptable long term toxicities.
OC29
SALVAGE HDR BRACHYTHERAPY FOR RECURRENT PROSTATE CANCER
AFTER PRIOR DEFINITIVE RADIOTHERAPY: FIVE YEAR OUTCOMES
C.P. Chen 1 , V. Weinberg 2 , K. Shinohara 3 , M. Nash 1 , A. Gottschalk 1 , M.
Roach III 1 , I. Hsu 1
1
UCSF Comprehensive Cancer Center, Radiation Oncology, San
Francisco, USA
2
Helen Diller Family Comprehensive Cancer Biostatistics Core,
Biostatistics, San Francisco, USA
3
University of California San Francisco, Urology, San Francisco, USA
: Evaluate the efficacy and toxicity of salvage high
dose rate brachytherapy (HDRB) for locally recurrent prostate cancer
after definitive radiotherapy (RT).
: From November 1998 to June 2009, we
retrospectively analyzed 52 consecutively accrued patients undergoing
salvage HDRB for locally recurrent prostate cancer after prior
definitive RT. After pathologic confirmation of locally recurrent
disease, all patients received 36 Gy in 6 fractions. Twentyfour
patients received neoadjuvant hormonal therapy prior to salvage
whereas no patients received adjuvant hormonal therapy.
Determination of biochemical failure (bF) after salvage HDRB was
based on the Phoenix definition. The 5 year probability estimates of
overall survival (OS) and bF were calculated using KaplanMeier
method. Univariate analyses were performed using the log rank test
for categorical variables and Cox’s proportional hazards model for
continuous variables to identify predictors of bF. Based on the
Common Terminology Criteria for Adverse Events (CTCAE version 4),
acute (less than 3 months postsalvage) and late (more than 3 months)
genitourinary (GU) and gastrointestinal (GI) toxicities were
documented.
: Median followup after salvage HDRB was 59.6 months
(range, 5.9 – 154.7 months). The 5year KaplanMeier estimate of OS
was 92% (95% confidence interval (CI) 8097%) without median survival
yet reached. Fiveyear biochemical control after salvage was 51% (95%
CI 3466%). Median PSA nadir postsalvage was 0.1 (range 0 – 7.2) for
all patients. However, patients who were bNED had median PSA nadir
of 0.025 (range 0 – 0.6) whereas those who recurred after salvage had
a median nadir (PSA) of 0.49 (range 0 – 7.2). On univariate analysis,
disease free interval after initial definitive radiotherapy (p=0.07),
interval from 1 st recurrence to salvage HDRB (p=0.09), and preHDRB
PSA (p=0.07) were of borderline significance in predicting bF after
salvage HDRB.
Fortysix patients are alive (27 NED) and 6 patients have died (2 NED).
Overall, after salvage HDRB, 22 patients developed disease
recurrence with 16 having biochemical failure without pathologic or
radiographic confirmation of recurrence, 3 with pathologic local
recurrence, 2 with regional recurrence, and one with distant
metastasis.
Overall there were no Grade 4 or 5 toxicities and very few Grade 3
acute or late symptoms. Acute and late grade 3 GU toxicities were
observed in only 2% and 2%, respectively. There was minimal GI
toxicity with no Grade 2 or higher acute events and only 4% grade 2
late events.
: We present the largest series of patients treated with
salvage HDR brachytherapy for locally recurrent prostate cancer after
prior definitive RT. Prostate HDR brachytherapy is an effective
salvage modality with few toxicities. We provide potential predictors
of biochemical control for prostate salvage HDR brachytherapy.
World Congress of Brachytherapy 2012 S 13
OC30
RESULTS OF I125 STRANDS + EBRT +ADT IN LOCALIZED PROSTATE
CANCER COMPARED TO KATTAN (2002) NOMOGRAM PREDICTIONS
J. Zimmermann 1 , P. Zimmermann 2 , C. Moustakis 3
1
Praxiszentrum Alstertal, and Interdisziplinäres Prostatazentrum
Kath. Marienkrankenhaus, Hamburg, Germany
2
Praxiszentrum Alstertal, Hamburg, Germany
3
Institut für Medizinische Physik, Klinik für Strahlentherapie,
Münster, Germany
: To evaluate the 5year biochemical progression
free survival after prostate brachytherapy with I125 strands +EBRT+
ADT and compare the results to pretherapeutic prediction tools.
Furtheron evaluation of TURP and clinical proctitis after treatment.
: Between 01/2004 and 12/2007, n=604
consecutive patients with localized prostate carcinoma (N0M0) were
treated in curative intention with iodine 125 strands (145 Gy
Mono/108 Gy with EBRT). N=71 patients had EBRT 45 Gy, n=153 ADT.
Intraop preplanning in 2004 and 2005, intraop online planning in 2006
and 2007. N=7 were lost to follow up, n=597 evaluable. N=313 had low
risk (LR), n=204 intermediate risk (IR) and n=80 high risk (HR) disease
according to the d´Amico classification. Mean follow up was 60,01
months (392). The endpoint was freedom from biochemical
progression (FFBP) according to the Phoenix criteria. The analysis
evaluates this endpoint for risk grouping, initial PSA level, Gleason
score, age, prior TURP, mean seed activity, additional ADT and more.
Furtheron we looked at side effects (TURP, proctitis). The results are
compared to the patient related averaged 5yearpredictions from the
Kattan/MSKCC nomogram (2002) in order a. to compare the results to
internationally established outcome predictions for RPX, EBRT and
Brachy +EBRT (BE), b. to normalize the subgroup results and c.
therefore to identify potential good or weak spots for quality
assurance.
: Overall FFBP was 93.3%. FFBP was 96.49% in LR group
(Kattan: RPE 90%/EBRT88%/BE 89%), 90,2% in IR (Kattan: RPE
75%/EBRT 77%/BE 80%) and 88,88 % in HR group (Kattan: RPE
62%/EBRT 56 %/BE 81%). PSA < 10 ng/ml showed a FFBP of 94.35%,
PSA 10 20 ng/ml of 95,24 (!) %. FFBP in Gleason =8 87.5%. After TURP for
LR patients, FFBP was 86.7% (Kattan: RPE 90%/EBRT 90%/BE 89%) ,
after TURP for IR patients 88.89 % (Kattan: RPE 77%/EBRT 79%/BE
84%) and after TURP for HR patients 75% (Kattan: RPE 62%/EBRT
56%/BE 83%) . FFBP in patients < 65 years was 93.79%, 6574 years
92.33% and in patients > 75 years 97.06 %. Patients without ADT had
FFBP of 94.37% (Kattan: RPE 84%/EBRT82%/BE 86%), patients with ADT
90.2% (Kattan: RPE 75%/EBRT74%/BE 80%).
Activity per seed 0.7 mCi of 95.24%.
After brachytherapy alone, TURP rate was 3,9%, rate of proctitis
I/II/III was 2.1%. After brachytherapy and EBRT, TURP rate was 6.5%
and proctitis I/II/III rate 8.7 %.
:
1. FFBP in all risk groups after a mean follow up of 60 months is
excellent and compared to the patient related predictions from 2002
Kattan/MSKCC nomograms signifantly better than predictions for RPX
and EBRT as well as for Brachy+EBRT.
2. It is possible to normalize the patients outcome in subgroups with
the individual progression risks, which is especially interesting for
analysis of subgroups with special aspects or individual risks.
3. Thus, comparing results with the subgroup related averaged
nomogram predictions might be a promising tool for intra/and
interinstitutional quality assurance or clinical trials.
OC31
COMPARISON OF DISTANT METASTASES FOR PROSTATE CANCER
PATIENTS TREATED WITH PROSTATECTOMY, BRACHYTHERAPY OR IMRT
M. Zelefsky 1 , J. Eastham 2 , P. Scardino 2 , X. Pei 1 , M. Kollmeier 1 , B.
Cox 1 , Y. Yamada 1
1
Memorial SloanKettering Cancer Center, Radiation Oncology, New
York, USA
2
Memorial SloanKettering Cancer Center, Urology, New York, USA
: To compare the longterm distant metastases
free survival outcomes (DMFS) for patients with clinically localized
prostate cancer treated with radical prostatectomy (RP),
brachytherapy (BRT) or intensity modulated external beam
radiotherapy (IMRT).
: Between 1993 and 2009, 5316 patients with
clinical stages T1cT2c were treated with RP (n=2870), BRT (n=1344)
or IMRT (n=1102). In the BRT cohort, 910 patients were treated with
monotherapy, and 434 patients with higherrisk disease were treated
with a combined modality approach which utilized supplemental IMRT
to a dose of 4550.4 Gy. Patients treated with IMRT alone were
treated to > 81 Gy. Patients were classified according to the NCCN
risk group classification. The median follow up was 4.8 years (range:
217 years).
: The 7year DMFS for the RP, BRT and IMRT groups were 1.5%,
0.8% and 3.6 % (p< 0.001). In the low risk group no significant
differences were observed between the treatment cohorts ; the 7
year DMFS rates were 0.7%, 0% and 1.2% for RP, BRT and IMRT groups
(overall p value=1.0). For the intermediate risk cohort, IMRT patients
experienced a higher incidence of distant metastases compared to the
other cohorts; the 7year DMFS rates were 2.5%, 2.5% and 4.9% for RP,
BRT and IMRT groups (p= 0.02). Cox regression analysis revealed the
following variables to be associated with an inferior DMFS: higher
clinical stage (p=0.004), biopsy Gleason score 7 vs 6 (p