Acute Toxicity for Acute Toxicity for Prostatectomy Patients - - PowerPoint PPT Presentation

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Acute Toxicity for Acute Toxicity for Prostatectomy Patients - - PowerPoint PPT Presentation

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Acute Toxicity for Acute Toxicity for Prostatectomy Patients receiving Prostatectomy Patients receiving y y g g I ntensity Modulated Radiotherapy I ntensity Modulated Radiotherapy V . Kong, T. Craig, A. Bayley, R. Bristow, C. Catton, P

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SLIDE 1

Acute Toxicity for Acute Toxicity for Prostatectomy Patients receiving Prostatectomy Patients receiving y g y g I ntensity Modulated Radiotherapy I ntensity Modulated Radiotherapy

V . Kong, T. Craig, A. Bayley, R. Bristow, C. Catton, P . Chung, M. Gospodarowicz, M. Milosevic, P . Warde, C. Ménard

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SLIDE 2

I ntroduction I ntroduction I ntroduction I ntroduction

Radical Prostatectomy

Effective treatment for patients with favorable

prognostic factors

Intent of Post-Operative Radiotherapy

Reduces local recurrence rate for high risk patients

Used as either adjuvant or salvage therapy

  • V. Kong, PMH Conference
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SLIDE 3

Post Post-Operative Radiotherapy Operative Radiotherapy Post Post Operative Radiotherapy Operative Radiotherapy

Treatment Volume & Technique

q

Defined using bony landmark 4 Field Box

  • V. Kong, PMH Conference
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SLIDE 4

Side effects from Radiotherapy Side effects from Radiotherapy Side effects from Radiotherapy Side effects from Radiotherapy

Gastrointestinal (GI) Gastrointestinal (GI)

Proctitis Loose bowel movement Loose bowel movement

  • r diarrhea

Genitourinary (GU)

y ( )

Urinary incontinence Increased frequency Pain/Burning senation

  • V. Kong, PMH Conference
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SLIDE 5

Advancement of Technology Advancement of Technology Advancement of Technology Advancement of Technology

New consensus guideline for prostate bed

g p Clinical Target Volume (CTV) definition

Increase volume? -> Increase toxicity?

  • V. Kong, PMH Conference
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SLIDE 6

The need to change The need to change The need to change The need to change

Treatment technique

q

Conformal 4 field box

62.7 Gy

  • V. Kong, PMH Conference

55.0 Gy

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SLIDE 7

Objectives Objectives Objectives Objectives

To describe the development of an Intensity

p y Modulated Radiotherapy (IMRT) technique for the Prostate Bed T t th li i l d i t i h t i ti f

To report the clinical dosimetric characteristics of

the new technique

To report acute GI and GU toxicity outcomes To report acute GI and GU toxicity outcomes To compare results with a historical cohort

treated by 4 field box technique (4FB) treated by 4 field box technique (4FB)

  • V. Kong, PMH Conference
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SLIDE 8

Method Method Method Method

50 patients accrued to prospective trial

p p p

  • V. Kong, PMH Conference
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SLIDE 9

Process Flowchart Process Flowchart Process Flowchart Process Flowchart

Patient Education Session at e t ducat o Sess o CT Simulation Delineation of Regions of Interest (ROI) Generation of IMRT Distribution Treatment

  • V. Kong, PMH Conference
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SLIDE 10

Process Flowchart Process Flowchart Process Flowchart Process Flowchart

Patient Education Session at e t ducat o Sess o CT Simulation Delineation of Regions of Interest (ROI) Generation of IMRT Distribution Treatment

  • V. Kong, PMH Conference
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SLIDE 11

CT Simulation CT Simulation CT Simulation CT Simulation

Full bladder and empty rectum

p y

Pelvic vacuum immobilization device

  • V. Kong, PMH Conference
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SLIDE 12

Process Flowchart Process Flowchart Process Flowchart Process Flowchart

Patient Education Session at e t ducat o Sess o CT Simulation Delineation of Regions of Interest (ROI) Generation of IMRT Distribution Treatment

  • V. Kong, PMH Conference
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SLIDE 13

Clinical Target Volume Clinical Target Volume Clinical Target Volume Clinical Target Volume

Inferior CTV (ICTV) Superior CTV (SCTV)

  • V. Kong, PMH Conference

Wiltshire et al. IJROBP 2007 69(4); 1090-1099

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SLIDE 14

Planning Target Volume Planning Target Volume Planning Target Volume Planning Target Volume

Planning Target Volume (PTV) Margin (mm)

g g ( ) g ( )

Online guidance using soft tissue/surgical clip

  • Chu, 2007

AP SI RL AP SI RL SCTV

14 13 7

I CTV

10 11 5

I CTV

10 11 5

  • V. Kong, PMH Conference
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SLIDE 15

Organ at Risk (OAR) Organ at Risk (OAR) Organ at Risk (OAR) Organ at Risk (OAR)

Rectal Wall (RW)

( )

Bladder Wall (BW) Penile Bulb (PB)

Penile Bulb (PB)

Femur

  • V. Kong, PMH Conference
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SLIDE 16

Process Flowchart Process Flowchart Process Flowchart Process Flowchart

Patient Education Session at e t ducat o Sess o CT Simulation Delineation of Regions of Interest (ROI) Generation of IMRT Distribution Treatment

  • V. Kong, PMH Conference
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SLIDE 17

I MRT I MRT I MRT I MRT

7 field step-and-shoot distribution

p

Dose fractionation

66Gy in 33 fractions

y

  • V. Kong, PMH Conference
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SLIDE 18

I MRT I MRT I MRT I MRT

  • Treatment planning objectives

p g j

1.

Avoid irradiating rectum circumferentially to 55 Gy

  • V. Kong, PMH Conference
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SLIDE 19

I MRT I MRT I MRT I MRT

Posterior Rectal Wall (pRW)

(p )

62 7 Gy 62.7 Gy 55.0 Gy

  • V. Kong, PMH Conference
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SLIDE 20

I MRT I MRT I MRT I MRT

  • Treatment planning objectives

p g j

1.

Avoid irradiating rectum circumferentially to 55 Gy

2.

PTV D99 ≥ 54 Gy

  • V. Kong, PMH Conference
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SLIDE 21

I MRT I MRT I MRT I MRT

  • Treatment planning objectives

p g j

1.

Avoid irradiating rectum circumferentially to 55 Gy

2.

PTV D99 ≥ 54 Gy

3.

Maximize % of PTV receiving 95% of i ti d V prescription dose – V95

  • V. Kong, PMH Conference
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SLIDE 22

Dose Constraints Dose Constraints Dose Constraints Dose Constraints

Organs at Risk Metric Dose (Gy)

Rectal Wall 1 cm3

≤ 66 0

Rectal Wall 1 cm3

≤ 66.0

Bladder Wall 2 cm3

≤ 67.3

Penile Bulb 0.5 cm3

≤ 66.0

Femur 1 cm3

≤ 55.0

  • V. Kong, PMH Conference
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SLIDE 23

Monitoring Side Effect Monitoring Side Effect Monitoring Side Effect Monitoring Side Effect

Acute Toxicity Scoring

y g

Common Terminology Criteria Adverse Events

(CTCAE) v3.0

  • V. Kong, PMH Conference
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SLIDE 24
  • V. Kong, PMH Conference
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SLIDE 25

Monitoring Side Effect Monitoring Side Effect Monitoring Side Effect Monitoring Side Effect

Acute Toxicity Scoring

y g

Common Terminology Criteria Adverse Events

(CTCAE) v3.0

GI GU

Diarrhea Frequency Diarrhea Frequency Proctitis Haematuria Cystitis Cystitis Spasm

  • V. Kong, PMH Conference
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SLIDE 26

I s I MRT better? I s I MRT better? I s I MRT better? I s I MRT better?

Comparison with 4FB technique

p q

23 patients with acute toxicity scored using

CTCAE v3.0

Dose to Rectal Wall and Bladder Wall Acute GI/GU toxicity

  • V. Kong, PMH Conference
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SLIDE 27

Result Result Result Result

Mean PTV V95 = 95.2% (SD = 2.1)

95

( )

16 18 20 10 12 14 16

Number

  • f

4 6 8

  • f

Patients

2 90 92 94 96 98 100

PTV V95 (% )

  • V. Kong, PMH Conference

PTV V95 (% )

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SLIDE 28

Result Result Result Result

64.0

Patient A

60.0 62.0 56.0 58.0

PTV D99 (Gy)

R

2 = 0.8514

52.0 54.0 90.0 92.0 94.0 96.0 98.0 100.0

Patient B

Mean PTV D99 = 57.8 Gy (Range: 53.4 – 62.9 Gy)

PTV V95 (%)

  • V. Kong, PMH Conference

99

y ( g y)

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SLIDE 29

Result Result Result Result

Patient A Patient B

62.7 Gy 55.0 Gy

  • V. Kong, PMH Conference
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SLIDE 30

Result Result Result Result

Acute GI Toxicity

y

Score Diarrhea Proctitis GI

19 (38%) 17 (34%) 10 (20%) 19 (38%) 17 (34%) 10 (20%) 1 25 (50%) 23 (46%) 27 (54%) 2 6 (12%) 13 (20%) 13 (26%) 2 6 (12%) 13 (20%) 13 (26%) 3

  • V. Kong, PMH Conference
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SLIDE 31

Result Result Result Result

Acute GI Toxicity

y

Score Diarrhea Proctitis GI

19 (38%) 17 (34%) 10 (20%) 19 (38%) 17 (34%) 10 (20%) 1 25 (50%) 23 (46%) 27 (54%) 2 6 (12%) 13 (20%) 13 (26%) 2 6 (12%) 13 (20%) 13 (26%) 3

  • V. Kong, PMH Conference
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SLIDE 32

Result Result Result Result

Acute GU Toxicity

Score Frequency Haematuria Cystitis Spasms GU

19 (38%) 45 (90%) 39 (78%) 27 (54%) 14 (28%) 19 (38%) 45 (90%) 39 (78%) 27 (54%) 14 (28%) 1 24 (48%) 5 (10%) 10 (20%) 20 (40%) 28 (56%) 2 5 (10%) 1 (2%) 3 (6%) 6 (12%) 3 2 (4%) 2 (4%)

  • V. Kong, PMH Conference
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SLIDE 33

Result Result Result Result

Acute GU Toxicity

Score Frequency Haematuria Cystitis Spasms GU

19 (38%) 45 (90%) 39 (78%) 27 (54%) 14 (28%) 19 (38%) 45 (90%) 39 (78%) 27 (54%) 14 (28%) 1 24 (48%) 5 (10%) 10 (20%) 20 (40%) 28 (56%) 2 5 (10%) 1 (2%) 3 (6%) 6 (12%) 3 2 (4%) 2 (4%)

  • V. Kong, PMH Conference
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SLIDE 34

Result Result Result Result

Comparison of Dose to Rectal Wall

p

100 4F B IMR T 60 80 N

  • rmalized

V

  • lume

IMR T 20 40 V

  • lume

(%) 1000 2000 3000 4000 5000 6000 7000 D

  • se (cG

y)

  • V. Kong, PMH Conference

D

  • se (cG

y)

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SLIDE 35

Result Result Result Result

Comparison of Dose to Bladder Wall

p

80 100 4F B IMR T 60 80 N

  • rmalized

V

  • lume

20 40 (%) 1000 2000 3000 4000 5000 6000 7000

Dose (G y)

  • V. Kong, PMH Conference

Dose (G y)

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SLIDE 36

Result Result Result Result

Comparison of Acute GI/GU Toxicity Score ≥ 2

p y

40 50

IM R T 4F B

20 30 40 N umber

  • f

P atient 10 20 (%)

G I G U

GI and GU Chi Square value = 5.21 & 9.77, df = 1, p < 0.05

  • V. Kong, PMH Conference

G a d GU C Squa e a ue 5 & 9 , d , p 0 05

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SLIDE 37

Conclusion Conclusion Conclusion Conclusion

Avoidance of circumferential irradiation of rectum

to 55Gy with minimal compromise of PTV coverage is achievable with IMRT

The use of IMRT reduces acute GI/GU toxicity rate

when compared with the 4FB technique

Ongoing investigation to determine if improved

dosimetry to OARs translates to improved late toxicity and biochemical control toxicity and biochemical control

  • V. Kong, PMH Conference
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SLIDE 38

Acknowledgment Acknowledgment Acknowledgment Acknowledgment

  • Dr. Kirsty Wiltshire

y

  • Dr. William Chu

Clinical Trial Co-ordinators

Clinical Trial Co ordinators

Debbie Tsuji Bernadeth Lao

  • V. Kong, PMH Conference