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Naples Urology Associates CyberKnife® Team:

Urologist: DavidM.Spellberg,M.D.,FACS

RadiationOncologist: DebraFreeman,M.D. JayFriedland,M.D.

MedicalPhysicist: MaryEllenMasterson-McGary,M.S.

CASE STUDY

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Case HistoryThis70-year-oldmalewithahistoryofatrialfibrillation,hypertensionandbenignprostatichyperplasia(BPH)presentedwithelevatedprostatespecificantigen(PSA)of4.5ng/ml.HehadbeenfollowedbyhisurologistfortheprevioussixyearswithregularPSAmonitoring.HehadnofamilyhistoryofprostatecancerandunderwentaTURP2yearspriorforBPH.HisatrialfibrillationandhypertensionweremanagedbyCoumadin,Toprol,LanoxinandZestoretic.

Thepatient’ssymptomsincludednocturiatimestwoandahistoryoferectiledysfunction.Patientdeniedahistoryofdysuria,hematuria,urinaryincontinence,urinaryurgency,urinaryfrequencyorhesitancy.Transrectalultrasound(TRUS)guidedbiopsyrevealedadenocarcinomaoftheprostatein6of12biopsycores,allofwhichwerelessthan5%positiveandaGleasonscoreof3+3.Tumorwasfoundinbothlobesoftheprostate,andwasstagedcT1cbydigitalrectalexamination.ACTscanoftheabdomen/pelviswasunremarkableandabonescanwasnegativeformetastaticdisease.

CyberKnife® Treatment Rationale ThepatientwasevaluatedbyUrologyandRadiationOncologyforhisprostatecancer.Treatmentoptionsincludedsurgery,externalbeamradiationtherapy(IMRT,conformal)andCyberKnife®monotherapy.ThepatientwantedalessinvasiveandconvenienttherapyinordertocontinuehisworkanddaytodayactivitiesandthereforeelectedforCyberKnifemonotherapy.

Currentliteraturesuggeststhatprostatecancerwillrespond

favorablytohypofractionatedradiotherapyduetoitslowα/αratioofprostatecancer.1,2Severalgroupshavedemonstratedthathypofractionationschemesforprostatecancerachieveexcellentlocalcontrolwithminimaltoxicitytotheurethraandrectum.3,4CyberKnifestereotacticradiosurgeryhasbeenshowntodecreaseprostatetumorvolumeanddecreasePSAlevelsofhumanprostatecancercellsinamousemodel.5InitialstudiesofCyberKnifemonotherapyhaveshownbeneficialeffects,includingdecreasedPSAresultsandlowtoxicityinpatientswithorgan-confinedprostatecancer.6,7

DEMOGRAPHICSSex: Male Age: 70 Histology: Prostate Adenocarcinoma: stage T1c

CLINICAL HISTORYReferred by: UrologistPast Medical History: Transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH)

Multiplanar pre-treatment planning images show all 4 fiducial markers placed within the prostate.

Treatment Planning ProcessFourfiducialmarkerswereplacedunderintravenousconscioussedationintheprostatebytheurologistusingaTRUS-guidedtemplate.ElevendayslateraCTstudywasperformedwiththepatientinthetreatmentpositionusingacustomimmobilizationdevice.Thefiduciallocationswereidentifiedandtheprostateandcriticalstructures(rectum,bladder,andurethra)werecontoured.Theplanningtargetvolume(PTV)includedtheprostatewitha5-mmmargininalldirectionsexceptforasmaller3-mmposteriormargintodecreasedosagetotherectum.Treatmentplanningwasdesignedtoencompass95%ofthetargetvolumeandminimizedosetocriticalstructures.

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Prostate Volume: 29.5 ccImaging Technique(s): CTRx Dose & Isodose: 35 Gy to 82%Conformality Index: 1.39Tumor Coverage: 95%Number of Beams: 130

Fractions: 5 Path Template: 3 path 900_1000 mmTracking Method: FiducialCollimator(s): 20 mm and 35 mm

TREATMENT DETAILS

Treatment DeliveryAfewdaysaftertreatmentplanningthepatientbegantreatment.Aprescriptiondoseof35Gywasdeliveredin5fractionsover5consecutivedaystothe82%isodoseline.Twocollimatorsizeswereusedandaconformalityindexof1.39wasachieved.Therewere130beamsfrom111nodesdelivered.Followingthefourthtreatment,thepatientexperiencednocturiaandwasgiven0.4mgFlomaxwithresolutionofsymptoms.Thepatientreportedmildurinaryfrequencyandmildurgency5daysaftercompletionoflastfractionofradiosurgeryandwastreatedwithPyridiumwithresolutionofsymptoms.Overall,thepatienttoleratedthetreatmentwell.

Coronal and axial treatment plans showing the 82% prescription isodose line relative to the prostate (red). Lower percentage isodose lines demonstrate sparing of the rectum (green).

Dose-Volume Histogram (DVH) for prostate.

Inferior-superior 3D of bony anatomy and CyberKnife beam positions showing treated tumor with rectal sparing.

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At Naples Urology Associates, we are proud to offer our patients the best treatment options for a wide range of conditions. Our staff provides patients with several cutting edge treatment options depending on their needs. We believe in treating each case according to its unique conditions, so each patient that we see gets a customized treatment plan. We choose the least invasive treatments possible, including CyberKnife Radiosurgery, with the goals of prolonging life and preserving quality of life. Since our CyberKnife program began in 2004, we have treated over 400 patients with prostate cancer. See our website (www.urologyofnaples.com) or call us at 239-434-8565.

Outcome and Follow-Up• ThepatientrespondedtoCyberKnife®treatmentwithadecreaseinPSAvaluefrom4.5ng/mlto1.3ng/mlatonemonth followingradiosurgeryandto0.3ng/mlat8months• Thepatientexperiencedmildacuteurinarytoxicitieswhichresolvedwithmedication• Therewerenoreportedacuterectaltoxicities• Thepatienthasnowbeenfollowedfor3years;PSAremainsstableat0.3ng/ml,andthepatienthasexperiencednochronic

urinaryorrectaltoxicities

Conclusion and CyberKnife Advantages• CyberKnifemonotherapyproducedanearlyandstablereductioninPSAinapatientwithlow-riskorgan-confined prostatecancerwithminimalacuteurinarytoxicitiesandnonotedchronictoxicitiestodate• CyberKnifetreatmentprovidesaconvenient,minimallyinvasiveoptionforpatientswithearly-stage,organ-confinedprostatecancer

References1. Brenner DJ and Hall EJ. Fractionation and Protraction for Radiotherapy of Prostate Carcinoma. Int J Radiat Oncol Biol Phys 43: 1095-1101, 1999.2. King CR and Cotrutz C. Hypofractionated Radiotherapy for Localized Prostate Cancer: Therapeutic Rationale and Feasibility of the CyberKnife. Robotic Radiosurgery –

Volume 1, 315-323, CyberKnife Society Press, 2005.3. Martinez A, Pataki I, Edmundson G, Sebastian E, Brabbins D, Gustafson G. Phase II Prospective Study of the Use of Conformal High-Dose Rate Brachytherapy as Monotherapy

for the Treatment of Favorable Stage Prostate Cancer: a Feasibility Report. Int J Rad Oncol Phys Biol 49: 61-69, 2001.4. Yoshioka Y, Nose T, Yoshida K, Oh RJ, Yamada Y, Tanaka E, Yamazaki E, Inoue T, Inoue T. High-Dose Rate Brachytherapy as Monotherapy for Localized Prostate Cancer: a Retrospective

Analysis with Special Focus on Tolerance and Chronic Toxicity. Int J Rad Oncol Biol Phys 56: 213-220, 2003.5. Lotan Y, Stanfield J, Cho C, Sherwood J, Abdel-Aziz KF, Chang C, Forster K, Kabbani W, Hsieh J, Choy H, Timmerman R. Efficacy of High-Dose per Fraction Radiation for Implanted Hu-

man Prostate Cancer in a Nude Mouse Model. J Urology 175: 1932-1936, 2006.6. Jo MK, Park K, Kim KH, Cho CG, Lee C. Feasibility of CyberKnife for the Treatment of Localized Prostate Cancer: Preliminary Results: presented at the American Urological Association

annual meeting, Atlanta, GA, May 2006, Abstract # 1167.7. King CR, Brooks JD, Gill H, Pawlicki T, Cotrutz C, Presti JC. Stereotactic body radiotherapy for localized prostate cancer: interim results of a prospective phase II clinical trial. Int J Radiat

Oncol Biol Phys 73:1043-1048, 2009.

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