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Prostate Update ~
What’s New in Radiation Therapy
DR. RAPHAEL CHEE FRANZCR
Asst. Prof. School of Surgery, UWA Radiation Oncologist &
Director of Cancer Services Genesis CancerCare Shenton House
“Holy Grail” of Radiation Therapy
The tumour receives 100% of the prescribed radiation therapy dose
The adjacent normal tissue receives 0% of dose
The dose is adequate to completely eradicate all cancer cells
Organ function is maintained
Case Study
Clinical • 57yo with PSA 6ug/L • DRE early T3a • TRUS = Gleason 4+4 • Staging CT = cN0M0 • WBBS = NED
RP & Pelvic node sampling • Gleason 4+5 • Bilateral periprostatic
invasion • Positive margins bladder
and lateral • Bilateral seminal vesicle
invasion • 0/6 pelvic nodes
Post-op Course
• PSA 2 months post-op = 0.1 ug/L
• Choline PET = NED
• Regained good urinary control & continence 2 months post-op
High Risk Prostate Cancer - Not necessarily poor prognosis • cT3-T4 or, • Gleason ≥ 8 (new ISUP Grade 4 & 5), or • PSA > 20 ug/L
• Predicts for >15% risk nodal metsPartin
• Prognosis for 1 vs 2 vs 3 features • PCSS (Belgium retrospective series post-open RP at 10
years): – 95% vs 88% vs 80% – Multi-modality Rx, multiple lines
Standard of Care
Treatment Plan
• Prostate/SV bed RT 66-70Gy (6-7 weeks)
• 2-3 years concurrent & adjuvant Androgen Deprivation Therapy (ADT)TROG 1996, RTOG 1986 & 1992
Toxicity Profile • Hot flushes • Fatigue • Impaired performance • Emotional lability/depression • Weight gain • Late Bladder/Bowel 3D-CRT
toxicity – 70% Grade 0 – 25% Grade 1 – 3% Grade 2 – 1% Grade 3
Volumetric Modulated Arc Therapy
Dose-Target Conformity VMAT vs 3DCRT
Daily treatment 7-10 mins VS 15-20mins
IGRT - Daily Cone-Beam CT
Pelvic RT with VMAT has low toxicity
• Genesis Cancer Care WA – 60 cases since 2013
• Bowel & bladder late effects – Grade 1 = 30% Bowel, 12% Bladder – Grade 2/3/4 = 0%
• PSA failure rate 15% at 3 years
– Most failures occur within 12 months of completing RT
– Rx ADT
PSMA PET is useful
• Prostate Specific Membrane Antigen • Still experimental • But sensitivity seems to drop if PSA < 0.5ug/L
Summary
• Curative-intent Pelvic VMAT is highly tolerable • Patient selection is important
– Nodal disease confined to pelvis – Predicted longevity of life
• If not curative, at least prolongs interval before ADT required
• Maintains Quality of Life