1. Prostate Radiotherapy A-Z
Dr Hamid Reza Dehghan Manshadi
Radiation Oncologist
Shahid Beheshti University of Medical Sciences

2. Distant metastasis (M)§
Staging
Clinical (cT)
T0 No evidence of primary tumor
T1 Clinically inapparent tumor neither palpable nor visible by imaging
T1a Tumor incidental histologic finding in 5 percent or less of tissue resected
T1b Tumor incidental histologic finding in more than 5 percent of tissue resected
T1c Tumor identified by needle biopsy (eg, because of elevated PSA)
T2 Tumor confined within prostate*
T2a Tumor involves one-half of one lobe or less
T2b Tumor involves more than one-half of one lobe but not both lobes
T2c Tumor involves both lobes
T3 Tumor extends through the prostate capsule•
T3a Extracapsular extension (unilateral or bilateral)
T3b Tumor invades seminal vesicle(s)
T4 Tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall
Distant metastasis (M)§
M0 No distant metastasis
M1 Distant metastasis
M1a Nonregional lymph node(s)
M1b Bone(s)
M1c Other site(s) with or without bone disease

3. TNM anatomic stage prognostic groups for prostate cancer*
Stage (T) (N) (M) PSA Gleason
I T1a-c N M PSA < Gleason ≤6
T2a N M PSA < Gleason ≤6
T1-2a N M PSA X Gleason X
IIA T1a-c N M PSA < Gleason 7
T1a-c N M PSA ≥10<20 Gleason ≤6
T2a N M PSA < Gleason ≤7
T2b N M PSA < Gleason ≤7
T2b N M PSA X Gleason X
IIB T2c N M Any PSA Any Gleason
T N M PSA ≥ Any Gleason
T N M Any PSA Gleason ≥8
III T3a-b N M Any PSA Any Gleason
IV T N M Any PSA Any Gleason
Any T N M0 Any PSA Any Gleason
Any T Any N M Any PSA Any Gleason

4. Risk stratification
• Low risk — Clinical stage T1c or T2a AND a serum PSA <10 ng/mL AND a biopsy Gleason score ≤6 (anatomic stage prognostic group I)
 • Intermediate risk — Clinical stage T2b OR a serum PSA between 10 and 20 ng/mL OR a biopsy Gleason score 7 (anatomic stage prognostic group IIA)
 • High risk — Clinical stage T2c disease OR a serum PSA >20 ng/mL, OR a biopsy Gleason score ≥8 (anatomic stage prognostic group IIB)

5. Treatment shedules EBRT : Brachytherapy : RADICAL PROSTATECTOMY
Indications : T1,/T2 some T3
Side Effects : Urinary incontinence, Impotence
EBRT :
Indications : T1/T4
Conformal, 3D , IMRT
Brachytherapy :
LDR (Seeds)
HDR (Ir 192)

6. Indications

7. Treatment options for localized prostate cancer
The Urologist’ s point of view
by country ? by hospital? by specialty ?
Differences in patients:
age (biologic), condition, QL--issues…
Differences: individual patient:
Anatomy,, erectile function…
Patient selection / Education
Cure potentials, Treatment Options

8. Equivalence between BT / EBT and Radical Prostatectomy
BT advantages :
PTV = CTV
- Real dose escalation (144 Gy)
- Fast treatment (/ERT)
- Low impotency rate (<RP and ERT)
- Low rectitis rate (/RTE)
- Low urinary complications (/RP)

9. Practical advantages of temporary HDR prostate brachytherapy
Radioprotection
– no free live sources
– no risk of source loss
– no radioprotection issues after discharge
Cheap: utilises existing HDR source and equipment
In some centers may be outpatient procedure

10. Physical advantages of temporary HDR prostate brachytherapy
• Brachytherapy enables localized high dose with reduced dose to critical normal tissues
– rectum, bladder, small bowel
• Uses volume definition after implant; can be
customised to individual volume with no organ
movement.
Can implant larger volume than permanent implant with certain dose delivery including extracapsular region and seminal vesicles

11. HDR implant: volume definition

13. HDR implant: biological advantage 2Gy EQD

14. Selection Criteria for Using HDR Brachytherapy in Patients With Prostate Cancer
Inclusion criteria
Tumor stages T1-T3b Tumor
invasion of
bladder neck
Any Gleason score
Any PSA level
Prostate volume ≤60-80 cc
Possible exclusion criteria
Distant metastases
Life expectancy <5 y
Substantial urinary obstruction
Inability to implant entire prostate
Patient unfit for anesthesia
TURP within previous 6 mo
Rectum-prostate distance <5 mm

15. HDR As Salvage (up To 76 Gy)
Indications and Patient selection for HDR-Brachytherapy(GEC- ESTRO) Recommendations
HDR As Boost To EBRT:
Stage >=T2B or, PSA>10 or GS>=7(intermediate/ Highrisk
HDR As Monotherapy:
Stage =<T2a and PSA=< 10 and GS=<7 (low risk
HDR As Salvage (up To 76 Gy)
No Mts, Biopsy confirmation, PSA relapse, Antianrogen resistance or intolerance

16. Indications for HDR prostate brachytherapy BOOST

19. CTV criteria GEC ESTRO guidelines
• CTV1: whole gland defined by capsule
– Margin around capsule may be added 3 –5 mm
• CTV2: peripheral zone
• CTV3: GTV
• PTV = CTV

20. OAR criteria GEC ESTRO guidelines
• Urethral dose <10Gy per fraction
• Rectal dose <6Gy per fraction

23. Intermediate risk prostate cancer External beam +HDR boost
– Highest overall BED
– Includes advantages of regional irradiation by external beam
– Includes advantages of conformality with HDR including extracapsular and seminal vesicle areas
– Optimal therapeutic ratio
– Dose delivery reliable

25. Dose and Fractions HDR Boost :PTV= CTV1 HDR Monotherapy : PTV=CTV1
45Gy EBRT + 2 implants (10.5 Gy*2)
 BED >94-100
HDR Monotherapy : PTV=CTV1
2 implants , 2* 9.5 Gy/implant total 38 Gy in 2 weeks BED =100 Gy
HDR Salvage :
4 implants * 6 Gy = 24 Gy in 12 weeks

26. EBRT + Boost : Less Failure, Less Toxicity
Results
HDR Boost :
Late toxicity : Rectum
EBRT (76 Gy ) EBRT+HDRBoost(86Gy)
Grade % %
Grade % %
Grade % (Bleeding) %
Grade %
Bladder
Grade % %
Grade % %
Grade % %
Grade
EBRT + Boost : Less Failure, Less Toxicity

27. LONG-TERM COMPLICATIONS ?
Brachy (a) RRP XRT
Urethritis % N/A %
Stricture % % %
Incontinence <1% (b) - 30 (c) % %
Rectal/proctitis 5% N/A %
Impotence:
< % % d
60 – % % d vs. 70% (e) 30%
> % % d
(a) No pre-implant TURP
(b) Center of excellence
(c) Population studies
(d) Nerve sparing
(e) Non-nerve sparing

31. Target Volume Delineation

32. HDR Monotherapy for Localised Prostate Cancer
HDR brachytherapy is an established technique enabling high dose delivery to prostate gland
HDR brachytherapy has potential advantages especially for more advanced prostate cancer
– Physical implant flexibility
– Biological advantage of large fractions

33. HDR Monotherapy for Localised Prostate Cancer Conclusions
HDR monotherapy is feasible and can deliver 4
fractions over 3 days with one implant procedure
Acute toxicity is limited to transient urinary
disturbance, returning to baseline at 12 weeks
Early biochemical results for advanced disease
are encouraging.
Further dose escalation is possible or necessary

36. Post operative follow up
Foley catheter removed on Day 2
No residual pain
Recommandations/information
Acute effects
Irritation syndrome
Retentionnal syndrome
Radiation hazards

37. HDR Monotherapy :
OS; 98.9% ,PSA Specific control :100%, Biochemical control : 97.2%
GU Toxicity GI Toxicity
Grade0 34% %
Grade % %
Grade %
Grade %