The Role of Cyberknife Stereotactic Body Radiation Therapy in the Treatment of Prostate Cancer Jay L. Friedland, MD.

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Presentation transcript:

The Role of Cyberknife Stereotactic Body Radiation Therapy in the Treatment of Prostate Cancer Jay L. Friedland, MD

History of Modern Prostate Radiotherapy LDR Brachytherapy Late 80’s-Present 3D-CRT Early 90’s - Present HDR Brachytherapy Mid-90’s - Present IMRT Late 90’s to Present IGRT (Cyberknife) 2001 - Present Jay L. Friedland, M.D.

The Balancing Act Convenience Invasive Toxicity Efficacy IMRT Low No High LDR BrachyTx Yes X 1 Mod HDR Moderate Yes X 2 Low/Mod Very High CK Very Low TBD Jay L. Friedland, M.D.

Dose Calculations for Cyberknife Stereotactic Body Radiation Therapy Perform BED dose calculations For CK, one can fractionate the therapy yet remain convenient and non-invasive for the patient CK doses are most like HDR, since the dose/fraction, total doses and time factors are similar SHARP trial from Virginia Mason Hospital with good results (33.5Gy/5fx) Thus, since we have intermediate and long term results with HDR, CK appears to be a reasonably well founded treatment option Jay L. Friedland, M.D.

BED Calculations External Beam Radiation Therapy / HDR BED = nd [ 1 + (d/ α/β) ] Low Dose Rate Permanent Decaying Implants BED = (Ro/ λ) { 1 + [ Ro/(μ+ λ)(α/β)] } Definitions of parameters n = # fractions d = daily dose Ro = initial dose rate of implant λ = radioactive decay constant = 0.693/T1/2 T1/2 = radioactive half-life of isotope μ = repair rate constant = 0.693/t1/2 t1/2 = tissue repair half-time Jay L. Friedland, M.D.

Calculating BED For Low Risk CaP Monotherapy Treatment Regimens 81Gy IMRT/ 45fx / 9 weeks (BED 1.5 = 178.2, BED 3 = 129.6 ) HDR monoTx @ 9.5Gy X 4fx (BED 1.5 = 278.7, BED 3 = 158.3) HDR monoTx @ 8.55Gy X 4fx (BED 1.5 = 229.1, BED 3 = 131.7) HDR monoTx @ 7.25Gy X 6fx (BED 1.5 = 253.7, BED 3 = 148.6) Cyberknife monoTx @ 7Gy X 5fx (BED 1.5 = 198.3, BED 3 = 116.7 ) Cyberknife monoTx @ 7.25Gy X 5fx (BED 1.5 = 211.5, BED 3 = 123.9 ) Biologically Equivalent Dose BED = D (1 + d/alpha beta ratio) D = total dose d = dose/fraction alpha/beta ratio = 1.5 for prostate 3 for late effects 10 for acute effects NCH Hospital, Naples, FL Jay L. Friedland, M.D.

Effectiveness and Applicability of CK CK monotherapy: Low risk and low intermediate risk CaP EBRT + CK boost: High risk and high intermediate risk CaP Basically, CK reproduces dose distributions very much like HDR, except more homogeneous and non-invasively May reduce the need for androgen deprivation therapy (ADT) for volume reduction or some patients with more extensive disease Jay L. Friedland, M.D.

Prostate PTV: gland expanded 5 mm in each direction except posteriorly where it is expanded 3 mm Jay L. Friedland, M.D.

Cyberknife Stereotactic Body Radiation Therapy Part 2: Results

Prostate Experience to Date Cyberknife SBRT First patient treated in Jan. 2005 Initiated Monotherapy protocol in Feb. 2005 Total patients treated: 200 Monotherapy: 162 Boost: 38 (Jan. 2005-May 2007) Jay L. Friedland, M.D.

Basic Demographics Will only present monotherapy results Stage cT1cNoMo to cT2bNoMo All patients treated between 1/5/2005 and 5/25/2007 Total number of Patients = 162 All patients treated by 2 Urologists and 2 Radiation Oncologists NCH Hospital, Naples, Florida Jay L. Friedland, M.D.

Hormonal Therapy Hormonal Therapy administered at discretion of Urologist 135 Patients treated without Hormonal therapy 27 Patients treated with Neoadjuvant Hormonal Therapy NCH Hospital, Naples, Florida Jay L. Friedland, M.D.

Histology Gleason grade 3 + 3 = 121 Patients NCH Hospital, Naples, Florida Jay L. Friedland, M.D.

Prostate Volumes Range = 15.5cc to 109cc Mean initial volume = 45.7 cc Median initial volume = 46.1 cc N= 111 NCH Hospital, Naples, Florida Jay L. Friedland, M.D.

Prostate Cyberknife MonoTx Dose Mean Dose = 3503 cGy (n=162) Median Dose = 3500 cGy Range = 3500cGy to 3755 cGy Number of Fractions = 5 NCH Hospital, Naples, Florida Jay L. Friedland, M.D.

Initial PSA’s Range = 1.1 to 17.2 ng/ml Mean initial PSA = 5.87 ng/ml Median initial PSA = 5.75 ng/ml N= 160 NCH Hospital, Naples, Florida Jay L. Friedland, M.D.

PSA Response to Cyberknife Monotherapy Only Jay L. Friedland, M.D.

PSA Response to Cyberknife (All 231 Patients treated between 12/7/2004 and 9/24/2007) Jay L. Friedland, M.D.

Case Review Patient with Recurrence after CK monotherapy 65 y/o wm with h/o rising PSA’s. Initial Presentation cT1cNoMo, PSA=4.3 in 2/2005, GG 4+3 in 2/12 cores (Lt lat base 10%, Lt med apex 20%) and GG 3+4 in 1/12 cores (Lt med base 5%), BS- and CT- Tx with CK monotherapy (35Gy/5 fx) completed on 6/10/05 PSA = 5.4 on 6/30/05 PSA = 10.2 on 9/15/05, repeat TRUS bx’s all negative (0/12) on 10/27/05 PSA = 24.1 on 11/14/05, repeat bone scan negative on 11/3/05 and CT abd/pelvis negative except small sclerotic lesion in head of Lt femur. MRI Lt hip on 12/6/05 negative but suspicious at L5 PSA = 87.5 on 3/31/06, Prostascint/CT fusion scan of abd/pelvis negative on 4/7/06, Started HTx in 3/2006 PSA declined to 2.6 on 6/26/206 but increased to 14 in 10/2006 Repeat bone scan +L5 on 11/28/06 and repeat CT abd/pelvis +blastic mets at T8, T10 and L5. Started systemic chemoTx in 11/2006. Jay L. Friedland, M.D.

Acute Toxicity Urinary hesitancy, urgency, frequency (Day 3-10) Tenesmus/ rectal discomfort (Day 5-8) Diarrhea (Day 5-8) Rx: Flomax Lomotil Decadron Anusol-HC supp. Jay L. Friedland, M.D.

Acute Toxicity Scoring (IPSS/RAS/SHIM) Baseline, days 2 and 5, post-treatment day 10, 1 month and 4 months Acute effects generally return to baseline by 1 months Urinary symptoms more marked in patients with IPSS baseline scores >20 No urethral strictures/ persistent rectal bleeding observed Jay L. Friedland, M.D.

IPSS Scores After Cyberknife SBRT Jay L. Friedland, M.D.

RAS and SHIM Scores after Cyberknife SBRT Jay L. Friedland, M.D.

Summary Cyberknife is a new and innovative treatment technique for prostate cancer. Cyberknife monotherapy appears to produce a reasonable early decline of PSA’s in low risk patients. The acute toxicity of Cyberknife monotherapy is acceptable. Cyberknife therapy is a noninvasive and convenient treatment option for patients with early stage prostate cancer. Prostate cancer patients treated with Cyberknife should be enrolled on research protocols, and the data collectively analyzed. Jay L. Friedland, M.D.

Thank You for Your Kind Attention