Mira Keyes MD FRCPCClinical Professor Radiation Oncology Department of Surgery UBCHead, BCCA prostate Brachytherapy Program BC Cancer, Vancouver Centre, Canada
Prostate Brachytherapy Master-class Part II
Quality Assurance in prostate Brachytherapy
Quality: A high level of value or excellenceUndetectable PSA (cure) No/minimal side effect Quality is easy to conceptualize, but difficult to quantitate
NRC recommendations INDIVIDUAL
Inadequate training Incorrect seed placement Observed poor placement of seeds and no corrective actions taken
PROGRAM STRUCTURE Inadequate procedures in the program Poor management oversight of program and
contractors No peer review process Lack of safety culture
4
QA makes a big difference in outcomes
13212010896847260483624120time since implant (months)
1.0
0.8
0.6
0.4
0.2
0.0
pro
po
rtio
n f
ree
of
recu
rren
ce
1500 pts 10 y bNED 93%22% QA
All QA
All QA
4
Zlefsky IJROBP 67:2007J. Morris Urology 2009
Merrick Brachytherapy 2010K.A. Hinnen IJROBP 2010
No QA
QA codes must be calibrated at and for each institutions
No shared experience of prostate contouring Different treatment planning algorithmsDifferent target coverage goals
Most important: a well developed functioning organized system with safeguards built in
Work flow, check points, for various teams and tasks, automated system so mistakes are reduced to a minimum
IT
Administrative support Limited hierarchy
Culture of safety
Uniform treatment policy, planning, one seed supplier
Permanent staffUniformity
Training and Mentorship
Keyes at al Brachytherapy Vol 12 2013 SYSTEMATIC DATA COLLECTION AND OUTCOMES
Pre vs. Intraoperative planningNo ideals system, if it works for you, use it !
Pre vs. Intraoperative planningMount Sinai NY
Intraoperative real time Pre-planning Exact volume and size
Can be fast and efficient
Based on activity per volume table
MICK applicator more flexible
Volume and size can be different
Very fast and efficient
Based on exact plan
Stranded seeds more flexible?
Pre vs. Intraoperative planningMount Sinai NY
Intraoperative Pre-planning Embolization
Intraoperative dose
Many extra seeds needed
No embolization issues
Intraoperative dose is uncertain
Seed order accurate
797 i-125 implant: mount sinai Mount Sinai797 I-125 patients
1990 - 2002
Nomograms
Peripheral Needle /seed Placement
Interior Needle /Seed Placement
Completed Implant
Low risk- 55%pts
BEDOptimal LDR dose? Multi institutional analysis 6 large institutions4000 pts; Low, intermediate and high dose
BED:low dose: 200 Gy
Intermediate risk-30% pts
High risk-14% ptsStone at al IJROBP 2007
D90 >180Gy
643 Selected ptsbNED: 97% & 93%medD90 197Gy100% D90 >180Gy
All 1006 ptsbNED 95 & 95%medD90 151Gy6% D90 >180Gy
Mount SinaiKao at al. IJROBP 2008
BCCAMorris at al. J Urology 2009
Intraoperative
Mick Applicator Dose to cover the
margins is generated form the inside the prostate
Dose is pushed out
Implants must be hot to achieve this
D90>180Gy
Preplan
Stranded seedsDose at margins form
seeds placed at the prostate periphery and peri-prostatic tissues
Dose for margins is planned
D90 150Gy is adequateImplants are not too hot
Intraoperative Preplan
Reinforce the QA feedback and understanding your own planning process
Optimal planning geometry
Bowel prep good imagePt positionBase where do you want your seedsApex - Length/ Saggital imageNumber of slices lengthx2 +1sliceSymmetry D rowHost 1.5 or 2 row
US volume study
Saggital
BCCA marginsAnt - 3 mmLat - 5 mm Post - 0 mmInf - 0-5 mm?
CTV = prostate expanded at base and apex + SV basePTV= CTV+ margins
ECE Partin tablesLow risk 20-50%Intermediate Risk- 20-60%High Risk 16-57%
Why do you add margins?Extra Capsular Extension
Mid and posterior prostate (50-60%)
Risk factors:PSA >10, GS =7, CS=T2bTwo risk factors ECE50% pts>4mm >20% pts
Davis at al. Cancer. 1999Bin at al. J. Cancer 2003Chao KK. At IJROBP 2006
I125 Dose decreases by 20 Gy/mm.
Seminal Vesicles involvement
1
15
27
58
0
1020
3040
5060
no risk f 1 risk f 2 risk f 3 risk f
risk factor cathegory
22
%
Risk factors:PSA >10GS =7CS =T2b
344 RP William BeaumontSV involved - 15 % ptsMedian length - 1 cm
Kestin LL at al IJROBP 2002 vol 54 22
1. Symmetry Left to Right2. Peri-uretral sparing3. Margins and SV covered4. High seed density in post
zones5. PTV/CTV ratio > 1.66. Generous margins7. Minimize # needles 8. Extra capsular seed ~30%
Planning Goals V100 - >98%V150 55-65%V200 - ~20%D90 - 120%UD50 ~120%
PTV
July 1998 pt #1
Pt# 4000 Nov 2011
Pt# 2 July 1998
Evolution of planning
Pt# ~6500Dec 2017
Mixed activity seeds activity
High Activity Implants1. Reduces number of needles trauma cost conformity dose homogeneity
2. Rectal dose and fistulas?
Low Activity1. More robust2. Less concern with
misplacement3. Prostate is in the seed
cloud4. Higher
Homogeneity Number of needles Trauma cost
High Activity Seeds? no consensus I-125 - 0.42U 0.84U
Solution mixed activity implants ?
Mixed activity seedsChoice of seed strength depends on technique and extra-prostatic seeds ( BCCA low activity).
Different seed activities have trade-offs between high and low activity
HDR brachytherapy dwell times at each position can be varied to optimize the dose distribution, can LDR achieve the same without having to plan seeds in risky locations ( rectum, urethra)?
Dosimetric study (Nick Chung PhD) 1. High activity 0.6U. 2. Mixed activity 0.4U, 0.6U or 0.9U3. Standard BCCA plans
Plan reconstruction is the process of finding the best correspondence between the preplan and post-plan.
1. ProblemIdentify the different activity seeds
Conclusions1. Method for reducing needle counts and covering the ASQ than high activity implants.
2. Urethral doses increased significantly, primarily as a consequence of higher activity seeds in the anterior base
2. Problem: Pre-implant quality assurance of mixed-activity needles is the subject of ongoing research
OR
Catheter to prostate apex
Check the base image with every needle
Dual images may be helpful
1
Sagittal images2.
1. Needle to mid prostate2. Than to final plane Less gland rotation
3
Needles close to rectumAdjust the template
Use sagittal images
Do not over-crowd seeds in front of the rectum on pre-plan
4 RECTUM
Post implant dosimetry and contouring
Urethra is not a small space
37
Apex
Mid gland
Base
NY contouring conferance: 15 participants > 500 cases eachEach contoured same 8 cases.
(slides from J. Crook)
38
MRI-CT fusionMore accurate dosimetryLabor intensive (VariSeed )(MIM better)More expensiveMay not be available
MR Sequence
3 mm slice/0 gapTE/TR =90/4500 echo time/repetition timeETL 10 echo train lengthFOV 18-20Matrix 320 x 224band width 31 Hz4 NEX (# of excitations)T2 FSE (or FRFSE) fast spin echoCone down on prostate
do not scan entire pelvis
40
What if I cant get an MRI?1. Use all the information you have
Pre-implant TRUS (length, width, height)
2. Use bladder contrast in your CT scan! 1.5 mls in 30mls pre-CT scan
Amys technique
US CT fusion
Joe Buccis technique
Suboptimal post-implant dosimetry
Low risk- 55%pts
BEDOptimal tumoricidal dose? Multi institutional analysis 6 large institutions4000 pts; Low, intermediate and high dose
BED:low dose: 200 Gy
Intermediate risk-30% pts
High risk-14% ptsStone at al IJROBP 2007
144GYCase
Age 57T2aGS 3+3=6LMM core +IPSS 2AS
V100: 59%D90: 70 Gy
Implant I - D90 70 Gy
144 Gy
Initial Implant day 30 CT
New seeds
Previously implanted seeds
1. Additional seeds were keyed in with 5 mm space between, to the cold areas of on post-implant CT (colour change).2. Composite isodose lines were observed on each CT image 3. Avoid 145-Gy isodose overlap between the reimplant and the initial implant.
Avoid any subsequent dragging of the seeds inferiorly to avoid creating overlap of the dose from the first and second implants.
144GY
Implant I - D90 70 Gy Re-implant II - D90 144 Gy
Dose: add up dose form both implants The net effect: alter the dose rate or increase in the overall treatment time. Jan 2018 FU
urethral stricture and has to self catheterizePSA < 0.02
Dosimetry: V100
50 60 70 80 90 100
V100 1stImplant (%)
V100 2ndImplant (%)
V100 1st Implant Mean: 78.2 %
V100 2nd Implant Mean: 93.7 %V100 90%
Chart2
937
7029
971
8315
8116
7918
7027
7620
8213
8015
5936
7321
8211
8112
8112
866
6031
837
6821
807
7410
6418
V100 1st Implant (%)
V100 2nd Implant (%)
Baseline
IDBCCA IDDate of BirthDate of DiagnosisAge at DiagnosisImplant LocationASCENDEInitial PSAT StagePrimary GleasonSecondary GleasonGleason TotalCores PositiveTotal CoresLocation of CoresNeoadjuvant HTErectile Potency BaselineBaseline IPSSDate First ImplantDate Second ImplantTime to ReimplantDate of Last Follow-upTime from Reimplant to last Follow upBiochemical FailureBiochemical Failure CategoryTime to failure or last follow upMetastatic DiseaseMost Recent PSAToxicity
1000488626-Feb-449-Mar-0056.03VCC3.9T2a33636LA, LM, LBnonormal1-Aug-003-Oct-0063.0831-Jan-1312.33031-Jan-130.02
2010630724-Sep-5128-Mar-0149.51VCC7T2a33636LM, LA, RByesnormal24-Jan-0223-Apr-0289.0516-Jul-1412.23016-Jul-140.01Self-catheter, TURP
4011614911-Nov-251-Oct-0175.89VCC7.8T2a43728LB, LMM, LAyesnormal18-Jul-023-Sep-0247.022-Oct-1210.0802-Oct-120.03
5011930928-Jul-503-Dec-0151.35VCC2.9T2a33623RM, RBnonormal19-Feb-0228-May-0297.9711-Jul-075.12011-Jul-070.04
6020513714-Dec-4320-Feb-0460.19VCC5T1c34718LByesimpotent30-Jul-025-Nov-0298.0028-Oct-052.98028-Oct-050.01
702077651-Apr-4015-Apr-0262.04VCC6.6T1c34746LA, LMM, LML, LByesnormal5-Sep-0229-Oct-0253.6128-May-085.58028-May-080.09IPSS 18
8030301021-Nov-3328-Jan-0369.19VICC8.8T1c336211L,Ryesnormal28-Aug-0327-Nov-0391.0027-Jul-106.66027-Jul-100.01radiation proctitis
9030320719-Mar-4430-Jan-0358.87VCCyes5.4T1c45999RB, RMM, RML,RA, LB, LMM, LML, LA, MPZyesnormal22-Apr-0422-Jun-0461.0024-Jul-1410.08024-Jul-140.04
10040985615-Oct-3312-May-0975.57CSIyes6.7T1c45928LB, LMyesimpotent2-Jun-101-Sep-1091.0014-Jul-143.86014-Jul-140.03
11042316024-Oct-4628-Jul-0457.76CSI5.04T2c43766LA, LB, LM, RA, RB, RMyesimpotent10-Feb-0526-Apr-0575.0028-Mar-148.9207-Apr-10107-Apr-1003-May-13
12050140328-May-276-Dec-0477.53VCCyes18T2c45968LA, LMM, RA, RM,RMM, RByesnormal8-Nov-0522-Dec-0543.928-Jan-137.0508-Jan-130.01
13050302729-May-3629-Dec-0468.59VICC3.2T2a34777L,Ryesimpotent20-Sep-053-Jan-06104.925-May-148.3305-May-140.02
1405235184-Sep-3719-Oct-0568.12VCC8.1T2a34728RA, RBnonormal2-Mar-0618-Apr-0647.424-Sep-148.3822-Aug-11122-Aug-11third implant R seminal vesicle, urinary and rectal incontinence
15060037427-Feb-4720-Dec-0558.81VCC5.8T2c33666L, Rno23-Mar-066-Jun-0674.9916-Nov-126.45016-Nov-120.02
1606012691-Jun-334-Oct-0572.34VCC3.5T2c34758RA, RB, LB, LMM, LMLno6-Apr-068-Jun-0662.965-Jun-136.9905-Jun-130.01
17061309916-Apr-419-Jun-0665.15VICC6.3T1c347412L, Rnopartial2-Nov-0612-Dec-0639.8631-Mar-147.30031-Mar-140.02
18070492519-Feb-3012-Dec-0676.81CSI3.04T2c43722yes12-Mar-0916-Jun-0996.0417-Jul-145.08017-Jul-140.1
19072358222-May-4217-Sep-0765.32VCC13.9Tx336210RML, LByesnormal7-Oct-0818-Dec-0872.0822-Oct-134.84022-Oct-130.12
2008107452-Apr-5230-Apr-0856.08CSI4.39T2a34728LM, LTyespartial4-Dec-0816-Jun-09193.4611-Aug-145.15011-Aug-140.1hematospermia
21081315722-Jun-3427-May-0873.93VICC7.3T2a43746L, Ryes20-Apr-0918-Aug-09119.7919-Jun-144.83019-Jun-140.1
22090595725-Feb-3518-Feb-0973.98VCC7.1T2b43728RMM, RMLnonormal18-Jun-0915-Sep-0988.8226-Sep-145.0317-May-11117-May-1113-Jun-11
23090700716-Oct-3427-Feb-0974.37CSI9.17T2a437311RA, LB, LMyesnormal7-Oct-0919-May-10223.9913-Jan-143.65013-Jan-140.12
24093036921-Nov-4023-Nov-0969.00CSI6.4T2a34778LB, LM, LA, LT, RM, RA, RTno24-Mar-1016-Jun-1084.1130-Jun-144.04030-Jun-140.1
2511100605-Feb-3729-Apr-1174.23VCC13T2a34768RB, RMM, RML, RA, LM, LAnoimpotent19-Jul-1130-Aug-1142.3930-Apr-142.6709-Aug-12109-Aug-12
26111400916-Apr-3910-Jun-1172.15CSI9.4T2b43748Ryes5-Jul-1214-Nov-12131.935-Dec-120.0605-Dec-12perioperative mortality (Dec 5, 2012)
2711153558-Oct-4117-Jun-1169.69VCC1.1T2b347512RAM, RAL, RMM, RML, RBLnopartial29-Sep-116-Dec-1167.5818-Jul-142.61018-Jul-140.03
28111893520-Oct-5118-Jul-1159.74CSI7.43T1c34788R, Lyesnormal1-Feb-123-May-1292.0813-Jun-142.11013-Jun-141.69
2912078632-Apr-4720-Mar-1264.97VCC14T2a347510RMM, LB, LMM, RBM, LBMnonormal31-May-1212-Jul-1242.0011-Mar-141.66011-Mar-140.17
30122740711-Mar-5723-Aug-1255.45VCC12.7T2c347612RM, LB, LM, LAnonormal24-Jan-1319-Feb-1325.8528-May-130.27028-May-13
3113181046-Jul-5327-May-1359.89VICC10T1c347720LMM, LML, LA, LA, TZnonormal24-Oct-1323-Jan-1491.0810-Jul-140.46010-Jul-140.89
32895133220-May-367-Jun-0266.05VICC11T2a336713R, Lyespartial3-Jul-037-Oct-0395.8814-Jul-062.77014-Jul-060.08
33922702824-Sep-4321-Jun-0157.74FVCC7.5T2a336110LMyesnormal12-Feb-0214-May-0291.002-Jul-1412.1302-Jul-140.04radiation proctitis, plasma coagulation June 2009
613
Baseline Characteristics
Number of Patients32
Age
Median66
Range50 -76
PSA
200
Gleason
83
Clinical Stage
T1c8
T2a14
T2b3
T2c6
Missing1
Risk Category
Low6
Intermediate23
High3
Prostate Volume
Median35.8
Range21.7 - 61.4
Neoadjuvant ADT
Yes19
No13
Location
VCC17
CSI8
VICC6
FVCC1
Time
20001
20010
20026
20032
20041
20053
20064
20070
20082
20094
20102
20112
20123
20132
Baseline
Dosimetry
First ImplantSecond Implant
IDBCCA IDD90V100%V150%V200%SeedsRectum V50Rectum V100Rectum V150D50 UrethraV150 (%)Cold AreaCT/US RatioD90V100(%)V150%V200%CT/US RatioSeedsRectum V50Rectum V100Rectum V150D50 UrethraV150 (%)
10004886
2010630791.2865926103104.59260241152340
4011614989.183368.51111210117.99863261321410
50119309127.8988057110
60205137105.69343131172130136.11007730
7020776585.38244221242461116.99567311512161
8030301066.6704621924170125.397783911661241.7
9030320784.880318881930115.89555161012151
10040985670119.097542283
11042316059.75930121121940114.89564311322460
12050140376.374331468194192.7843112781630
13050302776.265238991400
14052351867.4683214113305099.1894518142
15060037483.38253281051810113.19378511304570
16060126989.1833291081900100.19047141222210
170613099105.8926238150
18070492587.979301087115.59759251071300
190723582112.39656251272110
20081074570.4733613118600111.59460251512200
21081315782.96421876101095.882271196900
22090595785.1813591371300121.09771331632100
23090700762.876522694119.396592411763110
240930369118.297632777144.7100875385400
25111006012097632113350092.50131.49882561411720
26111400972.874431788500
27111535574.77032999263077.61142.39987451333350137.140
28111893587.8866133781520
29120786388.5813611156625082.90105.59347191704182104.71
301227407113.99559301272040116.10
31131810469.680603149174135.53890.48758281245380
32895133276.2816226721310105.793734788
33922702849.86036138830103101.79141121152450
Urinary Toxicity
IDBCCA IDBaseline (1st Implant)Date First ImplantBaseline IPSS (second implant)Date Second Implant6 weeks3 months6 months1 year18 months2 years30 months3 years42 months4 years54 months5 years6 years7 years8 years9 years10 years
100048861-Aug-003-Oct-00
2010630724-Jan-0223-Apr-02
40116149218-Jul-02263-Sep-0213878325
5011930919-Feb-023128-May-023222138
60205137930-Jul-02185-Nov-0229152295
7020776595-Sep-022629-Oct-02232318131718
80303010228-Aug-03927-Nov-0314717
9030320722-Apr-0422-Jun-04
1004098562-Jun-101-Sep-103
1104231602610-Feb-0526-Apr-05203415212423221424
1205014038-Nov-0522-Dec-05
130503027320-Sep-05153-Jan-06365695425
1405235182-Mar-0618-Apr-06145143182022
1506003741523-Mar-06276-Jun-06282412
160601269126-Apr-068-Jun-06111136874
17061309902-Nov-0612-Dec-061594473843
18070492512-Mar-091016-Jun-096434511
19072358207-Oct-081718-Dec-08187512115
20081074594-Dec-083116-Jun-094211867
210813157320-Apr-092918-Aug-0927
220905957418-Jun-091715-Sep-091314
23090700757-Oct-091319-May-1098423
240930369424-Mar-101216-Jun-10536331
2511100601219-Jul-1130-Aug-1129147
26111400945-Jul-121514-Nov-12
271115355629-Sep-116-Dec-11111
28111893561-Feb-12163-May-12272515
291207863131-May-1212-Jul-121376
301227407024-Jan-1319-Feb-1312
311318104124-Oct-13823-Jan-14109
32895133263-Jul-03107-Oct-0313
339227028412-Feb-0214-May-02244834312
Sheet1
First ImplantSecond Implant
IDD90V100%V150%V200%SeedsRectum V50Rectum V100Rectum V150D50 UrethraV150 (%)Cold AreaCT/US RatioD90V100(%)V150%V200%CT/US RatioSeedsRectum V50Rectum V100Rectum V150D50 UrethraV150 (%)
1
291.2865926103104.59260241152340
489.183368.51111210117.99863261321410
5127.8988057110
6105.69343131172130136.11007730
785.38244221242461116.99567311512161
866.6704621924170125.397783911661241.7
984.880318881930115.89555161012151
1070119.097542283
1159.75930121121940114.89564311322460
1276.374331468194192.7843112781630
1376.265238991400
1467.4683214113305099.1894518142
1583.38253281051810113.19378511304570
1689.1833291081900100.19047141222210
17105.8926238150
1887.979301087115.59759251071300
19112.39656251272110
2070.4733613118600111.59460251512200
2182.96421876101095.882271196900
2285.1813591371300121.09771331632100
2362.876522694119.396592411763110
24118.297632777144.7100875385400
2512097632113350092.50131.49882561411720
2672.874431788500
2774.77032999263077.61142.39987451333350137.140
2887.8866133781520
2988.5813611156625082.90105.59347191704182104.71
30113.99559301272040116.10
3169.680603149174135.53890.48758281245380
3276.2816226721310105.793734788
3349.86036138830103101.79141121152450
V100
IDV100%V200% Increase
24973100
6937100
27702999
2597198
4831598
22811697
18791897
8702797
23762096
7821395
9801595
11593695
20732194
15821193
29811293
32811293
286692
33603191
1683790
14682189
3180787
12741084
21641882
V100
V100 1st Implant (%)
V100 2nd Implant (%)
V200
218311
1214-212Mean13.0681818182Range-3 - 36
3313-11229.954545454511 - 56
169514
98816
1414418
2911819
226-224
2326-224
20131225
18101525
48.517.526
3131-328
6131730
722931
11121931
2292433
8211839
2793645
32262147
15282351
24272653
25213556
IDV200%
V200
V200 1st Implant (%)
V200 2nd Implant (%)
V150
V150%ChangeV150%
21627
33031
36541
321345
361147
321547
312455
60058
52759
302959
59160
362460
362763
303464
442367
353671
621173
433477
532578
463278
631982
632487
325587
V150
V150% 1st Implant
V150% 2nd Implant
D90
IDD90
24118.226.5144.7
2774.767.6142.3
6105.630.5136.1
2512011.4131.4
866.658.7125.3
2285.135.9121
2362.856.5119.3
489.128.8117.9
785.331.6116.9
984.831115.8
1887.927.6115.5
1159.755.1114.8
1583.329.8113.1
2070.441.1111.5
3276.229.5105.7
2988.517105.5
291.213.3104.5
3349.851.9101.7
1689.111100.1
1467.431.799.1
2182.912.995.8
1276.316.492.7
3169.620.890.4
D90
D90 1st Implant
D90 2nd Implant
Time to Reimplant
IDBCCA IDDate of BirthDate of DiagnosisAge at DiagnosisImplant LocationASCENDEInitial PSAT StagePrimary GleasonSecondary GleasonGleason TotalCores PositiveTotal CoresLocation of CoresNeoadjuvant HTErectile Potency BaselineBaseline IPSSDate First ImplantDate Second ImplantTime to ReimplantDate of Last Follow-upTime from Reimplant to last Follow upBiochemical FailureMetastatic DiseaseMost Recent PSAToxicity
30122740711-Mar-5723-Aug-1255.45VCC12.7T2c347612RM, LB, LM, LAnonormal24-Jan-1319-Feb-1325.8528-May-130.27
17061309916-Apr-419-Jun-0665.15VICC6.3T1c347412L, Rnopartial2-Nov-0612-Dec-0639.8631-Mar-147.300.02
2912078632-Apr-4720-Mar-1264.97VCC14T2a347510RMM, LB, LMM, RBM, LBMnonormal31-May-1212-Jul-1242.0011-Mar-141.660.17
2511100605-Feb-3729-Apr-1174.23VCC13T2a34768RB, RMM, RML, RA, LM, LAnoimpotent19-Jul-1130-Aug-1142.3930-Apr-142.6709-Aug-12
12050140328-May-276-Dec-0477.53VCCyes18T2c45968LA, LMM, RA, RM,RMM, RByesnormal8-Nov-0522-Dec-0543.928-Jan-137.050.01
4011614911-Nov-251-Oct-0175.89VCC7.8T2a43728LB, LMM, LAyesnormal18-Jul-023-Sep-0247.022-Oct-1210.080.03
1405235184-Sep-3719-Oct-0568.12VCC8.1T2a34728RA, RBnonormal2-Mar-0618-Apr-0647.424-Sep-148.3822-Aug-11third implant R seminal vesicle, urinary and rectal incontinence
702077651-Apr-4015-Apr-0262.04VCC6.6T1c34746LA, LMM, LML, LByesnormal5-Sep-0229-Oct-0253.6128-May-085.580.09IPSS 18
9030320719-Mar-4430-Jan-0358.87VCCyes5.4T1c45999RB, RMM, RML,RA, LB, LMM, LML, LA, MPZyesnormal22-Apr-0422-Jun-0461.0024-Jul-1410.080.04
1606012691-Jun-334-Oct-0572.34VCC3.5T2c34758RA, RB, LB, LMM, LMLno6-Apr-068-Jun-0662.965-Jun-136.990.01
1000488626-Feb-449-Mar-0056.03VCC3.9T2a33636LA, LM, LBnonormal1-Aug-003-Oct-0063.0831-Jan-1312.330.02
2711153558-Oct-4117-Jun-1169.69VCC1.1T2b347512RAM, RAL, RMM, RML, RBLnopartial29-Sep-116-Dec-1167.5818-Jul-142.610.03
19072358222-May-4217-Sep-0765.32VCC13.9Tx336210RML, LByesnormal7-Oct-0818-Dec-0872.0822-Oct-134.840.12
15060037427-Feb-4720-Dec-0558.81VCC5.8T2c33666L, Rno23-Mar-066-Jun-0674.9916-Nov-126.450.02
11042316024-Oct-4628-Jul-0457.76CSI5.04T2c43766LA, LB, LM, RA, RB, RMyesimpotent10-Feb-0526-Apr-0575.0028-Mar-148.9207-Apr-1003-May-13
24093036921-Nov-4023-Nov-0969.00CSI6.4T2a34778LB, LM, LA, LT, RM, RA, RTno24-Mar-1016-Jun-1084.1130-Jun-144.040.1
22090595725-Feb-3518-Feb-0973.98VCC7.1T2b43728RMM, RMLnonormal18-Jun-0915-Sep-0988.8226-Sep-145.0317-May-1113-Jun-11
2010630724-Sep-5128-Mar-0149.51VCC7T2a33636LM, LA, RByesnormal24-Jan-0223-Apr-0289.0516-Jul-1412.230.01Self-catheter, TURP
8030301021-Nov-3328-Jan-0369.19VICC8.8T1c336211L,Ryesnormal28-Aug-0327-Nov-0391.0027-Jul-106.660.01radiation proctitis
33922702824-Sep-4321-Jun-0157.74FVCC7.5T2a336110LMyesnormal12-Feb-0214-May-0291.002-Jul-1412.130.04radiation proctitis, plasma coagulation June 2009
10040985615-Oct-3312-May-0975.57CSIyes6.7T1c45928LB, LMyesimpotent2-Jun-101-Sep-1091.0014-Jul-143.860.03
3113181046-Jul-5327-May-1359.89VICC10T1c347720LMM, LML, LA, LA, TZnonormal24-Oct-1323-Jan-1491.0810-Jul-140.460.89
28111893520-Oct-5118-Jul-1159.74CSI7.43T1c34788R, Lyesnormal1-Feb-123-May-1292.0813-Jun-142.111.69
32895133220-May-367-Jun-0266.05VICC11T2a336713R, Lyespartial3-Jul-037-Oct-0395.8814-Jul-062.770.08
18070492519-Feb-3012-Dec-0676.81CSI3.04T2c43722yes12-Mar-0916-Jun-0996.0417-Jul-145.080.1
5011930928-Jul-503-Dec-0151.35VCC2.9T2a33623RM, RBnonormal19-Feb-0228-May-0297.9711-Jul-075.120.04
6020513714-Dec-4320-Feb-0460.19VCC5T1c34718LByesimpotent30-Jul-025-Nov-0298.0028-Oct-052.980.01
13050302729-May-3629-Dec-0468.59VICC3.2T2a34777L,Ryesimpotent20-Sep-053-Jan-06104.925-May-148.330.02
21081315722-Jun-3427-May-0873.93VICC7.3T2a43746L, Ryes20-Apr-0918-Aug-09119.7919-Jun-144.830.1
26111400916-Apr-3910-Jun-1172.15CSI9.4T2b43748Ryes5-Jul-1214-Nov-12131.935-Dec-120.06perioperative mortality (Dec 5, 2012)
2008107452-Apr-5230-Apr-0856.08CSI4.39T2a34728LM, LTyespartial4-Dec-0816-Jun-09193.4611-Aug-145.150.1hematospermia
23090700716-Oct-3427-Feb-0974.37CSI9.17T2a437311RA, LB, LMyesnormal7-Oct-0919-May-10223.9913-Jan-143.650.12
Days to Reimplant
< 301
30 - 607
60-9010
90-12011
>1203
D90 First Implant
D90 2nd Implant
Seeds
SeedsSeeds
1031151299
11113221
110
117
1241512720
9211624
8810113
708313
11213220
687810
99
11314229
10513025
10812214
150
8710720
127
11815133
769620
13716326
9411723
77858
1331418
88
9913334
78
15617014
127
124
728816
8811527
1st Implant
Median99
Range68 - 156
2nd Implant
Seeds Added
Median20
Range8 - 34
Sheet4
ID-30236121824303642485460728496108120
1
2
422613878325
5313222138
691829152295
7926232318131718
82914717
9
103
1126203415212423221424
12
13315365695425
14145143182022
151527282412
1612111136874
1701594473843
18106434511
19017187512115
209314211867
2132927
224171314
2351398423
24412536331
251229147
26415
276111
28616272515
2911376
30012
3118109
3261013
334244834312
1. Age 2. Comorbidities3. ADT4. Never done for boost
pts5. D90/V1006. Rectal dose7. Pathology
tumour location GS
Who to re-implant?
32 replants ( 2-3 per year/~400)
Salvage LDR vs. salvage HDR
LDR Salvage AUR 33%Late Gr3 - 27% (strictures)
Dose related Med 154 vs.134GyPSA failure 20%
Present practicePartial gland salvage MRI based
May 2007Jan 201420 centers, 92 analyzed Med follow up of 54 moMed age 70 Med EBRT dose 74GyPSA
Up to 70% of PSA failures after radiation are due to local recurrenceand these patients could benefit from potentially curative salvage
1. Conformal dose 2. Dose tightly controlled 3. Low / ratio of
HDR for salvage?
? Dose? Volume? Toxicity? Outcomes
N dose Gr3 bNED FU
UCLA 21 36Gy/6 14% 89% 2y
Chan 52 32Gy/4 - 68%
Wojcieszek 83 - - 67%
Sunnybrook 6 27Gy/2 - -
Eligibility Criteria1. Life expectancy >10 years2. Previous EBRT dose up to 78Gy/39 fractions, 81 Gy/45 fractions or 70
Gy/28 fractions3. > 3 year interval since EBRT 4. No late toxicity from prior EBRT > grade 25. Rising PSA < 10 ng/ml 6. PSA DT > 6 months 7. Negative staging with CT scan of the abdomen/pelvis and bone
scan 8. Radiographic evidence of MRI dominant intraprostatic lesion (DIL) as
only area of recurrence (i.e unifocal recurrence) and corresponding to site of original disease
9. Biopsy confirmation of DIL with pathology review by BCCA GU pathologist (TB)
10.ECOG performance status 0-1 prior to registration11. IPSS < 16, or adequate voiding study (post void residual < 100cc and
peak flow rate > 10 cc/second).12.No prior trans urethral prostatic resection
Dose: 13.5Gyx2Urethral Dmax < 115%
Rectal D1cc < 6Gy, D0.1cc
Thank you
One of the symptoms of an approaching nervous breakdown is the belief that ones work is terribly important. Bertrand Russell
Slide Number 1Slide Number 2NRC recommendations QA makes a big difference in outcomesSlide Number 5Slide Number 6Slide Number 7Pre vs. Intraoperative planningMount Sinai NYPre vs. Intraoperative planningMount Sinai NY797 i-125 implant: mount sinaiPeripheral Needle /seed PlacementInterior Needle /Seed PlacementCompleted ImplantSlide Number 14Slide Number 15Slide Number 16Slide Number 17Slide Number 18US volume studySlide Number 20Why do you add margins?Extra Capsular ExtensionSeminal Vesicles involvementSlide Number 23July 1998 pt #1Slide Number 25Slide Number 26Mixed activity seedsSlide Number 28Slide Number 29Slide Number 30Slide Number 31Slide Number 32Slide Number 33Slide Number 34Slide Number 35Slide Number 36Slide Number 37MRI-CT fusionMR SequenceWhat if I cant get an MRI?Slide Number 41Slide Number 42Slide Number 43Slide Number 44Slide Number 45Slide Number 46Slide Number 47Slide Number 48Slide Number 49Slide Number 50Slide Number 51Dosimetry: V100Who to re-implant?Slide Number 54Slide Number 55Slide Number 56Slide Number 57Slide Number 58Slide Number 59
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