Il trattamento
della malattia M0 con finalità radicali
LA RADIOTERAPIA Dr.ssa Milena Ferro
U.O. Radioterapia
❑ Indicazioni
❑ Trattamento
❑Simulazione
❑Dosi e Volumi
❑Stereotassi
❑IGRT
❑ Radioterapia adiuvante
❑ Associazione OT
❑ Tossicità
❑ Nuove prospettive
❑ Brachiterapia
Indicazioni
• Observation (expected SVV < 10 y)
• Active surveillance (eSVV 10 -> 20 y)
• Prostatectomy (eSVV > 20 y)
• EBRT (eSVV > 20 y)
• Brachytherapy (eSVV > 20 y)
• Observation (expected SVV < 10 y)
• Active surveillance (eSVV > 10 y)
• Prostatectomy (eSVV > 10 y)
• EBRT (eSVV > 10 y)
• Brachytherapy (eSVV > 10 y)
• Observation (expected SVV < 10 y)
• Active surveillance (eSVV > 10 y)
• Prostatectomy (eSVV > 10 y)
• EBRT
• Brachytherapy
• Observation (expected SVV < 10 y)
• Prostatectomy (eSVV > 10 y)
• EBRT ± ADT (4-6 mo) ± brachytherapy
• Brachytherapy
• EBRT + ADT (2-3 y)
• EBRT + brachytherapy + ADT
• Prostatectomy -> EBRT
• ADT (only for patients who are not candidates for definitive therapy)
NCCN Guidelines “Prostate Cancer” – Version 2.2019
Indicazioni
NCCN Guidelines “Prostate Cancer” – Version 2.2019
Trattamento - Simulazione
Trattamento – Contornazione
Trattamento - Tecniche, dosi e volumi
2D 3D-CRT IMRT
Trattamento - Tecniche, dosi e volumi
3D-CRT
Trattamento - Tecniche, dosi e volumi
IMRT
3D-CRT High dose
3D-CRT Low dose
IMRT Very high dose
Late toxicities after 3D-CRT and IMRT for localized CaP d M. J. ZELEFSKY et al. IJROBP, 2008
Lower Toxicity
Trattamento - Tecniche, dosi e volumi
What dose for prostate cancer? ● T. N. EADE et al. Int. J. Radiation Oncology Biol. Phys., Vol. 68, No. 3, pp. 682–689, 2007
High dose
Higher clinical progression-free survival
Trattamento - Tecniche, dosi e volumi
What dose for prostate cancer? ● T. N. EADE et al. Int. J. Radiation Oncology Biol. Phys., Vol. 68, No. 3, pp. 682–689, 2007
High dose
Higher FFDM
Trattamento - Tecniche, dosi e volumi
Trattamento - Tecniche, dosi e volumi
Trattamento - Tecniche, dosi e volumi
Trattamento - Tecniche, dosi e volumi
Trattamento - Tecniche, dosi e volumi
Trattamento - Tecniche, dosi e volumi
Hypofractionation
Stereotactic Radiotherapy
Standard fractionation
NCCN Guidelines “Prostate Cancer” – Version 2.2019
Trattamento - Stereotassi
Dominant Intraprostatic Lesion (Very high dose – 42.5 Gy)
Prostate
(High dose – 35 Gy)
DESTROY – 4
Trattamento - IGRT
Versa HD - Elekta
HexaPODTM evo RT
Versa HD offers 4D image-guided radiotherapy (IGRT)
Escalate dose while safely reducing margins
Deliver faster treatments to overcome patient movement and discomfort
Enable confident treatment of small and complex tumors—
such as in the lung, prostate and brain Fully integrated robotic
positioning system with six degrees of freedom
kV source Beam
modulator
kV detector
MV detector
Trattamento - IGRT
Trattamento - IGRT
Trattamento - IGRT
Trattamento - IGRT
Trattamento - IGRT
Zelefsky, IJROBP, 2012
RT adiuvante
Post-prostatectomy adverse pathologic features:
❖
pT3a-b
❖ R1
“Adjuvant RT is usually given within 1 year after RP and once any operative side effects have improved/stabilized”
Salvage RT:
❖ PSA > 0,2 ng/ml on 2 subsequent measurements
❖ Treatment is more effective when pre-RT PSA is low and PSADT (doubling time) is long.
❖ EBRT with 6 months of ADT improved biochemical or clinical progression at 5 years on a prospective randomized trial (GETUG-16) versus radiation alone.
NCCN Guidelines “Prostate Cancer” – Version 2.2019
Associazione Terapia Ormonale
Bria E, Cancer 2009
Associazione Terapia Ormonale
Bria E, Cancer 2009
Tossicità
Linee guida Carcinoma della Prostata - AIRO, 2016
Tossicità - GI
Le terapie di supporto in Radioterapia – AIRO LAM, 2018
Tossicità - GU
Le terapie di supporto in Radioterapia – AIRO LAM, 2018
Tossicità - GU
Alemozaffar, JAMA. 2011
Nuove prospettive - SpaceOAR System
Karsh, Urology 115, 2018
Hamstra DA, International Journal of Radiation Oncology • Biology • Physics 2017 97, 976-985DOI: (10.1016/j.ijrobp.2016.12.024 Copyright © 2017 The Authors
Nuove prospettive - SpaceOAR System
Nuove prospettive - SpaceOAR System
Hamstra DA, International Journal of Radiation Oncology • Biology • Physics 2017 97, 976-985DOI: (10.1016/j.ijrobp.2016.12.024 Copyright © 2017 The Authors
Nuove prospettive – Nerve sparing
Neurovascular bundles (Low dose - 22 Gy)
Dominant Intraprostatic Lesion (Very high dose – 42.5 Gy)
Prostate
(High dose – 35 Gy)
Brachiterapia
NCCN Guidelines “Prostate Cancer” – Version 2.2019
Low-dose rate (LDR) brachytherapy consist of placement of permanent seed implants in the prostate
Brachiterapia
NCCN Guidelines “Prostate Cancer” – Version 2.2019
A newer approach, high-dose rate radiotherapy, involves temporary insertion of a radiation source.
Brachiterapia
Localized disease
Similar control between brachytherapy and radical prostatectomy. At 6 months FUP continence was better in the brachytherapy group whereas potency was better in the radical prostatectomy group.Gilberti C, Can J Urol 2017
Brachytherapy boost
Morris WJ, ASCENDE-RT Trial, IJROBP 2017
Rodda S, ASCENDE-RT Trial, IJROBP 2017
