Winning Abstract
Number 3. "The risk of second cancers occurring more than 5 years after I-125 monotherapy for early prostate cancer."
Hima Musunuru, St James's Institute of Oncology, Leeds.
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Dispelling the Myth: TURP Does not cause Post-BXT Incontinence or Prevent Adequate Implant.
Eliot Chadwick, St Lukes Cancer Centre, Royal Surrey County Hospital.
- Multi-institutional outcomes following LDR brachytherapy in patients with higher risk cancer.
Ruth Conroy, Christie Hospital, Manchester
- The risk of second cancers occurring more than 5 years after I-125 monotherapy for early prostate cancer.
Hima Musunuru, St James's Institute of Oncology, Leeds.
- Impact and recovery of health related quality of life after single fraction HDR brachytherapy and EBRT for prostate cancer.
Jahangeer Malik, Christie Hospital, Manchester.
- Functional MRI guided HDR prostate brachytherapy tumour boost: a feasibility study.
Joshua Mason, St James's Institute of Oncology, Leeds.
1. Dispelling the Myth: TURP Does Not Cause Post-BXT Incontinence or Prevent Adequate Implant
Dr Eliot Chadwick
St Luke's Cancer Centre, Royal Surrey County Hospital
Mr Saqib Javed
Dept. of Urology, Royal Surrey County Hospital
Dr Robert Laing
St Lukes Cancer Centre, Royal Surrey County Hospital
Prof Stephen Langley
Dept. of Urology, Royal Surrey County Hospital
Aims / Introduction:
Historically, patients with a high IPSS (>15), or a recent transurethral resection of the prostate (TURP), have been excluded from brachytherapy due to concerns regarding urinary incontinence, urinary outflow obstruction and the ability to achieve acceptable dosimetry. However, since 2006, a limited TURP/bladder neck resection (BNR) has been offered to such patients. The dosimetry, subsequent urinary function and biochemical relapse free survival (bRFS) are described here.
Materials / Methods:
65 Pre-implant brachytherapy patients with at least 32 months follow up, with obstructive uroflowmetry, together with a high bladder neck on TRUS were offered a BNR / limited TURP 6 weeks before their implant. IPSS scores were recorded prospectively on a bespoke database. A questionnaire based on the Expanded Prostate Cancer Index Composite (EPIC) questionnaire was sent to patients retrospectively to assess incontinence.
Results:
Mean follow up was 47 months. 4 year bRFS was 97%. Mean post-implant D90 as a percentage of the prescribed dose was 112%. The percentage of patients with IPSS 0-8 was 55% pre-TURP and 77% at 3 years, whereas those with IPSS 17-35 were 9 and 3% pre-TURP and at 3 years respectively. No patient went into urinary retention or required intermittent self-catheterisation. The mean score for the EPIC incontinence domains was 93% and in particular, no-one was using pads.
Conclusion:
A limited TURP / BNR is a procedure which can be performed on patients with urinary outflow obstruction who might not otherwise have been offered brachytherapy, and is preferable to a post-implant TURP when tissue healing is less predictable. A pre-implant TURP does not cause urinary incontinence and is associated with low urinary morbidity. The dosimetry and bRFS demonstrate that the oncological management is not compromised.
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2. Multi-institutional outcomes following LDR brachytherapy in patients with higher risk prostate cancer
R. Conroy
The Christie NHS Foundation Trust, Manchester
P. Hoskin
Mount Vernon Hospital, Middlesex
D. Bottomley
St James's Institute of Oncology, Leeds
P.Mandell
The Christie NHS Foundation Trust, Manchester
R. Swindell
The Christie NHS Foundation Trust, Manchester
J. Wylie
The Christie NHS Foundation Trust, Manchester
Aims/Introduction:
We report the outcomes for a cohort of men with higher risk prostate adenocarcinoma treated with LDR brachytherapy in a multi-institutional UK practice.
Methods:
217 men treated between 2003-2007 with Iodine-125 brachytherapy at Christie, Leeds and Mount Vernon were identified from a multi-institutional database. Higher risk was defined as patients with ≥ 2 D'Amico intermediate risk factors (PSA 10-20, GS 7 or clinical T2c) or ≥1 high risk factor (PSA > 20, GS ≥ 8). Kaplan-Meier methods were used to estimate biochemical relapse free survival (BRFS) defined using both Phoenix and ASTRO definitions. A univariate analysis was performed to assess the significance of Gleason score, PSA, T-stage, pre- or post-implant dosimetry, and additional hormones on BRFS.
Results:
The median age was 65yrs (43-79yrs) with a median PSA follow up of 62months (14-102months).
Median pre-implant doses (ranges) were: V150 59.6(43.7-89.8), V200 20.1(11.6-36).
75 patients had post-implant dosimetry, median dose (range) was: D90 132.8Gy (75-192Gy).
No patients had external beam radiotherapy.
67 patients had additional hormone treatment, median duration 7 months (3 – 22 months).
The 3 and 5 year BRFS as defined by Phoenix were 85.4% and 74.4% and as defined by ASTRO were 76.6% and 69.8%.
On univariate analysis there were no statistically significant predictors of inferior outcome.
Conclusion:
Single modality LDR brachytherapy is a well established treatment for low risk prostate adenocarcinoma reporting excellent long term BRFS. Some authors have advocated the addition of external beam radiotherapy when treating higher risk disease. These results show that good BRFS can be obtained with LDR brachytherapy alone and no additional benefit has been shown by the addition of adjuvant hormone therapy. These results appear comparable with other treatment modalities available to these patients.
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3. Second Primary Cancers occurring after I-125 Brachytherapy as Monotherapy for Early Prostate Cancer
Authors:
A. Henry, H. B. Musunuru, M. Mason, D. Bottomley, K. Franks, P. Bownes, B. al-Qaisieh, B. Carey, J. Smith
St James's Institute of Oncology, Leeds, United Kingdom
R. Tatarek-Gintowt
Northern and Yorkshire Cancer Registry and Information Service, Leeds, United Kingdom
Purpose:
Prostate brachytherapy may be associated with a lower risk of radiation induced second primary cancer as a significantly smaller volume of normal tissue is irradiated when compared to external beam techniques. Limited data is available as it has been a routine treatment option for less than 20 years. This work identifies cases of second primary cancers (SPCs) in patients who underwent I-125 prostate brachytherapy in a single institution.
Methods:
SPC incidence was retrieved by conducting UK cancer registry search (NYCRIS) for 1805 patients with localised prostate cancer who received monotherapy with I-125 brachytherapy from 1995 to 2005.The completeness of registry search was 91% .All patients had a minimum follow up of 6 years with the maximum being 17 years.
Results:
A total of 201(11.1%) patients were diagnosed with SPCs arising at any site in the body (table 1). Of these patients 11 (5.47%) developed rectal cancer and 21(10.4%) developed bladder cancer. In our study the median time to develop bladder and rectal cancers was 4.2 and 4.7 years respectively. Only 3 out of 21 patients who developed bladder cancer and one out of 11 with rectal cancer (sarcoma) subsequently died from their SPC.
Conclusion:
Overall the incidence of SPC following I-125 in our cohort is comparable to other published data with no significant excess > 5 years from treatment. The likelihood of mortality secondary to SPC of the bladder or rectum is unusual.
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4. Impact and recovery of health related quality of life after single fraction HDR brachytherapy and EBRT for prostate cancer
J Malik, Clinical Research Fellow Uro-Oncology, C Arthur, Specialist Registrar Clinical Oncology, R Swindell, Department of Medical Statistics, P Mandall, Brachytherapy Data Manager, J Logue, Consultant Clinical Oncology, J Wylie, Consultant Clinical Oncology.
Christie Hospital NHS Foundation Trust, Manchester, UK
Introduction:
To investigate the changes in health related quality of life (HRQoL) after single fraction HDR brachytherapy and EBRT for prostate cancer.
Material and Methods:
A prospective database collected HRQoL data on all patients treated with HDR and EBRT between July 2008 and February 2011, using Expanded Prostate Cancer Index Composite (EPIC) questionnaire, completed at baseline, 6 weeks, 6 months, 12months, 18 months and 24months.
Median EPIC scores, Interquartile range (IQ) range were calculated and two sided p value of <0.01 was regarded as significant after applying Bonferroni correction for multiple comparisons.
Results:
N=177 patients.
T2/T3=154 cases (87%).
Median age 67 years (57-77), PSA 16.0 ng/ml (0.29-102), Gleason score 7(6-10),IPSS 8 (0-27) and duration of hormone therapy 6months (3-28).
HDR dose 12.5Gy till March 2010 and then 15Gy.
EBRT 37.5Gy/15 fractions over 3 weeks, started 3 weeks after HDR.
N=151(85%) completed questionnaire at baseline.
Median baseline EPIC urinary function (UFn) score 100(IQ range 88.0-100) and urinary bother (UBo) score 85.7 (IQ range 75.0-96.6).Urinary scores changed significantly at 6 weeks, median UFn 93.4((85.0-100)(P=0.002) and UBo 78.6 ((64.3-89.3)(p<0.0001)) but returned close to baseline at 6 months. At 6 months only 16.2 % (17/105) patients had ≥10% drop in EPIC total urinary score compared to baseline.
Median baseline EPIC bowel function (BFn) score 96.4 (92.9-100) and bowel bother (BBo) score 100 (92.9-100) and dropped significantly at 6 weeks with BFn 89.3 ((78.6-96.5) (p<0.0001)) and BBo 89.3((78.6-100)(p<0.0001)) but returned to baseline at 24 months. At 24 months only 18% (6/33) had total bowel score ≥10% lower from baseline.
Conclusion:
Median EPIC urinary scores recovered by 6 months, and median bowel scores after 18months. A single fraction HDR boost in combination with hypofractionated EBRT provides a convenient method of dose escalation with acceptable medium term impact on urinary and bowel QoL.
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5. Functional MRI guided HDR prostate brachytherapy tumour boost: a feasibility study
Josh Mason, Bashar Al-Qaisieh, Peter Bownes, Dan Wilson
Medical Physics, St James's Institute of Oncology, Leeds Teaching Hospitals NHS Trust
David L. Buckley
Division of Medical Physics, University of Leeds
David Thwaites
Institute of Medical Physics, School of Physics, University of Sydney, Australia
Brendan Carey
Radiology, St James's Institute of Oncology, Leeds Teaching Hospitals NHS Trust
Ann Henry
Clinical Oncology, St James's Institute of Oncology, Leeds Teaching Hospitals NHS Trust
Aims/Introduction:
For standard HDR prostate brachytherapy in combination with EBRT, a single 15Gy fraction is delivered to the whole prostate. In this study, the feasibility of identifying tumour regions using MRI, image registration of MRI to treatment planning trans-rectal ultrasound (TRUS) and dose optimisation to deliver increased dose to tumour regions is investigated.
Material/Methods:
15 patients underwent T2-weighted (T2W), diffusion weighted (DWI) and dynamic contrast-enhanced (DCE) MRI scans the day before HDR prostate brachytherapy treatment. For this feasibility study, all patients were analysed retrospectively. Tumour delineation was performed by a radiologist. Regions suspicious for tumour on all 3 MRI datasets were classed as gross tumour volume (GTV), regions suspicious on at least one MRI dataset were classed as clinical target volume (CTV). MRI GTV and CTVs were manually registered to treatment planning TRUS images. A margin of 3mm was applied to each CTV. Dose optimisation was investigated by comparing the dose delivered to the GTV, CTV and CTV + margin for (i) the delivered treatment plan and (ii) a modified version of the delivered plan optimising dose to the CTV.
Results:
GTVs were identified in 11 patients with mean volume 0.52 cc (range 0.01 – 1.7 cc). CTVs were identified in all patients with mean volume 2.6 cc (range 0.1-23.6 cc). Though no patient had more than 1 GTV, 5 patients had more than one CTV. For the first 5 patients included in the dose optimisation study, the mean D90 increased from 20.4Gy to 29.5Gy for GTV, from 18.6Gy to 25.9Gy for CTV, and from 18Gy to 21.9Gy for CTV+margin. Urethral and rectal dose were maintained with normal constraints.
Conclusion:
Functional MRI guided HDR prostate brachytherapy tumour boost is feasible. It is possible to achieve significant increased dose to tumour regions without violating urethral and rectal dose constraints.
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