prostate hdr technique
TRANSCRIPT
High dose rate brachytherapy for prostate cancer TECHNIQUE
Peter Hoskin Mount Vernon Cancer Centre
Northwood UK
Bladder 1 2 3 4 5 6
TRUltrasound 5 mm planes
Rectum
7 8
Steps in HDR prostate brachytherapy
• Implantation • Volume definition • Dosimetry planning • QA • Treatment delivery
TRUS stepper unit Set up is critical for Implant geometry
• TRUS guided •Transaxial and sagittal
• SET UP:
•Baseline to include posterior capsule and seminal vesicles •Urethra along Row D •Minimise probe pressure
•
Implant technique
Catheter insertion TWO SCHOOLS
Peripheral Uniform
Tips for a good implant
• Good peripheral coverage is essential
• Pay particular attention to superior catheters and baseline
• Monitor both transaxial and sagittal images; scroll through prostate length regularly
Positioning of posterior template row is crucial Adjustment through probe position and build up cap
Baseline definition Is critical Do not elevate gland Ensure inferior row will cover bottom of CTV …………… allow for any expansion
HDR implant: seminal vesicles
‘Overinsertion’
Needle / catheter fixation
• Rigid needle template
• Flexible latex template
Steps in HDR prostate brachytherapy
• Implantation • Volume definition • Dosimetry planning • QA • Treatment delivery
CTV definition
• Ultrasound
• CT
• MR
Vitesse • Intraoperative HDR planning • Eliminates the CT scanner step • Plan is created in parallel with patient
recovery using Brachyvision
Offenbach
HDR implant: volume definition
5mm planning CT Volume defined on screen
HDR implant: volume definition
MR vs CT outlining • CT: better needle tracking • MR: better soft tissue definition • Image registration:
– NB potential matching errors
CTV criteria GEC ESTRO guidelines
Kovacs et al 2006
• CTV1: whole gland defined by capsule – Margin around capsule may be added 3 –5 mm
• CTV2: peripheral zone
• CTV3: GTV
• PTV = CTV
Peripheral loading
Homogeneous loading
Seminal vesicles
Probability of ECE and seminal vesicle invasion [Partin 2001]
ECE SV PSA 6.1-10 T2b Gl 3+4 52% 16% Gl 4+3 60% 13% Gl 8-10 57% 17%
Rades et al 2007
Steps in HDR prostate brachytherapy
• Implantation • Volume definition • Dosimetry planning • QA • Treatment delivery
Quality control
Single step technique: Movement of template with catheters
Baltas 2009
DAY 1 DAY 2
DAY 1 DAY 2
Silicon Template
at skin
Catheter shift between fractions
HDR implant: verification for multiple fractions
Repeat skin to hub measures Repeat limited CT Adjust catheters Recalculate dose distribution
Prostate movement from CT before 1st and 2nd fractions
Mean 11.5mm Median 9.7mm Range 0-42mm
20 consecutive monotherapy implants 31.5Gy in 3 fractions in 2 days
RT&O 2009
Impact of implant dosimetry on local control Kovacs: Kiel
69 patients with local failure
HDR Brachytherapy
• Meticulous technique • Individualised dosimetry • Good QA