The Role of Cyberknife Stereotactic Body Radiation Therapy
![The Role of Cyberknife Stereotactic Body Radiation Therapy in the Treatment of Prostate Cancer The Role of Cyberknife Stereotactic Body Radiation Therapy in the Treatment of Prostate Cancer](https://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-1.jpg)
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 3 D-CRT Early 90’s - History of Modern Prostate Radiotherapy LDR Brachytherapy Late 80’s-Present 3 D-CRT Early 90’s -](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-2.jpg)
History of Modern Prostate Radiotherapy LDR Brachytherapy Late 80’s-Present 3 D-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 Low High LDR Brachy. The Balancing Act Convenience Invasive Toxicity Efficacy IMRT Low No Low High LDR Brachy.](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-3.jpg)
The Balancing Act Convenience Invasive Toxicity Efficacy IMRT Low No Low High LDR Brachy. Tx High Yes X 1 Mod High HDR Brachy. Tx Moderate Yes X 2 Low/Mod Very High CK High No Very Low TBD Jay L. Friedland, M. D.
![Dose Calculations for Cyberknife Stereotactic Body Radiation Therapy • Perform BED dose calculations • Dose Calculations for Cyberknife Stereotactic Body Radiation Therapy • Perform BED dose calculations •](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-4.jpg)
Dose Calculations for Cyberknife Stereotactic Body Radiation Therapy • Perform BED dose calculations • For CK, one can fractionate 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. 5 Gy/5 fx) • 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 [ BED Calculations • External Beam Radiation Therapy / HDR – BED = nd [](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-5.jpg)
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/T 1/2 = radioactive half-life of isotope μ = repair rate constant = 0. 693/t 1/2 = tissue repair half-time Jay L. Friedland, M. D.
![Calculating BED For Low Risk Ca. P Monotherapy Treatment Regimens • • • 81 Calculating BED For Low Risk Ca. P Monotherapy Treatment Regimens • • • 81](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-6.jpg)
Calculating BED For Low Risk Ca. P Monotherapy Treatment Regimens • • • 81 Gy IMRT/ 45 fx / 9 weeks Biologically Equivalent Dose (BED 1. 5 = 178. 2, BED 3 = 129. 6 ) BED = D (1 + d/alpha beta • HDR mono. Tx @ 9. 5 Gy X 4 fx ratio) (BED 1. 5 = 278. 7, BED 3 = 158. 3) D = total dose d = dose/fraction • HDR mono. Tx @ 8. 55 Gy X 4 fx alpha/beta ratio = (BED 1. 5 = 229. 1, BED 3 = 131. 7) 1. 5 for prostate • HDR mono. Tx @ 7. 25 Gy X 6 fx 3 for late effects (BED 1. 5 = 253. 7, BED 3 = 148. 6) 10 for acute effects • Cyberknife mono. Tx @ 7 Gy X 5 fx NCH Hospital, Naples, FL (BED 1. 5 = 198. 3, BED 3 = 116. 7 ) • Cyberknife mono. Tx @ 7. 25 Gy X 5 fx (BED 1. 5 = 211. 5, BED 3 = 123. 9 ) Jay L. Friedland, M. D.
![Effectiveness and Applicability of CK • CK monotherapy: Low risk and low intermediate risk Effectiveness and Applicability of CK • CK monotherapy: Low risk and low intermediate risk](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-7.jpg)
Effectiveness and Applicability of CK • CK monotherapy: Low risk and low intermediate risk Ca. P • EBRT + CK boost: High risk and high intermediate risk Ca. P • 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 Prostate PTV: gland expanded 5 mm in each direction except posteriorly where it is](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-8.jpg)
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 Cyberknife Stereotactic Body Radiation Therapy Part 2: Results](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-9.jpg)
Cyberknife Stereotactic Body Radiation Therapy Part 2: Results
![Prostate Experience to Date Cyberknife SBRT • First patient treated in Jan. 2005 • Prostate Experience to Date Cyberknife SBRT • First patient treated in Jan. 2005 •](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-10.jpg)
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 c. T 1 c. Basic Demographics • Will only present monotherapy results • Stage c. T 1 c.](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-11.jpg)
Basic Demographics • Will only present monotherapy results • Stage c. T 1 c. No. Mo to c. T 2 b. No. Mo • 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 Jay L. Friedland, M. D. NCH Hospital, Naples, Florida
![Hormonal Therapy • Hormonal Therapy administered at discretion of Urologist • 135 Patients treated Hormonal Therapy • Hormonal Therapy administered at discretion of Urologist • 135 Patients treated](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-12.jpg)
Hormonal Therapy • Hormonal Therapy administered at discretion of Urologist • 135 Patients treated without Hormonal therapy • 27 Patients treated with Neoadjuvant Hormonal Therapy Jay L. Friedland, M. D. NCH Hospital, Naples, Florida
![Histology Gleason grade 3 + 3 Gleason grade 3 + 4 Gleason grade 4 Histology Gleason grade 3 + 3 Gleason grade 3 + 4 Gleason grade 4](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-13.jpg)
Histology Gleason grade 3 + 3 Gleason grade 3 + 4 Gleason grade 4 + 3 Gleason grade 4 + 4 Gleason grade 5 + 4 Jay L. Friedland, M. D. = = = 121 Patients 31 Patients 8 Patients 1 Patient NCH Hospital, Naples, Florida
![Prostate Volumes Range = 15. 5 cc to 109 cc Mean initial volume = Prostate Volumes Range = 15. 5 cc to 109 cc Mean initial volume =](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-14.jpg)
Prostate Volumes Range = 15. 5 cc to 109 cc Mean initial volume = 45. 7 cc Median initial volume = 46. 1 cc N= 111 Jay L. Friedland, M. D. NCH Hospital, Naples, Florida
![Prostate Cyberknife Mono. Tx Dose Mean Dose = 3503 c. Gy (n=162) Median Dose Prostate Cyberknife Mono. Tx Dose Mean Dose = 3503 c. Gy (n=162) Median Dose](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-15.jpg)
Prostate Cyberknife Mono. Tx Dose Mean Dose = 3503 c. Gy (n=162) Median Dose = 3500 c. Gy Range = 3500 c. Gy to 3755 c. Gy Number of Fractions = 5 Jay L. Friedland, M. D. NCH Hospital, Naples, Florida
![Initial PSA’s Range = 1. 1 to 17. 2 ng/ml Mean initial PSA = Initial PSA’s Range = 1. 1 to 17. 2 ng/ml Mean initial PSA =](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-16.jpg)
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 Jay L. Friedland, M. D. NCH Hospital, Naples, Florida
![PSA Response to Cyberknife Jay L. Friedland, M. D. PSA Response to Cyberknife Jay L. Friedland, M. D.](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-17.jpg)
PSA Response to Cyberknife Jay L. Friedland, M. D.
![Case Review Patient with Recurrence after CK monotherapy • • 65 y/o wm with Case Review Patient with Recurrence after CK monotherapy • • 65 y/o wm with](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-18.jpg)
Case Review Patient with Recurrence after CK monotherapy • • 65 y/o wm with h/o rising PSA’s. Initial Presentation – c. T 1 c. No. Mo, 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 (35 Gy/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 L 5 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 +L 5 on 11/28/06 and repeat CT abd/pelvis +blastic mets at T 8, T 10 and L 5. Started systemic chemo. Tx in 11/2006. Jay L. Friedland, M. D.
![Acute Toxicity • Urinary hesitancy, urgency, frequency (Day 3 -10) • Tenesmus/ rectal discomfort Acute Toxicity • Urinary hesitancy, urgency, frequency (Day 3 -10) • Tenesmus/ rectal discomfort](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-19.jpg)
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 Acute Toxicity Scoring (IPSS/RAS/SHIM) • Baseline, days 2 and 5, post-treatment day 10, 1](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-20.jpg)
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. IPSS Scores After Cyberknife SBRT Jay L. Friedland, M. D.](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-21.jpg)
IPSS Scores After Cyberknife SBRT Jay L. Friedland, M. D.
![RAS and SHIM Scores after Cyberknife SBRT Jay L. Friedland, M. D. RAS and SHIM Scores after Cyberknife SBRT Jay L. Friedland, M. D.](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-22.jpg)
RAS and SHIM Scores after Cyberknife SBRT Jay L. Friedland, M. D.
![Summary • Cyberknife is a new and innovative treatment technique for prostate cancer. • Summary • Cyberknife is a new and innovative treatment technique for prostate cancer. •](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-23.jpg)
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 Thank You for Your Kind Attention](http://slidetodoc.com/presentation_image_h2/75ccee375c9bfdcd64ab23935edd5c27/image-24.jpg)
Thank You for Your Kind Attention
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