7/23/2014
SAM-HDR Brachytherapy II:
Integration of Real Time Imaging
US-based prostate brachytherapy:
are we there yet?
Dorin A. Todor, Ph.D.
Department of Radiation Oncology, Virginia Commonwealth University,
Richmond, VA 23298,
AAPM Annual Meeting, Austin, TX 2014
No conflict of interest
Learning objective:
to learn about the current status and future
developments in US-based HDR prostate
brachytherapy
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7/23/2014
Outline






Rationale
Typical workflows. Variations
Planning. TPS choices.
Errors and Uncertainties
Quality Assurance
Future. Novel uses. Focal therapy.
LOW RISK RESULTS
Weighted
100
% PSA Progression Free
Treatment Success
>40 months follow-up or less than 100 patients
68 51 50
92
46 11314
96
110
97 66 25
22
13 8
75
48
37
2014 816 6286
11435
44
3
60
41 82
33
32
203 6985
71
6584 3172 99 29 101 39103 11228 1067
98 89
42 94 95
61 93
18 88102
38
54
36
105 24
73
1947
43 55
78
2 26
64
40
12 83
202 58
1100 7 87
106
76 56
107
77
9
70 80
41
15 45
57 74 79
20
10959
17
90
53
HDR
90
80
Proton
+
27
LDR Brachy
111
5
16
115
52
104
Seeds
Surgery
EBRT
108
EBRT/IMRT
Surgery
CRYO
63
70
HIFU
7
34
Protons
← Years from Treatment →
91
60
Hypo EBRT
49
11
1
Seeds &
ADT
EBRT &
ADT
EBRT &
Seeds
Robot RP
HDR
2 3 4 5 6 7 8 9 10 11 12 13 14 15
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
Update of
7/23/2014
BJU Int, 2012, Vol. 109(Supp 1)
5
Prostate Cancer Center of Seattle
INTERMEDIATE RISK RESULTS weighted
Treatment Success
LDR SEEDS ALONE
100
54
10459 56
111
66 55
79
111 92 49
151
161 1544 96
57
36
30
109
99 77 45
111
105 152
107
82
975612
108
160
1
62 18 6393 4347
74 67 50
90
25
80
HDR
68
16 4
69
39
156 31 91
24 23 13
35
EBRT
89 94
+
34
40
38 58
83
42 73
3 72
46
84
EBRT + ADT
Robot RP
37
158
86
81 9571
28
150
90 92652
5
65
152 78 70 7 155
103
29
76 102
154
41
1
60100
48
32
8 87
85 88 53
2
19
10101 11
75
70
60
14
156
98
153F163
110
% PSA Progression Free
>40 months follow-up or less than 100 patients
27
17
64
157
EBRT & SEEDS
159
Surgery
Seeds + ADT
EBRT & Seeds
Hypo EBRT
Brachy
Seeds Alone
Surgery
EBRT
CRYO
HIFU
20
HDR
50
155
← Years from Treatment
→
40
21
80
1
2
3
4
5
22
6
7
8
9 10 11 12 13 14 15
EBRT, Seeds +
ADT
Protons
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
Update of
7/23/2014
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
6
2
7/23/2014
HIGH RISK RESULTS
Weighted
Treatment Success
% PSA Progression Free
>40 months follow-up or less than 100 patients
EBRT, Seeds & ADT
92 65
20
16
99 94 81
109
4
19 18
80
74
112
108
32
22
78
123137
67
136 122
17
123
55
131
112
4075
125 44 85
76
43
3
72
60135
12454
127
91 66 34
125 41 68
2
57
134
71 1364 79
48 128
59 10 114
42
50
56 1
24 28
12
8 61
132136
53 25
90
32
110 9 89
101 113 45
36
5 120
62 106 12933 111
21 9345
126
118
14
39 119 95
70
98 31
11 96
115
103
83 7 8226
35
6
52 63
84
36
73
30116
58 27
77 46
107
86 87
88
102 15
51
105
23 29
Years from 69
Treatment
Surg & EBRT
Surg & ADT
EBRT & ADT
EBRT + Seeds
EBRT + ADT
EBRT & Seeds
37
47
Hypo EBRT
104
133
EBRT
←
→
130
Protons
HDR
Surgery
49
EBRT Seeds +
ADT
Robot RP
• Prostate Cancer Results Study Group
• Numbers within symbols refer to references
HIFU
HDR + ADT
Update of
7/23/2014
BJU Int, 2012, Vol. 109(Supp 1)
Prostate Cancer Center of Seattle
7
in their 2013 ACR Appropriateness Criteria® HIGH-DOSE-RATE BRACHYTHERAPY FOR PROSTATE CANCER
Expert Panel on Radiation Oncology–Prostate: I-Chow Joe Hsu, MD; Yoshiya Yamada, MD; Gregory Merrick, MD;
Dean G. Assimos, MD; Anthony V. D'Amico, MD; Brian J. Davis, MD, PhD; Steven J. Frank, MD; Alexander R.
Gottschalk, MD, PhD; Gary S. Gustafson, MD; Patrick W. McLaughlin, MD; Paul L. Nguyen, MD; Seth A. Rosenthal,
MD; Al V. Taira, MD; Neha Vapiwala, MD.
the experts state that “The transrectal ultrasound-guided implant technique is the
backbone of modern prostate brachytherapy.”
In the 2013 “GEC/ESTRO recommendations on high dose rate afterloading brachytherapy for localised
prostate cancer: An update. Peter J. Hoskin , Alessandro Colombo , Ann Henry , Peter Niehoff , Taran Paulsen
Hellebust ,Frank-Andre Siebert , Gyorgy Kovacs
“In prostate cancer real-time transrectal ultrasound (TRUS) guided transperineal
template implant techniques represent the standard of care.”
Usage

Boost (together with EBRT, Androgen
deprivation). Typically 1-2 Fractions

Mono-therapy. Typically 2-4 Fractions but
recent results from small clinical trials
point towards a single fraction future.

Salvage vs. Primary (initial) treatment
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Usage

From a “Survey of practice in Australia” we learn that:
In Australia and New Zealand, 17 of 26 brachytherapy departments performed HDRPB in 2010 and 2011. Nucletron’s Oncentra TPS was used at 13 departments, one
department used Nucletron’s Plato TPS and three used Varian’s BrachyVision TPS.
Imaging modality for treatment planning
Thirteen departments generated a treatment plan using computerised tomography
data, and two departments used ultrasound (US) data. No departments reported
using MRIs or fused data sets for treatment planning.
All departments, except one, verified and corrected applicator displacement prior to
each fraction or, in the case of real-time US planning and more than one fraction,
subsequent fractions. Applicator displacement was corrected by one of three
methods to replicate the original plan: eight departments adjusted applicator
positions, four departments adjusted dwell positions and two departments created a
new treatment plan.
Survey of high-dose-rate prostate brachytherapy practice in Australia and New Zealand, 2010–2011, Jane van Nieuwenhuysen, David Waterhouse,
Sean Bydder, David Joseph, Martin Ebert and Nikki Caswell. Journal of Medical Imaging and Radiation Oncology 58 (2014) 101–108


Eighty-nine percent (89%) of respondents performed LDR and 49% perform highdose-rate brachytherapy.
HDR monotherapy - Of the respondents who perform HDR, 31% (10/32) perform
HDR monotherapy for low-risk patients and 19% (6/32) for intermediate-risk
patients. The remaining 16 respondents (50%) do not perform HDR monotherapy.

Imaging - Ultrasound remains the primary imaging modality. Ultrasound was in 83%
vs. 84% in 1998, CT in 9%, MRI in 0%, X-ray in 0%, and fluoroscopy in 17%.

Treatment planning - Pretreatment volume studies are performed with ultrasound in
94%, CT in 11%, and MRI in 6%. Twenty percent reported using more than one
imaging modality as ‘‘primary’’ modality.

LDR and HDR treatment planning software.
The software used for planning was institutional custom developed software in 2%
and commercially available in systems in 98%. The commercially available systems
were: Prowess (Prowess Inc., Concord, CA, USA) in 4%, Variseed (Varian Medical
Systems, Inc., Palo Alto, CA, USA) in 80%, Brachyvision (Varian Medical Systems) in
4%, and CMS (Elekta AB, Stockholm, Sweden) in 6%, Nucletron (Nucletron,
Columbia, MD, USA) in 4%, Varisource (Varian Medical Systems) in 5%, Oncentra
(Nucletron) in 2%, Varus (Varian Medical Systems) in 2%, and Plato (Nucletron) in
2% (percentages to not add to 100% owing to multiple systems for some
respondents).
A survey of current clinical practice in permanent and temporary prostate brachytherapy: 2010 update. Mark K. Buyyounouski, Brian
J. Davis, Bradley R. Prestidge, Thomas G. Shanahan,Richard G. Stock, Peter D. Grimm, D. Jeffrey Demanes, Marco Zaider, Eric M.
Horwitz. Brachytherapy 11 (2012) 299-305
‘Real-time’ workflow
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Initial imaging
Delineating structures
Define needles/applicators pattern
Needles/applicators Insertion
Update images & structures
Delineate applicators
Plan & Optimize Dose
QA for plan and applicators
Treatment delivery
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Image courtesy of Scott Campbell and Kim Chambers, Elekta/Nucletron
Image courtesy of Scott Campbell and Kim Chambers, Elekta/Nucletron
RAD 4145b 2013-01
Contouring
Freehand
Draw & edit
contours
using a pen
or brush tool
Real Time
Interpolation
Draw
necessary
contours &
Vitesse fills
in the rest
Shape
Stamper
Quickly
draw
urethra on
transverse
slices with
single click
Margin
Create a
symmetrical
or non
symmetrical
margin
structure
Review
Contour
Sagittal &
coronal
contour
review
Image courtesy of Kevin Spetz, Varian Brachytherapy
15 | VARIAN ONCOLOGY SYSTEMS
Vitesse
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Image courtesy of Scott Campbell and Kim Chambers, Elekta/Nucletron
Image courtesy of Kevin Spetz, Varian Brachytherapy
Image courtesy of Scott Campbell and Kim Chambers, Elekta/Nucletron
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RAD 4145b 2013-01
Needle Placement
o
Adjust planned needle
positions
o
Change needle angle
by aligning two nodes
o
Bend needle to align
with implanted needle
Image courtesy of Kevin Spetz, Varian Brachytherapy
19 | VARIAN ONCOLOGY SYSTEMS
Vitesse
RAD 4145b 2013-01
Needle Tip Adjustment Tool
Assists in correctly
aligning needle tips
Select reference needle(s)
based on confidence of
defined tip position
Enter exposed length of the
reference needle(s) from the
template
Select needle of concern
Enter exposed length of
selected needle
Tool displays the determined
offset of selected needle and
allows adjustment
Live image of the needle and
offset applied can be viewed
before accepting the change
Image courtesy of Kevin Spetz, Varian Brachytherapy
20 | VARIAN ONCOLOGY SYSTEMS
Vitesse
Image courtesy of Scott Campbell and Kim Chambers, Elekta/Nucletron
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RAD 4145b 2013-01
Volumetric Optimizer
Define DVH requirements for
any structure including
priority.
Define dwell time constraints.
Limit hot spots by adding a
basal dose limit.
o
o
o
22 | VARIAN ONCOLOGY SYSTEMS
Vitesse
Image courtesy of Scott Campbell and Kim Chambers, Elekta/Nucletron
Errors and uncertainties

Is an ultrasound based procedure as good as a
CT-based one?
RESULTS: A total of 574 needle tip positions have been compared between TRUS and CBCT. Of
these, 59% agreed within 1 mm, 27% within 1-2 mm, and 11% agreed within 2-3 mm. The
discrepancy between tip positions in the two modalities was greater than 3 mm for only 20 needles
(3%).
CONCLUSIONS: The US needle tip identification in vivo is at least as accurate as CT
identification, while providing all the advantages of a one-step procedure.
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Errors and uncertainties

During
multifractionated
HDR
treatment,
catheter
migration could cause degradation of dosimetry. Various
institutions had developed solutions to address this issue
and they involve, catheters adjustments based on tip
positions relative to fiducials, adjustments of dwell
positions or creating a new plan.
Applicator verification/correction
Cranio-caudal displacement of the applicators during multi-fraction HDR-PB can compromise
coverage of theCTV and introduce uncertainties in normal tissue doses. Tiong et al. assessed
applicator displacements over a 12-month period (more than 270 treatment fractions), and
concluded that <= 3 mm drift was tolerable with minimal detrimental impact upon tumour control
probability. The ABS advises that if applicator drift cannot be repositioned or corrected with a
new plan, treatment should be postponed.GEC/ESTRO-EAU advise to check the applicator
geometry prior to treatment and, if necessary, to modify the dosimetry.
Quality Assurance
Future
'It's tough to make predictions, especially about the future.'
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“The advantage of TRUS-based planning is that the entire procedure of catheter insertion, planning
and treatment delivery can be carried out in a shielded brachytherapy suite without having to move
the patient. This provides added confidence that the treatment delivered is exactly as planned.
If computed tomography or MRI is used for planning, the patient usually has to be transferred from
the procedure room to the computed tomography or MRI scanner and then back again to a shielded
room for treatment. Each step risks some displacement of the catheters and requires
careful repositioning before treatment is delivered. “
“Focal therapy is gaining popularity with the ability
of modern imaging (mpMRI) to identify dominant
areas of the disease within the prostate and again
HDRBT will have a major role to play in this area.
There is also increasing evidence for the role of
HDRBT in local recurrence after external beam
radiotherapy.
Future guidelines will seek to explore these areas
as published evidence emerges.”
THANK YOU
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7/23/2014
What is the most important advantage of Ultrasound-based
HDR prostate brachytherapy?
20% 1. It is inexpensive and widely available.
20% 2. Allows needle insertion and treatment delivery
without moving the patient, thus minimizing the
uncertainty in delivery of intended treatment
20% 3. Allows for visual guidance during needle
placement
20% 4. Both anatomical structures and applicators can
be visualized
20% 5. It is now available in color.
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Answer
• The correct answer is 2.
While 1. 3. and 4. are also advantages
one can argue that 2. is really the ‘most
important’ advantage
• Ref: “Brachytherapy: Current Status and Future Strategies: Can
High Dose Rate Replace Low Dose Rate and External Beam
Radiotherapy?” G.C. Morton, P.J. Hoskin, Clinical Oncology 25
(2013) 474-482
What is the major source of uncertainty in Ultrasoundbased HDR prostate brachytherapy?
20%
20%
20%
20%
1.
2.
3.
4.
Contouring of anatomical structures
Patient breathing
Needles/catheters displacement
Visualization and delineation of
needles/catheters and specifically their tip
20% 5. Calibration of Ultrasound scanners
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Answer:
• The correct answer is 3.
• This is a difficult question and I think arguments can be made for
either 3. particularly if multiple fractions are to be delivered or 4. for
the case of one fraction treatments. Contouring of prostate 1. would
be a third partially correct answer, even though evidence is that
comparisons between US and CT against the MR as gold standard
are putting US relatively close to the MR.
• Ref: ”Validation study of ultrasound-based high-dose-rate prostate
brachytherapy planning compared with CT-based planning”, Deidre
Batchelar, Miren Gaztanaga, Matt Schmid, Cynthia Araujo, Francois
Bachand, Juanita Crook, Brachytherapy 13 (2014) 75-79
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