(Prostate, GI and H&N) - UCSF Radiation Oncology

Overview of
Treatment techniques
at UCSF
(Prostate, GI and H&N)
O.Morin
Physics Resident Talk
04/29/09

• “Good to know” facts
• Anatomy (targets)
• Treatment options
Outline
• Gold standard for treatment
• New treatment techniques
Prostate
GI
Head and neck

Methods and equipment
to administer Tx
• Linacs
• IORT
• Cyberknife
• Brachytherapy
EBRT
Important question:
Monotherapy,
boost, palliative or
salvage

Prostate-Pearls
• Number one non-cutaneous cancer in men.
• Nearly 50-80% of tumors involve the prostate apex
and roughly 85% of patients have multifocal disease in
the prostate.
• Most frequently used prognosis factors are Gleason
score, clinical stage and pretreatment PSA.
• MR spectroscopy shows decrease citrate and increase
choline but its role in routine management has not yet
been studied.

Prostate-Pearls
• Lymph node drainage is primarily to the internal iliac
obturator, external iliac, common iliac, and paraaortic
nodes.
• Risk-classification schemed and nomograms are used
to help guide treatment decisions.

Prostate Anatomy
Base
Apex

Prostate Cancer Staging

• Surgery
Prostate Tx options
• Radiation therapy
• Hormone therapy
• Cryosurgery
• Chemotherapy
• Biologic therapy
• Thermal therapy
EBRT alone
EBRT + cyberknife boost
EBRT + PPI boost
PPI alone
EBRT + HDR
HDR alone

Prostate Tx UCSF
• At UCSF, patients are treated supine with alpha
cradle immobilization with ankle block.
• Patients are instructed to have full bladder and
empty rectum for simulation.
• Daily imaging (portal images or MVCBCT) is used
to monitor prostate motion.
• Gold markers implanted in the prostate 7-10 days
prior to simulation serve as surrogate for the
prostate.

Traditional whole pelvis RT + cone down boost
1. 4 fields
2. 4 to 7
3. Prostate only
1.8 Gy/fx

Traditional whole pelvis RT + cone down boost
1. 4 fields
2. 4 to 7
3. Prostate only
1.8 Gy/fx

Traditional whole pelvis RT + cone down boost
1. 4 fields
2. 4 to 7
3. Prostate only
1.8 Gy/fx

IMRT
Prostate with node coverage

IMRT
Prostate with node coverage

IMRT
Prostate with node coverage
Spinal cord

Current practice at UCSF
Prostate:
3D CRT:
High-Risk:
- 45 Gy Whole Pelvis
- 54 Gy Prost. + Seminal Vesicles
- 74 Gy Prost.
Low-Risk:
- 54 Gy Prost. + Seminal Vesicles
- 74 Gy Prost.
Approximately 40 fractions
IMRT:
- 54 Gy Seminal Vesicles
- 77 Gy Prostate
Approximately 33 fractions
12

Current practice at UCSF
Prostate:
Daily alignment based on
gold seeds using EPID
12

Current practice at UCSF
Prostate:
Daily alignment based on
gold seeds using EPID
12

Current practice at UCSF
Prostate:
Daily alignment based on
gold seeds using EPID
R
I
A
P
S
L
12

HDR
Prostate Tx Brachy
As
a
boost:
45
Gy
EBRT
+
HDR
2
fx
x
9.5
Gy
Monotherapy:
3
fx
x
10.5
Gy,
9.5
Gy
BID
x
2
days
Salvage
(re‐treatment):
2
implants
x
3
fx
of
6.0
Gy
PPI
Monotherapy: I-125 (144 Gy), Pd-103 (125 Gy).
After 40-50 Gy EBRT: I-125 (110 Gy), Pd-103 (90 Gy).

Gastrointestinal (GI)
• 22,000 new cases, 12,000
deaths from gastric cancer each
year in the US.
• Pancreatic cancer is 5th leading
cause of cancer mortality
although only 9th most
common.
• 5% of GI are esophagus.
• Colorectal cancer is the third
most frequently diagnosed
cancer in US.

GI-Lymph nodes

GI-Tx options
• Patient simulated in supine and prone (anal) position.
• EBRT: 3DCRT or IMRT
• Cyberknife showing good encouraging results (liver).
• May need to use more 18X photon beams with
EBRT.
• Large margins required for liver, stomach and
pancreas.
• PET may be useful but not routinely used.
• Nearly all plans are CT based.

Esophagus

Esophagus
Esophagus

Esophagus
Esophagus
Spinal cord

Stomach

Stomach
Stomach

Stomach
Stomach
Spinal cord

Anal CancerAnal Cancer

Anal CancerAnal Cancer
Spinal cord

Weekly portal imaging
Patient setup

Head and Neck (HN)
• Nasopharynx
• Nasal cavity and paranasal
sinus
• Oropharyngeal
• Lip and oral cavity
• Larynx and hypopharynx
• Salivary glands
• Thyroid cancer

Head and Neck (HN)
• Nasopharynx
• Nasal cavity and paranasal
sinus
• Oropharyngeal
• Lip and oral cavity
• Larynx and hypopharynx
• Salivary glands
• Thyroid cancer

HN-Tx Options
• EBRT: 3DCRT or IMRT
• Rarely use electron with and without bolus
• Brachy (floor of mouth, base of tongue, etc.)
• Cyberknife (salavage nasopharynx, orbit, optic
nerve, etc.)

HN-Target volumes
Several
 tumor
 volumes
 are
 often
 dePined
 for
 head
 and
 neck
 treatment.
Generally
they
are
dePined
as
follows:
GTV
=
clinical
and/or
radiographic
gross
disease
CTV1
 =
 site
 speciPic
 margin
 on
 primary
 &/or
 nodal
 GTV,
 microscopic
spread.
CTV2
=
elective
neck,
low‐risk
nodes
determined
by
the
clinician.
Other
treatment
volumes
may
be
present
depending
on
the
doctor.

• CT based plan
HN-Tx details
• CT with contrast, PET and MR greatly used.
• Thermoplastic mask covering the shoulders
• Neck holder (TIMO)
• Dental mold
• 3D CRT, IMRT and electron
• Bolus for superficial tumor
• Should not need 18X photon beam
• Not always uniformly distributed beam angles

Base of tongue

Base of Base tongue of tongue

Dose
tolerance:
EBRT
using
1.8­2.0
Gy
per
fraction
Stereotactic
radio
surgery
Whole
brain

Current practice at UCSF
Head and Neck:
Plan and prescription:
IMRT:
- 70 Gy GTV (visible tumor, (+) lymph nodes)
- 59.4 Gy CTV1 (Risk of microscopic disease + )
- 54 Gy CTV2 (Risk of microscopic disease)
PTV: 2-5 mm margin
Approximately 33 fractions
28

Current practice at UCSF
Head and Neck:
Plan and prescription:
IMRT:
- 70 Gy GTV (visible tumor, (+) lymph nodes)
- 59.4 Gy CTV1 (Risk of microscopic disease + )
- 54 Gy CTV2 (Risk of microscopic disease)
PTV: 2-5 mm margin
Approximately 33 fractions
Setup:
Thermoplastic mask
EPID or MVCBCT ONCE A WEEK
AP
LAT
28

MVCBCT:
Patient setup

Overview of
Treatment techniques
at UCSF
(Prostate, GI and H&N)
O.Morin
Physics Resident Talk
04/29/09