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Indication of radiotherapy
Indications of RT:
(1) very low risk, life expectancy 20 years
(2) low risk, life expectancy 10 years
Indications of RT+ADT:
(1) Intermediate risk
(2) high risk
(3) very high risk
(4) LN positive
Indications of adjuvant RT after radical prostatectomy
(1) positive margin
(2) seminal vesicle invasion
(3) extracapsular extension
(4) detectable PSA, or > 0.2 ng/ml on consecutive 2 measurement
(5) Gleason score 8-10
(6)Positive pelvis LN
2. CTV for distal seminal vesicles (CTVsv): above bifurcation of SV shown in CT.
3. CTV for prostate (CTVp): visible prostate with or without proximal SV.
4. Rules for creating PTV by expanding each CTV: since fiducial markers are
inserted into prostate and the position and shape of seminal vesicle will change
with the distension of bladder and rectum, the margin between CTV and PTV is
larger for SV than prostate in patients with fiducial markers.
A. PTVn: (0.5-1) 0.7cm expansion in 3 axis from CTVn
B. When fiducial marker is inserted for image guidance (PTV with i prefix):
i. iPTVsv: 5-7 mm in dorsal direction and 1-0.8 cm for the rest from CTVsv
ii. iPTVp: 5-8 mm in 3 axis from CTVp
C. Without fiducial marker
i. PTVsv: 7 mm expansion in dorsal direction and 1 cm for rest from CTVsv.
ii.
PTVp: 5-7 mm in dorsal direction and 1-0.8cm for rest from CTVp.
D. For SBRT
i. PTVp: 5mm in all direction, 3-5 mm in dorsal direction
Radiation dose
1. The dose escalation (78 Gy) will be only given to patients who are inserted with
fiducial marker and treated with image-guided RT (IGRT) because these techniques
improve the positional precision.
2. The reduction of RT dose is allowed if the dose constraints for rectal and bladder
can not meet the safety criteria, especially for patients with multiple co-morbidity
or taking anti-coagulant.
3. Radiation dose to primary tumors by external beam:
RT dose to prostate: 75.6 -81Gy in 1.8-2Gy/fractions.
RT dose to SV: 50.4-59.4 Gy/28-33 fx for T1-2, 75.6 78.4 Gy for T3.
RT dose to pelvic node: 45 Gy 50.4 Gy. Boost dose to gross LN is allowed.
4. SBRT dose
Low/intermediate risk: 700-750cGy x 5fractions, QD or QOD
High risk: after whole pelvis 45-50.4Gy, boost by SBRT with 700cGy x 3 fxs.
Boost dose to gross LN is allowed.
5. Radiation dose to primary tumors by external beam for adjuvant treatment:
RT dose to prostate and SV tumor bed: 64-72Gy in 1.8-2Gy/fractions.
RT dose to pelvic node: 45 Gy50.4 Gy. Boost dose to gross LN is allowed.
6. Radiation dose to primary tumors by external beam for salvage treatment:
RT dose to prostate and SV tumor bed: 64-72Gy in 1.8-2Gy/fractions.
Biopsy-proven gross recurrence may require higher doses.
RT dose to pelvic node: 45 Gy50.4 Gy. Boost dose to gross LN is allowed.
Dose constraints
V36Gy< 1c.c.
Combined EBRT: V14.5<17%, V20< 1c.c.
Bladder
Monotherapy: 100 < 5%, D90 <10%, D80 <20%, D50<50% or V37.5<
5.c.c.
Combined EBRT: V14.5<25%, V21< 5c.c.
Penile bulb
Monotherapy: V29.5 < 50%