Three-Dimensional Conformal Radiation Therapy (3DCRT) for Prostate Cancer

ADVANCED RADIOTHERAPY

MUHAMMAD SAFWAN BIN AHMAD FADZIL MUHAMMAD HAFEZ KHUZAIRI BIN GHAZALI MOHD NAJIB BIN SALIHI

Introduction

3DCRT
The goal of (3DCRT) is to have the prescribed

radiation dose distribution be shaped like or "conform" to a target volume. This 3D visualization allows the radiation oncologist to choose various radiation therapy beam arrangements to maximally cover the tumor with radiation and minimize exposure to the normal structures.

3DCRT
Once the beams are selected, the fields are shaped to

conform to the shape of the target volume in that projection. The dose distribution is then analyzed using graphical tools, such as dose volume histograms (DVHs), or 3D dose displays. DVHs are analytical tools that depict the volume of each organ or target tissue and the dose that it receives

3DCRT
Patient positioning is critical, and for this reason

immobilization devices are routinely used. 3DCRT often employs multiple treatment fields as many as six or eight. The use of lead alloy blocks for 3DCRT requires increased time with less efficiency in treatment delivery.

The Planning of 3D CRT

Step 1: Immobilization
This device helps improve the accuracy with which

radiation therapy treatments can be delivered

(Song et al. 1996)

Without any immobilization device

with alpha cradle from the waist to upper thight

With alpha cradle from hip to just below knees With a ready made strofoam leg immobilizer (below

knees) With aquaplast cast encomposing their entire abdomen and pelvis to mid-thigh with alpha cradle immobilization of their lower legs and feet

RESULT

Step 2: CT acquisition
Although physically similar to a diagnostic CT scan,

the treatment planning CT is acquired with the patient in his treatment position. Sometimes the use of contrast media is necessary to help visualize the prostate

(Roach Iii et al. 1996)

MRI-CT fused image

Firstly, we observed inability to distinguish the posterior

portion of the prostate from the anterior wall of the rectum on noncontrast CT compared to MRI. Secondly, we noted a disagreement between the urethrogram based definition for the location of the apex and the location of the apex defined by MRI. Third, we tended to confuse the posterior-inferior-apical portion of the prostate with the anterior portion of the levator ani muscles when assessed by noncontrast CT. Last, based on CT volume, we tended to include portions of the neurovascular bundles as part of the prostate volume proper.

Step 3: Planning (Volume Delineation)

Clinical Target Volume (CTV)
Prostate and seminal vesicles (SV) Regional lymph nodes included for high risk disease

Planning Target Volume (PTV)

1 cm margin around CTV Rectal-prostate interface - 6 mm margin only Superior border at tips of the SV Inferior border above penile bulb

Treatment Volume

PTV plus 5 mm except 10 mm at superior and inferior aspects to account for penumbra

Forward vs Inverse Planning (Fenoglietto et al. 2008)

Step 4: Verification
Portal film

EPID
OBI

(Logadttir et al. 2011)

kV images with the ExacTrac system

a CBCT scan with the OBI system

kV images were acquired using the OBI

Treatment Delivery

 3DCRT delivery is conventional fractionation.

A small daily fraction, 1.8-2.0 Gy/fraction (allows the

normal tissues to recover between treatments whereas tumor cells are less efficient at repairing radiation damage) Several acceptable methods for delivery of the radiation treatments.

4 fields 6 fields 7 fields

Comparison with IMRT

IMRT delivered (2.5Gy/fractions to 70Gy) resulted

in 5-year biochemical failure-free survival rates of 95%, 85%, and 68% for low-, intermediate-, and high-risk patients, respectively.
Hunt M, et al 2006. Ruth K, et al 2008.

CHALLENGES

Challenges
Target volume delineation
limitation of diagnostic modalities in pinpointing small volumes of disease. criteria for delineating these volumes are not well-defined for many disease sites, leading to significant differences in the outlining of the various targets among institutions, and among physicians in the same institution

Patient selection and predictive assay

high-dose 3DCRT will benefit only a subset of patients, those without occult metastasis and for whom a higher dose translates to a meaningful increase in tumour control probability. efforts to assess tumour radiosensitivity as predictive assays for individual patients tumours with either exquisite radiosensitivity or extreme radioresistance would not be optimal candidates for 3DCRT.

Challenges
Analysis of clinical outcome and dose-volume data

Conformal therapy planning avails 3D volume-dose data dosevolume histogram or DVH), which together with clinical data and knowledge of the biological basis of radiation-induced injury, may lead to a better understanding and potential circumvention of radiation-induced morbidity.
The organ-specific DVHs derived from treatment planning are only approximations, as the volume-dose pattern will be affected by set-up uncertainties and organ motion during each treatment session, and by anatomical changes during the treatment course.

Recognition and reduction of treatment uncertainty

Challenges
Assurance of treatment
Although computer-aided automation can alleviate the quotidian chores in treatment delivery, the verification of treatment is more difficult. improved set-up procedures and provide patient-specific and population-averaged frequency distributions of set-up errors. The population-average data increases our understanding of the magnitude and effect of arratomical motions and alterations, and renders a more realistic estimation of the dosimetric characteristics of the treatment plan.

Possible Side Effects

Study 1
Men with localized prostate cancer treated with a

(IMRT), have more than a quarter (26 percent) fewer late bowel and rectal side effects and a statistically improved lower dose of radiation to the bladder and rectum, compared to those who undergo 3D-CRT, according to a randomized study presented at the plenary session October 3, 2011, at the 53rd Annual Meeting of the American Society for Radiation Oncology (ASTRO).

Study 2
Men with prostate cancer treated with a (IMRT) have

fewer gastrointestinal complications compared to patients treated with conventional (3D-CRT), according to a study to be presented Nov. 1, 2010, at the 52nd Annual Meeting of the American Society for Radiation Oncology (ASTRO).

Study 3
IMRT causes fewer gastrointestinal side effects when

combined with hormone therapy than using 3D CRT, according to a study published in the June issue of theInternational Journal of Radiation OncologyBiologyPhysics, the official scientific journal of the American Society for Radiation Oncology (ASTRO). (3D-CRT) + hormone therapy has been proven very effective at treating men with intermediate to high-risk prostate cancer. However, these treatments can cause very uncomfortable gastrointestinal side effects due to exposure of the rectum to radiation during treatment.

3D CRT vs Conventional RT

Study..
Volume of normal bladder and rectum receiving a

high dose of radiation therapy is substantially reduced when using 3D CRT. Some institutions have demonstrated that early acute side effects are reduced with the use of 3DCRT. Hunt MA, et al 1992. Others have demonstrated that equal side effects are seen in patients treated with 3DCRT compared to conventional radiotherapy despite being treated with higher radiation doses using 3DCRT. Starkschall G, et al 1996.

Possible Side Effects

With conformal radiotherapy there is less normal tissue -

in the field of the radiotherapy. So the risk of side effects is lower. Might risk the patient to have some of this SE: Decrease in weight Skin rash/skin sensitive Skin erythema, Subcutaneous fibrosis Genital and/or leg edema Diarrhea Small bowel obstruction

REFERENCES

http://esciencenews.com/articles/2011/06/01/imrt.cuts.gi.side.effects.prostate.cancer.half.vs.3 d.crt http://medicalxpress.com/news/2011-09-imrt-rectal-side-effects-3d-crt.html http://www.sciencedaily.com/releases/2010/10/101025133757.htm Fenoglietto, P., B. Laliberte, A. Allaw, N. Ailleres, K. Idri, M. H. Hay, C. L. Moscardo, S. Gourgou, J.-B. Dubois & D. Azria 2008. Persistently better treatment planning results of intensity-modulated (IMRT) over conformal radiotherapy (3D-CRT) in prostate cancer patients with significant variation of clinical target volume and/or organs-at-risk. Radiotherapy and Oncology 88(1): 77-87. Logadttir, ., S. Korreman & P. M. Petersen 2011. Comparison of the accuracy and precision of prostate localization with 2D2D and 3D images. Radiotherapy and Oncology 98(2): 175-180. Roach Iii, M., P. Faillace-Akazawa, C. Malfatti, J. Holland & H. Hricak 1996. Prostate volumes defined by magnetic resonance imaging and computerized tomographic scans for threedimensional conformal radiotherapy. International Journal of Radiation Oncology*Biology*Physics 35(5): 1011-1018. Song, P. Y., M. Washington, F. Vaida, R. Hamilton, D. Spelbring, B. Wyman, J. Harrison, G. T. Y. Chen & S. Vijayakumar 1996. A comparison of four patient immobilization devices in the treatment of prostate cancer patients with three dimensional conformal radiotherapy. International Journal of Radiation Oncology*Biology*Physics 34(1): 213-219.

REFERENCES
Zelefsky MJ, Chan H, Hunt M, et al. Long-term outcome of high

dose intensity modulated radiation therapy for patients with clinically localized prostate cancer. J Urol. 2006;176:1415-9. Eade TN, Horwitz EM, Ruth K, et al. A comparison of acute and chronic toxicity for men with low-risk prostate cancer treated with intensity-modulated radiation therapy or (125)I permanent implant. Int J Radiat Oncol Biol Phys. 2008;71:338-45. Soffen EM, Hanks G, Hunt MA, et al.: Conformal static field radiation therapy treatment of early prostate cancer versus nonconformal techniques: A reduction in acute morbidity. Int J Radiat Oncol Biol Phys 1992; 24: 485. Pollack A, Zagars GK, Starkschall G, et al: Conventional vs. conformal radiotherapy for prostate cancer: Preliminary results of dosimetry and acute toxicity. Int J Radiat Oncol Biol Phys 1996; 34: 555.