Margot Lehman

Post-prostatectomy radiation therapy: Consensus guidelines of the Australian and New Zealand Radiation Oncology Genito-Urinary Group

BACKGROUND AND PURPOSE Three randomised trials have demonstrated the benefit of adjuvant post-prostatectomy radiotherapy (PPRT) for high risk patients. Data also documents the effectiveness of salvage radiotherapy following a biochemical relapse post-prostatectomy. The Radiation Oncology Genito-Urinary Group recognised the need to develop consensus guidelines on to whom, when and how to deliver PPRT. MATERIALS AND METHODS Draft guidelines were developed and refined at a consensus conference in June 2006 attended by 63 delegates where urological, radiotherapy and diagnostic imaging experts spoke on aspects of PPRT. Unresolved issues were further developed by working parties and redistributed until consensus was reached. RESULTS Central to the recommendations is that patients with positive surgical margins, seminal vesicle invasion and/or extracapsular extension have a high risk of residual local disease and should be informed of the options of either immediate adjuvant radiotherapy or active surveillance with early salvage in the event of biochemical recurrence. Salvage radiotherapy should be instituted at the earliest confirmation of biochemical recurrence. Detailed contouring guidelines have been developed, defining the regions at risk of residual microscopic disease which should be included in the clinical target volume. The recommended doses are 60-64Gy for adjuvant, and 60-66Gy for salvage radiotherapy. The role of hormone therapy in conjunction with PPRT is yet to be defined. CONCLUSIONS These consensus guidelines have been developed to give clinical and technical guidance to radiation oncologists and urologists in the management of high risk post-prostatectomy patients.

Australian & New Zealand Faculty of Radiation Oncology Genito-Urinary Group: 2010 consensus guidelines for definitive external beam radiotherapy for prostate carcinoma

External beam radiotherapy for prostate cancer has undergone substantial technological and clinical advances in the recent years. The Australian & New Zealand Faculty of Radiation Oncology Genito‐Urinary Group undertook a process to develop consensus clinical practice guidelines for external beam radiotherapy for prostate carcinoma delivered with curative intent, aiming to provide guidance for clinicians on the appropriate integration of clinical evidence and newer technologies. Draft guidelines were presented and discussed at a consensus workshop in May 2009 attended by radiation oncologists, radiation therapists and medical physicists. Amended guidelines were distributed to radiation oncologists in Australia, New Zealand and Singapore for comment, and modifications were incorporated where appropriate. Evidence based recommendations for risk stratification, the role of image‐guided and intensity‐modulated radiation therapy, prescribed dose, simulation and treatment planning, the role and duration of neo‐adjuvant/adjuvant androgen deprivation therapy and outcome reporting are presented. Central to the guidelines is the recommendation that image‐guided radiation therapy should be used when definitive external beam radiotherapy for prostate cancer is prescribed. The consensus guidelines provide a co‐operatively developed, evidence‐based framework for contemporary treatment of prostate cancer with external beam radiotherapy.

The less than whole breast radiotherapy approach.

The addition of conventional whole breast irradiation (WBI) to breast conserving surgery (BCS) reduces the risk of early breast cancer recurrence and leads to a statistically and clinically significant improvement in overall survival. However, the long duration of conventional WBI regimens negatively impacts on quality of life. This has led investigators to evaluate an alternative approach of delivering radiation to a limited volume of tissue around the tumour cavity only (partial breast irradiation) and delivering a larger than standard dose of radiation with each treatment (accelerated partial breast irradiation, APBI). This approach may be achieved by a number of techniques: interstitial brachytherapy, intracavitary brachytherapy using the Mammosite device, intraoperative techniques using electrons or low-energy photons, external beam radiotherapy or permanent seed implant. This articles will review the rationale for the less that whole breast radiotherapy approach and describe the techniques by which it can be achieved and the results obtained to date. Finally, the 7 prospective randomised controlled trials of conventional WBI versus APBI which are open and currently recruiting patients will be discussed.

Australian & New Zealand Faculty of Radiation Oncology Genito-Urinary Group: 2011 consensus guidelines for curative radiotherapy for urothelial carcinoma of the bladder.

Curative radiotherapy, with or without concurrent chemotherapy, is recognized as a standard treatment option for muscle‐invasive bladder cancer. It is commonly used for two distinct groups of patients: either for those medically unfit for surgery, or as part of a ‘bladder preserving’ management plan incorporating the possibility of salvage cystectomy. However, in both situations, the approach to radiotherapy varies widely around the world. The Australian and New Zealand Faculty of Radiation Oncology Genito‐Urinary Group recognised a need to develop consistent, evidence‐based guidelines for patient selection and radiotherapy technique in the delivery of curative radiotherapy. Following a workshop convened in May 2009, a working party collated opinions and conducted a wide literature appraisal linking each recommendation with the best available evidence. This process was subject to ongoing re‐presentation to the Faculty of Radiation Oncology Genito‐Urinary Group members prior to final endorsement. These Guidelines include patient selection, radiation target delineation, dose and fractionation schedules, normal tissue constraints and investigational techniques. Particular emphasis is given to the rationale for the target volumes described. These Guidelines provide a consensus‐based framework for the delivery of curative radiotherapy for muscle‐invasive bladder cancer. Widespread input from radiation oncologists treating bladder cancer ensures that these techniques are feasible in practice. We recommend these Guidelines be adopted widely in order to encourage a uniformly high standard of radiotherapy in this setting, and to allow for better comparison of outcomes.

The effect of beam arrangements and the impact of non‐coplanar beams on the treatment planning of stereotactic ablative radiation therapy for early stage lung cancer

The aim of this study was to compare various coplanar and non‐coplanar 3‐dimensional conformal radiation therapy (3DCRT) beam arrangements for the delivery of stereotactic ablative radiation therapy (SABR) to patients with early stage lung cancer, based on the dosimetric criteria from the Radiation Therapy Oncology Group (RTOG) 1021 protocol.

FROGG high-risk prostate cancer workshop: patterns of practice and literature review: part I: intact prostate

Australian and New Zealand radiation oncologists with an interest in uro‐oncology were invited to participate in a pattern‐of‐practice survey dealing with the management of intact high‐risk prostate cancer. Responses from 46 practitioners (representing 73% of all potential respondents) revealed that high‐dose radiation therapy is the standard of care. However, there is variability in practice with regard to the methods used to achieve dose escalation, the use of whole‐pelvic radiation therapy and the optimal duration of androgen deprivation therapy employed. A review of the literature outlining the current body of knowledge and the planned and ongoing studies in intact high‐risk prostate cancer is presented.

Can We Predict Plan Quality for External Beam Partial Breast Irradiation: Results of a Multicenter Feasibility Study (Trans Tasman Radiation Oncology Group Study 06.02)

PURPOSE Partial breast irradiation (PBI) after lumpectomy may be an option for selected patients with early breast cancer. A feasibility study of accelerated PBI delivered using external beam 3-dimensional conformal radiation therapy (RT) was undertaken at 8 Australasian centers. The present study evaluated the impact of patient, tumor, and RT technique-related factors on the quality of RT plans as determined by the dose-volume parameters of organs at risk. METHODS AND MATERIALS Forty-eight patients were enrolled in the study. All RT plans were centrally reviewed using predefined dosimetric criteria before commencement and after completion of protocol therapy. The RT plans of 47 patients met the dose-volume constraints, and all 47 patients received PBI to a prescribed dose of 38.5 Gy in 10 fractions. The RT plan quality was determined by volumes of the ipsilateral whole breast, lung, and heart that received 50% and 95%; 30%; and 5% of the prescribed dose, respectively. Patient, tumor, and RT technique-related factors were investigated for association with the parameters of RT plan quality. RESULTS The ratio of the planning target volume to the ipsilateral whole-breast volume was significantly associated with the ipsilateral breast doses on multiple variable analyses. The distance of the postlumpectomy surgical cavity from the heart and lung were predictive for heart and lung doses, respectively. A distance between surgical cavity and heart of >4 cm typically resulted in <1% of the heart volume receiving 5 Gy or less. It was more difficult to meet the heart dose constraint for left-sided and medially located tumors. CONCLUSIONS Partial breast irradiation using 3-dimensional conformal RT was feasible within the study constraints. The ratio of planning target volume to ipsilateral whole-breast volume and the distance of surgical cavity from the heart were significant predictors of the quality of treatment plan for external beam PBI.

Assessment of prostatic fiducial marker introduction: Patient morbidity, staff satisfaction and improved treatment field placement

Introduction: Increased accuracy when using fiducial markers for prostate localisation is well documented. This project aimed to establish the improvement in accuracy when using gold markers for daily prostate localisation, to assess patient satisfaction and morbidity from the transrectal implantation of gold seed markers and establish staff attitudes towards the newly introduced processes.

A randomized phase II trial of two regimens of moderate dose chemoradiation therapy for patients with non-small cell lung cancer not suitable for curative therapy trans tasman radiation oncology study TROG 03.07

Background: There are patients with stage I–III non-small cell lung cancer (NSCLC) who are not suitable for curative radical chemoradiation therapy. There are patients with an isolated solitary extracranial metastasis who have improved outcomes compared with those with cranial or multiple metastases. Patients of good performance status receiving moderate dose radiation therapy have improved survival. Two regimens of moderate dose chemoradiation therapy for such patients were compared in a randomized phase II trial. Methods: Patients were eligible if they had stage I–IIIB NSCLC, unsuitable for curative therapy, or stage IV with a PET-detected extracranial solitary metastasis. Patients were randomized to the following groups—arm A: 40 Gy/20 fractions/4 weeks with concurrent weekly vinorelbine 25 mg/m2 + cisplatin 20 mg/m2 or arm B: 30 Gy/15 fractions/3 weeks with concurrent weekly gemcitabine 200 mg. Primary end points were feasibility, response rates, and toxicity. Secondary end points were progression-free survival, overall survival, and quality of life. Results: Eighty-four patients were randomized. Compliance was above 90% for both arms. The overall response rate was 51% in arm A and 38% in arm B (p = 0.147). Grade 3/4 toxicity in both arms was acceptable. There was no difference in median progression-free survival between the two arms (5.5 versus 5.0 months, p = 0.19). Patients in arm A had longer median survival but this did not reach statistical significance (13.1 versus 8.3 months, p = 0.25). No difference in quality of life was observed. Conclusions: Arm A was chosen for a future phase II comparison with radiation therapy alone as it demonstrated a response rate greater than 50%, and data suggested that arm A had superior survival to arm B.

FROGG high‐risk prostate cancer workshop: Patterns of practice and literature review. Part II post‐radical prostatectomy

Australian and New Zealand radiation oncologists with an interest in uro‐oncology were invited to undertake a pattern of practice survey dealing with issues encountered in the management of high‐risk prostate cancer in the post‐prostatectomy setting. Responses from practitioners revealed a lack of consensus regarding the optimal timing of radiation therapy, the use of whole pelvic radiation therapy and the use of androgen deprivation therapy. A review of the literature outlining the current body of knowledge and the clinical studies that will inform future practice is presented.