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Resources for pelvic nodal volume in prostate hypofrac?

Chartreuse Wombat

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KHE88

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I don't think anybody knows optimal volumes. I recently saw a node of Cloquet failure. Most probably wouldn't have covered that.
Is there even consensus if nodes are regional disease in prostate or not? Why are we electively covering non-regional sites?
So where exactly is the regional at-risk areas worth electively covering in prostate? Do we have a good answer for this yet? I keep looking but I can't find one.

I believe in treating nodes in higher risk patients and tend to be a bit more generous due to lack of good consensus and plenty of reported failures outside of tradiational nodal volumes in other pelvic cancers

As far as dose painting...
I have done both 60/20 with 44/20 and 70/28 with 50.4/28. I think the question you are asking is what to cover. If there are recent consensus guidelines I'm not aware of, I'd be interested too.
 

taserlaser

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I don't think anybody knows optimal volumes. I recently saw a node of Cloquet failure. Most probably wouldn't have covered that.
Is there even consensus if nodes are regional disease in prostate or not? Why are we electively covering non-regional sites?
So where exactly is the regional at-risk areas worth electively covering in prostate? Do we have a good answer for this yet? I keep looking but I can't find one.

I believe in treating nodes in higher risk patients and tend to be a bit more generous due to lack of good consensus and plenty of reported failures outside of tradiational nodal volumes in other pelvic cancers

As far as dose painting...
I have done both 60/20 with 44/20 and 70/28 with 50.4/28. I think the question you are asking is what to cover. If there are recent consensus guidelines I'm not aware of, I'd be interested too.

The docs where I’m at use a lot of 44/20 for nodal volumes, or 25/5 for 5 fr SBRT cases. Not sure how much evidence if any for those, but it’s done.

I’ve also seen a draft version of an updated society atlas/guideline for prostate nodes based on PSMA data/recurrences which should hopefully be out soon (well, pre covid, who knows how much things got delayed), which may affect where people target as well
 
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scarbrtj

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I don't think anybody knows optimal volumes. I recently saw a node of Cloquet failure. Most probably wouldn't have covered that.
Is there even consensus if nodes are regional disease in prostate or not? Why are we electively covering non-regional sites?
So where exactly is the regional at-risk areas worth electively covering in prostate? Do we have a good answer for this yet? I keep looking but I can't find one.

I believe in treating nodes in higher risk patients and tend to be a bit more generous due to lack of good consensus and plenty of reported failures outside of tradiational nodal volumes in other pelvic cancers

As far as dose painting...
I have done both 60/20 with 44/20 and 70/28 with 50.4/28. I think the question you are asking is what to cover. If there are recent consensus guidelines I'm not aware of, I'd be interested too.
Again, as I'm oft wont to say, "I might be hallucinating" but if you go back and look at some of the old, pre-1980's classic surgical prostate cancer node involvement literature, the inguinal nodes were usually the first or second most commonly involved nodal met site. A kind of "inconvenient truth" maybe. But I never heard tell of rad onc nodal coverage guidelines explicitly advocating covering the inguinals in prostate cancer. It's a reason (apart from the really lackluster clinical data showing ENI helps, of course) I'm not big on ENI in prostate. Sorry, Mack.
 
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elementaryschooleconomics

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Again, as I'm oft wont to say, "I might be hallucinating" but if you go back and look at some of the old, pre-1980's classic surgical prostate cancer node involvement literature, the inguinal nodes were usually the first or second most commonly involved nodal met site. A kind of "inconvenient truth" maybe. But I never heard tell of rad onc nodal coverage guidelines explicitly advocating covering the inguinals in prostate cancer. It's a reason (apart from the really lackluster clinical data showing ENI helps, of course) I'm not big on ENI in prostate. Sorry, Mack.

Did you just pull out a YouTube video with 695 views???
 
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ramsesthenice

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I'm not big on ENI in prostate. Sorry, Mack.

Me neither. But I am doing hypofrac in patients with positive nodes from time to time. I don't have a source to point to but I essentially treat the nodes the same as I always would and treat them to 45-50 Gy in 25 fractions as an SIB. The prostate and gross nodes get what they get with they hypofrac regimen. I have yet to really notice any difference in acute toxicity with this than I did with conventional. I have never, nor do I know of anyone that hypofractionates the uninvolved nodes.
 

Mandelin Rain

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Again, as I'm oft wont to say, "I might be hallucinating" but if you go back and look at some of the old, pre-1980's classic surgical prostate cancer node involvement literature, the inguinal nodes were usually the first or second most commonly involved nodal met site. A kind of "inconvenient truth" maybe. But I never heard tell of rad onc nodal coverage guidelines explicitly advocating covering the inguinals in prostate cancer. It's a reason (apart from the really lackluster clinical data showing ENI helps, of course) I'm not big on ENI in prostate. Sorry, Mack.
Takeaway from video: I think Mack REALLY likes knowing that "every radiation resident has to memorize the Roach Equation because it's on the test."

Did love the actual randomized national trial that examined this question, "we're not going to spend a lot of time on this [switches slide after 2 seconds (shows that pelvic radiation had the best AND worst outcomes with prostate only arms directly between)]." {Spends an hour belaboring surgical data and retrospective data}.

Radiation oncology in a nutshell. Forget the data, I've got dogma.
 
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scarbrtj

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Takeaway from video: I think Mack REALLY likes knowing that "every radiation resident has to memorize the Roach Equation because it's on the test."

Did love the actual randomized national trial that examined this question, "we're not going to spend a lot of time on this [switches slide after 2 seconds (shows that pelvic radiation had the best AND worst outcomes with prostate only arms directly between)]." {Spends an hour belaboring surgical data and retrospective data}.

Radiation oncology in a nutshell. Forget the data, I've got dogma.
This is the well known reaction everyone had after Mack explained what RTOG 9413 meant in ASTRO plenary the year it came out.
 
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taserlaser

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Me neither. But I am doing hypofrac in patients with positive nodes from time to time. I don't have a source to point to but I essentially treat the nodes the same as I always would and treat them to 45-50 Gy in 25 fractions as an SIB. The prostate and gross nodes get what they get with they hypofrac regimen. I have yet to really notice any difference in acute toxicity with this than I did with conventional. I have never, nor do I know of anyone that hypofractionates the uninvolved nodes.

What I had mentioned above was explicitly uninvolved nodes in high risk patients. So there are some
 

ramsesthenice

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What I had mentioned above was explicitly uninvolved nodes in high risk patients. So there are some

I am sure there are. I meant I don't personally know anyone so I can't speak to what folks are doing or how well it is going :). I have no doubt in my mind that moderate hypofrac (in the 2-3 range) would probably go ok to the nodal volumes. I just haven't pulled the trigger yet. Im in the Scar camp and don't treat nodes that often in all but the highest risk N0 patients.
 
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scarbrtj

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Radiation oncology in a nutshell. Forget the data, I've got dogma.
FWIW & FYI, I learned a new word today, "aletheia," which is evidently the thorough opposite of "dogma." Came across it reading about Pope Francis' favorite movie of all time, 'Babette's Feast.'
 
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Palex80

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Here are some for SBRT:
 

beamseyeview

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Me neither. But I am doing hypofrac in patients with positive nodes from time to time. I don't have a source to point to but I essentially treat the nodes the same as I always would and treat them to 45-50 Gy in 25 fractions as an SIB. The prostate and gross nodes get what they get with they hypofrac regimen. I have yet to really notice any difference in acute toxicity with this than I did with conventional. I have never, nor do I know of anyone that hypofractionates the uninvolved nodes.

Fox Chase hypofrac trial treated elective nodes in high risk pts to 52 Gy/26 fx. I haven't done this personally, but there is data :shrug:

The prescription dose in the C-IMRT arm was 76 Gy to PTV1 and 56 Gy to PTV2 and PTV3 in 38 fractions. The prescription dose in the H-IMRT arm was 70.2 Gy to PTV1 and 50-52 Gy (most received 50 Gy) to PTV2 and PTV3 in 26 fractions. For C-IMRT, the rectal constraints were V65Gy (volume receiving at least 65 Gy) < 17% and V40Gy < 35%, and the bladder constraints were V65Gy < 25% and V40Gy < 50%. For H-IMRT, the bladder constraints were V50Gy <17% and V31Gy < 35%, and the rectal constraints were V50Gy < 25% and V31Gy < 50%. There were no protocol violations in the target or organs at risk dose constraints.


Protocol: https://ascopubs.org/doi/suppl/10.1200/JCO.19.01485/suppl_file/protocol_jco.19.01485.pdf
 
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