Resources for pelvic nodal volume in prostate hypofrac?

[chemsmith]

As the title says. Anyone have any dose-painting protocol they follow or anything?

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[Chartreuse Wombat]

DO you mean 4-5 weeks or 4-5 treatments. How extreme is your hypo?

 

[Chartreuse Wombat]

Dose constraints below from UK trial of moderate hypo

Phase 1/2 Dose-Escalation Study of the Use of Intensity Modulated Radiation Therapy to Treat the Prostate and Pelvic Nodes in Patients With Prostate Cancer - PubMed

This study shows the safety and tolerability of PLN-IMRT. Ongoing and planned phase 3 studies will need to demonstrate an increase in efficacy using PLN-IMRT to offset the small increase in bowel side effects compared with prostate-only IMRT.

pubmed.ncbi.nlm.nih.gov

 

[KHE88]

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]

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

 

[scarbrtj]

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.

 

[elementaryschooleconomics]

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???

 

[scarbrtj]

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

"My video got 695 views? That's a lot!" - most any radiation oncologist

 

[ramsesthenice]

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.

 

[evilbooyaa]

Not doing ENI really ever.

N+ patients can consider just taking to prescription dose I suppose, although I would worry about toxicity of 70/28 next to bowel and thus likely go with some sort of SIB plan in 25 fractions.

 

[Mandelin Rain]

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.

 

[elementaryschooleconomics]

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

The most fundamental truth in our field.

 

[scarbrtj]

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.

 

[taserlaser]

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]

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.

 

[scarbrtj]

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.'

 

[Palex80]

Here are some for SBRT:

Stereotactic body radiation therapy: the report of AAPM Task Group 101 - PubMed

Task Group 101 of the AAPM has prepared this report for medical physicists, clinicians, and therapists in order to outline the best practice guidelines for the external-beam radiation therapy technique referred to as stereotactic body radiation therapy (SBRT). The task group report includes a...

pubmed.ncbi.nlm.nih.gov