Please enable JavaScript.

Coggle requires JavaScript to display documents.

GU cancer ASTRO 2022/2025 - Coggle Diagram

- - - - ProtecT
        
        mostly low but some FIR
        
        no PSMA, targeted Bx, MRI
        
        3D only, no spaceOAR
        
        AS vs RT vs RP
        
        similar OS
        
        50% got treated by 10y
        
        AS had more DM
        
        at 15y PCSM <3%
        
        Urinary fn
        
        Nocturia peaks at 6 mo then returns to bl
        
        Pad use peaks at 6 mo-1yr in RP and stays elevated
        
        we need incontinence to stabilize, which can take up to a year after RP to give postop RT
        
        Sex fx
        
        ED after RP improved after 2 yrs, but never as good as AS or RT
        
        Bowel
        
        Worse with RT
        
        fecal leakage 12% vs 6% at 12Yr
        
        bloody stools in a minority of patients
        
        Fractionation
        
        Conventional is no longer SoC
        
        HFX is Soc
        
        SBRT may be main treatment
        
        3Gy x 20 Fx
        
        7.25Gy x 5 Fx
        
        MARCAP HYDRA MA
        
        Biologic isodose wrt prostate cancer cell kill: meant to have similar efficacy and tox
        
        Some trials had higher dose (mHFX) with expected superior efficacy
        
        Isodose mHFX had best biochem control with minimal G2+ GI tox
        
        PartiQOL: Protons
        
        no diff in GU incontinence, bowel tox, sexual QoL btw Protons or photons
        
        no diff in BCR, LR, DM
        
        MIRAGE: MR Linac
        
        PTV was 1.5cm, now its 3-5mm
        
        conventional arm: 4mm
        
        SBRT is about 3mm PTV
        
        MR arm: 2mm
        
        Improvement in short term (1mo) Urine and GI toxicity
        
        Spacers
        
        2 trials
        
        HFX trial: Mariados JAMA Onc 2023
        
        noninf, dosimetric endpoints
        
        no change in PRO QOL
        
        Debates
        
        Desai, Nagar IJROBP 2024
        
        Hall, Parker IJROBP 2024
        
        Brachytherapy
        
        Great alt to 9 wks of RT
        
        vs. PACE-B, no G3 tox, <5% recur at 5Y
        
        may still be among best tx for LR after RT (MASTER MA)
        
        1 more item...
      - Int Risk
        
        4-6mo ADT needed
        
        Hi Risk
        
        Surgery has picked up so many more PORT
        
        No randomized trials (ala ProtecT), but retro confirms lower DM vs. Sx
        
        23% vs 16% at 8Y
        
        Roy, GU ASCO, 2025
        
        Needs 1.5 Yrs ADT (DHARMA/MARCAP)
        
        Dose escalation
        
        improves PFS alone
        
        worsens toxicity
        
        Brachy: ASCENDE
        
        SIB: FLAME
        
        EBRT dose esc: GETUG-18
        
        Brachy Dose escalation
        
        ASCENDE RT
        
        Sathya et al
        
        Hoskin et al
        
        EBRT vs EBRT + LDR boost
        
        Better BCR
        
        Worse G3+ GU toxicity.
        
        ASCENDE 5Y urinary G3+ 18% vs 5%
        
        FLAME
        
        Whole gland plus SIB
        
        77Gy 35 fx w/ SIB 95 GTV
        
        hypoFLAME : 5 Fx
        
        Absolute Contraindications to brachy
        low life ex
        unacc op risk
        dist mets
        no rectum
        large TURP defects
        ATM
        Relative contraindications
        IPSS >20
        Prior pelvic RT
        TURP defects
        large median lobe
        gland >60cc
        IBD
        
        Post Prostatectomy
        
        if 0.6-1.5, maybe use ADT
        
        PSA 0.1-0.5 no MFS or OS benefit, worsens OCM
        
        Abiraterone for pN+
        
        Adj RT improves BCR, not OS, more toxic
        
        Early salvage: similar BCR, reduced overtreatment
        
        early salvage improves DM rates
        ARTISTIC MA
        
        SM+ or pT3 should not get adjuvant
        
        Dose is not clear: >66Gy
        Benefit of extending ADT is not as good in PORT than in definitive
        Spratt Eur Urol 2024
        
        N+ prostate cancer
        
        Heterogeneous
        
        high risk of LN+ on path but cN0
        
        POP-RT improved BCR and MFS benefit but ENI is toxic and can offer salvage PNRT
        
        more common cN+ w/ PSMA
        
        EBRT + ADT + Abi/pred
        
        Lawton JCO 2005
        
        Lin JNCI 2015
        
        James JAMA onc 2015
        
        Attard Lancet 2022
        
        20-25 fx is Soc : 55Gy /2-in N+, 44 Gy/20 ENI per CHHIP
        
        Newer trials: 25Gy ENI, SIB 35Gy to N+
        
        more common pN+ w/ RP PLND
        
        Salvage LND is insufficient
        
        more common oligoprogression/recurrence in LN w/ PSMA
        
        OLIGOPELVIS
        
        IMRT 54Gy/30 w/ ST ADT, SIB 66.6 to N+ PSMA
        
        1cm gap from prior RT
        
        G2 tox 10% GU, 2% GI
        
        Supiot, Eur Urol 2021
        
        pN1
        early salvage RT + ADT + abi/pred
        
        NRG GU-008
        RT w/ w/o Apalutamide
        
        High risk BCR
        Sp RT PSA doubling time <9 mo
        EMBARK
        
        Enza + lupron vs Placebo + Lupron
        
        Enzalutamide lupron superior MFS
        
        Freedland NEJM 2023
        
        Metastatic
        Different paradigms
        
        De novo (synchronous) vs recurrent (metachronous) vs Induced
        
        De novo: RT
        
        Recur: SBRT
        
        Low vol OMD vs widely Met
        
        SBRT to mets and primary has OS benefit in OMD
        
        RT to primary: < 5 bone mets, 3y OS improves 7%
        
        mCSPC
        
        ARPI is Soc
        
        SBRT to OMD is Soc
        
        mCRPC
        
        Lu PSMA becoming Soc
        
        2 more items...
        
        Definitions
        Adjuvant
        
        adverse path
        
        SM+
        
        ECE pT3a
        
        SVI pT3b
        
        undetectable PSA <0.2 historically
        
        Salvage
        
        0.2 w/ second confirmation
        
        Early salvage: < 0.5
        
        V early salvage: 0.01-0.2
        
        in the 2000's threshold PSA detection was 0.2
        
        Postop variables
        Zaorski Kishan Spratt; ASCO daily news 2025
        
        is recurrence going to local or distance
        
        combine clinical markers, anatomy, PSMA
        
        PORT after incontinence stabilizes
        
        Salvage Pelvic RT + ENI + ADT
        
        Add Abi/pred if N+ ; ARPI for high risk BCR
        
        OMD SBRT + ADT +/- ARPI
        
        Mets: ADT ARPI, Palliative RT
        
        Tendulkar 2016
        Abugharib J ruol 2017
        
        improved outcomes w/ early SRT
        
        may be selection bias
        
        PORT dose fx?
        NRG GU-003
        
        RT vs mHFX
        
        similar GU/GI in salvage RT at 2 years
        
        SHORTER
        Nagar ESTRO 2024
        20 vs 5 Fx MR Linac
        
        Volumes
        NRG guidelines
        
        Sonni JNM 2023
        
        many failures lateral, posterior, inferior to RTOG voumes
        
        1 more item...
        
        ADT
        Improves MFS and OS
        
        NNT = 8, vs NNT = 18 in Int risk; 10Y DM (MARCAP 1)
        
        Abiraterone has shown OS benefit
        
        STAMPEDE population (DHARMA)
        
        Systemic agent intensitfication
        
        no benefit for Taxol
        
        in VHR or M1 dz, benefit to adding Abiraterone
        
        GU-009 PREDICT-RT looking into Decipher stratification
        
        testing 24m ADT/Apalutamide/Abi/pred if >0.85
        
        Older studies showing OS benefit
        
        RTOG 9202: 4 vs 28m ADT
        
        Benefit on long term analysis GG 4-5
        
        EORTC 22961: 6 vs 36 m ADT
        
        OS and PCSM benefit
        
        DART 01/05 GICOR: 4 vs 28 m ADT
        
        OS5/OS10 benefit, MFS BCC
        
        TROG 03.04 RADAR: 6 vs 18 m ADT
        
        MFS and PCSS
        
        GETUG AFU 18: 3 y ADT
        
        improved PFS10/CSS10/OS10 w/o increased toxicity.
        
        MARCAP 2026? 12 m ADT supported
        
        PACE A
        Surgery vs SBRT
        "Battle of the Robots"
        
        RP had worse incontinence & sexual fn. Permanent
        
        (G2 ED 63% vs 18%)
        
        G2 Urine pad use 1+, 50% vs 6.5%
        
        SBRT had temp worse bowel bother s/s, even 12-24 mo after tx
        
        PACE B
        
        low-int risk
        
        non-inf
        
        CRT/mHFX 78/39 or 20fx vs SBRT 36.25/5
        
        36.25 Gy was prescribed to 95% of the PTV, while 40 Gy was secondarily prescribed to 95% of the CTV.
        
        1º EP biochem/clin fail. 5Y
        
        both have sim rates of FFBF, free from ADT, OS
        
        2yr G3+ <5%
        
        GU 2+ tox 27% vs 18%, SBRT worse
        
        PACE C
        mHFX vs SBRT
        
        ADT + RT
        
        Improves BCR, PCSM, DM; usually not OS
        
        RTOG 9408 secondary analysis of intermediate risk
        
        stratifying to FIR and UIR
        
        PCSM benefit to ADT in UIR (HR 0.4)
        PMID: 32902647
        
        NRG GU-010 GUIDANCE
        UIR + Decipher
        
        <0.4 randomized to RT vs RT + ST ADT
        
        0.4 rd to RT + ST ADT vs Included 6 mo Darolutamide (CAB: complete androgen blokade)
        
        Strategy: Dose escalation with no increase in ADT
        
        MARCAP 1 MA
        
        ADT benefit improves MFS and OS regardless of RT
        
        5000 pts 7 trials.
        
        Hormone Timing?
        
        neoadjuvant, concurrent, adjuvant
        
        MARCAP1 MA
        
        Neoadjuvant has no benefit on any outcomes
        
        Concurrent and adjuvant improves MFS and OS compared to neo w/ concurrent (SANDSTORM)
        
        Retrospective analysis of RTOG 0126
        PMID: 37137444
        
        Pre dose escalated Trials
        
        TROG 96.01
        
        int risk 0 vs 3 vs 6m ADT = Improved OS
        
        D'amico DFCI : 70 Gy
        
        0 vs 6m ADT = Inproved OS
        
        RTOG 9408 : 66.6 Gy
        
        0 vs 4m = OS10 benefit
        
        Dose escalated ADT trials
        
        RTOG 0815 : 79 Gy
        
        0 vs 6m ADT = PCM and DM benefit
        
        DART 01/05 GICOR : 76-82 Gy
        
        4 vs 28m ADT = BDFS, MFS, OS (SGA benefit HR only) so 28m not for IR.