Ultra Hypofractionnated Radiotherapy With HDR Brachytherapy Boost. (HYPO-5)

ULTRA-HYPO Fractionated (UHF) Compared to Moderate-HYPO Fractionated (MHF) Prostate IGRT With HDR Brachytherapy BOOST : A Phase 1-2 Study.

Phase 1-2 study, comparing ultra-hypofractionnated (UH) to a moderately hypofractionnated (MH) radiation therapy, with image guided HDR prostate brachytherapy. Using iso-equivalent doses, a non-inferiority analysis will be done in order to prove UH non-inferior to MH, toxicity wise. Acceptability, tolerability, acute and late toxicity will be reported. MRI visible dominant intra-prostatic lesion will be outlines and variability between radiation oncologists and radiologists will be reported. As secondary objective, biochemical and clinical failure free survival will be reported at 5 & 10 years.

Phase 1 : consists in a feasibility study (First 28 patients). Phase 2 : monocentric prospective comparative cohort study. Recruitment : "Centre intégré de cancérologie du CHU de Québec-Université Laval." Recruitment period: December 2015 to June 2023 Brachytherapy : Implantation under general or spinal anesthesia Foley catheter insertion in bladder. TRUS prostate localisation. Prostate volume measurement. Gold fiducial markers (3) insertion. Prostate brachytherapy catheters (14 à 21) insertion. Cystoscopy for bladder and urethra integrity control. Re-insertion of foley catheter after cystoscopy. Planning imaging: TRUS or CT scan (has needed). Structures delineation by radiation oncologist (brachytherapist). Prostate Seminale vesicles Rectum Colon sigmoïde Bladder Urethra Penile bulb Dosimetric optimisation Oncentra Prostate v. 4.2.2 d'Elekta brachytherapy (Veenendaal, The Netherlands) Oncentra Brachy version 4.6 (if under CT scan). Treatment (brachytherapy dose delivery). 15 Gy in one fraction Direct interstitial dose monitoring (20 patients or more). Fiber-optic dosimeter inserted in prostate brachytherpy catheter for live dose delivery mesurements. Foley ablation under full bladder, same day or day after therapy. Radiotherapy: Via IMRT, VMAT or SBRT technics. Dose : 25 Gy in 5 fractions administered over a 7 days period. 2 to 3 fractions separated by 2 days, weekend break. PTV includes prostate and the first centimeter of seminal vesicle. Simulation one week post brachytherapy standard has described in the department procedure manual. maximal CT scan slice thickness : 2-3mm. uretro-graphy done to identify urogenital sphincter. Multiparametric MRI If no counter-indication and available, a T2 tridimensional sequence for prostate delineation slice thickness : 1 mm. a diffusion weighted sequence will be done. a DTI with tractography can be done optionally. contrast media (gadolinium) is optional. Physique Linac energy (between 6 MV to 18 MV). ARC therapy technique will be used planification softwares: Éclipse, Pinnacle or Raystation. Portal (kV-kV) imagery will be used for marker match. CBCT will be done at each fraction delivered. Clinical and dosimetric data will be collected prior treatment. Primary objectives : Toxicity analysis will be quantitatively evaluated using CTCAE (v5) at 1, 2 and 5 years post-therapy, and has needed at FU visits. Kaplan-Meier statistical analysis will be used to report toxicity evolution through time. median IPSS scores will be reported at 3, 6, 12 months and yearly (1, 2, 3, 4 et 5) post-therapy. IPSS median time to baseline return will be calculated. IPSS urinary scores, sexual function (SHIM) and GI toxicity (CTCAE-v5) and quality of life questionnaires ( EPIC-26) will be given at 3, 6 months and yearly thereafter (1, 2, 3, 4 et 5) post-treatment. Secondary objectives : Biochemical disease-free survival has per Phoenix definition (by American Society of Radiation Oncology - ASTRO) recommendation will be reported using Kaplan-Meier analysis.

Prostate Cancer, Radiotherapy Side Effect, Hypofractionation, Brachytherapy, Radiotherapy, Localized Prostate Carcinoma

Prospective comparative cohort study with non inferiority analysis UH-IMRT combined to 15 Gy HDR Brachytherapy will considerably reduce the treatment fraction delivered while maintaining b-DFS and Side-effects at comparable levels to our actual reported prostate cancer patient population, without lymph nodes involvement (risk being less than 15%). We believe that this therapeutic regime will show to be non-inferior to our actual standard therapeutic regime

comparative PRO's of 25 Gy in 5 daily fractions (Ultra hypo fractionation) administered to prostate and 1st centimeter of proximal seminal vesicle, starting mid week and ending mid following week.

PRO's of moderate hypo fractionation, 37,5 Gy in 15 or 36 Gy in 12 daily fractions administered 5 days per week.

report and compare IPSS scores, report and compare EPIC26 scores, report and compare SHIM scores, report and compare CTCAE scores, report and compare clinical outcomes

Compare experimental ultra hypo fractionation (25 Gy in 5 daily fractions administered starting mid week and ending mid following week) to our standard fractionation (either 37,5 Gy given in 15 daily fractions, or 36 Gy in 12 daily fractions). Toxicity analysis will be quantitatively evaluated using CTCAE (v5) at 1, 2 and 5 years post-therapy, and has needed at FU visits. Kaplan-Meier statistical analysis will be used to report toxicity evolution through time. median IPSS scores will be reported at 3, 6, 12 months and yearly (1, 2, 3, 4 et 5) post-therapy. IPSS median time to baseline return will be calculated. IPSS urinary scores, sexual function (SHIM) and GI toxicity (CTCAE-v5) and quality of life questionnaires ( EPIC-26) will be given at 3, 6 months and yearly thereafter (1, 2, 3, 4 et 5) post-treatment.

median IPSS scores will be reported post-therapy and compare between arms at baseline, prior treatment

median EPIC26 scores will be reported post-therapy and compare between arms at baseline, prior treatment

median EPIC26 scores will be reported post-therapy and compare between arms at 3 months post-treatment

median EPIC26 scores will be reported post-therapy and compare between arms at 6 months post-treatment

median EPIC26 scores will be reported post-therapy and compare between arms at 2 years post-treatment

median EPIC26 scores will be reported post-therapy and compare between arms at 3 years post-treatment

median EPIC26 scores will be reported post-therapy and compare between arms at 4 years post-treatment

median EPIC26 scores will be reported post-therapy and compare between arms at 5 years post-treatment

Biochemical disease-free survival has per Phoenix definition (by American Society of Radiation Oncology - ASTRO) will be reported using Kaplan-Meier analysis, as well for disease free survival, metastasis free survival and overall survival.

Biochemical disease-free survival has per Phoenix definition (by American Society of Radiation Oncology - ASTRO) will be reported using Kaplan-Meier analysis, as well for disease free survival, metastasis free survival and overall survival.

Inclusion Criteria: Biopsy proven Prostate adenocarcinoma Stage T1c, T2 (Annex 2) Stage Nx or N0 Stage Mx or M0 PSA < 20ng/ml Gleason Score 6 or 7 Having the ability to sing a written consent Exclusion Criteria: Age < 18ans Clinical Stage T3 or T4 Stage N1 Stage M1 PSA > 20 Gleason Score 8 to 10 IPSS Score > 20 alpha-blocking medication. Prior pelvic radiotherapy. History of active collagenosis (Lupus, Sclerodermia, Dermatomyosis) Past history of Inflammatory Bowell Disease Bilateral hip prosthesis

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