101
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[Prostate-rectum spacers: optimization of prostate cancer irradiation]. Cancer Radiother 2014; 18:215-21; quiz 243-4, 247. [PMID: 24746454 DOI: 10.1016/j.canrad.2014.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/03/2014] [Accepted: 03/03/2014] [Indexed: 12/20/2022]
Abstract
In the curative radiotherapy of localized prostate cancer, improvements in biochemical control observed with dose escalation have been counterbalanced by an increase in radiation-induced toxicity. The injection of biodegradable spacers between prostate and rectum represents a new frontier in the optimization of radiotherapy treatments for patients with localized disease. Transperineal injection of different types of spacers under transrectal ultrasound guidance allows creating a 7-to-20 mm additional space between the prostate and the anterior rectal wall lasting 3 to 12 months. Dosimetrically, a relative reduction in the rectal volume receiving at least 70 Gy (V70) in the order of 43% to 84% is observed with all types of spacers, regardless of the radiotherapy technique used. Preliminary clinical results show for all spacers a good tolerance and a possible reduction in the acute side effects rate. The aim of the present systematic review of the literature is to report on indications as well as dosimetric and clinical advantages of the different types of prostate-rectum spacers commercially available (hydrogel, hyaluronic acid, collagen, biodegradable balloon).
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102
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Strom TJ, Wilder RB, Fernandez DC, Mellon EA, Saini AS, Hunt DC, Pow-Sang JM, Spiess PE, Sexton WJ, Poch MA, Biagioli MC. A dosimetric study of polyethylene glycol hydrogel in 200 prostate cancer patients treated with high-dose rate brachytherapy±intensity modulated radiation therapy. Radiother Oncol 2014; 111:126-31. [PMID: 24746567 DOI: 10.1016/j.radonc.2014.02.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 02/08/2014] [Accepted: 02/12/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE We sought to analyze the effect of polyethylene glycol (PEG) hydrogel on rectal doses in prostate cancer patients undergoing radiotherapy. MATERIALS AND METHODS Between July 2009 and April 2013, we treated 200 clinically localized prostate cancer patients with high-dose rate (HDR) brachytherapy±intensity modulated radiation therapy. Half of the patients received a transrectal ultrasound (TRUS)-guided transperineal injection of 10mL PEG hydrogel (DuraSeal™ Spinal Sealant System; Covidien, Mansfield, MA) in their anterior perirectal fat immediately prior to the first HDR brachytherapy treatment and 5mL PEG hydrogel prior to the second HDR brachytherapy treatment. Prostate, rectal, and bladder doses and prostate-rectal distances were calculated based upon treatment planning CT scans. RESULTS There was a success rate of 100% (100/100) with PEG hydrogel implantation. PEG hydrogel significantly increased the prostate-rectal separation (mean±SD, 12±4mm with gel vs. 4±2mm without gel, p<0.001) and significantly decreased the mean rectal D2 mL (47±9% with gel vs. 60±8% without gel, p<0.001). Gel decreased rectal doses regardless of body mass index (BMI). CONCLUSIONS PEG hydrogel temporarily displaced the rectum away from the prostate by an average of 12mm and led to a significant reduction in rectal radiation doses, regardless of BMI.
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Affiliation(s)
- Tobin J Strom
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Richard B Wilder
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Daniel C Fernandez
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Eric A Mellon
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Amarjit S Saini
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Dylan C Hunt
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Julio M Pow-Sang
- Department of Urology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Phillipe E Spiess
- Department of Urology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Wade J Sexton
- Department of Urology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Michael A Poch
- Department of Urology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Matthew C Biagioli
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA.
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103
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Krol R, Smeenk RJ, van Lin ENJT, Yeoh EEK, Hopman WPM. Systematic review: anal and rectal changes after radiotherapy for prostate cancer. Int J Colorectal Dis 2014; 29:273-83. [PMID: 24150230 DOI: 10.1007/s00384-013-1784-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Pelvic radiotherapy may lead to changes of anorectal function resulting in incontinence-related complaints. The aim of this study was to systematically review objective findings of late anorectal physiology and mucosal appearance after irradiation for prostate cancer. METHODS MEDLINE, EMBASE, and the Cochrane library were searched. Original articles in which anal function, rectal function, or rectal mucosa were examined ≥3 months after EBRT for prostate cancer were included. RESULTS Twenty-one studies were included with low to moderate quality. Anal resting pressures significantly decreased in 6 of the 9 studies including 277 patients. Changes of squeeze pressure and rectoanal inhibitory reflex were less uniform. Rectal distensibility was significantly impaired after EBRT in 7 of 9 studies (277 patients). In 4 of 9 studies on anal and in 5 of 9 on rectal function, disturbances were associated with urgency, frequent bowel movements or fecal incontinence. Mucosal changes as assessed by the Vienna Rectoscopy Score revealed telangiectasias in 73 %, congestion in 33 %, and ulceration in 4 % of patients in 8 studies including 346 patients, but no strictures or necrosis. Three studies reported mucosal improvement during follow-up. Telangiectasias, particularly multiple, were associated with rectal bleeding. Not all bowel complaints (30 %) were related to radiotherapy. CONCLUSIONS Low to moderate quality evidence indicates that EBRT reduces anal resting pressure, decreases rectal distensibility, and frequently induces telangiectasias of rectal mucosa. Objective changes may be associated with fecal incontinence, urgency, frequent bowel movements, and rectal bleeding, but these symptoms are not always related to radiation damage.
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Affiliation(s)
- Robin Krol
- 455 Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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104
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Ng M, Brown E, Williams A, Chao M, Lawrentschuk N, Chee R. Fiducial markers and spacers in prostate radiotherapy: current applications. BJU Int 2014; 113 Suppl 2:13-20. [DOI: 10.1111/bju.12624] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Michael Ng
- Radiation Oncology Victoria; Melbourne VIC Australia
| | - Elizabeth Brown
- Department of Radiation Oncology; Princess Alexandra Hospital; Brisbane QLD Australia
| | - Andrew Williams
- Department of Urology; Auckland City Hospital; Auckland New Zealand
| | - Michael Chao
- Radiation Oncology Victoria; Melbourne VIC Australia
| | - Nathan Lawrentschuk
- Department of Surgery and Ludwig Institute for Cancer Research; Austin Hospital; University of Melbourne; Melbourne VIC Australia
| | - Raphael Chee
- Genesis Cancer Care Western Australia; Joondalup WA Australia
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105
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Dosimetric Implications of an Injection of Hyaluronic Acid for Preserving the Rectal Wall in Prostate Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2014; 88:425-32. [DOI: 10.1016/j.ijrobp.2013.10.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Revised: 10/17/2013] [Accepted: 10/28/2013] [Indexed: 11/21/2022]
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106
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Pinkawa M, Klotz J, Djukic V, Schubert C, Escobar-Corral N, Caffaro M, Piroth MD, Holy R, Eble MJ. Learning curve in the application of a hydrogel spacer to protect the rectal wall during radiotherapy of localized prostate cancer. Urology 2013; 82:963-8. [PMID: 24074991 DOI: 10.1016/j.urology.2013.07.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 06/03/2013] [Accepted: 07/07/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the effect of increasing experience on hydrogel dimensions, rectal dose, and acute toxicity, and to discuss important technical issues gained from this experience. METHODS Sixty-four consecutive patients with prostate cancer were included in this analysis (G1/G2 corresponding to first/second 32 patients) after injection of 10 mL spacer gel. All patients were treated with a 5-field intensity-modulated radiotherapy technique to 76-78 Gy. Treatment toxicity was evaluated with a validated quality of life questionnaire (expanded prostate cancer index composite) before and after radiotherapy. RESULTS Rectum volume could be entirely excluded from the planning target volume in 31% in G1 vs 56% in G2 (P = .04). Increasing symmetry was detected comparing the first 15 patients to the subsequent rest, with mean differences between right and left of 0.6 cm vs 0.3 cm at the midgland (P = .03). Mean distance between prostate and anterior rectal wall increased from 0.8 cm/1.1 cm/0.8 cm (G1) at the base/middle/apex to 1.3 cm/1.5 cm/1.2 cm (G2), respectively, so that the dose to the rectum decreased significantly (6% vs 2% of the volume inside the 70 Gy isodose; P <.01). Bowel function and bother score changes were smaller comparing baseline with last day of radiotherapy levels (mean 16/18 in G1 vs 9/12 in G2). CONCLUSION A learning curve could be demonstrated in our patient population, respecting improved and more symmetrical spacer placement, improved treatment planning, and less treatment-related acute toxicity. Several important technical aspects need to be considered.
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Affiliation(s)
- Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany.
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107
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de Castro Abreu AL, Ma Y, Shoji S, Marien A, Leslie S, Gill I, Ukimura O. Denonvilliers' space expansion by transperineal injection of hydrogel: implications for focal therapy of prostate cancer. Int J Urol 2013; 21:416-8. [PMID: 24118183 DOI: 10.1111/iju.12290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 08/27/2013] [Indexed: 02/03/2023]
Abstract
We developed and assessed a technique of: (i) expanding Denonvilliers' space by hydrogel (polyethylene glycol) during focal cryoabation; and (ii) temperature mapping to ensure protection of the rectal wall. In a fresh cadaver, 20 cc of hydrogel was injected transperineally into Denonvilliers' space under transrectal ultrasound guidance. Successful expansion of Denonvilliers' space was achieved with a range of 9-11 mm thickness covering the entire posterior prostate surface. Two freeze-thaw cycles were used to expand the iceball reaching the rectal wall as an end-point. Intraoperative transrectal ultrasound monitoring and temperature mapping in Denonvilliers' space by multiple thermocouples documented real-time iceball expansion up to 10 mm beyond the prostate, and safety in protecting the rectal wall from thermal injury. The lowest temperatures of the thermocouples with a distance of 0 mm, 5 mm and 10 mm from the prostate were: -35°C, -18°C and 0°C (P < 0.001), respectively. In gross and microscopic examination, the hydrogel mass measured 11 × 40 × 34 mm, which was identical to the intraoperative transrectal ultrasound measurements, there was no infiltration of the hydrogel into the rectal wall or prostate and no injury to the pelvic organs. In conclusion, the expansion of Denonvilliers' space by transperineal injection of hydrogel is feasible and a promising technique to facilitate energy-based focal therapy of prostate cancer.
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Affiliation(s)
- Andre Luis de Castro Abreu
- USC Institute of Urology, Center for Prostate Cancer Focal Therapy, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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108
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Zaorsky NG, Harrison AS, Trabulsi EJ, Gomella LG, Showalter TN, Hurwitz MD, Dicker AP, Den RB. Evolution of advanced technologies in prostate cancer radiotherapy. Nat Rev Urol 2013; 10:565-79. [DOI: 10.1038/nrurol.2013.185] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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109
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Combs S, Debus J. Translationale Uroradioonkologie. Urologe A 2013; 52:1276-82. [DOI: 10.1007/s00120-013-3314-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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110
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Pinkawa M, Bornemann C, Escobar-Corral N, Piroth MD, Holy R, Eble MJ. Treatment planning after hydrogel injection during radiotherapy of prostate cancer. Strahlenther Onkol 2013; 189:796-800. [PMID: 23836063 DOI: 10.1007/s00066-013-0388-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 05/22/2013] [Indexed: 12/31/2022]
Abstract
PURPOSE Imaging for treatment planning shortly after hydrogel injection is optimal for practical purposes, reducing the number of appointments. The aim was to evaluate the actual difference between early and late imaging. PATIENTS AND METHODS Treatment planning computed tomography (CT) was performed shortly after injection of 10 ml hydrogel (CT1) and 1-2 weeks later (CT2) for 3 patients. The hydrogel was injected via the transperineal approach after dissecting the space between the prostate and rectum with a saline/lidocaine solution of at least 20-ml. Hydrogel volume and distances between the prostate and rectal wall were compared. Intensity-modulated radiotherapy (IMRT) plans up to a dose of 78 Gy were generated (rectum V70 < 20 %, rectum V50 < 50 %; with the rectum including hydrogel volume for planning). RESULTS A mean planning treatment volume of 104 cm(3) resulted for a prostate volume of 37 cm(3). Hydrogel volumes of 30 and 10 cm(3) were determined in CT1 and CT2, respectively. Distances between the prostate and rectal wall at the levels of the base, middle, and apex were 1.7 cm, 1.6 cm, 1.5 cm in CT1 and 1.3 cm, 1.2 cm, 0.8 cm in CT2, respectively, corresponding to a mean decrease of 24, 25, and 47 %. A small overlap between the PTV and the rectum was found only in 1 patient in CT2 (0.2 cm(3)). The resulting mean rectum (without hydrogel) V75, V70, V60, V50 increased from 0 %, 0 %, 0.6 %, 10 % in CT1 to 0.1 %, 1.2 %, 6 %, 20 % in CT2, respectively. CONCLUSION Treatment planning based on imaging shortly after hydrogel injection overestimates the actual hydrogel volume during the treatment as a result of not-yet-absorbed saline solution and air bubbles.
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Affiliation(s)
- M Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Pauwelsstr. 30, 52072, Aachen, Germany.
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111
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Alongi F, Cozzi L, Arcangeli S, Iftode C, Comito T, Villa E, Lobefalo F, Navarria P, Reggiori G, Mancosu P, Clerici E, Fogliata A, Tomatis S, Taverna G, Graziotti P, Scorsetti M. Linac based SBRT for prostate cancer in 5 fractions with VMAT and flattening filter free beams: preliminary report of a phase II study. Radiat Oncol 2013; 8:171. [PMID: 23835141 PMCID: PMC3718706 DOI: 10.1186/1748-717x-8-171] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 07/01/2013] [Indexed: 11/20/2022] Open
Abstract
Background To evaluate the feasibility and early side effects of a short course hypo-fractionated SBRT programme with Volumetric Modulated Arc Therapy (VMAT) and Flattening Filter Free (FFF) beams. Methods A prospective phase I-II study, started on February 2012. Inclusion criteria were: age ≤ 80 years, WHO-PS ≤ 2, PSA ≤ 20 ng/ml, histologically proven prostate adenocarcinoma, T1-T2 stage, no distant metastases, no previous surgery other than TURP, no malignant tumours in the previous 5 years, IPSS 0–7. The schedule was 35 Gy in 5 alternative days. SBRT was delivered with RapidArc VMAT, with 10MV FFF photons. Toxicity assessment was performed according to CTCAE v4.0 scale. EPIC questionnaires assessed Quality-of-Life. Neo-adjuvant/concomitant hormonal-therapy was prescribed according to risk classification. SpaceOAR™ gel was optionally implanted to increase the separation space between the prostate and the rectal wall. Results Median follow-up was 11 months (range: 5–16); 40 patients were recruited in the protocol and treated. According to NCCN criteria, 26/40 patients were low-risk and 14/40 were intermediate risk. Median age was 70 years (56–80), median initial PSA was 6.25 ng/ml (0.50-13.43 ng/ml). Median Gleason score was 6 (6–7). All patients completed the treatment as programmed (median 11.8 days (9–22). Acute Toxicities were as follow: Rectum G0: 30/40 cases (75%); G1: 6/40 (15%); G2: 4/40 (10%). Genito-urinary: G0: 16/40 (40%); G1: 8/40 (20%); G2: 16/34 (40%). In two G2 urinary retention cases, intermittent catheter was needed. No acute G3 or greater toxicity was found. Median treatment time was 126 sec (120–136). SpaceOAR™ was implanted in 8 patients. PSA reduction from the pre-treatment value of the marker was documented in all patients. Conclusions Early findings suggest that SBRT with RapidArc and FFF beams for prostate cancer in 5 fractions is feasible and tolerated in acute setting. Longer follow-up is needed for assessment of late toxicity and outcome.
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