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Crowther K, Cole A, Shiels P, Jain S, Shepherd P, Mitchell D. A pilot study of patient reported outcomes evaluating treatment related symptoms and quality of life for men receiving high dose rate brachytherapy combined with hypo-fractionated radiotherapy or hypo-fractionated radiotherapy alone for the treatment of localised prostate cancer. Tech Innov Patient Support Radiat Oncol 2019; 9:18-25. [PMID: 32095591 PMCID: PMC7033792 DOI: 10.1016/j.tipsro.2019.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 11/26/2018] [Accepted: 01/17/2019] [Indexed: 12/01/2022] Open
Abstract
PROMs have an important role to play in clinical practice. The radiographer-led collection of multiple PROMs is feasible. Monotherapy Group reported higher levels of bowel toxicity than Combination Group. RTOG scale was not of sufficient sensitivity and under-reported symptoms. A good QoL was maintained throughout treatment for both treatment groups.
Patient Reported Outcome Measures (PROMS) are useful metrics in evidence-based clinical care and translational research. Recording treatment-related symptoms and Quality of Life (QoL) can provide information in counselling patients to aid decision-making. This prospective study tested the feasibility of radiographer-led collection of multiple validated PROMS from Prostate Cancer (PCa) patients comparing High Dose Rate Brachytherapy combined with hypo-fractionated external beam radiotherapy (hEBRT) and hEBRT alone. From June to August 2017, 20 men with localised PCa (T1-T3aN0M0) consented to participate in the study. Ten patients received combination treatment (37.5 Gray/15 fractions followed by a 15 Gray implant), and ten patients received monotherapy (60 Gray/20 fractions). PROMS were collected at four time-points (1) at baseline, (2) final fraction of hEBRT, (3) 8 weeks after commencing radiotherapy and (4) 12 weeks after commencing radiotherapy. The PROMS used were EPIC-26, IPSS, IIEFF-5 and SF-12. The difference between the two groups were tested using Mann-Whitney U test and Wilcoxon Signed-Rank Test. All participants completed all PROMS (100% response-rate). The Monotherapy group reported a higher incidence of bowel symptoms compared to the combination group and at Week 12, EPIC-26 bowel summary score demonstrated a statistically significant difference (p = 0.005). The prevalence of erectile dysfunction increased within both groups. Maintenance of QoL was reported throughout treatment. This small study demonstrated feasibility of radiographer-led PROMS collection by 100% completion rate. Streamlining of these tools into integrated technology applications and real time PROMS measurement has the ability to benefit patients and guide clinicians in adapting therapies based on individual need.
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Affiliation(s)
- Karen Crowther
- Radiotherapy Department, Cancer Centre, Belfast City Hospital, Belfast Health and Social Care Trust, Lisburn Road, Belfast, United Kingdom
| | - Aidan Cole
- Radiotherapy Department, Cancer Centre, Belfast City Hospital, Belfast Health and Social Care Trust, Lisburn Road, Belfast, United Kingdom.,Centre for Cancer Research and Cell Biology, Queen's University of Belfast, Lisburn Road, Belfast, United Kingdom
| | - Pat Shiels
- Radiotherapy Department, Cancer Centre, Belfast City Hospital, Belfast Health and Social Care Trust, Lisburn Road, Belfast, United Kingdom
| | - Suneil Jain
- Radiotherapy Department, Cancer Centre, Belfast City Hospital, Belfast Health and Social Care Trust, Lisburn Road, Belfast, United Kingdom.,Centre for Cancer Research and Cell Biology, Queen's University of Belfast, Lisburn Road, Belfast, United Kingdom
| | - Paul Shepherd
- Ulster University, Therapeutic Radiography - School of Health Sciences, Belfast, United Kingdom
| | - Darren Mitchell
- Radiotherapy Department, Cancer Centre, Belfast City Hospital, Belfast Health and Social Care Trust, Lisburn Road, Belfast, United Kingdom
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202
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Hyaluronic gel injection into the vesicovaginal septum for high-dose-rate brachytherapy of uterine cervical cancer: an effective approach for bladder dose reduction. J Contemp Brachytherapy 2019; 11:1-7. [PMID: 30911303 PMCID: PMC6431109 DOI: 10.5114/jcb.2019.82612] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 12/17/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose The purpose of this study was to report our initial experience of hyaluronic acid gel injection (HGI) in the vesicovaginal septum (VVS) for bladder dose reduction in brachytherapy (BT) for uterine cervical carcinoma. Material and methods Between September 2016 and May 2018, 15 uterine cervical cancer patients received HGI in the VVS as a part of their definitive radiotherapy (RT) treatment consisting of external beam radiation therapy (EBRT) with additional BT. Of those, 9 patients received BT both with and without HGI, and remaining 6 patients were excluded because these 6 patients received HGI in the VVS for all BT fractions. All 9 patients received HGI in the rectovaginal septum. For these patients, the dosimetric parameters bladder D2cc, HR-CTV D90, and rectum D2cc were selected, and two groups were generated (BT with vs. without HGI in the VVS) for dosimetric comparison. Results The median cumulative EQD2 for HR-CTV, rectum D2cc, and bladder D2cc for the 9 patients were 73.3, 52.8, and 67.1, respectively. While no statistical difference could be detected for rectal dose reduction, bladder dose was significantly less in the group with HGI in the VVS compared to that without (449 cGy [range, 416-566, 1SD = 66.1] vs. 569 cGy [range, 449-647, 1SD = 59.5], p = 0.033), with no compromising of target coverage. Although it did not reach statistically significance, there was a trend toward better HR-CTV D90 in the group with HGI compared to that without HGI in the VVS (713 cGy vs. 706 cGy, p = 0.085). No severe bleeding, hematuria, bladder wall injury, or urethral injury requiring hospitalization was experienced in association with HGI in the VVS. Conclusions HGI in the VVS can be performed safely and can effectively reduce the bladder dose in BT for uterine cervical cancer patients.
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203
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Vanneste BG, Buettner F, Pinkawa M, Lambin P, Hoffmann AL. Ano-rectal wall dose-surface maps localize the dosimetric benefit of hydrogel rectum spacers in prostate cancer radiotherapy. Clin Transl Radiat Oncol 2019; 14:17-24. [PMID: 30456317 PMCID: PMC6234617 DOI: 10.1016/j.ctro.2018.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/31/2018] [Accepted: 10/31/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND PURPOSE To evaluate spatial differences in dose distributions of the ano-rectal wall (ARW) using dose-surface maps (DSMs) between prostate cancer patients receiving intensity-modulated radiation therapy with and without implantable rectum spacer (IMRT+IRS; IMRT-IRS, respectively), and to correlate this with late gastro-intestinal (GI) toxicities using validated spatial and non-spatial normal-tissue complication probability (NTCP) models. MATERIALS AND METHODS For 26 patients DSMs of the ARW were generated. From the DSMs various shape-based dose measures were calculated at different dose levels: lateral extent, longitudinal extent, and eccentricity. The contiguity of the ARW dose distribution was assessed by the contiguous-DSH (cDSH). Predicted complication rates between IMRT+IRS and IMRT-IRS plans were assessed using a spatial NTCP model and compared against a non-spatial NTCP model. RESULTS Dose surface maps are generated for prostate radiotherapy using an IRS. Lateral extent, longitudinal extent and cDSH were significantly lower in IMRT+IRS than for IMRT-IRS at high-dose levels. Largest significant differences were observed for cDSH at dose levels >50 Gy, followed by lateral extent at doses >57 Gy, and longitudinal extent in anterior and superior-inferior directions. Significant decreases (p = 0.01) in median rectal and anal NTCPs (respectively, Gr 2 late rectal bleeding and subjective sphincter control) were predicted when using an IRS. CONCLUSIONS Local-dose effects are predicted to be significantly reduced by an IRS. The spatial NTCP model predicts a significant decrease in Gr 2 late rectal bleeding and subjective sphincter control. Dose constraints can be improved for current clinical treatment planning.
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Affiliation(s)
| | | | - Michael Pinkawa
- Department of Radiation Oncology, MediClin Robert Janker Klinik, Bonn, Germany
| | - Philippe Lambin
- The D-Lab, GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Aswin L. Hoffmann
- MAASTRO Clinic, Maastricht, The Netherlands
- Institute of Radiooncology, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Radiotherapy, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
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204
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Prostate Brachytherapy: Clinical Efficacy and Future Trends. Brachytherapy 2019. [DOI: 10.1007/978-981-13-0490-3_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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205
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Rohr A, Werth K, Shen X, Collins Z, Fishback S, Jones J, Ash R, Williams V. MRI findings of absorbable hydrogel spacer for prostate cancer therapy: a pictorial review. Abdom Radiol (NY) 2019; 44:247-251. [PMID: 29967983 DOI: 10.1007/s00261-018-1685-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Prior studies have shown that dose-escalated radiation therapy for prostate cancer improves clinical outcomes. However, this is associated with increased rectal toxicity. Hydrogel spacer for prostate cancer therapy is an effective way of decreasing rectal toxicity in the late post-therapeutic stages. In some occasions, the gel spacer may not be placed symmetrically between the rectum and prostate. There are several forms of a malpositioned spacer, including lateral displacement, rectal wall infiltration, and prostate capsule infiltration. This manuscript is aimed at evaluating appropriately positioned and malpositioned gel spacers, primarily via magnetic resonance imaging. There are limited educational imaging guides that address what radiologists should evaluate on post-spacer placement imaging. This pictorial review will specifically evaluate post-injection pitfalls such as asymmetry, rectal wall infiltration, and subcapsular injection.
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Affiliation(s)
- Aaron Rohr
- Department of Interventional Radiology, University of Stanford, 300 Pasteur Drive, H3531, Stanford, CA, 94305, USA.
| | - Kyle Werth
- Department of Radiology, University of Kansas Health Systems, Kansas City, USA
| | - Xinglei Shen
- Department of Radiation Oncology, University of Kansas Health Systems, Kansas City, USA
| | - Zachary Collins
- Department of Radiology, University of Kansas Health Systems, Kansas City, USA
| | - Shelby Fishback
- Department of Radiology, University of Kansas Health Systems, Kansas City, USA
| | - Jill Jones
- Department of Radiology, University of Kansas Health Systems, Kansas City, USA
| | - Ryan Ash
- Department of Radiology, University of Kansas Health Systems, Kansas City, USA
| | - Vanessa Williams
- Department of Radiology, University of Kansas Health Systems, Kansas City, USA
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SpaceOAR to improve dosimetric outcomes for monotherapy high-dose-rate prostate implantation in a patient with ulcerative colitis. J Contemp Brachytherapy 2018; 10:577-582. [PMID: 30662483 PMCID: PMC6335554 DOI: 10.5114/jcb.2018.81001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 11/28/2018] [Indexed: 12/12/2022] Open
Abstract
High-dose-rate (HDR) brachytherapy is an attractive option for patients receiving definitive radiation therapy for prostate cancer with decreased overall dose to the pelvis. However, ulcerative colitis increases rectal toxicity risk and may be a contraindication. A synthetic hydrogel, SpaceOAR (Augmentix Inc., Waltham, MA, USA), can facilitate the use of HDR brachytherapy for patients where rectal toxicity is a limiting factor. SpaceOAR gel (13.19 cc) was utilized in a monotherapy HDR prostate treatment with Ir-192 under transrectal ultrasound guidance, with the intention of decreasing rectal dose. SpaceOAR gel was inserted transperineally into the patient 18 days prior to the procedure. The HDR brachytherapy procedure was tolerated without incident. All planning constraints were met, and the following dosimetry was achieved: Prostate - V100% = 97.3%, V150% = 35%, V200% = 14.5%; Urethra - V118% = 0%; Rectum - D2 cc = 51.6%, V75% = 0 cc. The rectum-catheter spacing was on average between 6-8 mm. Average spacing for our 10 most recent patients without SpaceOAR was 3 mm. SpaceOAR did not hinder or distort ultrasound imaging or increase treatment time. SpaceOAR successfully increases catheter-rectal wall spacing and decreases rectal dose due to improved planning capabilities, while decreasing the likelihood of rectal perforation. One application of this tool is presented to mitigate potential toxicities associated with ulcerative colitis. At five months, one week, and one day follow-up, the patient reported no bowel issues following HDR brachytherapy.
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207
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Matta R, Chapple CR, Fisch M, Heidenreich A, Herschorn S, Kodama RT, Koontz BF, Murphy DG, Nguyen PL, Nam RK. Pelvic Complications After Prostate Cancer Radiation Therapy and Their Management: An International Collaborative Narrative Review. Eur Urol 2018; 75:464-476. [PMID: 30573316 DOI: 10.1016/j.eururo.2018.12.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/04/2018] [Indexed: 02/06/2023]
Abstract
CONTEXT Radiotherapy used for treating localized prostate cancer is effective at prolonging cancer-specific and overall survival. Still, acute and late pelvic toxicities are a concern, with gastrointestinal (GI) and genitourinary (GU) sequelae being most common as well as other pelvic complications. OBJECTIVE To present a critical review of the literature regarding the incidence and risk factors of pelvic toxicity following primary radiotherapy for prostate cancer and to provide a narrative review regarding its management. EVIDENCE ACQUISITION A collaborative narrative review of the literature from 2010 to present was conducted. EVIDENCE SYNTHESIS Regardless of the modality used, the incidence of acute high-grade pelvic toxicity is low following conventionally fractionated external beam radiotherapy (EBRT). After moderate hypofractionation, the crude cumulative incidences for late grade 3 or higher (G3+) GI and GU complications are as high as 6% and 7%, respectively. After extreme hypofractionation, the 5-yr incidences of G2+ GU and GI toxicities are 3-9% and 0-4%, respectively. Following brachytherapy monotherapy, crude rates of late G3+ GU toxicity range from 6% to 8%, while late GI toxicity is rare. With combination therapy (EBRT and brachytherapy), the cumulative incidence of late GU toxicity is high, between 18% and 31%; however, the prevalence is lower at 4-14%. Whole pelvic radiotherapy remains a controversial treatment option as there is increased G3+ GI toxicity compared with prostate-only treatment, with no overall survival benefit. Proton beam therapy appears to have similar toxicity to photon therapies currently in use. With respect to specific complications, urinary obstruction and urethral stricture are the most common severe urinary toxicities. Rectal and urinary bleeding can be recurrent long-term toxicities. The risk of hip fracture is also increased following prostate radiotherapy. The literature is mixed on the risk of in-field secondary pelvic malignancies following prostate radiotherapy. Urinary and GI fistulas are rare complications. Management of these toxicities may require invasive treatment and reconstructive surgery for refractory and severe symptoms. CONCLUSIONS There has been progress in the delivery of radiotherapy, enabling the administration of higher doses with minimal tradeoff in terms of slightly increased or equal toxicity. There is a need to focus future improvements in radiotherapy on sparing critical structures to reduce GU and GI morbidities. While complications such as fistulae, bone toxicity, and secondary malignancy are rare, there is a need for higher-quality studies assessing these outcomes and their management. PATIENT SUMMARY In this report, we review the literature regarding pelvic complications following modern primary prostate cancer radiotherapy and their management. Modern radiotherapy technologies have enabled the administration of higher doses with minimal increases in toxicity. Overall, high-grade long-term toxicity following prostate radiotherapy is uncommon. Management of late high-grade pelvic toxicities can be challenging, with patients often requiring invasive therapies for refractory cases.
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Affiliation(s)
- Rano Matta
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Heidenreich
- Department of Urology, Uro-Oncology, Robot-Assisted and Reconstructive Surgery, University of Cologne, Cologne, Germany
| | - Sender Herschorn
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ronald T Kodama
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke Prostate and Urologic Cancers Center, Duke University Medical Center, Durham, NC, USA
| | - Declan G Murphy
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Robert K Nam
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Evaluating the Cost-Effectiveness of Hydrogel Rectal Spacer in Prostate Cancer Radiation Therapy. Pract Radiat Oncol 2018; 9:e172-e179. [PMID: 30342180 DOI: 10.1016/j.prro.2018.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 10/01/2018] [Accepted: 10/04/2018] [Indexed: 12/22/2022]
Abstract
PURPOSE A hydrogel rectal spacer (HRS) is a medical device that is approved by the U.S. Food and Drug Administration to increase the separation between the prostate and rectum. We conducted a cost-effectiveness analysis of HRS use for reduction in radiation therapy (RT) toxicities in patients with prostate cancer (PC) undergoing external beam RT (EBRT). METHODS AND MATERIALS A multistate Markov model was constructed from the U.S. payer perspective to examine the cost-effectiveness of HRS in men with localized PC receiving EBRT (EBRT alone vs EBRT + HRS). The subgroups analyzed included site of HRS placement (hospital outpatient, physician office, ambulatory surgery center) and proportion of patients with good baseline erectile function (EF). Data on EF, gastrointestinal and genitourinary toxicities incidence, and potential risks associated with HRS implantation were obtained from a recently published randomized clinical trial. Health utilities and costs were derived from the literature and the 2018 Physician Fee Schedule and were discounted 3% annually. Quality-adjusted life years (QALYs) and costs were modeled for a 5-year period from receipt of RT. Probabilistic sensitivity analysis and value-based threshold analyses were conducted. RESULTS The per-patient 5-year incremental cost for spacers administered in a hospital outpatient setting was $3578, and the incremental effectiveness was 0.0371 QALYs. The incremental cost-effectiveness ratio was $96,440/QALY for patients with PC undergoing HRS insertion in a hospital and $39,286/QALY for patients undergoing HRS insertion in an ambulatory facility. For men with good baseline EF, the incremental cost-effectiveness ratio was $35,548/QALY and $9627/QALY in hospital outpatient and ambulatory facility settings, respectively. CONCLUSIONS Based on the current Medicare Physician Fee Schedule, HRS is cost-effective at a willingness to pay threshold of $100,000. These results contain substantial uncertainty, suggesting more evidence is needed to refine future decision-making.
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209
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Morgan SC, Hoffman K, Loblaw DA, Buyyounouski MK, Patton C, Barocas D, Bentzen S, Chang M, Efstathiou J, Greany P, Halvorsen P, Koontz BF, Lawton C, Leyrer CM, Lin D, Ray M, Sandler H. Hypofractionated Radiation Therapy for Localized Prostate Cancer: An ASTRO, ASCO, and AUA Evidence-Based Guideline. J Clin Oncol 2018; 36:JCO1801097. [PMID: 30307776 PMCID: PMC6269129 DOI: 10.1200/jco.18.01097] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Scott C. Morgan
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Karen Hoffman
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - D. Andrew Loblaw
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mark K. Buyyounouski
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Caroline Patton
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Daniel Barocas
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Soren Bentzen
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael Chang
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jason Efstathiou
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Patrick Greany
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Per Halvorsen
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Bridget F. Koontz
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Colleen Lawton
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - C. Marc Leyrer
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Daniel Lin
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael Ray
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Howard Sandler
- Scott C. Morgan, The Ottawa Hospital and University of Ottawa, Ottawa; D. Andrew Loblaw, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Karen Hoffman, MD Anderson Cancer Center, Houston, TX; Mark K. Buyyounouski, Stanford University, Stanford; Palto Alto VA Health System, Palo Alto, CA; Caroline Patton, American Society for Radiation Oncology, Arlington, VA; Daniel Barocas, Vanderbilt University Medical Center, Nashville, TN; Soren Bentzen, University of Maryland School of Medicine, Baltimore, MD; Michael Chang, Hunter Holmes McGuire VA Medical Center and Virginia Commonwealth University, Richmond, VA; Jason Efstathiou, Massachusetts General Hospital, Boston MA; Patrick Greany, Patient representative, Tallahassee, FL; Per Halvorsen, Lahey Hospital and Medical Center, Burlington, MA; Bridget F. Koontz, Duke University Medical Center, Durham, NC; Colleen Lawton, Medical College of Wisconsin, Milwaukee, WI; C. Marc Leyrer, Wake Forest University, Winston-Salem, NC; Daniel Lin, University of Washington, Seattle, WA; Michael Ray, Radiology Associates of Appleton, ThedaCare Regional Cancer Center, Appleton, WI; and Howard Sandler, Cedars-Sinai Medical Center, Los Angeles, CA
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The use of hydrogel spacer in men undergoing high-dose prostate cancer radiotherapy: results of a prospective phase 2 clinical trial. World J Urol 2018; 37:1111-1116. [PMID: 30251049 DOI: 10.1007/s00345-018-2502-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 09/19/2018] [Indexed: 10/28/2022] Open
Abstract
PURPOSE The purpose of this study was to determine whether the degree of prostate to rectal separation using a hydrogel spacer (HS) and its effect on decreasing rectal dose can be reproduced in the community setting. METHODS Thirty one patients with cT1-3aN0M0 prostate adenocarcinoma receiving radical radiotherapy to 78 Gy were recruited to the study. The primary endpoint was the proportion of patients achieving at least 25% reduction in volume of rectum receiving 70 Gy (rV70). Other endpoints included degree of prostate to rectum separation, HS insertion-related adverse events and the proportion of patients with grade 1 or worse acute or late gastrointestinal (GI) and genitourinary (GU) toxicity. RESULTS All patients had successful insertion of their HS with no peri-operative toxicity. The mean prostate-rectal separation achieved was 10.5 mm. Twenty nine (93.5%) patients achieved a reduction in rV70 of at least 25%. Acute grade 1 GI toxicity was reported in 3 patients. All symptoms had resolved by 3 months post RT. Late grade 1 GI toxicity was reported in one patient (3.2%) with bowel frequency occurring at 6 months and resolving by 12 months post RT. There was no grade 2 or 3 acute or late GI toxicity seen. CONCLUSION In conclusion, this study illustrates that the application and benefits of HS on reducing GI rectal dose endpoints and toxicities during prostate cancer RT can be reliably replicated in a community setting similar to centres participating in the randomised trial under high quality assurance trial monitoring.
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211
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Development and preclinical testing of a novel biodegradable hydrogel vaginal packing technology for gynecologic high-dose-rate brachytherapy. J Contemp Brachytherapy 2018; 10:306-314. [PMID: 30237814 PMCID: PMC6142653 DOI: 10.5114/jcb.2018.77952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 07/06/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose We evaluated the performance of a novel hydrogel-based strategy developed for clinical use as vaginal packing using phantoms and cadavers, and to compare the hydrogel to gauze and balloon packing. Material and methods The biocompatible hydrogel is based on a thiol-Michael addition reaction, with delivery of reagents into the vaginal cavity using a custom-made system. Soft-cured cadavers were used for soft tissue-like mechanical properties. Two cadavers with intact uteri had magnetic resonance imaging (MRI) compatible with tandem and ovoids. For one cadaver, the temperature of the vaginal canal was measured before hydrogel application, during polymerization, and after hydrogel removal. The hydrogel packing and applicator was kept in a second cadaver, which was imaged using computed tomography (CT) and MRI. The hydrogel packing and imaging was repeated for an open multichannel MRI compatible, titanium-based vaginal cylinder placed in a post-hysterectomy cadaver. Results The gel reaction occurred within 90 seconds, indicating polymerization at clinical quantities with a 5°C increase in vaginal temperature. CT and MRI imaging identified the hydrogel readily and showed a conformance to anatomy with few air pockets. The entire hydrogel packing was readily retrieved upon completion of imaging. Conclusions The novel strategy for polyethylene glycol (PEG)-based hydrogel intra-vaginal packing was able to rapidly polymerize in human cadavers with minimal heat production. Delivery was efficient and able to fill the contours of the vaginal cavity and displace tissue away from the applicator axis. The hydrogel has favorable imaging characteristics on CT and MRI, and shows a potential for clinical use, warranting additional studies for the use in humans.
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212
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Prostate Stereotactic Body Radiation Therapy With a Focal Simultaneous Integrated Boost: Acute Toxicity and Dosimetry Results From a Prospective Trial. Adv Radiat Oncol 2018; 4:90-95. [PMID: 30706015 PMCID: PMC6349624 DOI: 10.1016/j.adro.2018.09.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 07/23/2018] [Accepted: 09/10/2018] [Indexed: 12/15/2022] Open
Abstract
Purpose This study aimed to report the early toxicity results of a prospective clinical trial of prostate stereotactic body radiation therapy (SBRT) to the entire prostate with a simultaneous integrated boost (SIB) to magnetic resonance imaging (MRI)-defined focal lesions. Methods and materials Eligible patients included men with biopsy-proven prostate stage T1c to T2c adenocarcinoma, a Gleason score ≤7, and prostate-specific antigen values of ≤20 ng/mL, who had at least 1 focal lesion visible on MRI and a total prostate volume no greater than 120 cm3. SBRT consisted of a dose of 36.25 Gy to the entire prostate with an SIB of 40 Gy to the MRI-defined lesions, delivered in 5 fractions. The primary purpose of the study was to confirm the feasibility of treatment planning/delivery and to estimate the rate of urinary retention requiring placement of a Foley catheter within 90 days of treatment. This study was to be considered successful if urinary retention occurred in no more than 15% of cases, with a planned enrollment of at least 25 patients. Results A total of 26 men were enrolled, and all underwent SBRT as planned. Twenty patients (77%) had intermediate-risk features, and the remainder were low risk. A treatment plan that met the protocol-defined goals for all cases was developed. Two patients (7.7%) developed acute urinary symptoms that required the temporary placement of a Foley catheter. No grade 3+ toxicity events were observed. Conclusions Planning and delivery of prostate SBRT with a whole prostate dose of 36.25 Gy and a focal 40 Gy SIB is feasible. Early follow-up suggests that this treatment is not associated with undue morbidity.
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213
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Musunuru HB, D'Alimonte L, Davidson M, Ho L, Cheung P, Vesprini D, Liu S, Chu W, Chung H, Ravi A, Deabreu A, Zhang L, Commisso K, Loblaw A. Phase 1-2 Study of Stereotactic Ablative Radiotherapy Including Regional Lymph Node Irradiation in Patients With High-Risk Prostate Cancer (SATURN): Early Toxicity and Quality of Life. Int J Radiat Oncol Biol Phys 2018; 102:1438-1447. [PMID: 30071295 DOI: 10.1016/j.ijrobp.2018.07.2005] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 07/02/2018] [Accepted: 07/22/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE Five-fraction stereotactic ablative radiation therapy appears to be gaining popularity in treatment of prostate cancer, but it has not been extensively tested in the context of pelvic radiation. The objective of this prospective prostate and pelvic SABR study is to report the acute toxicity, late toxicity, and quality of life (QoL) after study completion. METHODS AND MATERIALS A phase 1/2 study was conducted for patients with high-risk prostate cancer. Radiation therapy was planned to deliver 25 Gy to pelvis and seminal vesicles (SV) and a simultaneous integrated boost (SIB) of up to 40 Gy to the prostate in 5 fractions, weekly, over 29 days. Androgen deprivation therapy was used for 12 to 18 months. Common Terminology Criteria for Adverse Events version 3.0 was used to assess worst acute and late toxicities. QoL data was captured using the Expanded Prostate Cancer Index Composite questionnaire (EPIC). RESULTS Thirty patients completed the planned treatment with a median follow-up of 25.7 months (range, 18.5-30.7 months). The following "worst" acute and late toxicities were observed: grade 2 genitourinary toxicity, 46.7% and 52%, respectively; grade 2 gastrointestinal toxicity, 3.3% and 32%, respectively. No grade 3 or higher toxicities were noted. Mean (95% confidence interval) EPIC urinary QoL scores were 86.6 (81.9-91.3), 87.1 (81.4-92.6), and 87.9 (80.1-95.7) at baseline, 3 months and 24 months; bowel scores were 94.1 (91.3-97.0), 93.2 (89.1-97.2), and 92.4 (87.7- 97.1), respectively. CONCLUSIONS This gantry-based novel fractionation schedule incorporating pelvic radiation for high-risk prostate cancer in combination with androgen deprivation therapy is feasible and well tolerated.
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Affiliation(s)
| | - Laura D'Alimonte
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Ling Ho
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Patrick Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Vesprini
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Stanley Liu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Hans Chung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Ananth Ravi
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Deabreu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Liying Zhang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kristina Commisso
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Department of Health Policy, Measurement and Evaluation, University of Toronto, Toronto, Canada.
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Leiker AJ, Desai NB, Folkert MR. Rectal radiation dose-reduction techniques in prostate cancer: a focus on the rectal spacer. Future Oncol 2018; 14:2773-2788. [PMID: 29939069 DOI: 10.2217/fon-2018-0286] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Prostate cancer is the most common cancer in men. External beam radiotherapy by a variety of methods is a standard treatment option with excellent disease control. However, acute and late rectal side effects remain a limiting concern in intensification of therapy in higher-risk patients and in efforts to reduce treatment burden in others. A number of techniques have emerged that allow for high-radiation dose delivery to the prostate with reduced risk of rectal toxicity, including image-guided intensity-modulated radiation therapy, endorectal balloons and various forms of rectal spacers. Image-guided radiation therapy, either intensity-modulated radiation therapy or stereotactic ablative radiation therapy, in conjunction with a rectal spacer, is an efficacious means to reduce acute and long-term rectal toxicity.
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Affiliation(s)
- Andrew J Leiker
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
| | - Neil B Desai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
| | - Michael R Folkert
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
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Stish BJ, Davis BJ, Mynderse LA, McLaren RH, Deufel CL, Choo R. Low dose rate prostate brachytherapy. Transl Androl Urol 2018; 7:341-356. [PMID: 30050795 PMCID: PMC6043740 DOI: 10.21037/tau.2017.12.15] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Low dose rate (LDR) prostate brachytherapy is an evidence based radiation technique with excellent oncologic outcomes. By utilizing direct image guidance for radioactive source placement, LDR brachytherapy provides superior radiation dose escalation and conformality compared to external beam radiation therapy (EBRT). With this level of precision, late grade 3 or 4 genitourinary or gastrointestinal toxicity rates are typically between 1% and 4%. Furthermore, when performed as a same day surgical procedure, this technique provides a cost effective and convenient strategy. A large body of literature with robust follow-up has led multiple expert consensus groups to endorse the use of LDR brachytherapy as an appropriate management option for all risk groups of non-metastatic prostate cancer. LDR brachytherapy is often effective when delivered as a monotherapy, although for some patients with intermediate or high-risk disease, optimal outcome are achieved in combination with supplemental EBRT and/or androgen deprivation therapy (ADT). In addition to reviewing technical aspects and reported clinical outcomes of LDR prostate brachytherapy, this article will focus on the considerations related to appropriate patient selection and other aspects of its use in the treatment of prostate cancer.
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Affiliation(s)
- Bradley J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Brian J Davis
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | | | | | | | - Richard Choo
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
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Tang Q, Zhao F, Yu X, Wu L, Lu Z, Yan S. The role of radioprotective spacers in clinical practice: a review. Quant Imaging Med Surg 2018; 8:514-524. [PMID: 30050786 DOI: 10.21037/qims.2018.06.06] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The delivery of high dose radiotherapy to tumors is often limited by the proximity of the surrounding radiosensitive normal tissues, even using modern techniques such as intensity modulated radiation therapy (IMRT). Previous studies have reported that placement of a spacer can effectively displace normal tissues. So that they are some distance away from the lesion, thus allowing for the safe delivery of high-dose radiation. The application of radioprotective spacers was first reported 30 years ago regarding radiotherapy of tongue and abdominal cancers; more recently, they are increasingly being used in prostate cancer. This review focuses on the published data concerning the features of different types of spacers and their application in various tumor sites. Placement-related complications and the cost-effectiveness of the spacers are also discussed. With the increasing use of high-precision radiotherapy in clinical practice, especially the paradigm-changing stereotactic body radiotherapy (SBRT), more robust studies are warranted to further establish the role of radioprotective spacers through materials development and novel placement techniques.
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Affiliation(s)
- Qiuying Tang
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Feng Zhao
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Xiaokai Yu
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Lingyun Wu
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Zhongjie Lu
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Senxiang Yan
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
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Abstract
Radiation therapy (RT) is a curative treatment modality for localized prostate cancer. Over the past two decades, advances in technology and imaging have considerably changed RT in prostate cancer treatment. Treatment has evolved from 2-dimensional (2D) planning using X-ray fields based on pelvic bony landmarks to 3-dimensional (3D) conformal RT (CRT) which uses computed tomography (CT) based planning. Despite improvements with 3D-CRT, dose distributions often remained suboptimal with portions of the rectum and bladder receiving unacceptably high doses. In more recent years, intensity-modulated radiation therapy (IMRT) has become the standard of care to deliver external beam RT. IMRT uses multiple radiation beams of different shapes and intensities delivered from a wide range of angles to ‘paint’ the radiation dose onto the tumor. IMRT allows for a higher dose of radiation to be delivered to the prostate while reducing dose to surrounding organs. Multiple clinical trials have demonstrated improved cancer outcomes with dose escalation, but toxicities using 3D-CRT and escalated doses have been problematic. IMRT is a method to deliver dose escalated RT with more conformal dose distributions than 3D-CRT and has been associated with improved toxicity profiles. IMRT also appears to be the safest method to deliver hypofractionated RT and pelvic lymph node radiation. The purpose of this review is to summarize the technical aspects of IMRT planning and delivery, and to review the literature supporting the use of IMRT for prostate cancer.
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Affiliation(s)
- Ben W Fischer-Valuck
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Yuan James Rao
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
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BioPro-RCMI-1505 trial: multicenter study evaluating the use of a biodegradable balloon for the treatment of intermediate risk prostate cancer by intensity modulated radiotherapy; study protocol. BMC Cancer 2018; 18:566. [PMID: 29769060 PMCID: PMC5956854 DOI: 10.1186/s12885-018-4492-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 05/08/2018] [Indexed: 02/03/2023] Open
Abstract
Background Prospective trials have demonstrated the advantage of dose-escalated radiotherapy for the biochemical and clinical control of intermediate risk prostate cancer. Dose escalation improves outcomes but increases risks of urinary and bowel toxicity. Recently the contribution of “spacers” positioned in the septum between the rectum and the prostate could improve the functional results of intensity modulated radiation therapy (IMRT). To date most of the evaluated devices were polyethylen glycol (PEG) and hyaluronic acid (HA). Men on the Spacer arm had decreased bowel toxicity and less decline in both urinary and bowel quality of life as compared to Control men in a randomized trial. Methods This is an interventional, multi-center study to evaluate the use of biodegradable inflatable balloon for patients with intermediate risk prostate cancer treated by IMRT (74 to 80 Gy, 2 Gy/fraction) with daily image guided radiotherapy. Discussion This multicenter prospective study will yield new data regarding dosimetric gain and implantation stages of Bioprotect balloon. Acute and late toxicities and quality of life will be registered too. Trial registration NCT02478112, date of registration: 15/06/2015.
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Affiliation(s)
- Andrew Kneebone
- Department of Radiation Oncology; Royal North Shore Hospital
- Chair of the Faculty Of Radiation Oncology Genito-Urinary Group (FROGG)
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220
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Chao M, Ho H, Chan Y, Tan A, Pham T, Bolton D, Troy A, Temelcos C, Sengupta S, McMillan K, Cham CW, Liu M, Ding W, Subramanian B, Wasiak J, Lim Joon D, Spencer S, Lawrentschuk N. Prospective analysis of hydrogel spacer for patients with prostate cancer undergoing radiotherapy. BJU Int 2018. [PMID: 29520983 DOI: 10.1111/bju.14192] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To report on the dosimetric benefits and late toxicity outcomes after injection of hydrogel spacer (HS) between the prostate and rectum for patients treated with prostate radiotherapy (RT). PATIENTS AND METHODS In all, 76 patients with a clinical stage of T1-T3a prostate cancer underwent general anaesthesia for fiducial marker insertion plus injection of the HS into the perirectal space before intensity-modulated RT (IMRT) or volumetric-modulated arc RT (VMAT). HS safety, dosimetric benefits, and the immediate- to long-term effects of gastrointestinal (GI) toxicity were assessed. RESULTS There were no postoperative complications reported. The mean (range) prostate size was 66.0 (25.0-187.0) mm. Rectal dose volume parameters were observed and the volume of rectum receiving 70 Gy (rV70 ), 75 Gy (rV75 ) and 78 Gy (rV78 ) was 7.8%, 3.6% and 0.4%, respectively. In all, 21% of patients (16/76) developed acute Grade 1 GI toxicities, but all were resolved completely by 3 months after treatment; whilst, 3% of patients (2/76) developed late Grade 1 GI toxicities. No patients had acute or late Grade ≥2 GI toxicities. CONCLUSION Injection of HS resulted in a reduction of irradiated rectal dose volumes along with minimal GI toxicities, irrespective of prostate size.
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Affiliation(s)
- Michael Chao
- The Austin Hospital, Heidelberg, Vic., Australia.,Genesis Cancer Care Victoria, Ringwood East, Vic., Australia
| | - Huong Ho
- Genesis Cancer Care Victoria, Ringwood East, Vic., Australia
| | - Yee Chan
- The Austin Hospital, Heidelberg, Vic., Australia.,Ringwood Private Hospital, Ringwood East, Vic., Australia
| | - Alwin Tan
- The Bays Hospital, Mornington, Vic., Australia
| | - Trung Pham
- The Valley Private Hospital, Mulgrave, Vic., Australia
| | - Damien Bolton
- The Austin Hospital, Heidelberg, Vic., Australia.,Ringwood Private Hospital, Ringwood East, Vic., Australia
| | - Andrew Troy
- The Austin Hospital, Heidelberg, Vic., Australia
| | | | - Shomik Sengupta
- The Austin Hospital, Heidelberg, Vic., Australia.,Melbourne University; Eastern Health Clinical School, Monash University, Clayton, Vic., Australia
| | - Kevin McMillan
- Ringwood Private Hospital, Ringwood East, Vic., Australia
| | | | - Madalena Liu
- Ringwood Private Hospital, Ringwood East, Vic., Australia
| | - Wei Ding
- Genesis Cancer Care Victoria, Ringwood East, Vic., Australia
| | | | - Jason Wasiak
- The Austin Hospital, Heidelberg, Vic., Australia.,University of Melbourne, Melbourne, Vic., Australia
| | - Daryl Lim Joon
- The Austin Hospital, Heidelberg, Vic., Australia.,Genesis Cancer Care Victoria, Ringwood East, Vic., Australia
| | - Sandra Spencer
- Genesis Cancer Care Victoria, Ringwood East, Vic., Australia
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221
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Ávila M, Patel L, López S, Cortés-Sanabria L, Garin O, Pont À, Ferrer F, Boladeras A, Zamora V, Fosså S, Storås AH, Sanda M, Serra-Sutton V, Ferrer M. Patient-reported outcomes after treatment for clinically localized prostate cancer: A systematic review and meta-analysis. Cancer Treat Rev 2018; 66:23-44. [PMID: 29673922 DOI: 10.1016/j.ctrv.2018.03.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/23/2018] [Accepted: 03/23/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of this systematic review is to assess the impact of primary treatments with curative intention in patients with localized prostate cancer, measured with Patient-Reported Outcomes (PROs), and to examine differences among modalities within treatments. METHODS We conducted a systematic literature search for January 2005-March 2017 following PRISMA guidelines, including longitudinal studies measuring disease-specific PROs in localized prostate cancer patients with a follow-up from pre- to post-treatment (≥1 year). Two reviewers independently extracted data and assessed risk of bias. The study is registered in PROSPERO: CRD42015019747. RESULTS Of 148 identified studies, 60 were included in the meta-analyses. At the 1st year, radical prostatectomy patients showed small urinary irritative-obstructive improvement (0.37SD 95%CI 0.30, 0.45), but large deterioration for sexual function and incontinence with high heterogeneity (I2 = 77% and 93%). Moderate worsening in external radiotherapy patients for sexual function (-0.46SD 95%CI -0.55, -0.36), small urinary incontinence (-0.16SD 95%CI -0.23, -0.09) and bowel impairment (-0.31SD 95%CI -0.39, -0.23). Brachytherapy patients presented small deterioration in urinary incontinence (-0.29SD 95%CI -0.39, -0.19), irritative obstructive symptoms (-0.35SD 95%CI -0.47, -0.23), sexual function (-0.12SD 95%CI -0.24, -0.002), and bowel bother (-0.27SD 95%CI -0.42, -0.11). These patterns persisted up to the 5th year. High-intensity focused ultrasound and active surveillance only have results at 1st year, showing no statistically significant worsening. CONCLUSIONS No remarkable differences in PRO appeared between modalities within each treatment. Nowadays, available evidence supports brachytherapy as possible alternative to radical prostatectomy for patients seeking an attempted curative treatment limiting the risk for urinary incontinence and sexual dysfunction.
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Affiliation(s)
- Mónica Ávila
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain; Universitat Pompeu Fabra, Barcelona, Spain
| | | | - Silvia López
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Laura Cortés-Sanabria
- Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico
| | - Olatz Garin
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain; Universitat Pompeu Fabra, Barcelona, Spain.
| | - Àngels Pont
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain
| | | | | | - Victor Zamora
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Barcelona University UB, Barcelona, Spain
| | - Sophie Fosså
- Oslo University Hospital, University of Oslo, Norway
| | - Anne H Storås
- Oslo University Hospital, University of Oslo, Norway
| | - Martin Sanda
- Department of Urology, Emory University School of Medicine, United States
| | - Vicky Serra-Sutton
- Agency for Health Quality and Assessment of Catalonia (AQuAS), Barcelona, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain
| | - Montse Ferrer
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; CIBER en Epidemiología y Salud Pública, CIBERESP, Spain; Universitat Autònoma de Barcelona, Bellaterra, Spain.
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Feutren T, Herrera FG. Prostate irradiation with focal dose escalation to the intraprostatic dominant nodule: a systematic review. Prostate Int 2018; 6:75-87. [PMID: 30140656 PMCID: PMC6104294 DOI: 10.1016/j.prnil.2018.03.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/10/2018] [Accepted: 03/21/2018] [Indexed: 12/22/2022] Open
Abstract
Radiation therapy (RT) is a curative treatment option for localized prostate cancer. Prostate irradiation with focal dose escalation to the intraprostatic dominant nodule (IDN) is an emerging treatment option that involves the prophylactic irradiation of the whole prostate while increasing RT doses to the visible prostatic tumor. Because of the lack of large multicentre trials, a systematic review was performed in an attempt to get an overview on the feasibility and efficacy of focal dose escalation to the IDN. A bibliographic search for articles in English, which were listed in MEDLINE from 2000 to 2016 to identify publications on RT with focal directed boost to the IDN, was performed. The review was completed following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Twenty-two articles describing 1,378 patients treated with RT using focal boost were identified and fulfilled the selection criteria. Intensity-modulated radiation therapy (IMRT) was used in 720 patients (52.3%), volumetric modulated arc therapy was used in 45 patients (3.3%), stereotactic body radiation therapy (SBRT) in 113 patients (8.2%), and low–dose rate and high–dose rate brachytherapy (BT) were used in 305 patients (22.1%) and 195 patients (14.1%), respectively. Use of androgen deprivation therapy varied substantially among series. Biochemical disease-free survival at 5 years was reported for a cohort of 812 (58.9%) patients. The combined median biochemical disease-free survival for this group of patients was 85% (range: 78.8–100%; 95% confidence interval: 77.1–82.7%). The average occurrence of grade III or worse gastrointestinal and genitourinary late toxicity was, respectively, 2.5% and 3.1% for intensity-modulated RT boost, 10% and 6% for stereotactic body RT, 6% and 2% for low–dose rate BT, and 4% and 4.3% for high–dose rate BT. This review shows encouraging results for focal dose escalation to the IDN with acceptable short- to medium-term side effects and biochemical disease control rates. However, owing to the heterogeneity of patient population and the short follow-up, the results should be interpreted with caution. Considering that the clinical endpoint in the studies was biochemical recurrence, the use and duration of androgen deprivation therapy administration should be carefully considered before driving definitive conclusions. Randomized trials with long-term follow-up are needed before this technique can be generally recommended.
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Affiliation(s)
- Thomas Feutren
- Department of Radiotherapy, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Current Position Department of Radiotherapy, Institut de Cancérologie de Lorraine, Nancy, France
| | - Fernanda G. Herrera
- Department of Radiotherapy, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Corresponding author. Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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223
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Vanneste BGL, Van Limbergen EJ, van de Beek K, van Lin E, Lutgens L, Lambin P. A biodegradable rectal balloon implant to protect the rectum during prostate cancer radiotherapy for a patient with active Crohn's disease. Tech Innov Patient Support Radiat Oncol 2018; 6:1-4. [PMID: 32095571 PMCID: PMC7033750 DOI: 10.1016/j.tipsro.2018.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/26/2018] [Indexed: 12/22/2022] Open
Abstract
Active inflammatory bowel disease is an exclusion criterion for high-dose radiotherapy. A rectum spacer was inserted between the prostate and the rectal wall. The rectum spacer pushes the rectum outside of the high-dose area. No rectal toxicity of the radiotherapy or toxicity flare of the IBD was observed.
Background Radiotherapy in patients with active inflammatory bowel disease (IBD) is usually considered an absolute exclusion criterion for prostate cancer radiotherapy treatment. There are no reports available on the use of a biodegradable rectal balloon implantation (RBI) in patients with active IBD for prostate cancer radiotherapy. Case presentation We report on a patient with high-risk prostate cancer with the comorbidity of an active IBD with pancolitis location. He was treated with neo-adjuvant hormonal therapy and high-dose external beam radiotherapy to the prostate and the seminal vesicles. Before radiotherapy treatment, a biodegradable RBI was implanted between the prostate and the anterior rectal wall to push the rectum outside of the high-dose area. This patient at high-risk for rectal toxicity was successfully irradiated to his prostate with only a grade I urinary toxicity, no acute rectal toxicity or toxicity flare of the IBD. Conclusions This case describes the use of a RBI implantation in patients with active IBD for prostate cancer radiotherapy. The use of a biodegradable RBI proved to be a promised solution for such patients, and have to be further investigated.
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Affiliation(s)
- Ben G L Vanneste
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Evert J Van Limbergen
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Kees van de Beek
- Department of Urology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | | | - Ludy Lutgens
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
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Quon HC, Ong A, Cheung P, Chu W, Chung HT, Vesprini D, Chowdhury A, Panjwani D, Pang G, Korol R, Davidson M, Ravi A, McCurdy B, Zhang L, Mamedov A, Deabreu A, Loblaw A. Once-weekly versus every-other-day stereotactic body radiotherapy in patients with prostate cancer (PATRIOT): A phase 2 randomized trial. Radiother Oncol 2018; 127:206-212. [PMID: 29551231 DOI: 10.1016/j.radonc.2018.02.029] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 02/19/2018] [Accepted: 02/25/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Prostate stereotactic body radiotherapy (SBRT) regimens differ in time, dose, and fractionation. We completed a multicentre, randomized phase II study to investigate the impact of overall treatment time on quality of life (QOL). MATERIAL AND METHODS Men with low and intermediate-risk prostate cancer were randomly assigned to 40 Gy in 5 fractions delivered once per week (QW) vs. every other day (EOD). QOL was assessed using the Expanded Prostate Cancer Index Composite. The primary endpoint was the proportion with a minimum clinically important change (MCIC) in bowel QOL during the acute (≤12 week) period, and analysis was by intention-to-treat. ClinicalTrials.gov NCT01423474. RESULTS 152 men from 3 centres were randomized with median follow-up of 47 months. Patients treated QW had superior acute bowel QOL with 47/69 (68%) reporting a MCIC compared to 63/70 (90%) treated EOD (p = 0.002). Fewer patients treated QW reported moderate-severe problems with bowel QOL during the acute period compared with EOD (14/70 [20%] vs. 40/70 [57%], p < 0.001). Acute urinary QOL was also better in the QW arm, with 52/67 (78%) vs 65/69 (94%) experiencing a MCIC (p = 0.006). There were no significant differences in late urinary or bowel QOL at 2 years or last follow-up. CONCLUSION Prostate SBRT delivered QW improved acute bowel and urinary QOL compared to EOD. Patients should be counselled regarding the potential for reduced short-term toxicity and improved QOL with QW prostate SBRT.
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Affiliation(s)
| | | | - Patrick Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Hans T Chung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Danny Vesprini
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | | | - Geordi Pang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Renee Korol
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Ananth Ravi
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | - Liying Zhang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Alexandre Mamedov
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Andrea Deabreu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
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Vanneste BGL, van De Beek K, Lutgens L, Lambin P. Implantation of a biodegradable rectum balloon implant: tips, Tricks and Pitfalls. Int Braz J Urol 2018; 43:1033-1042. [PMID: 28338306 PMCID: PMC5734065 DOI: 10.1590/s1677-5538.ibju.2016.0494] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/20/2016] [Indexed: 12/18/2022] Open
Abstract
Introduction: A rectum balloon implant (RBI) is a new device to spare rectal structures during prostate cancer radiotherapy. The theoretical advantages of a RBI are to reduce the high radiation dose to the anterior rectum wall, the possibility of a post-implant correction, and their predetermined shape with consequent predictable position. Objective: To describe, step-by-step, our mini-invasive technique for hands-free transperineal implantation of a RBI before start of radiotherapy treatment. Materials and Methods: We provide step-by-step instructions for optimization of the transperineal implantation procedure performed by urologists and/or radiation oncologists experienced with prostate brachytherapy and the use of the real-time bi-plane transrectal ultrasonography (TRUS) probe. A RBI was performed in 15 patients with localised prostate cancer. Perioperative side-effects were reported. Results: We provide ‘tips and tricks’ for optimizing the procedure and proper positioning of the RBI. Please watch the animation, see video in https://vimeo.com/205852376/789df4fae4. The side-effects included mild discomfort to slight pain at the perineal region in 8 out of 15 patients. Seven patients (47%) had no complaints at all. Two patients developed redness of the skin, where prompt antibiotic regimen was started with no further sequelae. One patient revealed a temporary urine retention, which resolved in a few hours following conservative treatment. Further no perioperative complications occurred. Conclusion: This paper describes in detail the implantation procedure for an RBI. It is a feasible, safe and very well-tolerated procedure.
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Affiliation(s)
- Ben G L Vanneste
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Kees van De Beek
- Department of Urology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Ludy Lutgens
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, Netherlands
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Wu SY, Boreta L, Wu A, Cheung JP, Cunha JAM, Shinohara K, Chang AJ. Improved rectal dosimetry with the use of SpaceOAR during high-dose-rate brachytherapy. Brachytherapy 2018; 17:259-264. [DOI: 10.1016/j.brachy.2017.10.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/23/2017] [Accepted: 10/23/2017] [Indexed: 10/18/2022]
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Towards a Clinical Decision Support System for External Beam Radiation Oncology Prostate Cancer Patients: Proton vs. Photon Radiotherapy? A Radiobiological Study of Robustness and Stability. Cancers (Basel) 2018; 10:cancers10020055. [PMID: 29463018 PMCID: PMC5836087 DOI: 10.3390/cancers10020055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/19/2018] [Accepted: 02/14/2018] [Indexed: 12/25/2022] Open
Abstract
We present a methodology which can be utilized to select proton or photon radiotherapy in prostate cancer patients. Four state-of-the-art competing treatment modalities were compared (by way of an in silico trial) for a cohort of 25 prostate cancer patients, with and without correction strategies for prostate displacements. Metrics measured from clinical image guidance systems were used. Three correction strategies were investigated; no-correction, extended-no-action-limit, and online-correction. Clinical efficacy was estimated via radiobiological models incorporating robustness (how probable a given treatment plan was delivered) and stability (the consistency between the probable best and worst delivered treatments at the 95% confidence limit). The results obtained at the cohort level enabled the determination of a threshold for likely clinical benefit at the individual level. Depending on the imaging system and correction strategy; 24%, 32% and 44% of patients were identified as suitable candidates for proton therapy. For the constraints of this study: Intensity-modulated proton therapy with online-correction was on average the most effective modality. Irrespective of the imaging system, each treatment modality is similar in terms of robustness, with and without the correction strategies. Conversely, there is substantial variation in stability between the treatment modalities, which is greatly reduced by correction strategies. This study provides a ‘proof-of-concept’ methodology to enable the prospective identification of individual patients that will most likely (above a certain threshold) benefit from proton therapy.
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Lawrie TA, Green JT, Beresford M, Wedlake L, Burden S, Davidson SE, Lal S, Henson CC, Andreyev HJN. Interventions to reduce acute and late adverse gastrointestinal effects of pelvic radiotherapy for primary pelvic cancers. Cochrane Database Syst Rev 2018; 1:CD012529. [PMID: 29360138 PMCID: PMC6491191 DOI: 10.1002/14651858.cd012529.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND An increasing number of people survive cancer but a significant proportion have gastrointestinal side effects as a result of radiotherapy (RT), which impairs their quality of life (QoL). OBJECTIVES To determine which prophylactic interventions reduce the incidence, severity or both of adverse gastrointestinal effects among adults receiving radiotherapy to treat primary pelvic cancers. SEARCH METHODS We conducted searches of CENTRAL, MEDLINE, and Embase in September 2016 and updated them on 2 November 2017. We also searched clinical trial registries. SELECTION CRITERIA We included randomised controlled trials (RCTs) of interventions to prevent adverse gastrointestinal effects of pelvic radiotherapy among adults receiving radiotherapy to treat primary pelvic cancers, including radiotherapy techniques, other aspects of radiotherapy delivery, pharmacological interventions and non-pharmacological interventions. Studies needed a sample size of 20 or more participants and needed to evaluate gastrointestinal toxicity outcomes. We excluded studies that evaluated dosimetric parameters only. We also excluded trials of interventions to treat acute gastrointestinal symptoms, trials of altered fractionation and dose escalation schedules, and trials of pre- versus postoperative radiotherapy regimens, to restrict the vast scope of the review. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology. We used the random-effects statistical model for all meta-analyses, and the GRADE system to rate the certainty of the evidence. MAIN RESULTS We included 92 RCTs involving more than 10,000 men and women undergoing pelvic radiotherapy. Trials involved 44 different interventions, including radiotherapy techniques (11 trials, 4 interventions/comparisons), other aspects of radiotherapy delivery (14 trials, 10 interventions), pharmacological interventions (38 trials, 16 interventions), and non-pharmacological interventions (29 trials, 13 interventions). Most studies (79/92) had design limitations. Thirteen studies had a low risk of bias, 50 studies had an unclear risk of bias and 29 studies had a high risk of bias. Main findings include the following:Radiotherapy techniques: Intensity-modulated radiotherapy (IMRT) versus 3D conformal RT (3DCRT) may reduce acute (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.26 to 0.88; participants = 444; studies = 4; I2 = 77%; low-certainty evidence) and late gastrointestinal (GI) toxicity grade 2+ (RR 0.37, 95% CI 0.21 to 0.65; participants = 332; studies = 2; I2 = 0%; low-certainty evidence). Conformal RT (3DCRT or IMRT) versus conventional RT reduces acute GI toxicity grade 2+ (RR 0.57, 95% CI 0.40 to 0.82; participants = 307; studies = 2; I2 = 0%; high-certainty evidence) and probably leads to less late GI toxicity grade 2+ (RR 0.49, 95% CI 0.22 to 1.09; participants = 517; studies = 3; I2 = 44%; moderate-certainty evidence). When brachytherapy (BT) is used instead of external beam radiotherapy (EBRT) in early endometrial cancer, evidence indicates that it reduces acute GI toxicity (grade 2+) (RR 0.02, 95% CI 0.00 to 0.18; participants = 423; studies = 1; high-certainty evidence).Other aspects of radiotherapy delivery: There is probably little or no difference in acute GI toxicity grade 2+ with reduced radiation dose volume (RR 1.21, 95% CI 0.81 to 1.81; participants = 211; studies = 1; moderate-certainty evidence) and maybe no difference in late GI toxicity grade 2+ (RR 1.02, 95% CI 0.15 to 6.97; participants = 107; studies = 1; low-certainty evidence). Evening delivery of RT may reduce acute GI toxicity (diarrhoea) grade 2+ during RT compared with morning delivery of RT (RR 0.51, 95% CI 0.34 to 0.76; participants = 294; studies = 2; I2 = 0%; low-certainty evidence). There may be no difference in acute (RR 2.22, 95% CI 0.62 to 7.93, participants = 110; studies = 1) and late GI toxicity grade 2+ (RR 0.44, 95% CI 0.12 to 1.65; participants = 81; studies = 1) between a bladder volume preparation of 1080 mls and that of 540 mls (low-certainty evidence). Low-certainty evidence on balloon and hydrogel spacers suggests that these interventions for prostate cancer RT may make little or no difference to GI outcomes.Pharmacological interventions: Evidence for any beneficial effects of aminosalicylates, sucralfate, amifostine, corticosteroid enemas, bile acid sequestrants, famotidine and selenium is of a low or very low certainty. However, evidence on certain aminosalicylates (mesalazine, olsalazine), misoprostol suppositories, oral magnesium oxide and octreotide injections suggests that these agents may worsen GI symptoms, such as diarrhoea or rectal bleeding.Non-pharmacological interventions: Low-certainty evidence suggests that protein supplements (RR 0.23, 95% CI 0.07 to 0.74; participants = 74; studies = 1), dietary counselling (RR 0.04, 95% CI 0.00 to 0.60; participants = 74; studies = 1) and probiotics (RR 0.43, 95% CI 0.22 to 0.82; participants = 923; studies = 5; I2 = 91%) may reduce acute RT-related diarrhoea (grade 2+). Dietary counselling may also reduce diarrhoeal symptoms in the long term (at five years, RR 0.05, 95% CI 0.00 to 0.78; participants = 61; studies = 1). Low-certainty evidence from one study (108 participants) suggests that a high-fibre diet may have a beneficial effect on GI symptoms (mean difference (MD) 6.10, 95% CI 1.71 to 10.49) and quality of life (MD 20.50, 95% CI 9.97 to 31.03) at one year. High-certainty evidence indicates that glutamine supplements do not prevent RT-induced diarrhoea. Evidence on various other non-pharmacological interventions, such as green tea tablets, is lacking.Quality of life was rarely and inconsistently reported across included studies, and the available data were seldom adequate for meta-analysis. AUTHORS' CONCLUSIONS Conformal radiotherapy techniques are an improvement on older radiotherapy techniques. IMRT may be better than 3DCRT in terms of GI toxicity, but the evidence to support this is uncertain. There is no high-quality evidence to support the use of any other prophylactic intervention evaluated. However, evidence on some potential interventions shows that they probably have no role to play in reducing RT-related GI toxicity. More RCTs are needed for interventions with limited evidence suggesting potential benefits.
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Affiliation(s)
- Theresa A Lawrie
- Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group, 1st Floor Education Centre, Royal United Hospital, Combe Park, Bath, UK, BA1 3NG
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King RB, Osman SO, Fairmichael C, Irvine DM, Lyons CA, Ravi A, O'Sullivan JM, Hounsell AR, Mitchell DM, McGarry CK, Jain S. Efficacy of a rectal spacer with prostate SABR-first UK experience. Br J Radiol 2018; 91:20170672. [PMID: 29182384 DOI: 10.1259/bjr.20170672] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE This study assessed the use of implanted hydrogel rectal spacers for stereotactic ablative radiotherapy-volumetric modulated arc therapy (SABR-VMAT) patients, investigating practicality, dosimetric impact, normal tissue complication probability (NTCP) and early toxicity. METHODS Data from the first 6 patients treated within a prostate SABR and rectal spacer trial were examined to determine spacer insertion tolerability, resultant changes in treatment planning and dosimetry and early toxicity effects. CT scans acquired prior to spacer insertion were used to generate SABR plans which were compared to post-insertion plans. Plans were evaluated for target coverage, conformity, and organs at risk doses with NTCPs also determined from resultant dose fluences. Early toxicity data were also collected. RESULTS All patients had successful spacer insertion under local anaesthetic with maximal Grade 1 toxicity. All plans were highly conformal, with no significant differences in clinical target volume dose coverage between pre- and post-spacer plans. Substantial improvements in rectal dose metrics were observed in post-spacer plans, e.g. rectal volume receiving 36 Gy reduced by ≥42% for all patients. Median NTCP for Grade 2 + rectal bleeding significantly decreased from 4.9 to 0.8% with the use of a rectal spacer (p = 0.031). To date, two episodes of acute Grade 1 proctitis have been reported following treatment. CONCLUSION The spacer resulted in clinically and statistically significant reduction in rectal doses for all patients. Advances in knowledge: This is one of the first studies to investigate the efficacy of a hydrogel spacer in prostate SABR treatments. Observed dose sparing of the rectum is predicted to result in meaningful clinical benefit.
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Affiliation(s)
- Raymond B King
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Sarah Os Osman
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Ciaran Fairmichael
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Denise M Irvine
- 2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Ciara A Lyons
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland.,4 Department of Clinical Oncology, North West Cancer Centre, Altnagelvin Area Hospital , Londonderry , Northern Ireland
| | - Ananth Ravi
- 5 Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre , Toronto , Canada
| | - Joe M O'Sullivan
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Alan R Hounsell
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Darren M Mitchell
- 3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Conor K McGarry
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Suneil Jain
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
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Sexual quality of life following prostate intensity modulated radiation therapy (IMRT) with a rectal/prostate spacer: Secondary analysis of a phase 3 trial. Pract Radiat Oncol 2018; 8:e7-e15. [DOI: 10.1016/j.prro.2017.07.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 07/06/2017] [Accepted: 07/12/2017] [Indexed: 01/19/2023]
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231
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Kessler L, Gehrke S, Winnefeld M, Huber B, Hoch E, Walter T, Wyrwa R, Schnabelrauch M, Schmidt M, Kückelhaus M, Lehnhardt M, Hirsch T, Jacobsen F. Methacrylated gelatin/hyaluronan-based hydrogels for soft tissue engineering. J Tissue Eng 2017; 8:2041731417744157. [PMID: 29318000 PMCID: PMC5753891 DOI: 10.1177/2041731417744157] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 10/25/2017] [Indexed: 12/15/2022] Open
Abstract
In vitro–generated soft tissue could provide alternate therapies for soft tissue defects. The aim of this study was to evaluate methacrylated gelatin/hyaluronan as scaffolds for soft tissue engineering and their interaction with human adipose–derived stem cells (hASCs). ASCs were incorporated into methacrylated gelatin/hyaluronan hydrogels. The gels were photocrosslinked with a lithium phenyl-2,4,6-trimethylbenzoylphosphinate photoinitiator and analyzed for cell viability and adipogenic differentiation of ASCs over a period of 30 days. Additionally, an angiogenesis assay was performed to assess their angiogenic potential. After 24 h, ASCs showed increased viability on composite hydrogels. These results were consistent over 21 days of culture. By induction of adipogenic differentiation, the mature adipocytes were observed after 7 days of culture, their number significantly increased until day 28 as well as expression of fatty acid binding protein 4 and adiponectin. Our scaffolds are promising as building blocks for adipose tissue engineering and allowed long viability, proliferation, and differentiation of ASCs.
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Affiliation(s)
- Lukas Kessler
- Department of Plastic Surgery and Burn Centre, BG University Hospital Bergmannsheil GmbH, Ruhr University Bochum, Bochum, Germany
| | - Sandra Gehrke
- Research and Development, Beiersdorf AG, Hamburg, Germany
| | - Marc Winnefeld
- Research and Development, Beiersdorf AG, Hamburg, Germany
| | - Birgit Huber
- Institute for Interfacial Engineering and Plasma Technology, University of Stuttgart, Stuttgart, Germany
| | - Eva Hoch
- Institute for Interfacial Engineering and Plasma Technology, University of Stuttgart, Stuttgart, Germany
| | | | - Ralf Wyrwa
- Biomaterials Department, INNOVENT e. V., Jena, Germany
| | | | - Malte Schmidt
- Department of Plastic Surgery and Burn Centre, BG University Hospital Bergmannsheil GmbH, Ruhr University Bochum, Bochum, Germany
| | - Maximilian Kückelhaus
- Department of Plastic Surgery and Burn Centre, BG University Hospital Bergmannsheil GmbH, Ruhr University Bochum, Bochum, Germany
| | - Marcus Lehnhardt
- Department of Plastic Surgery and Burn Centre, BG University Hospital Bergmannsheil GmbH, Ruhr University Bochum, Bochum, Germany
| | - Tobias Hirsch
- Department of Plastic Surgery and Burn Centre, BG University Hospital Bergmannsheil GmbH, Ruhr University Bochum, Bochum, Germany
| | - Frank Jacobsen
- Department of Plastic Surgery and Burn Centre, BG University Hospital Bergmannsheil GmbH, Ruhr University Bochum, Bochum, Germany
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Berlin A, Di Tomasso A, Ballantyne H, Patterson S, Lam T, Sundaramurthy A, Helou J, Bayley A, Chung P. Use of hydrogel spacer for improved rectal dose-sparing in patients undergoing radical radiotherapy for localized prostate cancer: First Canadian experience. Can Urol Assoc J 2017; 11:373-375. [PMID: 29257741 DOI: 10.5489/cuaj.4681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We describe the initial experience using a hydrogel spacer (SpaceOAR) to separate the prostate-rectum interspace in patients planned to undergo radical hypofractionated, image-guided, intensity-modulated radiotherapy (IG-IMRT). We depict and discuss the impact of SpaceOAR in the context of hypofractionated IG-IMRT, and the particular considerations for its applications in the Canadian setting.
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Affiliation(s)
- Alejandro Berlin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Anne Di Tomasso
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Heather Ballantyne
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Susan Patterson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Tony Lam
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Aravind Sundaramurthy
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Joelle Helou
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Andrew Bayley
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Peter Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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233
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Placement of an absorbable rectal hydrogel spacer in patients undergoing low-dose-rate brachytherapy with palladium-103. Brachytherapy 2017; 17:251-258. [PMID: 29241706 DOI: 10.1016/j.brachy.2017.11.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/10/2017] [Accepted: 11/13/2017] [Indexed: 01/26/2023]
Abstract
PURPOSE Rates of rectal toxicity after low-dose-rate (LDR) brachytherapy for prostate cancer are dependent on rectal dose, which is associated with rectal distance from prostate and implanted seeds. Placement of a hydrogel spacer between the prostate and rectum has proven to reduce the volume of the rectum exposed to higher radiation dose levels in the setting of external beam radiotherapy. We present our findings with placing a rectal hydrogel spacer in patients following LDR brachytherapy, and we further assess the impact of this placement on dosimetry and acute rectal toxicity. METHODS AND MATERIALS Between January 2016 and April 2017, 74 patients had placement of a hydrogel spacer, immediately following a Pd-103 seed-implant procedure. Brachytherapy was delivered as follows: as a monotherapy to 26 (35%) patients; as part of planned combination therapy with external beam radiotherapy to 40 (54%) patients; or as a salvage monotherapy to eight (11%) patients. Postoperative MRI was used to assess separation achieved with rectal spacer. Acute toxicity was assessed retrospectively using Radiation Oncology Therapy Group radiation toxicity grading system. Rectal dosimetry was compared with a consecutive cohort of 136 patients treated with seed implantation at our institution without a spacer, using a 2-tailed paired Student's t test (p < 0.05 for statistical significance). RESULTS On average, 11.2-mm (SD 3.3) separation was achieved between the prostate and the rectum. The resultant mean rectal volume receiving 100% of prescribed dose (V100%), dose to 1 cc of rectum (D1cc), and dose to 2 cc of rectum (D2cc) were 0 (SD 0.05 cc), 25.3% (SD 12.7), and 20.5% (SD 9.9), respectively. All rectal dosimetric parameters improved significantly for the cohort with spacer placement as compared with the nonspacer cohort. Mean prostate volume, prostate V100 and dose to 90% of gland (D90) were 29.3 cc (SD 12.4), 94.0% (SD 3.81), and 112.4% (SD 12.0), respectively. Urethral D20, D5cc, and D1cc were 122.0% (SD 17.27), 133.8% (SD 22.8), and 144.0% (SD 25.4), respectively. After completing all treatments, at the time of first the followup, 7 patients reported acute rectal toxicity-6 experiencing Grade 1 rectal discomfort and 1 (with preexisting hemorrhoids) experiencing Grade 1 bleeding. CONCLUSIONS Injection of rectal spacer is feasible in the post-LDR brachytherapy setting and reduces dose to the rectum with minimal toxicity. Prostate and urethral dosimetries do not appear to be affected by the placement of a spacer. Further studies with long-term followup are warranted to assess the impact on reduction of late rectal toxicity.
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234
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Collery A, Forde E. Daily Rectal Dose-volume Histogram Variation in Prostate Intensity-modulated Radiation Therapy: Is It Clinically Significant in the Era of Image Guidance? J Med Imaging Radiat Sci 2017; 48:346-351. [DOI: 10.1016/j.jmir.2017.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 03/23/2017] [Accepted: 04/20/2017] [Indexed: 12/25/2022]
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235
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Padmanabhan R, Pinkawa M, Song DY. Hydrogel spacers in prostate radiotherapy: a promising approach to decrease rectal toxicity. Future Oncol 2017; 13:2697-2708. [DOI: 10.2217/fon-2017-0073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
High-dose radiation is a well-established method of treatment for prostate cancer. The main limiting structure for dose escalation is the rectum. The risk of rectal toxicity is related to dose received by the rectum. Several strategies for reducing dose to rectum have been explored; these include endorectal balloons as well as injection of rectal spacers like hydrogels. They create greater distance between rectal wall and prostate to confer a dosimetric advantage to the rectum. Early clinical studies with hydrogels have shown favorable outcomes. A low incidence of major procedural adverse effects with hydrogel use has been reported and it is well tolerated by patients. Hydrogel holds promise in establishing itself as an adjunct to standard of care in prostate radiation.
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Affiliation(s)
- Ranjani Padmanabhan
- Department of Radiation Oncology, INOVA Health System Fairfax, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Pauwelsstrasse 30, 52057 Aachen, Germany
| | - Daniel Y Song
- Johns Hopkins Medicine, Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University, 401 N Broadway, Baltimore, MD 21231, USA
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Karsh LI, Gross ET, Pieczonka CM, Aliotta PJ, Skomra CJ, Ponsky LE, Nieh PT, Han M, Hamstra DA, Shore ND. Absorbable Hydrogel Spacer Use in Prostate Radiotherapy: A Comprehensive Review of Phase 3 Clinical Trial Published Data. Urology 2017; 115:39-44. [PMID: 29174940 DOI: 10.1016/j.urology.2017.11.016] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/07/2017] [Accepted: 11/11/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To provide an update on SpaceOAR System, a Food and Drug Administration-approved hydrogel indicated to create distance between the prostate and the rectum which has been studied in phase 2 and 3 clinical trials. Here, we review and summarize these clinical results including the safety of prostate-rectum spacer application technique, the implant quality and resulting rectal dose reduction, acute and long-term rectal, urinary, and sexual toxicity, as well as patient-reported outcomes. MATERIALS AND METHODS A prospective, randomized patient-blinded clinical study was performed comparing image-guided intensity modulated prostate radiotherapy (79.2 Gy in 44 fractions) in men with or without prostate-rectum hydrogel spacer. Patients were followed up for 3 years, allowing assessment of long-term safety and efficacy. RESULTS Spacer application was well tolerated with a 99% technical success rate. The mean additional space created between the prostate and the rectum was just over 1 cm, which allowed significant rectum and penile bulb radiation dose reduction, resulting in less acute pain, lower rates of late rectal toxicity, and improved bowel and urinary quality of life (QOL) scores from 6 months onward. Improvements in sexual QOL were also observed at 37 months in baseline-potent men, with 37.5% of control and 66.7% of spacer men capable of "erections sufficient for intercourse." CONCLUSION Prostate-rectum hydrogel spacer application is a relatively safe technical procedure that is well tolerated and has a high technical success rate. Spacer application significantly reduces rectal radiation dose and results in long-term reductions in rectal toxicity, as well as improvements in bowel, urinary, and sexual QOL.
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Affiliation(s)
| | | | | | | | | | - Lee E Ponsky
- Urologic Oncology Center, University Hospitals Case Medical Center, Cleveland, OH
| | - Peter T Nieh
- Department of Urology, Emory University, Atlanta, GA
| | - Misop Han
- Department of Urology, The Johns Hopkins University, Baltimore, MD
| | - Daniel A Hamstra
- Department of Radiation Oncology, Beaumont Hospital, Dearborn, MI
| | - Neal D Shore
- Carolina Urologic Research Center, Myrtle Beach, SC.
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Vanneste BGL, van Wijk Y, Lutgens LC, Van Limbergen EJ, van Lin EN, van de Beek K, Lambin P, Hoffmann AL. Dynamics of rectal balloon implant shrinkage in prostate VMAT : Influence on anorectal dose and late rectal complication risk. Strahlenther Onkol 2017; 194:31-40. [PMID: 29038832 PMCID: PMC5752748 DOI: 10.1007/s00066-017-1222-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 09/19/2017] [Indexed: 01/20/2023]
Abstract
PURPOSE To assess the effect of a shrinking rectal balloon implant (RBI) on the anorectal dose and complication risk during the course of moderately hypofractionated prostate radiotherapy. METHODS In 15 patients with localized prostate cancer, an RBI was implanted. A weekly kilovolt cone-beam computed tomography (CBCT) scan was acquired to measure the dynamics of RBI volume and prostate-rectum separation. The absolute anorectal volume encompassed by the 2 Gy equieffective 75 Gy isodose (V75Gy) was recalculated as well as the mean anorectal dose. The increase in estimated risk of grade 2-3 late rectal bleeding (LRB) between the start and end of treatment was predicted using nomograms. The observed acute and late toxicities were evaluated. RESULTS A significant shrinkage of RBI volumes was observed, with an average volume of 70.4% of baseline at the end of the treatment. Although the prostate-rectum separation significantly decreased over time, it remained at least 1 cm. No significant increase in V75Gy of the anorectum was observed, except in one patient whose RBI had completely deflated in the third week of treatment. No correlation between mean anorectal dose and balloon deflation was found. The increase in predicted LRB risk was not significant, except in the one patient whose RBI completely deflated. The observed toxicities confirmed these findings. CONCLUSIONS Despite significant decrease in RBI volume the high-dose rectal volume and the predicted LRB risk were unaffected due to a persistent spacing between the prostate and the anterior rectal wall.
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Affiliation(s)
- Ben G L Vanneste
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands.
| | - Y van Wijk
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - L C Lutgens
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - E J Van Limbergen
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - E N van Lin
- Radiotherapy Bonn-Rhein-Sieg, Troisdorf, Germany
| | - K van de Beek
- Department of Urology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - P Lambin
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - A L Hoffmann
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
- Institute of Radiooncology - OncoRay, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Radiotherapy, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
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Development of a virtual spacer to support the decision for the placement of an implantable rectum spacer for prostate cancer radiotherapy: Comparison of dose, toxicity and cost-effectiveness. Radiother Oncol 2017; 125:107-112. [DOI: 10.1016/j.radonc.2017.07.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/12/2017] [Accepted: 07/25/2017] [Indexed: 02/06/2023]
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[Therapeutic innovations in radiation oncology for localized prostate cancer]. Cancer Radiother 2017; 21:454-461. [PMID: 28890087 DOI: 10.1016/j.canrad.2017.07.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 07/21/2017] [Accepted: 07/28/2017] [Indexed: 11/22/2022]
Abstract
Intensity-modulated radiation therapy, image-guided radiation therapy with fiducial markers and prostate brachytherapy allow the delivery of dose escalation for localized prostate cancer with very low rates of long-term toxicity and sequelae. Nowadays, modern radiotherapy techniques make it possible to shorten treatment time with hypofractionation, to better protect surrounding healthy tissues and to escalate the dose even further. Advances in radiotherapy are closely linked to advances in magnetic resonance imaging (MRI) and/or PET imaging. Functional imaging makes it possible to deliver personalised pelvic nodal radiotherapy, targeting the nodal areas at higher risk of microscopic involvement. In patients with an index lesion at baseline or at failure, MR-based focal therapy or focal dose escalation with brachytherapy or stereotactic body radiation therapy is also currently investigated. MR-based adaptive radiotherapy, which makes it possible to track prostate shifts during radiation delivery, is another step forward in the integration of MR imaging in radiation delivery.
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Damato AL, Kassick M, Viswanathan AN. Rectum and bladder spacing in cervical cancer brachytherapy using a novel injectable hydrogel compound. Brachytherapy 2017; 16:949-955. [PMID: 28619385 DOI: 10.1016/j.brachy.2017.04.236] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 03/19/2017] [Accepted: 04/13/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of this study was to evaluate injection of a novel hydrogel (TraceIT; Augmenix, Waltham, MA) between the cervix, rectum, and bladder in female cadavers compared with, and in addition to, the current standard of gauze packing, for organ-at-risk sparing in cervical cancer brachytherapy planning. METHODS AND MATERIALS This brachytherapy cadaver study used T2-weighted MRI and CT imaging to compare three scenarios: (1) gauze packing alone, (2) hydrogel injection placed in the cervical fornices and rectovaginal septum, and (3) gauze packing in conjunction with hydrogel injection. Hydrogel distribution was evaluated. Doses to 2 cm3 volumes (D2cc) for the rectum, bladder, and sigmoid were collected. Statistical significance (p < 0.05) was evaluated using a two-tailed paired t test. RESULTS Hydrogel was successfully injected to space the bladder and rectum from the cervix in all five cadavers. The spacer was easily identifiable on both CT and MRI. The use of hydrogel in addition to packing resulted in a 22% decrease in rectum D2cc dose (p = 0.02), a 10% decrease in bladder D2cc (p = 0.27), and no change in sigmoid D2cc dose. No difference was observed between hydrogel only vs. gauze packing only. CONCLUSIONS Our results revealed a significant clinically meaningful decrease in rectal D2cc associated with the use of hydrogel in addition to gauze packing-TraceIT hydrogel holds promise as a spacer in cervical cancer therapy.
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Affiliation(s)
- Antonio L Damato
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Science, Johns Hopkins Medicine, Baltimore, MD.
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Abstract
Stereotactic body radiation therapy (SBRT) has become a viable treatment option for the many patients who receive a diagnosis of localized prostate cancer each year. Technological advancements have led to tight target conformality, allowing for high-dose-per-fraction delivery without untoward normal tissue toxicity. Biochemical control, now reported up to 5 years, appears to compare favorably with dose-escalated conventionally fractionated radiotherapy. Moreover, toxicity and quality of life follow-up data indicate genitourinary and gastrointestinal toxicities are likewise comparable to conventional radiation therapy. Nevertheless, because of the long natural history of prostate cancer, extended follow-up will be necessary to confirm these impressive initial results. Within this prostate SBRT review, we explore the detailed rationale for SBRT treatment, the diverse SBRT techniques utilized and their unique technical considerations, and finally data for SBRT clinical efficacy and treatment-related toxicity.
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Singh R, Jackson PS, Blake M, Cutlip J, Sharma S. Minimal Rectal Toxicity in the Setting of Comorbid Crohn's Disease Following Prostate Cancer Radiotherapy with a Hydrogel Rectal Spacer. Cureus 2017; 9:e1533. [PMID: 28983442 PMCID: PMC5624568 DOI: 10.7759/cureus.1533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We present one of the first cases of a prostate cancer (PCa) patient with inflammatory bowel disease (IBD) treated with intensity-modulated radiotherapy (IMRT) and a hydrogel rectal spacer. A 73-year-old male with a past medical history significant for Crohn’s disease (CD) and the recent diagnosis of T1cN0M0 high-risk PCa was referred for definitive radiotherapy. Given the patient’s history of CD and the possible increased risk of gastrointestinal (GI) toxicity and disease exacerbation, prior to IMRT, a hydrogel spacer was placed between the prostate and the anterior rectal wall to further minimize irradiation to the rectum. The patient then received IMRT (78 Gy/2 Gy fractions at a 100 percent isodose line). Over the course of treatment, Radiation Therapy Oncology Group (RTOG) Grade 1 GI toxicities of mild diarrhea were noted during the fifth and sixth weeks of treatment as well as an RTOG Grade 1 genitourinary (GU) toxicity of a decrease in the urinary stream that resolved with tamsulosin. At the 3, 6, 9, and 12-month follow-ups, bowel movements and urinary stream were reported to be at baseline with prostate-specific antigen (PSA) levels of 0.18 ng/mL and 0.03 ng/mL at the three and nine-month follow-ups, respectively. As such, this case report suggests that IBD patients with localized PCa may be viable candidates for radiotherapy given the promising results of hydrogel spacers in combination with IMRT in limiting rectal toxicity.
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Affiliation(s)
- Raj Singh
- Department of Radiation Oncology, Joan C. Edwards School of Medicine, Marshall University
| | | | - Mollie Blake
- Department of Radiation Oncology, St. Mary's Medical Center
| | - James Cutlip
- Department of Radiation Oncology, St. Mary's Medical Center
| | - Sanjeev Sharma
- Department of Radiation Oncology, St. Mary's Medical Center
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Jones RT, Hassan Rezaeian N, Desai NB, Lotan Y, Jia X, Hannan R, Kim DWN, Hornberger B, Dubas J, Laine AM, Zelefsky MJ, Timmerman RD, Folkert MR. Dosimetric comparison of rectal-sparing capabilities of rectal balloon vs injectable spacer gel in stereotactic body radiation therapy for prostate cancer: lessons learned from prospective trials. Med Dosim 2017; 42:341-347. [PMID: 28774760 DOI: 10.1016/j.meddos.2017.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 05/28/2017] [Accepted: 07/03/2017] [Indexed: 11/15/2022]
Abstract
This study aimed to compare the rectal-sparing capabilities of rectal balloons vs absorbable injectable spacer gel in stereotactic body radiation therapy (SBRT) for prostate cancer. Patient samples included in this analysis were obtained from 2 multi-institutional prospective trials of SBRT for prostate cancer using a rectal balloon (n = 36 patients) and injectable spacer gel (n = 36). Treatment prescription dose was 45 Gy in 5 fractions in 42 patients; for equal comparison, the remaining 30 patients were rescaled to 45 Gy from 47.5 Gy prescription (n = 6) and 50 Gy prescription (n = 24). The median prostate volumes and body mass index in the 2 patient samples were not statistically significantly different (p= 0.67 and 0.45, respectively), supporting anatomic similarity between cohorts. The injectable spacer gel achieved dosimetric superiority over the rectal balloon with respect to the maximum dose to the rectum (42.3 vs 46.2 Gy, p < 0.001), dose delivered to 33% of the rectal circumference (28 vs 35.1 Gy, p < 0.001), and absolute volume of rectum receiving 45 Gy (V45Gy), V40Gy, and V30Gy (0.3 vs 1.7 cc, 1 vs 5.4 cc, and 4.1 vs 9.6 cc, respectively; p < 0.001 in all cases). There was no difference between the 2 groups with respect to the V50Gy of the rectum or the dose to 50% of the rectal circumference (p= 0.29 and 0.06, respectively). The V18.3Gy of the bladder was significantly larger with the rectal balloon (19.9 vs 14.5 cc, p= 0.003). In this analysis of patients enrolled on 2 consecutive multi-institutional prospective trials of SBRT for prostate cancer, the injectable spacer gel outperformed the rectal balloon in the majority of the examined and relevant dosimetric rectal-sparing parameters. The rectal balloon did not outperform the injectable spacer gel in any measured rectal dose parameter.
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Affiliation(s)
- Ryan T Jones
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nima Hassan Rezaeian
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Neil B Desai
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yair Lotan
- Department of Radiation Urology, Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Xun Jia
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Raquibul Hannan
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - D W Nathan Kim
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brad Hornberger
- Department of Radiation Urology, Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeffrey Dubas
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Aaron M Laine
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert D Timmerman
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael R Folkert
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Guimas V, Quivrin M, Bertaut A, Martin E, Chambade D, Maingon P, Mazoyer F, Cormier L, Créhange G. Focal or whole-gland salvage prostate brachytherapy with iodine seeds with or without a rectal spacer for postradiotherapy local failure: How best to spare the rectum? Brachytherapy 2017; 15:406-411. [PMID: 27317949 DOI: 10.1016/j.brachy.2016.03.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 03/31/2016] [Accepted: 03/31/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE Salvage prostate permanent implant (sPPI) for postradiation local failure provides high rates of biochemical control. The cumulative dose delivered to the prostate and the rectum is still unknown. METHODS AND MATERIALS We reviewed the postimplant CT-based dosimetry of 18 selected patients who underwent sPPI with (125)I seeds for isolated biopsy-proven local failure several years after external beam radiation therapy. Ten patients had whole-prostate sPPI, and 8 patients had multiparametric MRI-based focal sPPI. In 8 patients, hyaluronic acid (HA) gel was injected into the prostate-rectum space. RESULTS The median cumulative biological effective dose after EBRT + sPPI for the prostate and the rectum was higher in patients treated with whole-gland sPPI than in patients treated with focal sPPI (313.5 Gy2 vs. 174.4 Gy2; p = 0.06 and 258.1 Gy3 vs. 172.6 Gy3; p < 0.01, respectively). The median D0.1cc for the rectum was significantly lower in patients who had HA gel: 63.3 Gy (29.0-78.3) vs. 83.9 Gy (34.9-180.0) (p = 0.04). CONCLUSIONS Cumulative prostate and rectum biological effective doses were lower with focal sPPI. D0.1cc delivered to the rectum was significantly lower with HA gel, while there was no difference between focal or whole-gland plans.
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Affiliation(s)
- Valentine Guimas
- Department of Radiation Oncology, Centre Georges François Leclerc, University of Burgundy, Dijon, Burgundy, France
| | - Magali Quivrin
- Department of Radiation Oncology, Centre Georges François Leclerc, University of Burgundy, Dijon, Burgundy, France; Medical Imaging Group, IMAC CNRS 6306, University of Burgundy, Dijon, Burgundy, France
| | - Aurélie Bertaut
- Department of Biostatistics, Centre Georges François Leclerc, University of Burgundy, Dijon, Burgundy, France
| | - Etienne Martin
- Department of Radiation Oncology, Centre Georges François Leclerc, University of Burgundy, Dijon, Burgundy, France
| | - Damien Chambade
- Department of Radiation Oncology, Centre Georges François Leclerc, University of Burgundy, Dijon, Burgundy, France
| | - Philippe Maingon
- Department of Radiation Oncology, Centre Georges François Leclerc, University of Burgundy, Dijon, Burgundy, France
| | - Frédéric Mazoyer
- Department of Radiation Oncology, Centre Georges François Leclerc, University of Burgundy, Dijon, Burgundy, France
| | - Luc Cormier
- Department of Urology, University Hospital François Mitterand, Dijon, France
| | - Gilles Créhange
- Department of Radiation Oncology, Centre Georges François Leclerc, University of Burgundy, Dijon, Burgundy, France; Medical Imaging Group, IMAC CNRS 6306, University of Burgundy, Dijon, Burgundy, France.
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Pinkawa M, Berneking V, Schlenter M, Krenkel B, Eble MJ. Quality of Life After Radiation Therapy for Prostate Cancer With a Hydrogel Spacer: 5-Year Results. Int J Radiat Oncol Biol Phys 2017; 99:374-377. [PMID: 28871986 DOI: 10.1016/j.ijrobp.2017.05.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/16/2017] [Accepted: 05/22/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE To evaluate quality of life changes up to 5 years after prostate cancer radiation therapy (RT) with a hydrogel spacer. METHODS AND MATERIALS In the years 2010 to 2011, 114 patients received external beam radiation therapy to the prostate; 54 patients were selected for a hydrogel injection before the beginning of RT. Treatment was performed applying fractions of 2 Gy up to a total dose of 76 Gy (n=96) or 78 Gy (n=18, all with hydrogel). Patients were surveyed before RT; at the last day of RT; and a median time of 2 months, 17 months, and 63 months after RT using a validated questionnaire (Expanded Prostate Cancer Index Composite). A mean score change of >5 points was defined as clinically relevant. RESULTS For patients treated with a hydrogel spacer, mean bowel function and bother score changes of >5 points in comparison with baseline levels were found only at the end of RT (10-15 points; P<.01). No spacer patient reported moderate or big problems with his bowel habits overall. Mean bother score changes of 21 points at the end of RT, 8 points at 2 months, 7 points at 17 months, and 6 points at 63 months after RT were found for patients treated without a spacer. A bowel bother score change >10 points was found in 6% versus 32% (P<.01) at 17 months and in 5% versus 14% (P=.2) at 63 months with versus without a spacer. CONCLUSIONS The first 5-year quality of life results in a group of prostate cancer patients treated with a hydrogel spacer demonstrate excellent treatment tolerability, in particular regarding bowel problems. Further studies with dose-escalated or re-irradiation concepts can be encouraged.
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Affiliation(s)
- Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany; Department of Radiation Oncology, MediClin Robert Janker Klinik, Bonn, Germany.
| | - Vanessa Berneking
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany
| | - Marsha Schlenter
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany
| | - Barbara Krenkel
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany
| | - Michael J Eble
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany
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Hydrogel spacer distribution within the perirectal space in patients undergoing radiotherapy for prostate cancer: Impact of spacer symmetry on rectal dose reduction and the clinical consequences of hydrogel infiltration into the rectal wall. Pract Radiat Oncol 2017; 7:195-202. [DOI: 10.1016/j.prro.2016.10.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/10/2016] [Accepted: 10/12/2016] [Indexed: 11/21/2022]
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Paydar I, Pepin A, Cyr RA, King J, Yung TM, Bullock EG, Lei S, Satinsky A, Harter KW, Suy S, Dritschilo A, Lynch JH, Kole TP, Collins SP. Intensity-Modulated Radiation Therapy with Stereotactic Body Radiation Therapy Boost for Unfavorable Prostate Cancer: A Report on 3-Year Toxicity. Front Oncol 2017; 7:5. [PMID: 28224113 PMCID: PMC5293802 DOI: 10.3389/fonc.2017.00005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 01/05/2017] [Indexed: 12/16/2022] Open
Abstract
Background Recent data suggest that intensity-modulated radiation therapy (IMRT) plus brachytherapy boost for unfavorable prostate cancer provides improved biochemical relapse-free survival over IMRT alone. Stereotactic body radiation therapy (SBRT) may be a less invasive alternative to brachytherapy boost. Here, we report the 3-year gastrointestinal (GI) and genitourinary (GU) toxicities of IMRT plus SBRT boost. Materials and methods Between March 2008 and September 2012, patients with prostate cancer were treated with robotic SBRT (19.5 Gy in three fractions) followed by fiducial-guided IMRT (45–50.4 Gy) on an institutional protocol. Toxicity was prospectively graded using the common terminology criteria for adverse events version 4.0 (CTCAEv.4) at the start of and at 1- to 6-month intervals after therapy. Rectal telangiectasias were graded using the Vienna Rectoscopy Score (VRS). Results At a median follow-up of 4.2 years (2.4–7.5), 108 patients (4 low-, 45 intermediate-, and 59 high-risk) with a median age of 74 years (55–92) were treated with SBRT plus IMRT, with 8% on anticoagulation and an additional 48% on antiplatelet therapy at the start of therapy. The cumulative incidence of late ≥grade 2 GI toxicity was 12%. Of these, 7% were due to late rectal bleeding, with six patients requiring up to two coagulation procedures. One patient with rectal telangiectasias was treated with hyperbaric oxygen (grade 3 toxicity). No rectal fistulas or stenoses were observed. Ten patients had multiple non-confluent telangiectasias (VRS grade 2), and three patients had multiple confluent telangiectasias (VRS grade 3). The cumulative incidence of late grade 3 GU toxicity was 6%. Most late toxicities were due to hematuria requiring bladder fulguration. There were no late ≥grade 4 GU toxicities. Conclusion Rates of clinically significant GI and GU toxicities are modest following IMRT plus SBRT boost. Future studies should compare cancer control, quality of life, and toxicity with other treatment modalities for patients with high-risk prostate cancer.
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Affiliation(s)
- Ima Paydar
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | | | - Robyn A Cyr
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Joseph King
- University of South Carolina School of Medicine , Columbia, SC , USA
| | - Thomas M Yung
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Elizabeth G Bullock
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Andrew Satinsky
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - K William Harter
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Anatoly Dritschilo
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - John H Lynch
- Department of Urology, Georgetown University Hospital , Washington, DC , USA
| | - Thomas P Kole
- Department of Radiation Oncology, The Valley Hospital , Ridgewood, NJ , USA
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
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Te Velde BL, Westhuyzen J, Awad N, Wood M, Shakespeare TP. Can a peri-rectal hydrogel spaceOAR programme for prostate cancer intensity-modulated radiotherapy be successfully implemented in a regional setting? J Med Imaging Radiat Oncol 2017; 61:528-533. [PMID: 28151584 DOI: 10.1111/1754-9485.12580] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/11/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The aim of this study was to investigate whether the implementation of a hydrogel spacer (SpaceOAR) programme for patients treated with 81 Gy prostate intensity-modulated radiotherapy (IMRT) in a regional setting can reduce rectal doses and toxicity. METHODS In this retrospective study, 125 patients with localised prostate cancer treated between April 2014 (programme commencement) and June 2015 were compared: 65 with SpaceOAR (inserted by five different urologists) and 60 patients treated over the same time period without SpaceOAR. Patients were treated with 81 Gy in 45Fx of IMRT over 9 weeks. Planning aims included restricting rectal doses to V40 Gy < 35%, V65 Gy < 17%, V75 Gy < 10%. Acute toxicity was assessed weekly during radiotherapy and at 12 weeks. RESULTS Rectal volume parameters were all significantly lower in the SpaceOAR group, with an associated reduction in acute diarrhoea (13.8% vs 31.7%). There were no significant differences in the very low rates of acute and late faecal incontinence or proctitis, however, there was a trend towards increased haemorrhoid rate in the SpaceOAR group (11.7% vs 3.1%, P = 0.09). CONCLUSION A SpaceOAR programme in a regional setting with urologists performing low volumes of insertions (<1 per month on average) is of clinical benefit, and was associated with significantly lower radiation doses to the rectum and lower rates of acute diarrhoea.
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Affiliation(s)
- Bridget L Te Velde
- Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Justin Westhuyzen
- Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Nader Awad
- Radiation Oncology, Mid-North Coast Cancer Institute, Port Macquarie, New South Wales, Australia
| | - Maree Wood
- Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Thomas P Shakespeare
- Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
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