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Achard V, Zilli T, Lamanna G, Jorcano S, Bral S, Rubio C, Oliveira A, Bottero M, Bruynzeel AME, Ibrahimov R, Minn H, Symon Z, Constantin G, Miralbell R. Urethra-Sparing Prostate Cancer Stereotactic Body Radiation Therapy: Sexual Function and Radiation Dose to the Penile Bulb, the Crura, and the Internal Pudendal Arteries From a Randomized Phase 2 Trial. Int J Radiat Oncol Biol Phys 2024; 119:1137-1146. [PMID: 38160915 DOI: 10.1016/j.ijrobp.2023.12.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/17/2023] [Accepted: 12/23/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE Erectile dysfunction (ED) is a common side effect after prostate cancer stereotactic body radiation therapy (SBRT). We aimed to assess the correlation between the dose to the penile bulb (PB), internal pudendal arteries (IPA), and crura with the development of ED after ultrahypofractionation as part of a phase 2 clinical trial of urethra-sparing prostate SBRT. METHODS AND MATERIALS Among the 170 patients with localized prostate cancer from 9 centers included in the trial, 90 men with Common Terminology Criteria for Adverse Events version 4.03 grade 0 to 1 ED (ED-) at baseline treated with 36.25 Gy in 5 fractions were selected for the present analysis. Doses delivered to the PB, crura, and IPA were analyzed and correlated with grade 2 to 3 ED (ED+) development. The effect on quality of life, assessed by the European Organisation for Research and Treatment of Cancer (EORTC QLQ-PR25) questionnaire, was reported. RESULTS After a median follow-up of 6.5 years, 43% (n = 39) of the patients developed ED+, and 57% (n = 51) remained ED-. The dose delivered to the crura was significantly higher in ED+ patients than in ED- patients (7.7 vs 3.6 Gy [P = .014] for the Dmean and 18.5 vs 7.2 Gy [P = .015] for the D2%, respectively). No statistically significant difference between ED+ and ED- patients was observed for the dose delivered to the PB and IPA. The median ED+-free survival was worse in patients receiving a crura Dmean ≥ 4.7 versus < 4.7 Gy (51.5% vs 71.7%, P = .005) and a crura D2% > 12 versus ≤ 12 Gy (54.9% vs 68.9%, P = .015). No ED+-free survival differences were observed for doses delivered to the PB and IPA. Decline in EORTC QLQ-PR25 sexual functioning was significantly more pronounced in patients with higher doses to the crura. CONCLUSIONS By keeping a Dmean and D2% to crura below 4.7 and 12 Gy, respectively, the risk of developing ED+ after prostate SBRT may be significantly reduced.
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Affiliation(s)
- Vérane Achard
- Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Radiation Oncology, HFR Fribourg, Villars-sur-Glâne, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Thomas Zilli
- Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland; Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), Bellinzona, Switzerland; Faculty of Medicine, Università della Svizzera Italiana, Lugano, Switzerland.
| | - Giorgio Lamanna
- Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Radiation Oncology, HFR Fribourg, Villars-sur-Glâne, Switzerland
| | - Sandra Jorcano
- Radiation Oncology, Teknon Oncologic Institute, Barcelona, Spain
| | - Samuel Bral
- Radiation Oncology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
| | - Carmen Rubio
- Radiation Oncology, Hospital Universitario Sanchinarro, Madrid, Spain
| | - Angelo Oliveira
- Radiation Oncology, Portuguese Institut of Oncology, Porto, Portugal
| | - Marta Bottero
- Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Anna M E Bruynzeel
- Radiation Oncology, Amsterdam UMC, Location Vrije Universteit, Amsterdam, The Netherlands
| | - Roman Ibrahimov
- Radiation Oncology, Neolife Medical Center, Istanbul, Turkey
| | - Heikki Minn
- Radiation Oncology, University Hospital Turku, Turku, Finland
| | - Zvi Symon
- Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Raymond Miralbell
- Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland; Radiation Oncology, Teknon Oncologic Institute, Barcelona, Spain
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2
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Galienne M, Risbourg S, Lacornerie T, Taillez A, Lartigau E, Barthoulot M, Pasquier D. Extreme hypofractionated stereotactic radiotherapy for localized prostate Cancer: Efficacy and late urinary toxicity according to transurethral resection of the prostate history. Clin Transl Radiat Oncol 2024; 46:100779. [PMID: 38681137 PMCID: PMC11047194 DOI: 10.1016/j.ctro.2024.100779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/08/2024] [Accepted: 04/17/2024] [Indexed: 05/01/2024] Open
Abstract
Background and purpose Extreme hypofractionated stereotactic body radiotherapy (SBRT) is a therapeutic alternative for localized low- or intermediate-risk prostate cancer. Despite the availability of several studies, the toxicity profile of SBRT has not been comprehensively described. This real-world evidence study assessed the efficacy and toxicities associated with this regimen, and potential prognosis factors for genitourinary toxicities. Materials and methods This retrospective study included 141 consecutive patients with localized prostatic adenocarcinoma treated with CyberKnife™ SBRT, as primary irradiation, at the Oscar Lambret Center between 2010 and 2020. The prescribed dose was 36.25 Gy in 5 fractions. Acute and late toxicities were graded according to the CTCAE (version 5.0). Biochemical recurrence-free survival (bRFS) and overall survival (OS) were estimated using the Kaplan-Meier method. The cumulative incidence of biochemical recurrence (cBR) was estimated using the Kalbfleisch-Prentice method. Results Among the included patients, 13.5 % had a history of transurethral resection of the prostate (TURP). The median follow-up was 48 months. At 5 years, bRFS, cBR, and OS were 72 % (95 %CI: 61-81), 7 % (95 %CI: 3-14), and 82 % (95 %CI: 73-89), respectively. Twenty-nine patients experienced at least one late toxicity of grade ≥ 2; genitourinary (N = 29), including 3 cases of chronic hematuria, and/or gastrointestinal (N = 1). The cumulative incidence of late urinary toxicity of grade ≥ 2 was 20.6 % at 5 years (95 %CI: 13.9-28.1). Multivariate analysis revealed that a history of TURP was significantly associated with late urinary toxicity of grade ≥ 2, after adjusting for clinical target volume (Odds Ratio = 3.06; 95%CI: 1.05-8.86; P = 0.04). Conclusion Extreme hypofractionated SBRT is effective for localized prostate cancer with a low risk of late toxicity. A history of TURP is associated with a higher risk of late urinary toxicity. These findings may contribute to the optimal management of patients treated with this regimen, particularly those with a history of TURP.
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Affiliation(s)
- Maxime Galienne
- University of Picardie Jules Verne, Amiens, France
- Department of Radiotherapy, Amiens-Picardie University Hospital (South Site), Amiens, France
| | - Séverine Risbourg
- Department of Methodology and Biostatistics, Oscar Lambret Center, Clinical Research and Innovation Directorate, Lille, France
| | | | | | - Eric Lartigau
- Department of Radiotherapy, Oscar Lambret Center, Lille, France
- University of Lille & CRIStAL (Research Center in Computer Science, Signal and Automatic Control of Lille ((UMR 9189), Lille, France
| | - Maël Barthoulot
- Department of Methodology and Biostatistics, Oscar Lambret Center, Clinical Research and Innovation Directorate, Lille, France
| | - David Pasquier
- Department of Radiotherapy, Oscar Lambret Center, Lille, France
- University of Lille & CRIStAL (Research Center in Computer Science, Signal and Automatic Control of Lille ((UMR 9189), Lille, France
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3
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Gomez-Iturriaga A, Büchser D, Lopez-Campos F, Maldonado X. Enhancing Androgen Deprivation Therapy (ADT) integration in prostate cancer: Insights for Stereotactic Body Radiotherapy (SBRT) and brachytherapy modalities. Clin Transl Radiat Oncol 2024; 45:100733. [PMID: 38322544 PMCID: PMC10844661 DOI: 10.1016/j.ctro.2024.100733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/17/2024] [Accepted: 01/21/2024] [Indexed: 02/08/2024] Open
Abstract
The utilization of Androgen Deprivation Therapy (ADT) in conjunction with Stereotactic Body Radiotherapy (SBRT) and Brachytherapy (BT) boost in prostate cancer treatment is a subject of ongoing debate and evolving clinical practice. While contemporary trends lean towards underutilizing ADT with these modalities, existing evidence suggests that its omission may lead to potentially inferior oncologic outcomes. Recommendations for ADT use should be patient-centric, considering individual risk profiles and comorbidities, with a focus on achieving optimal oncologic outcomes while minimizing potential side effects. Ongoing clinical trials, such as PACE-C, SPA, SHIP 0804, and SHIP 36B, are anticipated to provide valuable insights into the optimal use and duration of ADT in both SBRT and BT settings. Until new evidence emerges, it is recommended to initiate ADT for unfavorable intermediate-risk and high-risk prostate cancer patients undergoing radiotherapy, with a minimum duration of 6 months for unfavorable intermediate-risk patients and at least 12 months for those with high-risk characteristics. The decision to incorporate ADT into these radiation therapy modalities should be individualized, acknowledging the unique needs of each patient and emphasizing a tailored approach to achieve the best possible oncologic outcomes.
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Affiliation(s)
- A. Gomez-Iturriaga
- Hospital Universitario Cruces/ Biobizkaia Health Research Institute, Radiation Oncology, Barakaldo, Spain
- Department of Surgery and Radiology and Physical Medicine, University of the Basque Country UPV/EHU, Spain
| | - D. Büchser
- Hospital Universitario Cruces/ Biobizkaia Health Research Institute, Radiation Oncology, Barakaldo, Spain
- Department of Surgery and Radiology and Physical Medicine, University of the Basque Country UPV/EHU, Spain
| | - F. Lopez-Campos
- Hospital Universitario Ramon y Cajal, Radiation Oncology, Madrid, Spain
| | - X. Maldonado
- Hospital Vall d́Hebron, Radiation Oncology, Barcelona, Spain
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Ong WL, Allan Hupman M, Davidson M, Ruschin M, Detsky J, Liu S, Vesprini D, Loblaw A. Urethra contouring on computed tomography urethrogram versus magnetic resonance imaging for stereotactic body radiotherapy in prostate cancer. Clin Transl Radiat Oncol 2024; 45:100722. [PMID: 38234697 PMCID: PMC10792737 DOI: 10.1016/j.ctro.2023.100722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/24/2023] [Accepted: 12/30/2023] [Indexed: 01/19/2024] Open
Abstract
Accurate urethra contouring is critical in prostate SBRT. We compared urethra contouring on CT-urethrogram and T2-weighted MRI. The dice similarity coefficient, Jaccard index, Hausdorff distance and mean distance to agreement were evaluated. All four metrics indicate better agreement and less variability in urethra contouring on CT-urethrogram, compared to T2-weighted MRI.
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Affiliation(s)
- Wee Loon Ong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
- Alfred Health Radiation Oncology, Monash University, Melbourne, Australia
| | - M. Allan Hupman
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Mark Ruschin
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Jay Detsky
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Stanley Liu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Danny Vesprini
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
- Department of Health Policy, Measurement and Evaluation, University of Toronto, Canada
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Ma TM, Ladbury C, Tran M, Keiper TD, Andraos T, Gogineni E, Mohideen N, Siva S, Loblaw A, Tree AC, Cheung P, Kresl J, Collins S, Cao M, Kishan AU. Stereotactic Body Radiation Therapy: A Radiosurgery Society Guide to the Treatment of Localized Prostate Cancer Illustrated by Challenging Cases. Pract Radiat Oncol 2024; 14:e117-e131. [PMID: 37661040 DOI: 10.1016/j.prro.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/02/2023] [Accepted: 08/22/2023] [Indexed: 09/05/2023]
Abstract
Traditionally, external beam radiotherapy (EBRT) for localized prostate cancer (PCa) involved lengthy courses with low daily doses. However, advancements in radiation delivery and a better understanding of prostate radiobiology have enabled the development of shorter courses of EBRT. Ultrahypofractionated radiotherapy, administering doses greater than 5 Gy per fraction, is now considered a standard of care regimen for localized PCa, particularly for intermediate-risk disease. Stereotactic body radiotherapy (SBRT), a specific type of ultrahypofractionated radiotherapy employing advanced planning, imaging, and treatment technology to deliver in five or fewer fractions, is gaining prominence as a cost-effective, convenient, and safe alternative to longer radiotherapy courses. It is crucial to address practical considerations related to patient selection, fractionation scheme, target delineation, and planning objectives. This is especially important in challenging clinical situations where clear evidence for guidance may be lacking. The Radiosurgery Society endorses this case-based guide with the aim of providing a practical framework for delivering SBRT to the intact prostate, exemplified by two case studies. The article will explore common SBRT dose/fractionation schemes and dose constraints for organs-at-risk. Additionally, it will review existing evidence and expert opinions on topics such as SBRT dose escalation, the use of rectal spacers, the role of androgen deprivation therapy in the context of SBRT, SBRT in special patient populations (e.g., high-risk disease, large prostate, high baseline urinary symptom burdens, and inflammatory bowel disease), as well as new imaging-guidance techniques like Magnetic Resonance Imaging for SBRT delivery.
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Affiliation(s)
- Ting Martin Ma
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Colton Ladbury
- Department of Radiation Oncology, City of Hope National Cancer Center, Duarte, California
| | - Maxwell Tran
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, South Carolina
| | - Timothy D Keiper
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California
| | - Therese Andraos
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Emile Gogineni
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Najeeb Mohideen
- Department of Radiation Oncology, Northwest Community Hospital, Arlington Heights, Illinois
| | - Shankar Siva
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Loblaw
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, United Kingdom
| | - Patrick Cheung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada
| | - John Kresl
- Phoenix CyberKnife and Radiation Oncology Center, Phoenix, Arizona
| | - Sean Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, D.C
| | - Minsong Cao
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California; Department of Urology, University of California Los Angeles, Los Angeles, California.
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Mathier E, Althaus A, Zwahlen D, Lustenberger J, Zamboglou C, De Bari B, Aebersold DM, Guckenberger M, Zilli T, Shelan M. HypoFocal SRT Trial: Ultra-hypofractionated focal salvage radiotherapy for isolated prostate bed recurrence after radical prostatectomy; single-arm phase II study; clinical trial protocol. BMJ Open 2024; 14:e075846. [PMID: 38296279 PMCID: PMC10828884 DOI: 10.1136/bmjopen-2023-075846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 01/08/2024] [Indexed: 02/03/2024] Open
Abstract
INTRODUCTION Despite radical prostatectomy (RP) and radiotherapy (RT) being established treatments for localised prostate cancer, a significant number of patients experience recurrent disease. While conventionally fractionated RT is still being used as a standard treatment in the postoperative setting, ultra-hypofractionated RT has emerged as a viable option with encouraging results in patients with localised disease in the primary setting. In addition, recent technological advancements in RT delivery and precise definition of isolated macroscopic recurrence within the prostate bed using prostate-specific membrane antigen-positron emission tomography (PSMA-PET) and multiparametric MRI (mpMRI) allow the exploration of ultra-hypofractionated schedules in the salvage setting using five fractions. METHODS AND ANALYSIS In this single-arm prospective phase II multicentre trial, 36 patients with node-negative prostate adenocarcinoma treated with RP at least 6 months before trial registration, tumour stage pT2a-3b, R0-1, pN0 or cN0 according to the UICC TNM 2009 and evidence of measurable local recurrence within the prostate bed detected by PSMA PET/CT and mpMRI within the last 3 months, will be included. The patients will undergo focal ultra-hypofractionated salvage RT with 34 Gy in five fractions every other day to the site of local recurrence in combination with 6 months of androgen deprivation therapy. The primary outcome of this study is biochemical relapse-free survival at 2 years. Secondary outcomes include acute side effects (until 90 days after the end of RT) of grade 3 or higher based on Common Terminology Criteria for Adverse Events V.5, progression-free survival, metastasis-free survival, late side effects and the quality of life (based on European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30, QLQ-PR25). ETHICS AND DISSEMINATION The study has received ethical approval from the Ethics Commission of the Canton of Bern (KEK-BE 2022-01026). Academic dissemination will occur through publications and conference presentations. TRIAL REGISTRATION NUMBER NCT05746806.
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Affiliation(s)
- Etienne Mathier
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Althaus
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Zwahlen
- Department of Radiation Oncology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Jens Lustenberger
- Department of Radiation Oncology, University Hospital Basel, Basel, Switzerland
| | | | - Berardino De Bari
- Department of Radiation Oncology, Réseau hospitalier neuchâtelois, Neuchatel, Switzerland
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Thomas Zilli
- Department of Radiation Oncology, Oncological Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
- Università della Svizzera italiana, Lugano, Switzerland
| | - Mohamed Shelan
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Schröder C, Mose L, Mathier E, Zwahlen DR, Aebersold DM, Förster R, Shelan M. Five Fractions versus Seven Fractions SBRT for Intermediate- and High-Risk Prostate Cancer: A Propensity Score Matched Pair Analysis. Cancers (Basel) 2023; 15:5815. [PMID: 38136360 PMCID: PMC10741876 DOI: 10.3390/cancers15245815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/07/2023] [Accepted: 12/09/2023] [Indexed: 12/24/2023] Open
Abstract
PURPOSE To compare two stereotactic body radiotherapy (SBRT) regimens in patients with intermediate- or high-risk prostate cancer with regards toxicity and efficacy. METHODS/MATERIAL We retrospectively collected data from 198 patients treated with SBRT for prostate cancer at two different institutions. Patients received either 35-36.25 Gy in five fractions (group A) using Cyberknife robotic platform or 42.7 Gy in seven fractions (group B) using a C-arm LINAC (image-guided). Propensity score matching was done (2:1 nearest neighbor matching without replacement), resulting in 120 patients (80 patients for group A, 40 patients for group B). Toxicity, PSA nadir, biochemical failure and disease-free survival (DFS) were analyzed. RESULTS Median follow up of all patients was 13 months (range 1-91 months). Overall, 23.3% of patients had ≥G2 acute GU toxicity (21.1% group A versus 30% group B (p = 0.222)) and 6.6% of patients ≥G2 GI toxicity (2.5% versus 15% (p = 0.010)). There was one acute G3 GU toxicity in arm A and one acute G4 rectal bleeding in group B (anticoagulated patient). Regarding late toxicity, 14.1% of patients had ≥G2 late GU toxicity (17.4% versus 6.6% (p = 0.159)) and 5.0% of patients had ≥G2 late GI toxicity (1.4% versus 13.3% (p = 0.013)). There was one G3 late GU toxicity in arm B and two G3 late GI toxicities, one in each arm. Relative median PSA reduction was 92.4% (-53.9-99.9%) from baseline PSA (93.7% (-53.9-99.9%) in group A versus 87.7% (39.8-99.9%) in group B (p = 0.043). In total, 4.2% of patients had biochemical relapse, 5.0% in group A and 2.5% in group B (p = 0.518). One-year DFS in the overall cohort was 97.3%, 98.8% in group A and 94.3% in group B (p = 0.318). CONCLUSION Both SBRT regimens have acceptable acute and late toxicity and good efficacy. There are significantly more GI toxicities in the seven-fraction regimen. Longer follow-up is warranted for better comparison of long-term efficacy.
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Affiliation(s)
- Christina Schröder
- Department of Radiation Oncology, Cantonal Hospital Winterthur, 8400 Winterthur, Switzerland
| | - Lucas Mose
- Department of Radiation Oncology, Inselspital/Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland; (L.M.); (M.S.)
| | - Etienne Mathier
- Department of Radiation Oncology, Inselspital/Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland; (L.M.); (M.S.)
| | - Daniel Rudolf Zwahlen
- Department of Radiation Oncology, Cantonal Hospital Winterthur, 8400 Winterthur, Switzerland
| | - Daniel Matthias Aebersold
- Department of Radiation Oncology, Inselspital/Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland; (L.M.); (M.S.)
| | - Robert Förster
- Department of Radiation Oncology, Cantonal Hospital Winterthur, 8400 Winterthur, Switzerland
| | - Mohamed Shelan
- Department of Radiation Oncology, Inselspital/Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland; (L.M.); (M.S.)
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Zilli T, Jorcano S, Bral S, Symon Z, Rubio C, Bruynzeel AME, Ibrahimov R, Minn H, Oliveira A, Bertaut A, Constantin G, Miralbell R. Every-Other-Day Versus Once-a-Week Urethra-Sparing Prostate Stereotactic Body Radiation Therapy: 5-Year Results of a Randomized Phase 2 Trial. Int J Radiat Oncol Biol Phys 2023; 117:791-798. [PMID: 37001763 DOI: 10.1016/j.ijrobp.2023.03.057] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE The objective of this study was to present the 5-year results from a prospective, multicenter, phase 2 randomized trial of every-other-day (EOD) versus once-a-week (QW) urethra-sparing stereotactic body radiation therapy for localized prostate cancer. METHODS AND MATERIALS Between 2012 and 2015, 170 patients with cT1c-3aN0M0 prostate cancer from 9 European institutions were randomized to 36.25 Gy in 5 fractions (6.5 Gy/fraction to the urethra) delivered either EOD (arm A, n = 84) or QW (arm B, n = 86). The median follow-up was 78 months (interquartile range, 66-89 months) and 77 months (interquartile range, 66-82 months) for arms A and B, respectively. RESULTS Among the 165 patients treated and retained for the final analysis (arm A, n = 82; arm B, n = 83), acute toxicity (National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03 scale) was mild or absent, with no differences between arms. The 5-year grade 2 or greater genitourinary toxicity-free survival was 75.9% and 76.1% for arms A and B, respectively (P = .945), whereas the 5-year grade 2 or greater gastrointestinal toxicity-free survival was 89% and 92% for arms A and B, respectively (P = .596). No changes in European Organisation for Research and Treatment of Cancer QLQ-PR25 scores were observed in both arms for genitourinary, gastrointestinal, and sexual domains at 5-year follow-up compared with baseline. At the last follow-up, biochemical failure was observed in 14 patients in the EOD arm and in 7 patients in the QW arm, with a 5-year biochemical relapse-free survival rate of 92.2% and 93% for arms A and B, respectively (P = .13). CONCLUSIONS Stereotactic body radiation therapy for prostate cancer with a 10% dose reduction to urethra was associated with a minimal effect on urinary function and quality of life regardless of an EOD or QW fractionation schedule. Biochemical control so far has been encouraging and much alike in both study arms, although longer follow-up is probably needed to assess the true value of overall treatment time on disease outcome.
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Affiliation(s)
- Thomas Zilli
- Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland; Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), Bellinzona, Switzerland.
| | - Sandra Jorcano
- Radiation Oncology, Teknon Oncologic Institute, Barcelona, Spain
| | - Samuel Bral
- Radiation Oncology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
| | - Zvi Symon
- Radiation Oncology, Sheba Medical Center, Ramat Gan, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Carmen Rubio
- Radiation Oncology, Hospital Universitario Sanchinarro, Madrid, Spain
| | - Anna M E Bruynzeel
- Radiation Oncology, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Roman Ibrahimov
- Radiation Oncology, Neolife Medical Center, Istanbul, Turkey
| | - Heikki Minn
- Radiation Oncology, University Hospital Turku, Turku, Finland
| | - Angelo Oliveira
- Radiation Oncology, Portuguese Institut of Oncology, Porto, Portugal
| | - Aurélie Bertaut
- Methodology and Biostatistics, Centre Georges-François-Leclerc, Dijon, France
| | | | - Raymond Miralbell
- Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland; Radiation Oncology, Teknon Oncologic Institute, Barcelona, Spain
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Ong WL, Davidson M, Cheung P, Chung H, Chu W, Detsky J, Liu S, Morton G, Szumacher E, Tseng CL, Vesprini D, Ravi A, McGuffin M, Zhang L, Mamedov A, Deabreu A, Kulasingham-Poon M, Loblaw A. Dosimetric correlates of toxicities and quality of life following two-fraction stereotactic ablative radiotherapy (SABR) for prostate cancer. Radiother Oncol 2023; 188:109864. [PMID: 37619656 DOI: 10.1016/j.radonc.2023.109864] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE There is no evidence-based data to guide dose constraints in two-fraction prostate stereotactic ablative radiotherapy (SABR). Using individual patient-data from two prospective trials, we aimed to correlate dosimetric parameters with toxicities and quality of life (QoL) outcomes. MATERIALS AND METHODS We included 60 patients who had two-fraction prostate SABR in the 2STAR (NCT02031328) and 2SMART (NCT03588819) trials. The prescribed dose was 26 Gy to the prostate+/-32 Gy boost to the dominant intraprostatic lesions. Toxicities and QoL data were prospectively collected using CTCAEv4 and EPIC-26 questionnaire. The outcomes evaluated were acute and late grade ≥ 2 toxicities, and late minimal clinical important changes (MCIC) in QoL domains. Dosimetric parameters for bladder, urethra, rectum, and penile bulb were evaluated. RESULTS The median follow-up was 56 months (range: 39-78 months). The cumulative incidence of grade ≥ 2 genitourinary (GU), gastrointestinal (GI), and sexual toxicities were 62%, 3%, and 17% respectively in the acute setting (<3 months), and 57%, 15%, and 52% respectively in late setting (>6 months). There were 36%, 28%, and 29% patients who had late MCIC in urinary, bowel and sexual QoL outcomes respectively. Bladder 0.5 cc was significant predictor for late grade ≥ 2 GU toxicities, with optimal cut-off of 25.5 Gy. Penile bulb D5cc was associated of late grade ≥ 2 sexual toxicities (no optimal cut-off was identified). No dosimetric parameters were identified to be associated with other outcomes. CONCLUSION Using real-life patient data from prospective trials with medium-term follow-up, we identified additional dose constraints that may mitigate the risk of late treatment-related toxicities for two-fraction prostate SABR.
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Affiliation(s)
- Wee Loon Ong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada; Alfred Health Radiation Oncology, Monash University, Melbourne, Australia
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Patrick Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Hans Chung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Jay Detsky
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Stanley Liu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Gerard Morton
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Ewa Szumacher
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Chia-Lin Tseng
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Danny Vesprini
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Ananth Ravi
- Department of Radiation Oncology, University of Toronto, Canada; Molli Surgical, Toronto, Canada
| | - Merrylee McGuffin
- 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; Department of Radiation Oncology, University of Toronto, Canada; Department of Health Policy, Measurement and Evaluation, University of Toronto, Canada.
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10
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Le Guevelou J, Bosetti DG, Castronovo F, Angrisani A, de Crevoisier R, Zilli T. State of the art and future challenges of urethra-sparing stereotactic body radiotherapy for prostate cancer: a systematic review of literature. World J Urol 2023; 41:3287-3299. [PMID: 37668718 PMCID: PMC10632210 DOI: 10.1007/s00345-023-04579-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/11/2023] [Indexed: 09/06/2023] Open
Abstract
PURPOSE Doses delivered to the urethra have been associated with an increased risk to develop long-term urinary toxicity in patients undergoing stereotactic body radiotherapy (SBRT) for prostate cancer (PCa). Aim of the present systematic review is to report on the role of urethra-sparing SBRT (US-SBRT) techniques for prostate cancer, with a focus on outcome and urinary toxicity. METHOD A systematic review of the literature was performed on the PubMed database on May 2023. Based on the urethra-sparing technique, 13 studies were selected for the analysis and classified in the two following categories: "urethra-steering" SBRT (restriction of hotspots to the urethra) and "urethra dose-reduction" SBRT (dose reduction to urethra below the prescribed dose). RESULTS By limiting the urethra Dmax to 90GyEQD2 (α/β = 3 Gy) with urethra-steering SBRT techniques, late genitourinary (GU) grade 2 toxicity remains mild, ranging between 12.1% and 14%. With dose-reduction strategies decreasing the urethral dose below 70 GyEQD2, the risk of late GU toxicity was further reduced (< 8% at 5 years), while maintaining biochemical relapse-free survival rates up to 93% at 5 years. CONCLUSION US-SBRT techniques limiting maximum doses to urethra below a 90GyEQD2 (α/β = 3 Gy) threshold result in a low rate of acute and late grade ≥ 2 GU toxicity. A better understanding of clinical factors and anatomical substructures involved in the development of GU toxicity, as well as the development and use of adapted dose constraints, is expected to further reduce the long-term GU toxicity of prostate cancer patients treated with SBRT.
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Affiliation(s)
| | - Davide Giovanni Bosetti
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, Via Ospedale, 6500, Bellinzona, Switzerland
| | - Francesco Castronovo
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, Via Ospedale, 6500, Bellinzona, Switzerland
| | - Antonio Angrisani
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, Via Ospedale, 6500, Bellinzona, Switzerland
| | | | - Thomas Zilli
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, Via Ospedale, 6500, Bellinzona, Switzerland.
- Facoltà Di Scienze Biomediche, Università Della Svizzera Italiana (USI), Lugano, Switzerland.
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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11
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Bosetti DG, Angrisani A, Castronovo FM, Pesce GA, Zilli T. Magnetic resonance imaging-guided stereotactic body radiotherapy for prostate cancer: more than a simple "MIRAGE"? Transl Cancer Res 2023; 12:2454-2457. [PMID: 37969364 PMCID: PMC10643941 DOI: 10.21037/tcr-23-611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 09/18/2023] [Indexed: 11/17/2023]
Affiliation(s)
- Davide Giovanni Bosetti
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
| | - Antonio Angrisani
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
| | - Francesco Mosè Castronovo
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
| | - Gianfranco Angelo Pesce
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
| | - Thomas Zilli
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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12
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Dover L, Dulaney C. Spine Stereotactic Radiosurgery, Prostate Radiation Frequency, Adjuvant Chemotherapy for Cervical Cancer, Bacteria and Radiation Dermatitis, and Breast Conservation Therapy for Multifocal Disease. Pract Radiat Oncol 2023; 13:379-383. [PMID: 37652622 DOI: 10.1016/j.prro.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 09/02/2023]
Affiliation(s)
- Laura Dover
- Department of Radiation Oncology, Ascension St. Vincent's East, Birmingham, Alabama.
| | - Caleb Dulaney
- Department of Radiation Oncology, Anderson Regional Health System, Meridian, Mississippi
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13
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De Cock L, Draulans C, Pos FJ, Isebaert S, De Roover R, van der Heide UA, Smeenk RJ, Kunze-Busch M, van der Voort van Zyp J, de Boer H, Kerkmeijer LGW, Haustermans K. From once-weekly to semi-weekly whole prostate gland stereotactic radiotherapy with focal boosting: Primary endpoint analysis of the multicenter phase II hypo-FLAME 2.0 trial. Radiother Oncol 2023; 185:109713. [PMID: 37178932 DOI: 10.1016/j.radonc.2023.109713] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/03/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND AND PURPOSE The hypo-FLAME trial showed that once-weekly (QW) focal boosted prostate stereotactic body radiotherapy (SBRT) is associated with acceptable acute genitourinary (GU) and gastrointestinal (GI) toxicity. Currently, we investigated the safety of reducing the overall treatment time (OTT) of focal boosted prostate SBRT from 29 to 15 days. MATERIAL AND METHODS Patients with intermediate- and high-risk prostate cancer were treated with SBRT delivering 35 Gy in 5 fractions to the whole prostate gland with an iso-toxic boost up to 50 Gy to the intraprostatic lesion(s) in a semi-weekly (BIW) schedule. The primary endpoint was radiation-induced acute toxicity (CTCAE v5.0). Changes in quality of life (QoL) were examined in terms of proportions achieving a minimal clinically important change (MCIC). Finally, acute toxicity and QoL scores of the BIW schedule were compared with the results of the prior QW hypo-FLAME schedule (n = 100). RESULTS Between August 2020 and February 2022, 124 patients were enrolled and treated BIW. No grade ≥3 GU or GI toxicity was observed. The 90-days cumulative incidence of grade 2 GU and GI toxicity rates were 47.5% and 7.4%, respectively. Patients treated QW scored significant less grade 2 GU toxicity (34.0%, p = 0.01). No significant differences in acute GI toxicity were observed. Furthermore, patients treated QW had a superior acute bowel and urinary QoL. CONCLUSION Semi-weekly prostate SBRT with iso-toxic focal boosting is associated with acceptable acute GU and GI toxicity. Based on the comparison between the QW and BIW schedule, patients should be counselled regarding the short-term advantages of a more protracted schedule. Registration number ClinicalTrials.gov: NCT04045717.
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Affiliation(s)
- Lisa De Cock
- Department of Oncology, KU Leuven, Leuven, Belgium.
| | | | - Floris J Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Sofie Isebaert
- Department of Oncology, KU Leuven, Leuven, Belgium; Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.
| | - Robin De Roover
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Martina Kunze-Busch
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | | | - Hans de Boer
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands.
| | - Linda G W Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands.
| | - Karin Haustermans
- Department of Oncology, KU Leuven, Leuven, Belgium; Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.
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14
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Kato Y, Okumiya S, Okudaira K, Ito J, Kumagai M, Kamomae T, Noguchi Y, Kawamura M, Ishihara S, Naganawa S. Urethral identification using three-dimensional magnetic resonance imaging and interfraction urethral motion evaluation for prostate stereotactic body radiotherapy. NAGOYA JOURNAL OF MEDICAL SCIENCE 2023; 85:504-517. [PMID: 37829483 PMCID: PMC10565580 DOI: 10.18999/nagjms.85.3.504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/15/2022] [Indexed: 10/14/2023]
Abstract
Prostatic urethra identification is crucial in prostate stereotactic body radiotherapy (SBRT) to reduce the risk of urinary toxicity. Although computed tomography (CT) with a catheter is commonly employed, it is invasive, and catheter placement may displace the urethral position, resulting in possible planning inaccuracies. However, magnetic resonance imaging (MRI) can overcome these weaknesses. Accurate urethral identification and minimal daily variation could ensure a highly accurate SBRT. In this study, we investigated the usefulness of a three-dimensional (3D) T2-weighted (T2W) sequence for urethral identification, and the interfractional motion of the prostatic urethra on CT with a catheter and MRI without a catheter for implementing noninvasive SBRT. Thirty-two patients were divided into three groups. The first group underwent MRI without a catheter to evaluate urethral identification by two-dimensional (2D)- and 3D-T2W sequences using mean slice-wise Hausdorff distance (MSHD) and Dice similarity coefficient (DSC) of the contouring by two operators and using visual assessment. The second group provided 3-day MRI data without a catheter using 3D-T2W, and the third provided 3-day CT data with a catheter to evaluate the interfractional motion using MSHD, DSC, and displacement distance (Dd). The MSHD and DSC for the interoperator variability in urethral identification and visual assessment were superior in 3D-T2W than in 2D-T2W. Regarding interfractional motion, the Dd value for prostatic urethra was smaller in MRI than in CT. These findings indicate that the 3D-T2W yielded adequate prostatic urethral identification, and catheter-free MRI resulted in less interfractional motion, suggesting that 3D-T2W MRI without a catheter is a feasible noninvasive approach to performing prostate SBRT.
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Affiliation(s)
- Yutaka Kato
- Department of Radiological Technology, Nagoya University Hospital, Nagoya, Japan
| | - Shintaro Okumiya
- Department of Radiological Technology, Nagoya University Hospital, Nagoya, Japan
| | - Kuniyasu Okudaira
- Department of Radiological Technology, Nagoya University Hospital, Nagoya, Japan
| | - Junji Ito
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Motoki Kumagai
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Kamomae
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yumiko Noguchi
- Department of Radiological Technology, Nagoya University Hospital, Nagoya, Japan
| | - Mariko Kawamura
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shunichi Ishihara
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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15
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Achard V, Zilli T. Prostate cancer intensity-modulated radiotherapy and long term genitourinary toxicity: an evolving therapeutic landscape. Prostate Cancer Prostatic Dis 2023; 26:1-2. [PMID: 35488121 DOI: 10.1038/s41391-022-00535-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/10/2022] [Accepted: 03/29/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Vérane Achard
- Department of Radiation Oncology, Geneva University Hospital, Geneva, and Faculty of Medicine, Geneva, Switzerland
| | - Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, and Faculty of Medicine, Geneva, Switzerland.
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16
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Five fractions of SBRT for prostate cancer. Lancet Oncol 2022; 23:e530. [DOI: 10.1016/s1470-2045(22)00615-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 11/30/2022]
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17
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Tree AC, Ostler P, van der Voet H, Chu W, Loblaw A, Ford D, Tolan S, Jain S, Martin A, Staffurth J, Armstrong J, Camilleri P, Kancherla K, Frew J, Chan A, Dayes IS, Duffton A, Brand DH, Henderson D, Morrison K, Brown S, Pugh J, Burnett S, Mahmud M, Hinder V, Naismith O, Hall E, van As N. Intensity-modulated radiotherapy versus stereotactic body radiotherapy for prostate cancer (PACE-B): 2-year toxicity results from an open-label, randomised, phase 3, non-inferiority trial. Lancet Oncol 2022; 23:1308-1320. [PMID: 36113498 DOI: 10.1016/s1470-2045(22)00517-4] [Citation(s) in RCA: 124] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Localised prostate cancer is commonly treated with external beam radiotherapy and moderate hypofractionation is non-inferior to longer schedules. Stereotactic body radiotherapy (SBRT) allows shorter treatment courses without impacting acute toxicity. We report 2-year toxicity findings from PACE-B, a randomised trial of conventionally fractionated or moderately hypofractionated radiotherapy versus SBRT. METHODS PACE is an open-label, multicohort, randomised, controlled, phase 3 trial conducted at 35 hospitals in the UK, Ireland, and Canada. In PACE-B, men aged 18 years and older with a WHO performance status 0-2 and low-risk or intermediate-risk histologically-confirmed prostate adenocarcinoma (Gleason 4 + 3 excluded) were randomly allocated (1:1) by computerised central randomisation with permuted blocks (size four and six), stratified by centre and risk group to control radiotherapy (CRT; 78 Gy in 39 fractions over 7·8 weeks or, following protocol amendment on March 24, 2016, 62 Gy in 20 fractions over 4 weeks) or SBRT (36·25 Gy in five fractions over 1-2 weeks). Androgen deprivation was not permitted. Co-primary outcomes for this toxicity analysis were Radiation Therapy Oncology Group (RTOG) grade 2 or worse gastrointestinal and genitourinary toxicity at 24 months after radiotherapy. Analysis was by treatment received and included all patients with at least one fraction of study treatment assessed for late toxicity. Recruitment is complete. Follow-up for oncological outcomes continues. The trial is registered with ClinicalTrials.gov, NCT01584258. FINDINGS We enrolled and randomly assigned 874 men between Aug 7, 2012, and Jan 4, 2018 (441 to CRT and 433 to SBRT). In this analysis, 430 patients were analysed in the CRT group and 414 in the SBRT group; a total of 844 (97%) of 874 randomly assigned patients. At 24 months, RTOG grade 2 or worse genitourinary toxicity was seen in eight (2%) of 381 participants assigned to CRT and 13 (3%) of 384 participants assigned to SBRT (absolute difference 1·3% [95% CI -1·3 to 4·0]; p=0·39); RTOG grade 2 or worse gastrointestinal toxicity was seen in 11 (3%) of 382 participants in the CRT group versus six (2%) of 384 participants in the SBRT group (absolute difference -1·3% [95% CI -3·9 to 1·1]; p=0·32). No serious adverse events (defined as RTOG grade 4 or worse) or treatment-related deaths were reported within the analysis timeframe. INTERPRETATION In the PACE-B trial, 2-year RTOG toxicity rates were similar for five fraction SBRT and conventional schedules of radiotherapy. Prostate SBRT was found to be safe and associated with low rates of side-effects. Biochemical outcomes are awaited. FUNDING Accuray.
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Affiliation(s)
- Alison C Tree
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK.
| | | | | | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Daniel Ford
- University Hospitals Birmingham, Birmingham, UK
| | - Shaun Tolan
- The Clatterbridge Cancer Centre, Liverpool, UK
| | | | - Alexander Martin
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - John Armstrong
- Cancer Trials Ireland, Dublin, Ireland; St Luke's Radiation Oncology Network, St Lukes Hospital, Dublin, Ireland
| | | | | | | | - Andrew Chan
- University Hospitals Coventry & Warwickshire, Coventry, UK
| | - Ian S Dayes
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Douglas H Brand
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | | | - Kirsty Morrison
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | | | - Julia Pugh
- The Institute of Cancer Research, London, UK
| | | | | | | | - Olivia Naismith
- The Royal Marsden Hospital, London, UK; Radiotherapy Trials QA Group, London, UK
| | - Emma Hall
- The Institute of Cancer Research, London, UK
| | - Nicholas van As
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
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18
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Leeman JE, Cagney DN, Mak RH, Huynh MA, Tanguturi SK, Singer L, Catalano P, Martin NE, D'Amico AV, Mouw KW, Nguyen PL, King MT, Han Z, Williams C, Huynh E. Magnetic Resonance-Guided Prostate Stereotactic Body Radiation Therapy With Daily Online Plan Adaptation: Results of a Prospective Phase 1 Trial and Supplemental Cohort. Adv Radiat Oncol 2022; 7:100934. [PMID: 35847547 PMCID: PMC9280019 DOI: 10.1016/j.adro.2022.100934] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/17/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Stereotactic magnetic resonance (MR)-guided adaptive radiation therapy (SMART) for prostate cancer allows for MR-based contouring, real-time MR motion management, and daily plan adaptation. The clinical and dosimetric benefits associated with prostate SMART remain largely unknown. Methods and Materials A phase 1 trial of prostate SMART was conducted with primary endpoints of safety and feasibility. An additional cohort of patients similarly treated with prostate SMART were included in the analysis. SMART was delivered to 36.25 Gy in 5 fractions to the prostate ± seminal vesicles using the MRIdian linear accelerator system (ViewRay, Inc). Rates of urinary and gastrointestinal toxic effects and patient-reported outcome measures were assessed. Dosimetric analyses were conducted to evaluate the specific benefits of daily plan adaptation. Results The cohort included 22 patients (n = 10 phase 1, n = 12 supplemental) treated in 110 fractions. Median follow-up was 7.9 months. Acute grade 2 urinary and gastrointestinal toxic effects were observed in 22.7% and 4.5%, respectively, and 4.5% and 0%, respectively, at last follow-up. No grade 3+ events were observed. Expanded Prostate Cancer Index-26 urinary obstructive scores decreased during SMART (mean, 9.3 points; P = .03) and returned to baseline by 3 months. No other significant changes in patient-reported outcome measures were observed. One-hundred percent of fractions required plan adaptation owing to exceeding organ-at-risk metrics (68%) or suboptimal target coverage (33%) resulting from anatomic changes. Minimum acceptable planning target volume, rectal, bladder, and urethra/bladder neck metrics were violated in 24%, 20%, 24%, and 33% of predicted plans, respectively; 0% of reoptimized plans violated metrics. Underlying causes for deficient dosimetry before reoptimization included changes in bladder filling, seminal vesicle position, prostate volume (median 4.7% increase by fraction 3; range, 0%-56%), and hotspots shifting into urethra/bladder neck. Conclusions Prostate SMART results in low risk of acute toxic effects with improvements in target and organ-at-risk dosimetry. The clinical benefits resulting from daily plan adaptation, including urethra/bladder neck protection, warrant further investigation.
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Affiliation(s)
- Jonathan E. Leeman
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel N. Cagney
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Raymond H. Mak
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mai Anh Huynh
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shyam K. Tanguturi
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lisa Singer
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Paul Catalano
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Neil E. Martin
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anthony V. D'Amico
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kent W. Mouw
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paul L. Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Martin T. King
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zhaohui Han
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher Williams
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Huynh
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Pham J, Savjani RR, Yoon SM, Yang T, Gao Y, Cao M, Hu P, Sheng K, Low DA, Steinberg M, Kishan A, Yang Y. Urethral Interfractional Geometric and Dosimetric Variations of Prostate Cancer Patients: A Study Using an Onboard MRI. Front Oncol 2022; 12:916254. [PMID: 35912253 PMCID: PMC9334678 DOI: 10.3389/fonc.2022.916254] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/14/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose For a cohort of prostate cancer patients treated on an MR-guided radiotherapy (MRgRT) system, we retrospectively analyzed urethral interfractional geometric and dosimetric variations based on onboard MRIs acquired at different timepoints and evaluated onboard prostatic urethra visualization for urethra-focused online adaptive RT. Methods Twenty-six prostate cancer patients were prospectively scanned on a 0.35-T MRgRT system using an optimized T2-weighted HASTE sequence at simulation and final fraction. Two radiation oncologists (RO1 and RO2) contoured the urethras on all HASTE images. The simulation and final fraction HASTE images were rigidly registered, and urethral interobserver and interfractional geometric variation was evaluated using the 95th percentile Hausdorff distance (HD95), mean distance to agreement (MDA), center-of-mass shift (COMS), and DICE coefficient. For dosimetric analysis, simulation and final fraction HASTE images were registered to the 3D bSSFP planning MRI and 3D bSSFP final setup MRI, respectively. Both ROs’ urethra contours were transferred from HASTE images for initial treatment plan optimization and final fraction dose estimation separately. Stereotactic body radiotherapy (SBRT) plans, 40 Gy in 5 fractions, were optimized to meet clinical constraints, including urethral V42Gy ≤0.03 cc, on the planning MRI. The initial plan was then forward calculated on the final setup MRI to estimate urethral dose on the final fraction and evaluate urethral dosimetric impact due to anatomy change. Results The average interobserver HD95, MDA, COMS, and DICE were 2.85 ± 1.34 mm, 1.02 ± 0.36 mm, 3.16 ± 1.61 mm, and 0.58 ± 0.15, respectively. The average interfractional HD95, MDA, COMS, and DICE were 3.26 ± 1.54 mm, 1.29 ± 0.54 mm, 3.34 ± 2.01 mm, and 0.49 ± 0.18, respectively. All patient simulation MRgRT plans met all clinical constraints. For RO1 and RO2, 23/26 (88%) and 21/26 (81%) patients’ final fraction estimated urethral dose did not meet the planned constraint. The average urethral V42Gy change was 0.48 ± 0.58 cc. Conclusion Urethral interfractional motion and anatomic change can result in daily treatment violating urethral constraints. Onboard MRI with good visualization of the prostatic urethra can be a valuable tool to help better protect the urethra through patient setup or online adaptive RT.
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Affiliation(s)
- Jonathan Pham
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Ricky R. Savjani
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Stephanie M. Yoon
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Tiffany Yang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Yu Gao
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Peng Hu
- Department of Radiology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Ke Sheng
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Daniel A. Low
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Michael Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Yingli Yang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
- *Correspondence: Yingli Yang,
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Westley R, Hall E, Tree A. HERMES: Delivery of a Speedy Prostate Cancer Treatment. Clin Oncol (R Coll Radiol) 2022; 34:426-429. [PMID: 35093251 PMCID: PMC8802653 DOI: 10.1016/j.clon.2022.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/23/2021] [Accepted: 01/04/2022] [Indexed: 12/27/2022]
Affiliation(s)
- R Westley
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, London, UK
| | - E Hall
- The Institute of Cancer Research, London, UK
| | - A Tree
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, London, UK.
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21
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Surgical Treatments of Benign Prostatic Hyperplasia and Prostate Cancer Stereotactic Radiotherapy: Impact on Long-Term Genitourinary Toxicity. Clin Oncol (R Coll Radiol) 2022; 34:e392-e399. [PMID: 35715340 DOI: 10.1016/j.clon.2022.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/16/2022] [Accepted: 05/31/2022] [Indexed: 11/20/2022]
Abstract
AIMS Although the results on acute and late toxicity of ultrahypofractionation are encouraging, data on safety in prostate cancer patients with a medical history of transurethral resection of the prostate (TURP) or adenomectomy remain scarce, especially in cases of repeated procedures. The aim of the present study was to report on long-term toxicities after stereotactic body radiotherapy (SBRT) of prostate cancer patients with previous surgical treatment of benign prostatic hyperplasia. MATERIALS AND METHODS Among 150 patients treated with SBRT (median dose 36.25 Gy in five fractions) realised from 2014 to 2019 in a single-centre institution, data of 24 men with a history of TURP (n = 19) or adenomectomy (n = 5) were analysed. Repeated TURP was carried out in three patients, with a median time between surgery and SBRT of 54 months. Genitourinary toxicity was assessed using the Common Terminology Criteria for Adverse Events v4.0 grading scale. RESULTS With a median follow-up of 45 months, 10 of 24 (42%) patients experienced at least one episode of transient haematuria. One patient (4%) with three previous TURP presented a grade 3 acute non-infective cystitis. Late grade 2 and 3 genitourinary toxicities were observed in eight (33%) and four patients (17%) (two treated with adenomectomy, one with multiple TURP and one with a 140 cm3 prostate size), respectively, with no grade ≥4 adverse events. A complete recovery of grade 3 genitourinary toxicities was observed for all patients after hyperbaric oxygen therapy. CONCLUSION Prostate SBRT is feasible and well-tolerated in patients with a medical history of surgical treatments of benign hyperplasia. Patients with prior adenomectomy or multiple TURP are at higher risk of developing severe genitourinary toxicity and should be carefully evaluated before SBRT treatments.
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22
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Zilli T, Achard V, Guevelou JL. Intraprostatic Urethra: The New Kid on the Block for Prostate Cancer Radiation Therapy? Int J Radiat Oncol Biol Phys 2022; 113:92-95. [DOI: 10.1016/j.ijrobp.2022.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/16/2022] [Indexed: 10/18/2022]
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23
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Greco C, Pares O, Pimentel N, Louro V, Nunes B, Kociolek J, Stroom J, Vieira S, Mateus D, Cardoso MJ, Soares A, Marques J, Freitas E, Coelho G, Fuks Z. Urethra Sparing With Target Motion Mitigation in Dose-Escalated Extreme Hypofractionated Prostate Cancer Radiotherapy: 7-Year Results From a Phase II Study. Front Oncol 2022; 12:863655. [PMID: 35433469 PMCID: PMC9012148 DOI: 10.3389/fonc.2022.863655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/24/2022] [Indexed: 11/15/2022] Open
Abstract
Purpose To explore whether the rectal distension-mediated technique, harnessing human physiology to achieve intrafractional prostate motion mitigation, enables urethra sparing by inverse dose painting, thus promoting dose escalation with extreme hypofractionated stereotactic ablative radiotherapy (SABR) in prostate cancer. Materials and Methods Between June 2013 and December 2018, 444 patients received 5 × 9 Gy SABR over 5 consecutive days. Rectal distension-mediated SABR was employed via insertion of a 150-cm3 air-inflated endorectal balloon. A Foley catheter loaded with 3 beacon transponders was used for urethra visualization and online tracking. MRI-based planning using Volumetric Modulated Arc Therapy - Image Guided Radiotherapy (VMAT-IGRT) with inverse dose painting was employed in delivering the planning target volume (PTV) dose and in sculpting exposure of organs at risk (OARs). A 2-mm margin was used for PTV expansion, reduced to 0 mm at the interface with critical OARs. All plans fulfilled Dmean ≥45 Gy. Target motion ≥2 mm/5 s motions mandated treatment interruption and target realignment prior to completion of the planned dose delivery. Results Patient compliance to the rectal distension-mediated immobilization protocol was excellent, achieving reproducible daily prostate localization at a patient-specific retropubic niche. Online tracking recorded ≤1-mm intrafractional target deviations in 95% of treatment sessions, while target realignment in ≥2-mm deviations enabled treatment completion as scheduled in all cases. The cumulative incidence rates of late grade ≥2 genitourinary (GU) and gastrointestinal (GI) toxicities were 5.3% and 1.1%, respectively. The favorable toxicity profile was corroborated by patient-reported quality of life (QOL) outcomes. Median prostate-specific antigen (PSA) nadir by 5 years was 0.19 ng/ml. The cumulative incidence rate of biochemical failure using the Phoenix definition was 2%, 16.6%, and 27.2% for the combined low/favorable-intermediate, unfavorable intermediate, and high-risk categories, respectively. Patients with a PSA failure underwent a 68Ga-labeled prostate-specific membrane antigen (68Ga-PSMA) scan showing a 20.2% cumulative incidence of intraprostatic relapses in biopsy International Society of Urological Pathology (ISUP) grade ≥3. Conclusion The rectal distension-mediated technique is feasible and well tolerated. Dose escalation to 45 Gy with urethra-sparing results in excellent toxicity profiles and PSA relapse rates similar to those reported by other dose-escalated regimens. The existence of intraprostatic recurrences in patients with high-risk features confirms the notion of a high α/β ratio in these phenotypes resulting in diminished effectiveness with hypofractionated dose escalation.
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Affiliation(s)
- Carlo Greco
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Oriol Pares
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Nuno Pimentel
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Vasco Louro
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Beatriz Nunes
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Justyna Kociolek
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Joep Stroom
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Sandra Vieira
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Dalila Mateus
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Maria Joao Cardoso
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Ana Soares
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Joao Marques
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Elda Freitas
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Graça Coelho
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Zvi Fuks
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
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Spohn SKB, Adebahr S, Huber M, Jenkner C, Wiehle R, Nagavci B, Schmucker C, Carl EG, Chen RC, Weber WA, Mix M, Rühle A, Sprave T, Nicolay NH, Gratzke C, Benndorf M, Wiegel T, Weis J, Baltas D, Grosu AL, Zamboglou C. Feasibility, pitfalls and results of a structured concept-development phase for a randomized controlled phase III trial on radiotherapy in primary prostate cancer patients. BMC Cancer 2022; 22:337. [PMID: 35351058 PMCID: PMC8960686 DOI: 10.1186/s12885-022-09434-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/09/2022] [Indexed: 11/15/2022] Open
Abstract
Objective Failure rate in randomized controlled trials (RCTs) is > 50%, includes safety-problems, underpowered statistics, lack of efficacy, lack of funding or insufficient patient recruitment and is even more pronounced in oncology trials. We present results of a structured concept-development phase (CDP) for a phase III RCT on personalized radiotherapy (RT) in primary prostate cancer (PCa) patients implementing prostate specific membrane antigen targeting positron emission tomography (PSMA-PET). Materials and methods The 1 yr process of the CDP contained five main working packages: (i) literature search and scoping review, (ii) involvement of individual patients, patients’ representatives and patients’ self-help groups addressing the patients’ willingness to participate in the preparation process and the conduct of RCTs as well as the patient informed consent (PIC), (iii) involvement of national and international experts and expert panels (iv) a phase II pilot study investigating the safety of implementation of PSMA-PET for focal dose escalation RT and (v) in-silico RT planning studies assessing feasibility of envisaged dose regimens and effects of urethral sparing in focal dose escalation. Results (i) Systematic literature searches confirmed the high clinical relevance for more evidence on advanced RT approaches, in particular stereotactic body RT, in high-risk PCa patients. (ii) Involvement of patients, patient representatives and randomly selected males relevantly changed the PIC and initiated a patient empowerment project for training of bladder preparation. (iii) Discussion with national and international experts led to adaptions of inclusion and exclusion criteria. (iv) Fifty patients were treated in the pilot trial and in- and exclusion criteria as well as enrollment calculations were adapted accordingly. Parallel conduction of the pilot trial revealed pitfalls on practicability and broadened the horizon for translational projects. (v) In-silico planning studies confirmed feasibility of envisaged dose prescription. Despite large prostate- and boost-volumes of up to 66% of the prostate, adherence to stringent anorectal dose constraints was feasible. Urethral sparing increased the therapeutic ratio. Conclusion The dynamic framework of interdisciplinary working programs in CDPs enhances robustness of RCT protocols and may be associated with decreased failure rates. Structured recommendations are warranted to further define the process of such CDPs in radiation oncology trials. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09434-2.
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25
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Schröder C, Tang H, Windisch P, Zwahlen DR, Buchali A, Vu E, Bostel T, Sprave T, Zilli T, Murthy V, Förster R. Stereotactic Radiotherapy after Radical Prostatectomy in Patients with Prostate Cancer in the Adjuvant or Salvage Setting: A Systematic Review. Cancers (Basel) 2022; 14:cancers14030696. [PMID: 35158961 PMCID: PMC8833497 DOI: 10.3390/cancers14030696] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/22/2022] [Accepted: 01/26/2022] [Indexed: 12/04/2022] Open
Abstract
Simple Summary Stereotactic body radiotherapy, a type of high-precision radiotherapy delivering high doses within few treatment sessions has proven to be effective and well tolerated in prostate cancer patients treated with definite radiotherapy. This systematic review summarizes the available data and analyzes whether this modern treatment may routinely be offered to prostate cancer patients after radical prostatectomy. Abstract (1) Background: Prostate cancer is the most common cancer in men and can be treated with radical prostatectomy (RPE) or radiotherapy in the primary setting. Stereotactic radiotherapy (SBRT) has proven to be effective and well tolerated in this setting. However, if SBRT is an equally promising treatment option if applied in the adjuvant or salvage setting after RPE remains unknown. (2) Methods: We searched the PubMed and Embase databases with the following full-text queries in August 2021 for any combination of the terms “SBRT”, “prostate”, “adjuvant”, “postoperative”, “salvage”, “stereotactic radiotherapy”, “prostate bed”. There were no limitations regarding publication date or language. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. (3) Results: We identified 11 individual studies that were included in this systematic review. Three publications included patients without prior radiotherapy and the remaining eight patients with prior radiotherapy. In all but two publications the radiation target was the macroscopic recurrence. SBRT was overall well tolerated with acceptable rates of acute and late gastrointestinal or genitourinary toxicity. Quality of life was published for two phase I trials with good results. There was a very heterogeneous reporting on biochemical control after SBRT. (4) Conclusions: At this point, ultra-hypofractionated RT using SBRT to the prostate bed remains experimental and its use should be restricted to clinical trials. Given the biological rationale for extreme hypofractionation in patients with prostate cancer and the acceptable toxicity rates that have been reported, further exploration of this field is warranted.
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Affiliation(s)
- Christina Schröder
- Institute for Radiation Oncology, Cantonal Hospital Winterthur (KSW), 8400 Winterthur, Switzerland; (C.S.); (H.T.); (P.W.); (D.R.Z.)
| | - Hongjian Tang
- Institute for Radiation Oncology, Cantonal Hospital Winterthur (KSW), 8400 Winterthur, Switzerland; (C.S.); (H.T.); (P.W.); (D.R.Z.)
| | - Paul Windisch
- Institute for Radiation Oncology, Cantonal Hospital Winterthur (KSW), 8400 Winterthur, Switzerland; (C.S.); (H.T.); (P.W.); (D.R.Z.)
| | - Daniel Rudolf Zwahlen
- Institute for Radiation Oncology, Cantonal Hospital Winterthur (KSW), 8400 Winterthur, Switzerland; (C.S.); (H.T.); (P.W.); (D.R.Z.)
| | - André Buchali
- Department of Radiation Oncology, Ruppiner Kliniken GmbH, Brandenburg Medical School (MHB), 16816 Neuruppin, Germany;
| | - Erwin Vu
- Department of Radiation Oncology, Cantonal Hospital St. Gallen (KSSG), 9000 St. Gallen, Switzerland;
| | - Tilman Bostel
- Department of Radiation Oncology, University Hospital Mainz, 55131 Mainz, Germany;
| | - Tanja Sprave
- Department of Radiation Oncology, University Hospital Freiburg, 79106 Freiburg im Breisgau, Germany;
| | - Thomas Zilli
- Department of Radiation Oncology, University Hospital Geneva (HUG), 1205 Geneva, Switzerland;
| | - Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Hospital and Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai 400012, India;
| | - Robert Förster
- Institute for Radiation Oncology, Cantonal Hospital Winterthur (KSW), 8400 Winterthur, Switzerland; (C.S.); (H.T.); (P.W.); (D.R.Z.)
- Correspondence: ; Tel.: +41-52-266-31-40
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26
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Leeman JE, Chen YH, Catalano P, Bredfeldt J, King M, Mouw KW, D'Amico AV, Orio P, Nguyen PL, Martin N. Radiation Dose to the Intraprostatic Urethra Correlates Strongly With Urinary Toxicity After Prostate Stereotactic Body Radiation Therapy: A Combined Analysis of 23 Prospective Clinical Trials. Int J Radiat Oncol Biol Phys 2022; 112:75-82. [PMID: 34711459 DOI: 10.1016/j.ijrobp.2021.06.037] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/13/2021] [Accepted: 06/22/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Clinical trials assessing evaluation prostate stereotactic body radiation therapy (SBRT) have used a wide range of allowed doses to the intraprostatic urethra, but the relationship between urethral dose and urinary toxicity has not been thoroughly evaluated. The goal of this study was to characterize urinary toxicity outcomes according to urethral dose administered during prostate SBRT. METHODS AND MATERIALS The MEDLINE (PubMed) database was searched for published prospective studies of prostate SBRT through August 2020 that documented a maximum urethral dose metric (MUDM). Reported acute and late urinary toxicity rates were collected. Logistic regression and weighted Pearson correlation models were used to assess associations between urinary toxicity rates and MUDM. RESULTS Twenty-three unique studies (n = 2232 patients) met the inclusion criteria and included a wide range of MUDMs (equivalent dose in 2 Gy fractions [EQD2]: 69-141.75 Gy; α/β = 3 Gy). The median follow-up ranged from 3 to 67 months (median, 32 months). On logistic regression analysis, the MUDM EQD2 was significantly associated with multiple urinary toxicity endpoints, including acute grade (G) 2+ (odds ratio [OR], 1.02; P < .001), late G2+ (OR, 1.03; P < .0001), and late G3+ (OR, 1.04; P = .003) urinary toxicity. On weighted Pearson correlation analysis, the MUDM was more closely associated with all evaluated urinary toxicity endpoints than prescription dose, including acute G2+ (r = 0.51; P = .02), late G2+ (r = 0.9; P < .0001), and late G3+ toxicity (r = 0.7; P = .003). Multivariate analysis accounting for age, prostate size, bladder dosimetry, and baseline urinary function confirmed associations between urinary outcomes and MUDM. Within the studied dose range, each increase of 1 Gy to the MUDM corresponded to a 0.8% and 1.0% increase in acute G2+ and late G2+ toxicity, respectively. CONCLUSIONS Radiation dose to the urethra correlates closely with urinary toxicity in patients with prostate cancer treated with SBRT. Attention should be paid to the urethral dose when delivering prostate SBRT to high doses, and approaches for urethral dose reduction warrant further investigation.
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Affiliation(s)
- Jonathan E Leeman
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Yu-Hui Chen
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Paul Catalano
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jeremy Bredfeldt
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Martin King
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kent W Mouw
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anthony V D'Amico
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Peter Orio
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Neil Martin
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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27
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Benhmida S, Beneux A, Udrescu C, Rouviere O, Horn S, Enachescu C, Lapierre A, Chapet O. Dosimetric feasibility of stereotactic irradiation of primary prostate cancer at 5x9 Gy with a method of urethral sparing. Br J Radiol 2021; 94:20210142. [PMID: 34283647 DOI: 10.1259/bjr.20210142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The most commonly used dose for prostate cancer stereotactic body radiotherapy (SBRT) is 5 × 7.25 Gy. The aim of this study was to evaluate the dosimetric feasibility of a 5 × 9 Gy SBRT regimen while still limiting the dose to the urethra to 5 × 7.25 Gy. This dosimetric study is part of the groundwork for a future Phase III randomized trial. METHODS The prostate, the urethra and the tumors were delineated on 20 dosimetric CT-scans with MRI-registration. The planning target volume (PTVp) was defined as a 5 mm expansion (3 mm posteriorly) of the prostate. The planning at risk volume (PRVu) was defined as a 2 mm expansion of the urethra. The tumors were delineated on the MRI (GTVt) and a 3 mm-margin was added to create a tumoral planning target volume (PTVt). IMRT plans were optimized to deliver 5 × 9 Gy to the PTVp, limiting the dose to the PRVu to 5 × 7.25 Gy. Results are presented using average (range) values. RESULTS PTVp doses were D98% = 36.2 Gy (35.6-36.8), D2% = 46.9 Gy (46.5-47.5) and mean dose = 44.1 Gy (43.8-44.5). The dose to the PRVu was within tolerance limits for all 20 patients: V34.4Gy = 99.8% (99.2-100) and D5% = 38.7 Gy (38.6-38.8). Dose coverage of PTV-PRVu was D95% = 40.6 Gy (40.5-40.9), D5% = 46.6 Gy (46.2-47.2) and mean dose = 44.6 Gy (44.3-44.9). Dose to the PTVt reached 44.6 Gy (41.2-45.9). Doses to the OAR were respected, except V36Gy ≤1 cc for the rectum. CONCLUSION A SBRT dose-escalation to 5 × 9 Gy on the prostate while sparing the urethra + 2 mm at 36.25 Gy is feasible without compromising dose coverage to the tumor. This radiation regimen will be used for a Phase-III trial. ADVANCES IN KNOWLEDGE In prostate SBRT, dose optimization on the urethra is feasible and could decrease urinary toxicities.
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Affiliation(s)
- Salim Benhmida
- Department of Radiation Oncology, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - Amandine Beneux
- Department of Medical Physics and Radioprotection, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - Corina Udrescu
- Department of Radiation Oncology, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - Olivier Rouviere
- Department of Urological Radiology, Hopital Edouard Herriot, Lyon, France
| | - Samy Horn
- Department of Radiation Oncology, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - Ciprian Enachescu
- Department of Radiation Oncology, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - Ariane Lapierre
- Department of Radiation Oncology, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - Olivier Chapet
- Department of Radiation Oncology, Centre Hospitalier Lyon Sud, Pierre Benite, France
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28
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Magli A, Farneti A, Faiella A, Ferriero M, Landoni V, Giannarelli D, Moretti E, de Paula U, Gomellini S, Sanguineti G. Toxicity at 1 Year After Stereotactic Body Radiation Therapy in 3 Fractions for Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2021; 111:93-100. [PMID: 33745951 DOI: 10.1016/j.ijrobp.2021.03.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/20/2021] [Accepted: 03/14/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE To assess the toxicity profile of prostate cancer stereotactic body radiation therapy (SBRT) in 3 fractions. METHODS AND MATERIALS This was a prospective, multicenter phase 2 toxicity study enrolling patients with low to favorable intermediate-risk prostate cancer. Before simulation, 3 to 4 fiducial markers along with a rectal spacer were placed. The target (prostate only) was prescribed 40 Gy, whereas the maximum dose to the urethra was limited to 33 Gy with the highest priority at planning; less stringent objectives were placed on the bladder, the filling of which was controlled via a Foley catheter. Treatment was delivered every other day. Toxicity was prospectively scored with Common Terminology Criteria for Adverse Events, and several patient-reported outcomes were collected. The maximum allowed prevalence rate of grade 2+ genitourinary (GU) toxicity at 1 year was set at 15%, and the study was sized accordingly. RESULTS Between November 2015 and May 2019, 59 patients were enrolled by 3 participating institutions. Acute gastrointestinal toxicity was occasional and mild, whereas 11.9% of patients developed acute grade 2 GU toxicity and 1.7% developed acute grade 3 GU toxicity. No patient had persistent treatment-related grade 2+ GU toxicity at 12 months after SBRT; thus, the null hypothesis was rejected. We observed a clinically relevant worsening of both International Prostate Symptom Score (IPSS) and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) scores at 12 months compared with baseline. Moreover, we found a strong association between all selected bladder dose/volume metrics at planning and ICIQ-SF worsening at 12 months, whereas for the IPSS, the correlation with bladder dose metrics was marginal. CONCLUSIONS The results suggest that at 12 months after treatment, the toxicity profile of SBRT in 3 fractions is acceptable.
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Affiliation(s)
- Alessandro Magli
- Radiation Oncology, Azienda Sanitaria-Universitaria Friuli Centrale, Udine, Italy
| | - Alessia Farneti
- Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Adriana Faiella
- Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | | | - Valeria Landoni
- Physics, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Diana Giannarelli
- Biostatistics, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Eugenia Moretti
- Physics, Azienda Sanitaria-Universitaria Friuli Centrale, Udine, Italy
| | - Ugo de Paula
- Radiation Oncology, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Sara Gomellini
- Radiation Oncology, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Giuseppe Sanguineti
- Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy.
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Keyriläinen J, Sjöblom O, Turnbull-Smith S, Hovirinta T, Minn H. Clinical experience and cost evaluation of magnetic resonance imaging -only workflow in radiation therapy planning of prostate cancer. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2021; 19:66-71. [PMID: 34307921 PMCID: PMC8295845 DOI: 10.1016/j.phro.2021.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/31/2021] [Accepted: 07/01/2021] [Indexed: 12/24/2022]
Abstract
Using MRI-only for prostate cancer radiation therapy planning (RTP) can reduce costs. An MRI-only workflow is particularly suitable for medium-sized and large departments. Omitting CT in the RTP workflow saves scanner, staff, and patient time.
Background and purpose In radiation therapy (RT), significant improvements have been made recently particularly in the practices of planning imaging. This study aimed to conduct a cost evaluation between magnetic resonance imaging (MRI) -only and combined computed tomography (CT) and MRI workflows. Materials and methods The time-driven activity-based costing (TDABC) model was used to conduct a cost evaluation between the two workflows in those steps, where cost differences were expected. Costs were divided into capital costs and operational costs. The former consisted of fixed, one-time expenses, e.g. the purchase of a scanner, whereas the latter were partially based on the amount of activity consumed i.e. time required for image acquisition, image registration and structure contouring. Results In a review over a period of 10 years for 300 annual prostate cancer patients, the total cost of the workflow steps included in the study for an individual patient applying the MRI-only workflow was 903 € (100%), comprised of 537 € (59%) capital costs and 366 € (41%) operational costs. The corresponding total cost for an individual patient applying the CT + MRI workflow was 922 € (100%), comprised of 197 € (21%) capital costs and 726 € (79%) operational costs. In 10 years for 3000 patients, a total saving of 58,544 € (2%) was achieved with the MRI-only workflow compared with the dual imaging workflow. Conclusions MRI-only workflow is a feasible and economic way to perform clinical RT for localized prostate cancer, in particular for medium- and large-sized departments treating a sufficient number of patients.
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Affiliation(s)
- Jani Keyriläinen
- Department of Medical Physics, Turku University Hospital, Hämeentie 11, FI-20521 Turku, Finland
- Department of Oncology and Radiotherapy, Turku University Hospital, Hämeentie 11, FI-20521 Turku, Finland
- Corresponding author at: Hämeentie 11, FIN-20521 Turku, Finland.
| | - Olli Sjöblom
- Turku University School of Economics, Information Systems Science, Rehtorinpellonkatu 3, FI-20500 Turku, Finland
| | - Sonja Turnbull-Smith
- Philips Oy, Philips Medical Systems MR Finland, Radiation Oncology Helsinki, Äyritie 4, FI-01510 Vantaa, Finland
| | - Taru Hovirinta
- Department of Finance, The Hospital District of Southwest Finland, Kiinamyllynkatu 4-8, FI-20521 Turku, Finland
| | - Heikki Minn
- Department of Oncology and Radiotherapy, Turku University Hospital, Hämeentie 11, FI-20521 Turku, Finland
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Spohn SKB, Sachpazidis I, Wiehle R, Thomann B, Sigle A, Bronsert P, Ruf J, Benndorf M, Nicolay NH, Sprave T, Grosu AL, Baltas D, Zamboglou C. Influence of Urethra Sparing on Tumor Control Probability and Normal Tissue Complication Probability in Focal Dose Escalated Hypofractionated Radiotherapy: A Planning Study Based on Histopathology Reference. Front Oncol 2021; 11:652678. [PMID: 34055621 PMCID: PMC8160377 DOI: 10.3389/fonc.2021.652678] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/08/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose Multiparametric magnetic resonance tomography (mpMRI) and prostate specific membrane antigen positron emission tomography (PSMA-PET/CT) are used to guide focal radiotherapy (RT) dose escalation concepts. Besides improvements of treatment effectiveness, maintenance of a good quality of life is essential. Therefore, this planning study investigates whether urethral sparing in moderately hypofractionated RT with focal RT dose escalation influences tumour control probability (TCP) and normal tissue complication probability (NTCP). Patients and Methods 10 patients with primary prostate cancer (PCa), who underwent 68Ga PSMA-PET/CT and mpMRI followed by radical prostatectomy were enrolled. Intraprostatic tumour volumes (gross tumor volume, GTV) based on both imaging techniques (GTV-MRI and -PET) were contoured manually using validated contouring techniques and GTV-Union was created by summing both. For each patient three IMRT plans were generated with 60 Gy to the whole prostate and a simultaneous integrated boost up to 70 Gy to GTV-Union in 20 fractions by (Plan 1) not respecting and (Plan 2) respecting dose constraints for urethra as well as (Plan 3) respecting dose constraints for planning organ at risk volume for urethra (PRV = urethra + 2mm expansion). NTCP for urethra was calculated applying a Lyman-Kutcher-Burman model. TCP-Histo was calculated based on PCa distribution in co-registered histology (GTV-Histo). Complication free tumour control probability (P+) was calculated. Furthermore, the intrafractional movement was considered. Results Median overlap of GTV-Union and PRV-Urethra was 1.6% (IQR 0-7%). Median minimum distance of GTV-Histo to urethra was 3.6 mm (IQR 2 - 7 mm) and of GTV-Union to urethra was 1.8 mm (IQR 0.0 - 5.0 mm). The respective prescription doses and dose constraints were reached in all plans. Urethra-sparing in Plans 2 and 3 reached significantly lower NTCP-Urethra (p = 0.002) without significantly affecting TCP-GTV-Histo (p = p > 0.28), NTCP-Bladder (p > 0.85) or NTCP-Rectum (p = 0.85), resulting in better P+ (p = 0.006). Simulation of intrafractional movement yielded even higher P+ values for Plans 2 and 3 compared to Plan 1. Conclusion Urethral sparing may increase the therapeutic ratio and should be implemented in focal RT dose escalation concepts.
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Affiliation(s)
- Simon K B Spohn
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ilias Sachpazidis
- Division of Medical Physics, Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rolf Wiehle
- Division of Medical Physics, Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benedikt Thomann
- Division of Medical Physics, Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - August Sigle
- Department of Urology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Bronsert
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Juri Ruf
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Benndorf
- Department of Radiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany
| | - Anca L Grosu
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany
| | - Dimos Baltas
- German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany.,Division of Medical Physics, Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantinos Zamboglou
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Ma TM, Lamb JM, Casado M, Wang X, Basehart TV, Yang Y, Low D, Sheng K, Agazaryan N, Nickols NG, Cao M, Steinberg ML, Kishan AU. Magnetic resonance imaging-guided stereotactic body radiotherapy for prostate cancer (mirage): a phase iii randomized trial. BMC Cancer 2021; 21:538. [PMID: 33975579 PMCID: PMC8114498 DOI: 10.1186/s12885-021-08281-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 05/02/2021] [Indexed: 02/07/2023] Open
Abstract
Background Stereotactic body radiotherapy (SBRT) is becoming increasingly used in treating localized prostate cancer (PCa), with evidence showing similar toxicity and efficacy profiles when compared with longer courses of definitive radiation. Magnetic resonance imaging (MRI)-guided radiotherapy has multiple potential advantages over standard computed tomography (CT)-guided radiotherapy, including enhanced prostate visualization (abrogating the need for fiducials and MRI fusion), enhanced identification of the urethra, the ability to track the prostate in real-time, and the capacity to perform online adaptive planning. However, it is unknown whether these potential advantages translate into improved outcomes. This phase III randomized superiority trial is designed to prospectively evaluate whether toxicity is lower after MRI-guided versus CT-guided SBRT. Methods Three hundred men with localized PCa will be randomized in a 1:1 ratio to SBRT using CT or MRI guidance. Randomization will be stratified by baseline International Prostate Symptom Score (IPSS) (≤15 or > 15) and prostate gland volume (≤50 cc or > 50 cc). Five fractions of 8 Gy will be delivered to the prostate over the course of fourteen days, with or without hormonal therapy and elective nodal radiotherapy (to a dose of 5 Gy per fraction) as per the investigator’s discretion. The primary endpoint is the incidence of physician-reported acute grade ≥ 2 genitourinary (GU) toxicity (during the first 90 days after SBRT), as assessed by the CTCAE version 4.03 scale. Secondary clinical endpoints include incidence of acute grade ≥ 2 gastrointestinal (GI) toxicity, 5-year cumulative incidences of physician-reported late grade ≥ 2 GU and GI toxicity, temporal changes in patient-reported quality of life (QOL) outcomes, 5-year biochemical recurrence-free survival and the proportion of fractions of MRI-guided SBRT in which online adaptive radiotherapy is used. Discussion The MIRAGE trial is the first randomized trial comparing MRI-guided with standard CT-guided SBRT for localized PCa. The primary hypothesis is that MRI-guided SBRT will lead to an improvement in the cumulative incidence of acute grade ≥ 2 GU toxicity when compared to CT-guided SBRT. The pragmatic superiority design focused on an acute toxicity endpoint will allow an early comparison of the two technologies. Trial registration Clinicaltrials.gov identifier: NCT04384770. Date of registration: May 12, 2020. https://clinicaltrials.gov/ct2/show/NCT04384770 Protocol version Version 2.1, Aug 28, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08281-x.
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Affiliation(s)
- Ting Martin Ma
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA, 90095, USA
| | - James M Lamb
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA, 90095, USA
| | - Maria Casado
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA, 90095, USA
| | - Xiaoyan Wang
- Department of Medicine Statistics Core, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA, 90095, USA
| | - T Vincent Basehart
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA, 90095, USA
| | - Yingli Yang
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA, 90095, USA
| | - Daniel Low
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA, 90095, USA
| | - Ke Sheng
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA, 90095, USA
| | - Nzhde Agazaryan
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA, 90095, USA
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA, 90095, USA
| | - Minsong Cao
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA, 90095, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA, 90095, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA, 90095, USA. .,Department of Urology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA, 90095, USA.
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Foerster R, Zwahlen DR, Buchali A, Tang H, Schroeder C, Windisch P, Vu E, Akbaba S, Bostel T, Sprave T, Zamboglou C, Zilli T, Stelmes JJ, Telkhade T, Murthy V. Stereotactic Body Radiotherapy for High-Risk Prostate Cancer: A Systematic Review. Cancers (Basel) 2021; 13:cancers13040759. [PMID: 33673077 PMCID: PMC7918664 DOI: 10.3390/cancers13040759] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/04/2021] [Accepted: 02/09/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Radiotherapy (RT) is an established, potentially curative treatment option for all risk constellations of localized prostate cancer (PCA). Androgen deprivation therapy (ADT) and dose-escalated RT can further improve outcome in high-risk (HR) PCA. In recent years, shorter RT schedules based on hypofractionated RT have shown equal outcome. Stereotactic body radiotherapy (SBRT) is a highly conformal RT technique enabling ultra-hypofractionation which has been shown to be safe and efficient in patients with low- and intermediate-risk PCA. There is a paucity of data on the role of SBRT in HR PCA. In particular, the need for pelvic elective nodal irradiation (ENI) needs to be addressed. Therefore, we conducted a systematic review to analyze the available data on observed toxicities, ADT prescription practice, and oncological outcome to shed more light on the value of SBRT in HR PCA. METHODS We searched the PubMed and Embase electronic databases for the terms "prostate cancer" AND "stereotactic" AND "radiotherapy" in June 2020. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. RESULTS After a rigorous selection process, we identified 18 individual studies meeting all selection criteria for further analyses. Five additional studies were included because their content was judged as relevant. Three trials have reported on prostate SBRT including pelvic nodes; 2 with ENI and 1 with positive pelvic nodes only. The remaining studies investigated SBRT of the prostate only. Grade 2+ acute genitourinary (GU) toxicity was between 12% and 46.7% in the studies investigating pelvic nodes irradiation and ranged from 0% to 89% in the prostate only studies. Grade 2+ chronic GU toxicity was between 7% and 60% vs. 2% and 56.7%. Acute gastrointestinal (GI) grade 2+ toxicity was between 0% to 4% and 0% to 18% for studies with and without pelvic nodes irradiation, respectively. Chronic GI grade 2+ toxicity rates were between 4% and 50.1% vs. 0% and 40%. SBRT of prostate and positive pelvic nodes only showed similar toxicity rates as SBRT for the prostate only. Among the trials that reported on ADT use, the majority of HR PCA patients underwent ADT for at least 2 months; mostly neoadjuvant and concurrent. Biochemical control rates ranged from 82% to 100% after 2 years and 56% to 100% after 3 years. Only a few studies reported longer follow-up data. CONCLUSION At this point, SBRT with or without pelvic ENI cannot be considered the standard of care in HR PCA, due to missing level 1 evidence. Treatment may be offered to selected patients at specialized centers with access to high-precision RT. While concomitant ADT is the current standard of care, the necessary duration of ADT in combination with SBRT remains unclear. Ideally, all eligible patients should be enrolled in clinical trials.
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Affiliation(s)
- Robert Foerster
- Institute for Radiation Oncology, Cantonal Hospital Winterthur (KSW), 8401 Winterthur, Switzerland; (D.R.Z.); (H.T.); (C.S.); (P.W.)
- Medical Faculty, University of Zurich (UZH), 8091 Zurich, Switzerland
- Correspondence: ; Tel.: +41-52-266-31-40
| | - Daniel Rudolf Zwahlen
- Institute for Radiation Oncology, Cantonal Hospital Winterthur (KSW), 8401 Winterthur, Switzerland; (D.R.Z.); (H.T.); (C.S.); (P.W.)
- Medical Faculty, University of Zurich (UZH), 8091 Zurich, Switzerland
| | - Andre Buchali
- Department of Radiation Oncology, Ruppiner Kliniken GmbH, Brandenburg Medical School (MHB), 16816 Neuruppin, Germany;
| | - Hongjian Tang
- Institute for Radiation Oncology, Cantonal Hospital Winterthur (KSW), 8401 Winterthur, Switzerland; (D.R.Z.); (H.T.); (C.S.); (P.W.)
| | - Christina Schroeder
- Institute for Radiation Oncology, Cantonal Hospital Winterthur (KSW), 8401 Winterthur, Switzerland; (D.R.Z.); (H.T.); (C.S.); (P.W.)
- Department of Radiation Oncology, Ruppiner Kliniken GmbH, Brandenburg Medical School (MHB), 16816 Neuruppin, Germany;
- Center for Proton Therapy, Paul Scherrer Institute (PSI), ETH Domain, 5232 Villingen, Switzerland
| | - Paul Windisch
- Institute for Radiation Oncology, Cantonal Hospital Winterthur (KSW), 8401 Winterthur, Switzerland; (D.R.Z.); (H.T.); (C.S.); (P.W.)
| | - Erwin Vu
- Department of Radiation Oncology, Cantonal Hospital St. Gallen (KSSG), 9007 St. Gallen, Switzerland;
| | - Sati Akbaba
- Department of Radiation Oncology, University Hospital Mainz, 55131 Mainz, Germany; (S.A.); (T.B.)
| | - Tilman Bostel
- Department of Radiation Oncology, University Hospital Mainz, 55131 Mainz, Germany; (S.A.); (T.B.)
| | - Tanja Sprave
- Department of Radiation Oncology, University Hospital Freiburg, 79106 Freiburg, Germany; (T.S.); (C.Z.)
| | - Constantinos Zamboglou
- Department of Radiation Oncology, University Hospital Freiburg, 79106 Freiburg, Germany; (T.S.); (C.Z.)
| | - Thomas Zilli
- Department of Radiation Oncology, University Hospital Geneva (HUG), 1205 Geneva, Switzerland;
| | - Jean-Jacques Stelmes
- Department of Radiation Oncology, Oncological Institute of Southern Switzerland (IOSI), Cantonal Hospitals (EOC), 6500 Bellinzona, Switzerland;
| | - Tejshri Telkhade
- Department of Radiation Oncology, Tata Memorial Hospital and Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai 400012, India; (T.T.); (V.M.)
| | - Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Hospital and Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai 400012, India; (T.T.); (V.M.)
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Single-fraction prostate stereotactic body radiotherapy: Dose reconstruction with electromagnetic intrafraction motion tracking. Radiother Oncol 2020; 156:145-152. [PMID: 33310011 DOI: 10.1016/j.radonc.2020.12.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/30/2020] [Accepted: 12/02/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To reconstruct the dose delivered during single-fraction urethra-sparing prostate stereotactic body radiotherapy (SBRT) accounting for intrafraction motion monitored by intraprostatic electromagnetic transponders (EMT). METHODS We analyzed data of 15 patients included in the phase I/II "ONE SHOT" trial and treated with a single fraction of 19 Gy to the planning target volume (PTV) and 17 Gy to the urethra planning risk volume. During delivery, prostate motion was tracked with implanted EMT. SBRT was interrupted when a 3-mm threshold was trespassed and corrected unless the offset was transient. Motion-encoded reconstructed (MER) plans were obtained by splitting the original plans into multiple sub-beams with isocenter shifts based on recorded EMT positions, mimicking prostate motion during treatment. We analyzed intrafraction motion and compared MER to planned doses. RESULTS The median EMT motion range (±SD) during delivery was 0.26 ± 0.09, 0.22 ± 0.14 and 0.18 ± 0.10 cm in the antero-posterior, supero-inferior, and left-right axes, respectively. Treatment interruptions were needed for 8 patients because of target motion beyond limits in the antero-posterior (n = 6) and/or supero-inferior directions (n = 4). Comparing MER vs. original plan there was a median relative dose difference of -1.9% (range, -7.9 to -1.0%) and of +0.5% (-0.3-1.7%) for PTV D98% and D2%, respectively. The clinical target volume remained sufficiently covered with a median D98% difference of -0.3% (-1.6-0.5%). Bladder and rectum dosimetric parameters showed significant differences between original and MER plans, but mostly remained within acceptable limits. CONCLUSIONS The dosimetric impact of intrafraction prostate motion was minimal for target coverage for single-fraction prostate SBRT with real-time electromagnetic tracking combined with beam gating.
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Urethra-Sparing Stereotactic Body Radiation Therapy for Prostate Cancer: Quality Assurance of a Randomized Phase 2 Trial. Int J Radiat Oncol Biol Phys 2020; 108:1047-1054. [PMID: 32535161 DOI: 10.1016/j.ijrobp.2020.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/12/2020] [Accepted: 06/01/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE To present the radiation therapy quality assurance results from a prospective multicenter phase 2 randomized trial of short versus protracted urethra-sparing stereotactic body radiation therapy (SBRT) for localized prostate cancer. METHODS AND MATERIALS Between 2012 and 2015, 165 patients with prostate cancer from 9 centers were randomized and treated with SBRT delivered either every other day (arm A, n = 82) or once a week (arm B, n = 83); 36.25 Gy in 5 fractions were prescribed to the prostate with (n = 92) or without (n = 73) inclusion of the seminal vesicles (SV), and the urethra planning-risk volume received 32.5 Gy. Patients were treated either with volumetric modulated arc therapy (VMAT; n = 112) or with intensity modulated radiation therapy (IMRT; n = 53). Deviations from protocol dose constraints, planning target volume (PTV) homogeneity index, PTV Dice similarity coefficient, and number of monitor units for each treatment plan were retrospectively analyzed. Dosimetric results of VMAT versus IMRT and treatment plans with versus without inclusion of SV were compared. RESULTS At least 1 major protocol deviation occurred in 51 patients (31%), whereas none was observed in 41. Protocol violations were more frequent in the IMRT group (P < .001). Furthermore, the use of VMAT yielded better dosimetric results than IMRT for urethra planning-risk volume D98% (31.1 vs 30.8 Gy, P < .0001), PTV D2% (37.9 vs 38.7 Gy, P < .0001), homogeneity index (0.09 vs 0.10, P < .0001), Dice similarity coefficient (0.83 vs 0.80, P < .0001), and bladder wall V50% (24.5% vs 33.5%, P = .0001). To achieve its goals volumetric modulated arc therapy required fewer monitor units than IMRT (2275 vs 3378, P <.0001). The inclusion of SV in the PTV negatively affected the rectal wall V90% (9.1% vs 10.4%, P = .0003) and V80% (13.2% vs 15.7%, P = .0003). CONCLUSIONS Protocol deviations with potential impact on tumor control or toxicity occurred in 31% of patients in this prospective clinical trial. Protocol deviations were more frequent with IMRT. Prospective radiation therapy quality assurance protocols should be strongly recommended for SBRT trials to minimize potential protocol deviations.
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Tetar SU, Bruynzeel AME, Oei SS, Senan S, Fraikin T, Slotman BJ, Moorselaar RJAV, Lagerwaard FJ. Magnetic Resonance-guided Stereotactic Radiotherapy for Localized Prostate Cancer: Final Results on Patient-reported Outcomes of a Prospective Phase 2 Study. Eur Urol Oncol 2020; 4:628-634. [PMID: 32536573 DOI: 10.1016/j.euo.2020.05.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/07/2020] [Accepted: 05/15/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND The recent introduction of magnetic resonance-guided radiation therapy (MRgRT) has allowed improved treatment planning and delivery of stereotactic body radiotherapy (SBRT) in prostate cancer (PC). The health-related quality of life (HRQoL) outcomes using this novel approach are important in shared decision making for patients. OBJECTIVE To report HRQoL using both patient- and clinician-reported outcomes at 1 yr following stereotactic MRgRT for patients with localized PC. DESIGN, SETTING, AND PARTICIPANTS A prospective phase 2 trial included 101 patients with localized PC. INTERVENTION All patients received 36.25Gy in five fractions of MRgRT delivered within 2 wk. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS HRQoL was prospectively assessed at baseline, at the last fraction, at 6 wk, and at 3, 6, 9, and 12 mo after treatment, by patient-reported outcome measures using European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-PR25 questionnaires, and International Prostate Symptom Score. At the same time points, clinicians reported on symptomatic adverse events (AEs). Effect sizes for changes in HRQoL were calculated with repeated measures analysis of variance. RESULTS AND LIMITATIONS Availability of HRQoL data exceeded 95% at all study time points. From both questionnaires and the recorded AEs, the largest treatment effects on urinary and bowel symptoms were recorded in the first 6 wk of follow-up. Thereafter, all symptoms decreased and returned to baseline values at 12 mo. No grade ≥3 toxicity was reported. No patient reported any relevant limitation due to urinary symptoms, and only 2.2% of patients reported a relevant impact on daily activities due to bowel problems at 1 yr. The majority of patients had intermediate- or high-risk PC for which androgen deprivation therapy (83.2%) was prescribed, thereby precluding study of MRgRT on sexual function. Longer follow-up is awaited in order to evaluate the oncological outcome. CONCLUSIONS Delivery of MRgRT for SBRT resulted in low toxicity at 1 yr. PATIENT SUMMARY All patients completed magnetic resonance-guided radiation therapy, which was well tolerated with only transient early urinary and bowel symptoms, which resolved 1 yr after treatment, as confirmed by patient-reported outcome measures.
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Affiliation(s)
- Shyama U Tetar
- Department of Radiation Oncology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Anna M E Bruynzeel
- Department of Radiation Oncology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Swie S Oei
- Department of Radiation Oncology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Suresh Senan
- Department of Radiation Oncology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Tamara Fraikin
- Department of Radiation Oncology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Berend J Slotman
- Department of Radiation Oncology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | | | - Frank J Lagerwaard
- Department of Radiation Oncology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
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36
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Zilli T, Jorcano S, Bral S, Rubio C, Bruynzeel AME, Oliveira A, Abacioglu U, Minn H, Symon Z, Miralbell R. Once-a-week or every-other-day urethra-sparing prostate cancer stereotactic body radiotherapy, a randomized phase II trial: 18 months follow-up results. Cancer Med 2020; 9:3097-3106. [PMID: 32160416 PMCID: PMC7196054 DOI: 10.1002/cam4.2966] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/01/2020] [Accepted: 02/19/2020] [Indexed: 01/08/2023] Open
Abstract
Background To present the 18 months results from a prospective multicenter phase II randomized trial of short vs protracted urethra‐sparing stereotactic body radiotherapy (SBRT) for localized prostate cancer (PCa). Methods Between 2012 and 2015, a total of 170 PCa patients were randomized to 36.25 Gy in 5 fractions (6.5 Gy × 5 to the urethra) delivered either every other day (EOD, arm A, n = 84) or once a week (QW, arm B, n = 86). Genitourinary (GU) and gastrointestinal (GI) toxicity (CTCAE v4.0 scale), IPSS, and QoL scores were assessed at baseline, at the 5th fraction (5fx), 12th weeks (12W), and every 6 months after SBRT. The primary endpoint was biochemical control at 18 months and grade ≥ 3 toxicity (including grade ≥ 2 for urinary obstruction/retention) during the first 3 months. Results Among the 165 patients analyzed, the toxicity stopping rule was never activated during the acute phase. Maximum acute grade 2 GU toxicity rates at 5fx were 17% and 19% for arms A and B, respectively, with only 2 cases of grade 2 GI toxicity at 5fx in arm A. At month 18, grade ≥ 2 GU and GI toxicity decreased below 5% and 2% for both arms. No changes in EORTC QLQ‐PR25 scores for GU, GI, and sexual domains were observed in both arms between baseline and month 18. Four biochemical failures were observed, 2 in each arm, rejecting the null hypothesis of an unfavorable response rate ≤ 85% in favor of an acceptable ≥ 95% rate. Conclusions At 18 months, urethra‐sparing SBRT showed a low toxicity profile, with minimal impact on QoL and favorable biochemical control rates, regardless of overall treatment time (EOD vs QW).
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Affiliation(s)
| | | | | | - Carmen Rubio
- Hospital Universitario HM Sanchinarro, Madrid, Spain
| | | | | | | | | | - Zvi Symon
- Sheba Medical Center, Ramat Gan, Israel
| | - Raymond Miralbell
- Geneva University Hospital, Geneva, Switzerland.,Teknon Oncologic Institute, Barcelona, Spain
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