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Song D, Dabkowski M, Costa P, Nurani R, Kos M, Vanneste B, Magel D, Sapir E, Zimberg S, Boychak O, Soffen E, Alhasso A, Tokita K, Wang D, Symon PZ, Hudes R. Prospective, Randomized, Controlled Pivotal Trial of Biodegradable Balloon Rectal Spacer for Prostate Radiation Therapy. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)02959-6. [PMID: 39032758 DOI: 10.1016/j.ijrobp.2024.07.2145] [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: 11/27/2023] [Revised: 07/02/2024] [Accepted: 07/04/2024] [Indexed: 07/23/2024]
Abstract
PURPOSE/OBJECTIVES Rectal spacers have been shown to reduce rectal side effects in patients receiving prostate radiation. However, concerns remain regarding precise and reproducible gel injection. We evaluated efficacy and safety of a novel rectoprostatic spacer balloon which allows potential for controlled, adaptable deployment. This study tested co-primary hypotheses: 1) Balloon spacer would result in ≥ 25% reduction of rectal V70 in > 75% of subjects, and 2) Implantation procedure-related and rectal ≥ Grade 1 adverse events within 6 months (duration ≥ 2 days, CTCAE 4.0) would be non-inferior in balloon vs control subjects. MATERIALS/METHODS 222 subjects were enrolled at 16 centers. All patients had T1-T3 prostate cancer without MRI evidence of posterior extraprostatic invasion. Randomization was 2:1 (balloon: control) and subject-blinded. Patients underwent transperineal TRUS-guided fiducial placement +/- balloon, followed by IMRT (81 Gy in 1.8 Gy fractions or biologically equivalent hypofractionated dose). For efficacy comparisons, plans were generated by a central core lab on pre- and post-implant CT scans. RESULTS The primary efficacy endpoint was met, with 97.9% of balloon subjects (139/142) having rectal V70 reduction >25% (p<0.001). Mean V70 was 7.0 % pre- vs 1.1% post- implant. The primary safety endpoint was met with balloon subjects experiencing fewer ≥ Grade 1 events, 18% vs 23% (p < 0.001 for non-inferiority). On pre-defined secondary endpoint of ≥ Grade 2 events, rates trended lower in balloon subjects (4.3% vs 6.5%, p=0.527). Mean perirectal spacing was 19 ±3.7mm and maintained through radiation treatment (18 ±3.9mm). Balloon resorption was observed on 6-month CT in 98.5% (133/135) of subjects. The EPIC QOL instrument was collected throughout study, and did not differ statistically between the study arms. CONCLUSIONS Biodegradable rectal spacer balloon was effective in significantly reducing dose to rectum, and associated with decreased cumulative rectal plus implantation-related adverse events. Balloon resorption was consistently observed by 6 months.
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Affiliation(s)
- Daniel Song
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center 401 N Broadway; Suite 1440 Baltimore.
| | - Mateusz Dabkowski
- Onology Center Institute of Maria Skłodowska Curie (MCMCC) Department of Brachytherapy 60 Roentgena Str 02-781 Warsaw, Poland
| | - Paulo Costa
- CUF Porto Instituto Rua Fonte das Sete Bicas 170 Piso-1 4460 - 188 Senhora da Hora Matosinhos, 4460-188 Portugal
| | - Rizwan Nurani
- Western Radiation Oncology (WRO) 2165 S. Bascom Ave. Suite, B Campbell, CA 95008
| | - Michael Kos
- Northern Nevada Radiation Oncology 10745 Double R Blvd. Reno, NV, 89521
| | - Ben Vanneste
- MAASTRO Clinic Dr. Tanslaan 12, 6229 ET Maastricht, The Netherlands
| | - David Magel
- Rabin Medical Center Zeev Jabutinsky Rd 39 Petah Tikva, 4941492, Israel
| | - Eli Sapir
- Ha-Refu'a St 7 Ashdod, 7747629 Israel
| | - Shawn Zimberg
- Advanced Radiation Centers of New York 3111 New Hyde Park Rd. Lake Success, NY, 11042
| | - Oleksandr Boychak
- St Luke's Hospital Highfield Road, Rathgar, Dublin 6 D06E1C9, Ireland
| | - Edward Soffen
- Regional Cancer Care Associates 9 Centre Drive Ste. 115 Monroe Township, NJ, 07601
| | - Abdulla Alhasso
- Beatson West of Scotland Cancer Centre 1053 Great Western Road Glasgow Scotland, G12 0YN, United Kingdom
| | - Kenneth Tokita
- KSK Medical Center 16100 Sand Canyon Ave. Suite 130 Irvine, CA, 92618
| | - Dian Wang
- Rush University Medical Center,1653 West Congress Parkway, Chicago, IL, 60612
| | - Prof Zvi Symon
- Shiba Medical Center Derech Sheba 2, Tel Hashomer, 5265601, Israel
| | - Richard Hudes
- Chesapeake Urology Research Associates 21 Crossroads Drive Suite 200 Owings Mills
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Costa P, Vale J, Fonseca G, Costa A, Kos M. Use of rectal balloon spacer in patients with localized prostate cancer receiving external beam radiotherapy. Tech Innov Patient Support Radiat Oncol 2024; 29:100237. [PMID: 38322778 PMCID: PMC10846399 DOI: 10.1016/j.tipsro.2024.100237] [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: 09/27/2023] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 02/08/2024] Open
Abstract
Objective To evaluate the efficacy of the balloon spacer when used to reduce the radiation dose delivered to the rectum in prostate cancer patients undergoing external beam radiotherapy. Method A single center retrospective analysis including 75 PC patients with localized T1-T3a disease who received balloon spacer followed by EBRT. Pre- and post-implantation computed tomography (CT) scans were utilized for treatment planning for standard EBRT (78-81 Gy in 1.8-2 Gy fractions). Rectal dosimetry was assessed using DVHs, and toxicities were graded with CTCAE v.4. Results A median (IQR) prostate-rectum separation resulted in 1.6 cm (1.4-2.0) post balloon spacer implantation. Overall, 90.6 % (68/75) of patients had a clinically significant 25 % relative reduction in the rectal with a median relative reduction of 91.8 % (71.2-98.6 %) at rV70. Three (4.0 %) patients reported mild procedural adverse events, anal discomfort and dysuria. Within 90 days post-implantation, five patients (6.67 %) and 1 patient (1.33 %) reported grade 1 and grade 2 rectal toxicities (anal pain, constipation, diarrhea and hemorrhoids). Genitourinary (GU) grade 1 toxicity was reported in 37 patients (49.33 %), with only one patient (1.33 %) experiencing grade 2 GU toxicity. No grade ≥ 3 toxicity was reported. Conclusion Balloon spacer implantation effectively increased prostate-rectum separation and associated with dosimetric gains EBRT for PC stage T1-T3a. Further controlled studies are required to ascertain whether this spacer allows for radiotherapy dose escalation and minimizes gastrointestinal (GI) toxicity.
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Affiliation(s)
- Paulo Costa
- CUF Porto Instituto, Rua Fonte das Sete Bicas, 170 - Piso -1 – 4460-188 SENHORA DA HORA, Porto Portugal
| | - Joana Vale
- CUF Porto Instituto, Rua Fonte das Sete Bicas, 170 - Piso -1 – 4460-188 SENHORA DA HORA, Porto Portugal
| | - Graça Fonseca
- CUF Porto Instituto, Rua Fonte das Sete Bicas, 170 - Piso -1 – 4460-188 SENHORA DA HORA, Porto Portugal
| | - Adelina Costa
- CUF Porto Instituto, Rua Fonte das Sete Bicas, 170 - Piso -1 – 4460-188 SENHORA DA HORA, Porto Portugal
| | - Michael Kos
- Brachytherapy Radiation Specialists Summit Cancer, 6506 Regal Ct., Reno, NV 99223, USA
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Ramot Y, Levin-Harrus T, Ezratty A, Steiner M, Ezov N, Domb AJ, Abdel-Haq M, Shohat S, Aperman L, Adler L, Dolkart O, Nyska A. Assessment of Bioprotect's Biodegradable Balloon System as a Rectal Spacer in Radiotherapy: An Animal Study on Tissue Response and Biocompatibility. Pharmaceutics 2023; 15:2744. [PMID: 38140085 PMCID: PMC10747072 DOI: 10.3390/pharmaceutics15122744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023] Open
Abstract
Prostate cancer is a significant health concern for men, emphasizing the need for effective treatment strategies. Dose-escalated external beam radiotherapy shows promise in improving outcomes but presents challenges due to radiation effects on nearby structures, such as the rectum. Innovative techniques, including rectal spacers, have emerged to mitigate these effects. This study comprehensively assessed tissue responses following the implantation of the Bioprotect biodegradable fillable balloon as a rectal spacer in a rat model. Evaluation occurred at multiple time points (4, 26, and 52 weeks) post-implantation. Results revealed localized tissue responses consistent with the expected reaction to biodegradable materials, characterized by mild to moderate fibrotic reactions and encapsulation, underscoring the safety and biocompatibility of the balloon. Importantly, no other adverse events occurred, and the animals remained healthy throughout the study. These findings support its potential clinical utility in radiotherapy treatments to enhance patient outcomes and minimize long-term implant-related complications, serving as a benchmark for future similar studies and offering valuable insights for researchers in the field. In conclusion, the findings from this study highlight the safety, biocompatibility, and potential clinical applicability of the Bioprotect biodegradable fillable balloon as a promising rectal spacer in mitigating radiation-induced complications during prostate cancer radiotherapy.
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Affiliation(s)
- Yuval Ramot
- Department of Dermatology, Hadassah Medical Center, Jerusalem 9112001, Israel;
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel
| | - Tal Levin-Harrus
- Envigo CRS Israel Limited, Ness Ziona 7414001, Israel; (T.L.-H.); (A.E.); (M.S.); (N.E.)
| | - Adva Ezratty
- Envigo CRS Israel Limited, Ness Ziona 7414001, Israel; (T.L.-H.); (A.E.); (M.S.); (N.E.)
| | - Michal Steiner
- Envigo CRS Israel Limited, Ness Ziona 7414001, Israel; (T.L.-H.); (A.E.); (M.S.); (N.E.)
| | - Nati Ezov
- Envigo CRS Israel Limited, Ness Ziona 7414001, Israel; (T.L.-H.); (A.E.); (M.S.); (N.E.)
| | - Abraham J. Domb
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (A.J.D.); (M.A.-H.)
| | - Muhammad Abdel-Haq
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (A.J.D.); (M.A.-H.)
| | - Shaul Shohat
- BioProtect, Tzur Yigal 4486200, Israel; (S.S.); (L.A.); (L.A.)
| | - Liron Aperman
- BioProtect, Tzur Yigal 4486200, Israel; (S.S.); (L.A.); (L.A.)
| | - Lee Adler
- BioProtect, Tzur Yigal 4486200, Israel; (S.S.); (L.A.); (L.A.)
| | - Oleg Dolkart
- Assuta Ashdod University Hospital, Ben-Gurion University of the Negev, Beer Sheba 8410501, Israel;
| | - Abraham Nyska
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6200515, Israel
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Ahmad Khalil D, Wulff J, Jazmati D, Geismar D, Bäumer C, Kramer PH, Steinmeier T, Schleithoff SS, Tschirdewahn S, Hadaschik B, Timmermann B. Is an Endorectal Balloon Beneficial for Rectal Sparing after Spacer Implantation in Prostate Cancer Patients Treated with Hypofractionated Intensity-Modulated Proton Beam Therapy? A Dosimetric and Radiobiological Comparison Study. Curr Oncol 2023; 30:758-768. [PMID: 36661707 PMCID: PMC9857887 DOI: 10.3390/curroncol30010058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/21/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The aim of this study is to examine the dosimetric influence of endorectal balloons (ERB) on rectal sparing in prostate cancer patients with implanted hydrogel rectum spacers treated with dose-escalated or hypofractionated intensity-modulated proton beam therapy (IMPT). METHODS Ten patients with localized prostate cancer included in the ProRegPros study and treated at our center were investigated. All patients underwent placement of hydrogel rectum spacers before planning. Two planning CTs (with and without 120 cm3 fluid-filled ERB) were applied for each patient. Dose prescription was set according to the h strategy, with 72 Gray (Gy)/2.4 Gy/5× weekly to prostate + 1 cm of the seminal vesicle, and 60 Gy/2 Gy/5× weekly to prostate + 2 cm of the seminal vesicle. Planning with two laterally opposed IMPT beams was performed in both CTs. Rectal dosimetry values including dose-volume statistics and normal tissue complication probability (NTCP) were compared for both plans (non-ERB plans vs. ERB plans). RESULTS For ERB plans compared with non-ERB, the reductions were 8.51 ± 5.25 Gy (RBE) (p = 0.000) and 15.76 ± 11.11 Gy (p = 0.001) for the mean and the median rectal doses, respectively. No significant reductions in rectal volumes were found after high dose levels. The use of ERB resulted in significant reduction in rectal volume after receiving 50 Gy (RBE), 40 Gy (RBE), 30 Gy (RBE), 20 Gy (RBE), and 10 Gy (RBE) with p values of 0.034, 0.008, 0.003, 0.001, and 0.001, respectively. No differences between ERB and non-ERB plans for the anterior rectum were observed. ERB reduced posterior rectal volumes in patients who received 30 Gy (RBE), 20 Gy (RBE), or 10 Gy (RBE), with p values of 0.019, 0.003, and 0.001, respectively. According to the NTCP models, no significant reductions were observed in mean or median rectal toxicity (late rectal bleeding ≥ 2, necrosis or stenosis, and late rectal toxicity ≥ 3) when using the ERB. CONCLUSION ERB reduced rectal volumes exposed to intermediate or low dose levels. However, no significant reduction in rectal volume was observed in patients receiving high or intermediate doses. There was no benefit and also no disadvantage associated with the use of ERB for late rectal toxicity, according to available NTCP models.
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Affiliation(s)
- Dalia Ahmad Khalil
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), 45147 Essen, Germany
| | - Jörg Wulff
- Faculty of Physics, TU Dortmund University, 44227 Dortmund, Germany
| | - Danny Jazmati
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), 45147 Essen, Germany
| | - Dirk Geismar
- Faculty of Physics, TU Dortmund University, 44227 Dortmund, Germany
| | - Christian Bäumer
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), 45147 Essen, Germany
| | | | - Theresa Steinmeier
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), 45147 Essen, Germany
| | | | - Stephan Tschirdewahn
- Department of Urology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Boris Hadaschik
- Department of Urology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), 45147 Essen, Germany
- Faculty of Physics, TU Dortmund University, 44227 Dortmund, Germany
- German Cancer Consortium (DKTK), 45147 Essen, Germany
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Björeland U, Notstam K, Fransson P, Söderkvist K, Beckman L, Jonsson J, Nyholm T, Widmark A, Thellenberg Karlsson C. Hyaluronic acid spacer in prostate cancer radiotherapy: dosimetric effects, spacer stability and long-term toxicity and PRO in a phase II study. Radiat Oncol 2023; 18:1. [PMID: 36593460 PMCID: PMC9809044 DOI: 10.1186/s13014-022-02197-x] [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: 11/15/2022] [Accepted: 12/30/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Perirectal spacers may be beneficial to reduce rectal side effects from radiotherapy (RT). Here, we present the impact of a hyaluronic acid (HA) perirectal spacer on rectal dose as well as spacer stability, long-term gastrointestinal (GI) and genitourinary (GU) toxicity and patient-reported outcome (PRO). METHODS In this phase II study 81 patients with low- and intermediate-risk prostate cancer received transrectal injections with HA before external beam RT (78 Gy in 39 fractions). The HA spacer was evaluated with MRI four times; before (MR0) and after HA-injection (MR1), at the middle (MR2) and at the end (MR3) of RT. GI and GU toxicity was assessed by physician for up to five years according to the RTOG scale. PROs were collected using the Swedish National Prostate Cancer Registry and Prostate cancer symptom scale questionnaires. RESULTS There was a significant reduction in rectal V70% (54.6 Gy) and V90% (70.2 Gy) between MR0 and MR1, as well as between MR0 to MR2 and MR3. From MR1 to MR2/MR3, HA thickness decreased with 28%/32% and CTV-rectum space with 19%/17% in the middle level. The cumulative late grade ≥ 2 GI toxicity at 5 years was 5% and the proportion of PRO moderate or severe overall bowel problems at 5 years follow-up was 12%. Cumulative late grade ≥ 2 GU toxicity at 5 years was 12% and moderate or severe overall urinary problems at 5 years were 10%. CONCLUSION We show that the HA spacer reduced rectal dose and long-term toxicity.
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Affiliation(s)
- Ulrika Björeland
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Radiation Physics, Umeå University, 901 87 Umeå, Sweden
| | - Kristina Notstam
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
| | - Per Fransson
- grid.12650.300000 0001 1034 3451Department of Nursing, Umeå University, 901 87 Umeå, Sweden
| | - Karin Söderkvist
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
| | - Lars Beckman
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
| | - Joakim Jonsson
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Radiation Physics, Umeå University, 901 87 Umeå, Sweden
| | - Tufve Nyholm
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Radiation Physics, Umeå University, 901 87 Umeå, Sweden
| | - Anders Widmark
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
| | - Camilla Thellenberg Karlsson
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
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Vanneste BG, Lutgens L, Van Limbergen EJ. Evaluation of hyaluronic acid gel dissolution with hyaluronidase in an in-vitro prostate cancer model. Clin Transl Radiat Oncol 2022; 33:53-56. [PMID: 35036588 PMCID: PMC8749177 DOI: 10.1016/j.ctro.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/30/2021] [Indexed: 11/29/2022] Open
Abstract
Hyaluronic acid (HA) is an implantable rectum spacer used to decrease rectal radiation dose in prostate cancer radiotherapy. Hyaluronidase (HAS) is an enzyme that degrades HA, when wrongly positioned. A ratio of HA:HAS of 1:2 has already a decrease of half of volume on the 2nd day.
Aim To determine a dose response relationship of disintegration of a hyaluronic acid (HA) and hyaluronidase (HAS) used in prostate cancer radiotherapy. Materials and methods Five in-vitro models are applicated with 3 ml (ml) HA. For dissolution varying doses of HAS were used: 6 ml, 3 ml, 1.5 ml, and 0 ml. One ml contains 150 International Units (IU). Each HAS was added with saline till the complementary amount of 6 ml. One phantom was solely implanted with a HA 3 ml acting as a control. Length, width and height were measured on different time points: 1st day 4 times, 2nd day 3 times, third day 2 times, and then once daily during one week, with a final measurement 2 weeks after implantation. The experiments were performed in duplicate to exclude variations and confirm the results. Results The fastest dissolution was observed with the highest concentration of HAS, already observed at the first time point 2 h after implantation, with volume decrease of 50% on the second day, and less than 1 ml residue (33%) on day 4. The 2 other concentrations of HAS also showed a volume decrease, with less than 2 ml (66%) on day 4. All the applied quantities of HAS are observed with a residue of less than 1 ml after 7 days. After 14 days the control phantom and the saline filled one remains on steady state volume (3 ml). Conclusions A dose response was observed by HAS injection: highest volumes of HAS dissolute most swiftly. Using a ratio of HA:HAS of 1:2 results in a decrease to half of initial volume within 24 h. This is of special interest when used in clinical practice following erroneous positioning, and dissolution is urgently needed.
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Affiliation(s)
- Ben G.L. Vanneste
- Corresponding author at: MAASTRO Clinic, P.O. Box 3035, 6202 NA Maastricht, the Netherlands.
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Latorzeff I, Bruguière E, Bogart E, Le Deley MC, Lartigau E, Marre D, Pasquier D. Use of a Biodegradable, Contrast-Filled Rectal Spacer Balloon in Intensity-Modulated Radiotherapy for Intermediate-Risk Prostate Cancer Patients: Dosimetric Gains in the BioPro-RCMI-1505 Study. Front Oncol 2021; 11:701998. [PMID: 34513681 PMCID: PMC8427159 DOI: 10.3389/fonc.2021.701998] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/21/2021] [Indexed: 01/12/2023] Open
Abstract
Background/purpose Dose-escalated external beam radiotherapy (RT) is effective in the control of prostate cancer but is associated with a greater incidence of rectal adverse events. We assessed the dosimetric gain and safety profile associated with implantation of a new biodegradable rectal spacer balloon. Materials/methods Patients scheduled for image-guided, intensity-modulated RT for intermediate-risk prostate cancer were prospectively included in the French multicenter BioPro-RCMI-1505 study (NCT02478112). We evaluated the dosimetric gain, implantation feasibility, adverse events (AEs), and prostate-cancer-specific quality of life associated with use of the balloon spacer. Results After a scheduled review of the initial recruitment target of 50 patients by the study's independent data monitoring committee (IDMC), a total of 24 patients (including 22 with dosimetry data) were included by a single center between November 2016 and May 2018. The interventional radiologist who implanted the balloons considered that 86% of the procedures were easy. 20 of the 24 patients (83.3%) received IMRT and 4 (16.7%) received volumetric modulated arc therapy (78-80 Gy delivered in 39 fractions). The dosimetric gains associated with spacer implantation were highly significant (p<0.001) for most variables. For the rectum, the median (range) relative gain ranged from 15.4% (-9.2-47.5) for D20cc to 91.4% (36.8-100.0) for V70 Gy (%). 15 patients (62%) experienced an acute grade 1 AE, 8 (33%) experienced a late grade 1 AE, 1 (4.2%) experienced an acute grade 2 AE, and 3 experienced a late grade 2 AE. No grade 3 AEs were reported. Quality of life was good at baseline (except for sexual activity) and did not markedly worsen during RT and up to 24 months afterwards. Conclusion The use of a biodegradable rectal spacer balloon is safe, effective and associated with dosimetric gains in modern RT for intermediate-risk prostate cancer.
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Affiliation(s)
- Igor Latorzeff
- Department of Radiotherapy, Clinique Pasteur, Toulouse, France
| | - Eric Bruguière
- Department of Imaging, Clinique Pasteur, Toulouse, France
| | - Emilie Bogart
- Methodology and Biostatistics Unit, Centre Oscar Lambret, Lille, France
| | | | - Eric Lartigau
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France.,CRIStAL UMR CNRS 9189, Lille University, Lille, France
| | - Delphine Marre
- Department of Physics, Clinique Pasteur, Toulouse, France
| | - David Pasquier
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France.,CRIStAL UMR CNRS 9189, Lille University, Lille, France
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Hooshangnejad H, Youssefian S, Guest JK, Ding K. FEMOSSA: Patient-specific finite element simulation of the prostate-rectum spacer placement, a predictive model for prostate cancer radiotherapy. Med Phys 2021; 48:3438-3452. [PMID: 34021606 DOI: 10.1002/mp.14990] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Major advances in delivery systems in recent years have turned radiotherapy (RT) into a more effective way to manage prostate cancer. Still, adjacency of organs at risk (OARs) can severely limit RT benefits. Rectal spacer implant in recto-prostatic space provides sufficient separation between prostate and rectum, and therefore, the opportunity for potential dose escalation to the target and reduction of OAR dose. Pretreatment simulation of spacer placement can potentially provide decision support to reduce the risks and increase the efficacy of the spacer placement procedure. METHODS A novel finite element method-oriented spacer simulation algorithm, FEMOSSA, was developed in this study. We used the finite element (FE) method to model and predict the deformation of rectum and prostate wall, stemming from hydrogel injection. Ten cases of prostate cancer, which undergone hydrogel placement before the RT treatment, were included in this study. We used the pre-injection organ contours to create the FE model and post-injection spacer location to estimate the distribution of the virtual spacer. Material properties and boundary conditions specific to each patient's anatomy were assigned. The FE analysis was then performed to determine the displacement vectors of regions of interest (ROIs), and the results were validated by comparing the virtually simulated contours with the real post-injection contours. To evaluate the different aspects of our method's performance, we used three different figures of merit: dice similarity coefficient (DSC), nearest neighbor distance (NND), and overlapped volume histogram (OVH). Finally, to demonstrate a potential dosimetric application of FEMOSSA, the predicted rectal dose after virtual spacer placement was compared against the predicted post-injection rectal dose. RESULTS Our simulation showed a realistic deformation of ROIs. The post-simulation (virtual spacer) created the same separation between prostate and rectal wall, as post-injection spacer. The average DSCs for prostate and rectum were 0.87 and 0.74, respectively. Moreover, there was a statistically significant increase in rectal contour similarity coefficient (P < 0.01). Histogram of NNDs showed the same overall shape and a noticeable shift from lower to higher values for both post-simulation and post-injection, indicative of the increase in distance between prostate and rectum. There was less than 2.2- and 2.1-mm averaged difference between the mean and fifth percentile NNDs. The difference between the OVH distances and the corresponding predicted rectal dose was, on average, less than 1 mm and 1.5 Gy, respectively. CONCLUSIONS FEMOSSA provides a realistic simulation of the hydrogel injection process that can facilitate spacer placement planning and reduce the associated uncertainties. Consequently, it increases the robustness and success rate of spacer placement procedure that in turn improves prostate cancer RT quality.
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Affiliation(s)
- Hamed Hooshangnejad
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sina Youssefian
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Department of Civil and Systems Engineering, The Johns Hopkins University, Baltimore, Maryland, USA
| | - James K Guest
- Department of Civil and Systems Engineering, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Kai Ding
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Vanneste BG, Van Limbergen EJ, Marcelissen T, Reynders K, Melenhorst J, van Roermund JG, Lutgens L. Is prostate cancer radiotherapy using implantable rectum spacers safe and effective in inflammatory bowel disease patients? Clin Transl Radiat Oncol 2021; 27:121-125. [PMID: 33604459 PMCID: PMC7875819 DOI: 10.1016/j.ctro.2021.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Prostate cancer radiotherapy (RT) in patients with (active) inflammatory bowel disease (IBD) remains controversial. We hypothesized that RT in combination with a biodegradable prostate-rectum spacer balloon implantation, might be a safe treatment approach with acceptable toxicities for these high risk for rectal toxicity patients. MATERIALS AND METHODS We report on a small prospective mono-centric series of 8 patients with all-risk prostate cancer with the comorbidity of an IBD. Four patients had Crohn's disease and 4 patients had ulcerative colitis. One out of four had an active status of IBD. All patients were intended to be treated with curative high-dose RT: 5 patients were treated with external beam RT (70 Gray (Gy) in 28 fractions), and 3 patients were treated with 125I-implant (145 Gy). Toxicities were scored according to the CTCAE v4.03: acute side effects occur up to 3 months after RT, and late side effects start after 3 months. RESULTS Median follow-up was 13 months (range: 3-42 months). Only one acute grade 2 gastro-intestinal (GI) toxicity was observed: an increased diarrhea (4-6 above baseline) during RT, which resolved completely 6 weeks after treatment. No late grade 3 or more GI toxicity was reported, and no acute and late grade ≥2 genitourinary toxicity events were observed. CONCLUSION Prostate cancer patients with IBD are a challenge to treat with RT. Our results suggest that RT in combination with a balloon implant in selective patients with (active) IBD may be promising, however additional validation is needed.
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Affiliation(s)
- Ben G.L. Vanneste
- Department of Radiation Oncology (MAASTRO), GROW – School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Evert J. Van Limbergen
- Department of Radiation Oncology (MAASTRO), GROW – School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Tom Marcelissen
- Department of Urology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Kobe Reynders
- Department of Radiation Oncology (MAASTRO), GROW – School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Joep G.H. van Roermund
- Department of Urology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Ludy Lutgens
- Department of Radiation Oncology (MAASTRO), GROW – School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
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10
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Böckelmann F, Putz F, Kallis K, Lettmaier S, Fietkau R, Bert C. Adaptive radiotherapy and the dosimetric impact of inter- and intrafractional motion on the planning target volume for prostate cancer patients. Strahlenther Onkol 2020; 196:647-656. [PMID: 32157345 PMCID: PMC7305089 DOI: 10.1007/s00066-020-01596-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/03/2020] [Indexed: 12/25/2022]
Abstract
Purpose To investigate the dosimetric influence of daily interfractional (inter) setup errors and intrafractional (intra) target motion on the planning target volume (PTV) and the possibility of an offline adaptive radiotherapy (ART) method to correct larger patient positioning uncertainties in image-guided radiotherapy for prostate cancer (PCa). Materials and methods A CTV (clinical target volume)-to-PTV margin ranging from 15 mm in LR (left-right) and SI (superior-inferior) and 5–10 mm in AP (anterior-posterior) direction was applied to all patients. The dosimetric influence of this margin was retrospectively calculated by analysing systematic and random components of inter and intra errors of 31 consecutive intermediate- and high-risk localized PCa patients using daily cone beam computed tomography and kV/kV (kilo-Voltage) imaging. For each patient inter variation was assessed by observing the first 4 treatment days, which led to an offline ART-based treatment plan in case of larger variations. Results: Systematic inter uncertainties were larger (1.12 in LR, 2.28 in SI and 1.48 mm in AP) than intra systematic errors (0.44 in LR, 0.69 in SI and 0.80 mm in AP). Same findings for the random error in SI direction with 3.19 (inter) and 2.30 mm (intra), whereas in LR and AP results were alike with 1.89 (inter) and 1.91 mm (intra) and 2.10 (inter) and 2.27 mm (intra), respectively. The calculated margin revealed dimensions of 4–5 mm in LR, 8–9 mm in SI and 6–7 mm in AP direction. Treatment plans which had to be adapted showed smaller variations with 1.12 (LR) and 1.72 mm (SI) for Σ and 4.17 (LR) and 3.75 mm (SI) for σ compared to initial plans with 1.77 and 2.62 mm for Σ and 4.46 and 5.39 mm for σ in LR and SI, respectively. Conclusion The currently clinically used margin of 15 mm in LR and SI and 5–10 mm in AP direction includes inter and intra uncertainties. The results show that offline ART is feasible which becomes a necessity with further reductions in PTV margins. Electronic supplementary material The online version of this article (10.1007/s00066-020-01596-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Felix Böckelmann
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany
| | - Florian Putz
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany
| | - Karoline Kallis
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany.
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11
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Miura H, Ozawa S, Doi Y, Nakao M, Ohnishi K, Kenjo M, Nagata Y. Automatic gas detection in prostate cancer patients during image-guided radiation therapy using a deep convolutional neural network. Phys Med 2019; 64:24-28. [PMID: 31515026 DOI: 10.1016/j.ejmp.2019.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/04/2019] [Accepted: 06/17/2019] [Indexed: 12/29/2022] Open
Abstract
PURPOSE The detection of intestinal/rectal gas is very important during image-guided radiation therapy (IGRT) of prostate cancer patients because intestinal/rectal gas increases the inter- and intra-fractional prostate motion. We propose a deep convolutional neural network (DCNN) to detect intestinal/rectal gas in the pelvic region. MATERIAL AND METHODS We selected 300 anterior-posterior kilo-voltage (kV) X-ray images from 30 prostate cancer patients. Thirty images were randomly chosen for a test set, and the remaining 270 images used as the training set. The intestinal/rectal gas was manually delineated on kV X-ray images and segmented. The training images were augmented by applying artificial shifts and fed into a DCNN. The network models were trained to keep the quality of the output image close to the quality of the input image by pooling and upsampling. The training set was used to adjust the parameters of the DCNN, and the test set was used to assess the performance of the model. The performance of the DCNN was evaluated using a fivefold cross-validation procedure. The dice similarity coefficient (DSC) was calculated to evaluate the detection accuracy between the manual contour and auto-segmentation. RESULTS The DCNN was trained within approximately 17 min with a time step of 20 s/epoch. The training and validation accuracy of the models after 50epochs were 0.94 and 0.85, respectively. The average ± standard deviation of the DSC for 30 test images was 0.85 ± 0.08. CONCLUSIONS The proposed DCNN method can automatically detect the intestinal/rectal gas in kV images with good accuracy.
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Affiliation(s)
- Hideharu Miura
- Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan; Department of Radiation Oncology, Institute of Biomedical & Health Science, Hiroshima University, Hiroshima, Japan.
| | - Shuichi Ozawa
- Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan; Department of Radiation Oncology, Institute of Biomedical & Health Science, Hiroshima University, Hiroshima, Japan
| | - Yoshiko Doi
- Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan; Department of Radiation Oncology, Institute of Biomedical & Health Science, Hiroshima University, Hiroshima, Japan
| | - Minoru Nakao
- Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan; Department of Radiation Oncology, Institute of Biomedical & Health Science, Hiroshima University, Hiroshima, Japan
| | - Keiichi Ohnishi
- Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan
| | - Masahiro Kenjo
- Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan; Department of Radiation Oncology, Institute of Biomedical & Health Science, Hiroshima University, Hiroshima, Japan
| | - Yasushi Nagata
- Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan; Department of Radiation Oncology, Institute of Biomedical & Health Science, Hiroshima University, Hiroshima, Japan
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12
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Decision Support Systems in Prostate Cancer Treatment: An Overview. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4961768. [PMID: 31281840 PMCID: PMC6590598 DOI: 10.1155/2019/4961768] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 04/02/2019] [Accepted: 05/06/2019] [Indexed: 12/11/2022]
Abstract
Background A multifactorial decision support system (mDSS) is a tool designed to improve the clinical decision-making process, while using clinical inputs for an individual patient to generate case-specific advice. The study provides an overview of the literature to analyze current available mDSS focused on prostate cancer (PCa), in order to better understand the availability of decision support tools as well as where the current literature is lacking. Methods We performed a MEDLINE literature search in July 2018. We divided the included studies into different sections: diagnostic, which aids in detection or staging of PCa; treatment, supporting the decision between treatment modalities; and patient, which focusses on informing the patient. We manually screened and excluded studies that did not contain an mDSS concerning prostate cancer and study proposals. Results Our search resulted in twelve diagnostic mDSS; six treatment mDSS; two patient mDSS; and eight papers that could improve mDSS. Conclusions Diagnosis mDSS is well represented in the literature as well as treatment mDSS considering external-beam radiotherapy; however, there is a lack of mDSS for other treatment modalities. The development of patient decision aids is a new field of research, and few successes have been made for PCa patients. These tools can improve personalized medicine but need to overcome a number of difficulties to be successful and require more research.
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13
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Vanneste BG, Buettner F, Pinkawa M, Lambin P, Hoffmann AL. Ano-rectal wall dose-surface maps localize the dosimetric benefit of hydrogel rectum spacers in prostate cancer radiotherapy. Clin Transl Radiat Oncol 2019; 14:17-24. [PMID: 30456317 PMCID: PMC6234617 DOI: 10.1016/j.ctro.2018.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/31/2018] [Accepted: 10/31/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND PURPOSE To evaluate spatial differences in dose distributions of the ano-rectal wall (ARW) using dose-surface maps (DSMs) between prostate cancer patients receiving intensity-modulated radiation therapy with and without implantable rectum spacer (IMRT+IRS; IMRT-IRS, respectively), and to correlate this with late gastro-intestinal (GI) toxicities using validated spatial and non-spatial normal-tissue complication probability (NTCP) models. MATERIALS AND METHODS For 26 patients DSMs of the ARW were generated. From the DSMs various shape-based dose measures were calculated at different dose levels: lateral extent, longitudinal extent, and eccentricity. The contiguity of the ARW dose distribution was assessed by the contiguous-DSH (cDSH). Predicted complication rates between IMRT+IRS and IMRT-IRS plans were assessed using a spatial NTCP model and compared against a non-spatial NTCP model. RESULTS Dose surface maps are generated for prostate radiotherapy using an IRS. Lateral extent, longitudinal extent and cDSH were significantly lower in IMRT+IRS than for IMRT-IRS at high-dose levels. Largest significant differences were observed for cDSH at dose levels >50 Gy, followed by lateral extent at doses >57 Gy, and longitudinal extent in anterior and superior-inferior directions. Significant decreases (p = 0.01) in median rectal and anal NTCPs (respectively, Gr 2 late rectal bleeding and subjective sphincter control) were predicted when using an IRS. CONCLUSIONS Local-dose effects are predicted to be significantly reduced by an IRS. The spatial NTCP model predicts a significant decrease in Gr 2 late rectal bleeding and subjective sphincter control. Dose constraints can be improved for current clinical treatment planning.
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Affiliation(s)
| | | | - Michael Pinkawa
- Department of Radiation Oncology, MediClin Robert Janker Klinik, Bonn, Germany
| | - Philippe Lambin
- The D-Lab, GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Aswin L. Hoffmann
- MAASTRO Clinic, Maastricht, The Netherlands
- Institute of Radiooncology, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Radiotherapy, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
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14
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Kim KH, Chung JB, Suh TS, Kang SW, Kang SH, Eom KY, Song C, Kim IA, Kim JS. Dosimetric and radiobiological comparison in different dose calculation grid sizes between Acuros XB and anisotropic analytical algorithm for prostate VMAT. PLoS One 2018; 13:e0207232. [PMID: 30419058 PMCID: PMC6231664 DOI: 10.1371/journal.pone.0207232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/27/2018] [Indexed: 11/19/2022] Open
Abstract
To investigate feasible treatment planning parameters, we aimed to evaluate the dosimetric and radiobiological impact of the dose calculation algorithm and grid size in the volumetric modulated arc therapy (VMAT) plan for prostate cancer. Twenty patients were selected, and the treatment plans were initially generated with anisotropic analytical algorithm (AAA) and recalculated with Acuros XB (AXB) algorithm. Various dose grids were used for AXB (1, 2, and 3 mm) and AAA (1, 3, and 5 mm) plan. Dosimetric parameters such as homogeneity index (HI) and conformity index (CI), and radiobiological parameters such as tumor control probability (TCP) and normal tissue complication probability (NTCP) were calculated. Significant differences were observed in the planning target volume (PTV) coverage between both algorithms, and the V95%, HI, and CI of AAA were significantly affected by grid (p < 0.01). On 1 mm grid, the mean rectal dose difference between both algorithms was 2.87% of the prescription dose (p < 0.01), which was the highest among the critical organs. The TCP and NTCP of the AAA were higher than those of AXB (p < 0.01). Compared to AXB with 1 mm grid, the 2 mm grid showed comparable dose calculation accuracy with short calculation time. This study found that the PTV and rectum show significant differences according to dose calculation algorithm and grid. Considering the dose calculation performance for heterogeneous area, we recommend AXB with 2 mm grid for improving treatment efficiency of prostate VMAT.
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Affiliation(s)
- Kyeong-Hyeon Kim
- Department of Biomedicine & Health Sciences, Research Institute of Biomedical Engineering, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Jin-Beom Chung
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
- * E-mail: (JBC); (TSS)
| | - Tae Suk Suh
- Department of Biomedicine & Health Sciences, Research Institute of Biomedical Engineering, College of Medicine, the Catholic University of Korea, Seoul, Korea
- * E-mail: (JBC); (TSS)
| | - Sang-Won Kang
- Department of Biomedicine & Health Sciences, Research Institute of Biomedical Engineering, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Seong-Hee Kang
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Keun-Yong Eom
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Changhoon Song
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In-Ah Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae-Sung Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
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15
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van Wijk Y, Vanneste BGL, Jochems A, Walsh S, Oberije CJ, Pinkawa M, Ramaekers BLT, Vega A, Lambin P. Development of an isotoxic decision support system integrating genetic markers of toxicity for the implantation of a rectum spacer. Acta Oncol 2018; 57:1499-1505. [PMID: 29952681 DOI: 10.1080/0284186x.2018.1484156] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Previous studies revealed that dose escalated radiotherapy for prostate cancer patients leads to higher tumor control probabilities (TCP) but also to higher rectal toxicities. An isotoxic model was developed to maximize the given dose while controlling the toxicity level. This was applied to analyze the effect of an implantable rectum spacer (IRS) and extended with a genetic test of normal tissue radio-sensitivity. A virtual IRS (V-IRS) was tested using this method. We hypothesized that the patients with increased risk of toxicity would benefit more from an IRS. MATERIAL AND METHODS Sixteen localized prostate cancer patients implanted with an IRS were included in the study. Treatment planning was performed on computed tomography (CT) images before and after the placement of the IRS and with a V-IRS. The normal tissue complication probability (NTCP) was calculated using a QUANTEC reviewed model for Grade > =2 late rectal bleeding and the number of fractions of the plans were adjusted until the NTCP value was under 5%. The resulting treatment plans were used to calculate the TCP before and after placement of an IRS. This was extended by adding the effect of two published genetic single nucleotide polymorphisms (SNP's) for late rectal bleeding. RESULTS The median TCP resulting from the optimized plans in patients before the IRS was 75.1% [32.6-90.5%]. With IRS, the median TCP is significantly higher: 98.9% [80.8-99.9%] (p < .01). The difference in TCP between the V-IRS and the real IRS was 1.8% [0.0-18.0%]. Placing an IRS in the patients with SNP's improved the TCP from 49.0% [16.1-80.8%] and 48.9% [16.0-72.8%] to 96.3% [67.0-99.5%] and 90.1% [49.0-99.5%] (p < .01) respectively for either SNP. CONCLUSION This study was a proof-of-concept for an isotoxic model with genetic biomarkers with a V-IRS as a multifactorial decision support system for the decision of a placement of an IRS.
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Affiliation(s)
- Yvonka van Wijk
- The D‐Lab: Decision Support for Precision Medicine, GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Ben G. L. Vanneste
- Department of Radiation Oncology (MAASTRO), GROW – School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Arthur Jochems
- The D‐Lab: Decision Support for Precision Medicine, GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Sean Walsh
- The D‐Lab: Decision Support for Precision Medicine, GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Cary J. Oberije
- The D‐Lab: Decision Support for Precision Medicine, GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany
- Department of Radiation Oncology, MediClin Robert Janker Klinik, Bonn, Germany
| | - Bram L. T. Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Ana Vega
- Fundación Pública Galega de Medicina Xenómica-SERGAS, Grupo de Medicina Xenómica-USC, CIBERER, IDIS, Santiago de Compostela, Spain
| | - Philippe Lambin
- The D‐Lab: Decision Support for Precision Medicine, GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
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Vanneste BGL, Van Limbergen EJ, van de Beek K, van Lin E, Lutgens L, Lambin P. A biodegradable rectal balloon implant to protect the rectum during prostate cancer radiotherapy for a patient with active Crohn's disease. Tech Innov Patient Support Radiat Oncol 2018; 6:1-4. [PMID: 32095571 PMCID: PMC7033750 DOI: 10.1016/j.tipsro.2018.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/26/2018] [Indexed: 12/22/2022] Open
Abstract
Active inflammatory bowel disease is an exclusion criterion for high-dose radiotherapy. A rectum spacer was inserted between the prostate and the rectal wall. The rectum spacer pushes the rectum outside of the high-dose area. No rectal toxicity of the radiotherapy or toxicity flare of the IBD was observed.
Background Radiotherapy in patients with active inflammatory bowel disease (IBD) is usually considered an absolute exclusion criterion for prostate cancer radiotherapy treatment. There are no reports available on the use of a biodegradable rectal balloon implantation (RBI) in patients with active IBD for prostate cancer radiotherapy. Case presentation We report on a patient with high-risk prostate cancer with the comorbidity of an active IBD with pancolitis location. He was treated with neo-adjuvant hormonal therapy and high-dose external beam radiotherapy to the prostate and the seminal vesicles. Before radiotherapy treatment, a biodegradable RBI was implanted between the prostate and the anterior rectal wall to push the rectum outside of the high-dose area. This patient at high-risk for rectal toxicity was successfully irradiated to his prostate with only a grade I urinary toxicity, no acute rectal toxicity or toxicity flare of the IBD. Conclusions This case describes the use of a RBI implantation in patients with active IBD for prostate cancer radiotherapy. The use of a biodegradable RBI proved to be a promised solution for such patients, and have to be further investigated.
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Affiliation(s)
- Ben G L Vanneste
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Evert J Van Limbergen
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Kees van de Beek
- Department of Urology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | | | - Ludy Lutgens
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
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