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Cheng Y, Zhang H, Wei H, Yu CY. Injectable hydrogels as emerging drug-delivery platforms for tumor therapy. Biomater Sci 2024; 12:1151-1170. [PMID: 38319379 DOI: 10.1039/d3bm01840g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Tumor therapy continues to be a prominent field within biomedical research. The development of various drug carriers has been propelled by concerns surrounding the side effects and targeting efficacy of various chemotherapeutic drugs and other therapeutic agents. These carriers strive to enhance drug concentration at tumor sites, minimize systemic side effects, and improve therapeutic outcomes. Among the reported delivery systems, injectable hydrogels have emerged as an emerging candidate for the in vivo delivery of chemotherapeutic drugs due to their minimal invasive drug delivery properties. This review systematically summarizes the composition and preparation methodologies of injectable hydrogels and further highlights the delivery mechanisms of diverse drugs using these hydrogels for tumor therapy, along with an in-depth discussion on the optimized therapeutic efficiency of drugs encapsulated within the hydrogels. The work concludes by providing a dynamic forward-looking perspective on the potential challenges and possible solutions of the in situ injectable hydrogels for non-surgical and real-time diagnostic applications.
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Affiliation(s)
- Yao Cheng
- Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study & School of Pharmaceutical Science, Hengyang Medical School, University of South China, 28 W Changsheng Road, Hengyang 421001, Hunan, China.
| | - Haitao Zhang
- Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study & School of Pharmaceutical Science, Hengyang Medical School, University of South China, 28 W Changsheng Road, Hengyang 421001, Hunan, China.
| | - Hua Wei
- Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study & School of Pharmaceutical Science, Hengyang Medical School, University of South China, 28 W Changsheng Road, Hengyang 421001, Hunan, China.
| | - Cui-Yun Yu
- Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study & School of Pharmaceutical Science, Hengyang Medical School, University of South China, 28 W Changsheng Road, Hengyang 421001, Hunan, China.
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Vaggers S, Rai BP, Chedgy ECP, de la Taille A, Somani BK. Polyethylene glycol-based hydrogel rectal spacers for prostate brachytherapy: a systematic review with a focus on technique. World J Urol 2021; 39:1769-1780. [PMID: 32840655 PMCID: PMC8217059 DOI: 10.1007/s00345-020-03414-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/13/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Radiation dose to the rectum in prostate brachytherapy (PBT) can be reduced by the use of polyethylene glycol (PEG) hydrogel spacers. This reduces the rate of rectal toxicity and allows dose escalation to the prostate. Our objectives were to provide an overview of technique for injection of a PEG hydrogel spacer, reduction in rectal dosimetry, gastrointestinal toxicity and potential complications. METHODS We systematically reviewed the role of PEG hydrogel spacers in PBT using the Cochrane and PRISMA methodology for all English-language articles from January 2013 to December 2019. Data was extracted for type of radiotherapy, number of patients, type of PEG-hydrogel used, mean prostate-rectum separation, rectal dosimetry, acute and late GI toxicity, procedure-related complications and the technique used for hydrogel insertion. RESULTS Nine studies (671 patients and 537 controls) met our inclusion criteria. Of these 4 used DuraSeal® and 5 used SpaceOAR®. The rectal spacing achieved varied between 7.7-16 mm. Failure of hydrogel insertion was seen only in 12 patients, mostly related to failure of hydrodissection in patients undergoing salvage PBT. Where reported, the rectal D2 cc was reduced by between 21.6 and 52.6% and the median rectal V75% cc was reduced by between 91.8-100%. Acute GI complications were mostly limited to grade 1 or 2 toxicity (n = 153, 33.7%) with low levels of grade 3 or 4 toxicity (n = 1, 0.22%). Procedure-related complications were limited to tenesmus (0.14%), rectal discomfort (1.19%), and bacterial prostatitis (0.44%). CONCLUSIONS PEG hydrogel spacers are safe to insert. Gel insertion is easy, fast and has a low rate of failure. These studies convincingly demonstrate a significant reduction in rectal dosimetry. Although the results of spacers in reducing rectal toxicity is promising, these need to be confirmed in prospective randomised trial.
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Affiliation(s)
- S. Vaggers
- University Hospital Southampton NHS Trust, Southampton, UK
| | | | | | - A. de la Taille
- Department of Urology, Robotic and Miniinvasive Surgery, Assistance Publique des Hopitaux de Paris, 94000 Créteil, France
| | - B. K. Somani
- University Hospital Southampton NHS Trust, Southampton, UK
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Applewhite J, Barker J, Vestal JC. Successful Use of Absorbable Hydrogel Rectal Spacers (SpaceOAR) Before Salvage Radiation Therapy After Previous Prostate Cryotherapy. Adv Radiat Oncol 2021; 6:100647. [PMID: 33748548 PMCID: PMC7966841 DOI: 10.1016/j.adro.2021.100647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 01/05/2021] [Indexed: 12/15/2022] Open
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Afkhami Ardekani M, Ghaffari H. Optimization of prostate brachytherapy techniques with polyethylene glycol-based hydrogel spacers: A systematic review. Brachytherapy 2019; 19:13-23. [PMID: 31542390 DOI: 10.1016/j.brachy.2019.08.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/01/2019] [Accepted: 08/21/2019] [Indexed: 01/07/2023]
Abstract
PURPOSE The objective of this overview was to critically evaluate the effect of polyethylene glycol (PEG)-based hydrogel spacers during prostate brachytherapy with regard to dosimetric and clinical benefits, as well as procedure-related toxicity. METHODS AND MATERIALS A systematic search in the PubMed database was performed. RESULTS A total of 12 studies, involving 615 patients with PEG hydrogel injection, were included. Overall, patients well tolerated the implantation of PEG hydrogel spacers with an excellent safety profile. However, although there were some procedure-related complications, rates of these complications were very rare. Toxicities related to the spacer were limited to Grade 1 rectal discomfort and pain (9/615 patients), Grade 2 rectal ulceration (1 in 615 patients), perineal abscess (1 in 615 patients), and bacterial prostatitis (2/615 patients) according to Common Terminology Criteria for Adverse Events v4.0 grading scheme. The application of PEG hydrogel spacers significantly reduced radiation doses to the rectum during prostate brachytherapy in the different setting. Although there was no prospective randomized clinical trial, retrospective studies showed that reducing rectal doses by the implantation of PEG hydrogel may result in an improvement in rectal toxicity. CONCLUSIONS The insertion of hydrogel spacers is safe, resulting in a significant decrease in rectal doses. This may lead to a reduction in rectal or gastrointestinal toxicity. Prospective randomized clinical trials are warranted to confirm the clinical impact of rectal dosimetric improvements.
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Affiliation(s)
- Mahdieh Afkhami Ardekani
- Department of Radiology, Faculty of Para-Medicine, Hormozgan University of Medical Sciences, Bandar-Abbas, Iran
| | - Hamed Ghaffari
- Department of Medical Physics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
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Kashihara T, Murakami N, Tselis N, Kobayashi K, Tsuchida K, Shima S, Masui K, Yoshida K, Takahashi K, Inaba K, Umezawa R, Igaki H, Ito Y, Kato T, Uno T, Itami J. Hyaluronate gel injection for rectum dose reduction in gynecologic high-dose-rate brachytherapy: initial Japanese experience. JOURNAL OF RADIATION RESEARCH 2019; 60:501-508. [PMID: 31034570 PMCID: PMC6640896 DOI: 10.1093/jrr/rrz016] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/29/2019] [Indexed: 06/09/2023]
Abstract
Perirectal hyaluronate gel injection (HGI) appears to be a promising technique for healthy tissue dose sparing in pelvic radiotherapy. In this analysis, we report our initial experience of HGI in gynecologic brachytherapy, focusing on its safety and effectiveness for dose reduction to the rectum. Between July 2013 and May 2014, 36 patients received HGI for primary/salvage gynecologic brachytherapy. Dosimetric effect analysis was based on pre- and post-HGI computed tomography dataset registration with corresponding dose-volume histogram evaluation. The maximum dose to the most exposed 0.1 cm3 (D0.1cm3) and 2.0 cm3 (D2.0cm3) were used as index values for rectum and bladder dose evaluation. The dose indexes for target volume (TV) coverage were TV D90/V100. In all cases, HGI was well tolerated, with no acute or late adverse events documented at a median follow-up of 220 days (range, 18-1046 days). Rectum D2.0cm3 and D0.1cm3 were significantly decreased by HGI (P < 0.001 and P = 0.003, respectively), with no significant impact on dosimetric parameters of bladder and TV coverage. Factors correlating negatively with the dosimetric effect of HGI were an increasing number of interstitial catheters (P = 0.003) as well as Lcranial100% (P = 0.014) and Lcranial80% (P = 0.001) [i.e. the length from the anal verge to the most cranial point at which the 100% and 80% isodose lines, respectively, crossed the rectum]. The concept of HGI for gynecologic brachytherapy is plausible, and our initial experience indicates it to be an effective technique for rectal dose reduction in radiotherapy of intrapelvic tumours.
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Affiliation(s)
- Tairo Kashihara
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Nikolaos Tselis
- Department of Radiotherapy and Oncology, University of Frankfurt, Theodor-W.-Adorno-Platz 1 , Frankfurt am Main, Germany
| | - Kazuma Kobayashi
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Keisuke Tsuchida
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Satoshi Shima
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Koji Masui
- Department of Radiology, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, Japan
| | - Ken Yoshida
- Department of Radiation Oncology, Osaka Medical College, Daigakucho 2-7, Takatsuki, Osaka, Japan
| | - Kana Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Rei Umezawa
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Yoshinori Ito
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Tomoyasu Kato
- Department of Gynecologic Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Takashi Uno
- Department of Radiology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, Japan
| | - Jun Itami
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
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6
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Autologous fat as a rectal–prostate spacer for prostate brachytherapy: Results at 6 months. Brachytherapy 2019; 18:462-469. [DOI: 10.1016/j.brachy.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 12/13/2022]
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Yu S, He C, Chen X. Injectable Hydrogels as Unique Platforms for Local Chemotherapeutics-Based Combination Antitumor Therapy. Macromol Biosci 2018; 18:e1800240. [DOI: 10.1002/mabi.201800240] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/15/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Shuangjiang Yu
- Key Laboratory of Polymer Ecomaterials; Changchun Institute of Applied Chemistry; Chinese Academy of Sciences; Changchun 130022 China
| | - Chaoliang He
- Key Laboratory of Polymer Ecomaterials; Changchun Institute of Applied Chemistry; Chinese Academy of Sciences; Changchun 130022 China
| | - Xuesi Chen
- Key Laboratory of Polymer Ecomaterials; Changchun Institute of Applied Chemistry; Chinese Academy of Sciences; Changchun 130022 China
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8
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Leiker AJ, Desai NB, Folkert MR. Rectal radiation dose-reduction techniques in prostate cancer: a focus on the rectal spacer. Future Oncol 2018; 14:2773-2788. [PMID: 29939069 DOI: 10.2217/fon-2018-0286] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Prostate cancer is the most common cancer in men. External beam radiotherapy by a variety of methods is a standard treatment option with excellent disease control. However, acute and late rectal side effects remain a limiting concern in intensification of therapy in higher-risk patients and in efforts to reduce treatment burden in others. A number of techniques have emerged that allow for high-radiation dose delivery to the prostate with reduced risk of rectal toxicity, including image-guided intensity-modulated radiation therapy, endorectal balloons and various forms of rectal spacers. Image-guided radiation therapy, either intensity-modulated radiation therapy or stereotactic ablative radiation therapy, in conjunction with a rectal spacer, is an efficacious means to reduce acute and long-term rectal toxicity.
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Affiliation(s)
- Andrew J Leiker
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
| | - Neil B Desai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
| | - Michael R Folkert
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
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Chao M, Ho H, Chan Y, Tan A, Pham T, Bolton D, Troy A, Temelcos C, Sengupta S, McMillan K, Cham CW, Liu M, Ding W, Subramanian B, Wasiak J, Lim Joon D, Spencer S, Lawrentschuk N. Prospective analysis of hydrogel spacer for patients with prostate cancer undergoing radiotherapy. BJU Int 2018. [PMID: 29520983 DOI: 10.1111/bju.14192] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To report on the dosimetric benefits and late toxicity outcomes after injection of hydrogel spacer (HS) between the prostate and rectum for patients treated with prostate radiotherapy (RT). PATIENTS AND METHODS In all, 76 patients with a clinical stage of T1-T3a prostate cancer underwent general anaesthesia for fiducial marker insertion plus injection of the HS into the perirectal space before intensity-modulated RT (IMRT) or volumetric-modulated arc RT (VMAT). HS safety, dosimetric benefits, and the immediate- to long-term effects of gastrointestinal (GI) toxicity were assessed. RESULTS There were no postoperative complications reported. The mean (range) prostate size was 66.0 (25.0-187.0) mm. Rectal dose volume parameters were observed and the volume of rectum receiving 70 Gy (rV70 ), 75 Gy (rV75 ) and 78 Gy (rV78 ) was 7.8%, 3.6% and 0.4%, respectively. In all, 21% of patients (16/76) developed acute Grade 1 GI toxicities, but all were resolved completely by 3 months after treatment; whilst, 3% of patients (2/76) developed late Grade 1 GI toxicities. No patients had acute or late Grade ≥2 GI toxicities. CONCLUSION Injection of HS resulted in a reduction of irradiated rectal dose volumes along with minimal GI toxicities, irrespective of prostate size.
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Affiliation(s)
- Michael Chao
- The Austin Hospital, Heidelberg, Vic., Australia.,Genesis Cancer Care Victoria, Ringwood East, Vic., Australia
| | - Huong Ho
- Genesis Cancer Care Victoria, Ringwood East, Vic., Australia
| | - Yee Chan
- The Austin Hospital, Heidelberg, Vic., Australia.,Ringwood Private Hospital, Ringwood East, Vic., Australia
| | - Alwin Tan
- The Bays Hospital, Mornington, Vic., Australia
| | - Trung Pham
- The Valley Private Hospital, Mulgrave, Vic., Australia
| | - Damien Bolton
- The Austin Hospital, Heidelberg, Vic., Australia.,Ringwood Private Hospital, Ringwood East, Vic., Australia
| | - Andrew Troy
- The Austin Hospital, Heidelberg, Vic., Australia
| | | | - Shomik Sengupta
- The Austin Hospital, Heidelberg, Vic., Australia.,Melbourne University; Eastern Health Clinical School, Monash University, Clayton, Vic., Australia
| | - Kevin McMillan
- Ringwood Private Hospital, Ringwood East, Vic., Australia
| | | | - Madalena Liu
- Ringwood Private Hospital, Ringwood East, Vic., Australia
| | - Wei Ding
- Genesis Cancer Care Victoria, Ringwood East, Vic., Australia
| | | | - Jason Wasiak
- The Austin Hospital, Heidelberg, Vic., Australia.,University of Melbourne, Melbourne, Vic., Australia
| | - Daryl Lim Joon
- The Austin Hospital, Heidelberg, Vic., Australia.,Genesis Cancer Care Victoria, Ringwood East, Vic., Australia
| | - Sandra Spencer
- Genesis Cancer Care Victoria, Ringwood East, Vic., Australia
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Daar E, Bradley D, Alkhorayef M, Al-Mugren K, Abdallat R, Al-Dousari H. Towards evaluating post-irradiation tissue alterations. Radiat Phys Chem Oxf Engl 1993 2017. [DOI: 10.1016/j.radphyschem.2016.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Zaorsky NG, Davis BJ, Nguyen PL, Showalter TN, Hoskin PJ, Yoshioka Y, Morton GC, Horwitz EM. The evolution of brachytherapy for prostate cancer. Nat Rev Urol 2017; 14:415-439. [PMID: 28664931 PMCID: PMC7542347 DOI: 10.1038/nrurol.2017.76] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Brachytherapy (BT), using low-dose-rate (LDR) permanent seed implantation or high-dose-rate (HDR) temporary source implantation, is an acceptable treatment option for select patients with prostate cancer of any risk group. The benefits of HDR-BT over LDR-BT include the ability to use the same source for other cancers, lower operator dependence, and - typically - fewer acute irritative symptoms. By contrast, the benefits of LDR-BT include more favourable scheduling logistics, lower initial capital equipment costs, no need for a shielded room, completion in a single implant, and more robust data from clinical trials. Prospective reports comparing HDR-BT and LDR-BT to each other or to other treatment options (such as external beam radiotherapy (EBRT) or surgery) suggest similar outcomes. The 5-year freedom from biochemical failure rates for patients with low-risk, intermediate-risk, and high-risk disease are >85%, 69-97%, and 63-80%, respectively. Brachytherapy with EBRT (versus brachytherapy alone) is an appropriate approach in select patients with intermediate-risk and high-risk disease. The 10-year rates of overall survival, distant metastasis, and cancer-specific mortality are >85%, <10%, and <5%, respectively. Grade 3-4 toxicities associated with HDR-BT and LDR-BT are rare, at <4% in most series, and quality of life is improved in patients who receive brachytherapy compared with those who undergo surgery.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, Pennsylvania 19111-2497, USA
| | - Brian J Davis
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Charlton Bldg/Desk R - SL, Rochester, Minnesota 5590, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital, 75 Francis St BWH. Radiation Oncology, Boston, Massachusetts 02115, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, 1240 Lee St, Charlottesville, Virginia 22908, USA
| | - Peter J Hoskin
- Mount Vernon Cancer Centre, Rickmansworth Road, Northwood, Middlesex HA6 2RN, UK
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan
| | - Gerard C Morton
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, Pennsylvania 19111-2497, USA
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Rectal separation using hydroxypropyl methylcellulose in intracavitary brachytherapy of cervical cancer: an innovative approach. J Contemp Brachytherapy 2016; 8:399-403. [PMID: 27895681 PMCID: PMC5116447 DOI: 10.5114/jcb.2016.62951] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 08/22/2016] [Indexed: 11/17/2022] Open
Abstract
PURPOSE This study was initiated to prove feasibility of hydrogel application in recto-vaginal space in intracavitary brachytherapy (ICBT) of cervical cancer in order to reduce rectal toxicity. MATERIAL AND METHODS In a case of stage IIB cervical cancer, after external beam radiotherapy (EBRT), we planned ICBT 7 Gy × 3 fractions. In 1st fraction (Plan 1), due to narrow separation between rectum and cervix (0.18 cm), only 5 Gy was delivered at point A (with high-risk clinical target volume [HR-CTV] D90 5.94 Gy, intermediate risk clinical target volume [IR-CTV] D90 4.54 Gy, rectum D2cc 5.72 Gy, bladder D2cc 5.52 Gy, and sigmoid colon 5.82 Gy). In 2nd fraction (Plan 2), interstitial brachytherapy (ISBT) was attempted. For the prescription of 5 Gy, we get dose levels almost similar to the 1st insertion: HR-CTV D90 (6.7 Gy), IR-CTV D90 (3.06 Gy), bladder D2cc (5.7 Gy), rectum D2cc (4.8 Gy), sigmoid colon D2cc (1.3 Gy) (separation = 0.23 cm). During 3rd fraction (Plan 3), prior doing interstitial insertion, we instilled 50 cc of hydroxypropyl methylcellulose (Viscomet®) up to the tip of recto-vaginal septum. A repeat computed tomography (CT) scan was done 4 hours after Plan 3 treatment and it was re-planned (Plan 4) to find out migration of hydrogel if any and its dosimetric impact. RESULTS 9 Gy was delivered to point A with a separation of 1.1 cm in Plan 3 (with HR-CTV D90 16.4 Gy, IR-CTV D90 11.3 Gy, rectum D2cc 3.6 Gy, bladder D2cc 6.9 Gy, and sigmoid colon 2.2 Gy). We achieved an optimum cumulative EQD2 dose (HR-CTV D90 98.4 Gy, IR-CTV D90 76.1 Gy, rectum D2cc 67.7 Gy, bladder D2cc 73.2 Gy, and sigmoid colon 59.3 Gy). Hydrogel volume was decreased in Plan 4 without a major dosimetric changes. CONCLUSIONS Hydrogel instillation is a useful tool for recto-vaginal separation during cervical cancer brachytherapy. It increases therapeutic ratio without any adverse event.
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Müller AC, Mischinger J, Klotz T, Gagel B, Habl G, Hatiboglu G, Pinkawa M. Interdisciplinary consensus statement on indication and application of a hydrogel spacer for prostate radiotherapy based on experience in more than 250 patients. Radiol Oncol 2016; 50:329-36. [PMID: 27679550 PMCID: PMC5024663 DOI: 10.1515/raon-2016-0036] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 04/17/2016] [Indexed: 12/19/2022] Open
Abstract
Background The aim of the study was to reach a consensus on indication and application of a hydrogel spacer based on multicentre experience and give new users important information to shorten the learning curve for this innovative technique. Methods The interdisciplinary meeting was attended by radiation oncologists and urologists, each with experience of 23 – 138 hydrogel injections (SpaceOAR®) in prostate cancer patients before dose-escalated radiotherapy. User experience was discussed and questions were defined to comprise practical information relevant for successful hydrogel injection and treatment. Answers to the defined key questions were generated. Hydrogel-associated side effects were collected to estimate the percentage, treatment and prognosis of potential risks. Results The main indication for hydrogel application was dose-escalated radiotherapy for histologically confirmed low or intermediate risk prostate cancer. It was not recommended in locally advanced prostate cancer. The injection or implantation was performed under transrectal ultrasound guidance via the transperineal approach after prior hydrodissection. The rate of injection-related G2-toxicity was 2% (n = 5) in a total of 258 hydrogel applications. The most frequent complication (n = 4) was rectal wall penetration, diagnosed at different intervals after hydrogel injection and treated conservatively. Conclusions A consensus was reached on the application of a hydrogel spacer. Current experience demonstrated feasibility, which could promote initiation of this method in more centres to reduce radiation-related gastrointestinal toxicity of dose-escalated IGRT. However, a very low rate of a potential serious adverse event could not be excluded. Therefore, the application should carefully be discussed with the patient and be balanced against potential benefits.
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Affiliation(s)
| | | | - Theodor Klotz
- Department of Urology, Hospital Weiden, Weiden, Germany
| | - Bernd Gagel
- Department of Radiation Oncology, Hospital Weiden, Weiden, Germany
| | - Gregor Habl
- Department of Radiation Oncology, Technical University Munich, Munich, Germany
| | - Gencay Hatiboglu
- Department of Urology, University of Heidelberg, Heidelberg, Germany
| | - Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany
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Trifiletti DM, Garda AE, Showalter TN. Implanted spacer approaches for pelvic radiation therapy. Expert Rev Med Devices 2016; 13:633-40. [DOI: 10.1080/17434440.2016.1195682] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Daniel M. Trifiletti
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Allison E. Garda
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Timothy N. Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
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15
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Abstract
Definitive radiotherapy is a well-recognized treatment option for localized prostate cancer. Rectum toxicity is the dose-limiting toxicity. Dose-volume correlations have been reported in many studies. The application of a spacer to increase the distance between the prostate and anterior rectal wall is an innovative technique, considerably reducing the dose to the rectum. Hyaluronic acid, human collagen, an inflatable balloon or hydrogel are potential materials to create the desired effect. The number of clinical studies is rapidly increasing. Well-tolerated injection or implantation techniques and low rectal treatment-related toxicity have been demonstrated in prospective studies. Long-term clinical results and the results of randomized studies are needed to better define the beneficial effect for the patient.
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Affiliation(s)
- Michael Pinkawa
- *Department of Radiation Oncology, Rheinisch-Westfaelische Technische Hochschule Aachen University, Pauwelsstrasse 30, 52057 Aachen, Germany;
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Late rectal toxicity after low-dose-rate brachytherapy: incidence, predictors, and management of side effects. Brachytherapy 2014; 14:148-59. [PMID: 25516492 DOI: 10.1016/j.brachy.2014.11.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 11/05/2014] [Accepted: 11/06/2014] [Indexed: 12/20/2022]
Abstract
As clinical outcomes for patients with clinically localized prostate cancer continue to improve, patients and physicians are increasing making treatment decisions based on concerns regarding long-term morbidity. A primary concern is late radiation proctitis, a clinical entity embodied by various signs and symptoms, ranging from diarrhea to rectal fistulas. Here, we present a comprehensive literature review examining the clinical manifestations and pathophysiology of late radiation proctitis after low-dose-rate brachytherapy (BT), as well as its incidence and predictors. The long-term risks of rectal bleeding after BT are on the order of 5-7%, whereas the risks of severe ulceration or fistula are on the order of 0.6%. The most robust predictor appears to be the volume of rectum receiving the prescription dose. In certain situations (e.g., salvage setting, for patients with increased radiosensitivity, and following aggressive biopsy after BT), the risk of these severe toxicities may be increased by up to 10-fold. A variety of excellent management options exist for rectal bleeding, with endoscopic methods being the most commonly used.
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Pinkawa M, Schubert C, Escobar-Corral N, Holy R, Eble MJ. Application of a hydrogel spacer for postoperative salvage radiotherapy of prostate cancer. Strahlenther Onkol 2014; 191:375-9. [PMID: 25339311 DOI: 10.1007/s00066-014-0769-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 10/03/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND In contrast to primary radiotherapy, no reports are available for a hydrogel spacer application in postoperative salvage radiotherapy for prostate cancer. CASE REPORT A 77-year-old patient presented 20 years after radical prostatectomy with a digitally palpable local recurrence at the urethrovesical anastomosis (PSA 5.5 ng/ml). The hydrogel spacer (10 ml, SpaceOAR™) was injected between the local recurrence and rectal wall under transrectal ultrasound guidance. Treatment planning was performed with an intensity-modulated technique up to a total dose of 76 Gy in 2-Gy fractions. The same planning was performed based on computed tomography before spacer injection for comparison. RESULTS The local recurrence, initially directly on the rectal wall, could be displaced more than 1 cm from the rectal wall after hydrogel injection. With a mean total dose of 76 Gy to the planning target volume, rectal wall volumes included in the 70 Gy, 60 Gy, 50 Gy isodoses were 0 cm(3), 0 cm(3), and 0.4 cm(3) with a spacer and 2.9 cm(3), 4.5 cm(3), and 6.2 cm(3) without a spacer, respectively. The patient reported rectal urgency during radiotherapy, completely resolving after the end of treatment. The PSA level was 5.4 ng/ml a week before the end of radiotherapy and dropped to 0.9 ng/ml 5 months after radiotherapy. CONCLUSION A hydrogel spacer was successfully applied for dose-escalated radiotherapy in a patient with macroscopic local prostate cancer recurrence at the urethrovesical anastomosis to decrease the dose at the rectal wall. This option can be considered in specifically selected patients.
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Affiliation(s)
- Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Pauwelsstrasse 30, 52057, Aachen, Germany,
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Mahal BA, Ziehr DR, Hyatt AS, Neubauer-Sugar EH, O'Farrell DA, O'Leary MP, Steele GS, Niedermayr TR, Beard CJ, Martin NE, Orio PF, D'Amico AV, Devlin PM, Nguyen PL. Use of a rectal spacer with low-dose-rate brachytherapy for treatment of prostate cancer in previously irradiated patients: Initial experience and short-term results. Brachytherapy 2014; 13:442-9. [DOI: 10.1016/j.brachy.2014.05.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/19/2014] [Accepted: 05/01/2014] [Indexed: 11/16/2022]
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Ng M, Brown E, Williams A, Chao M, Lawrentschuk N, Chee R. Fiducial markers and spacers in prostate radiotherapy: current applications. BJU Int 2014; 113 Suppl 2:13-20. [DOI: 10.1111/bju.12624] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Michael Ng
- Radiation Oncology Victoria; Melbourne VIC Australia
| | - Elizabeth Brown
- Department of Radiation Oncology; Princess Alexandra Hospital; Brisbane QLD Australia
| | - Andrew Williams
- Department of Urology; Auckland City Hospital; Auckland New Zealand
| | - Michael Chao
- Radiation Oncology Victoria; Melbourne VIC Australia
| | - Nathan Lawrentschuk
- Department of Surgery and Ludwig Institute for Cancer Research; Austin Hospital; University of Melbourne; Melbourne VIC Australia
| | - Raphael Chee
- Genesis Cancer Care Western Australia; Joondalup WA Australia
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Viswanathan AN, Damato AL, Nguyen PL. Novel use of a hydrogel spacer permits reirradiation in otherwise incurable recurrent gynecologic cancers. J Clin Oncol 2013; 31:e446-7. [PMID: 24145342 DOI: 10.1200/jco.2012.47.9931] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Akila N Viswanathan
- Brigham and Women's Hospital/Dana-Farber Cancer Institute; Harvard Medical School, Boston, MA
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