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Salari K, Hazy AJ, Ye H, Sebastian E, Limbacher A, Johnson M, Mitchell B, Thompson AB, Seymour ZA, Nandalur SR, Krauss DJ. 21 Gy single fraction prostate HDR brachytherapy: 5-year results of a single institution prospective pilot study. Brachytherapy 2024; 23:321-328. [PMID: 38514368 DOI: 10.1016/j.brachy.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 11/16/2023] [Accepted: 02/19/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE To present the outcome and toxicity results of a prospective trial of 21 Gy single fraction high-dose-rate (HDR) brachytherapy for men with low- or intermediate-risk prostate cancer. METHODS AND MATERIALS Patients were treated according to an IRB-approved prospective study of single fraction HDR brachytherapy. Eligible patients had low- or intermediate-risk prostate cancer with tumor stage ≤ T2b, PSA ≤ 15, and Gleason score ≤ 7. Patients underwent trans-rectal ultrasound-guided trans-perineal implant of the prostate followed by single fraction HDR brachytherapy to a dose of 21 Gy. The primary endpoint was grade ≥ 2 urinary/GI toxicity rates. RESULTS Twenty-six patients were enrolled with a median follow up of 5.1 years and median age of 64 years. 88.5% of patients had T1 disease, 15.4% had Gleason score 6 (84.6% Gleason 7), and median pre-treatment PSA was 5.0 ng/mL. Acute and chronic grade ≥ 2 urinary toxicity rates were 38.5% and 38.5%, respectively. There were no grade ≥ 2 acute or chronic GI toxicities. Six (23.1%) patients experienced biochemical failure, six (23.1%) patients experienced radiographic local failure, and five (19.2%) patients had biopsy-proven local failure. No patients developed regional lymph node recurrence or distant metastasis. 5-year overall survival and cause-specific survival were 96.2% and 100%, respectively. CONCLUSIONS 21 Gy single fraction HDR brachytherapy was associated with modestly higher-than-anticipated chronic urinary toxicity, as well as high biochemical and local failure rates. The results from this prospective pilot study do not support the use of this regimen in standard clinical practice.
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Affiliation(s)
- Kamran Salari
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, MI.
| | - Allison J Hazy
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, MI
| | - Hong Ye
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, MI
| | - Evelyn Sebastian
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, MI
| | - Amy Limbacher
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, MI
| | - Matthew Johnson
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, MI; Department of Radiation Oncology, Karmanos Cancer Institute at McLaren Port Huron, Port Huron, MI
| | - Beth Mitchell
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, MI
| | - Andrew B Thompson
- Department of Radiation Oncology, Corewell Health Beaumont Troy Hospital, Troy, MI
| | - Zachary A Seymour
- Department of Radiation Oncology, Corewell Health Dearborn Hospital, Dearborn, MI
| | - Sirisha R Nandalur
- Department of Radiation Oncology, Corewell Health Beaumont Troy Hospital, Troy, MI
| | - Daniel J Krauss
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, MI
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Kamran SC, Vapiwala N. Approach to Patients with High-Risk Localized Prostate Cancer: Radiation Oncology Perspective. Curr Treat Options Oncol 2024; 25:84-96. [PMID: 38167980 DOI: 10.1007/s11864-023-01163-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2023] [Indexed: 01/05/2024]
Abstract
OPINION STATEMENT High-risk localized prostate cancer is a challenging clinical entity to treat, with heterogeneous responses to an evolving array of multidisciplinary treatment approaches. In addition, this disease state is growing in incidence due to a variety of factors, including shifting recommendations that discouraged routine prostate cancer screening. Current guidelines now incorporate an informed decision-making process for prostate cancer screening and evaluation. More work is underway to improve targeted screening for certain at-risk populations and to implement greater personalization in the use of diagnostic tools. Once diagnosed with high-risk localized disease, a multimodality treatment paradigm is warranted. Radiation-in its various forms and combinations-plays a large and continually evolving role in the management of high-risk prostate cancer, yet treatment outcomes are still suboptimal. There is a growing need to improve upon current treatment approaches, and better personalize a particular treatment recommendation based on both tumor and patient characteristics, as well as patient preference and goals of therapy. Given that treatment generally requires more than one therapy, there are notable implications on long-term quality of life, especially with respect to overlapping and cumulative side effects of local and systemic therapies, respectively. The desire for aggressive therapy to optimize cancer control outcomes must be weighed against the risk of morbidities and overtreatment and discussed with each patient so that an informed decision about treatment and care can be determined. High-level evidence to support treatment recommendations, where available, is critical for a data-driven and tailored approach to address all goals of care.
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Affiliation(s)
- Sophia C Kamran
- Department of Radiation Oncology, Massachusetts General Cancer Center, Harvard Medical School, 55 Fruit Street, Cox 3, Boston, MA, 02114, USA.
| | - Neha Vapiwala
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Perelman School of Medicine, 3400 Civic Center Boulevard, TRC 4 West, Philadelphia, PA, 19104, USA
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Hjälm-Eriksson M, Nilsson S, Brandberg Y, Johansson H, Lennernäs B, Lundell G, Castellanos E, Ullén A. High rate of local control and cure at 10 years after treatment of prostate cancer with external beam radiotherapy and high-dose-rate brachytherapy: a single centre experience. Acta Oncol 2021; 60:1301-1307. [PMID: 34498986 DOI: 10.1080/0284186x.2021.1953706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE To analyse the cumulative incidence of any failure (AF), prostate cancer-specific failure (PCSF), any death (AD), prostate cancer-specific death (PCSD), and local control in 2387 men with prostate cancer (PC), consecutively treated with combined high-dose-rate brachytherapy (HDRBT) and external beam radiotherapy (EBRT) from 1998 to 2010. MATERIAL AND METHODS A retrospective, single-institution study of men with localised PC. The mean age was 66 years and 54.7% had high-risk PC according to the Cambridge prognostic group (CPG) classification. The treatment was delivered as EBRT (2 Gy × 25) and HDRBT (10 Gy × 2) with combined androgen blockade (CAB). The median follow-up was 10.2 years. RESULTS The cumulative incidence of PCSD at 10 years was 5% [CI 95% 0.04-0.06]. The 10 years PCSD per risk group were: low (L) 0.4%, intermediate favourable (IF) 1%, intermediate unfavourable (IU) 4.3%, high-risk favourable (HF) 5.8%, and high-risk unfavourable (HU) 13.9%. The PCSF rate at 10 years was 16.5% [CI 95% 0.15-0.18]. The PCSF per risk group at 10 years were: L 2.5%, IF 5.5%, IU 15.9%, HF 15.6%, and HU 38.99%. PCSF occurred in 399 men, of whom 15% were found to have local failure. The estimated frequency of local failure in the entire cohort was 1.2%. CONCLUSIONS HDRBT combined with EBRT is an effective treatment with long-term overall survival and excellent local control for patients with PC. The low rate of local recurrence among men with relapse suggests that these patients were micro metastasised at time of treatment, which calls for improved methods to detect disseminated disease.
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Affiliation(s)
- Marie Hjälm-Eriksson
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Department of Oncology, Capio S:t Göran’s Hospital, Stockholm, Sweden
| | - Sten Nilsson
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Yvonne Brandberg
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Department of Pelvic Cancer, Psychosocial Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Hemming Johansson
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Bo Lennernäs
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Göran Lundell
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Enrique Castellanos
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Ullén
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Karolinska University Hospital, Stockholm, Sweden
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The Impact of Different Timing Schedules on Prostate HDR-Mono-Brachytherapy. A TCP Modeling Investigation. Cancers (Basel) 2021; 13:cancers13194899. [PMID: 34638379 PMCID: PMC8507871 DOI: 10.3390/cancers13194899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 11/22/2022] Open
Abstract
Simple Summary Reported clinical data on high dose rate mono brachytherapy of prostate cancer carried out using two different treatment regimens are analyzed in this study. The analysis is based on a mechanistic tumor control probability model, which accounts for a possible increase in the tumor radio-sensitivity during treatment. The aim of the study was to verify a hypothesis that the clinically observed better performance of the longer treatment regimen (28 days vs. 14 days) might be due to a state of initial hypoxia and its ensued overcoming by re-oxygenation and, hence, re-sensitization of the prostate cancer. The performed investigation confirmed the assumption of initially hypoxic stage of the tumor followed by its re-sensitization, thus providing a foundation for the use of prolonged schedules for low- to intermediate-risk prostate cancer treatment. Abstract Background: Mechanistic TCP (tumor control probability) models exist that account for possible re-sensitization of an initially hypoxic tumor during treatment. This phenomenon potentially explains the better outcome of a 28-day vs 14-day treatment schedule of HDR (high dose rate) brachytherapy of low- to intermediate-risk prostate cancer as recently reported. Methods: A TCP model accounting for tumor re-sensitization developed earlier is used to analyze the reported clinical data. In order to analyze clinical data using individual TCP model, TCP distributions are constructed assuming inter-individual spread in radio-sensitivity. Results: Population radio-sensitivity parameter values are found that result in TCP population values which are close to the reported ones. Using the estimated population parameters, two hypothetical regimens are investigated that are shorter than the ones used clinically. The impact of the re-sensitization rate on the calculated treatment outcome is also investigated as is the anti-hypothesis that there is no re-sensitization during treatment. Conclusions: The carried out investigation shows that the observed clinical data cannot be described without assuming an initially hypoxic state of the tumor followed by re-oxygenation and, hence, re-sensitization. This phenomenon explains the better outcome of the prolonged treatment schedule compared to shorter regimens based on the fact that prostate cancer is a slowly repopulating tumor.
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Armstrong S, Tsang Y, Lowe G, Tharmalingam H, Alonzi R, Ostler P, Hughes R, Hoskin P. Dosimetry of local failure with single dose 19 Gy high-dose-rate brachytherapy for prostate cancer. Radiother Oncol 2021; 157:93-98. [PMID: 33493500 DOI: 10.1016/j.radonc.2021.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 01/05/2021] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE/OBJECTIVE Long-term follow up of single dose high-dose rate brachytherapy (HDR BT) for localised prostate cancer has revealed higher than expected rates of biochemical and local failure. This study aimed (i) to investigate the pattern of relapse within the prostate with reference to the initial site of disease in those patients; and (ii) to examine if there were any relationships between the HDR BT dosimetric parameters to these areas of recurrence. MATERIALS/METHODS A retrospective review of treatment records of patients who received 19 Gy single fraction of HDR BT was carried out. A matched pair analysis used one control for each biochemical recurrence case matched with pre-treatment Clinical target volume (CTV) size, Gleason score, T stage, risk category and presence of an identifiable dominant intraprostatic nodule (DIL) for each biochemical recurrence case identified. For all datasets, the pre HDR BT DILs were delineated on the diagnostic pre-treatment T2-weighted MRI and planning CT images. For patients with local recurrence post HDR BT, the recurrent nodules were contoured on the diagnostic T2-weighted MRI and choline PET which were registered to the original HDR BT planning CT. Dosimetric parameters of CTV, planning target volume (PTV), DIL and organs at risk (OARs) were evaluated. Wilcoxon signed-rank test was performed to investigate if there were any significant differences in dosimetric parameters between cases and controls. Cox regression analysis was performed to explore if there were any clinical and dosimetric parameters predicting for biochemical progression free survival (bPFS), local recurrence free survival (LR-PFS) and DIL recurrence free survival (DIL-PFS). RESULTS Between 2013 and 2018, 180 patients received 19 Gy HDR-BT monotherapy. With a median follow up of 36 months, 19 (10.6%) patients developed biochemical recurrence. Of the 19 patients with biochemical failure, 13 had a local recurrence, including 7 who occurred at the site of DIL. Thirty-eight intermediate/high risk patients were included in the matched pair analysis. No statistically significant differences were found in all CTV, PTV, DIL and OAR dosimetric parameters between cases and controls (p > 0.05). For the Cox regression analysis, none of the covariates investigated were found to be statistically significant factors to predict for bPFS, LC-PFS and DIL-PFS. CONCLUSION No associations between biochemical recurrences and HDR BT dosimetry were identified in our cohort of patients receiving 19 Gy single fraction HDR BT. A large proportion of recurrences occurred at the site of original disease. HDR BT for intermediate/high risk prostate cancer should be undertaken using a minimum of two fractions.
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Affiliation(s)
| | | | - Gerry Lowe
- Mount Vernon Cancer Centre, Northwood, UK
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Hoskin PJ, Rojas AM, Ostler PJ, Bryant L, Lowe GJ. Randomised trial of external-beam radiotherapy alone or with high-dose-rate brachytherapy for prostate cancer: Mature 12-year results. Radiother Oncol 2020; 154:214-219. [PMID: 33011207 DOI: 10.1016/j.radonc.2020.09.047] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE A randomised phase-III trial compared external beam radiotherapy (EBRT) alone with EBRT combined with high-dose-rate brachytherapy boost (HDR-BTb) in localised prostate adenocarcinoma. Previous analysis, at median follow up of 85 months, demonstrated improved relapse free survival (RFS) with EBRT + HDR-BTb. This data has now been updated with a median follow up of 131 months. MATERIALS AND METHODS From December 1997 to August 2005, patients were assigned either to EBRT alone delivering 55 Gy in 20 fractions over 4 weeks or EBRT followed by a temporary high-dose-rate implant delivering 2 × 8·5 Gy over 24 h. The primary endpoint was RFS defined by a PSA rise ≥2.0 µg/l above nadir, clinical progression or death. Actuarial survival rates and Hazard Ratios (HRs) were calculated using the Kaplan-Meier method and Cox's Proportional Hazard Model, respectively. Secondary endpoints were overall survival (OS), urinary and bowel toxicity. RESULTS One hundred and six patients received EBRT alone and 110 EBRT + HDR-BTb. Median time to relapse was 137 months in the HDR-BTb arm compared to 82 months for EBRT alone (p = 0·01). A 27% risk of recurrence with EBRT alone was observed (p = 0·001), resulting in a 21% improvement in RFS at 12 years with EBRT + HDR-BTb. In multivariate analysis treatment arm, risk category and no androgen deprivation therapy were significant covariates for risk of relapse. Differences in overall survival were not significant. CONCLUSION At 12 years there remains a significant improvement in RFS after EBRT + HDR-BTb; both treatments were equitoxic for severe late urinary and bowel events and urethral strictures.
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Affiliation(s)
- Peter J Hoskin
- Cancer Centre, Mount Vernon Hospital, Northwood, UK; University of Manchester, UK.
| | - Ana M Rojas
- Cancer Centre, Mount Vernon Hospital, Northwood, UK
| | | | - Linda Bryant
- Cancer Centre, Mount Vernon Hospital, Northwood, UK
| | - Gerry J Lowe
- Cancer Centre, Mount Vernon Hospital, Northwood, UK
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Doussot A, Vernerey D, Rullier E, Lefevre JH, Meillat H, Cotte E, Piessen G, Tuech JJ, Panis Y, Mege D, Meurisse A, De Bari B, Heyd B, Lakkis Z. Surgical Management and Outcomes of Rectal Cancer with Synchronous Prostate Cancer: A Multicenter Experience from the GRECCAR Group. Ann Surg Oncol 2020; 27:4286-4293. [PMID: 32500342 DOI: 10.1245/s10434-020-08683-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Synchronous prostate cancer (PC) and rectal cancer (RC) is a rare clinical situation. While combining curative-intent management for both cancers can be challenging, available data for guiding the multidisciplinary strategy are lacking. METHODS Consecutive patients undergoing rectal resection for a mid-low RC with synchronous PC treated at 9 tertiary-care centers between 2008 and 2018 were included. Management strategy and data on postoperative and long-term outcomes were retrospectively analyzed. RESULTS Overall, 25 patients underwent curative-intent RC resection combined with PC management. Nine (36%), 10 (40%) and 6 (24%) patients had low-, intermediate-, and high-risk PC, respectively. Management mostly consisted of chemoradiotherapy combined in 18 patients (72%) with either TME in 12 patients or pelvic exenteration for resection of both cancers in 6 patients. Most patients underwent RC resection using a laparoscopic approach (n = 16, 64%). Anastomosis was performed in 18 patients (72%) of whom 13 received diverting ileostomy. The complete R0 resection rate was 96% (n = 24). The overall morbidity rate was 64% (n = 16) and 5 patients (20%) experienced severe surgical morbidity of which two died within 90 days of surgery after pelvic exenteration. Among patients with anastomosis, 2 patients (11%) experienced anastomotic leak requiring surgical management. After a median follow-up of 31.2 months, 3-year OS and RFS were 80.2% (CI 95% 58.8-92.2) and 68.6% (CI 95% 42.3-84.8), respectively. CONCLUSIONS This series is the largest to report that simultaneous curative-intent management of synchronous PC and RC is feasible and safe. Pelvic exenteration might be a better option when RC complete resection seems not achievable through TME.
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Affiliation(s)
- Alexandre Doussot
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, Besançon Cedex, France
| | - Dewi Vernerey
- Methodological and Quality of Life Unit in Oncology, University Hospital of Besançon, Besançon, France
| | - Eric Rullier
- Department of Colorectal Surgery, Haut-Lévèque Hospital, Pessac, France
| | - Jérémie H Lefevre
- Department of Digestive Surgery, AP-HP, Hôpital Saint Antoine, Sorbonne Université, Paris, France
| | - Hélène Meillat
- Department of Digestive Surgical Oncology, Department of Mini Invasive Interventions (DIMI), Paoli Calmettes Institute, Marseille, France
| | - Eddy Cotte
- Department of Digestive and Oncological Surgery, Lyon Sud University Hospital, Pierre Bénite, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, Clichy, France
| | - Diane Mege
- Department of Digestive and General Surgery, Timone Hospital, Marseille, France
| | - Aurélia Meurisse
- Methodological and Quality of Life Unit in Oncology, University Hospital of Besançon, Besançon, France
| | - Berardino De Bari
- Department of Radiotherapy, University Hospital of Besançon, Besançon, France.,Department of Radiotherapy, University Hospital of Lausanne, Lausanne, Switzerland
| | - Bruno Heyd
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, Besançon Cedex, France
| | - Zaher Lakkis
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, Besançon Cedex, France.
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Phase II study of accelerated Linac-based SBRT in five consecutive fractions for localized prostate cancer. Strahlenther Onkol 2018; 195:113-120. [DOI: 10.1007/s00066-018-1338-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 07/04/2018] [Indexed: 12/26/2022]
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Kellermeier M, Herbolzheimer J, Kreppner S, Lotter M, Strnad V, Bert C. Electromagnetic tracking (EMT) technology for improved treatment quality assurance in interstitial brachytherapy. J Appl Clin Med Phys 2017; 18:211-222. [PMID: 28291934 PMCID: PMC5689872 DOI: 10.1002/acm2.12021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 10/27/2016] [Indexed: 11/09/2022] Open
Abstract
Electromagnetic Tracking (EMT) is a novel technique for error detection and quality assurance (QA) in interstitial high dose rate brachytherapy (HDR-iBT). The purpose of this study is to provide a concept for data acquisition developed as part of a clinical evaluation study on the use of EMT during interstitial treatment of breast cancer patients. The stability, accuracy, and precision of EMT-determined dwell positions were quantified. Dwell position reconstruction based on EMT was investigated on CT table, HDR table and PDR bed to examine the influence on precision and accuracy in a typical clinical workflow. All investigations were performed using a precise PMMA phantom. The track of catheters inserted in that phantom was measured by manually inserting a 5 degree of freedom (DoF) sensor while recording the position of three 6DoF fiducial sensors on the phantom surface to correct motion influences. From the corrected data, dwell positions were reconstructed along the catheter's track. The accuracy of the EMT-determined dwell positions was quantified by the residual distances to reference dwell positions after using a rigid registration. Precision and accuracy were investigated for different phantom-table and sensor-field generator (FG) distances. The measured precision of the EMT-determined dwell positions was ≤ 0.28 mm (95th percentile). Stability tests showed a drift of 0.03 mm in the first 20 min of use. Sudden shaking of the FG or (large) metallic objects close to the FG degrade the precision. The accuracy with respect to the reference dwell positions was on all clinical tables < 1 mm at 200 mm FG distance and 120 mm phantom-table distance. Phantom measurements showed that EMT-determined localization of dwell positions in HDR-iBT is stable, precise, and sufficiently accurate for clinical assessment. The presented method may be viable for clinical applications in HDR-iBT, like implant definition, error detection or quantification of uncertainties. Further clinical investigations are needed.
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Affiliation(s)
- Markus Kellermeier
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany
| | - Jens Herbolzheimer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany
| | - Stephan Kreppner
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany
| | - Michael Lotter
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054, Erlangen, Germany
| | - Vratislav Strnad
- 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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Hoskin P, Rojas A, Ostler P, Hughes R, Alonzi R, Lowe G. Single-dose high-dose-rate brachytherapy compared to two and three fractions for locally advanced prostate cancer. Radiother Oncol 2017; 124:56-60. [DOI: 10.1016/j.radonc.2017.06.014] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/28/2017] [Accepted: 06/07/2017] [Indexed: 10/19/2022]
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Chicas-Sett R, Farga D, Perez-Calatayud MJ, Celada F, Roldan S, Fornes-Ferrer V, Ibanez-Rosello B, Tormo A, Benlloch JM, Perez-Calatayud J. High-dose-rate brachytherapy boost for prostate cancer: Analysis of dose-volume histogram parameters for predicting late rectal toxicity. Brachytherapy 2017; 16:511-517. [DOI: 10.1016/j.brachy.2017.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/01/2017] [Accepted: 03/03/2017] [Indexed: 11/30/2022]
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12
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Sánchez-Gómez LM, Polo-deSantos M, Rodríguez-Melcón JI, Angulo JC, Luengo-Matos S. High-dose rate brachytherapy as monotherapy in prostate cancer: A systematic review of its safety and efficacy. Actas Urol Esp 2017; 41:71-81. [PMID: 27496770 DOI: 10.1016/j.acuro.2016.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 05/23/2016] [Accepted: 06/09/2016] [Indexed: 11/15/2022]
Abstract
CONTEXT High-dose rate brachytherapy (HDR-BT) is an increasingly popular treatment for patients with localised prostate cancer (PC). OBJECTIVE To assess the safety and efficacy of HDR-BT as monotherapy in PC. ACQUISITION OF EVIDENCE A systematic literature review was conducted through searches on MEDLINE (PubMed), Cochrane Library, CDR, ClinicalTrials and EuroScan. We assessed safety and efficacy indicators. SUMMARY OF THE EVIDENCE We selected 2 reviews and 12 uncontrolled studies, included in these 2 reviews. In terms of efficacy, local control in 6 studies was 97-100%. The biochemical progression-free survival varied as follows: 85-100% for low risk and 79-92% for high risk. Survival free of metastases was >95% at 8 years, except in one study where the survival rate was 87% at 5 years. The overall survival was ≥95% in 8 studies. In terms of safety, most of the studies recorded acute and long-term genitourinary and gastrointestinal complications, especially grade ≥2. Only 3 studies found grade 4 complications. All studies, except for one without complications, observed genitourinary complications that were more frequent and severe than the gastrointestinal complications. Two studies assessed the quality of life and showed an initial reduction in various domains and subsequent partial or total recovery, except in the sexual domain. CONCLUSIONS HDR-BT is effective as monotherapy, especially in cases of low to intermediate risk. There is insufficient information on high-risk patients. The short to medium-term toxicity was acceptable. Further research needs to be funded to provide more information on the long-term safety and efficacy of this treatment.
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Affiliation(s)
- L M Sánchez-Gómez
- Agencia de Evaluación de Tecnologías Sanitarias (AETS), Instituto de Salud Carlos III (ISCIII), Ministerio de Economía y Competitividad, Madrid, España; Instituto de Investigación Sanitaria, Hospital Universitario de La Princesa (IP), Madrid, España; Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), España.
| | - M Polo-deSantos
- Agencia de Evaluación de Tecnologías Sanitarias (AETS), Instituto de Salud Carlos III (ISCIII), Ministerio de Economía y Competitividad, Madrid, España
| | - J I Rodríguez-Melcón
- Servicio de Oncología Radioterápica, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, España
| | - J C Angulo
- Servicio de Urología, Hospital Universitario de Getafe, Universidad Europea de Madrid, Madrid, España
| | - S Luengo-Matos
- Agencia de Evaluación de Tecnologías Sanitarias (AETS), Instituto de Salud Carlos III (ISCIII), Ministerio de Economía y Competitividad, Madrid, España
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Prostate Cancer Radiation Therapy: What Do Clinicians Have to Know? BIOMED RESEARCH INTERNATIONAL 2016; 2016:6829875. [PMID: 28116302 PMCID: PMC5225325 DOI: 10.1155/2016/6829875] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/18/2016] [Accepted: 10/31/2016] [Indexed: 12/11/2022]
Abstract
Radiotherapy (RT) for prostate cancer (PC) has steadily evolved over the last decades, with improving biochemical disease-free survival. Recently population based research also revealed an association between overall survival and doses ≥ 75.6 Gray (Gy) in men with intermediate- and high-risk PC. Examples of improved RT techniques are image-guided RT, intensity-modulated RT, volumetric modulated arc therapy, and stereotactic ablative body RT, which could facilitate further dose escalation. Brachytherapy is an internal form of RT that also developed substantially. New devices such as rectum spacers and balloons have been developed to spare rectal structures. Newer techniques like protons and carbon ions have the intrinsic characteristics maximising the dose on the tumour while minimising the effect on the surrounding healthy tissue, but clinical data are needed for confirmation in randomised phase III trials. Furthermore, it provides an overview of an important discussion issue in PC treatment between urologists and radiation oncologists: the comparison between radical prostatectomy and RT. Current literature reveals that all possible treatment modalities have the same cure rate, but a different toxicity pattern. We recommend proposing the possible different treatment modalities with their own advantages and side-effects to the individual patient. Clinicians and patients should make treatment decisions together (shared decision-making) while using patient decision aids.
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Hosni A, Carlone M, Rink A, Ménard C, Chung P, Berlin A. Dosimetric feasibility of ablative dose escalated focal monotherapy with MRI-guided high-dose-rate (HDR) brachytherapy for prostate cancer. Radiother Oncol 2016; 122:103-108. [PMID: 27916416 DOI: 10.1016/j.radonc.2016.11.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 11/04/2016] [Accepted: 11/10/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE To determine the dosimetric feasibility of dose-escalated MRI-guided high-dose-rate brachytherapy (HDR-BT) focal monotherapy for prostate cancer (PCa). METHODS In all patients, GTV was defined with mpMRI, and deformably registered onto post-catheter insertion planning MRI. PTV included the GTV plus 9mm craniocaudal and 5mm in every other direction. In discovery-cohort, plans were obtained for each PTV independently aiming to deliver ⩾16.5Gy/fraction (two fraction schedule) while respecting predefined organs-at-risk (OAR) constraints or halted when achieved equivalent single-dose plan (24Gy). Dosimetric results of original and focal HDR-BT plans were evaluated to develop a planning protocol for the validation-cohort. RESULTS In discovery-cohort (20-patients, 32-GTVs): PTV D95% ⩾16.5Gy could not be reached in a single plan (3%) and was accomplished (range 16.5-23.8Gy) in 15 GTVs (47%). Single-dose schedule was feasible in 16 (50%) plans. In the validation-cohort (10-patients, 10-GTVs, two separate implants each): plans met acceptable and ideal criteria in 100% and 43-100% respectively. Migration to single-dose treatment schedule was feasible in 7 implants (35%), without relaxing OAR's constraints or increasing the dose (D100% and D35%) to mpMRI-normal prostate (p>0.05). CONCLUSION Focal ablative dose-escalated radiation is feasible with the proposed protocol. Prospective studies are warranted to determine the clinical outcomes.
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Affiliation(s)
- Ali Hosni
- Radiation Medicine Program, Princess Margaret Cancer Centre - University Health Network, Department of Radiation Oncology, University of Toronto, Canada
| | - Marco Carlone
- Radiation Medicine Program, Princess Margaret Cancer Centre - University Health Network, Department of Radiation Oncology, University of Toronto, Canada
| | - Alexandra Rink
- Radiation Medicine Program, Princess Margaret Cancer Centre - University Health Network, Department of Radiation Oncology, University of Toronto, Canada
| | - Cynthia Ménard
- Département de radio-oncologie, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
| | - Peter Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre - University Health Network, Department of Radiation Oncology, University of Toronto, Canada
| | - Alejandro Berlin
- Radiation Medicine Program, Princess Margaret Cancer Centre - University Health Network, Department of Radiation Oncology, University of Toronto, Canada.
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15
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Electromagnetic tracking for treatment verification in interstitial brachytherapy. J Contemp Brachytherapy 2016; 8:448-453. [PMID: 27895688 PMCID: PMC5116452 DOI: 10.5114/jcb.2016.63356] [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: 09/05/2016] [Accepted: 10/04/2016] [Indexed: 11/29/2022] Open
Abstract
Electromagnetic tracking (EMT) is used in several medical fields to determine the position and orientation of dedicated sensors, e.g., attached to surgical tools. Recently, EMT has been introduced to brachytherapy for implant reconstruction and error detection. The manuscript briefly summarizes the main issues of EMT and error detection in brachytherapy. The potential and complementarity of EMT as treatment verification technology will be discussed in relation to in vivo dosimetry and imaging.
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16
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An evaluation of the robustness of organ-at-risk recommendations made by GEC/ESTRO according to interobserver variability: a single-center experience. J Contemp Brachytherapy 2016; 8:349-55. [PMID: 27648090 PMCID: PMC5018524 DOI: 10.5114/jcb.2016.61738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/20/2016] [Indexed: 12/25/2022] Open
Abstract
Purpose Groupe Européen de Curiethérapie (GEC) and European Society for Radiotherapy & Oncology (ESTRO) has proposed a rectal dose constraint of the most exposed 2-cc volume (D2cc of ≤ 75 Gy EQD2α/β = 3) during external-beam plus high-dose-rate brachytherapy (HDR-BT) in localized prostate cancer patients. This study aimed to evaluate D2cc for rectal contouring via interobserver variability. Material and methods Four blinded observers contoured rectums of 5 patients. Rectal contouring anatomical limits were determined through previous consensus. Dose-volume histogram (DVH) dosimetric parameters (D0.1cc, D1cc, and D2cc) were analyzed according to GEC/ESTRO recommendations and subjected to intra- and interobserver comparisons. Latter comparisons involved coefficients of variation. For each parameter, the mean, standard deviation (SD), and range were evaluated. The effect of interobserver variation on total dose was analyzed by estimating the biologically equivalent rectal dose (EQD2α/β = 3). Results Interobserver coefficients of variation for D0.1cc, D1cc, and D2cc were 5.7%, 4.5%, and 4%, respectively. The highest interobserver rectal delineation variation yielded a rectal dose difference up to 5.8 Gy EQD2. Estimated intraobserver variation for the reported D2cc was 5.5% in the worst-case scenario (non-significant). Conclusions We observed acceptable interobserver variability in EQD2 for D2cc, with strong impacts on clinical threshold levels (D2cc ≤ 75 Gy EQD2) in some cases. This small, single-center analysis will be extended in a multicenter study.
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De Bari B, Arcangeli S, Ciardo D, Mazzola R, Alongi F, Russi EG, Santoni R, Magrini SM, Jereczek-Fossa BA. Extreme hypofractionation for early prostate cancer: Biology meets technology. Cancer Treat Rev 2016; 50:48-60. [PMID: 27631875 DOI: 10.1016/j.ctrv.2016.08.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/11/2016] [Accepted: 08/16/2016] [Indexed: 02/07/2023]
Abstract
The aim of this review is to present the available radiobiological, technical and clinical data about extreme hypofractionation in primary prostate cancer radiotherapy. The interest in this technique is based on the favourable radiobiological characteristics of prostate cancer and supported by advantageous logistic aspects deriving from short overall treatment time. The clinical validity of short-term treatment schedule is proven by a body of non-randomised studies, using both isocentric (LINAC-based) or non-isocentric (CyberKnife®-based) stereotactic body irradiation techniques. Twenty clinical studies, each enrolling more than 40 patients for a total of 1874 treated patients, were revised in terms of technological setting, toxicity, outcome and quality of life assessment. The implemented strategies for the tracking of the prostate and the sparing of the rectal wall have been investigated with particular attention. The urinary toxicity after prostate stereotactic body irradiation seems slightly more pronounced as compared to rectal adverse events, and this is more evident for late occurring events, but no worse as respect to conventional fractionation schemes. As far as the rate of severe acute toxicity is concerned, in all the available studies the treatment was globally well tolerated. While awaiting long-term data on efficacy and toxicity, the analysed studies suggest that the outcome profile of this approach, alongside the patient convenience and reduced costs, is promising. Forty-eight ongoing clinical trials are also presented as a preview of the expectation from the near future.
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Affiliation(s)
- Berardino De Bari
- Division of Radiation Oncology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Stefano Arcangeli
- Division of Radiation Oncology, San Camillo-Forlanini Hospitals, Rome, Italy
| | - Delia Ciardo
- Division of Radiation Oncology, European Institute of Oncology, Milan, Italy.
| | - Rosario Mazzola
- Division of Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Filippo Alongi
- Division of Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Elvio G Russi
- S.C. di Radioterapia Oncologica, Azienda ospedaliera S. Croce e Carle, Cuneo, Italy
| | - Riccardo Santoni
- Università di Roma, Tor Vergata, U.O.C. di Radioterapia, Policlinico Tor Vergata, Roma, Italy
| | - Stefano M Magrini
- Istituto del Radio "O. Alberti", Spedali Civili, Università di Brescia, Brescia, Italy
| | - Barbara A Jereczek-Fossa
- Division of Radiation Oncology, European Institute of Oncology, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
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Sivaraman A, Barret E. Focal Therapy for Prostate Cancer: An “À la Carte” Approach. Eur Urol 2016; 69:973-5. [DOI: 10.1016/j.eururo.2015.12.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 12/11/2015] [Indexed: 10/22/2022]
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Wojcieszek P, Szlag M, Głowacki G, Cholewka A, Gawkowska-Suwińska M, Kellas-Ślęczka S, Białas B, Fijałkowski M. Salvage high-dose-rate brachytherapy for locally recurrent prostate cancer after primary radiotherapy failure. Radiother Oncol 2016; 119:405-10. [PMID: 27165612 DOI: 10.1016/j.radonc.2016.04.032] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 04/15/2016] [Accepted: 04/20/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE To evaluate high-dose-rate brachytherapy (HDR BT) as a salvage modality for locally recurrent prostate cancer after primary radiotherapy failure. MATERIALS AND METHODS Eighty-three prostate cancer patients, who locally relapsed after radiotherapy, were treated with salvage HDR BT. The schedule was three implantations, every two weeks, with 10Gy per implant, to a total dose of 30Gy. Acute and late toxicity rates were evaluated. Overall survival (OS) and biochemical control were calculated using Kaplan-Meier method. RESULTS Median follow-up after salvage HDR was 41months. The 3-year and 5-year OS were 93% and 86%, respectively. The 3-year and 5-year biochemical disease-free survival (bDFS) were 76% and 67%, respectively. The single factor associated with biochemical control was time to achieve salvage PSA nadir (p-.006). OS was linked significantly with primary nadir level (p-.001) while primary biochemical relapse interval was of borderline significance (p-.07). CONCLUSIONS Salvage HDR BT is a promising treatment option for patients with localized relapse of previously irradiated prostate cancer. Lower PSA nadir after primary radiotherapy and longer primary disease-free interval influence the outcome.
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Affiliation(s)
- Piotr Wojcieszek
- Brachytherapy Department, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland.
| | - Marta Szlag
- Radiotherapy and Brachytherapy Treatment Planning Department, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
| | - Grzegorz Głowacki
- Radiotherapy Department, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
| | - Agnieszka Cholewka
- Radiotherapy and Brachytherapy Treatment Planning Department, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
| | - Marzena Gawkowska-Suwińska
- III Department of Radiotherapy and Chemotherapy, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
| | - Sylwia Kellas-Ślęczka
- Brachytherapy Department, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
| | - Brygida Białas
- Brachytherapy Department, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
| | - Marek Fijałkowski
- Brachytherapy Department, MSC Memorial Cancer Centre and Institute of Oncology, Gliwice, Ul. Wybrzeze Armii Krajowej 15, 44-100 Gliwice, Poland
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