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Patel KR, Rydzewski NR, Schott E, Cooley-Zgela T, Ning H, Cheng J, Salerno K, Huang EP, Lindenberg L, Mena E, Choyke P, Turkbey B, Citrin DE. A Phase 1 Trial of Salvage Stereotactic Body Radiation Therapy for Radiorecurrent Prostate Cancer After Brachytherapy. Int J Radiat Oncol Biol Phys 2024; 119:1471-1480. [PMID: 38428681 PMCID: PMC11262986 DOI: 10.1016/j.ijrobp.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/16/2024] [Accepted: 02/08/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE NCT03253744 is a phase 1 trial with the primary objective to identify the maximum tolerated dose (MTD) of salvage stereotactic body radiation therapy (SBRT) in patients with local prostate cancer recurrence after brachytherapy. Additional objectives included biochemical control and imaging response. METHODS AND MATERIALS This trial was initially designed to test 3 therapeutic dose levels (DLs): 40 Gy (DL1), 42.5 Gy (DL2), and 45 Gy (DL3) in 5 fractions. Intensity modulation was used to deliver the prescription dose to the magnetic resonance imaging and prostate-specific membrane antigen-based positron emission tomography imaging-defined gross tumor volume while simultaneously delivering 30 Gy to an elective volume defined by the prostate gland. This phase 1 trial followed a 3+3 design with a 3-patient expansion at the MTD. Toxicities were scored until trial completion at 2 years post-SBRT using Common Terminology Criteria for Adverse Events version 5.0. Escalation was halted if 2 dose limiting toxicities occurred, defined as any persistent (>4 days) grade 3 toxicity occurring within the first 3 weeks after SBRT or any grade ≥3 genitourinary (GU) or grade 4 gastrointestinal toxicity thereafter. RESULTS Between August 2018 and January 2023, 9 patients underwent salvage SBRT and were observed for a median of 22 months (Q1-Q3, 20-43 months). No grade 3 to 5 adverse events related to study treatment were observed; thus, no dose limiting toxicities occurred during the observation period. Escalation was halted by amendment given excellent biochemical control in DL1 and DL2 in the setting of a high incidence of clinically significant late grade 2 GU toxicity. Therefore, the MTD was considered 42.5 Gy in 5 fractions (DL2). One- and 2-year biochemical progression-free survival were 100% and 86%, representing a single patient in the trial cohort with biochemical failure (prostate-specific antigen [PSA] nadir + 2.0) at 20 months posttreatment. CONCLUSIONS The MTD of salvage SBRT for the treatment of intraprostatic radiorecurrence after brachytherapy was 42.5 Gy in 5 fractions producing an 86% 2-year biochemical progression-free survival rate, with 1 poststudy failure at 20 months. The most frequent clinically significant toxicity was late grade 2 GU toxicity.
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Affiliation(s)
- Krishnan R Patel
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Nicholas R Rydzewski
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Erica Schott
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Theresa Cooley-Zgela
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Holly Ning
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jason Cheng
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Kilian Salerno
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Erich P Huang
- Biometric Research Program, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Liza Lindenberg
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Esther Mena
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Peter Choyke
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Baris Turkbey
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Deborah E Citrin
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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2
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Hudson JM, Loblaw A, McGuffin M, Chung HT, Tseng CL, Helou J, Cheung P, Szumacher E, Liu S, Zhang L, Deabreu A, Mamedov A, Morton G. Prostate high dose-rate brachytherapy as monotherapy for low and intermediate-risk prostate cancer: Efficacy results from a randomized phase II clinical trial of one fraction of 19 Gy or two fractions of 13.5 Gy: A 9-year update. Radiother Oncol 2024; 198:110381. [PMID: 38879130 DOI: 10.1016/j.radonc.2024.110381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/05/2024] [Accepted: 06/08/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND AND PURPOSE High dose-rate (HDR) brachytherapy as a monotherapy is an accepted treatment for localized prostate cancer, but the optimal dose and fractionation schedule remain unknown. We report on the efficacy of a randomized Phase II trial comparing HDR monotherapy delivered as 27 Gy in 2 fractions vs. 19 Gy in 1 fraction with a median follow-up of 9 years. MATERIALS AND METHODS Enrolled patients had low or intermediate-risk disease, <60 cc prostate volume and no androgen deprivation use. Patients were randomized to 27 Gy in 2 fractions delivered one week apart vs a single fraction of 19 Gy. RESULTS 170 patients were randomized: median age 65 years, median follow-up 107 months and median baseline PSA 6.35 ng/ml. NCCN risk categories comprised low (19 %), favourable (51 %), and unfavourable intermediate risk (30 %). The median PSA at 8 years was 0.08 ng/ml in the 2-fraction arm vs. 0.89 ng/ml in the single-fraction arm. The cumulative incidence of local failure at 8 years was 11.2 % in the 2-fraction arm vs. 35.9 % in the single-fraction arm (p < 0.001). The incidence of distant failure at 8 years was 3.8 % in the 2-fraction arm and 2.5 % in the single-fraction arm (p = 0.6). CONCLUSIONS HDR monotherapy delivered in two fractions of 13.5 Gy demonstrated a persistent cancer control rate at 8 years and was well-tolerated. Single-fraction monotherapy yielded poor oncologic control and is not recommended. These findings contribute to the ongoing discourse on optimal HDR monotherapy strategies for low and intermediate-risk prostate cancer.
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Affiliation(s)
- John M Hudson
- Sunnybrook Odette Cancer Centre, University of Toronto, Canada
| | - Andrew Loblaw
- Sunnybrook Odette Cancer Centre, University of Toronto, Canada
| | | | - Hans T Chung
- Sunnybrook Odette Cancer Centre, University of Toronto, Canada
| | - Chia-Lin Tseng
- Sunnybrook Odette Cancer Centre, University of Toronto, Canada
| | - Joelle Helou
- Sunnybrook Odette Cancer Centre, University of Toronto, Canada
| | - Patrick Cheung
- Sunnybrook Odette Cancer Centre, University of Toronto, Canada
| | - Ewa Szumacher
- Sunnybrook Odette Cancer Centre, University of Toronto, Canada
| | - Stanley Liu
- Sunnybrook Odette Cancer Centre, University of Toronto, Canada
| | - Liying Zhang
- Sunnybrook Odette Cancer Centre, University of Toronto, Canada
| | - Andrea Deabreu
- Sunnybrook Odette Cancer Centre, University of Toronto, Canada
| | | | - Gerard Morton
- Sunnybrook Odette Cancer Centre, University of Toronto, Canada.
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Ekanger C, Helle SI, Reisæter L, Hysing LB, Kvåle R, Honoré A, Gravdal K, Pilskog S, Dahl O. Salvage Reirradiation for Locally Recurrent Prostate Cancer: Results From a Prospective Study With 7.2 Years of Follow-Up. J Clin Oncol 2024; 42:1934-1942. [PMID: 38652872 PMCID: PMC11191049 DOI: 10.1200/jco.23.01391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 01/24/2024] [Accepted: 02/28/2024] [Indexed: 04/25/2024] Open
Abstract
PURPOSE There are no well-established re-treatment options for local recurrence after primary curative radiation therapy for prostate cancer (PCa), as prospective studies with long-term follow-up are lacking. Here, we present results from a prospective study on focal salvage reirradiation with external-beam radiation therapy with a median follow-up of 7.2 years. MATERIALS AND METHODS From 2013 to 2017, 38 patients with biopsy-proven locally recurrent PCa >2 years after previous treatment and absence of grade 2-3 toxicity from the first course of radiation were included. The treatment was 35 Gy in five fractions to the MRI-based target volume and 6 months of androgen-deprivation therapy starting 3 months before radiation. The Phoenix criteria defined biochemical recurrence-free survival (bRFS), and toxicity was scored according to Radiation Therapy Oncology Group criteria. RESULTS Median age was 70 years, and median time from primary radiation to prostate-specific antigen (PSA) recurrence was 83 months. The actuarial 2-year and 5-year bRFS were 81% (95% CI, 69 to 94) and 58% (95% CI, 49 to 74), respectively. The actuarial 5-year local recurrence-free survival was 93% (95% CI, 82 to 100), metastasis-free survival was 82% (95% CI, 69 to 95), and overall survival was 87% (95% CI, 76 to 98). Two patients (5%) had durable grade 3 genitourinary toxicity, one combined with GI grade 3 toxicity. A PSA doubling time ≤6 months at salvage, a Gleason score >7, and a PSA nadir ≥0.1 ng/mL predicted a worse outcome. CONCLUSION Reirradiation with EBRT for locally recurrent PCa after primary curative radiation therapy is clinically feasible and demonstrated a favorable outcome with acceptable toxicity in this prospective study with long-term follow-up.
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Affiliation(s)
- Christian Ekanger
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Svein Inge Helle
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Lars Reisæter
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Liv Bolstad Hysing
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
- Department of Technology and Physics, Faculty of Mathematics and Natural Sciences, University of Bergen, Bergen, Norway
| | - Rune Kvåle
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
- Department of Research, Cancer Registry of Norway, Oslo, Norway
| | - Alfred Honoré
- Department of Urology, Haukeland University Hospital, Bergen, Norway
| | - Karsten Gravdal
- Department of Patohology, Haukeland University Hospital, Bergen, Norway
| | - Sara Pilskog
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
- Department of Technology and Physics, Faculty of Mathematics and Natural Sciences, University of Bergen, Bergen, Norway
| | - Olav Dahl
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
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Dhar A, Cendejas-Gomez JDJ, Castro Mendez L, Boldt G, McArthur E, Zamboglou C, Bauman G. Using multiparametric Magnetic Resonance Imaging and Prostate Specific Membrane Antigen Positron Emission Tomography to detect and delineate the gross tumour volume of intraprostatic lesions - A systematic review and meta-analysis. Radiother Oncol 2024; 192:110070. [PMID: 38262815 DOI: 10.1016/j.radonc.2023.110070] [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: 11/11/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND AND PURPOSE Radiation therapy is used frequently for patients with prostate cancer. Dose escalation to intraprostatic lesions (IPLs) has been shown to improve oncologic outcomes, without increasing toxicity. Both multiparametric MRI (mpMRI) and PSMA PET can be used to identify IPLs. MATERIALS AND METHODS A systematic review was conducted to determine the ability of mpMRI, PSMA PET and their combination to detect IPLs prior to radical prostatectomy (RP) as correlated with the histology. Trials included patients that had mpMRI, PSMA PET, or both, prior to RP. The quality of the histopathological-radiological co-registration was assessed as high or low for each study. Recorded outcomes include sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). A meta-analysis was conducted using a bivariate model to determine the pooled sensitivity and specificity for each imaging modality. This systematic review was registered through PROSPERO (CRD42023389092). RESULTS Altogether, 42 studies were included in the systematic review. Of these, 20 could be included in the meta-analysis. The pooled sensitivity (95 % CI), specificity (95 % CI) and AUROC for mpMRI (n = 13 studies) were 64.7 % (50.2 % - 76.9 %), 86.4 % (79.7 % - 91.1 %), and 0.852; the pooled outcomes for PSMA PET (n = 12) were 75.7 % (64.0 % - 84.5 %), 87.1 % (80.2 % - 91.9 %), and 0.889; for their combination (n = 5), the pooled outcomes were 70.3 % (64.1 % - 75.9 %), 81.9 % (71.9 % - 88.8 %), and 0.796. When reviewing studies with a high-quality histopathological-radiological co-registration, IPL delineation recommendations varied by study and the imaging modality used. CONCLUSION All of mpMRI, PSMA PET or their combination were found to have very good diagnostic outcomes for detecting IPLs. Recommendations for delineating IPLs varied based on the imaging modalities used and between research groups. Consensus guidelines for IPL delineation would help with creating consistency for focal boost radiation treatments in future studies.
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Affiliation(s)
- Aneesh Dhar
- London Regional Cancer Program, London, Ontario, Canada
| | | | | | - Gabriel Boldt
- London Health Sciences Centre, London, Ontario, Canada
| | - Eric McArthur
- London Health Sciences Centre, London, Ontario, Canada
| | - Constantinos Zamboglou
- Department of Radiation Oncology, Medical Center - University of Freiburg, Freiburg, Germany; German Oncology Center, European University Cyprus, Limassol, Cyprus
| | - Glenn Bauman
- London Regional Cancer Program, London, Ontario, Canada.
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Light A, Lazic S, Houghton K, Bayne M, Connor MJ, Tam H, Ahmed HU, Shah TT, Barwick TD. Diagnostic Performance of 68Ga-PSMA-11 PET/CT Versus Multiparametric MRI for Detection of Intraprostatic Radiorecurrent Prostate Cancer. J Nucl Med 2024; 65:379-385. [PMID: 38212074 DOI: 10.2967/jnumed.123.266527] [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: 08/10/2023] [Revised: 10/04/2023] [Accepted: 10/04/2023] [Indexed: 01/13/2024] Open
Abstract
For men with prostate cancer who develop biochemical failure after radiotherapy, European guidelines recommend reimaging with 68Ga-PSMA-11 PET/CT and multiparametric MRI (mpMRI). However, the accuracy of 68Ga-PSMA-11 PET/CT for detecting intraprostatic recurrences is unclear, both with and without mpMRI. Methods: A single-center retrospective study of a series of patients investigated for radiorecurrence between 2016 and 2022 is described. All patients underwent 68Ga-PSMA-11 PET/CT, mpMRI, and prostate biopsy. PET/CT images were interpreted independently by 2 expert readers masked to other imaging and clinical data. The primary outcome was the diagnostic accuracy of PET/CT versus mpMRI and of PET/CT with mpMRI together versus mpMRI alone. The secondary outcome was the proportion of cancers missed by mpMRI but detected by PET/CT. Diagnostic accuracy analysis was performed at the prostate hemigland level using cluster bootstrapping. Results: Thirty-five men (70 hemiglands) were included. Cancer was confirmed by biopsy in 43 of 70 hemiglands (61%). PET/CT sensitivity and negative predictive values (NPVs) were 0.89 (95% CI, 0.78-0.98) and 0.79 (95% CI, 0.62-0.95), respectively, which were not significantly different from results by MRI (sensitivity of 0.72; 95% CI, 0.61-0.83; P = 0.1) (NPV of 0.59; 95% CI, 0.41-0.75; P = 0.07). Specificity and positive predictive values were not significantly different. When PET/CT and MRI were used together, the sensitivity was 0.98 (95% CI, 0.92-1.00) and NPV was 0.93 (95% CI, 0.75-1.00), both significantly higher than MRI alone (P = 0.003 and P < 0.001, respectively). Specificity and positive predictive values remained not significantly different. MRI missed 12 of 43 cancers (28%; 95% CI, 17%-43%), of which 11 of 12 (92%; 95% CI, 62%-100%) were detected by PET/CT. Conclusion: For detecting intraprostatic radiorecurrence, 68Ga-PSMA-11 PET/CT has high sensitivity that is not significantly different from mpMRI. When 68Ga-PSMA-11 PET/CT and mpMRI were used together, the results conferred a significantly greater sensitivity and NPV than with mpMRI alone. 68Ga-PSMA-11 PET/CT may therefore be a useful tool in the diagnosis of localized radiorecurrence.
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Affiliation(s)
- Alexander Light
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Stefan Lazic
- Department of Imaging, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; and
| | - Kate Houghton
- Department of Imaging, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; and
| | - Max Bayne
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Martin J Connor
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Henry Tam
- Department of Imaging, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; and
| | - Hashim U Ahmed
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Taimur T Shah
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Tara D Barwick
- Department of Imaging, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; and
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Latorzeff I, Camps-Maléa A, Supiot S, de Crevoisier R, Farcy-Jacquet MP, Hannoun-Lévi JM, Riou O, Pommier P, Artignan X, Chapet O, Créhange G, Marchesi V, Pasquier D, Sargos P. Indication and perspectives of radiation therapy in the setting of de-novo metastatic prostate cancer. Cancer Radiother 2024; 28:49-55. [PMID: 37827959 DOI: 10.1016/j.canrad.2023.05.004] [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: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 10/14/2023]
Abstract
Prostate cancer is the most common cancer and the third leading cause of cancer mortality in men. Each year, approximately 10% of prostate cancers are diagnosed metastatic at initial presentation. The standard treatment option for de-novo metastatic prostate cancer is androgen deprivation therapy with novel hormonal agent or with chemotherapy. Recently, PEACE-1 trial highlighted the benefit of triplet therapy resulting in the combination of androgen deprivation therapy combined with docetaxel and abiraterone. Radiotherapy can be proposed in a curative intent or to treat local symptomatic disease. Nowadays, radiotherapy of the primary disease is only recommended for de novo low-burden/low-volume metastatic prostate cancer, as defined in the CHAARTED criteria. However, studies on stereotactic radiotherapy on oligometastases have shown that this therapeutic approach is feasible and well tolerated. Prospective research currently focuses on the benefit of intensification by combining treatment of the metastatic sites and the primary all together. The contribution of metabolic imaging to better define the target volumes and specify the oligometastatic character allows a better selection of patients. This article aims to define indications of radiotherapy and perspectives of this therapeutic option for de-novo metastatic prostate cancer.
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Affiliation(s)
- I Latorzeff
- Department of Radiation Oncology, clinique Pasteur, Toulouse, France.
| | - A Camps-Maléa
- Department of Radiation Oncology, hôpital Bretonneau, CHU de Tours, Tours, France
| | - S Supiot
- Department of Radiation Oncology, institut de cancérologie de l'Ouest centre René-Gauducheau, Saint-Herblain, France; CNRS, Nantes, France; Université de Nantes, Nantes, France
| | - R de Crevoisier
- Department of Radiation Oncology, centre Eugène-Marquis, Rennes, France
| | - M-P Farcy-Jacquet
- Fédération universitaire d'oncologie radiothérapie, institut de cancérologie du Gard, CHU de Nîmes, Nîmes, France
| | - J-M Hannoun-Lévi
- Department of Radiation Oncology, centre Antoine-Lacassagne, Nice, France
| | - O Riou
- Department of Radiation Oncology, institut du cancer de Montpellier, Montpellier, France; Fédération universitaire d'oncologie radiothérapie de Méditerranée Occitanie, université de Montpellier, Montpellier, France; U1194, Inserm, Montpellier, France; IRCM, Montpellier, France
| | - P Pommier
- Department of Radiation Oncology, institut de cancérologie de l'Ouest, Angers, France
| | - X Artignan
- Department of Radiation Oncology, centre hospitalier privé Saint-Grégoire, Rennes, France
| | - O Chapet
- Department of Radiation Oncology, centre hospitalier Lyon Sud, Pierre-Bénite, France
| | - G Créhange
- Department of Radiation Oncology, institut Curie, Saint-Cloud, France
| | - V Marchesi
- Department of Medical Physics, centre Alexis-Vautrin, Vandœuvre-lès-Nancy, France
| | - D Pasquier
- Academic Department of Radiation Oncology, centre Oscar-Lambret, Lille, France; UMR 9189 - CRIStAL, université de Lille, CNRS, école Centrale Lille, 59000 Lille, France
| | - P Sargos
- Department of Radiotherapy, institut Bergonié, Bordeaux, France
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King MT, Orio PF, D'Amico AV. Can Extreme Dose Escalation With External Beam Radiation Therapy and Low-Dose-Rate Brachytherapy Boost Obviate the Need for Long-Term Androgen Deprivation Therapy in Patients With High-Risk Localized Prostate Cancer? Int J Radiat Oncol Biol Phys 2024; 118:402-403. [PMID: 38220257 DOI: 10.1016/j.ijrobp.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/05/2023] [Indexed: 01/16/2024]
Affiliation(s)
- Martin T King
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Peter F Orio
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anthony V D'Amico
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
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8
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Kishan AU, Valle LF, Marks LS. Bullseye or Tip of the Iceberg: Magnetic Resonance Imaging-visible Disease in Radiorecurrent Prostate Cancer. Eur Urol 2024; 85:47-48. [PMID: 37805372 DOI: 10.1016/j.eururo.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/19/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, CA, USA; Department of Urology, University of California-Los Angeles, Los Angeles, CA, USA.
| | - Luca F Valle
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, CA, USA; Department of Radiation Oncology, Greater Los Angeles Veteran Affairs, Los Angeles, CA, USA
| | - Leonard S Marks
- Department of Urology, University of California-Los Angeles, Los Angeles, CA, USA
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9
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Light A, Kanthabalan A, Otieno M, Pavlou M, Omar R, Adeleke S, Giganti F, Brew-Graves C, Williams NR, Emara A, Haroon A, Latifoltojar A, Sidhu H, Freeman A, Orczyk C, Nikapota A, Dudderidge T, Hindley RG, Virdi J, Arya M, Payne H, Mitra AV, Bomanji J, Winkler M, Horan G, Moore CM, Emberton M, Punwani S, Ahmed HU, Shah TT. The Role of Multiparametric MRI and MRI-targeted Biopsy in the Diagnosis of Radiorecurrent Prostate Cancer: An Analysis from the FORECAST Trial. Eur Urol 2024; 85:35-46. [PMID: 37778954 DOI: 10.1016/j.eururo.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 08/01/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND The role of multiparametric magnetic resonance imaging (MRI) for detecting recurrent prostate cancer after radiotherapy is unclear. OBJECTIVE To evaluate MRI and MRI-targeted biopsies for detecting intraprostatic cancer recurrence and planning for salvage focal ablation. DESIGN, SETTING, AND PARTICIPANTS FOcal RECurrent Assessment and Salvage Treatment (FORECAST; NCT01883128) was a prospective cohort diagnostic study that recruited 181 patients with suspected radiorecurrence at six UK centres (2014 to 2018); 144 were included here. INTERVENTION All patients underwent MRI with 5 mm transperineal template mapping biopsies; 84 had additional MRI-targeted biopsies. MRI scans with Likert scores of 3 to 5 were deemed suspicious. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS First, the diagnostic accuracy of MRI was calculated. Second, the pathological characteristics of MRI-detected and MRI-undetected tumours were compared using the Wilcoxon rank sum test and chi-square test for trend. Third, four biopsy strategies involving an MRI-targeted biopsy alone and with systematic biopsies of one to two other quadrants were studied. Fisher's exact test was used to compare MRI-targeted biopsy alone with the best other strategy for the number of patients with missed cancer and the number of patients with cancer harbouring additional tumours in unsampled quadrants. Analyses focused primarily on detecting cancer of any grade or length. Last, eligibility for focal therapy was evaluated for men with localised (≤T3bN0M0) radiorecurrent disease. RESULTS AND LIMITATIONS Of 144 patients, 111 (77%) had cancer detected on biopsy. MRI sensitivity and specificity at the patient level were 0.95 (95% confidence interval [CI] 0.92 to 0.99) and 0.21 (95% CI 0.07 to 0.35), respectively. At the prostate quadrant level, 258/576 (45%) quadrants had cancer detected on biopsy. Sensitivity and specificity were 0.66 (95% CI 0.59 to 0.73) and 0.54 (95% CI 0.46 to 0.62), respectively. At the quadrant level, compared with MRI-undetected tumours, MRI-detected tumours had longer maximum cancer core length (median difference 3 mm [7 vs 4 mm]; 95% CI 1 to 4 mm, p < 0.001) and a higher grade group (p = 0.002). Of the 84 men who also underwent an MRI-targeted biopsy, 73 (87%) had recurrent cancer diagnosed. Performing an MRI-targeted biopsy alone missed cancer in 5/73 patients (7%; 95% CI 3 to 15%); with additional systematic sampling of the other ipsilateral and contralateral posterior quadrants (strategy 4), 2/73 patients (3%; 95% CI 0 to 10%) would have had cancer missed (difference 4%; 95% CI -3 to 11%, p = 0.4). If an MRI-targeted biopsy alone was performed, 43/73 (59%; 95% CI 47 to 69%) patients with cancer would have harboured undetected additional tumours in unsampled quadrants. This reduced but only to 7/73 patients (10%; 95% CI 4 to 19%) with strategy 4 (difference 49%; 95% CI 36 to 62%, p < 0.0001). Of 73 patients, 43 (59%; 95% CI 47 to 69%) had localised radiorecurrent cancer suitable for a form of focal ablation. CONCLUSIONS For patients with recurrent prostate cancer after radiotherapy, MRI and MRI-targeted biopsy, with or without perilesional sampling, will diagnose cancer in the majority where present. MRI-undetected cancers, defined as Likert scores of 1 to 2, were found to be smaller and of lower grade. However, if salvage focal ablation is planned, an MRI-targeted biopsy alone is insufficient for prostate mapping; approximately three of five patients with recurrent cancer found on an MRI-targeted biopsy alone harboured further tumours in unsampled quadrants. Systematic sampling of the whole gland should be considered in addition to an MRI-targeted biopsy to capture both MRI-detected and MRI-undetected disease. PATIENT SUMMARY After radiotherapy, magnetic resonance imaging (MRI) is accurate for detecting recurrent prostate cancer, with missed cancer being smaller and of lower grade. Targeting a biopsy to suspicious areas on MRI results in a diagnosis of cancer in most patients. However, for every five men who have recurrent cancer, this targeted approach would miss cancers elsewhere in the prostate in three of these men. If further focal treatment of the prostate is planned, random biopsies covering the whole prostate in addition to targeted biopsies should be considered so that tumours are not missed.
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Affiliation(s)
- Alexander Light
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Abi Kanthabalan
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Marjorie Otieno
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Menelaos Pavlou
- Department of Statistical Science, University College London, London, UK
| | - Rumana Omar
- Department of Statistical Science, University College London, London, UK
| | - Sola Adeleke
- Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
| | - Francesco Giganti
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Chris Brew-Graves
- Division of Medicine, Faculty of Medicine, University College London, London, UK
| | - Norman R Williams
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Amr Emara
- Department of Urology, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Athar Haroon
- Department of Nuclear Medicine, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK; Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Arash Latifoltojar
- Division of Medicine, Faculty of Medicine, University College London, London, UK; Department of Radiology, Royal Marsden NHS Foundation Trust, Surrey, UK
| | - Harbir Sidhu
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK; Division of Medicine, Faculty of Medicine, University College London, London, UK
| | - Alex Freeman
- Department of Histopathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Clement Orczyk
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Ashok Nikapota
- Sussex Cancer Centre, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Tim Dudderidge
- Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Richard G Hindley
- Department of Urology, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Jaspal Virdi
- Department of Urology, The Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Manit Arya
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Heather Payne
- Department of Histopathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Anita V Mitra
- Department of Oncology, University College London Hospital NHS Foundation Trust, London, UK
| | - Jamshed Bomanji
- Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mathias Winkler
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Gail Horan
- Department of Oncology, Queen Elizabeth Hospital, The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
| | - Caroline M Moore
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Shonit Punwani
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK; Division of Medicine, Faculty of Medicine, University College London, London, UK
| | - Hashim U Ahmed
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery & Interventional Science, University College London, London, UK
| | - Taimur T Shah
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery & Interventional Science, University College London, London, UK.
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10
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Koehler D, Trappe S, Shenas F, Karimzadeh A, Apostolova I, Klutmann S, Ambrosini F, Budäus L, Falkenbach F, Knipper S, Maurer T. Prostate-specific membrane antigen radioguided surgery with negative histopathology: an in-depth analysis. Eur J Nucl Med Mol Imaging 2024; 51:548-557. [PMID: 37750908 PMCID: PMC10774205 DOI: 10.1007/s00259-023-06442-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/15/2023] [Indexed: 09/27/2023]
Abstract
PURPOSE To identify reasons for negative histopathology of specimens from prostate-specific membrane antigen (PSMA) radioguided surgery (PSMA-RGS) in recurrent prostate cancer (PCa) after prostatectomy. METHODS Of 302 patients who underwent PSMA-RGS, 17 (5.6%) demonstrated a negative histopathology. Preoperative data, PSMA PET, PSMA SPECT, and follow-up information were analyzed retrospectively to differentiate true/false positive (TP/FP) from true/false negative (TN/FN) lesions. RESULTS The median prostate-specific antigen at PET was 0.4 ng/ml (interquartile range [IQR] 0.3-1.2). Twenty-five index lesions (median short axis 7 mm, IQR 5-8; median long-axis 12 mm, IQR 8-17) had a median SUVmax of 4 (IQR 2.6-6; median PSMA expression score 1, IQR 1-1). Six lesions were TP, twelve were FP, one was TN, and six remained unclear. All TP lesions were in the prostatic fossa or adjacent to the internal iliac arteries. Three suspected local recurrences were FP. All FP lymph nodes were located at the distal external iliac arteries or outside the pelvis. A low PSMA-expressing TN node was identified next to a common iliac artery. Unclear lesions were located next to the external iliac arteries or outside the pelvis. CONCLUSION In most cases with a negative histopathology from PSMA-RGS, lesions were FP on PSMA PET. Unspecific uptake should be considered in low PSMA-expressing lymph nodes at the distal external iliac arteries or outside the pelvis, especially if no PSMA-positive lymph nodes closer to the prostatic fossa are evident. Rarely, true positive metastases were missed by surgery or histopathology.
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Affiliation(s)
- Daniel Koehler
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany.
| | - Samuel Trappe
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Farzad Shenas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Amir Karimzadeh
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Ivayla Apostolova
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Susanne Klutmann
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Francesca Ambrosini
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Lars Budäus
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Falkenbach
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Sophie Knipper
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Maurer
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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11
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Kim J, Sung J, Lee SJ, Cho KS, Chung BH, Yang D, Kim J, Kim JW. Optimal planning target margin for prostate radiotherapy based on interfractional and intrafractional variability assessment during 1.5T MRI-guided radiotherapy. Front Oncol 2023; 13:1337626. [PMID: 38173837 PMCID: PMC10761547 DOI: 10.3389/fonc.2023.1337626] [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: 11/13/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024] Open
Abstract
Introduction We analyzed daily pre-treatment- (PRE) and real-time motion monitoring- (MM) MRI scans of patients receiving definitive prostate radiotherapy (RT) with 1.5 T MRI guidance to assess interfractional and intrafractional variability of the prostate and suggest optimal planning target volume (PTV) margin. Materials and methods Rigid registration between PRE-MRI and planning CT images based on the pelvic bone and prostate anatomy were performed. Interfractional setup margin (SM) and interobserver variability (IO) were assessed by comparing the centroid values of prostate contours delineated on PRE-MRIs. MM-MRIs were used for internal margin (IM) assessment, and PTV margin was calculated using the van Herk formula. Results We delineated 400 prostate contours on PRE-MRI images. SM was 0.57 ± 0.42, 2.45 ± 1.98, and 2.28 ± 2.08 mm in the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) directions, respectively, after bone localization and 0.76 ± 0.57, 1.89 ± 1.60, and 2.02 ± 1.79 mm in the LR, AP, and SI directions, respectively, after prostate localization. IO was 1.06 ± 0.58, 2.32 ± 1.08, and 3.30 ± 1.85 mm in the LR, AP, and SI directions, respectively, after bone localization and 1.11 ± 0.55, 2.13 ± 1.07, and 3.53 ± 1.65 mm in the LR, AP, and SI directions, respectively, after prostate localization. Average IM was 2.12 ± 0.86, 2.24 ± 1.07, and 2.84 ± 0.88 mm in the LR, AP, and SI directions, respectively. Calculated PTV margin was 2.21, 5.16, and 5.40 mm in the LR, AP, and SI directions, respectively. Conclusions Movements in the SI direction were the largest source of variability in definitive prostate RT, and interobserver variability was a non-negligible source of margin. The optimal PTV margin should also consider the internal margin.
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Affiliation(s)
- Jina Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jiwon Sung
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seo Jin Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kang Su Cho
- Department of Urology, Prostate Cancer Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung Ha Chung
- Department of Urology, Prostate Cancer Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dongjoon Yang
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jihun Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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12
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Gómez-Aparicio MA, López-Campos F, Lozano AJ, Maldonado X, Caballero B, Zafra J, Suarez V, Moreno E, Arcangeli S, Scorsetti M, Couñago F. Novel Approaches in the Systemic Management of High-Risk Prostate Cancer. Clin Genitourin Cancer 2023; 21:e485-e494. [PMID: 37453915 DOI: 10.1016/j.clgc.2023.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/18/2023] [Accepted: 06/01/2023] [Indexed: 07/18/2023]
Abstract
Locally advanced prostate cancer comprises approximately 20% of new prostate cancer diagnoses. For these patients, international guidelines recommend treatment with radiotherapy (RT) to the prostate in combination with long-term (2-3 years) androgen deprivation therapy (ADT), or radical prostatectomy in combination with extended pelvic lymph node dissection (PLND) as another treatment option for selected patients as part of multimodal therapy. Improvements in overall survival with docetaxel or an androgen receptor signaling inhibitor have been achieved in patients with metastatic castration sensitive or castration resistant prostate cancer. However, the role of systemic therapy combinations for high risk and/or unfavorable prostate cancer is unclear. In this context, the aim of this review is to assess the current evidence for systemic treatment combinations as part of primary definitive therapy in patients with high-risk localized prostate cancer.
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Affiliation(s)
| | - Fernando López-Campos
- Department of Radiation Oncology, Hospital Universitario Ramon y Cajal, Madrid, Spain.
| | - Antonio José Lozano
- Department of Radiation Oncology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Xavier Maldonado
- Department of Radiation Oncology, Hospital Vall d´Hebron, Barcelona, Spain
| | - Begoña Caballero
- Department of Radiation Oncology, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
| | - Juan Zafra
- Department of Radiation Oncology, Hospital Virgen de la Victoria, Malaga, Spain
| | - Vladamir Suarez
- Department of Radiation Oncology, GenesisCare Malaga, Malaga, Spain
| | - Elena Moreno
- Department of Radiation Oncology, GenesisCare Madrid, Madrid, Spain
| | - Stefano Arcangeli
- Department of Radiation Oncology, University of Milan, Bicocca, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Felipe Couñago
- Department of Radiation Oncology, GenesisCare Madrid, Madrid, Spain; Department of Radiation Oncology, GenesisCare Madrid Clinical Director, Hospital San Francisco de Asís and Hospital Vithas La Milagrosa, National Chair of Research and Clinical Trials, GenesisCare, Madrid, Spain
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13
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Duque-Santana V, Diaz-Gavela A, Recio M, Guerrero LL, Peña M, Sanchez S, López-Campos F, Thuissard IJ, Andreu C, Sanz-Rosa D, Achard V, Gómez-Iturriaga A, Molina Y, Del Cerro Peñalver E, Couñago F. Jorge clinical study: 10-year outcomes of risk-adapted radiotherapy defined by multiparametric MRI for prostate cancer. World J Urol 2023; 41:3829-3838. [PMID: 37966505 DOI: 10.1007/s00345-023-04682-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/08/2023] [Indexed: 11/16/2023] Open
Abstract
PURPOSE To analyze the 10-year biochemical relapse-free survival (BRFS), locoregional relapse-free survival (LRFS), metastasis-free survival (MFS), and overall survival (OS) in patients diagnosed with localized prostate adenocarcinoma treated with radiotherapy (RT) ± androgen deprivation therapy (ADT), according to the risk groups based on multiparametric magnetic resonance imaging (mpMRI) instead of digital rectal exam (DRE). METHODS We retrospectively evaluated 140 consecutive patients diagnosed with localized prostate adenocarcinoma, stratified into different risk groups-low (LR), intermediate (IR), and high (HR) by mpMRI results. RESULTS After a median follow-up of 104 months, in LR group (n = 15), 10-year BRFS was 86.7%, 10-year LRFS was 86.7%, 10-year MFS was 93.3%, and 10-year OS was 100%. In IR group (n = 80), 10-year BRFS was 80.5%, 10-year LRFS was 86.1%, 10-year MFS was 92.6%, and 10-year OS was 76%. In HR group (n = 45), 10-year BRFS was 72.8%, 10-year LRFS was 78.7%, 10-year MFS was 82.1%, and 10-year OS was 77% (2 deaths from prostate cancer). According to mpMRI results, 36 (25.7%) patients change the risk group and 125 (89.28%) patients change the TNM stage. There was a trend for higher metastatic relapse in patients who switched from IR to HR (due to mpMRI) versus the patients who remained in the IR (20%, vs. 1.81% p = 0.059). Multivariate analysis showed that locoregional relapse was strongly associated with distant relapse (OR = 9.28; 95%CI: 2.60-33.31). There were no cases of acute grade 3 toxicity. Late grade 3 genitourinary, gastrointestinal, and sexual toxicity were 2.8%, 0.7%, and 1.2%, respectively. CONCLUSION This is the first study with a 10-year median follow-up of patients diagnosed with localized prostate cancer treated with radiotherapy according to the risk groups established by mpMRI. Our findings show that mpMRI is a key tool to diagnose and establish risk groups in these patients, to optimize their treatment.
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Affiliation(s)
- Victor Duque-Santana
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid y Hospital La Luz, Universidad Europea de Madrid, Madrid, Spain
| | - Ana Diaz-Gavela
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid y Hospital La Luz, Universidad Europea de Madrid, Madrid, Spain
| | - Manuel Recio
- Department of Radiology, Hospital Universitario Quironsalud Madrid, Madrid, Spain
| | - Luis Leonardo Guerrero
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid y Hospital La Luz, Universidad Europea de Madrid, Madrid, Spain
| | - Marina Peña
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid y Hospital La Luz, Universidad Europea de Madrid, Madrid, Spain
| | - Sofia Sanchez
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid y Hospital La Luz, Universidad Europea de Madrid, Madrid, Spain
| | - Fernando López-Campos
- Department of Radiation Oncology, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Israel J Thuissard
- Department of Biomedical and Health Sciences, Universidad Europea de Madrid, Madrid, Spain
| | - Cristina Andreu
- Department of Biomedical and Health Sciences, Universidad Europea de Madrid, Madrid, Spain
| | - David Sanz-Rosa
- Department of Biomedical and Health Sciences, Universidad Europea de Madrid, Madrid, Spain
| | - Vérane Achard
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | | | - Yolanda Molina
- Department of Medical Physics, Hospital Universitario Quirónsalud Madrid, Madrid, Spain
| | - Elia Del Cerro Peñalver
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid y Hospital La Luz, Universidad Europea de Madrid, Madrid, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital San Francisco de Asís y La Milagrosa, Clinical Director, National Chair of Research and Clinical Trials, GenesisCare, Madrid, Spain.
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14
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Jahreiβ MC, Incrocci L, Dirkx M, de Vries KC, Aben KKH, Bangma C, Heemsbergen WD. Long-term Overall Survival after External Beam Radiotherapy for Localised Prostate Cancer. Clin Oncol (R Coll Radiol) 2023; 35:e689-e698. [PMID: 37852813 DOI: 10.1016/j.clon.2023.09.017] [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: 05/26/2023] [Revised: 08/28/2023] [Accepted: 09/28/2023] [Indexed: 10/20/2023]
Abstract
AIMS Knowledge on survival probabilities is essential for determining optimal treatment strategies. We studied overall survival and associated prognostic factors in Dutch patients with localised prostate cancer (PCa) selected for external beam radiotherapy. MATERIALS AND METHODS For this single-centre retrospective cohort study, we identified all T1-T3 PCa patients (aged 55-80 years) in the radiotherapy planning database with a start date between January 2006 and December 2013, treated with 72-78 Gy in 2 Gy fractions to the prostate ± seminal vesicles (n = 1536). Long-term androgen deprivation therapy (ADT) was predominantly prescribed in the case of extracapsular disease (>T3). Overall survival was estimated using the Kaplan-Meier method. Prognostic factors were evaluated in Cox regression models for the intermediate-risk and high-risk groups. RESULTS The median follow-up was 12 years for patients who were alive. Ten-year survival rates were 79.0% for low-risk (n = 120), 59.9% for intermediate-risk (n = 430) and 56.8% for high-risk patients (n = 986). A higher age, higher comorbidity score, active smoking and Gleason score ≥8 had a statistically significant negative impact on overall survival at multivariable analysis. ADT was associated with superior overall survival in the high-risk group translating into overall survival rates similar to the intermediate-risk group. CONCLUSIONS Although PCa patients selected for external beam radiotherapy are typically in good health, their comorbidity score and smoking habits appeared to be dominant predictors for overall survival. Overall survival rates within the high-risk group varied, showing improved overall survival with ADT prescription and worse overall survival in the case of Gleason score ≥8.
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Affiliation(s)
- M-C Jahreiβ
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - L Incrocci
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M Dirkx
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - K C de Vries
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - K K H Aben
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands; Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - C Bangma
- Department of Urology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - W D Heemsbergen
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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15
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Roy S, Romero T, Michalski JM, Feng FY, Efstathiou JA, Lawton CA, Bolla M, Maingon P, de Reijke T, Joseph D, Ong WL, Sydes MR, Dearnaley DP, Tree AC, Carrier N, Nabid A, Souhami L, Incrocci L, Heemsbergen WD, Pos FJ, Zapatero A, Guerrero A, Alvarez A, San-Segundo CG, Maldonado X, Reiter RE, Rettig MB, Nickols NG, Steinberg ML, Valle LF, Ma TM, Farrell MJ, Neilsen BK, Juarez JE, Deng J, Vangala S, Avril N, Jia AY, Zaorsky NG, Sun Y, Spratt D, Kishan AU. Biochemical Recurrence Surrogacy for Clinical Outcomes After Radiotherapy for Adenocarcinoma of the Prostate. J Clin Oncol 2023; 41:5005-5014. [PMID: 37639648 PMCID: PMC10642893 DOI: 10.1200/jco.23.00617] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/30/2023] [Accepted: 07/12/2023] [Indexed: 08/31/2023] Open
Abstract
PURPOSE The surrogacy of biochemical recurrence (BCR) for overall survival (OS) in localized prostate cancer remains controversial. Herein, we evaluate the surrogacy of BCR using different surrogacy analytic methods. MATERIALS AND METHODS Individual patient data from 11 trials evaluating radiotherapy dose escalation, androgen deprivation therapy (ADT) use, and ADT prolongation were obtained. Surrogate candidacy was assessed using the Prentice criteria (including landmark analyses) and the two-stage meta-analytic approach (estimating Kendall's tau and the R2). Biochemical recurrence-free survival (BCRFS, time from random assignment to BCR or any death) and time to BCR (TTBCR, time from random assignment to BCR or cancer-specific deaths censoring for noncancer-related deaths) were assessed. RESULTS Overall, 10,741 patients were included. Dose escalation, addition of short-term ADT, and prolongation of ADT duration significantly improved BCR (hazard ratio [HR], 0.71 [95% CI, 0.63 to 0.79]; HR, 0.53 [95% CI, 0.48 to 0.59]; and HR, 0.54 [95% CI, 0.48 to 0.61], respectively). Adding short-term ADT (HR, 0.91 [95% CI, 0.84 to 0.99]) and prolonging ADT (HR, 0.86 [95% CI, 0.78 to 0.94]) significantly improved OS, whereas dose escalation did not (HR, 0.98 [95% CI, 0.87 to 1.11]). BCR at 48 months was associated with inferior OS in all three groups (HR, 2.46 [95% CI, 2.08 to 2.92]; HR, 1.51 [95% CI, 1.35 to 1.70]; and HR, 2.31 [95% CI, 2.04 to 2.61], respectively). However, after adjusting for BCR at 48 months, there was no significant treatment effect on OS (HR, 1.10 [95% CI, 0.96 to 1.27]; HR, 0.96 [95% CI, 0.87 to 1.06] and 1.00 [95% CI, 0.90 to 1.12], respectively). The patient-level correlation (Kendall's tau) for BCRFS and OS ranged between 0.59 and 0.69, and that for TTBCR and OS ranged between 0.23 and 0.41. The R2 values for trial-level correlation of the treatment effect on BCRFS and TTBCR with that on OS were 0.563 and 0.160, respectively. CONCLUSION BCRFS and TTBCR are prognostic but failed to satisfy all surrogacy criteria. Strength of correlation was greater when noncancer-related deaths were considered events.
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Affiliation(s)
- Soumyajit Roy
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL
| | - Tahmineh Romero
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jeff M. Michalski
- Department of Radiation Oncology, Washington University, St Louis, MO
| | - Felix Y. Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Jason A. Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Colleen A.F. Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Michel Bolla
- Radiotherapy Department, University Hospital, Grenoble, France
| | - Philippe Maingon
- Department of Oncology, Hematology, and Supportive Care, Sorbonne University, Paris, France
| | - Theo de Reijke
- Department of Urology, Prostate Cancer Network in the Netherlands, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - David Joseph
- Department of Medicine and Surgery, University of Western Australia, Perth, WA, Australia
| | - Wee Loon Ong
- Alfred Health Radiation Oncology, Monash University, Melbourne, VIC, Australia
| | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - David P. Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research and Department of Urology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alison C. Tree
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Nathalie Carrier
- Clinical Research Center, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Abdenour Nabid
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Centre, Montréal, QC, Canada
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Wilma D. Heemsbergen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Floris J. Pos
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | | | - Ana Alvarez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Robert E. Reiter
- Department of Urology, University of California Los Angeles, Los Angeles, CA
| | - Matthew B. Rettig
- Department of Medical Oncology, University of California Los Angeles, Los Angeles, CA
| | - Nicholas G. Nickols
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Michael L. Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Luca F. Valle
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - T. Martin Ma
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Matthew J. Farrell
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Beth K. Neilsen
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Jesus E. Juarez
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Jie Deng
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Sitaram Vangala
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Norbert Avril
- Department of Radiology, Division of Nuclear Medicine, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Angela Y. Jia
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Nicholas G. Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Yilun Sun
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
- Department of Population Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Daniel Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
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16
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Light A, Peters M, Reddy D, Kanthabalan A, Otieno M, Pavlou M, Omar R, Adeleke S, Giganti F, Brew-Graves C, Williams NR, Emara A, Haroon A, Latifoltojar A, Sidhu H, Freeman A, Orczyk C, Nikapota A, Dudderidge T, Hindley RG, Virdi J, Arya M, Payne H, Mitra AV, Bomanji J, Winkler M, Horan G, Moore C, Emberton M, Punwani S, Ahmed HU, Shah TT. External validation of a risk model predicting failure of salvage focal ablation for prostate cancer. BJU Int 2023; 132:520-530. [PMID: 37385981 PMCID: PMC10615865 DOI: 10.1111/bju.16102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVES To externally validate a published model predicting failure within 2 years after salvage focal ablation in men with localised radiorecurrent prostate cancer using a prospective, UK multicentre dataset. PATIENTS AND METHODS Patients with biopsy-confirmed ≤T3bN0M0 cancer after previous external beam radiotherapy or brachytherapy were included from the FOcal RECurrent Assessment and Salvage Treatment (FORECAST) trial (NCT01883128; 2014-2018; six centres), and from the high-intensity focussed ultrasound (HIFU) Evaluation and Assessment of Treatment (HEAT) and International Cryotherapy Evaluation (ICE) UK-based registries (2006-2022; nine centres). Eligible patients underwent either salvage focal HIFU or cryotherapy, with the choice based predominantly on anatomical factors. Per the original multivariable Cox regression model, the predicted outcome was a composite failure outcome. Model performance was assessed at 2 years post-salvage with discrimination (concordance index [C-index]), calibration (calibration curve and slope), and decision curve analysis. For the latter, two clinically-reasonable risk threshold ranges of 0.14-0.52 and 0.26-0.36 were considered, corresponding to previously published pooled 2-year recurrence-free survival rates for salvage local treatments. RESULTS A total of 168 patients were included, of whom 84/168 (50%) experienced the primary outcome in all follow-ups, and 72/168 (43%) within 2 years. The C-index was 0.65 (95% confidence interval 0.58-0.71). On graphical inspection, there was close agreement between predicted and observed failure. The calibration slope was 1.01. In decision curve analysis, there was incremental net benefit vs a 'treat all' strategy at risk thresholds of ≥0.23. The net benefit was therefore higher across the majority of the 0.14-0.52 risk threshold range, and all of the 0.26-0.36 range. CONCLUSION In external validation using prospective, multicentre data, this model demonstrated modest discrimination but good calibration and clinical utility for predicting failure of salvage focal ablation within 2 years. This model could be reasonably used to improve selection of appropriate treatment candidates for salvage focal ablation, and its use should be considered when discussing salvage options with patients. Further validation in larger, international cohorts with longer follow-up is recommended.
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Affiliation(s)
- Alexander Light
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London UK
| | - Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Deepika Reddy
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London UK
| | - Abi Kanthabalan
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Marjorie Otieno
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Menelaos Pavlou
- Department of Statistical Science, University College London, London, UK
| | - Rumana Omar
- Department of Statistical Science, University College London, London, UK
| | - Sola Adeleke
- Department of Oncology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- School of Cancer & Pharmaceutical Sciences, King’s College London, London, UK
| | - Francesco Giganti
- Division of Surgery and Interventional Sciences, University College London, London, UK
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Chris Brew-Graves
- Division of Medicine, Faculty of Medicine, University College London, UK
| | - Norman R. Williams
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Amr Emara
- Department of Urology, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Athar Haroon
- Department of Nuclear Medicine, St Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
- Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Arash Latifoltojar
- Division of Medicine, Faculty of Medicine, University College London, UK
- Department of Radiology, Royal Marsden NHS Foundation Trust, Surrey, UK
| | - Harbir Sidhu
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
- Division of Medicine, Faculty of Medicine, University College London, UK
| | - Alex Freeman
- Department of Histopathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Clement Orczyk
- Division of Surgery and Interventional Sciences, University College London, London, UK
- Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Ashok Nikapota
- Sussex Cancer Centre, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Tim Dudderidge
- Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Richard G. Hindley
- Department of Urology, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Jaspal Virdi
- Department of Urology, The Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Manit Arya
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London UK
| | - Heather Payne
- Department of Histopathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Anita V. Mitra
- Department of Oncology, University College London Hospital NHS Foundation Trust, London, UK
| | - Jamshed Bomanji
- Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mathias Winkler
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London UK
| | - Gail Horan
- Department of Oncology, Queen Elizabeth Hospital, The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust, King's Lynn, UK
| | - Caroline Moore
- Division of Surgery and Interventional Sciences, University College London, London, UK
- Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Sciences, University College London, London, UK
- Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Shonit Punwani
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
- Division of Medicine, Faculty of Medicine, University College London, UK
| | - Hashim U. Ahmed
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London UK
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Taimur T. Shah
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London UK
- Division of Surgery and Interventional Sciences, University College London, London, UK
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17
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Scheltema MJ, Katelaris A, Stricker PD. Salvage irreversible electroporation for radio-recurrent prostate cancer. Nat Rev Urol 2023; 20:517-518. [PMID: 36859611 DOI: 10.1038/s41585-023-00750-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Affiliation(s)
- Matthijs J Scheltema
- St Vincent's Prostate Cancer Research Centre, Sydney, New South Wales, Australia.
| | - Athos Katelaris
- St Vincent's Prostate Cancer Research Centre, Sydney, New South Wales, Australia
| | - Phillip D Stricker
- St Vincent's Prostate Cancer Research Centre, Sydney, New South Wales, Australia
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18
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Schmidt DR, Gramatikov IMT, Sheen A, Williams CL, Hurwitz M, Dodge LE, Holupka E, Kiger WS, Cornwall-Brady MR, Huang W, Mak HH, Cormier KS, Condon C, Dane Wittrup K, Yilmaz ÖH, Stevenson MA, Down JD, Floyd SR, Roper J, Vander Heiden MG. Ablative radiotherapy improves survival but does not cure autochthonous mouse models of prostate and colorectal cancer. COMMUNICATIONS MEDICINE 2023; 3:108. [PMID: 37558833 PMCID: PMC10412558 DOI: 10.1038/s43856-023-00336-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 07/24/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Genetically engineered mouse models (GEMMs) of cancer are powerful tools to study mechanisms of disease progression and therapy response, yet little is known about how these models respond to multimodality therapy used in patients. Radiation therapy (RT) is frequently used to treat localized cancers with curative intent, delay progression of oligometastases, and palliate symptoms of metastatic disease. METHODS Here we report the development, testing, and validation of a platform to immobilize and target tumors in mice with stereotactic ablative RT (SART). Xenograft and autochthonous tumor models were treated with hypofractionated ablative doses of radiotherapy. RESULTS We demonstrate that hypofractionated regimens used in clinical practice can be effectively delivered in mouse models. SART alters tumor stroma and the immune environment, improves survival in GEMMs of primary prostate and colorectal cancer, and synergizes with androgen deprivation in prostate cancer. Complete pathologic responses were achieved in xenograft models, but not in GEMMs. CONCLUSIONS While SART is capable of fully ablating xenografts, it is unable to completely eradicate disease in GEMMs, arguing that resistance to potentially curative therapy can be modeled in GEMMs.
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Affiliation(s)
- Daniel R Schmidt
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA.
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Iva Monique T Gramatikov
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Allison Sheen
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Christopher L Williams
- Harvard Medical School, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Martina Hurwitz
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Laura E Dodge
- Harvard Medical School, Boston, MA, USA
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Edward Holupka
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - W S Kiger
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Milton R Cornwall-Brady
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Wei Huang
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Howard H Mak
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Kathleen S Cormier
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Charlene Condon
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - K Dane Wittrup
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Ömer H Yilmaz
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, USA
| | - Mary Ann Stevenson
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Julian D Down
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Scott R Floyd
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC, USA
| | - Jatin Roper
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Medicine, Division of Gastroenterology, and Department of Pharmacology and Cancer Biology, Duke University, Durham, NC, USA
| | - Matthew G Vander Heiden
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA.
- Dana-Farber Cancer Institute, Boston, MA, USA.
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19
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Peyrottes A, Achard V, Dariane C. How To Manage T3b Prostate Cancer in the Contemporary Era: The Benefits of Surgery. EUR UROL SUPPL 2023; 53:55-57. [PMID: 37287634 PMCID: PMC10241842 DOI: 10.1016/j.euros.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/09/2023] Open
Affiliation(s)
- Arthur Peyrottes
- Department of Urology, Hôpital européen Georges-Pompidou, AP-HP, Paris, France
- Prostate Group, Comité de Cancérologie de l’Association Française d’Urologie, Junior Member, Paris, France
| | - Verane Achard
- Department of Radiation Oncology, HFR Fribourg, Villars-sur-Glâne, Switzerland
| | - Charles Dariane
- Department of Urology, Hôpital européen Georges-Pompidou, AP-HP, Paris, France
- Prostate Group, Comité de Cancérologie de l’Association Française d’Urologie, Paris, France
- U1151 Inserm-INEM, Paris University, Paris, France
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20
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Ku AT, Shankavaram U, Trostel SY, Zhang H, Sater HA, Harmon SA, Carrabba NV, Liu Y, Wood BJ, Pinto PA, Choyke PL, Stoyanova R, Davicioni E, Pollack A, Turkbey B, Sowalsky AG, Citrin DE. Radiogenomic profiling of prostate tumors prior to external beam radiotherapy converges on a transcriptomic signature of TGF-β activity driving tumor recurrence. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.01.23288883. [PMID: 37205576 PMCID: PMC10187349 DOI: 10.1101/2023.05.01.23288883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Background Patients with localized prostate cancer have historically been assigned to clinical risk groups based on local disease extent, serum prostate specific antigen (PSA), and tumor grade. Clinical risk grouping is used to determine the intensity of treatment with external beam radiotherapy (EBRT) and androgen deprivation therapy (ADT), yet a substantial proportion of patients with intermediate and high risk localized prostate cancer will develop biochemical recurrence (BCR) and require salvage therapy. Prospective identification of patients destined to experience BCR would allow treatment intensification or selection of alternative therapeutic strategies. Methods Twenty-nine individuals with intermediate or high risk prostate cancer were prospectively recruited to a clinical trial designed to profile the molecular and imaging features of prostate cancer in patients undergoing EBRT and ADT. Whole transcriptome cDNA microarray and whole exome sequencing were performed on pretreatment targeted biopsy of prostate tumors (n=60). All patients underwent pretreatment and 6-month post EBRT multiparametric MRI (mpMRI), and were followed with serial PSA to assess presence or absence of BCR. Genes differentially expressed in the tumor of patients with and without BCR were investigated using pathways analysis tools and were similarly explored in alternative datasets. Differential gene expression and predicted pathway activation were evaluated in relation to tumor response on mpMRI and tumor genomic profile. A novel TGF-β gene signature was developed in the discovery dataset and applied to a validation dataset. Findings Baseline MRI lesion volume and PTEN/TP53 status in prostate tumor biopsies correlated with the activation state of TGF-β signaling measured using pathway analysis. All three measures correlated with the risk of BCR after definitive RT. A prostate cancer-specific TGF-β signature discriminated between patients that experienced BCR vs. those that did not. The signature retained prognostic utility in an independent cohort. Interpretation TGF-β activity is a dominant feature of intermediate-to-unfavorable risk prostate tumors prone to biochemical failure after EBRT with ADT. TGF-β activity may serve as a prognostic biomarker independent of existing risk factors and clinical decision-making criteria. Funding This research was supported by the Prostate Cancer Foundation, the Department of Defense Congressionally Directed Medical Research Program, National Cancer Institute, and the Intramural Research Program of the NIH, National Cancer Institute, Center for Cancer Research.
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Affiliation(s)
- Anson T. Ku
- Laboratory of Genitourinary Cancer Pathogenesis, National Cancer Institute, Bethesda, MD, USA
| | - Uma Shankavaram
- Radiation Oncology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Shana Y. Trostel
- Laboratory of Genitourinary Cancer Pathogenesis, National Cancer Institute, Bethesda, MD, USA
| | - Hong Zhang
- Radiation Oncology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Houssein A. Sater
- Genitourinary Malignancies Branch, National Cancer Institute, Bethesda, MD, USA
| | | | - Nicole V. Carrabba
- Laboratory of Genitourinary Cancer Pathogenesis, National Cancer Institute, Bethesda, MD, USA
| | - Yang Liu
- Veracyte, Inc., South San Francisco, CA, USA
| | - Bradford J. Wood
- Center for Interventional Oncology, NIH Clinical Center, Bethesda, MD, USA
| | - Peter A. Pinto
- Urologic Oncology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Peter L. Choyke
- Molecular Imaging Branch, National Cancer Institute, Bethesda, MD, USA
| | - Radka Stoyanova
- Department of Radiation Oncology, University of Miami, Miami, FL, USA
| | | | - Alan Pollack
- Department of Radiation Oncology, University of Miami, Miami, FL, USA
| | - Baris Turkbey
- Molecular Imaging Branch, National Cancer Institute, Bethesda, MD, USA
| | - Adam G. Sowalsky
- Laboratory of Genitourinary Cancer Pathogenesis, National Cancer Institute, Bethesda, MD, USA
| | - Deborah E. Citrin
- Radiation Oncology Branch, National Cancer Institute, Bethesda, MD, USA
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21
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Mendez LC, Dhar A, Laidley D, Moussa M, Gomez JA, Chin J, Lee TY, Thiessen JD, Hoover D, Surrey K, Helou J, Velker V, Correa RJ, D'Souza D, Bayani J, Bauman G. The use of Lutetium-177 PSMA radioligand therapy with high dose rate brachytherapy for locally recurrent prostate cancer after previous definitive radiation therapy: a randomized, single-institution, phase I/II study (ROADSTER). BMC Cancer 2023; 23:362. [PMID: 37081426 PMCID: PMC10116658 DOI: 10.1186/s12885-023-10851-0] [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: 12/02/2022] [Accepted: 04/14/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Isolated local failure (ILF) can occur in patients who initially receive definitive radiation therapy for prostate cancer. Salvage therapy for ILF includes high dose rate (HDR) brachytherapy. Prostate Specific Membrane Antigen (PSMA) Positron Emission Tomography (PET) can accurately detect ILF and can exclude extraprostatic disease. Lutetium-177 PSMA Radioligand Therapy (RLT) is a novel treatment for prostate cancer that can target prostate cancer accurately, while sparing radiation dose to normal tissues. METHODS ROADSTER is a phase I/II randomized, single-institution study. Patients with an ILF of prostate cancer after definitive initial radiation therapy are eligible. The ILF will be confirmed with biopsy, magnetic resonance imaging (MRI) and PSMA PET. Patients will be randomized between HDR brachytherapy in two fractions (a standard of care salvage treatment at our institution) (cohort 1) or one treatment of intravenous Lutetium-177 PSMA RLT, followed by one fraction of HDR brachytherapy (cohort 2). The primary endpoints for the phase I portion of the study (n = 12) will be feasibility, defined as 10 or more patients completing the study protocol within 24 months of study activation; and safety, defined as zero or one patients in cohort 2 experiencing grade 3 or higher toxicity in the first 6 months post-treatment. If feasibility and safety are achieved, the study will expand to a phase II study (n = 30 total) where preliminary efficacy data will be evaluated. Secondary endpoints include changes in prostate specific antigen levels, acute toxicity, changes in quality of life, and changes in translational biomarkers. Translational endpoints will include interrogation of blood, urine, and tissue for markers of DNA damage and immune activation with each treatment. DISCUSSION ROADSTER explores a novel salvage therapy for ILF after primary radiotherapy with combined Lutetium-177 PSMA RLT and HDR brachytherapy. The randomized phase I/II design will provide a contemporaneous patient population treated with HDR alone to facilitate assessment of feasibility, tolerability, and biologic effects of this novel therapy. TRIAL REGISTRATION NCT05230251 (ClinicalTrials.gov).
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Affiliation(s)
- Lucas C Mendez
- London Health Sciences Centre, London, Ontario, Canada
- Department of Oncology, Western University, London, Ontario, Canada
| | - Aneesh Dhar
- London Health Sciences Centre, London, Ontario, Canada
| | - David Laidley
- London Health Sciences Centre, London, Ontario, Canada
| | | | - Jose A Gomez
- London Health Sciences Centre, London, Ontario, Canada
| | - Joseph Chin
- London Health Sciences Centre, London, Ontario, Canada
| | - T-Y Lee
- Lawson Health Research Institute, London, Ontario, Canada
| | | | - Douglas Hoover
- London Health Sciences Centre, London, Ontario, Canada
- Department of Oncology, Western University, London, Ontario, Canada
- Department of Medical Biophysics, Western University, London, Ontario, Canada
| | | | - Joelle Helou
- London Health Sciences Centre, London, Ontario, Canada
- Department of Oncology, Western University, London, Ontario, Canada
| | - Vikram Velker
- London Health Sciences Centre, London, Ontario, Canada
- Department of Oncology, Western University, London, Ontario, Canada
| | - Rohann J Correa
- London Health Sciences Centre, London, Ontario, Canada
- Department of Oncology, Western University, London, Ontario, Canada
| | - David D'Souza
- London Health Sciences Centre, London, Ontario, Canada
- Department of Oncology, Western University, London, Ontario, Canada
| | - Jane Bayani
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Glenn Bauman
- London Health Sciences Centre, London, Ontario, Canada.
- Lawson Health Research Institute, London, Ontario, Canada.
- Department of Oncology, Western University, London, Ontario, Canada.
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22
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Smith CP, Proudfoot JA, Boutros PC, Reiter RE, Valle L, Rettig MB, Nickols NG, Feng FY, Nguyen PL, Nagar H, Spratt DE, Attard G, Weiner A, Weidhaas JB, Calais J, Ma TM, Davicioni E, Xiang M, Kishan AU. Transcriptomic Heterogeneity in High-risk Prostate Cancer and Implications for Extraprostatic Disease at Presentation on Prostate-specific Membrane Antigen Positron Emission Tomography. Eur Urol Oncol 2023; 6:224-227. [PMID: 36870853 DOI: 10.1016/j.euo.2023.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/10/2023] [Accepted: 02/03/2023] [Indexed: 03/06/2023]
Abstract
Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) has greater specificity and sensitivity for detection of extraprostatic prostate cancer (PCa) at presentation than conventional imaging. Although the long-term clinical significance of acting on these findings is unknown, it has been shown that the risk of upstaging is prognostic for long-term outcomes in men with high-risk (HR) or very high-risk (VHR) PCa. We evaluated the association between the risk of upstaging on PSMA PET and the Decipher genomic classifier score, a known prognostic biomarker in localized PCa that is being evaluated for its predictive ability to direct systemic therapy intensification. In a cohort of 4625 patients with HR or VHR PCa, the risk of upstaging on PSMA PET was significantly correlated with the Decipher score (p < 0.001). These results should be seen as hypothesis-generating and warrant further studies on the causal pathways linking PSMA findings, Decipher scores, extraprostatic disease, and long-term clinical outcomes. PATIENT SUMMARY: We found significant correlation between the risk of having prostate cancer outside the prostate gland on a sensitive scan (based on prostate-specific membrane antigen [PSMA]) at initial staging and the Decipher genetic score. The results warrant further studies on the causal pathways between PSMA scan findings, Decipher scores, disease outside the prostate, and long-term outcomes.
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Affiliation(s)
- Clayton P Smith
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, CA, USA
| | | | - Paul C Boutros
- Department of Human Genetics, University of California-Los Angeles, Los Angeles, CA, USA; Department of Urology, University of California-Los Angeles, Los Angeles, CA, USA
| | - Robert E Reiter
- Department of Urology, University of California-Los Angeles, Los Angeles, CA, USA
| | - Luca Valle
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, CA, USA
| | - Matthew B Rettig
- Department of Urology, University of California-Los Angeles, Los Angeles, CA, USA; Division of Hematology/Oncology, Department of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, CA, USA
| | - Felix Y Feng
- Department of Radiation Oncology, University of California-San Francisco, San Francisco, CA, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Himanshu Nagar
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Gert Attard
- University College London Cancer Institute, London, UK
| | - Adam Weiner
- Department of Urology, University of California-Los Angeles, Los Angeles, CA, USA
| | - Joanne B Weidhaas
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, CA, USA
| | - Jeremie Calais
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | - T Martin Ma
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, CA, USA
| | | | - Michael Xiang
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, CA, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, CA, USA; Department of Urology, University of California-Los Angeles, Los Angeles, CA, USA.
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23
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Ma TM, Czernin J, Felix C, Alano R, Wilhalme H, Valle L, Steinberg ML, Dahlbom M, Reiter RE, Rettig MB, Cao M, Calais J, Kishan AU. LUNAR: a randomized Phase 2 study of 177 Lutetium-PSMA Neoadjuvant to Ablative Radiotherapy for Oligorecurrent Prostate Cancer (clinical trial protocol). BJU Int 2023. [PMID: 36797449 DOI: 10.1111/bju.15988] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE To assess the efficacy of 177 Lu-PNT2002, a novel radiolabelled small molecule that binds with high affinity to prostate-specific membrane antigen (PSMA), in combination with stereotactic body radiotherapy (SBRT) to all sites of metastasis, vs SBRT alone, in men with oligorecurrent metastatic hormone-sensitive prostate cancer (mHSPC). PATIENTS AND METHODS The 177 Lutetium-PSMA Neoadjuvant to Ablative Radiotherapy for Oligorecurrent Prostate Cancer (LUNAR) trial is an open-label, randomized, stratified, two-arm, single-centre, Phase 2 trial to compare the efficacy and safety of neoadjuvant 177 Lu-PNT2002 plus SBRT vs SBRT alone in men with oligorecurrent mHSPC. Key eligibility criteria include one to five lesions identified on a PSMA positron emission tomography (PET)/computed tomography (CT) scan centrally reviewed by a board-certified nuclear medicine physician. Key exclusion criteria include castrate-resistant disease, de novo oligometastatic disease and receipt of androgen deprivation therapy (ADT) within 6 months of trial enrolment. The trial aims to enrol 100 patients who will be centrally randomized to one of the two treatment arms, in a 1:1 ratio. Patients in the control arm receive SBRT to all sites of disease. Patients in the experimental arm receive two cycles of neoadjuvant 177 Lu-PNT2002 (6.8 GBq) 6-8 weeks apart, followed by an interval PSMA PET/CT in 4-6 weeks and dose-adapted SBRT to all sites of disease 1-2 weeks later. The primary endpoint is progression-free survival. Secondary endpoints are radiographic and prostate-specific antigen-based progression, acute and late physician-scored toxicity, patient-reported quality of life, ADT-free survival, time to progression, overall survival, locoregional control, and duration of response. Enrolment in the study commenced in September 2022. RESULTS AND CONCLUSIONS The addition of 177 Lu-PNT2002 to metastasis-directed therapy alone may potentially further forestall disease progression. The results of this Phase 2 trial will determine, for the first time in a randomized fashion, the added benefit of 177 Lu-PNT2002 to SBRT in patients with oligorecurrent mHSPC.
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Affiliation(s)
- Ting Martin Ma
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Johannes Czernin
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, CA, USA.,Physics and Biology in Medicine Interdepartmental Graduate Program, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Carol Felix
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Rejah Alano
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, CA, USA
| | - Holly Wilhalme
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Luca Valle
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Magnus Dahlbom
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, CA, USA.,Physics and Biology in Medicine Interdepartmental Graduate Program, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Robert E Reiter
- Department of Urology, University of California, Los Angeles, CA, USA
| | - Matthew B Rettig
- Division of Hematology and Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA
| | - Jeremie Calais
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, CA, USA.,Physics and Biology in Medicine Interdepartmental Graduate Program, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, CA, USA.,Department of Urology, University of California, Los Angeles, CA, USA
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24
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Blazevski A, Geboers B, Scheltema MJ, Gondoputro W, Doan P, Katelaris A, Agrawal S, Baretto D, Matthews J, Haynes AM, Delprado W, Shnier R, van den Bos W, Thompson JE, Lawrentschuk N, Stricker PD. Salvage irreversible electroporation for radio-recurrent prostate cancer - the prospective FIRE trial. BJU Int 2022. [PMID: 36495482 DOI: 10.1111/bju.15947] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To prospectively assess the safety, functional- and oncological-outcomes of irreversible electroporation (IRE) as salvage therapy for radio-recurrent focal prostate cancer in a multicenter setting. PATIENTS AND METHODS Men with focal recurrent PCa after external beam radiation or brachytherapy without metastatic disease on staging imaging and co-registration between mpMRI and biopsies were prospectively included in this multicenter trial. Adverse events were reported following the Clavien-Dindo classification. Validated questionnaires were used for patient-reported functional outcomes. Follow-up consisted of 3 monthly prostate specific antigen (PSA) levels, a 6-month mpMRI and standardised transperineal template mapping biopsies at 12-months. Thereafter follow-up was guided by MRI and/or PSMA-PET/CT and PSA. Local recurrence was defined as any ISUP score ≥2 on biopsies. RESULTS 37 patients were analysed with a median (interquartile range (IQR)) follow up of 29 (22-43) months. Median age was 71 (53-83), median PSA was 3.5 ng/mL (2.7-6.1). 28 (75.5%) patients harboured intermediate risk and 9 patients (24.5%) high risk PCa. Seven patients (19%) reported self-limiting urgency, frequency, or hematuria (grade 1-2). Seven patients (19%) developed a grade 3 AE; urethral sludge requiring transurethral resection. At 12 months post treatment 93% of patients remained continent and erectile function sufficient for intercourse deteriorated from 35% to 15% (4/27). Local control was achieved in 29 patients (78%) and 27 patients (73%) were clear of local and systemic disease. Four (11%) patients had local recurrence only. Six (16%) patients developed metastatic disease with a median time to metastasis of 8 months. CONCLUSION The FIRE trial shows that salvage IRE after failed radiation therapy for localised PCa is safe with minimal toxicity, and promising functional and oncological outcomes. Salvage IRE can offer a possible solution for notoriously difficult to manage radio recurrent prostate tumours.
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Affiliation(s)
- Alexandar Blazevski
- Garvan Institute of Medical Research & The Kinghorn Cancer Centre, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Prostate Cancer Research Centre, Department of Urology, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Bart Geboers
- Garvan Institute of Medical Research & The Kinghorn Cancer Centre, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Prostate Cancer Research Centre, Department of Urology, Darlinghurst, Sydney, New South Wales, Australia
| | - Matthijs J Scheltema
- Garvan Institute of Medical Research & The Kinghorn Cancer Centre, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Prostate Cancer Research Centre, Department of Urology, Darlinghurst, Sydney, New South Wales, Australia
| | - William Gondoputro
- Garvan Institute of Medical Research & The Kinghorn Cancer Centre, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Prostate Cancer Research Centre, Department of Urology, Darlinghurst, Sydney, New South Wales, Australia
| | - Paul Doan
- Garvan Institute of Medical Research & The Kinghorn Cancer Centre, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Prostate Cancer Research Centre, Department of Urology, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Athos Katelaris
- Garvan Institute of Medical Research & The Kinghorn Cancer Centre, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Prostate Cancer Research Centre, Department of Urology, Darlinghurst, Sydney, New South Wales, Australia
| | - Shikha Agrawal
- Garvan Institute of Medical Research & The Kinghorn Cancer Centre, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Prostate Cancer Research Centre, Department of Urology, Darlinghurst, Sydney, New South Wales, Australia
| | - Daniela Baretto
- Garvan Institute of Medical Research & The Kinghorn Cancer Centre, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Prostate Cancer Research Centre, Department of Urology, Darlinghurst, Sydney, New South Wales, Australia
| | - Jayne Matthews
- Garvan Institute of Medical Research & The Kinghorn Cancer Centre, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Prostate Cancer Research Centre, Department of Urology, Darlinghurst, Sydney, New South Wales, Australia
| | - Anne-Maree Haynes
- Garvan Institute of Medical Research & The Kinghorn Cancer Centre, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Prostate Cancer Research Centre, Department of Urology, Darlinghurst, Sydney, New South Wales, Australia
| | - Warick Delprado
- Douglass Hanly Moir Pathology, Sydney, New South Wales, Australia
| | - Ron Shnier
- I-MED Radiology, Sydney, New South Wales, Australia
| | - Willemien van den Bos
- Amsterdam UMC, Department of Radiology and Nuclear Medicine, Amsterdam, the Netherlands
| | - James E Thompson
- Garvan Institute of Medical Research & The Kinghorn Cancer Centre, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Prostate Cancer Research Centre, Department of Urology, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Nathan Lawrentschuk
- University of Melbourne, Melbourne, Victoria, Australia
- EJ Whitten Prostate Cancer Research Centre at Epworth, Melbourne, Victoria, Australia
| | - Phillip D Stricker
- Garvan Institute of Medical Research & The Kinghorn Cancer Centre, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Prostate Cancer Research Centre, Department of Urology, Darlinghurst, Sydney, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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25
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Zhong J, Brown S, Serra M, Shuttleworth P, Bownes P, Thompson C, Reed R, Reeves K, Dubec M, McHugh D, Eccles C, Chuter R, Tsang YM, Taylor NJ, West C, Buckley D, Scarsbrook A, Choudhury A, Hoskin P, Henry A. Reirradiation Options for Previously Irradiated Prostate cancer (RO-PIP): Feasibility study investigating toxicity outcomes following reirradiation with stereotactic body radiotherapy (SBRT) versus high-dose-rate brachytherapy (HDR-BT). BMJ Open 2022; 12:e068580. [PMID: 36351720 PMCID: PMC9644357 DOI: 10.1136/bmjopen-2022-068580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/07/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Radiotherapy is the most common curative treatment for non-metastatic prostate cancer; however, up to 13% of patients will develop local recurrence within 10 years. Patients can undergo further and potentially curative treatment including salvage surgery, brachytherapy (BT), external beam radiotherapy, high-intensity focused ultrasound and cryotherapy. Systematic review shows that high-dose-rate (HDR) BT and stereotactic body radiotherapy (SBRT) have the best outcomes in terms of biochemical control and lowest side effects. The reirradiation options for previously irradiated prostate cancer (RO-PIP) trial aims to determine the feasibility of recruitment to a trial randomising patients to salvage HDR-BT or SBRT and provide prospective data on patient recorded toxicity outcomes that will inform a future phase III trial. METHODS AND ANALYSIS The primary endpoint of the RO-PIP feasibility study is to evaluate the patient recruitment potential over 2 years to a trial randomising to either SBRT or HDR-BT for patients who develop local recurrence of prostate cancer following previous radiation therapy. The aim is to recruit 60 patients across 3 sites over 2 years and randomise 1:1 to SBRT or HDR-BT. Secondary objectives include recording clinician and patient-reported outcome measures to evaluate treatment-related toxicity. In addition, the study aims to identify potential imaging, genomic and proteomic biomarkers that are predictive of toxicity and outcome based on hypoxia status, a prognostic marker of prostate cancer. ETHICS AND DISSEMINATION This study has been approved by the Yorkshire and The Humber-Bradford Leeds Research Ethics Committee (Reference: 21/YH/0305, IRAS: 297060, January 2022). The results will be presented in national and international conferences, published in peer-reviewed journals and will be communicated to relevant stakeholders. A plain English report will be shared with the study participants, patients' organisations and media. TRIAL REGISTRATION NUMBER ISRCTN 12238218 (Amy Ackroyd NIHR CPMS Team).
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Affiliation(s)
- Jim Zhong
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Radiology, St James's University Hospital, Leeds, UK
| | - Sarah Brown
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Maria Serra
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Pam Shuttleworth
- Department of Clinical Oncology, St James's University Hospital, Leeds, UK
| | - Peter Bownes
- Department of Clinical Oncology, St James's University Hospital, Leeds, UK
| | | | - Rachel Reed
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Kimberley Reeves
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Michael Dubec
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Damien McHugh
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Cynthia Eccles
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Robert Chuter
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Yat Man Tsang
- Department of Clinical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - N Jane Taylor
- Paul Strickland Scanner Centre, Mount Vernon Hospital, Northwood, UK
| | - Catharine West
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - David Buckley
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Andrew Scarsbrook
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Radiology, St James's University Hospital, Leeds, UK
| | - Ananya Choudhury
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Peter Hoskin
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
- Department of Clinical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Ann Henry
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Clinical Oncology, St James's University Hospital, Leeds, UK
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26
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Real-world utilisation of brachytherapy boost and patient-reported functional outcomes in men who had external beam radiation therapy for prostate cancer in Australia. Clin Transl Radiat Oncol 2022; 37:19-24. [PMID: 36052020 PMCID: PMC9424260 DOI: 10.1016/j.ctro.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 11/20/2022] Open
Abstract
Background and purpose We aimed to evaluate utilisation of brachytherapy (BT) boost in men who had external beam radiation therapy (EBRT) for prostate cancer, and to compare patient-reported functional outcomes (PRO) following each approach in a population-based setting in Australia. Materials and methods This is a population-based cohort of men with localised prostate cancer enrolled in the Victorian Prostate Cancer Outcomes Registry, who had EBRT between 2015 and 2020. Primary outcomes were proportion who had BT-boost, and PRO (assessed using the EPIC-26 questionnaires) 12 months post-treatment. Multivariable logistic regressions were used to evaluate factors associated with BT-boost, and linear regressions were used to estimate differences in EPIC-26 domain scores between EBRT alone and EBRT + BT. Results Of the 1,626 men in the study, 88 (5.4 %) had BT-boost. Factors independently associated with BT-boost were younger age, higher socioeconomic status, and treatment in public institutions. 1,555 men completed EPIC-26 questionnaires. No statistically or clinically significant differences in EPIC-26 urinary, sexual and bowel functional domain scores were observed between men who had EBRT + BT vs EBRT alone, with adjusted mean differences in urinary incontinence, urinary irritative/ obstruction, sexual, and bowel domain of 1.28 (95 %CI = -3.23 to 5.79), -2.87 (95 %CI = -6.46 to 0.73), 0.49 (95 %CI = -4.78 to 5.76), and 2.89 (95 %CI = -0.83 to 6.61) respectively. Conclusion 1-in-20 men who had EBRT for prostate cancer had BT-boost. This is the first time that PRO following EBRT+/-BT is reported at a population-based level in Australia, with no evidence to suggest worse PRO with addition of BT-boost 12 months post-treatment.
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27
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Tang T, Gulstene S, McArthur E, Warner A, Boldt G, Velker V, D'Souza D, Bauman G, Mendez LC. Does brachytherapy boost improve survival outcomes in Gleason Grade Group 5 patients treated with external beam radiotherapy and androgen deprivation therapy? A systematic review and meta-analysis. Clin Transl Radiat Oncol 2022; 38:21-27. [PMID: 36353652 PMCID: PMC9637706 DOI: 10.1016/j.ctro.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/20/2022] [Accepted: 10/24/2022] [Indexed: 11/09/2022] Open
Abstract
Adding a BT boost to external beam radiation can be used to intensify treatment. BT boost improves DMFS but not PCSS or OS in Gleason GG5 prostate cancer. There is no prospective data evaluating BT boost in Gleason GG5 disease.
Background Localized Gleason Grade Group 5 (GG5) prostate cancer has a poor prognosis and is associated with a higher risk of treatment failure, metastases, and death. Treatment intensification with the addition of a brachytherapy (BT) boost to external beam radiation (EBRT) maximizes local control, which may translate into improved survival outcomes. Methods A systematic review and meta-analysis was performed to compare survival outcomes for Gleason GG5 patients treated with androgen deprivation therapy (ADT) and either EBRT or EBRT + BT. The MEDLINE (PubMed), EMBASE and Cochrane databases were searched to identify relevant studies. Survival probabilities for distant metastasis-free survival (DMFS), prostate cancer-specific survival (PCSS), and overall survival (OS) were extracted and pooled to create a summary survival curve for each treatment modality, which were then compared at fixed points in time. An additional analysis was performed among studies directly comparing EBRT and EBRT + BT using a random-effects model. Results Eight retrospective studies were selected for inclusion, representing a total of 1393 EBRT patients and 877 EBRT + BT patients. EBRT + BT was associated with higher DMFS starting at 6 years (86.8 % vs 78.8 %; p = 0.018) and extending out to 10 years (81.8 % vs 66.1 %; p < 0.001), with an overall hazard ratio of 0.53 (p = 0.02). There was no difference in PCSS or OS between treatment modalities. Differences in toxicity were not assessed. There was a wide range of heterogeneity between studies. Conclusion The addition of BT boost is associated with improved long-term DMFS in Gleason GG5 prostate cancer, but its impact on PCSS and OS remains unclear. These results may be confounded by the heterogeneity across study populations with concern for a risk of bias. Therefore, prospective studies are necessary to further elucidate the survival advantage associated with BT boost, which must ultimately be weighed against the toxicity-related implications of this treatment strategy.
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Algohary A, Alhusseini M, Breto AL, Kwon D, Xu IR, Gaston SM, Castillo P, Punnen S, Spieler B, Abramowitz MC, Dal Pra A, Kryvenko ON, Pollack A, Stoyanova R. Longitudinal Changes and Predictive Value of Multiparametric MRI Features for Prostate Cancer Patients Treated with MRI-Guided Lattice Extreme Ablative Dose (LEAD) Boost Radiotherapy. Cancers (Basel) 2022; 14:cancers14184475. [PMID: 36139635 PMCID: PMC9496901 DOI: 10.3390/cancers14184475] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/01/2022] [Accepted: 09/10/2022] [Indexed: 11/16/2022] Open
Abstract
We investigated the longitudinal changes in multiparametric MRI (mpMRI) (T2-weighted, Apparent Diffusion Coefficient (ADC), and Dynamic Contrast Enhanced (DCE-)MRI) of prostate cancer patients receiving Lattice Extreme Ablative Dose (LEAD) radiotherapy (RT) and the capability of their imaging features to predict RT outcome based on endpoint biopsies. Ninety-five mpMRI exams from 25 patients, acquired pre-RT and at 3-, 9-, and 24-months post-RT were analyzed. MRI/Ultrasound-fused biopsies were acquired pre- and at two-years post-RT (endpoint). Five regions of interest (ROIs) were analyzed: Gross tumor volume (GTV), normally-appearing tissue (NAT) and peritumoral volume in both peripheral (PZ) and transition (TZ) zones. Diffusion and perfusion radiomics features were extracted from mpMRI and compared before and after RT using two-tailed Student t-tests. Selected features at the four scan points and their differences (Δ radiomics) were used in multivariate logistic regression models to predict the endpoint biopsy positivity. Baseline ADC values were significantly different between GTV, NAT-PZ, and NAT-TZ (p-values < 0.005). Pharmaco-kinetic features changed significantly in the GTV at 3-month post-RT compared to baseline. Several radiomics features at baseline and three-months post-RT were significantly associated with endpoint biopsy positivity and were used to build models with high predictive power of this endpoint (AUC = 0.98 and 0.89, respectively). Our study characterized the RT-induced changes in perfusion and diffusion. Quantitative imaging features from mpMRI show promise as being predictive of endpoint biopsy positivity.
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Affiliation(s)
- Ahmad Algohary
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Mohammad Alhusseini
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Adrian L. Breto
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Deukwoo Kwon
- Biostatistics and Bioinformatics Shared Resource, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Isaac R. Xu
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Sandra M. Gaston
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Patricia Castillo
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Sanoj Punnen
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Benjamin Spieler
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Matthew C. Abramowitz
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Alan Dal Pra
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Oleksandr N. Kryvenko
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Desai Sethi Urology Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Alan Pollack
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Radka Stoyanova
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Correspondence: ; Tel.: +1-305-243-5856
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Chang D, Blanchard P, Siva S. The Deep Blue of Prostate Cancer Metastasis Evolution: The LEVIATHAN Pooled Analysis. Eur Urol 2022; 82:499-500. [PMID: 35995643 DOI: 10.1016/j.eururo.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/03/2022] [Indexed: 11/04/2022]
Affiliation(s)
- David Chang
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia; Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Pierre Blanchard
- Department of Radiation Oncology, Gustave Roussy, Université Paris Saclay, Inserm U1018 Oncostat, Villejuif, France
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia; Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.
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