1
|
Dal Pra A, Dirix P, Khoo V, Carrie C, Cozzarini C, Fonteyne V, Ghadjar P, Gomez-Iturriaga A, Panebianco V, Zapatero A, Bossi A, Wiegel T. ESTRO ACROP guideline on prostate bed delineation for postoperative radiotherapy in prostate cancer. Clin Transl Radiat Oncol 2023; 41:100638. [PMID: 37251620 PMCID: PMC10209331 DOI: 10.1016/j.ctro.2023.100638] [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: 05/03/2023] [Accepted: 05/06/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose/Objective Radiotherapy to the prostate bed is a potentially curative salvage option after radical prostatectomy. Although prostate bed contouring guidelines are available in the literature, important variabilities exist. The objective of this work is to provide a contemporary consensus guideline for prostate bed delineation for postoperative radiotherapy. Methods An ESTRO-ACROP contouring consensus panel consisting of 11 radiation oncologists and one radiologist, all with known subspecialty expertise in prostate cancer, was established. Participants were asked to delineate the prostate bed clinical target volumes (CTVs) in 3 separate clinically relevant scenarios: adjuvant radiation, salvage radiation with PSA progression, and salvage radiation with persistently elevated PSA. These cases focused on the presence of positive surgical margin, extracapsular extension, and seminal vesicles involvement. None of the cases had radiographic evidence of local recurrence on imaging. A single computed tomography (CT) dataset was shared via FALCON platform and contours were performed using EduCaseTM software. Contours were analyzed qualitatively using heatmaps which provided a visual assessment of controversial regions and quantitatively analyzed using Sorensen-Dice similarity coefficients. Participants also answered case-specific questionnaires addressing detailed recommendations on target delineation. Discussions via electronic mails and videoconferences for final editing and consensus were performed. Results The mean CTV for the adjuvant case was 76 cc (SD = 26.6), salvage radiation with PSA progression was 51.80 cc (SD = 22.7), and salvage radiation with persistently elevated PSA 57.63 cc (SD = 25.2). Compared to the median, the mean Sorensen-Dice similarity coefficient for the adjuvant case was 0.60 (SD 0.10), salvage radiation with PSA progression was 0.58 (SD = 0.12), and salvage radiation with persistently elevated PSA 0.60 (SD = 0.11). A heatmap for each clinical scenario was generated. The group agreed to proceed with a uniform recommendation for all cases, independent of the radiotherapy timing. Several controversial areas of the prostate bed CTV were identified based on both heatmaps and questionnaires. This formed the basis for discussions via videoconferences where the panel achieved consensus on the prostate bed CTV to be used as a novel guideline for postoperative prostate cancer radiotherapy. Conclusion Variability was observed in a group formed by experienced genitourinary radiation oncologists and a radiologist. A single contemporary ESTRO-ACROP consensus guideline was developed to address areas of dissonance and improve consistency in prostate bed delineation, independent of the indication.There is important variability in existing contouring guidelines for postoperative prostate bed (PB) radiotherapy (RT) after radical prostatectomy. This work aimed at providing a contemporary consensus guideline for PB delineation. An ESTRO ACROP consensus panel including radiation oncologists and a radiologist, all with known subspecialty expertise in prostate cancer, delineated the PB CTV in 3 scenarios: adjuvant RT, salvage RT with PSA progression, and salvage RT with persistently elevated PSA. None of the cases had evidence of local recurrence. Contours were analysed qualitatively using heatmaps for visual assessment of controversial regions and quantitatively using Sorensen-Dice coefficient. Case-specific questionnaires were also discussed via e-mails and videoconferences for consensus. Several controversial areas of the PB CTV were identified based on both heatmaps and questionnaires. This formed the basis for discussions via videoconferences. Finally, a contemporary ESTRO-ACROP consensus guideline was developed to address areas of dissonance and improve consistency in PB delineation, independent of the indication.
Collapse
Affiliation(s)
- Alan Dal Pra
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, USA
- University of Bern, Bern University Hospital, Bern, Switzerland
| | - Piet Dirix
- Department of Radiation Oncology, Iridium Network, Antwerp, Belgium
| | - Vincent Khoo
- Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | | | - Cesare Cozzarini
- Department of Radiotherapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valérie Fonteyne
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium
| | - Pirus Ghadjar
- Department of Radiation Oncology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | - Alfonso Gomez-Iturriaga
- Radiation Oncology, Biocruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | - Valeria Panebianco
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Almudena Zapatero
- Department of Radiation Oncology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria IP, Madrid, Spain
| | - Alberto Bossi
- Radiation Oncology, Centre Charlebourg, La Garenne Colombe, France
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| |
Collapse
|
2
|
Horsley PJ, Koo CM, Eade T, Hsiao E, Emmett L, Brown C, Kneebone A, Hruby G. Mapping of Local Recurrences After Radical Prostatectomy Using 68-Gallium-Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography: Implications for Postprostatectomy Radiation Therapy Clinical Target Volumes. Int J Radiat Oncol Biol Phys 2023; 115:106-117. [PMID: 35716849 DOI: 10.1016/j.ijrobp.2022.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/23/2022] [Accepted: 05/28/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Our objective is to describe the distribution of local recurrences after radical prostatectomy (RP) as delineated using 68-Gallium-prostate-specific membrane antigen positron emission tomography/computed tomography (68Ga-PSMA PET/CT) to identify areas where current consensus guideline clinical target volumes (CTVs) are insufficient or excessive and to identify predictors of recurrence location within the fossa. METHODS AND MATERIALS Retrospective review of databases from 2 tertiary referral centers was performed to identify patients who underwent 68Ga-PSMA PET/CT for biochemical recurrence after RP. Those with a component of local recurrence were included for further analysis. The epicenter of each recurrence was defined relative to reference points in 3 axes, categorized into 1 of 7 levels in the superior/inferior axis relative to the vesicourethral anastomosis, and recorded as within or outside the Faculty of Radiation Oncology Genito-urinary Group (FROGG) and Radiation Therapy Oncology Group consensus CTVs. Univariate and multivariate analysis was performed to identify predictors of recurrence location based on clinical and histopathologic variables. RESULTS One thousand forty-nine 68Ga-PSMA PET/CT scans were reviewed. One hundred forty sites of local recurrence were identified on 132 scans. Relative to the vesicourethral anastomosis, 13 (9%), 31 (22%), 17 (12%), 24 (17%), 27 (19%), 20 (14%), and 8 (6%) recurrences occurred >5 mm inferior; within 5 mm above or below; and 6 to 15 mm, 16 to 25 mm, 26 to 35 mm, 36 to 45 mm, and >45 mm superiorly, respectively. Thirteen (9%) and 2 (1.4%) recurrences occurred beyond the FROGG and Radiation Therapy Oncology Group consensus CTVs, respectively, with all below the inferior CTV margin. CONCLUSIONS In the largest study to date mapping local recurrences after RP in 3-dimensions, we provide several insights to inform future contouring guidelines; in particular, 9% of recurrences occurred inferior to the FROGG CTV.
Collapse
Affiliation(s)
- Patrick J Horsley
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
| | - Chung Mo Koo
- Department of Nuclear Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Thomas Eade
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, New South Wales, Australia; GenesisCare, Sydney, New South Wales, Australia; University of Sydney, Camperdown, New South Wales, Australia
| | - Edward Hsiao
- Department of Nuclear Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Louise Emmett
- Department of Nuclear Medicine and Theranostics, St. Vincent's Hospital, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia
| | - Chris Brown
- NHMRC Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Andrew Kneebone
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, New South Wales, Australia; GenesisCare, Sydney, New South Wales, Australia; University of Sydney, Camperdown, New South Wales, Australia
| | - George Hruby
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, New South Wales, Australia; GenesisCare, Sydney, New South Wales, Australia; University of Sydney, Camperdown, New South Wales, Australia
| |
Collapse
|
3
|
Dundee P, Furrer MA, Corcoran NM, Peters J, Pan H, Ballok Z, Ryan A, Guerrieri M, Costello AJ. Defining Prostatic Vascular Pedicle Recurrence and the Anatomy of Local Recurrence of Prostate Cancer on Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography. EUR UROL SUPPL 2022; 41:116-122. [PMID: 35813255 PMCID: PMC9257633 DOI: 10.1016/j.euros.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 11/30/2022] Open
Abstract
Background The term local recurrence in prostate cancer is considered to mean persistent local disease in the prostatic bed, most commonly at the site of the vesicourethral anastomosis (VUA). Since the introduction of prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) and magnetic resonance imaging for assessment of early biochemical recurrence (BCR), we have found histologically confirmed prostate cancer in the prostatic vascular pedicle (PVP). If a significant proportion of local recurrences are distant to the VUA, it may be possible to alter adjuvant and salvage radiation fields in order to reduce the potential morbidity of radiation in selected patients. Objective To describe PVP local recurrence and to map the anatomic pattern of prostate bed recurrence on PSMA PET/CT. Design, setting, and participants This was a retrospective multicentre study of 185 patients imaged with PSMA PET/CT following radical prostatectomy (RP) between January 2016 and November 2018. All patient data and clinical outcomes were prospectively collected. Recurrences were documented according to anatomic location. For patients presenting with local recurrence, the precise location of the recurrence within the prostate bed was documented. Intervention PSMA PET/CT for BCR following RP. Results and limitations A total of 43 local recurrences in 41/185 patients (22%) were identified. Tumour recurrence at the PVP was found in 26 (63%), VUA in 15 (37%), and within a retained seminal vesicle and along the anterior rectal wall in the region of the neurovascular bundle in one (2.4%) each. Histological and surgical evidence of PVP recurrence was acquired in two patients. The study is limited by its retrospective nature with inherent selection bias. This is an observational study reporting on the anatomy of local recurrence and does not include follow-up for patient outcomes. Conclusions Our study showed that prostate cancer can recur in the PVP and is distant to the VUA more commonly than previously thought. This may have implications for RP technique and for the treatment of selected patients in the local recurrence setting. Patient summary We investigated more precise identification of the location of tumour recurrence after removal of the prostate for prostate cancer. We describe a new definition of local recurrence in an area called the prostatic vascular pedicle. This new concept may alter the treatment recommended for recurrent disease.
Collapse
Affiliation(s)
- Philip Dundee
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Grattan Street Parkville, Australia 3052
- The Australian Medical Robotics Academy, North Melbourne, Australia
- Australian Prostate Cancer Centre, North Melbourne, Australia
- Epworth Healthcare, Melbourne, Australia
- Corresponding author. Department of Urology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia. Tel. +61 3 9342 7294.
| | - Marc A. Furrer
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Grattan Street Parkville, Australia 3052
- The Australian Medical Robotics Academy, North Melbourne, Australia
- Epworth Healthcare, Melbourne, Australia
- Department of Urology, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Niall M. Corcoran
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Grattan Street Parkville, Australia 3052
- Australian Prostate Cancer Centre, North Melbourne, Australia
| | - Justin Peters
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Grattan Street Parkville, Australia 3052
- The Australian Medical Robotics Academy, North Melbourne, Australia
- Australian Prostate Cancer Centre, North Melbourne, Australia
- Epworth Healthcare, Melbourne, Australia
| | - Henry Pan
- Department of Urology, University Hospital of Bern, University of Bern, Bern, Switzerland
| | | | - Andrew Ryan
- Healthcare Imaging Services, Melbourne, Australia
| | | | - Anthony J. Costello
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Grattan Street Parkville, Australia 3052
- The Australian Medical Robotics Academy, North Melbourne, Australia
- Australian Prostate Cancer Centre, North Melbourne, Australia
- Epworth Healthcare, Melbourne, Australia
| |
Collapse
|
4
|
Renard-Penna R, Zhang-Yin J, Montagne S, Aupin L, Bruguière E, Labidi M, Latorzeff I, Hennequin C. Targeting Local Recurrence After Surgery With MRI Imaging for Prostate Cancer in the Setting of Salvage Radiation Therapy. Front Oncol 2022; 12:775387. [PMID: 35242702 PMCID: PMC8887697 DOI: 10.3389/fonc.2022.775387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/05/2022] [Indexed: 11/18/2022] Open
Abstract
Magnetic resonance imaging (MRI) is being increasingly used for imaging suspected recurrence in prostate cancer therapy. Functional MRI with diffusion and perfusion imaging has the potential to demonstrate local recurrence even at low PSA value. Detection of recurrence can modify the management of postprostatectomy biochemical recurrence. MRI scan acquired before salvage radiotherapy is useful for the localization of recurrent tumors and also in the delineation of the target volume. The objective of this review is to assess the role and potential impact of MRI in targeting local recurrence after surgery for prostate cancer in the setting of salvage radiation therapy.
Collapse
Affiliation(s)
- Raphaële Renard-Penna
- Academic Department of Radiology, Hôpital Pitié-Salpétrière, Assistance Publique des Hôpitaux de Paris, Paris, France.,Sorbonne University, Paris, France
| | - Jules Zhang-Yin
- Nuclear Medicine Department, Tenon Hospital, Assistance Publique des Hôpitaux de Paris (APHP), Paris, France
| | - Sarah Montagne
- Academic Department of Radiology, Hôpital Pitié-Salpétrière, Assistance Publique des Hôpitaux de Paris, Paris, France.,Sorbonne University, Paris, France
| | - Laurene Aupin
- Academic Department of Radiology, Hôpital Pitié-Salpétrière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Eric Bruguière
- Department of Imaging, Clinique Pasteur, Toulouse, France
| | - Mouna Labidi
- Department of Oncology, Saint-Louis Hospital, Université de Paris, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Igor Latorzeff
- Department of Radiotherapy, Clinique Pasteur, Toulouse, France
| | - Christophe Hennequin
- Department of Oncology, Saint-Louis Hospital, Université de Paris, Assistance Publique des Hôpitaux de Paris, Paris, France
| |
Collapse
|
5
|
Chao M, Ho H, Joon DL, Chan Y, Spencer S, Ng M, Wasiak J, Lawrentschuk N, McMillan K, Sengupta S, Tan A, Koufogiannis G, Cokelek M, Foroudi F, Khong TS, Bolton D. The use of tissue fiducial markers in improving the accuracy of post-prostatectomy radiotherapy. Radiat Oncol J 2019; 37:43-50. [PMID: 30947480 PMCID: PMC6453813 DOI: 10.3857/roj.2018.00556] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/12/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE The aim of this retrospective study was to investigate the use of a radiopaque tissue fiducial marker (TFM) in the treatment of prostate cancer patients who undergo post-prostatectomy radiotherapy (PPRT). TFM safety, its role and benefit in quantifying the set-up uncertainties in patients undergoing PPRT image-guided radiotherapy were assessed. MATERIALS AND METHODS A total of 45 consecutive PPRT patients underwent transperineal implantation of TFM at the level of vesicourethral anastomosis in the retrovesical tissue prior to intensity-modulated radiotherapy. Prostate bed motion was calculated by measuring the position of the TFM relative to the pelvic bony anatomy on daily cone-beam computed tomography. The stability and visibility of the TFM were assessed in the initial 10 patients. RESULTS No postoperative complications were recorded. A total of 3,500 images were analysed. The calculated prostate bed motion for bony landmark matching relative to TFM were 2.25 mm in the left-right, 5.89 mm in the superior-inferior, and 6.59 mm in the anterior-posterior directions. A significant 36% reduction in the mean volume of rectum receiving 70 Gy (rV70) was achieved for a uniform planning target volume (PTV) margin of 7 mm compared with the Australian and New Zealand Faculty of Radiation Oncology Genito-Urinary Group recommended PTV margin of 10 mm. CONCLUSION The use of TFM was safe and can potentially eliminate set-up errors associated with bony landmark matching, thereby allowing for tighter PTV margins and a consequent favourable reduction in dose delivered to the bladder and rectum, with potential improvements in toxicities.
Collapse
Affiliation(s)
- Michael Chao
- The Austin Hospital, Heidelberg, Australia.,Genesis Cancer Care Victoria, Melbourne, Australia
| | - Huong Ho
- Genesis Cancer Care Victoria, Melbourne, Australia
| | | | - Yee Chan
- The Austin Hospital, Heidelberg, Australia
| | | | - Michael Ng
- Genesis Cancer Care Victoria, Melbourne, Australia
| | | | | | | | | | - Alwin Tan
- The Bays Hospital, Mornington, Australia
| | | | | | | | | | | |
Collapse
|
6
|
El Kabbaj O, Robin P, Bourhis D, Dissaux G, Rosenfelder N, Valeri A, Fournier G, Salaun PY, Pradier O, Malhaire JP, Abgral R, Schick U. Target definition in salvage postoperative radiotherapy for prostate cancer: 18F-fluorocholine PET/CT assessment of local recurrence. Acta Oncol 2018; 57:375-381. [PMID: 28984165 DOI: 10.1080/0284186x.2017.1385843] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Inadequate clinical target volume (CTV) definition is likely to be a major contributing factor to local recurrence (LR) rate after radiotherapy. Our aims were to identify sites of prostate cancer LR in biochemical recurrence post-prostatectomy using 18F-Fluorocholine (18F-FCH) positron emission tomography/computed tomography (PET/CT) and to compare different CTV-delineation guidelines in a cohort of postoperative patients. MATERIAL AND METHODS Thirty-six patients presenting with LR within the prostatic bed on 18F-FCH PET/CT between 10/2011 and 06/2016 were included in this retrospective study. Median PSA at the time of 18F-FCH PET/CT was 2.7 ng/mL (0.8-9.4) and median PSA doubling time was 11 months (3-28). For each patient, the CTVRTOG, CTVFROGG and CTVEORTC following the corresponding guidelines were outlined and compared. Forty-one LR were delineated using a gradient-based method and the percentage of FCH uptake included in each CTV was evaluated. RESULTS The anastomosis was the most common recurrence site (52.8%), followed by the retrovesical region (31.7%) and the bladder neck (7%). The median SUV max value was 4.8 (2.3-16.1). The percentage of LR entirely included in the CTVRTOG was not significantly different from that included in the CTVFROGG (84% versus 83%, p = .5). Significantly more recurrences were included in the CTVRTOG volume compared to the CTVEORTC (84% versus 68%, p=.006), due to a better coverage of the bladder neck and retrovesical regions. Six out of 10 relapses occurring in the posterior region of the anastomosis were not covered by any of the CTVs. CONCLUSIONS In our study, the CTVRTOG and CTVFROGG ensured the best coverage of LR seen on 18F-FCH PET/CT. When outlining the prostatic fossa, greater coverage of the posterior vesico-urethral region may allow better coverage of potential microscopic disease.
Collapse
Affiliation(s)
- Osman El Kabbaj
- Radiation Oncology Department, University Hospital Morvan, Brest, France
| | - Philippe Robin
- Nuclear Medicine Department, University Hospital Morvan, Brest, France
- Urology Unit, University Hospital Cavale Blanche, Brest, France
| | - David Bourhis
- Nuclear Medicine Department, University Hospital Morvan, Brest, France
| | - Gurvan Dissaux
- Radiation Oncology Department, University Hospital Morvan, Brest, France
| | | | - Antoine Valeri
- Urology Unit, University Hospital Cavale Blanche, Brest, France
| | | | - Pierre-Yves Salaun
- Nuclear Medicine Department, University Hospital Morvan, Brest, France
- EA 3878 GETBO, University Hospital Cavale Blanche, Brest, France
| | - Olivier Pradier
- Radiation Oncology Department, University Hospital Morvan, Brest, France
- INSERM UMR1101, Brest, France
| | | | - Ronan Abgral
- Nuclear Medicine Department, University Hospital Morvan, Brest, France
- EA 3878 GETBO, University Hospital Cavale Blanche, Brest, France
| | - Ulrike Schick
- Radiation Oncology Department, University Hospital Morvan, Brest, France
- INSERM UMR1101, Brest, France
| |
Collapse
|
7
|
Franzese C, Lopci E, Di Brina L, D'Agostino GR, Navarria P, Mancosu P, Tomatis S, Chiti A, Scorsetti M. 11C-Choline-Pet Guided Stereotactic Body Radiation Therapy for Lymph Node Metastases in Oligometastatic Prostate Cancer. Cancer Invest 2017; 35:586-593. [PMID: 28980836 DOI: 10.1080/07357907.2017.1375116] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION aim is outcome of 11C-Choline-PET guided SBRT on lymph node metastases. MATERIALS AND METHODS patients with 1 - 4 lymph node metastases detected by 11C-choline-PET were treated with SBRT. Toxicity, treated metastases control and Progression Free Survival were computed. RESULTS twenty-six patients, 38 lymph node metastases were irradiated. No grade ≥ 2 toxicity. Median PSA-nadir after RT was 1.02 ng/mL. Post-treatment 11C-Choline-PET showed metabolic complete response in 17 metastases (44,7%), partial response in 9 metastases (38%). CONCLUSION SBRT is effective and safe for lymph node metastases. PET is important in identification of gross tumor and evaluation of the response.
Collapse
Affiliation(s)
- Ciro Franzese
- a Radiotherapy and Radiosurgery , Humanitas Clinical and Research Center , Via Manzoni Rozzano ( Milano ) - Italy
| | - Egesta Lopci
- b Nuclear Medicine , Humanitas Clinical and Research Center , Via Manzoni Rozzano ( Milano ) - Italy
| | - Lucia Di Brina
- a Radiotherapy and Radiosurgery , Humanitas Clinical and Research Center , Via Manzoni Rozzano ( Milano ) - Italy
| | - Giuseppe Roberto D'Agostino
- a Radiotherapy and Radiosurgery , Humanitas Clinical and Research Center , Via Manzoni Rozzano ( Milano ) - Italy
| | - Pierina Navarria
- a Radiotherapy and Radiosurgery , Humanitas Clinical and Research Center , Via Manzoni Rozzano ( Milano ) - Italy
| | - Pietro Mancosu
- a Radiotherapy and Radiosurgery , Humanitas Clinical and Research Center , Via Manzoni Rozzano ( Milano ) - Italy
| | - Stefano Tomatis
- a Radiotherapy and Radiosurgery , Humanitas Clinical and Research Center , Via Manzoni Rozzano ( Milano ) - Italy
| | - Arturo Chiti
- b Nuclear Medicine , Humanitas Clinical and Research Center , Via Manzoni Rozzano ( Milano ) - Italy.,c Humanitas University , Department of Biomedical Sciences , Via Manzoni 113 20089 Rozzano ( Milano ) - Italy
| | - Marta Scorsetti
- a Radiotherapy and Radiosurgery , Humanitas Clinical and Research Center , Via Manzoni Rozzano ( Milano ) - Italy.,c Humanitas University , Department of Biomedical Sciences , Via Manzoni 113 20089 Rozzano ( Milano ) - Italy
| |
Collapse
|
8
|
Isharwal S, Stephenson AJ. Post-prostatectomy radiation therapy for locally recurrent prostate cancer. Expert Rev Anticancer Ther 2017; 17:1003-1012. [PMID: 28922958 DOI: 10.1080/14737140.2017.1378575] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Approximately 15-30% of men with localized prostate cancer will experience biochemical recurrence (BCR) after radical prostatectomy. Postoperative radiation therapy is used in men with adverse pathological features to reduce the risk of BCR or with curative intent in men with known BCR. In this study, we review the evidence for the adjuvant and salvage radiation therapy after radical prostatectomy. Areas covered: A literature review of the Medline and Embase databases was performed. The search strategy included the following terms: prostate cancer, adjuvant radiotherapy, salvage radiotherapy, radical prostatectomy, biochemical recurrence, and prostate cancer recurrence. Prospective randomized trials for the adjuvant radiotherapy and observational studies supporting salvage radiotherapy were included for discussion. Expert commentary: As postoperative radiotherapy is associated with non-trivial risks of acute and long-term toxicity and given the absence of compelling data supporting adjuvant over early salvage radiotherapy, the authors advocate, with rare exceptions, close observation and timely (early) salvage radiotherapy for patients with BCR and long life expectancy. Adjuvant radiotherapy may be considered in patients at high-risk for recurrence. Observation is appropriate in patients with limited life expectancy and/or absence of adverse features.
Collapse
Affiliation(s)
- Sudhir Isharwal
- a Department of Urology , Glickman Urology and Kidney Institute, Cleveland Clinic , Cleveland , OH , USA
| | - Andrew J Stephenson
- a Department of Urology , Glickman Urology and Kidney Institute, Cleveland Clinic , Cleveland , OH , USA
| |
Collapse
|
9
|
Zilli T, Jorcano S, Peguret N, Caparrotti F, Hidalgo A, Khan HG, Vees H, Miralbell R. Results of Dose-adapted Salvage Radiotherapy After Radical Prostatectomy Based on an Endorectal MRI Target Definition Model. Am J Clin Oncol 2017; 40:194-199. [PMID: 25222076 DOI: 10.1097/coc.0000000000000130] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the outcome of patients treated with a dose-adapted salvage radiotherapy (SRT) protocol based on an endorectal magnetic resonance imaging (erMRI) failure definition model after radical prostatectomy (RP). METHODS We report on 171 relapsing patients after RP who had undergone an erMRI before SRT. 64 Gy were prescribed to the prostatic bed with, in addition, a boost of 10 Gy to the suspected local relapse as detected on erMRI in 131 patients (76.6%). RESULTS The 3-year biochemical relapse-free survival (bRFS), local relapse-free survival, distant metastasis-free survival, cancer-specific survival, and overall survival were 64.2±4.3%, 100%, 85.2±3.2%, 100%, and 99.1±0.9%, respectively. A PSA value >1 ng/mL before salvage (P=0.006) and an absence of biochemical progression during RT (P=0.001) were both independently correlated with bRFS on multivariate analysis. No significant difference in 3-year bRFS was observed between the boost and no-boost groups (68.4±4.6% vs. 49.7±10%, P=0.251). CONCLUSIONS A PSA value >1 ng/mL before salvage and a biochemical progression during RT were both independently correlated with worse bRFS after SRT. By using erMRI to select patients who are most likely expected to benefit from dose-escalated SRT protocols, this dose-adapted SRT approach was associated with good biochemical control and outcome, serving as a hypothesis-generating basis for further prospective trials aimed at improving the therapeutic ratio in the salvage setting.
Collapse
Affiliation(s)
- Thomas Zilli
- *Department of Radiation Oncology, Hôpitaux Universitaires de Genève §Institute of Radiology Jean Violette, Geneva, Switzerland †Servei de Radio-oncologia ‡Servei de Radiodiagnòstic, Institut Oncòlogic Teknon, Barcelona, Spain
| | | | | | | | | | | | | | | |
Collapse
|
10
|
Latorzeff I, Sargos P, Loos G, Supiot S, Guerif S, Carrie C. Delineation of the Prostate Bed: The "Invisible Target" Is Still an Issue? Front Oncol 2017; 7:108. [PMID: 28620579 PMCID: PMC5449739 DOI: 10.3389/fonc.2017.00108] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 05/10/2017] [Indexed: 11/13/2022] Open
Abstract
For pathological high-risk prostate cancer, adjuvant irradiation has shown a survival benefit. Phase III studies have highlighted that half men would face biochemical relapse and would be candidate for radiotherapy at adjuvant or salvage times. Despite at least four published international contouring guidelines from different collaborative groups, discrepancies remain for volumes, delineation, and margins to be considered in order to optimize radiotherapy planning. This article from “Groupe d’Etude des Tumeurs UroGénitales (GETUG)” members will focus on controversies to help clinicians to create best volume delineation for adjuvant or salvage post prostatectomy radiotherapy.
Collapse
Affiliation(s)
- Igor Latorzeff
- Department of Oncology Radiotherapy, Bât Atrium, Clinique Pasteur, Toulouse, France
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
| | - Geneviève Loos
- Department of Radiotherapy, Centre Jean-Perrin, Clermont-Ferrand, France
| | - Stéphane Supiot
- Department of Radiotherapy, Institut de Cancérologie de L'Ouest René Gauducheau, Nantes, France
| | - Stéphane Guerif
- Department of Radiotherapy, CHU de Poitiers, Poitiers, France
| | | |
Collapse
|
11
|
Salvage Radiation Therapy Dose Response for Biochemical Failure of Prostate Cancer After Prostatectomy-A Multi-Institutional Observational Study. Int J Radiat Oncol Biol Phys 2016; 96:1046-1053. [PMID: 27745980 DOI: 10.1016/j.ijrobp.2016.08.043] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/23/2016] [Accepted: 08/26/2016] [Indexed: 12/28/2022]
Abstract
PURPOSE To determine whether a dose-response relationship exists for salvage radiation therapy (RT) of biochemical failure after prostatectomy for prostate cancer. METHODS AND MATERIALS Individual data from 1108 patients who underwent salvage RT at 10 academic centers were pooled. The cohort was enriched for selection criteria more likely associated with tumor recurrence in the prostate bed (margin positive and pre-RT prostate-specific antigen [PSA] level of ≤2.0 ng/mL) and without the confounding of planned androgen suppression. The cumulative incidence of biochemical failure and distant metastasis over time was computed, and competing risks hazard regression models were used to investigate the association between potential predictors and these outcomes. The association of radiation dose with outcomes was the primary focus. RESULTS With a 65.2-month follow-up duration, the 5- and 10-year estimates of freedom from post-RT biochemical failure (PSA level >0.2 ng/mL and rising) was 63.5% and 49.8%, respectively, and the cumulative incidence of distant metastasis was 12.4% by 10 years. A Gleason score of ≥7, higher pre-RT PSA level, extraprostatic tumor extension, and seminal vesicle invasion were associated with worse biochemical failure and distant metastasis outcomes. A salvage radiation dose of ≥66.0 Gy was associated with a reduced cumulative incidence of biochemical failure, but not of distant metastasis. CONCLUSIONS The use of salvage radiation doses of ≥66.0 Gy are supported by evidence presented in the present multicenter pooled analysis of individual patient data. The observational reporting method, limited sample size, few distant metastasis events, modest follow-up duration, and elective use of salvage therapy might have diminished the opportunity to identify an association between the radiation dose and this endpoint.
Collapse
|
12
|
Herrera FG, Berthold DR. Radiation Therapy after Radical Prostatectomy: Implications for Clinicians. Front Oncol 2016; 6:117. [PMID: 27242957 PMCID: PMC4860423 DOI: 10.3389/fonc.2016.00117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 04/25/2016] [Indexed: 12/11/2022] Open
Abstract
Depending on the pathological findings, up to 60% of prostate cancer patients who undergo radical prostatectomy (RP) will develop biochemical relapse and require further local treatment. Radiotherapy (RT) immediately after RP may potentially eradicate any residual localized microscopic disease in the prostate bed, and it is associated with improved biochemical, clinical progression-free survival, and overall survival in patients with high-risk pathological features according to published randomized trials. Offering immediate adjuvant RT to all men with high-risk pathological factors we are over-treating around 50% of patients who would anyway be cancer-free, exposing them to unnecessary toxicity and adding costs to the health-care system. The current dilemma is, thus, whether to deliver adjuvant immediate RT solely on the basis of high-risk pathology, but in the absence of measurable prostate-specific antigen, or whether early salvage radiotherapy would yield equivalent outcomes. Randomized trials are ongoing to definitely answer this question. Retrospective analyses suggest that there is a dose–response favoring doses >70 Gy to the prostate bed. The evidence regarding the role of androgen deprivation therapy is emerging, and ongoing randomized trials are underway.
Collapse
Affiliation(s)
- Fernanda G Herrera
- Radiation Oncology Services, Department of Oncology, Lausanne University Hospital , Lausanne , Switzerland
| | - Dominik R Berthold
- Medical Oncology Services, Department of Oncology, Lausanne University Hospital , Lausanne , Switzerland
| |
Collapse
|
13
|
Starobinets O, Korn N, Iqbal S, Noworolski SM, Zagoria R, Kurhanewicz J, Westphalen AC. Practical aspects of prostate MRI: hardware and software considerations, protocols, and patient preparation. Abdom Radiol (NY) 2016; 41:817-30. [PMID: 27193785 DOI: 10.1007/s00261-015-0590-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The use of multiparametric MRI scans for the evaluation of men with prostate cancer has increased dramatically and is likely to continue expanding as new developments come to practice. However, it has not yet gained the same level of acceptance of other imaging tests. Partly, this is because of the use of suboptimal protocols, lack of standardization, and inadequate patient preparation. In this manuscript, we describe several practical aspects of prostate MRI that may facilitate the implementation of new prostate imaging programs or the expansion of existing ones.
Collapse
Affiliation(s)
- Olga Starobinets
- Graduate Group of Bioengineering, Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street, Box 0946, San Francisco, CA, 94143, USA
| | - Natalie Korn
- Graduate Group of Bioengineering, Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street, Box 0946, San Francisco, CA, 94143, USA
| | - Sonam Iqbal
- Graduate Group of Bioengineering, Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street, Box 0946, San Francisco, CA, 94143, USA
| | - Susan M Noworolski
- Graduate Group of Bioengineering, Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street, Box 0946, San Francisco, CA, 94143, USA
| | - Ronald Zagoria
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, M372, Box 0628, San Francisco, CA, 94143, USA
| | - John Kurhanewicz
- Graduate Group of Bioengineering, Department of Radiology and Biomedical Imaging, University of California San Francisco, 1700 4th Street, Ste. 203, San Francisco, CA, 94158, USA
| | - Antonio C Westphalen
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, M372, Box 0628, San Francisco, CA, 94143, USA.
| |
Collapse
|
14
|
Salomon L, Ploussard G, Hennequin C, Richaud P, Soulié M. Traitements complémentaires de la chirurgie du cancer de la prostate et chirurgie de la récidive. Prog Urol 2015; 25:1086-107. [DOI: 10.1016/j.purol.2015.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 08/06/2015] [Indexed: 10/22/2022]
|
15
|
Phase 2 trial of guideline-based postoperative image guided intensity modulated radiation therapy for prostate cancer: Toxicity, biochemical, and patient-reported health-related quality-of-life outcomes. Pract Radiat Oncol 2015; 5:e473-e482. [DOI: 10.1016/j.prro.2015.02.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 02/19/2015] [Accepted: 02/27/2015] [Indexed: 02/03/2023]
|
16
|
Zaorsky NG, Yamoah K, Thakur ML, Trabulsi EJ, Showalter TN, Hurwitz MD, Dicker AP, Den RB. A paradigm shift from anatomic to functional and molecular imaging in the detection of recurrent prostate cancer. Future Oncol 2014; 10:457-74. [PMID: 24559451 PMCID: PMC6615465 DOI: 10.2217/fon.13.196] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Approximately a third of men with localized prostate cancer who are treated with external beam radiation therapy (EBRT) or radical prostatectomy (RP) develop biochemical failure (BF). Presumably, BF will progress to distant metastasis and prostate cancer-specific mortality in some patients over subsequent years. Accurate detection of recurrent disease is important because it allows for appropriate treatment selection (e.g., local vs systemic therapy) and early delivery of therapy (e.g., salvage EBRT), which affect patient outcome. In this article, we discuss the paradigm shift in imaging technology in the detection of recurrent prostate cancer. First, we discuss the commonly used morphological and anatomical imaging modalities and their role in the post-RP and post-EBRT settings of BF. Second, we discuss the accuracy of functional and molecular imaging techniques, many of which are under investigation. Further studies are needed to establish the role of imaging techniques for detection of cancer recurrence and clinical decision-making.
Collapse
Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, PA, USA
- Department of Radiation Oncology, Jefferson Medical College of Thomas Jefferson University, PA, USA
| | - Kosj Yamoah
- Department of Radiation Oncology, Jefferson Medical College of Thomas Jefferson University, PA, USA
| | - Madhukar L Thakur
- Department of Radiology, Jefferson Medical College of Thomas Jefferson University, PA, USA
| | - Edouard J Trabulsi
- Department of Urology, Jefferson Medical College of Thomas Jefferson University, PA, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, PA, USA
| | - Mark D Hurwitz
- Department of Radiation Oncology, Jefferson Medical College of Thomas Jefferson University, PA, USA
| | - Adam P Dicker
- Department of Radiation Oncology, Jefferson Medical College of Thomas Jefferson University, PA, USA
| | - Robert B Den
- Department of Radiation Oncology, Jefferson Medical College of Thomas Jefferson University, PA, USA
| |
Collapse
|
17
|
Suggestion for the prostatic fossa clinical target volume in adjuvant or salvage radiotherapy after a radical prostatectomy. Radiother Oncol 2014; 110:240-4. [PMID: 24485354 DOI: 10.1016/j.radonc.2014.01.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 01/02/2014] [Accepted: 01/02/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE To assess the location of recurrent tumors and suggest the optimal target volume in adjuvant or salvage radiotherapy (RT) after a radical prostatectomy (RP). MATERIAL AND METHODS From January 2000 to December 2012, 113 patients had been diagnosed with suspected recurrent prostate cancer by MRI scan and received salvage RT in the Samsung Medical Center. This study assessed the location of the suspected tumor recurrences and used the inferior border of the pubic symphysis as a point of reference. RESULTS There were 118 suspect tumor recurrences. The most common site of recurrence was the anastomotic site (78.8%), followed by the bladder neck (15.3%) and retrovesical area (5.9%). In the cranial direction, 106 (87.3%) lesions were located within 30 mm of the reference point. In the caudal direction, 12 lesions (10.2%) were located below the reference point. In the transverse plane, 112 lesions (94.9%) were located within 10mm of the midline. CONCLUSIONS A MRI scan acquired before salvage RT is useful for the localization of recurrent tumors and the delineation of the target volume. We suggest the optimal target volume in adjuvant or salvage RT after RP, which includes 97% of suspected tumor recurrences.
Collapse
|
18
|
Zilli T, Jorcano S, Peguret N, Caparrotti F, Hidalgo A, Khan HG, Vees H, Weber DC, Miralbell R. Dose-adapted salvage radiotherapy after radical prostatectomy based on an erMRI target definition model: toxicity analysis. Acta Oncol 2014; 53:96-102. [PMID: 24032443 DOI: 10.3109/0284186x.2013.837584] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND To assess treatment tolerance by patients treated with a dose-adapted salvage radiotherapy (SRT) protocol based on an multiparametric endorectal magnetic resonance imaging (erMRI) failure definition model after radical prostatectomy (RP). MATERIAL AND METHODS A total of 171 prostate cancer patients recurring after RP undergoing erMRI before SRT were analyzed. A median dose of 64 Gy was delivered to the prostatic bed (PB) with, in addition, a boost of 10 Gy to the suspected relapse as visualized on erMRI in 131 patients (76.6%). Genitourinary (GU) and gastrointestinal (GI) toxicities were scored using the RTOG scale. RESULTS Grade ≥ 3 GU and GI acute toxicity were observed in three and zero patients, respectively. The four-year grade ≥ 2 and ≥ 3 late GU and GI toxicity-free survival rates (109 patients with at least two years of follow-up) were 83.9 ± 4.7% and 87.1 ± 4.2%, and 92.1 ± 3.6% and 97.5 ± 1.7%, respectively. Boost (p = 0.048) and grade ≥ 2 acute GU toxicity (p = 0.008) were independently correlated with grade ≥ 2 late GU toxicity on multivariate analysis. CONCLUSIONS A dose-adapted, erMRI-based SRT approach treating the PB with a boost to the suspected local recurrence may potentially improve the therapeutic ratio by selecting patients that are most likely expected to benefit from SRT doses above 70 Gy as well as by reducing the size of the highest-dose target volume. Further prospective trials are needed to investigate the use of erMRI in SRT as well as the role of dose-adapted protocols and the best fractionation schedule.
Collapse
Affiliation(s)
- Thomas Zilli
- Department of Radiation Oncology, Hôpitaux Universitaires de Genève , Geneva , Switzerland
| | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Khalifa J, Commandeur F, Bachaud JM, de Crevoisier R. Radiothérapie conformationnelle prostatique : quelles marges ? Cancer Radiother 2013; 17:461-9. [DOI: 10.1016/j.canrad.2013.06.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 06/07/2013] [Indexed: 11/24/2022]
|
20
|
|
21
|
Alongi F, De Bari B, Franco P, Ciammella P, Chekrine T, Livi L, Jereczek-Fossa BA, Filippi AR. The PROCAINA (PROstate CAncer INdication Attitudes) Project (Part I): a survey among Italian radiation oncologists on postoperative radiotherapy in prostate cancer. Radiol Med 2013; 118:660-78. [PMID: 23358818 DOI: 10.1007/s11547-012-0913-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 02/20/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE Radiotherapy (RT) has an established role in the postoperative treatment of prostate cancer patients with extracapsular extension, positive surgical margins or a detectable post-operative prostate-specific antigen (PSA). Despite the large number of patients treated with postoperative RT, some issues about optimal technique, doses, volumes, timing and association with androgen deprivation are still subject of debate. The aim of this survey was to determine the patterns of choice of Italian radiation oncologists in two different clinical cases of postoperative prostate cancer patients. STUDY DESIGN During the 2010 National Congress of the Italian Association of Radiation Oncology (AIRO), four clinical cases were presented to the attending radiation oncologists. Two of them were cases of postoperative prostate cancer, differing in T stage of the primary tumour according to the TNM classification, preoperative staging procedures, preoperative PSA (iPSA), Gleason score of biopsies and definitive pathological specimen after surgery and postoperative PSA. For each clinical case, the radiation oncologists were asked to: (a) give indication to new pre-treatment procedures for staging; b) give indication to postoperative treatment; (c) to define specifically, where indicated, the total dose, type of fractionation, treatment volumes, type of technique, type of image-guided setup control; (d) indicate whether adjuvant hormonal therapy should be prescribed; (e) define criteria that mostly influenced the prescription. A descriptive statistical analysis was then performed. RESULTS A total of 300 questionnaires were distributed amongst radiation oncologists attending the congress; 128 were completed and considered for this analysis (41%). Some important differences were shown in prescribing and performing postoperative radiotherapy, and some significant differences with international guidelines and data available from the literature were also reviewed and discussed. CONCLUSIONS Despite the results of clinical trials, significant differences still exist among Italian radiation oncologists in deciding postoperative treatment in prostate cancer patients. These patients probably deserve a more uniform approach based on updated, detailed and evidence-based recommendations.
Collapse
Affiliation(s)
- F Alongi
- Radiotherapy and Radiosurgery Department, Istituto Clinico Humanitas, Humanitas Cancer Center, Rozzano, MI, Italy
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Radiotherapy after radical prostatectomy: immediate or early delayed? Strahlenther Onkol 2012; 188:1096-101. [DOI: 10.1007/s00066-012-0234-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 09/17/2012] [Indexed: 11/25/2022]
|
23
|
Rischke HC, Schäfer AO, Nestle U, Volegova-Neher N, Henne K, Benz MR, Schultze-Seemann W, Langer M, Grosu AL. Detection of local recurrent prostate cancer after radical prostatectomy in terms of salvage radiotherapy using dynamic contrast enhanced-MRI without endorectal coil. Radiat Oncol 2012; 7:185. [PMID: 23114282 PMCID: PMC3560084 DOI: 10.1186/1748-717x-7-185] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 10/26/2012] [Indexed: 12/29/2022] Open
Abstract
Purpose To evaluate the value of dynamic contrast enhanced Magnetic Resonance Imaging (DCE-MRI) without endorectal coil (EC) in the detection of local recurrent prostate cancer (PC) after radical prostatectomy (RP). Material and methods Thirty-three patients with recurrent PC underwent DCE-MRI without EC before salvage radiotherapy (RT). At median 15 (mean 16±4.9, range 12–27) months after completion of RT all patients showed complete biochemical response. Additional follow up post RT DCE-MRI scans were available. Prostate specific antigen (PSA) levels at the time of imaging were correlated to the imaging findings. Results In 22/33 patients (67%) early contrast enhancing nodules were detected in the post-prostatectomy fossa on pre-RT DCE-MRI images. The average pre-RT PSA level of the 22 patients with positive pre-RT DCE-MRI findings was significantly higher (mean, 0.74±0.64 ng/mL) compared to the pre-RT PSA level of the 11 patients with negative pre-RT DCE-MRI (mean, 0.24±0.13 ng/mL) (p<0.001). All post-RT DCE-MRI images showed complete resolution of initial suspicious lesions. A pre-RT PSA cut-off value of ≥0.54 ng/ml readily predicted a positive DCE-MRI finding. Conclusions This is the first study that shows that DCE-MRI without EC can detect local recurrent PC with an estimated accuracy of 83% at low PSA levels. All false negative DCE-MRI scans were detected using a PSA cut-off of ≥0.54 ng/mL.
Collapse
Affiliation(s)
- Hans Christian Rischke
- Department of Radiation Oncology, University of Freiburg, Robert Koch Str. 3, Freiburg 79106, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Liauw SL, Pitroda SP, Eggener SE, Stadler WM, Pelizzari CA, Vannier MW, Oto A. Evaluation of the prostate bed for local recurrence after radical prostatectomy using endorectal magnetic resonance imaging. Int J Radiat Oncol Biol Phys 2012; 85:378-84. [PMID: 22717242 DOI: 10.1016/j.ijrobp.2012.05.015] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 04/26/2012] [Accepted: 05/06/2012] [Indexed: 01/07/2023]
Abstract
PURPOSE To summarize the results of a 4-year period in which endorectal magnetic resonance imaging (MRI) was considered for all men referred for salvage radiation therapy (RT) at a single academic center; to describe the incidence and location of locally recurrent disease in a contemporary cohort of men with biochemical failure after radical prostatectomy (RP), and to identify prognostic variables associated with MRI findings in order to define which patients may have the highest yield of the study. METHODS AND MATERIALS Between 2007 and 2011, 88 men without clinically palpable disease underwent eMRI for detectable prostate-specific antigen (PSA) after RP. The median interval between RP and eMRI was 32 months (interquartile range, 14-57 months), and the median PSA level was 0.30 ng/mL (interquartile range, 0.19-0.72 ng/mL). Magnetic resonance imaging scans consisting of T2-weighted, diffusion-weighted, and dynamic contrast-enhanced imaging were evaluated for features consistent with local recurrence. The prostate bed was scored from 0-4, whereby 0 was definitely normal, 1 probably normal, 2 indeterminate, 3 probably abnormal, and 4 definitely abnormal. Local recurrence was defined as having a score of 3-4. RESULTS Local recurrence was identified in 21 men (24%). Abnormalities were best appreciated on T2-weighted axial images (90%) as focal hypointense lesions. Recurrence locations were perianastomotic (67%) or retrovesical (33%). The only risk factor associated with local recurrence was PSA; recurrence was seen in 37% of men with PSA >0.3 ng/mL vs 13% if PSA ≤0.3 ng/mL (P<.01). The median volume of recurrence was 0.26 cm(3) and was directly associated with PSA (r=0.5, P=.02). The correlation between MRI-based tumor volume and PSA was even stronger in men with positive margins (r=0.8, P<.01). CONCLUSIONS Endorectal MRI can define areas of local recurrence after RP in a minority of men without clinical evidence of disease, with yield related to PSA. Further study is necessary to determine whether eMRI can improve patient selection and success of salvage RT.
Collapse
Affiliation(s)
- Stanley L Liauw
- Department of Radiation Oncology, University of Chicago, Chicago, Illinois 60637, USA.
| | | | | | | | | | | | | |
Collapse
|
25
|
Bellavita R, Massetti M, Abraha I, Lupattelli M, Mearini L, Falcinelli L, Farneti A, Palumbo I, Porena M, Aristei C. Conformal postoperative radiotherapy in patients with positive resection margins and/or pT3-4 prostate adenocarcinoma. Int J Radiat Oncol Biol Phys 2012; 84:e299-304. [PMID: 22572075 DOI: 10.1016/j.ijrobp.2012.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 03/03/2012] [Accepted: 04/02/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE To evaluate outcome and toxicity of high-dose conformal radiotherapy (RT) after radical prostatectomy. METHODS AND MATERIALS Between August 1998 and December 2007, 182 consecutive patients with positive resection margins and/or pT3-4, node-negative prostate adenocarcinoma underwent postoperative conformal RT. The prescribed median dose to the prostate/seminal vesicle bed was 66.6 Gy (range 50-70). Hormone therapy (a luteinizing hormone-releasing hormone analogue and/or antiandrogen) was administered to 110/182 (60.5%) patients with high-risk features. Biochemical relapse was defined as an increase of more than 0.2 ng/mL over the lowest postoperative prostate-specific antigen (PSA) value measured on 3 occasions, each at least 2 weeks apart. RESULTS Median follow-up was 55.6 months (range 7.6-141.9 months). The 3- and 5-year probability of biochemical relapse-free survival were 87% and 81%, respectively. In univariate analysis, more advanced T stages, preoperative PSA values ≥10 ng/mL, and RT doses <70 Gy were significant factors for biochemical relapse. Pre-RT PSA values >0.2 ng/mL were significant for distant metastases. In multivariate analysis, risk factors for biochemical relapse were higher preoperative and pre-RT PSA values, hormone therapy for under 402 days and RT doses of <70 Gy. Higher pre-RT PSA values were the only independent predictor of distant metastases. Acute genitourinary (GU) and gastrointestinal (GI) toxicities occurred in 72 (39.6%) and 91 (50%) patients, respectively. There were 2 cases of Grade III GI toxicity but no cases of Grade IV. Late GU and GI toxicities occurred in 28 (15.4%) and 14 (7.7%) patients, respectively: 11 cases of Grade III toxicity: 1 GI (anal stenosis) and 10 GU, all urethral strictures requiring endoscopic urethrotomy. CONCLUSIONS Postoperative high-dose conformal RT in patients with high-risk features was associated with a low risk of biochemical relapse as well as minimal morbidity.
Collapse
Affiliation(s)
- Rita Bellavita
- Institute of Radiation Oncology, General Hospital and Perugia University, Perugia, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Rouvière O. Imaging techniques for local recurrence of prostate cancer: for whom, why and how? Diagn Interv Imaging 2012; 93:279-90. [PMID: 22464995 DOI: 10.1016/j.diii.2012.01.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Since there are salvage solutions, it is important to detect local recurrence of prostate cancer as early as possible. The first sign is "biochemical failure" in that the prostate specific antigen (PSA) concentration rises again. The definition of biochemical failure varies depending on the initial treatment: PSA greater than 0.2ng/mL after prostatectomy, nadir+2ng/mL after radiotherapy. There is no standardised definition of biochemical failure after cryotherapy, focused ultrasound, or brachytherapy. Magnetic resonance imaging (MRI) (particularly dynamic MRI) can detect local recurrence with good sensitivity. The role of spectroscopy is still under discussion. For the moment, ultrasound techniques are less effective than MRI.
Collapse
Affiliation(s)
- O Rouvière
- Department of Urinary and Vascular Imaging, hospices civils de Lyon, hôpital Édouard-Herriot, 5, place d'Arsonval, 69437 Lyon, France.
| |
Collapse
|
27
|
Croke J, Malone S, Roustan Delatour N, Belanger E, Avruch L, Morash C, Kayser C, Underhill K, Spaans J. Postoperative radiotherapy in prostate cancer: the case of the missing target. Int J Radiat Oncol Biol Phys 2012; 83:1160-8. [PMID: 22270169 DOI: 10.1016/j.ijrobp.2011.09.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 07/22/2011] [Accepted: 09/29/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE Postoperative radiotherapy (XRT) increases survival in high-risk prostate cancer patients. Approximately 50% of patients on long-term follow-up relapse despite adjuvant XRT and the predominant site of failure remains local. Four consensus guidelines define postoperative clinical target volume (CTV) in prostate cancer. We explore the possibility that inadequate CTV coverage is an important cause of local failure. This study evaluates the utility of preoperative magnetic resonance imaging (MRI) in defining prostate bed CTV. METHODS AND MATERIALS Twenty prostate cancer patients treated with postoperative XRT who also had preoperative staging MRI were included. The four guidelines were applied and the CTVs were expanded to create planning target volumes (PTVs). Preoperative MRIs were fused with postoperative planning CT scans. MRI-based prostate and gross visible tumors were contoured. Three-dimensional (3D) conformal four- and six-field XRT plans were developed and dose-volume histograms analyzed. Subtraction analysis was conducted to assess the adequacy of prostate/gross tumor coverage. RESULTS Gross tumor was visible in 18 cases. In all 20 cases, the consensus CTVs did not fully cover the MRI-defined prostate. On average, 35% of the prostate volume and 32% of the gross tumor volume were missed using six-field 3D treatment plans. The entire MRI-defined gross tumor volume was completely covered in only two cases (six-field plans). The expanded PTVs did not cover the entire prostate bed in 50% of cases. Prostate base and mid-zones were the predominant site of inadequate coverage. CONCLUSIONS Current postoperative CTV guidelines do not adequately cover the prostate bed and/or gross tumor based on preoperative MRI imaging. Additionally, expanded PTVs do not fully cover the prostate bed in 50% of cases. Inadequate CTV definition is likely a major contributing factor for the high risk of relapse despite adjuvant XRT. Preoperative imaging may lead to more accurate CTV definition, which should result in further improvements in survival for patients with high-risk prostate cancer.
Collapse
Affiliation(s)
- Jennifer Croke
- Division of Radiation Oncology, The Ottawa Hospital Cancer Centre, The University of Ottawa, Ottawa, Ontario, Canada
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Daly T, Hickey BE, Lehman M, Francis DP, See AM. Adjuvant radiotherapy following radical prostatectomy for prostate cancer. Cochrane Database Syst Rev 2011:CD007234. [PMID: 22161411 DOI: 10.1002/14651858.cd007234.pub2] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Men who have a radical prostatectomy (RP) for prostate cancer that does not involve lymph nodes, but extends beyond the prostate capsule into the seminal vesicles or to surgical margins, are at increased risk of relapse. In men with these high risk factors, radiotherapy (RT) directed at the prostate bed after surgery may reduce this risk, and be curative. OBJECTIVES To evaluate the effect of adjuvant RT following RP for prostate cancer in men with high risk features compared with RP. SEARCH METHODS We searched the Cochrane Prostatic Diseases and Urological Cancers Specialised Register (23 February 2011), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE (January 1966 to February 2011), PDQ® (Physician Data Query) trial registry databases for ongoing studies (2 November 2010), reference lists from selected studies and reviews, and handsearched relevant conference proceedings. SELECTION CRITERIA Randomised controlled trials (RCT) comparing RP followed by RT with RP alone. DATA COLLECTION AND ANALYSIS Two authors independently assessed the studies for inclusion and bias and extracted data for analysis. Authors were contacted to clarify data and obtain missing information. MAIN RESULTS We found three RCTs involving 1815 men. Adjuvant RT following prostatectomy did not affect overall survival at 5 years (RD (risk difference) 0.00; 95% CI -0.03 to 0.03), but improved survival at 10 years (RD -0.11; 95% CI -0.20 to -0.02). Adjuvant RT did not improve prostate cancer-specific mortality at 5 years (RD -0.01; 95% CI -0.03 to 0.00). Adjuvant RT did not reduce metastatic disease at 5 years (RD -0.00; 95% CI -0.04 to 0.03), but reduced it at 10 years (RD -0.11; 95% CI -0.20 to -0.01). It improved local control at 5 and 10 years (RD -0.10; 95% CI -0.13 to -0.06 and RD -0.14; 95% CI -0.21 to -0.07, respectively), and biochemical progression-free survival at 5 years and 10 years (RD -0.16; 95% CI -0.21 to -0.11 and RD -0.29; 95% CI -0.39 to -0.19, respectively). There were no data for clinical disease-free survival. Adjuvant RT increased acute and late gastrointestinal toxicity [do you have the rd for this?], urinary stricture (RD 0.05; 95% CI 0.01 to 0.09) and incontinence (RD 0.04; 95% CI 0.01 to 0.08). It did not increase erectile dysfunction or degrade quality of life (RD 0.01; 95% CI -0.06 to -0.26), but with limited data. AUTHORS' CONCLUSIONS Adjuvant RT after RP improves overall survival and reduces the rate of distant metastases, but these effects are only evident with longer follow up. At 5 and 10 years it improves local control and reduces the risk of biochemical failure, although the latter is not a clinical endpoint. Moderate or severe acute and late toxicity is minimal. There is an increased risk of urinary stricture and incontinence, but no detriment to quality of life, based on limited data. Given that the majority of men who have undergone a RP have a longer life expectancy, radiotherapy should be considered for those with high-risk features following radical prostatectomy. The optimal timing is unclear.
Collapse
Affiliation(s)
- Tiffany Daly
- Mater Centre Radiation Oncology Service, Princess Alexandra Hospital, 31 Raymond Terrace, South Brisbane, QLD, Australia, 4101
| | | | | | | | | |
Collapse
|
29
|
Mishra MV, Champ CE, Den RB, Scher ED, Shen X, Trabulsi EJ, Lallas CD, Knudsen KE, Dicker AP, Showalter TN. Postprostatectomy radiation therapy: an evidence-based review. Future Oncol 2011; 7:1429-40. [DOI: 10.2217/fon.11.120] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
While the majority of men with localized prostate cancer who undergo a radical prostatectomy will remain disease free, men with certain clinical and pathological features are known to be at an increased risk for developing a biochemical recurrence and, ultimately, distant metastatic disease. The optimal management of these patients continues to be a source of controversy. To date, three randomized Phase III trials have demonstrated that adjuvant radiation therapy (ART) for patients with certain adverse pathological features results in an improvement in several clinically-relevant end points, including biochemical recurrence-free survival and overall survival. Despite the evidence from these trials showing a benefit for ART, many believe that ART results in overtreatment and unwarranted treatment morbidity for a significant number of patients. Many physicians, therefore, instead advocate for close observation followed by early salvage radiation therapy (SRT) at the time of a biochemical recurrence. The purpose of this review is to evaluate the evidence for and to distinguish between ART and early SRT. We will also highlight current and future areas of research for this patient population, including radiation treatment dose escalation, hypofractionation and androgen deprivation therapy. We will also discuss the cost–effectiveness of ART and early SRT.
Collapse
Affiliation(s)
- Mark V Mishra
- Department of Radiation Oncology, Kimmel Cancer Center, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Colin E Champ
- Department of Radiation Oncology, Kimmel Cancer Center, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Robert B Den
- Department of Radiation Oncology, Kimmel Cancer Center, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Eli D Scher
- University of Medicine & Dentistry of New Jersey, Robert Wood Johnson School of Osteopathic Medicine, New Brunswick, NJ, USA
| | - Xinglei Shen
- Department of Radiation Oncology, Kimmel Cancer Center, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Edouard J Trabulsi
- Department of Urology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Costas D Lallas
- Department of Urology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Karen E Knudsen
- Department of Urology, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Cancer Biology, Kimmel Cancer Center, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam P Dicker
- Department of Radiation Oncology, Kimmel Cancer Center, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Timothy N Showalter
- Thomas Jefferson University, Bodine Center for Cancer Treatment, 111 S. 11th Street, Philadelphia, PA 19107, USA
| |
Collapse
|
30
|
Technology assessment of automated atlas based segmentation in prostate bed contouring. Radiat Oncol 2011; 6:110. [PMID: 21906279 PMCID: PMC3180272 DOI: 10.1186/1748-717x-6-110] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 09/09/2011] [Indexed: 11/17/2022] Open
Abstract
Background Prostate bed (PB) contouring is time consuming and associated with inter-observer variability. We evaluated an automated atlas-based segmentation (AABS) engine in its potential to reduce contouring time and inter-observer variability. Methods An atlas builder (AB) manually contoured the prostate bed, rectum, left femoral head (LFH), right femoral head (RFH), bladder, and penile bulb of 75 post-prostatectomy cases to create an atlas according to the recent RTOG guidelines. 5 other Radiation Oncologists (RO) and the AABS contoured 5 new cases. A STAPLE contour for each of the 5 patients was generated. All contours were anonymized and sent back to the 5 RO to be edited as clinically necessary. All contouring times were recorded. The dice similarity coefficient (DSC) was used to evaluate the unedited- and edited- AABS and inter-observer variability among the RO. Descriptive statistics, paired t-tests and a Pearson correlation were performed. ANOVA analysis using logit transformations of DSC values was calculated to assess inter-observer variability. Results The mean time for manual contours and AABS was 17.5- and 14.1 minutes respectively (p = 0.003). The DSC results (mean, SD) for the comparison of the unedited-AABS versus STAPLE contours for the PB (0.48, 0.17), bladder (0.67, 0.19), LFH (0.92, 0.01), RFH (0.92, 0.01), penile bulb (0.33, 0.25) and rectum (0.59, 0.11). The DSC results (mean, SD) for the comparison of the edited-AABS versus STAPLE contours for the PB (0.67, 0.19), bladder (0.88, 0.13), LFH (0.93, 0.01), RFH (0.92, 0.01), penile bulb (0.54, 0.21) and rectum (0.78, 0.12). The DSC results (mean, SD) for the comparison of the edited-AABS versus the expert panel for the PB (0.47, 0.16), bladder (0.67, 0.18), LFH (0.83, 0.18), RFH (0.83, 0.17), penile bulb (0.31, 0.23) and rectum (0.58, 0.09). The DSC results (mean, SD) for the comparison of the STAPLE contours and the 5 RO are PB (0.78, 0.15), bladder (0.96, 0.02), left femoral head (0.87, 0.19), right femoral head (0.87, 0.19), penile bulb (0.70, 0.17) and the rectum (0.89, 0.06). The ANOVA analysis suggests inter-observer variability among at least one of the 5 RO (p value = 0.002). Conclusion The AABS tool results in a time savings, and when used to generate auto-contours for the femoral heads, bladder and rectum had superior to good spatial overlap. However, the generated auto-contours for the prostate bed and penile bulb need improvement.
Collapse
|
31
|
Smeenk RJ, van Lin ENJT, van Kollenburg P, McColl GM, Kunze-Busch M, Kaanders JHAM. Endorectal balloon reduces anorectal doses in post-prostatectomy intensity-modulated radiotherapy. Radiother Oncol 2011; 101:465-70. [PMID: 21872953 DOI: 10.1016/j.radonc.2011.07.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 07/25/2011] [Accepted: 07/26/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND PURPOSE To investigate the effect of an endorectal balloon (ERB) on anal wall (Awall) and rectal wall (Rwall) doses in high-dose post-prostatectomy intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS For 20 patients, referred for salvage IMRT after prostatectomy for prostate cancer, two planning CT-scans were performed: one with and one without an air-filled ERB. A planning target volume (PTV) was defined, using international guidelines. Furthermore, the Awall and Rwall were delineated. In both the scans, IMRT plans were generated with a prescribed dose of 70 Gy. The mean dose (D(mean)), maximum dose, minimum dose, and volumes exposed to doses ranging from ≥ 20 to ≥ 70 Gy (V(20)-V(70)) to the Awall and Rwall were calculated. Finally, inner Rwall surface areas exposed to doses ranging from ≥ 20 to ≥ 70 Gy (A(20)-A(70)) were calculated. Dose-parameters were compared between plans with and without ERB. RESULTS All Awall parameters, except V(70), were significantly reduced by the ERB with an overall D(mean) reduction of 6 Gy. Absolute reductions in dose-volume parameters varied from 5% to 11%. Significantly reduced Rwall V(30), V(40), and A(40) were observed with ERB, irrespective of the target volume size. CONCLUSION ERB application significantly reduces Awall and to a lesser degree Rwall doses in high-dose post-prostatectomy IMRT.
Collapse
Affiliation(s)
- Robert Jan Smeenk
- Department of Radiation Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | | | | | | | | | | |
Collapse
|
32
|
Sia M, Pickles T, Morton G, Souhami L, Lukka H, Warde P. Salvage radiotherapy following biochemical relapse after radical prostatectomy: proceedings of the Genito-Urinary Radiation Oncologists of Canada consensus meeting. Can Urol Assoc J 2011; 2:500-7. [PMID: 18953445 DOI: 10.5489/cuaj.916] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
For patients with recurrent prostate cancer after radical prostatectomy, salvage radiotherapy is the only potentially curative treatment option. However, until recently there has been a paucity of data on the effectiveness of this approach. In light of recently published studies, the Genito-Urinary Radiation Oncologists of Canada (GUROC) met and crafted a consensus statement regarding the current place of salvage radiotherapy. GUROC also identified gaps in current knowledge and identified ongoing study protocols that will advance our knowledge in this area.This report summarizes the main conclusions of the meeting and the commentary provided during the consensus-building process, and outlines the consensus statement that was subsequently adopted.
Collapse
Affiliation(s)
- Michael Sia
- Radiation Oncology Program, Tom Baker Cancer Centre, Calgary, Alta., the
| | | | | | | | | | | |
Collapse
|
33
|
An interobserver study of prostatic fossa clinical target volume delineation in clinical practice: are regions of recurrence adequately targeted? Am J Clin Oncol 2011; 34:145-9. [PMID: 20523209 DOI: 10.1097/coc.0b013e3181d2edc3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To study interphysician variability of delineation of the prostatic fossa clinical target volume (pfCTV) to be irradiated in patients with residual or recurrent microscopic prostate cancer following radical prostatectomy and to estimate the risk for a geographical miss. METHODS Thirty-eight pfCTV were delineated on postradical prostatectomy computerized tomography scans of 8 patients by 5 observers. To estimate the risk of a geographical miss, a high risk volume (HRV) was defined and the percentage of "missed" HRV was calculated for each pfCTV. RESULTS Interphysician variability was considerable with a mean pfCTV of 39.09 cm (range, 11.8-72.5 cm). At least 25% of the HRV at the bladder neck/anastomosis and the retro-vesical space was excluded in 11 pfCTVs. The mean "missed" HRV was 27.5% (range, 2.3%-78.7%). A pfCTV of less than 30 cm was associated with a geographical miss in 66% of cases versus 17.2% for pfCTV of 30 cm or more (P = 0.006). Observer identity was significantly associated with excluded HRV (P = 0.03). CONCLUSIONS pfCTV delineation is subject to considerable interobserver variability associated with a significant risk of inadequate targeting of the anastomosis/bladder neck region and the retrovesical space. The failure to recognize regions at high risk for harboring microscopic disease may be due to a lack of familiarity with tissue redistribution following radical surgery, and a lack of literature-based guidelines for pfCTV delineation. A strategy to improve pfCTV delineation is proposed.
Collapse
|
34
|
Influence of (11)C-choline PET/CT on the treatment planning for salvage radiation therapy in patients with biochemical recurrence of prostate cancer. Radiother Oncol 2011; 99:193-200. [PMID: 21620494 DOI: 10.1016/j.radonc.2011.05.005] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Revised: 04/20/2011] [Accepted: 05/03/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE The present study evaluates the incidence of (11)C-choline PET/CT positive findings in patients with recurrent prostate cancer referred for salvage radiotherapy (SRT) and the influence on the definition of the planning target volume (PTV). MATERIAL AND METHODS Thirty-seven patients treated with radical prostatectomy and referred to SRT to the prostatic fossa because of biochemical relapse, were analysed retrospectively. All patients underwent (11)C-choline PET/CT before radiotherapy. The influence of PET/CT on the extent of the PTV was analysed. The median total follow up after SRT was 51.2 months. RESULTS 11/37 (30%) patients had a positive finding in the (11)C-choline PET/CT, 5 (13%) outside of the prostatic fossa (iliac lymph nodes), implicating an extension of the PTV. Patients with positive (11)C-choline PET/CT had a significant higher PSA value than patients with no pathologic uptake (p=0.03). Overall, at the end of follow up 56% of the patients had a PSA ≤ 0.2ng/ml and 44% had a biochemical relapse of prostate cancer. CONCLUSIONS (11)C-choline PET/CT detects abnormalities outside of the prostatic fossa in 13% of patients referred for SRT because of biochemical relapse after radical prostatectomy, affecting the extent of the PTV. Prospective studies need to be implemented to evaluate the benefit of SRT with a PTV based on (11)C-choline PET/CT.
Collapse
|
35
|
Harrison A, Studenski M, Harvey A, Trabulsi EJ, Xiao Y, Yu Y, Dicker AP, Showalter TN. Potential for dose escalation in the postprostatectomy setting with intensity-modulated radiation therapy: a dosimetric study using EORTC consensus guidelines for target volume contours. Pract Radiat Oncol 2011; 1:105-14. [DOI: 10.1016/j.prro.2010.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 10/25/2010] [Accepted: 10/25/2010] [Indexed: 10/18/2022]
|
36
|
Choo R. Salvage radiotherapy for patients with PSA relapse following radical prostatectomy: issues and challenges. Cancer Res Treat 2010; 42:1-11. [PMID: 20369045 DOI: 10.4143/crt.2010.42.1.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A progressively rising level of serum prostate specific antigen (PSA) after radical prostatectomy (RP) invariably indicates the recurrence of prostate cancer. The optimal management of patients with post-RP PSA relapse has remained uncertain due to a wide variability in the natural course of post-RP PSA relapse and the inability to separate a recurrent disease confined to the prostate bed from that with occult distant metastasis. Management uncertainty is further compounded by the lack of phase III clinical studies demonstrating which therapeutic approach, if any, would prolong life with no significant morbidity. Radiotherapy has been the main therapeutic modality with a curative potential for patients with post-RP PSA relapse. This review article depicts issues and challenges in the management of patients with post-RP PSA relapse, presents the literature data for the efficacy of salvage radiotherapy, either alone or in combination of androgen ablation therapy, and discusses future directions that can optimize treatment strategies.
Collapse
Affiliation(s)
- Richard Choo
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA.
| |
Collapse
|
37
|
A Systematic Review of the Role of Imaging before Salvage Radiotherapy for Post-prostatectomy Biochemical Recurrence. Clin Oncol (R Coll Radiol) 2010; 22:46-55. [DOI: 10.1016/j.clon.2009.10.015] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Revised: 10/01/2009] [Accepted: 10/14/2009] [Indexed: 11/21/2022]
|
38
|
Rouvière O, Vitry T, Lyonnet D. Imaging of prostate cancer local recurrences: why and how? Eur Radiol 2009; 20:1254-66. [DOI: 10.1007/s00330-009-1647-4] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2009] [Revised: 09/07/2009] [Accepted: 10/09/2009] [Indexed: 10/20/2022]
|
39
|
|
40
|
Weber DC, Wang H, Cozzi L, Dipasquale G, Khan HG, Ratib O, Rouzaud M, Vees H, Zaidi H, Miralbell R. RapidArc, intensity modulated photon and proton techniques for recurrent prostate cancer in previously irradiated patients: a treatment planning comparison study. Radiat Oncol 2009; 4:34. [PMID: 19740429 PMCID: PMC2749024 DOI: 10.1186/1748-717x-4-34] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 09/09/2009] [Indexed: 11/27/2022] Open
Abstract
Background A study was performed comparing volumetric modulated arcs (RA) and intensity modulation (with photons, IMRT, or protons, IMPT) radiation therapy (RT) for patients with recurrent prostate cancer after RT. Methods Plans for RA, IMRT and IMPT were optimized for 7 patients. Prescribed dose was 56 Gy in 14 fractions. The recurrent gross tumor volume (GTV) was defined on 18F-fluorocholine PET/CT scans. Plans aimed to cover at least 95% of the planning target volume with a dose > 50.4 Gy. A maximum dose (DMax) of 61.6 Gy was allowed to 5% of the GTV. For the urethra, DMax was constrained to 37 Gy. Rectal DMedian was < 17 Gy. Results were analyzed using Dose-Volume Histogram and conformity index (CI90) parameters. Results Tumor coverage (GTV and PTV) was improved with RA (V95% 92.6 ± 7.9 and 83.7 ± 3.3%), when compared to IMRT (V95% 88.6 ± 10.8 and 77.2 ± 2.2%). The corresponding values for IMPT were intermediate for the GTV (V95% 88.9 ± 10.5%) and better for the PTV (V95%85.6 ± 5.0%). The percentages of rectal and urethral volumes receiving intermediate doses (35 Gy) were significantly decreased with RA (5.1 ± 3.0 and 38.0 ± 25.3%) and IMPT (3.9 ± 2.7 and 25.1 ± 21.1%), when compared to IMRT (9.8 ± 5.3 and 60.7 ± 41.7%). CI90 was 1.3 ± 0.1 for photons and 1.6 ± 0.2 for protons. Integral Dose was 1.1 ± 0.5 Gy*cm3 *105 for IMPT and about a factor three higher for all photon's techniques. Conclusion RA and IMPT showed improvements in conformal avoidance relative to fixed beam IMRT for 7 patients with recurrent prostate cancer. IMPT showed further sparing of organs at risk.
Collapse
Affiliation(s)
- Damien C Weber
- Department of Radiation Oncology, University Hospital of Geneva, Geneva, Switzerland.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Bottke D, de Reijke TM, Bartkowiak D, Wiegel T. Salvage radiotherapy in patients with persisting/rising PSA after radical prostatectomy for prostate cancer. Eur J Cancer 2009; 45 Suppl 1:148-57. [DOI: 10.1016/s0959-8049(09)70027-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
42
|
Radiothérapie chez les patients à haut risque après prostatectomie radicale : postopératoire ou de rattrapage ? Prog Urol 2009; 19:447-56. [DOI: 10.1016/j.purol.2009.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 03/01/2009] [Accepted: 03/09/2009] [Indexed: 11/19/2022]
|
43
|
Pasquier D, Hugentobler A, Masson P. [Which imaging methods should be used prior to salvage radiotherapy after prostatectomy for prostate cancer?]. Cancer Radiother 2009; 13:173-81. [PMID: 19414277 DOI: 10.1016/j.canrad.2009.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2008] [Revised: 01/30/2009] [Accepted: 02/09/2009] [Indexed: 11/17/2022]
Abstract
Prostatectomy is one of the most widely used methods for treatment of adenocarcinoma of the prostate. According to anatomopathological criteria, between 10 and 40% of patients will display biochemical relapse in the absence of adjuvant radiotherapy. Anatomopathological and biochemical criteria are powerful tools for selecting patients for salvage radiotherapy. The aim of this article is to review literature on the latest progress in radiological and nuclear medicine techniques and their performance levels, in order to determine local, regional and metastatic relapses associated with the techniques and specify the radiotherapy target volume. Magnetic resonance imaging (MRI) displays the best sensitivity and specificity for examination of the prostate bed and enables simultaneous assessment of the pelvic region - thus diminishing the utility of computed tomography. The performance levels of MRI will probably continue to improve, with the use of dynamic MRI and MR spectroscopy. Despite the development of new markers like (11)C and (18)F choline and acetate, the sensitivity of positron emission tomography is still low. Prospective studies with an appropriate methodology are necessary for specifying the technique's value in this context.
Collapse
Affiliation(s)
- D Pasquier
- Service de radiothérapie, centre Galilée, polyclinique de la Louvière, 59000 Lille, France.
| | | | | |
Collapse
|
44
|
Michalski JM, Lawton C, El Naqa I, Ritter M, O'Meara E, Seider MJ, Lee WR, Rosenthal SA, Pisansky T, Catton C, Valicenti RK, Zietman AL, Bosch WR, Sandler H, Buyyounouski MK, Ménard C. Development of RTOG consensus guidelines for the definition of the clinical target volume for postoperative conformal radiation therapy for prostate cancer. Int J Radiat Oncol Biol Phys 2009; 76:361-8. [PMID: 19394158 DOI: 10.1016/j.ijrobp.2009.02.006] [Citation(s) in RCA: 285] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 01/29/2009] [Accepted: 02/03/2009] [Indexed: 12/21/2022]
Abstract
PURPOSE To define a prostate fossa clinical target volume (PF-CTV) for Radiation Therapy Oncology Group (RTOG) trials using postoperative radiotherapy for prostate cancer. METHODS AND MATERIALS An RTOG-sponsored meeting was held to define an appropriate PF-CTV after radical prostatectomy. Data were presented describing radiographic failure patterns after surgery. Target volumes used in previous trials were reviewed. Using contours independently submitted by 13 radiation oncologists, a statistical imputation method derived a preliminary "consensus" PF-CTV. RESULTS Starting from the model-derived CTV, consensus was reached for a CT image-based PF-CTV. The PF-CTV should extend superiorly from the level of the caudal vas deferens remnant to >8-12 mm inferior to vesicourethral anastomosis (VUA). Below the superior border of the pubic symphysis, the anterior border extends to the posterior aspect of the pubis and posteriorly to the rectum, where it may be concave at the level of the VUA. At this level, the lateral border extends to the levator ani. Above the pubic symphysis, the anterior border should encompass the posterior 1-2 cm of the bladder wall; posteriorly, it is bounded by the mesorectal fascia. At this level, the lateral border is the sacrorectogenitopubic fascia. Seminal vesicle remnants, if present, should be included in the CTV if there is pathologic evidence of their involvement. CONCLUSIONS Consensus on postoperative PF-CTV for RT after prostatectomy was reached and is available as a CT image atlas on the RTOG website. This will allow uniformity in defining PF-CTV for clinical trials that include postprostatectomy RT.
Collapse
Affiliation(s)
- Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Pasquier D, Ballereau C. Adjuvant and salvage radiotherapy after prostatectomy for prostate cancer: a literature review. Int J Radiat Oncol Biol Phys 2008; 72:972-9. [PMID: 18954710 DOI: 10.1016/j.ijrobp.2008.07.026] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Revised: 06/27/2008] [Accepted: 07/10/2008] [Indexed: 12/28/2022]
Abstract
PURPOSE Given that postprostatectomy recurrence of prostate cancer occurs in 10-40% of patients, the best use of immediate postoperative radiotherapy (RT) in high-risk patients and salvage RT for biochemical recurrence remains a topic of debate. We assessed the levels of evidence (in terms of efficacy, prognostic factors, and toxicity) for the following treatment strategies: immediate postoperative RT alone, salvage RT alone, and the addition of androgen deprivation therapy to the two RT strategies. METHODS AND MATERIALS A systematic literature search for controlled randomized trials, noncontrolled trials, and retrospective studies between 1990 and 2008 was performed on PubMed, CancerLit, and MEDLINE. Only relevant articles that had appeared in peer-reviewed journals were selected. We report on the levels of evidence (according to the National Cancer Institute guidelines) supporting the various treatment strategies. RESULTS Immediate postoperative RT improves biochemical and clinical progression-free survival (Level of evidence, 1.ii) but has no significant effect on metastasis-free survival or overall survival. A pathologic review is of particular importance for correctly analyzing the treatment strategies. Low-grade morbidity has been significantly greater in the postoperative groups, but no severe toxicity has been observed. The influence of immediate postoperative RT on postprostatectomy continence appears to be slight; therefore, immediate postoperative RT should be considered in patients with major risk factors for local relapse (Level of evidence, 1.ii). On the basis of extensive retrospective data, salvage RT is effective in biochemical relapse after prostatectomy; some patients with few adverse prognostic factors might also benefit from salvage RT (Level of evidence, 3.ii). The addition of androgen deprivation therapy to immediate postoperative or salvage RT has only been supported by weak, retrospective data (Level of evidence, 3.ii). CONCLUSION Prospective randomized trials are needed to compare immediate postoperative RT with salvage RT and to assess the value of androgen deprivation therapy in this setting.
Collapse
Affiliation(s)
- David Pasquier
- Department of Radiation Oncology, Centre Galilée, Clinique de la Louvière, Lille, France.
| | | |
Collapse
|
46
|
|
47
|
The role of imaging in the detection of prostate cancer local recurrence after radiation therapy and surgery. Curr Opin Urol 2008; 18:87-97. [PMID: 18090496 DOI: 10.1097/mou.0b013e3282f13ac3] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this article is to review novel MRI and nuclear medicine methods for detecting and planning salvage treatment for prostate cancer local recurrence after radical prostatectomy or radiation therapy. RECENT FINDINGS Traditional methods for detecting local recurrence (i.e., digital rectal exam or transrectal ultrasound and digital rectal exam or transrectal ultrasound-guided biopsy) have limited accuracy in determining the presence and extent of local recurrence and therefore have limited ability to guide salvage therapy. Recent studies indicate that conventional T1 and T2-weighted prostate MRI could improve the detection of recurrent prostate cancer after radical prostatectomy or radiation therapy and salvage treatment planning. Promising new sequences could further increase the accuracy of MRI. In addition, the use of technically improved PET/computed tomography scanners with new tracers like (11)C and (18)F choline and acetate might offer better assessment of recurrent prostate cancer than (18)F-2-fluoro-D-deoxyglucose-PET and monoclonal antibody imaging with the prostate specific membrane antigen antibody (111)In-capromab pendetide (ProstaScint). SUMMARY With systemic therapies for recurrent prostate cancer after radical prostatectomy or radiation therapy being noncurative, the application of MRI and nuclear medicine modalities can help to identify patients who have isolated local recurrence amenable to salvage treatment.
Collapse
|
48
|
Sciarra A, Panebianco V, Salciccia S, Osimani M, Lisi D, Ciccariello M, Passariello R, Di Silverio F, Gentile V. Role of dynamic contrast-enhanced magnetic resonance (MR) imaging and proton MR spectroscopic imaging in the detection of local recurrence after radical prostatectomy for prostate cancer. Eur Urol 2007; 54:589-600. [PMID: 18226441 DOI: 10.1016/j.eururo.2007.12.034] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Accepted: 12/14/2007] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To assess the accuracy of magnetic resonance (MR) spectroscopic imaging (1H-MRSI) and dynamic contrast-enhanced MR (DCEMR) in the depiction of local prostate cancer recurrence in patients with biochemical progression after radical prostatectomy (RP). MATERIALS AND METHODS 1H-MRSI and DCEMR were performed in 70 patients at high risk of local recurrence after RP. The population was divided on the basis of the clinical validation of MR results with the use of a transrectal ultrasound biopsy examination in a group of 50 patients (group A) and the prostate-specific antigen (PSA) serum level restitution after external beam radiotherapy, in a group of 20 patients (group B). RESULTS In group A, 1H-MRSI analysis alone showed a sensitivity of 84% and a specificity of 88%; the DCEMR analysis alone, a sensitivity of 71% and a specificity of 94%; combined 1HMRSI-DCEMR, a sensitivity of 87% and specificity of 94%. Areas under the receiver operating characteristic (ROC) curve for 1HMRSI, DCEMR, and combined 1HMRSI /DCEMR were 0.942, 0.93,1 and 0.964, respectively. In group B, 1HMRSI alone showed a sensitivity of 71% and a specificity of 83%; DCEMR, a sensitivity of 79% and a specificity of 100%; combined 1HMRSI and DCEMR, a sensitivity of 86% and a specificity of 100%. Areas under the ROC curve for each of these groups were 0.81, 0.923, and 0.94, respectively. CONCLUSION Our results show that combined 1H-MRSI and DCMRE is an accurate method to identify local prostate cancer recurrence in patients with biochemical progression after RP.
Collapse
|
49
|
Wiltshire KL, Brock KK, Haider MA, Zwahlen D, Kong V, Chan E, Moseley J, Bayley A, Catton C, Chung PWM, Gospodarowicz M, Milosevic M, Kneebone A, Warde P, Ménard C. Anatomic boundaries of the clinical target volume (prostate bed) after radical prostatectomy. Int J Radiat Oncol Biol Phys 2007; 69:1090-9. [PMID: 17967303 DOI: 10.1016/j.ijrobp.2007.04.068] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Revised: 04/24/2007] [Accepted: 04/25/2007] [Indexed: 12/21/2022]
Abstract
PURPOSE We sought to derive and validate an interdisciplinary consensus definition for the anatomic boundaries of the postoperative clinical target volume (CTV, prostate bed). METHODS AND MATERIALS Thirty one patients who had planned for radiotherapy after radical prostatectomy were enrolled and underwent computed tomography and magnetic resonance imaging (MRI) simulation prior to radiotherapy. Through an iterative process of consultation and discussion, an interdisciplinary consensus definition was derived based on a review of published data, patterns of local failure, surgical practice, and radiologic anatomy. In validation, we analyzed the distribution of surgical clips in reference to the consensus CTV and measured spatial uncertainties in delineating the CTV and vesicourethral anastomosis. Clinical radiotherapy plans were retrospectively evaluated against the consensus CTV (prostate bed). RESULTS Anatomic boundaries of the consensus CTV (prostate bed) are described. Surgical clips (n = 339) were well distributed throughout the CTV. The vesicourethral anastomosis was accurately localized using central sagittal computed tomography reconstruction, with a mean +/- standard deviation uncertainty of 1.8 +/- 2.5 mm. Delineation uncertainties were small for both MRI and computed tomography (mean reproducibility, 0-3.8 mm; standard deviation, 1.0-2.3); they were most pronounced in the anteroposterior and superoinferior dimensions and at the superior/posterior-most aspect of the CTV. Retrospectively, the mean +/- standard deviation CTV (prostate bed) percentage of volume receiving 100% of prescribed dose was only 77% +/- 26%. CONCLUSIONS We propose anatomic boundaries for the CTV (prostate bed) and present evidence supporting its validity. In the absence of gross recurrence, the role of MRI in delineating the CTV remains to be confirmed. The CTV is larger than historically practiced at our institution and should be encompassed by a microscopic tumoricidal dose.
Collapse
Affiliation(s)
- Kirsty L Wiltshire
- Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Poortmans P, Bossi A, Vandeputte K, Bosset M, Miralbell R, Maingon P, Boehmer D, Budiharto T, Symon Z, van den Bergh ACM, Scrase C, Van Poppel H, Bolla M. Guidelines for target volume definition in post-operative radiotherapy for prostate cancer, on behalf of the EORTC Radiation Oncology Group. Radiother Oncol 2007; 84:121-7. [PMID: 17706307 DOI: 10.1016/j.radonc.2007.07.017] [Citation(s) in RCA: 229] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2007] [Revised: 07/07/2007] [Accepted: 07/14/2007] [Indexed: 01/03/2023]
Abstract
The appropriate application of 3-D conformal radiotherapy, intensity modulated radiotherapy or image guided radiotherapy for patients undergoing post-operative radiotherapy for prostate cancer requires a standardisation of the target volume definition and delineation as well as standardisation of the clinical quality assurance procedures. Recommendations for this are presented on behalf of the European Organisation for Research and Treatment of Cancer (EORTC) Radiation Oncology Group and in addition to the already published guidelines for radiotherapy as the primary treatment.
Collapse
Affiliation(s)
- Philip Poortmans
- Department of Radiotherapy, Dr. B. Verbeeten Institute, Tilburg, The Netherlands.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|