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Wüthrich D, Wang Z, Zeverino M, Bourhis J, Bochud F, Moeckli R. Comparison of volumetric modulated arc therapy and helical tomotherapy for prostate cancer using Pareto fronts. Med Phys 2024; 51:3010-3019. [PMID: 38055371 DOI: 10.1002/mp.16868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 11/02/2023] [Accepted: 11/14/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Studies comparing different radiotherapy treatment techniques-such as volumetric modulated arc therapy (VMAT) and helical tomotherapy (HT)-typically compare one treatment plan per technique. Often, some dose metrics favor one plan and others favor the other, so the final plan decision involves subjective preferences. Pareto front comparisons provide a more objective framework for comparing different treatment techniques. A Pareto front is the set of all treatment plans where improvement in one criterion is possible only by worsening another criterion. However, different Pareto fronts can be obtained depending on the chosen machine settings. PURPOSE To compare VMAT and HT using Pareto fronts and blind expert evaluation, to explain the observed differences, and to illustrate limitations of using Pareto fronts. METHODS We generated Pareto fronts for twenty-four prostate cancer patients treated at our clinic for VMAT and HT techniques using an in-house script that controlled a commercial treatment planning system. We varied the PTV under-coverage (100% - V95%) and the rectum mean dose, and fixed the mean doses to the bladder and femoral heads. In order to ensure a fair comparison, those fixed mean doses were the same for the two treatment techniques and the sets of objective functions were chosen so that the conformity indexes of the two treatment techniques were also the same. We used the same machine settings as are used in our clinic. Then, we compared the VMAT and HT Pareto fronts using a specific metric (clinical distance measure) and validated the comparison using a blinded expert evaluation of treatment plans on these fronts for all patients in the cohort. Furthermore, we investigated the observed differences between VMAT and HT and pointed out limitations of using Pareto fronts. RESULTS Both clinical distance and blind treatment plan comparison showed that VMAT Pareto fronts were better than HT fronts. VMAT fronts for 10 and 6 MV beam energy were almost identical. HT fronts improved with different machine settings, but were still inferior to VMAT fronts. CONCLUSIONS That VMAT Pareto fronts are better than HT fronts may be explained by the fact that the linear accelerator can rapidly vary the dose rate. This is an advantage in simple geometries that might vanish in more complex geometries. Furthermore, one should be cautious when speaking about Pareto optimal plans as the best possible plans, as their calculation depends on many parameters.
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Affiliation(s)
- Diana Wüthrich
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Zirun Wang
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Michele Zeverino
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Jean Bourhis
- Department of Radiation Oncology, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - François Bochud
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Raphaël Moeckli
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
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Takagi M, Hasegawa Y, Tateoka K, Takada Y, Hareyama M. Dosimetric Comparison Study of Proton Therapy Using Line Scanning versus Passive Scattering and Volumetric Modulated Arc Therapy for Localized Prostate Cancer. Cancers (Basel) 2024; 16:403. [PMID: 38254892 PMCID: PMC10814771 DOI: 10.3390/cancers16020403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND The proton irradiation modality has transitioned from passive scattering (PS) to pencil beam scanning. Nevertheless, the documented outcomes predominantly rely on PS. METHODS Thirty patients diagnosed with prostate cancer were selected to assess treatment planning across line scanning (LS), PS, and volumetric modulated arc therapy (VMAT). Dose constraints encompassed clinical target volume (CTV) D98 ≥ 73.0 Gy (RBE), rectal wall V65 < 17% and V40 < 35%, and bladder wall V65 < 25% and V40 < 50%. The CTV, rectal wall, and bladder wall dose volumes were calculated and evaluated using the Freidman test. RESULTS The LS technique adhered to all dose limitations. For the rectal and bladder walls, 10 (33.3%) and 21 (70.0%) patients in the PS method and 5 (16.7%) and 1 (3.3%) patients in VMAT, respectively, failed to meet the stipulated requirements. The wide ranges of the rectal and bladder wall volumes (V10-70) were lower with LS than with PS and VMAT. LS outperformed VMAT across all dose-volume rectal and bladder wall indices. CONCLUSION The LS method demonstrated a reduction in rectal and bladder doses relative to PS and VMAT, thereby suggesting the potential for mitigating toxicities.
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Affiliation(s)
- Masaru Takagi
- Department of Radiation Oncology, Sapporo Teishinkai Hospital, Sapporo 065-0033, Japan
| | - Yasuhiro Hasegawa
- Department of Radiation Physics, Sapporo Teishinkai Hospital, Sapporo 065-0033, Japan
| | - Kunihiko Tateoka
- Department of Radiation Physics, Sapporo Teishinkai Hospital, Sapporo 065-0033, Japan
| | - Yu Takada
- Department of Radiation Oncology, Sapporo Teishinkai Hospital, Sapporo 065-0033, Japan
| | - Masato Hareyama
- Department of Radiation Oncology, Sapporo Teishinkai Hospital, Sapporo 065-0033, Japan
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Bull C, Morén AT, Skokic V, Wilderäng U, Malipatlolla D, Alevronta E, Dunberger G, Sjöberg F, Bergmark K, Steineck G. Intra-abdominal Surgery and Intestinal Syndromes After Pelvic Radiation Therapy. Adv Radiat Oncol 2024; 9:101303. [PMID: 38260232 PMCID: PMC10801660 DOI: 10.1016/j.adro.2023.101303] [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] [Received: 01/11/2023] [Accepted: 06/16/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose To determine the effects of intra-abdominal surgery on the intensities of 5 radiation-induced intestinal syndromes in survivors of pelvic cancer. Methods and Materials The analysis included 623 women born in 1927 or later who had survived cancer. They all had received external radiation therapy toward the pelvic area to treat gynecologic cancers. Information from 344 women who did not undergo irradiation, matched for age and residency, was also included. Main outcome measures after the surgical procedures were the intensity scores for 5 radiation-induced intestinal syndromes: urgency-tenesmus syndrome, fecal-leakage syndrome, excessive mucus discharge, excessive gas discharge, and blood discharge. The scores were based on symptom frequencies obtained from patient-reported outcomes and on factor loadings obtained from a previously reported factor analysis. Follow-up was 2 to 15 years after radiation therapy. Results Among survivors of cancer, intra-abdominal surgery increased the intensity of the urgency-tenesmus syndrome, the fecal-leakage syndrome, excessive gas discharge, and blood discharge but had a negligible effect on mucus discharge. Intra-abdominal surgery had an especially negative effect on the urgency-tenesmus syndrome. Although the combination of appendectomy with 1 or more other intra-abdominal surgeries resulted in the highest score for all syndromes, appendectomy alone had weak to no effect. In women who did not undergo irradiation, a similar pattern was seen, albeit with much lower scores. Conclusions We found intra-abdominal surgery to be a risk factor among survivors of gynecologic cancer, increasing the intensity score of 4 out of 5 radiation-induced intestinal syndromes. During radiation therapy, it may be worthwhile to pay extra attention to the dose of unwanted ionizing radiation to the intestines if the patient previously has undergone intra-abdominal surgery.
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Affiliation(s)
- Cecilia Bull
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Amelie Toft Morén
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Viktor Skokic
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
- Division of Clinical Cancer Epidemiology, Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden
| | - Ulrica Wilderäng
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Dilip Malipatlolla
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Eleftheria Alevronta
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Gail Dunberger
- Department of Health Care Sciences, Marie Cederschiöld University, Stockholm, Sweden
| | - Fei Sjöberg
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
- Department of Infectious Diseases at the Institute of Biomedicine, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Karin Bergmark
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Gunnar Steineck
- Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
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Wüthrich D, Zeverino M, Bourhis J, Bochud F, Moeckli R. Influence of optimisation parameters on directly deliverable Pareto fronts explored for prostate cancer. Phys Med 2023; 114:103139. [PMID: 37757500 DOI: 10.1016/j.ejmp.2023.103139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/30/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
PURPOSE In inverse radiotherapy treatment planning, the Pareto front is the set of optimal solutions to the multi-criteria problem of adequately irradiating the planning target volume (PTV) while reducing dose to organs at risk (OAR). The Pareto front depends on the chosen optimisation parameters whose influence (clinically relevant versus not clinically relevant) is investigated in this paper. METHODS Thirty-one prostate cancer patients treated at our clinic were randomly selected. We developed an in-house Python script that controlled the commercial treatment planning system RayStation to calculate directly deliverable Pareto fronts. We calculated reference Pareto fronts for a given set of objective functions, varying the PTV coverage and the mean dose of the primary OAR (rectum) and fixing the mean doses of the secondary OARs (bladder and femoral heads). We calculated the fronts for different sets of objective functions and different mean doses to secondary OARs. We compared all fronts using a specific metric (clinical distance measure). RESULTS The in-house script was validated for directly deliverable Pareto front calculations in two and three dimensions. The Pareto fronts depended on the choice of objective functions and fixed mean doses to secondary OARs, whereas the parameters most influencing the front and leading to clinically relevant differences were the dose gradient around the PTV, the weight of the PTV objective function, and the bladder mean dose. CONCLUSIONS Our study suggests that for multi-criteria optimisation of prostate treatments using external therapy, dose gradient around the PTV and bladder mean dose are the most influencial parameters.
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Affiliation(s)
- Diana Wüthrich
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Rue du Grand-Pré 1, CH-1007 Lausanne, Switzerland.
| | - Michele Zeverino
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Rue du Grand-Pré 1, CH-1007 Lausanne, Switzerland.
| | - Jean Bourhis
- Department of Radiation Oncology, Lausanne University Hospital and Lausanne University, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland.
| | - François Bochud
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Rue du Grand-Pré 1, CH-1007 Lausanne, Switzerland.
| | - Raphaël Moeckli
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Rue du Grand-Pré 1, CH-1007 Lausanne, Switzerland.
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Kopčalić K, Matić IZ, Besu I, Stanković V, Bukumirić Z, Stanojković TP, Stepanović A, Nikitović M. Circulating levels of IL-6 and TGF-β1 in patients with prostate cancer undergoing radiotherapy: associations with acute radiotoxicity and fatigue symptoms. BMC Cancer 2022; 22:1167. [DOI: 10.1186/s12885-022-10255-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 10/31/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The goal of research was to investigate the possible relations between serum concentrations of IL-6 and TGF-β1, individual and clinical characteristics, and adverse effects of radiotherapy in patients with prostate cancer: acute and late genitourinary and gastrointestinal toxicity, and fatigue.
Methods
Thirty-nine patients with localized or locally advanced prostate cancer who were treated with radiotherapy were enrolled in this study. The acute radiotoxicity grades and fatigue levels were assessed during the radiotherapy and 1 month after the radiotherapy. Estimation of the late radiotoxicity was performed every three months in the first year, every four months in the second year, and then every six months. Serum levels of IL-6 and TGF-β1 were determined before radiotherapy and after the 25th radiotherapy fraction by ELISA.
Results
The significant positive association between diabetes mellitus and changes in acute genitourinary toxicity grades during the radiotherapy was observed in prostate cancer patients. In addition, patients who were smokers had significantly higher maximum fatigue levels in comparison with patients who were non-smokers. The circulating IL-6 levels were significantly higher after the 25th radiotherapy fraction in comparison with levels determined before radiotherapy. The significant positive correlations between pretreatment TGF-β1 levels and maximum genitourinary toxicity grades and between TGF-β1 levels after the 25th fraction and genitourinary toxicity grades after the 25th fraction, were found. The pretreatment IL-6 concentrations and TGF-β1 concentrations after the 25th fraction were positively correlated with maximum genitourinary toxicity grades. The IL-6 levels after the 25th fraction were positively associated with genitourinary toxicity grades after this fraction. The pretreatment IL-6 concentrations were significantly positively correlated with maximum fatigue scores. The significant positive correlation between IL-6 concentrations and fatigue scores after the 25th fraction was determined. The positive correlations between IL-6 and TGF-β1 concentrations measured after the 25th fraction and maximum fatigue scores were observed.
Conclusions
Our results suggest that serum levels of IL-6 and TGF-β1 might influence the severity of acute genitourinary radiotoxicity and fatigue in patients with prostate cancer. Combining clinical parameters and circulating cytokine levels might be useful for the prediction of adverse reactions to radiotherapy.
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Sargos P, Faye MD, Bacci M, Supiot S, Latorzeff I, Azria D, Niazi TM, Vuong T, Vendrely V, de Crevoisier R. Late Gastrointestinal Tolerance After Prostate Radiotherapy: Is the Anal Canal the Culprit? A Narrative Critical Review. Front Oncol 2021; 11:666962. [PMID: 34221983 PMCID: PMC8242201 DOI: 10.3389/fonc.2021.666962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/13/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Late gastro-intestinal toxicities (LGIT) secondary to pelvic radiotherapy (RT) are well described in the literature. LGIT are mainly related to rectal or ano-rectal irradiation; however, involvement of the anal canal (AC) in the occurrence of LGIT remains poorly described and understood. MATERIALS AND METHODS The aim of this work was to explore the potential role of the AC in the development of LGIT after prostate irradiation and identify predictive factors that could be optimized in order to limit these toxicities. This narrative literature review was realized using the Pubmed database. We identified original articles published between June 1997 and July 2019, relating to LGIT after RT for localized prostate cancer and for which AC was identified independently. Articles defining the AC as part of an anorectal or rectal volume only were excluded. RESULTS A history of abdominal surgery or cardio-vascular risk, anticoagulant or tobacco use, and the occurrence of acute GIT during RT increases the risk of LGIT. A dose-effect relationship was identified between dose to the AC and development of LGIT. Identification and contouring of the AC and adjacent anatomical structures (muscles or nerves) are justified to apply specific dose constraints. As a limitation, our review mainly considered on 3DCRT which is no longer the standard of care nowadays; we did not identify any reports in the literature using moderately hypofractionated RT for the prostate and AC specific dosimetry. CONCLUSION These results suggest that the AC may have an important role in the development of LGIT after pelvic RT for prostate cancer. The individualization of the AC during planning should be recommended in prospective studies.
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Affiliation(s)
- Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux Cedex, France
| | - Mame Daro Faye
- Department of Radiation Oncology, Jewish General Hospital, Montreal, QC, Canada
| | - Manon Bacci
- Department of Radiation Oncology, Institut Bergonié, Bordeaux Cedex, France
| | - Stéphane Supiot
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | - Igor Latorzeff
- Department of Radiation Oncology, Clinique Pasteur, Toulouse, France
| | - David Azria
- Department of Radiation Oncology, Institut de Cancérologie de Montpellier, Montpellier, France
| | - Tamim M Niazi
- Department of Radiation Oncology, Jewish General Hospital, Montreal, QC, Canada
| | - Te Vuong
- Department of Radiation Oncology, Jewish General Hospital, Montreal, QC, Canada
| | - Véronique Vendrely
- Department of Radiation Oncology, Bordeaux University Hospital, Bordeaux, France
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Bijman R, Rossi L, Sharfo AW, Heemsbergen W, Incrocci L, Breedveld S, Heijmen B. Automated Radiotherapy Planning for Patient-Specific Exploration of the Trade-Off Between Tumor Dose Coverage and Predicted Radiation-Induced Toxicity-A Proof of Principle Study for Prostate Cancer. Front Oncol 2020; 10:943. [PMID: 32695670 PMCID: PMC7339044 DOI: 10.3389/fonc.2020.00943] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/13/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Currently, radiation-oncologists generally evaluate a single treatment plan for each patient that is possibly adapted by the planner prior to final approval. There is no systematic exploration of patient-specific trade-offs between planning aims, using a set of treatment plans with a-priori defined (slightly) different balances. To this purpose, we developed an automated workflow and explored its use for prostate cancer. Materials and Methods: For each of the 50 study patients, seven plans were generated, including the so-called clinical plan, with currently clinically desired ≥99% dose coverage for the low-dose planning target volume (PTVLow). The six other plans were generated with different, reduced levels of PTVLow coverage, aiming at reductions in rectum dose and consequently in predicted grade≥2 late gastro-intestinal (GI) normal tissue complication probabilities (NTCPs), while keeping other dosimetric differences small. The applied NTCP model included diabetes as a non-dosimetric predictor. All plans were generated with a clinically applied, in-house developed algorithm for automated multi-criterial plan generation. Results: With diabetes, the average NTCP reduced from 24.9 ± 4.5% for ≥99% PTVLow coverage to 17.3 ± 2.6% for 90%, approaching the NTCP (15.4 ± 3.0%) without diabetes and full PTVLow coverage. Apart from intended differences in PTVLow coverage and rectum dose, other differences between the clinical plan and the six alternatives were indeed minor. Obtained NTCP reductions were highly patient-specific (ranging from 14.4 to 0.1%), depending on patient anatomy. Even for patients with equal NTCPs in the clinical plan, large differences were found in NTCP reductions. Conclusions: A clinically feasible workflow has been proposed for systematic exploration of patient-specific trade-offs between various treatment aims. For each patient, automated planning is used to generate a limited set of treatment plans with well-defined variations in the balances between the aims. For prostate cancer, trade-offs between PTVLow coverage and predicted GI NTCP were explored. With relatively small coverage reductions, significant NTCP reductions could be obtained, strongly depending on patient anatomy. Coverage reductions could also make up for enhanced NTCPs related to diabetes as co-morbidity, again dependent on the patient. The proposed system can play an important role in further personalization of patient care.
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Affiliation(s)
- Rik Bijman
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
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Onjukka E, Fiorino C, Cicchetti A, Palorini F, Improta I, Gagliardi G, Cozzarini C, Degli Esposti C, Gabriele P, Valdagni R, Rancati T. Patterns in ano-rectal dose maps and the risk of late toxicity after prostate IMRT. Acta Oncol 2019; 58:1757-1764. [PMID: 31298076 DOI: 10.1080/0284186x.2019.1635267] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Purpose: The aim of this work was to determine how the spatial pattern of dose in the ano-rectal wall is related to late gastro-intestinal toxicity for prostate cancer patients treated with mainly IMRT.Patients and methods: Patients from the DUE-01 multicentre study with patient-reported (prospective) follow-up and available dosimetric data were included. Conventionally fractionated patients received 74-80 Gy and hypofractionated patients received 65-75.2 Gy. A large majority of the patients were treated with intensity-modulated radiotherapy (IMRT). Dose-surface maps (DSMs) for the anal canal and rectum as a single structure, and for the anal canal and the rectum separately, were co-registered rigidly in two dimensions and, for the patients with and without toxicity, respectively, the mean value of the dose in each pixel was calculated. A pixel-wise t-test was used to highlight the anatomical areas where there was a significant difference between the 'mean dose maps' of each group. Univariate models were also fitted to a range of spatial parameters. The endpoints considered were a mean grade ≥1 late fecal incontinence and a maximum grade ≥2 late rectal bleeding.Results: Twenty-six out of 213 patients had fecal incontinence, while 21/225 patients had rectal bleeding. Incontinence was associated with a higher dose in the caudal region of the anal canal; the most relevant spatial parameter was the lateral extent of the low and medium isodoses (5-49 Gy in EQD2). Bleeding was associated with high isodoses reaching the posterior rectal wall. The spatial dose parameters with the highest AUC value (.69) were the lateral extent of the 60-70 Gy isodoses.Conclusions: To avoid fecal incontinence it is important to limit the portion of the anal canal irradiated. Our analysis confirms that rectal bleeding is a function of similar spatial dose parameters for patients treated with IMRT, compared to previous studies on patients treated with three-dimensional conformal radiotherapy.
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Affiliation(s)
- Eva Onjukka
- Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | | | | | | | | | - Pietro Gabriele
- Istituto di Candiolo - Fondazione del Piemonte per l'Oncologia IRCCS, Candiolo, Italy
| | | | - Tiziana Rancati
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
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In Reply to Loganadane et al. Int J Radiat Oncol Biol Phys 2019; 103:777-778. [DOI: 10.1016/j.ijrobp.2018.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 11/01/2018] [Accepted: 11/02/2018] [Indexed: 11/21/2022]
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Multivariable model for predicting acute oral mucositis during combined IMRT and chemotherapy for locally advanced nasopharyngeal cancer patients. Oral Oncol 2018; 86:266-272. [PMID: 30409311 DOI: 10.1016/j.oraloncology.2018.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/25/2018] [Accepted: 10/05/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION/OBJECTIVE Oral and oropharyngeal mucositis (OM) represents amultifactorialand complexinterplayof patient-, tumor-, and treatment-related factors. We aimed to build a predictive model for acute OM for locally advanced nasopharyngeal carcinoma (NPC) patients by combining clinical and dosimetric factors. MATERIALS/METHODS A series of consecutive NPC patients treated curatively with IMRT/VMAT + chemotherapy at 70 Gy (2-2.12 Gy/fr) was considered. For each patient, clinical- tumor- and treatment-related data were retrospectively collected. oral cavity (OC) and parotid glands (PG, considered as a single organ) were selected as organs-at-risk (OARs). Acute OM was assessed according to CTCAE v4.0 at baseline and weekly during RT. Two endpoints were considered: grade ≥3 and mean grade ≥1.5. DVHs were reduced to Equivalent Uniform Dose (EUD). Dosimetric and clinical/treatment features selected via LASSO were inserted into a multivariable logistic model. Goodness of fit was evaluated through Hosmer-Lemeshow test and calibration plot. RESULTS Data were collected for 132 patients. G ≥ 3 and mean G ≥ 1.5 OM were reported in 40 patients (30%). Analyses resulted in a 3-variables model for G ≥ 3 OM, including OC EUD with n = 0.05 (OR = 1.02), PG EUD with n = 1 (OR = 1.06), BMI ≥ 30 (OR = 3.8, for obese patients), and a single variable model for mean G ≥ 1.5 OM, i.e. OC EUD with n = 1 (mean dose) (OR = 1.07). Calibration was good in both cases. CONCLUSION OC mean dose was found to impact most on OM duration (mean G ≥ 1.5), while G ≥ 3 OM was associated to a synergic effect between PG mean dose and high dose received by small OC volumes, with BMI acting as a dose-modifying factor.
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Cicchetti A, Avuzzi B, Palorini F, Ballarini F, Stucchi C, Fellin G, Gabriele P, Vavassori V, Esposti CD, Cozzarini C, Fiorino C, Rancati T, Valdagni R. Predicting Late Fecal Incontinence Risk After Radiation Therapy for Prostate Cancer: New Insights From External Independent Validation. Int J Radiat Oncol Biol Phys 2018; 102:127-136. [PMID: 29970313 DOI: 10.1016/j.ijrobp.2018.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 03/30/2018] [Accepted: 05/02/2018] [Indexed: 12/24/2022]
Abstract
PURPOSE This study aimed to validate a previously published predictive model for late fecal incontinence (FI) in a contemporary population of prostate cancer patients treated with radical radiation therapy. METHODS AND MATERIALS The validation included patients treated with intensity-modulated radiation therapy (IMRT) (2010-2014). Prescribed dose range was 65-80 Gy, including conventional and moderate hypo-fractionated treatments. Rectal toxicity was scored using LENT/SOMA, a minimum 2-year follow up was considered. We chose to validate the model published by Rancati et al for predicting chronic FI, developed on a 3-dimensional conformal radiation therapy (3DCRT) population. It considered a longitudinal endpoint defined as the average toxicity grade during the follow up. This continuous endpoint was dichotomized using a cut-off value of mean FI grade >1. The model included mean rectal dose (Dmean), previous diseases of the colon (COLO) and previous abdominal surgery (SURG). Doses were corrected to 2 Gy/fraction using the linear-quadratic model and applying alpha/beta ratio = 4.8 Gy. RESULTS 228 patients constituted the validation population. A mean FI grade >1 was scored in 25 patients (11%). Logistic regression confirmed risk factors reported in the literature, with similar odds ratios (ORs) for Dmean (1.04 ± 0.03 vs 1.06 ± 0.04) and SURG (1.9 ± 1.7 vs 1.6 ± 1.45); COLO was not confirmed. Consequently, the predictive models including Dmean/Dmean + SURG were evaluated using calibration plots. Both showed a clear discriminative trend, but the absolute observed toxicity rates were underestimated (ie, absolute predicted rates were always lower than corresponding absolute observed rates). This result was consistent with an unexpected effect of hypofractionation (OR = 2.20, conventional = 8.1% vs hypofractionated = 17.4%) beyond the standard correction using linear-quadratic model. Nevertheless, the FI rate in the conventionally treated group was almost double the rate observed in the previously studied cohort (4.3% vs 8.1%). CONCLUSIONS The study confirms previously published results indicating that abdominal surgery and rectal mean dose are risk factors for late FI. Calibration plots highlight a possible role of hypofractionation beyond linear-quadratic correction.
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Affiliation(s)
- Alessandro Cicchetti
- Fondazione IRCCS Istituto Nazionale dei Tumori, Prostate Cancer Program, Milan, Italy; Università degli Studi di Pavia, Physics Department, Pavia, Italy
| | - Barbara Avuzzi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Radiation Oncology 1, Milan, Italy
| | - Federica Palorini
- Fondazione IRCCS Istituto Nazionale dei Tumori, Prostate Cancer Program, Milan, Italy
| | - Francesca Ballarini
- Università degli Studi di Pavia, Physics Department, Pavia, Italy; INFN-Section of Pavia, Pavia, Italy
| | - Claudio Stucchi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Medical Physics, Milan, Italy
| | | | - Pietro Gabriele
- Istituto di Candiolo- Fondazione del Piemonte per l'Oncologia IRCCS, Radiotherapy, Torino, Italy
| | | | | | - Cesare Cozzarini
- San Raffaele Scientific Institute, Radiation Oncology, Milan, Italy
| | - Claudio Fiorino
- San Raffaele Scientific Institute, Medical Physics, Milan, Italy
| | - Tiziana Rancati
- Fondazione IRCCS Istituto Nazionale dei Tumori, Prostate Cancer Program, Milan, Italy.
| | - Riccardo Valdagni
- Fondazione IRCCS Istituto Nazionale dei Tumori, Prostate Cancer Program, Milan, Italy; Fondazione IRCCS Istituto Nazionale dei Tumori, Radiation Oncology 1, Milan, Italy; Università degli Studi di Milano, Department of Oncology and Hemato-oncology, Milan, Italy
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12
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Carrara M, Massari E, Cicchetti A, Giandini T, Avuzzi B, Palorini F, Stucchi C, Fellin G, Gabriele P, Vavassori V, Degli Esposti C, Cozzarini C, Pignoli E, Fiorino C, Rancati T, Valdagni R. Development of a Ready-to-Use Graphical Tool Based on Artificial Neural Network Classification: Application for the Prediction of Late Fecal Incontinence After Prostate Cancer Radiation Therapy. Int J Radiat Oncol Biol Phys 2018; 102:1533-1542. [PMID: 30092335 DOI: 10.1016/j.ijrobp.2018.07.2014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 06/19/2018] [Accepted: 07/26/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE This study was designed to apply artificial neural network (ANN) classification methods for the prediction of late fecal incontinence (LFI) after high-dose prostate cancer radiation therapy and to develop a ready-to-use graphical tool. MATERIALS AND METHODS In this study, 598 men recruited in 2 national multicenter trials were analyzed. Information was recorded on comorbidity, previous abdominal surgery, use of drugs, and dose distribution. Fecal incontinence was prospectively evaluated through self-reported questionnaires. To develop the ANN, the study population was randomly split into training (n = 300), validation (n = 149), and test (n = 149) sets. Mean grade of longitudinal LFI (ie, expressed as the average incontinence grade over the first 3 years after radiation therapy) ≥1 was considered the endpoint. A suitable subset of variables able to better predict LFI was selected by simulating 100,000 ANN configurations. The search for the definitive ANN was then performed by varying the number of inputs and hidden neurons from 4 to 5 and from 1 to 9, respectively. A final classification model was established as the average of the best 5 among 500 ANNs with the same architecture. An ANN-based graphical method to compute LFI prediction was developed to include one continuous and n dichotomous variables. RESULTS An ANN architecture was selected, with 5 input variables (mean dose, previous abdominal surgery, use of anticoagulants, use of antihypertensive drugs, and use of neoadjuvant and adjuvant hormone therapy) and 4 hidden neurons. The developed classification model correctly identified patients with LFI with 80.8% sensitivity and 63.7% ± 1.0% specificity and an area under the curve of 0.78. The developed graphical tool may efficiently classify patients in low, intermediate, and high LFI risk classes. CONCLUSIONS An ANN-based model was developed to predict LFI. The model was translated in a ready-to-use graphical tool for LFI risk classification, with direct interpretation of the role of the predictors.
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Affiliation(s)
- Mauro Carrara
- Department of Medical Physics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Eleonora Massari
- Department of Medical Physics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alessandro Cicchetti
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Tommaso Giandini
- Department of Medical Physics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Barbara Avuzzi
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Federica Palorini
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Claudio Stucchi
- Department of Medical Physics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giovanni Fellin
- Department of Radiation Oncology, Ospedale Santa Chiara, Trento, Italy
| | - Pietro Gabriele
- Department of Radiation Oncology, Istituto di Candiolo-Fondazione del Piemonte per l'Oncologia IRCCS, Candiolo, Italy
| | - Vittorio Vavassori
- Department of Radiation Oncology, Cliniche Gavazzeni-Humanitas, Bergamo, Italy
| | | | - Cesare Cozzarini
- Department of Radiation Oncology, San Raffaele Scientific Institute, Milano, Italy
| | - Emanuele Pignoli
- Department of Medical Physics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Claudio Fiorino
- Department of Medical Physics, San Raffaele Scientific Institute, Milano, Italy
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Riccardo Valdagni
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Department of Oncology and Hemato-oncology, Università degli Studi di Milano, Milan, Italy
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13
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Gulliford S, Ghose S, Ebert M, Kennedy A, Dowling J, Mitra J, Joseph D, Denham J. Radiotherapy dose-distribution to the perirectal fat space (PRS) is related to gastrointestinal control-related complications. Clin Transl Radiat Oncol 2017; 7:62-70. [PMID: 29594231 PMCID: PMC5862665 DOI: 10.1016/j.ctro.2017.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 10/02/2017] [Accepted: 10/03/2017] [Indexed: 11/25/2022] Open
Abstract
Traditionally rectal symptoms following pelvic/prostate radiotherapy are correlated to the dosimetry of the anorectum or a substructure of this. It has been suggested that the perirectal fat space (PRS) surrounding the rectum may also be relevant. This study considers the delineation and dosimetry of the PRS related to both rectal bleeding and control-related toxicity. Initially, a case-control cohort of 100 patients from the RADAR study were chosen based on presence/absence of rectal control-related toxicity. Automated contouring was developed to delineate the PRS. 79 of the 100 auto-segmentations were considered successful. Balanced case-control cohorts were defined from these cases. Atlas of Complication Incidence (ACI) were generated to relate the DVH of the PRS with specific rectal symptoms; rectal bleeding and control-related symptoms (LENT/SOM). ACI demonstrated that control-related symptoms were related to the dose distribution to the PRS which was confirmed with Wilcoxon rank sum test (p < 0.05). To the authors knowledge this is the first study implicating the dose distribution to the PRS to the incidence of control-related symptoms of rectal toxicity.
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Affiliation(s)
- S.L. Gulliford
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, United Kingdom
| | - S. Ghose
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA
| | - M.A. Ebert
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Western Australia, Australia
- School of Physics, University of Western Australia, Western Australia, Australia
| | - A. Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Western Australia, Australia
| | - J. Dowling
- Australian e-Health Research Centre, CSIRO, Brisbane, Queensland, Australia
| | - J. Mitra
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA
| | - D.J. Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Western Australia, Australia
- School of Surgery, University of Western Australia, Western Australia, Australia
| | - J.W. Denham
- School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
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14
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Delobel JB, Gnep K, Ospina JD, Beckendorf V, Chira C, Zhu J, Bossi A, Messai T, Acosta O, Castelli J, de Crevoisier R. Nomogram to predict rectal toxicity following prostate cancer radiotherapy. PLoS One 2017. [PMID: 28640871 PMCID: PMC5480987 DOI: 10.1371/journal.pone.0179845] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To identify predictors of acute and late rectal toxicity following prostate cancer radiotherapy (RT), while integrating the potential impact of RT technique, dose escalation, and moderate hypofractionation, thus enabling us to generate a nomogram for individual prediction. METHODS In total, 972 patients underwent RT for localized prostate cancer, to a total dose of 70 Gy or 80 Gy, using two different fractionations (2 Gy or 2.5 Gy/day), by means of several RT techniques (3D conformal RT [3DCRT], intensity-modulated RT [IMRT], or image-guided RT [IGRT]). Multivariate analyses were performed to identify predictors of acute and late rectal toxicity. A nomogram was generated based on the logistic regression model used to predict the 3-year rectal toxicity risk, with its accuracy assessed by dividing the cohort into training and validation subgroups. RESULTS Mean follow-up for the entire cohort was 62 months, ranging from 6 to 235. The rate of acute Grade ≥2 rectal toxicity was 22.2%, decreasing when combining IMRT and IGRT, compared to 3DCRT (RR = 0.4, 95%CI: 0.3-0.6, p<0.01). The 5-year Grade ≥2 risks for rectal bleeding, urgency/tenesmus, diarrhea, and fecal incontinence were 9.9%, 4.5%, 2.8%, and 0.4%, respectively. The 3-year Grade ≥2 risk for overall rectal toxicity increased with total dose (p<0.01, RR = 1.1, 95%CI: 1.0-1.1) and dose per fraction (2Gy vs. 2.5Gy) (p = 0.03, RR = 3.3, 95%CI: 1.1-10.0), and decreased when combining IMRT and IGRT (RR = 0.50, 95% CI: 0.3-0.8, p<0.01). Based on these three parameters, a nomogram was generated. CONCLUSIONS Dose escalation and moderate hypofractionation increase late rectal toxicity. IMRT combined with IGRT markedly decreases acute and late rectal toxicity. Performing combined IMRT and IGRT can thus be envisaged for dose escalation and moderate hypofractionation. Our nomogram predicts the 3-year rectal toxicity risk by integrating total dose, fraction dose, and RT technique.
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Affiliation(s)
- Jean-Bernard Delobel
- Dept. of Gastroenterology, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - Khemara Gnep
- LTSI, Inserm U1099, Université de Rennes 1, Rennes, France
- Centre Eugene Marquis, Rennes, France
- * E-mail:
| | - Juan David Ospina
- LTSI, Inserm U1099, Université de Rennes 1, Rennes, France
- Escuela de Estadística, Universidad Nacional de Colombia, Medellin, Colombia
| | | | | | - Jian Zhu
- LTSI, Inserm U1099, Université de Rennes 1, Rennes, France
- Laboratory of Image Science and Technology, Southeast University, Nanjing, PR China
- Centre de Recherche en Information Biomédicale Sino-Français (CRIBs), Rennes, France
| | | | | | - Oscar Acosta
- LTSI, Inserm U1099, Université de Rennes 1, Rennes, France
| | - Joël Castelli
- LTSI, Inserm U1099, Université de Rennes 1, Rennes, France
- Centre Eugene Marquis, Rennes, France
| | - Renaud de Crevoisier
- LTSI, Inserm U1099, Université de Rennes 1, Rennes, France
- Centre Eugene Marquis, Rennes, France
- Centre de Recherche en Information Biomédicale Sino-Français (CRIBs), Rennes, France
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15
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Nightingale H, Conroy R, Elliott T, Coyle C, Wylie J, Choudhury A. A national survey of current practices of preparation and management of radical prostate radiotherapy patients during treatment. Radiography (Lond) 2017; 23:87-93. [DOI: 10.1016/j.radi.2017.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/18/2016] [Accepted: 01/03/2017] [Indexed: 11/26/2022]
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16
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Expert system classifier for adaptive radiation therapy in prostate cancer. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2017; 40:337-348. [PMID: 28290067 DOI: 10.1007/s13246-017-0535-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 02/09/2017] [Indexed: 10/20/2022]
Abstract
A classifier-based expert system was developed to compare delivered and planned radiation therapy in prostate cancer patients. Its aim is to automatically identify patients that can benefit from an adaptive treatment strategy. The study predominantly addresses dosimetric uncertainties and critical issues caused by motion of hollow organs. 1200 MVCT images of 38 prostate adenocarcinoma cases were analyzed. An automatic daily re-contouring of structures (i.e. rectum, bladder and femoral heads), rigid/deformable registration and dose warping was carried out to simulate dose and volume variations during therapy. Support vector machine, K-means clustering algorithms and similarity index analysis were used to create an unsupervised predictive tool to detect incorrect setup and/or morphological changes as a consequence of inadequate patient preparation due to stochastic physiological changes, supporting clinical decision-making. After training on a dataset that was considered sufficiently dosimetrically stable, the system identified two equally sized macro clusters with distinctly different volumetric and dosimetric baseline properties and defined thresholds for these two clusters. Application to the test cohort resulted in 25% of the patients located outside the two macro clusters thresholds and which were therefore suspected to be dosimetrically unstable. In these patients, over the treatment course, mean volumetric changes of 30 and 40% for rectum and bladder were detected which possibly represents values justifying adjustment of patient preparation, frequent re-planning or a plan-of-the-day strategy. Based on our research, by combining daily IGRT images with rigid/deformable registration and dose warping, it is possible to apply a machine learning approach to the clinical setting obtaining useful information for a decision regarding an individualized adaptive strategy. Especially for treatments influenced by the movement of hollow organs, this could reduce inadequate treatments and possibly reduce toxicity, thereby increasing overall RT efficacy.
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17
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van Oorschot B, Uitterhoeve L, Oomen I, Ten Cate R, Medema JP, Vrieling H, Stalpers LJA, Moerland PD, Franken NAP. Prostate Cancer Patients with Late Radiation Toxicity Exhibit Reduced Expression of Genes Involved in DNA Double-Strand Break Repair and Homologous Recombination. Cancer Res 2017; 77:1485-1491. [PMID: 28108515 DOI: 10.1158/0008-5472.can-16-1966] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/17/2016] [Accepted: 11/18/2016] [Indexed: 11/16/2022]
Abstract
Severe late damage to normal tissue is a major limitation of cancer radiotherapy in prostate cancer patients. In a recent retrospective study, late radiation toxicity was found to relate to a decreased decay of γ-H2AX foci and reduced induction of DNA double-strand break repair genes. Here, we report evidence of prognostic utility in prostate cancer for γ-H2AX foci decay ratios and gene expression profiles derived from ex vivo-irradiated patient lymphocytes. Patients were followed ≥2 years after radiotherapy. Clinical characteristics were assembled, and toxicity was recorded using the Common Terminology Criteria (CTCAE) v4.0. No clinical factor was correlated with late radiation toxicity. The γ-H2AX foci decay ratio correlated negatively with toxicity grade, with a significant difference between grade ≥3 and grade 0 patients (P = 0.02). A threshold foci decay ratio, determined in our retrospective study, correctly classified 23 of 28 patients with grade ≥3 toxicity (sensitivity 82%) and 9 of 14 patients with grade 0 toxicity (specificity 64%). Induction of homologous recombination (HR) repair genes was reduced with increasing toxicity grade. The difference in fold induction of the HR gene set was most pronounced between grade 0 and grade ≥3 toxicity (P = 0.008). Notably, reduced responsiveness of HR repair genes to irradiation and inefficient double-strand break repair correlated with severe late radiation toxicity. Using a decay ratio classifier, we correctly classified 82% of patients with grade ≥3 toxicity, suggesting a prognostic biomarker for cancer patients with a genetically enhanced risk for late radiation toxicity to normal tissues after radiotherapy. Cancer Res; 77(6); 1485-91. ©2017 AACR.
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Affiliation(s)
- Bregje van Oorschot
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Molecular Medicine (CEMM), Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
| | - Lon Uitterhoeve
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Molecular Medicine (CEMM), Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Ilja Oomen
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Molecular Medicine (CEMM), Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Rosemarie Ten Cate
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Molecular Medicine (CEMM), Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan Paul Medema
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Molecular Medicine (CEMM), Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Harry Vrieling
- Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands
| | - Lukas J A Stalpers
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Molecular Medicine (CEMM), Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Perry D Moerland
- Bioinformatics Laboratory, Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Nicolaas A P Franken
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Molecular Medicine (CEMM), Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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18
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Cicchetti A, Rancati T, Ebert M, Fiorino C, Palorini F, Kennedy A, Joseph DJ, Denham JW, Vavassori V, Fellin G, Avuzzi B, Stucchi C, Valdagni R. Modelling late stool frequency and rectal pain after radical radiotherapy in prostate cancer patients: Results from a large pooled population. Phys Med 2016; 32:1690-1697. [PMID: 27720692 DOI: 10.1016/j.ejmp.2016.09.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/30/2016] [Accepted: 09/22/2016] [Indexed: 11/27/2022] Open
Abstract
AIM To investigate late gastrointestinal toxicity in a large pooled population of prostate cancer patients treated with radical radiotherapy. Normal tissue complication probability models were developed for late stool frequency and late rectal pain. METHODS AND MATERIALS Population included 1336 patients, 3-year minimum follow-up, treated with 66-80Gy. Toxicity was scored with LENT-SOMA-scale. Two toxicity endpoints were considered: grade ⩾2 rectal pain and mean grade (average score during follow-up) in stool frequency >1. DVHs of anorectum were reduced to equivalent uniform dose (EUD). The best-value of the volume parameter n was determined through numerical optimization. Association between EUD/clinical factors and the endpoints was investigated by logistic analyses. Likelihood, Brier-score and calibration were used to evaluate models. External calibration was also carried out. RESULTS 4% of patients (45/1122) reported mean stool frequency grade >1; grade ⩾2 rectal pain was present in the TROG 03.04 RADAR population only (21/677, 3.1%): for this endpoint, the analysis was limited to this population. Analysis of DVHs highlighted the importance of mid-range doses (30-50Gy) for both endpoints. EUDs calculated with n=1 (OR=1.04) and n=0.35 (OR=1.06) were the most suitable dosimetric descriptors for stool frequency and rectal pain respectively. The final models included EUD and cardiovascular diseases (OR=1.78) for stool frequency and EUD and presence of acute gastrointestinal toxicity (OR=4.2) for rectal pain. CONCLUSION Best predictors of stool frequency and rectal pain are consistent with findings previously reported for late faecal incontinence, indicating an important role in optimization of mid-range dose region to minimize these symptoms highly impacting the quality-of-life of long surviving patients.
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Affiliation(s)
- A Cicchetti
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - T Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - M Ebert
- Medical Physics, University of Western Australia, Perth, Western Australia, Australia; Physics Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - C Fiorino
- Medical Physics, San Raffaele Scientific Institute, Milan, Italy
| | - F Palorini
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - A Kennedy
- Physics Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - D J Joseph
- Physics Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - J W Denham
- School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
| | - V Vavassori
- Radiotherapy, Cliniche Humanitas-Gavazzeni, Bergamo, Italy
| | - G Fellin
- Radiotherapy, Ospedale Santa Chiara, Trento, Italy
| | - B Avuzzi
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - C Stucchi
- Medical Physics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - R Valdagni
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Oncology and Hemato-oncology, Università degli Studi di Milano, Milan, Italy
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19
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Landoni V, Fiorino C, Cozzarini C, Sanguineti G, Valdagni R, Rancati T. Predicting toxicity in radiotherapy for prostate cancer. Phys Med 2016; 32:521-32. [PMID: 27068274 DOI: 10.1016/j.ejmp.2016.03.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/15/2016] [Accepted: 03/02/2016] [Indexed: 02/08/2023] Open
Abstract
This comprehensive review addresses most organs at risk involved in planning optimization for prostate cancer. It can be considered an update of a previous educational review that was published in 2009 (Fiorino et al., 2009). The literature was reviewed based on PubMed and MEDLINE database searches (from January 2009 up to September 2015), including papers in press; for each section/subsection, key title words were used and possibly combined with other more general key-words (such as radiotherapy, dose-volume effects, NTCP, DVH, and predictive model). Publications generally dealing with toxicity without any association with dose-volume effects or correlations with clinical risk factors were disregarded, being outside the aim of the review. A focus was on external beam radiotherapy, including post-prostatectomy, with conventional fractionation or moderate hypofractionation (<4Gy/fraction); extreme hypofractionation is the topic of another paper in this special issue. Gastrointestinal and urinary toxicity are the most investigated endpoints, with quantitative data published in the last 5years suggesting both a dose-response relationship and the existence of a number of clinical/patient related risk factors acting as dose-response modifiers. Some results on erectile dysfunction, bowel toxicity and hematological toxicity are also presented.
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Affiliation(s)
- Valeria Landoni
- Medical Physics, Istituto Nazionale Tumori Regina Elena, Rome, Italy
| | - Claudio Fiorino
- Medical Physics, Raffaele Scientific Institute IRCCS, Milan, Italy
| | | | | | - Riccardo Valdagni
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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20
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Muren LP, Jornet N, Georg D, Garcia R, Thwaites DI. Improving radiotherapy through medical physics developments. Radiother Oncol 2015; 117:403-6. [DOI: 10.1016/j.radonc.2015.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 11/19/2015] [Indexed: 01/21/2023]
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21
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Yahya N, Ebert MA, Bulsara M, House MJ, Kennedy A, Joseph DJ, Denham JW. Urinary symptoms following external beam radiotherapy of the prostate: Dose-symptom correlates with multiple-event and event-count models. Radiother Oncol 2015; 117:277-82. [PMID: 26476560 DOI: 10.1016/j.radonc.2015.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 09/30/2015] [Accepted: 10/03/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE This study aimed to compare urinary dose-symptom correlates after external beam radiotherapy of the prostate using commonly utilised peak-symptom models to multiple-event and event-count models which account for repeated events. MATERIALS AND METHODS Urinary symptoms (dysuria, haematuria, incontinence and frequency) from 754 participants from TROG 03.04-RADAR trial were analysed. Relative (R1-R75 Gy) and absolute (A60-A75Gy) bladder dose-surface area receiving more than a threshold dose and equivalent uniform dose using exponent a (range: a ∈[1 … 100]) were derived. The dose-symptom correlates were analysed using; peak-symptom (logistic), multiple-event (generalised estimating equation) and event-count (negative binomial regression) models. RESULTS Stronger dose-symptom correlates were found for incontinence and frequency using multiple-event and/or event-count models. For dysuria and haematuria, similar or better relationships were found using peak-symptom models. Dysuria, haematuria and high grade (⩾ 2) incontinence were associated to high dose (R61-R71 Gy). Frequency and low grade (⩾ 1) incontinence were associated to low and intermediate dose-surface parameters (R13-R41Gy). Frequency showed a parallel behaviour (a=1) while dysuria, haematuria and incontinence showed a more serial behaviour (a=4 to a ⩾ 100). Relative dose-surface showed stronger dose-symptom associations. CONCLUSIONS For certain endpoints, the multiple-event and event-count models provide stronger correlates over peak-symptom models. Accounting for multiple events may be advantageous for a more complete understanding of urinary dose-symptom relationships.
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Affiliation(s)
- Noorazrul Yahya
- School of Physics, University of Western Australia, Australia; School of Health Sciences, National University of Malaysia, Malaysia.
| | - Martin A Ebert
- School of Physics, University of Western Australia, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Australia
| | - Max Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Australia
| | - Michael J House
- School of Physics, University of Western Australia, Australia
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Australia
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Australia; School of Surgery, University of Western Australia, Australia
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, Australia
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22
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Warner A, Pickles T, Crook J, Martin AG, Souhami L, Catton C, Lukka H, Rodrigues G. Development of ProCaRS Clinical Nomograms for Biochemical Failure-free Survival Following Either Low-Dose Rate Brachytherapy or Conventionally Fractionated External Beam Radiation Therapy for Localized Prostate Cancer. Cureus 2015; 7:e276. [PMID: 26180700 PMCID: PMC4494461 DOI: 10.7759/cureus.276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 06/11/2015] [Indexed: 11/27/2022] Open
Abstract
Purpose: Although several clinical nomograms predictive of biochemical failure-free survival (BFFS) for localized prostate cancer exist in the medical literature, making valid comparisons can be challenging due to variable definitions of biochemical failure, the disparate distribution of prognostic factors, and received treatments in patient populations. The aim of this investigation was to develop and validate clinically-based nomograms for 5-year BFFS using the ASTRO II “Phoenix” definition for two patient cohorts receiving low-dose rate (LDR) brachytherapy or conventionally fractionated external beam radiation therapy (EBRT) from a large Canadian multi-institutional database. Methods and Materials: Patients were selected from the GUROC (Genitourinary Radiation Oncologists of Canada) Prostate Cancer Risk Stratification (ProCaRS) database if they received (1) LDR brachytherapy ≥ 144 Gy (n=4208) or (2) EBRT ≥ 70 Gy (n=822). Multivariable Cox regression analysis for BFFS was performed separately for each cohort and used to generate clinical nomograms predictive of 5-year BFFS. Nomograms were validated using calibration plots of nomogram predicted probability versus observed probability via Kaplan-Meier estimates. Results: Patients receiving LDR brachytherapy had a mean age of 64 ± 7 years, a mean baseline PSA of 6.3 ± 3.0 ng/mL, 75% had a Gleason 6, and 15% had a Gleason 7, whereas patients receiving EBRT had a mean age of 70 ± 6 years, a mean baseline PSA of 11.6 ± 10.7 ng/mL, 30% had a Gleason 6, 55% had a Gleason 7, and 14% had a Gleason 8-10. Nomograms for 5-year BFFS included age, use and duration of androgen deprivation therapy (ADT), baseline PSA, T stage, and Gleason score for LDR brachytherapy and an ADT (months), baseline PSA, Gleason score, and biological effective dose (Gy) for EBRT. Conclusions: Clinical nomograms examining 5-year BFFS were developed for patients receiving either LDR brachytherapy or conventionally fractionated EBRT and may assist clinicians in predicting an outcome. Future work should be directed at examining the role of additional prognostic factors, comorbidities, and toxicity in predicting survival outcomes.
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Affiliation(s)
- Andrew Warner
- Radiation Oncology, London Health Sciences Centre, London, Ontario, CA
| | - Tom Pickles
- Radiation Oncology, BC Cancer Agency, Vancouver Centre, University of British Columbia
| | | | - Andre-Guy Martin
- Radiation Oncology, Centre Hospitalier Universitaire de Québec - L'Hôtel-Dieu de Québec, Québec, QC
| | - Luis Souhami
- Department of Oncology, Division of Radiation Oncology, McGill University Health Center
| | - Charles Catton
- Radiation Oncology, University of Toronto and Universitry Health Network
| | - Himu Lukka
- Radiation Oncology, Juravinski Cancer Centre, Hamilton, ON
| | - George Rodrigues
- Department of Oncology, London Health Sciences Centre; Schulich School of Medicine & Dentistry, Western University, London, Ontario, CA
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Ebert MA, Foo K, Haworth A, Gulliford SL, Kennedy A, Joseph DJ, Denham JW. Gastrointestinal dose-histogram effects in the context of dose-volume-constrained prostate radiation therapy: analysis of data from the RADAR prostate radiation therapy trial. Int J Radiat Oncol Biol Phys 2015; 91:595-603. [PMID: 25596108 DOI: 10.1016/j.ijrobp.2014.11.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 11/07/2014] [Accepted: 11/11/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE To use a high-quality multicenter trial dataset to determine dose-volume effects for gastrointestinal (GI) toxicity following radiation therapy for prostate carcinoma. Influential dose-volume histogram regions were to be determined as functions of dose, anatomical location, toxicity, and clinical endpoint. METHODS AND MATERIALS Planning datasets for 754 participants in the TROG 03.04 RADAR trial were available, with Late Effects of Normal Tissues (LENT) Subjective, Objective, Management, and Analytic (SOMA) toxicity assessment to a median of 72 months. A rank sum method was used to define dose-volume cut-points as near-continuous functions of dose to 3 GI anatomical regions, together with a comprehensive assessment of significance. Univariate and multivariate ordinal regression was used to assess the importance of cut-points at each dose. RESULTS Dose ranges providing significant cut-points tended to be consistent with those showing significant univariate regression odds-ratios (representing the probability of a unitary increase in toxicity grade per percent relative volume). Ranges of significant cut-points for rectal bleeding validated previously published results. Separation of the lower GI anatomy into complete anorectum, rectum, and anal canal showed the impact of mid-low doses to the anal canal on urgency and tenesmus, completeness of evacuation and stool frequency, and mid-high doses to the anorectum on bleeding and stool frequency. Derived multivariate models emphasized the importance of the high-dose region of the anorectum and rectum for rectal bleeding and mid- to low-dose regions for diarrhea and urgency and tenesmus, and low-to-mid doses to the anal canal for stool frequency, diarrhea, evacuation, and bleeding. CONCLUSIONS Results confirm anatomical dependence of specific GI toxicities. They provide an atlas summarizing dose-histogram effects and derived constraints as functions of anatomical region, dose, toxicity, and endpoint for informing future radiation therapy planning.
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Affiliation(s)
- Martin A Ebert
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; School of Physics, University of Western Australia, Perth, Western Australia, Australia.
| | - Kerwyn Foo
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Annette Haworth
- Department of Physical Sciences, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Sarah L Gulliford
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, United Kingdom
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; School of Surgery, University of Western Australia, Perth, Western Australia, Australia
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
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Yamazaki H, Nakamura S, Nishimura T, Yoshida K, Yoshioka Y, Koizumi M, Ogawa K. Transitioning from conventional radiotherapy to intensity-modulated radiotherapy for localized prostate cancer: changing focus from rectal bleeding to detailed quality of life analysis. JOURNAL OF RADIATION RESEARCH 2014; 55:1033-1047. [PMID: 25204643 PMCID: PMC4229926 DOI: 10.1093/jrr/rru061] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/27/2014] [Accepted: 06/09/2014] [Indexed: 06/02/2023]
Abstract
With the advent of modern radiation techniques, we have been able to deliver a higher prescribed radiotherapy dose for localized prostate cancer without severe adverse reactions. We reviewed and analyzed the change of toxicity profiles of external beam radiation therapy (EBRT) from the literature. Late rectal bleeding is the main adverse effect, and an incidence of >20% of Grade ≥2 adverse events was reported for 2D conventional radiotherapy of up to 70 Gy. 3D conformal radiation therapy (3D-CRT) was found to reduce the incidence to ∼10%. Furthermore, intensity-modulated radiation therapy (IMRT) reduced it further to a few percentage points. However, simultaneously, urological toxicities were enhanced by dose escalation using highly precise external radiotherapy. We should pay more attention to detailed quality of life (QOL) analysis, not only with respect to rectal bleeding but also other specific symptoms (such as urinary incontinence and impotence), for two reasons: (i) because of the increasing number of patients aged >80 years, and (ii) because of improved survival with elevated doses of radiotherapy and/or hormonal therapy; age is an important prognostic factor not only for prostate-specific antigen (PSA) control but also for adverse reactions. Those factors shift the main focus of treatment purpose from survival and avoidance of PSA failure to maintaining good QOL, particularly in older patients. In conclusion, the focus of toxicity analysis after radiotherapy for prostate cancer patients is changing from rectal bleeding to total elaborate quality of life assessment.
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Affiliation(s)
- Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Satoaki Nakamura
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Takuya Nishimura
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Ken Yoshida
- Department of Radiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki-City, Osaka, 569-8686, Japan
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, 565-0871 Osaka, Japan
| | - Masahiko Koizumi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, 565-0871 Osaka, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, 565-0871 Osaka, Japan
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25
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Ospina JD, Zhu J, Chira C, Bossi A, Delobel JB, Beckendorf V, Dubray B, Lagrange JL, Correa JC, Simon A, Acosta O, de Crevoisier R. Random forests to predict rectal toxicity following prostate cancer radiation therapy. Int J Radiat Oncol Biol Phys 2014; 89:1024-1031. [PMID: 25035205 DOI: 10.1016/j.ijrobp.2014.04.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 04/14/2014] [Accepted: 04/15/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To propose a random forest normal tissue complication probability (RF-NTCP) model to predict late rectal toxicity following prostate cancer radiation therapy, and to compare its performance to that of classic NTCP models. METHODS AND MATERIALS Clinical data and dose-volume histograms (DVH) were collected from 261 patients who received 3-dimensional conformal radiation therapy for prostate cancer with at least 5 years of follow-up. The series was split 1000 times into training and validation cohorts. A RF was trained to predict the risk of 5-year overall rectal toxicity and bleeding. Parameters of the Lyman-Kutcher-Burman (LKB) model were identified and a logistic regression model was fit. The performance of all the models was assessed by computing the area under the receiving operating characteristic curve (AUC). RESULTS The 5-year grade ≥2 overall rectal toxicity and grade ≥1 and grade ≥2 rectal bleeding rates were 16%, 25%, and 10%, respectively. Predictive capabilities were obtained using the RF-NTCP model for all 3 toxicity endpoints, including both the training and validation cohorts. The age and use of anticoagulants were found to be predictors of rectal bleeding. The AUC for RF-NTCP ranged from 0.66 to 0.76, depending on the toxicity endpoint. The AUC values for the LKB-NTCP were statistically significantly inferior, ranging from 0.62 to 0.69. CONCLUSIONS The RF-NTCP model may be a useful new tool in predicting late rectal toxicity, including variables other than DVH, and thus appears as a strong competitor to classic NTCP models.
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Affiliation(s)
- Juan D Ospina
- LTSI, Université de Rennes 1, Rennes, France; INSERM, U1099, Rennes, France; Escuela de Estadística, Universidad Nacional de Colombia Sede Medellín, Medellín, Colombia
| | - Jian Zhu
- LTSI, Université de Rennes 1, Rennes, France; Laboratory of Image Science and Technology, Southeast University, Nanjing, PR China; Department of Radiation Physics, Shandong Cancer Hospital and Institute, Jinan, PR China; Centre de Recherche en Information Biomédical Sino-Français, Rennes, France
| | - Ciprian Chira
- Département de Radiothérapie, Centre Eugène Marquis, Rennes, France
| | - Alberto Bossi
- Département de Radiothérapie, Institut Gustave-Roussy, Villejuif, France
| | - Jean B Delobel
- Département de Radiothérapie, Centre Eugène Marquis, Rennes, France
| | | | - Bernard Dubray
- Département de Radiothérapie, CRLCC Henri Becquerel, Rouen, France
| | | | - Juan C Correa
- Escuela de Estadística, Universidad Nacional de Colombia Sede Medellín, Medellín, Colombia
| | - Antoine Simon
- LTSI, Université de Rennes 1, Rennes, France; INSERM, U1099, Rennes, France; Centre de Recherche en Information Biomédical Sino-Français, Rennes, France
| | - Oscar Acosta
- LTSI, Université de Rennes 1, Rennes, France; INSERM, U1099, Rennes, France
| | - Renaud de Crevoisier
- LTSI, Université de Rennes 1, Rennes, France; INSERM, U1099, Rennes, France; Département de Radiothérapie, Centre Eugène Marquis, Rennes, France; Centre de Recherche en Information Biomédical Sino-Français, Rennes, France.
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26
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Fellin G, Rancati T, Fiorino C, Vavassori V, Antognoni P, Baccolini M, Bianchi C, Cagna E, Borca VC, Girelli G, Iacopino B, Maliverni G, Mauro FA, Menegotti L, Monti AF, Romani F, Stasi M, Valdagni R. Long term rectal function after high-dose prostatecancer radiotherapy: results from a prospective cohort study. Radiother Oncol 2013; 110:272-7. [PMID: 24332020 DOI: 10.1016/j.radonc.2013.09.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 07/05/2013] [Accepted: 09/07/2013] [Indexed: 12/15/2022]
Abstract
PURPOSE To prospectively evaluate long-term late rectal bleeding (lrb) and faecal incontinence (linc) after high-dose radiotherapy (RT) for prostate cancer in the AIROPROS 0102 population, and to assess clinical/dosimetric risk factors. MATERIALS AND METHODS Questionnaires of 515 patients with G0 baseline incontinence and bleeding scores (follow-up ≥6 years) were analysed. Correlations between lrb/linc and many clinical and dosimetric parameters were investigated by univariate and multivariate logistic analyses. The correlation between lrb/linc and symptoms during the first 3 years after RT was also investigated. RESULTS Of 515 patients lrb G1, G2 and G3 was found in 32 (6.1%), 2 (0.4%) and 3 (0.6%) patients while linc G1, G2 and G3 was detected in 50 (9.7%), 3 (0.6%) and 3 (0.6%), respectively. The prevalence of G2-G3 lrb events was significantly reduced compared to the first 3-years (1% vs 2.7%, p=0.016) ≥G1 lrb was significantly associated with V75 Gy (OR=1.07). In multivariate analysis, ≥G1 linc was associated with V40 Gy (OR=1.015), use of antihypertensive medication (OR=0.38), abdominal surgery before RT (OR=4.7), haemorrhoids (OR=2.6), and G2-G3 acute faecal incontinence (OR=4.4), a nomogram to predict the risk of long-term ≥G1 linc was proposed. Importantly, the prevalence of ≥G1 linc was significantly correlated with the mean incontinence score during the first 3 years after RT (OR=16.3). CONCLUSIONS Long-term (median: 7 years) rectal symptoms are prevalently mild and strongly correlated with moderate/severe events occurring in the first 3 years after RT. Linc was associated with several risk factors.
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Affiliation(s)
- Gianni Fellin
- Department of Radiotherapy, Ospedale Santa Chiara, Trento, Italy
| | - Tiziana Rancati
- Prostate Cancer Program, Ospedale San Raffaele, Milan, Italy.
| | | | | | - Paolo Antognoni
- Department of Radiotherapy, Ospedale di Circolo, Varese, Italy
| | - Michela Baccolini
- Department of Medical Physics, Ospedale Villa Maria Cecilia, Lugo di Romagna, Italy
| | - Carla Bianchi
- Department of Medical Physics, Ospedale di Circolo, Varese, Italy
| | - Emanuela Cagna
- Department of Radiotherapy, Ospedale Sant'Anna, Como, Italy
| | | | | | - Bruno Iacopino
- Department of Radiotherapy, Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | | | - Flora A Mauro
- Department of Radiotherapy, Ospedale Villa Maria Cecilia, Lugo di Romagna, Italy
| | - Loris Menegotti
- Department of Medical Physics, Ospedale Santa Chiara, Trento, Italy
| | - Angelo F Monti
- Department of Medical Physics, Ospedale Sant'Anna, Como, Italy
| | - Fabrizio Romani
- Department of Medical Physics, Policlinico Sant'Orsola Malpighi Bologna, Italy
| | | | - Riccardo Valdagni
- Prostate Cancer Program, Ospedale San Raffaele, Milan, Italy; Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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27
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Cella L, D'Avino V, Liuzzi R, Conson M, Doria F, Faiella A, Loffredo F, Salvatore M, Pacelli R. Multivariate normal tissue complication probability modeling of gastrointestinal toxicity after external beam radiotherapy for localized prostate cancer. Radiat Oncol 2013; 8:221. [PMID: 24053357 PMCID: PMC3852304 DOI: 10.1186/1748-717x-8-221] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 09/15/2013] [Indexed: 11/10/2022] Open
Abstract
Background The risk of radio-induced gastrointestinal (GI) complications is affected by several factors other than the dose to the rectum such as patient characteristics, hormonal or antihypertensive therapy, and acute rectal toxicity. Purpose of this work is to study clinical and dosimetric parameters impacting on late GI toxicity after prostate external beam radiotherapy (RT) and to establish multivariate normal tissue complication probability (NTCP) model for radiation-induced GI complications. Methods A total of 57 men who had undergone definitive RT for prostate cancer were evaluated for GI events classified using the RTOG/EORTC scoring system. Their median age was 73 years (range 53–85). The patients were assessed for GI toxicity before, during, and periodically after RT completion. Several clinical variables along with rectum dose-volume parameters (Vx) were collected and their correlation to GI toxicity was analyzed by Spearman’s rank correlation coefficient (Rs). Multivariate logistic regression method using resampling techniques was applied to select model order and parameters for NTCP modeling. Model performance was evaluated through the area under the receiver operating characteristic curve (AUC). Results At a median follow-up of 30 months, 37% (21/57) patients developed G1-2 acute GI events while 33% (19/57) were diagnosed with G1-2 late GI events. An NTCP model for late mild/moderate GI toxicity based on three variables including V65 (OR = 1.03), antihypertensive and/or anticoagulant (AH/AC) drugs (OR = 0.24), and acute GI toxicity (OR = 4.3) was selected as the most predictive model (Rs = 0.47, p < 0.001; AUC = 0.79). This three-variable model outperforms the logistic model based on V65 only (Rs = 0.28, p < 0.001; AUC = 0.69). Conclusions We propose a logistic NTCP model for late GI toxicity considering not only rectal irradiation dose but also clinical patient-specific factors. Accordingly, the risk of G1-2 late GI increases as V65 increases, it is higher for patients experiencing previous acute toxicity and it is lower for patients who take AH/AC drugs. The developed NTCP model could represent a potentially useful tool to be used in prospective trial and for comparison among different RT techniques.
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Affiliation(s)
- Laura Cella
- Institute of Biostructures and Bioimaging, National Council of Research (CNR), Naples, Italy.
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28
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Valdagni R, Rancati T. Reducing rectal injury during external beam radiotherapy for prostate cancer. Nat Rev Urol 2013; 10:345-57. [PMID: 23670182 DOI: 10.1038/nrurol.2013.96] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Rectal bleeding and faecal incontinence are serious injuries that men with prostate cancer who receive radiotherapy can experience. Although technical advances--including the use of intensity-modulated radiotherapy coupled with image-guided radiotherapy--have enabled the delivery of dose distributions that conform to the shape of the tumour target with steep dose gradients that reduce the dose given to surrounding tissues, radiotherapy-associated toxicity can not be avoided completely. Many large-scale prospective studies have analysed the correlations of patient-related and treatment-related parameters with acute and late toxicity to optimize patient selection and treatment planning. The careful application of dose-volume constraints and the tuning of these constraints to the individual patient's characteristics are now considered the most effective ways of reducing rectal morbidity. Additionally, the use of endorectal balloons (to reduce the margins between the clinical target volume and planning target volume) and the insertion of tissue spacers into the region between the prostate and anterior rectal wall have been investigated as means to further reduce late rectal injury. Finally, some drugs and other compounds are also being considered to help protect healthy tissue. Overall, a number of approaches exist that must be fully explored in large prospective trials to address the important issue of rectal toxicity in prostate cancer radiotherapy.
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Affiliation(s)
- Riccardo Valdagni
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan 20133, Italy
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29
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Kobayashi H, Sugihara K. Surgical management and chemoradiotherapy of T1 rectal cancer. Dig Endosc 2013; 25 Suppl 2:11-5. [PMID: 23617642 DOI: 10.1111/den.12068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Accepted: 01/07/2013] [Indexed: 12/21/2022]
Abstract
T1 rectal cancer can be treated using various strategies. Endoscopic or transanal resection is the first choice of treatment when tumors are not associated with risk for lymph node metastasis. However, transabdominal resection with lymphadenectomy is recommended for tumors that do confer risk of lymph node metastasis. The prognosis after transabdominal resection is satisfactory, but various dysfunctions impair the postoperative quality of life. The standard treatment for T3-T4 rectal cancer is total mesorectal excision with preoperative chemoradiotherapy in Western countries and total mesorectal excision with laterallymph node dissection in Japan. Previous reports indicate that preoperative radiotherapy contributes to a lower rate of local recurrence, although overall survival is not affected. In addition, radiotherapy increases the prevalence of sexual dysfunction and fecal incontinence. The effect of perioperative chemoradiotherapy for T1-T2 rectal cancer remains unclear.
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Affiliation(s)
- Hirotoshi Kobayashi
- Center for Minimally Invasive Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan.
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30
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Eckert F, Alloussi S, Paulsen F, Bamberg M, Zips D, Spillner P, Gani C, Kramer U, Thorwarth D, Schilling D, Müller AC. Prospective evaluation of a hydrogel spacer for rectal separation in dose-escalated intensity-modulated radiotherapy for clinically localized prostate cancer. BMC Cancer 2013; 13:27. [PMID: 23336502 PMCID: PMC3558402 DOI: 10.1186/1471-2407-13-27] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 01/18/2013] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND As dose-escalation in prostate cancer radiotherapy improves cure rates, a major concern is rectal toxicity. We prospectively assessed an innovative approach of hydrogel injection between prostate and rectum to reduce the radiation dose to the rectum and thus side effects in dose-escalated prostate radiotherapy. METHODS Acute toxicity and planning parameters were prospectively evaluated in patients with T1-2 N0 M0 prostate cancer receiving dose-escalated radiotherapy after injection of a hydrogel spacer. Before and after hydrogel injection, we performed MRI scans for anatomical assessment of rectal separation. Radiotherapy was planned and administered to 78 Gy in 39 fractions. RESULTS From eleven patients scheduled for spacer injection the procedure could be performed in ten. In one patient hydrodissection of the Denonvillier space was not possible. Radiation treatment planning showed low rectal doses despite dose-escalation to the target. In accordance with this, acute rectal toxicity was mild without grade 2 events and there was complete resolution within four to twelve weeks. CONCLUSIONS This prospective study suggests that hydrogel injection is feasible and may prevent rectal toxicity in dose-escalated radiotherapy of prostate cancer. Further evaluation is necessary including the definition of patients who might benefit from this approach. TRIAL REGISTRATION German Clinical Trials Register DRKS00003273.
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Affiliation(s)
- Franziska Eckert
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Saladin Alloussi
- Department of Urology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Michael Bamberg
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Daniel Zips
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Patrick Spillner
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Cihan Gani
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Ulrich Kramer
- Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - David Schilling
- Department of Urology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Arndt-Christian Müller
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
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Böhmer D. Strahlentherapie des fortgeschrittenen und rezidivierenden Prostatakarzinoms. Urologe A 2012; 51:1759-69; quiz 1770-1. [DOI: 10.1007/s00120-012-3030-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kintzinger C, Demoor-Goldschmidt C, Abderrahmani R, Paris F, Supiot S. Toxicité rectale de la radiothérapie : signes cliniques, physiopathologie et prise en charge. Cancer Radiother 2012; 16:372-6. [DOI: 10.1016/j.canrad.2012.05.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 05/28/2012] [Indexed: 12/29/2022]
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Valdagni R, Vavassori V, Rancati T, Fellin G, Baccolini M, Bianchi C, Cagna E, Gabriele P, Mauro F, Menegotti L, Monti AF, Stasi M, Fiorino C. Increasing the risk of late rectal bleeding after high-dose radiotherapy for prostate cancer: The case of previous abdominal surgery. Results from a prospective trial. Radiother Oncol 2012; 103:252-5. [DOI: 10.1016/j.radonc.2012.03.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 03/23/2012] [Accepted: 03/26/2012] [Indexed: 11/25/2022]
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Inclusion of clinical risk factors into NTCP modelling of late rectal toxicity after high dose radiotherapy for prostate cancer. Radiother Oncol 2011; 100:124-30. [DOI: 10.1016/j.radonc.2011.06.032] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 06/14/2011] [Accepted: 06/14/2011] [Indexed: 12/25/2022]
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