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Hurwitz JC, Haas J, Mendez C, Sanchez A, Santos VF, Akerman M, Carpenter T, Tam M, Katz A, Corcoran A, Mahadevan A, Taneja SS, Lepor H, Lischalk JW. Stereotactic Body Radiation Therapy for the Curative Treatment of Prostate Cancer in Ultralarge (≥100 cc) Glands. Pract Radiat Oncol 2024; 14:241-251. [PMID: 37984713 DOI: 10.1016/j.prro.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/01/2023] [Accepted: 11/06/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE Historically, toxicity concerns have existed in patients with large prostate glands treated with radiation therapy, particularly brachytherapy. There are questions whether this risk extends to stereotactic body radiation therapy (SBRT). In this retrospective review, we examine clinical outcomes of patients with prostate glands ≥100 cc treated curatively with SBRT. METHODS AND MATERIALS We retrospectively analyzed a large institutional database to identify patients with histologically confirmed localized prostate cancer in glands ≥100 cc, who were treated with definitive-robotic SBRT. Prostate volume (PV) was determined by treatment planning magnetic resonance imaging. Toxicity was measured using Common Terminology Criteria for Adverse Events, version 5.0. Many patients received the Expanded Prostate Cancer Index Composite Quality of Life questionnaires. Minimum follow-up (FU) was 2 years. RESULTS Seventy-one patients were identified with PV ≥100 cc. Most had grade group (GG) 1 or 2 (41% and 37%, respectively) disease. All patients received a total dose of 3500 to 3625 cGy in 5 fractions. A minority (27%) received androgen deprivation therapy (ADT), which was used for gland size downsizing in only 10% of cases. Nearly half (45%) were taking GU medications for urinary dysfunction before RT. Median toxicity FU was 4.0 years. Two-year rates of grade 1+ genitourinary (GU), grade 1+ gastrointestinal (GI), and grade 2+ GU toxicity were 43.5%, 15.9%, and 30.4%, respectively. Total grade 3 GU toxicities were very limited (2.8%). There were no grade 3 GI toxicities. On logistic regression analysis, pretreatment use of GU medications was significantly associated with increased rate of grade 2+ GU toxicity (odds ratio, 3.19; P = .024). Furthermore, PV (analyzed as a continuous variable) did not have an effect on toxicity, quality of life, or oncologic outcomes. CONCLUSIONS With early FU, ultra large prostate glands do not portend increased risk of high-grade toxicity after SBRT but likely carry an elevated risk of low-grade GU toxicity.
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Affiliation(s)
- Joshua C Hurwitz
- Department of Radiation Oncology, New York University Long Island School of Medicine, Mineola, New York
| | - Jonathan Haas
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Christopher Mendez
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Astrid Sanchez
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Vianca F Santos
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Meredith Akerman
- Division of Health Services Research, New York University Long Island School of Medicine, New York University Langone Health, New York, New York
| | - Todd Carpenter
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Moses Tam
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Aaron Katz
- Department of Urology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Anthony Corcoran
- Department of Urology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Anand Mahadevan
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Grossman School of Medicine, New York, New York
| | - Samir S Taneja
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Grossman School of Medicine, New York, New York
| | - Herbert Lepor
- Department of Urology, Perlmutter Cancer Center at New York University Grossman School of Medicine, New York, New York
| | - Jonathan W Lischalk
- Department of Radiation Oncology, New York University Long Island School of Medicine, Mineola, New York.
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2
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Barten DLJ, Pieters BR, Bouter A, van der Meer MC, Maree SC, Hinnen KA, Westerveld H, Bosman PAN, Alderliesten T, van Wieringen N, Bel A. Towards artificial intelligence-based automated treatment planning in clinical practice: A prospective study of the first clinical experiences in high-dose-rate prostate brachytherapy. Brachytherapy 2023; 22:279-289. [PMID: 36635201 DOI: 10.1016/j.brachy.2022.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/28/2022] [Accepted: 11/28/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE This prospective study evaluates our first clinical experiences with the novel ``BRachytherapy via artificial Intelligent GOMEA-Heuristic based Treatment planning'' (BRIGHT) applied to high-dose-rate prostate brachytherapy. METHODS AND MATERIALS Between March 2020 and October 2021, 14 prostate cancer patients were treated in our center with a 15Gy HDR-brachytherapy boost. BRIGHT was used for bi-objective treatment plan optimization and selection of the most desirable plans from a coverage-sparing trade-off curve. Selected BRIGHT plans were imported into the commercial treatment planning system Oncentra Brachy . In Oncentra Brachy a dose distribution comparison was performed for clinical plan choice, followed by manual fine-tuning of the preferred BRIGHT plan when deemed necessary. The reasons for plan selection, clinical plan choice, and fine-tuning, as well as process speed were monitored. For each patient, the dose-volume parameters of the (fine-tuned) clinical plan were evaluated. RESULTS In all patients, BRIGHT provided solutions satisfying all protocol values for coverage and sparing. In four patients not all dose-volume criteria of the clinical plan were satisfied after manual fine-tuning. Detailed information on tumour coverage, dose-distribution, dwell time pattern, and insight provided by the patient-specific trade-off curve, were used for clinical plan choice. Median time spent on treatment planning was 42 min, consisting of 16 min plan optimization and selection, and 26 min undesirable process steps. CONCLUSIONS BRIGHT is implemented in our clinic and provides automated prostate high-dose-rate brachytherapy planning with trade-off based plan selection. Based on our experience, additional optimization aims need to be implemented to further improve direct clinical applicability of treatment plans and process efficiency.
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Affiliation(s)
- Danique L J Barten
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands.
| | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Anton Bouter
- Centrum Wiskunde & Informatica (CWI), Life Sciences and Health, Amsterdam, The Netherlands
| | - Marjolein C van der Meer
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Stef C Maree
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Karel A Hinnen
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Henrike Westerveld
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Peter A N Bosman
- Centrum Wiskunde & Informatica (CWI), Life Sciences and Health, Amsterdam, The Netherlands
| | - Tanja Alderliesten
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Niek van Wieringen
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
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3
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Dose Distribution of High Dose-Rate and Low Dose-Rate Prostate Brachytherapy at Different Intervals-Impact of a Hydrogel Spacer and Prostate Volume. Cancers (Basel) 2023; 15:cancers15051396. [PMID: 36900188 PMCID: PMC10000179 DOI: 10.3390/cancers15051396] [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: 01/20/2023] [Revised: 02/13/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
The study aimed to compare the dose distribution in permanent low-dose-rate brachytherapy (LDR-BT) and high-dose-rate brachytherapy (HDR-BT), specifically focusing on the impact of a spacer and prostate volume. The relative dose distribution of 102 LDR-BT patients (prescription dose 145 Gy) at different intervals was compared with the dose distribution of 105 HDR-BT patients (232 HDR-BT fractions with prescription doses of 9 Gy, n = 151, or 11.5 Gy, n = 81). A hydrogel spacer (10 mL) was only injected before HDR-BT. For the analysis of dose coverage outside the prostate, a 5 mm margin was added to the prostate volume (PV+). Prostate V100 and D90 of HDR-BT and LDR-BT at different intervals were comparable. HDR-BT was characterized by a considerably more homogenous dose distribution and lower doses to the urethra. The minimum dose in 90% of PV+ was higher for larger prostates. As a consequence of the hydrogel spacer in HDR-BT patients, the intraoperative dose at the rectum was considerably lower, especially in smaller prostates. However, prostate volume dose coverage was not improved. The dosimetric results well explain clinical differences between these techniques reported in the literature review, specifically comparable tumor control, higher acute urinary toxicity rates in LDR-BT in comparison to HDR-BT, decreased rectal toxicity after spacer placement, and improved tumor control after HDR-BT in larger prostate volumes.
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4
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Natesan D, Carpenter DJ, Floyd W, Oyekunle T, Niedzwiecki D, Waters L, Godfrey D, Moravan MJ, Lee WR, Salama JK. Effect of Large Prostate Volume on Efficacy and Toxicity of Moderately Hypofractionated Radiation Therapy in Patients With Prostate Cancer. Adv Radiat Oncol 2022; 7:100805. [PMID: 35387417 PMCID: PMC8977852 DOI: 10.1016/j.adro.2021.100805] [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: 03/22/2021] [Accepted: 08/10/2021] [Indexed: 11/20/2022] Open
Abstract
Purpose To evaluate the effect of prostate volume on outcomes after moderately hypofractionated radiation therapy (mHFRT) for prostate cancer. Methods and Materials Prostate cancer patients treated with mHFRT at a Veteran's Affairs Medical Center from August 20, 2008, to January 31, 2018, were identified. Patients were placed into a large prostate planning target volume (LPTV) cohort if their prostate PTV was in the highest quartile. Acute/late genitourinary (GU) and gastrointestinal toxicity events among patients with and without LPTV were compared. Multivariable analyses estimated the effect of factors on toxicity. Overall survival, biochemical recurrence-free survival, and freedom from late GU/gastrointestinal toxicity of patients with and without LPTV were estimated via Kaplan-Meier. Results Four hundred and seventy-two patients were included. Ninety-three percent received 70 Gy in 2.5 Gy fractions; 75% received androgen deprivation therapy. Median follow-up was 69 months. Patients with LPTV (PTV >138.4 cm3) had a higher late 2 + GU toxicity compared with those without (59% vs 48%, P = .03). Earlier time to late 2 + GU toxicity was associated with LPTV (hazard ratio 1.36; 95% confidence interval [CI], 1.00-1.86; P = .047), androgen deprivation therapy use (hazard ratio 1.60; 95% CI, 1.13-2.27; P = .01), and higher baseline American Urologic Association symptom score (odds ratio 1.03; 95% CI, 1.02-1.05; P < .001). At 2 years, freedom from late 2 + GU toxicity was 46% (95% CI, 47%-54%) for those with LPTV versus 61% (95% CI, 55%-65%) for those without (P = .04). Late grade 3 GU toxicity was 7% for those with LPTV and 4% for those without. No differences in overall survival or biochemical recurrence-free survival were observed between patients with or without LPTV. Conclusions LPTV did not affect efficacy of mHFRT for prostate cancer; however, it was associated with increased risk and earlier onset of late grade 2 + GU toxicity.
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5
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Henry A, Pieters BR, André Siebert F, Hoskin P. GEC-ESTRO ACROP prostate brachytherapy guidelines. Radiother Oncol 2022; 167:244-251. [PMID: 34999134 DOI: 10.1016/j.radonc.2021.12.047] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/31/2021] [Indexed: 02/07/2023]
Abstract
This is an evidence-based guideline for prostate brachytherapy. Throughout levels of evidence quoted are those from the Oxford Centre for Evidence based Medicine (https://www.cebm.ox.ac.uk/resources/levels-of-evidence/oxford-centre-for-evidence-based-medicine-levels-of-evidence-march-2009). Prostate interstitial brachytherapy using either permanent or temporary implantation is an established and evolving treatment technique for non-metastatic prostate cancer. Permanent brachytherapy uses Low Dose Rate (LDR) sources, most commonly I-125, emitting photon radiation over months. Temporary brachytherapy involves first placing catheters within the prostate and, on confirmation of accurate positioning, temporarily introducing the radioactive source, generally High Dose Rate (HDR) radioactive sources of Ir-192 or less commonly Co-60. Pulsed dose rate (PDR) brachytherapy has also been used for prostate cancer [1] but few centres have adopted this approach. Previous GEC ESTRO recommendations have considered LDR and HDR separately [2-4] but as there is considerable overlap, this paper provides updated guidance for both treatment techniques. Prostate brachytherapy allows safe radiation dose escalation beyond that achieved using external beam radiotherapy alone as it has greater conformity around the prostate, sparing surrounding rectum, bladder, and penile bulb. In addition there are fewer issues with changes in prostate position during treatment delivery. Systematic review and randomised trials using both techniques as boost treatments demonstrate improved PSA control when compared to external beam radiotherapy alone [5-7].
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Affiliation(s)
- Ann Henry
- St James University Hospital, Leeds, UK
| | - Bradley R Pieters
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Frank André Siebert
- University of Kiel/University Hospital Schleswig-Holstein Campus Kiel, Germany
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, UK; University of Manchester, Manchester, UK.
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Remick JS, Sabouri P, Zhu M, Bentzen SM, Sun K, Kwok Y, Kaiser A. Simulation of an HDR "Boost" with Stereotactic Proton versus Photon Therapy in Prostate Cancer: A Dosimetric Feasibility Study. Int J Part Ther 2021; 7:11-23. [PMID: 33604412 PMCID: PMC7886266 DOI: 10.14338/ijpt-20-00029.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/19/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose/Objectives To compare the dose escalation potential of stereotactic body proton therapy (SBPT) versus stereotactic body photon therapy (SBXT) using high-dose rate prostate brachytherapy (HDR-B) dose-prescription metrics. Patients and Methods Twenty-five patients previously treated with radiation for prostate cancer were identified and stratified by prostate size (≤ 50cc; n = 13, > 50cc; n = 12). Initial CT simulation scans were re-planned using SBXT and SBPT modalities using a prescription dose of 19Gy in 2 fractions. Target coverage goals were designed to mimic the dose distributions of HDR-B and maximized to the upper limit constraint for the rectum and urethra. Dosimetric parameters between SBPT and SBXT were compared using the signed-rank test and again after stratification for prostate size (≤ 50cm3 and >50cm3) using the Wilcoxon rank test. Results Prostate volume receiving 100% of the dose (V100) was significantly greater for SBXT (99%) versus SBPT (96%) (P ≤ 0.01), whereas the median V125 (82% vs. 73%, P < 0.01) and V200 (12% vs. 2%, P < 0.01) was significantly greater for SBPT compared to SBXT. Median V150 was 49% for both cohorts (P = 0.92). V125 and V200 were significantly correlated with prostate size. For prostates > 50cm3, V200 was significantly greater with SBPT compared to SBXT (14.5% vs. 1%, P = 0.005), but not for prostates 50cm3 (9% vs 4%, P = 0.11). Median dose to 2cm3 of the bladder neck was significantly lower with SBPT versus SBXT (9.6 Gy vs. 14 Gy, P < 0.01). Conclusion SBPT and SBXT can be used to simulate an HDR-B boost for locally advanced prostate cancer. SBPT demonstrated greater dose escalation potential than SBXT. These results are relevant for future trial design, particularly in patients with high risk prostate cancer who are not amenable to brachytherapy.
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Affiliation(s)
- Jill S Remick
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Pouya Sabouri
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mingyao Zhu
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Søren M Bentzen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kai Sun
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Young Kwok
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Adeel Kaiser
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
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Aghdam N, Pepin A, Buchberger D, Hirshberg J, Lei S, Ayoob M, Danner M, Yung T, Kumar D, Collins BT, Lynch J, Kataria S, Suy S, Collins SP. Stereotactic Body Radiation Therapy (SBRT) for Prostate Cancer in Men With a High Baseline International Prostate Symptom Score (IPSS ≥ 15). Front Oncol 2020; 10:1060. [PMID: 32719744 PMCID: PMC7350884 DOI: 10.3389/fonc.2020.01060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 05/28/2020] [Indexed: 01/25/2023] Open
Abstract
Background: Patients with a high pretreatment IPSS may have higher rates of late urinary morbidity after radiation therapy for prostate cancer (1). Stereotactic body radiation therapy (SBRT) delivers fewer high-dose fractions of radiation, which may be radiobiologically favorable to the conventional low-dose external beam fractions. The urinary toxicity associated with SBRT, however, remains unclear in patients with a high IPSS (1). We report our experience using SBRT for localized prostate cancer in patients with pretreatment IPSS ≥ 15. Methods: Localized prostate cancer patients with a pre-treatment IPSS ≥ 15 treated with SBRT at Georgetown University Hospital from 2009 to 2016 were included in this retrospective review of prospectively collected data. These patients were treated to 35–36.25 Gy in five fractions delivered via CyberKnife (Accuray Inc., Sunnyvale, CA). Urinary toxicity was assessed using the Common Terminology Criteria for Adverse Events version 4.0 (CTCAE v4). Urinary quality of life was assessed using validated questionnaires (IPSS and EPIC-26). Results: 53 patients at a median age of 71 years (range 57–89 years) received SBRT with a minimum follow up of 3 years. The median prostate size was 37 cm3 (range 12–100 cm3) and 30.2% patients received ADT. The 3-years incidence rate of Grade 3 urinary toxicity was 7.5% with median time to toxicity of 2.9 years. There were no Grade 4 or 5 toxicities. A mean baseline IPSS score of 19.8 significantly decreased to 12.9 at 3 months post-SBRT (p = 0.002) and remained stable at 36 months (13.7). A mean baseline EPIC-26 obstructive/irritative score of 64.1 significantly improved to 80.2 at 3 months (p = 0.002). This improvement was maintained to 36 months. There was no significant change from the mean baseline EPIC-26 urinary incontinence score at any point during follow up. Conclusions: SBRT for clinically localized prostate cancer was well-tolerated in men with baseline IPSS ≥ 15 (1). Grade 3 toxicities occurred but resolved with time. Our data suggest that poor baseline urinary function does not worsen following SBRT and may even improve. High baseline IPSS score should not be considered a contraindication to SBRT.
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Affiliation(s)
- Nima Aghdam
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Abigail Pepin
- George Washington University, School of Medicine and Health Sciences, Washington, DC, United States
| | - David Buchberger
- University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Jason Hirshberg
- Arizona College of Osteopathic Medicine, Glendale, AZ, United States
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Deepak Kumar
- Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Brian T Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - John Lynch
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Shaan Kataria
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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8
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Press RH, Morgan TM, Cutrell PK, Zhang C, Chen Z, Rahnema S, Sanda M, Pattaras J, Patel P, Jani AB, Rossi PJ. Patient-reported health-related quality of life outcomes after HDR brachytherapy between small (<60 cc) and large (≥60 cc) prostate glands. Brachytherapy 2018; 18:13-21. [PMID: 30262410 DOI: 10.1016/j.brachy.2018.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/02/2018] [Accepted: 08/15/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE Patients with large prostate glands are underrepresented in clinical trials incorporating brachytherapy due to concerns for excessive toxicity. We sought to compare health-related quality of life (HRQOL) outcomes between small (<60 cc) and large (≥60 cc) prostates treated with high-dose-rate brachytherapy (HDR-B). METHODS AND MATERIALS One hundred thirty patients at Emory University were treated with HDR-B monotherapy (n = 75) or HDR-B in combination with external beam radiation therapy (n = 55). American Urologic Association Symptom Score (AUASS) and expanded prostate cancer index composite for clinical practice (EPIC-CP) scores were recorded. A linear mixed model was performed dichotomizing prostate volume (<60 and ≥ 60 cc) with AUASS, individual EPIC-CP domains (urinary incontinence, urinary irritation/obstruction [UIO], bowel function, sexual function, and vitality/hormonal function), and overall EPIC-CP HRQOL scores. RESULTS Median followup was 22.6 months (range 2.2-55.8). The median gland volume for the entire cohort (n = 130), <60 cc cohort (n = 104), and ≥60 cc cohort (n = 26) was 44 cc, 41.1 cc, and 68.0 cc, respectively. There were no baseline differences in HRQOL scores between cohorts. At 2 months, AUASS and UIO scores increased similarly between cohorts (AUASS p = 0.807; UIO p = 0.539), then decreased (longitudinal effect p < 0.001 and p = 0.005, respectively) to remain not significantly different at 12 months (AUASS p = 0.595; UIO p = 0.673). Overall, prostate volume was not significantly associated with change in AUASS (p = 0.403), urinary incontinence (p = 0.322), UIO symptoms (p = 0.779), bowel symptoms (p = 0.757), vitality/hormonal symptoms (p = 0.503), or overall HRQOL (p = 0.382). CONCLUSIONS In appropriately selected patients, HDR-B appears well tolerated in patients with ≥60 cc prostate glands without an increase in patient-reported toxicity. Volume should not be a strict contraindication in those with adequate baseline function.
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Affiliation(s)
- Robert H Press
- Deptartment of Radiation Oncology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA.
| | - Tiffany M Morgan
- Deptartment of Radiation Oncology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Patrick K Cutrell
- Deptartment of Radiation Oncology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Chao Zhang
- Deptartment of Biostatistics and Bioinformatics Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Zhengjia Chen
- Deptartment of Biostatistics and Bioinformatics Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Sara Rahnema
- Deptartment of Radiation Oncology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Martin Sanda
- Deptartment of Urology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - John Pattaras
- Deptartment of Urology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Pretesh Patel
- Deptartment of Radiation Oncology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Ashesh B Jani
- Deptartment of Radiation Oncology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Peter J Rossi
- Deptartment of Radiation Oncology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
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9
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Pryor DI, Turner SL, Tai KH, Tang C, Sasso G, Dreosti M, Woo HH, Wilton L, Martin JM. Moderate hypofractionation for prostate cancer: A user's guide. J Med Imaging Radiat Oncol 2018; 62:232-239. [PMID: 29336109 DOI: 10.1111/1754-9485.12703] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 12/12/2017] [Indexed: 01/16/2023]
Abstract
Three large randomised controlled trials have been published in the last year demonstrating the non-inferiority of moderate hypofractionation compared to conventional fractionation for localised prostate cancer with respect to both disease control and late toxicity at 5 years. Furthermore, no clinically significant differences in patient-reported outcomes have emerged. More mature follow-up data are now also available from phase 2 studies confirming that moderate hypofractionation is associated with low rates of significant toxicity at 10 years. Moving forward it is likely that appropriate patient selection, integration of androgen deprivation and attention to optimising technique will play a more important role than modest differences in dose-fractionation schedules. Here we briefly review the evidence, discuss issues of patient selection and provide an approach to implementing moderately hypofractionated radiation therapy for prostate cancer in clinical practice.
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Affiliation(s)
- David I Pryor
- Princess Alexandra Hospital, Brisbane, Queensland, Australia.,APCRC-Q, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sandra L Turner
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,University of Sydney, Camperdown, New South Wales, Australia
| | - Keen Hun Tai
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Colin Tang
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Giuseppe Sasso
- Auckland City Hospital, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand
| | - Marcus Dreosti
- Genesis Cancer Care, Adelaide, South Australia, Australia
| | - Henry H Woo
- Sydney Adventist Hospital Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Lee Wilton
- Calvary Mater Newcastle, Waratah, New South Wales, Australia
| | - Jarad M Martin
- Calvary Mater Newcastle, Waratah, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
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10
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Does prostate volume has an impact on biochemical failure in patients with localized prostate cancer treated with HDR boost? Radiother Oncol 2016; 121:304-309. [PMID: 27776748 DOI: 10.1016/j.radonc.2016.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 09/22/2016] [Accepted: 09/24/2016] [Indexed: 11/21/2022]
Abstract
PURPOSE To compare biochemical failure free survival (BFFS) of patients with small and large prostate glands treated with external beam radiation therapy (EBRT) and HDR (high dose rate) brachytherapy boost. MATERIALS AND METHODS Between 2002 and 2012, 548 patients were treated with EBRT followed by HDR boost. The effect of covariates and prostate volume on biochemical failure was analyzed by survival analysis and Cox regression model. RESULTS The median follow-up and age were not different between the two groups. The mean prostate gland volume at the time of CT planning was 48.1 and 76.0cc in small (<60cc) and large (⩾ 60cc) prostate volume, respectively (p<0.001). When PSA bounces were excluded, there was no significant difference between the two groups with a 5-years BFFS of 95.8% vs 92.3%, p=0.094. There were no significant differences between the two groups for urinary symptoms (IPSS) as well as acute and late GI toxicities. CONCLUSIONS This study showed that a HDR brachytherapy boost in large prostate gland cases is feasible at the price of increased PSA bounces. When the benign bounces are excluded, there is no significant difference between the two groups for tumor control and toxicity. Therefore, in our experience, there is no rational precluding the use of HDR boost in patients with a prostate size of 60 cc or more so long as an adequate dosimetry is achievable.
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11
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Thiruthaneeswaran N, Hoskin PJ. High dose rate brachytherapy for prostate cancer: Standard of care and future direction. Cancer Radiother 2016; 20:66-72. [PMID: 26811209 DOI: 10.1016/j.canrad.2016.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 12/14/2015] [Accepted: 12/16/2015] [Indexed: 10/22/2022]
Abstract
High dose rate brachytherapy is a highly conformal method of radiation dose escalation for prostate cancer and one of several treatment options for men with localised disease. The large doses per fraction exploit the low alpha/beta ratio of prostate cancer cells so that biological radiation dose delivered is substantially greater than that achieved with conventional external beam delivery. This review article presents contemporary data on the rationale for high dose rate brachytherapy including treatment technique and future directions.
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Affiliation(s)
- N Thiruthaneeswaran
- Cancer Centre, Mount Vernon Hospital, Rickmansworth Road, Northwood, HA6 2RN, United Kingdom
| | - P J Hoskin
- Cancer Centre, Mount Vernon Hospital, Rickmansworth Road, Northwood, HA6 2RN, United Kingdom.
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12
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Prostate: High-Dose Rate Brachytherapy in the Treatment of Clinically Organ-Confined Prostate Cancer. Brachytherapy 2016. [DOI: 10.1007/978-3-319-26791-3_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Yang G, Strom TJ, Wilder RB, Shrinath K, Mellon EA, Fernandez DC, Biagioli MC. Dosimetric coverage of the prostate, normal tissue sparing, and acute toxicity with high-dose-rate brachytherapy for large prostate volumes. Int Braz J Urol 2015. [PMID: 26200536 PMCID: PMC4752135 DOI: 10.1590/s1677-5538.ibju.2014.0289] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Purpose To evaluate dosimetric coverage of the prostate, normal tissue sparing, and acute toxicity with HDR brachytherapy for large prostate volumes. Materials and Methods One hundred and two prostate cancer patients with prostate volumes >50 mL (range: 5-29 mL) were treated with high-dose-rate (HDR) brachytherapy ± intensity modulated radiation therapy (IMRT) to 4,500 cGy in 25 daily fractions between 2009 and 2013. HDR brachytherapy monotherapy doses consisted of two 1,350-1,400 cGy fractions separated by 2-3 weeks, and HDR brachytherapy boost doses consisted of two 950-1,150 cGy fractions separated by 4 weeks. Twelve of 32 (38%) unfavorable intermediate risk, high risk, and very high risk patients received androgen deprivation therapy. Acute toxicity was graded according to the Common Terminology Criteria for Adverse Events (CTCAE) version 4. Results Median follow-up was 14 months. Dosimetric goals were achieved in over 90% of cases. Three of 102 (3%) patients developed Grade 2 acute proctitis. No variables were significantly associated with Grade 2 acute proctitis. Seventeen of 102 (17%) patients developed Grade 2 acute urinary retention. American Urological Association (AUA) symptom score was the only variable significantly associated with Grade 2 acute urinary retention (p=0.04). There was no ≥ Grade 3 acute toxicity. Conclusions Dosimetric coverage of the prostate and normal tissue sparing were adequate in patients with prostate volumes >50 mL. Higher pre-treatment AUA symptom scores increased the relative risk of Grade 2 acute urinary retention. However, the overall incidence of acute toxicity was acceptable in patients with large prostate volumes.
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Affiliation(s)
- George Yang
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Tobin J Strom
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | | | - Kushagra Shrinath
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Eric A Mellon
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Daniel C Fernandez
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Matthew C Biagioli
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
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14
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The impact of prostate gland dimension in genitourinary toxicity after definitive prostate cancer treatment with moderate hypofractionation and volumetric modulated arc radiation therapy. Clin Transl Oncol 2015; 18:317-21. [DOI: 10.1007/s12094-015-1371-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 07/28/2015] [Indexed: 01/08/2023]
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15
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Janowski E, Chen LN, Kim JS, Lei S, Suy S, Collins B, Lynch J, Dritschilo A, Collins S. Stereotactic body radiation therapy (SBRT) for prostate cancer in men with large prostates (≥50 cm(3)). Radiat Oncol 2014; 9:241. [PMID: 25398516 PMCID: PMC4239322 DOI: 10.1186/s13014-014-0241-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 10/18/2014] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Patients with large prostate volumes have been shown to have higher rates of genitourinary and gastrointestinal toxicities after conventional radiation therapy for prostate cancer. The efficacy and toxicity of stereotactic body radiation therapy (SBRT), which delivers fewer high-dose fractions of radiation treatment, is unknown for large prostate volume prostate cancer patients. We report our early experience using SBRT for localized prostate cancer in patients with large prostate volumes. METHODS 57 patients with prostate volumes ≥50 cm(3) prior to treatment with SBRT for localized prostate carcinoma and with a minimum follow up of two years were included in this retrospective review of prospectively collected data. Treatment was delivered using Cyberknife (Accuray) with doses of 35-36.25 Gy in 5 fractions. Biochemical control was assessed using the Phoenix definition. Toxicities were scored using the CTCAE v.4. Quality of life was assessed using the American Urological Association (AUA) Symptom Score and the Expanded Prostate Cancer Index Composite (EPIC)-26. RESULTS 57 patients (23 low-, 25 intermediate- and 9 high-risk according to the D'Amico classification) at a median age of 69 years (range, 54-83 years) received SBRT with a median follow-up of 2.9 years. The median prostate size was 62.9 cm(3) (range 50-138.7 cm(3)). 33.3% of patients received ADT. The median pre-treatment prostate-specific antigen (PSA) was 6.5 ng/ml and decreased to a median PSA of 0.4 ng/ml by 2 years (p <0.0001). A mean baseline AUA symptom score of 7.5 significantly increased to 13 at 1 month (p = 0.001) and returned to baseline by 3 months (p = 0.21). 23% of patients experienced a late transient urinary symptom flare in the first two years following treatment. Mean baseline EPIC bowel scores of 95.8 decreased to 78.1 at 1 month (p <0.0001), but subsequently improved to 93.5 three months (p = 0.08). The 2-year actuarial incidence rates of GU and GI toxicity ≥ grade 2 were 49.1% and 1.8%, respectively. Two patients (3.5%) experienced grade 3 urinary toxicity, and no patient experienced grade 3 gastrointestinal toxicity. CONCLUSIONS SBRT for clinically localized prostate cancer was well tolerated in men with large prostate volumes.
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Affiliation(s)
- Einsley Janowski
- Department of Radiation Medicine, Georgetown University Hospital, Washington DC, 20007, USA.
| | - Leonard N Chen
- Department of Radiation Medicine, Georgetown University Hospital, Washington DC, 20007, USA.
| | - Joy S Kim
- Department of Radiation Medicine, Georgetown University Hospital, Washington DC, 20007, USA.
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital, Washington DC, 20007, USA.
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington DC, 20007, USA.
| | - Brian Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington DC, 20007, USA.
| | - John Lynch
- Department of Urology, Georgetown University Hospital, Washington DC, 20007, USA.
| | - Anatoly Dritschilo
- Department of Radiation Medicine, Georgetown University Hospital, Washington DC, 20007, USA.
| | - Sean Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington DC, 20007, USA.
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16
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Dankulchai P, Alonzi R, Lowe GJ, Burnley J, Padhani AR, Hoskin PJ. Optimal source distribution for focal boosts using high dose rate (HDR) brachytherapy alone in prostate cancer. Radiother Oncol 2014; 113:121-5. [DOI: 10.1016/j.radonc.2014.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 07/16/2014] [Accepted: 09/06/2014] [Indexed: 11/16/2022]
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17
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Yan W, Chen J, Zhou Y, Zhou Z, Mai Z, Ji Z, Li H, Zhang F. Long-term outcome of early stage prostate cancer treated with brachytherapy analysis after a mean follow-up of 7 years. SPRINGERPLUS 2014; 3:357. [PMID: 25089248 PMCID: PMC4117862 DOI: 10.1186/2193-1801-3-357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 07/07/2014] [Indexed: 11/11/2022]
Abstract
Purpose To investigate the long-term efficacy of 125I brachytherapy in early-stage prostate cancer and to identify correlating factors. Methods This study included 117 cases of early stage prostate cancer. The patients ranged in age from 51 to 84 years, with a mean of 73 years. The features of the study population were as follows: the PSA ranged from 0.4 to 47.6 ng/ml (median, 14.7); the Gleason score ranged from 4 to 9 (mean, 6.4); the clinical stage ranged from T1b to T2c; and the positive biopsy rate ranged from 0.08 to 1.0 (mean, 0.45). The mean D90 was 142 Gy and ranged from 106 Gy to 170 Gy. The numbers of low-risk, intermediate-risk and high-risk prostate cancer cases were 22, 29 and 66, respectively. The biochemical no evidence of disease (bNED) rate and overall survival were recorded. Factors that correlated with the outcomes were evaluated. Results With a mean follow up of 84 months, 33 cases had biochemical recurrence, with a bNED rate of 72%. The overall survival rate was 90%, and the cancer-specific survival rate was 97%. The bNED rates in the low-risk, intermediate-risk and high-risk groups were 86%, 79% and 64%, respectively (P = 0.040). The patients with PSA <20 ng/ml, a positive biopsy rate lower than 0.5, and D90 ≥ 140 Gy had lower biochemical recurrence (P = 0.028, 0.006, 0.009, respectively). Conclusions The long-term efficacy of 125I brachytherapy in early stage prostate cancer was shown. bNED is related to risk stratification, PSA level, positive biopsy rate and D90.
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Affiliation(s)
- Weigang Yan
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730 China
| | - Jian Chen
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730 China
| | - Yi Zhou
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730 China
| | - Zhien Zhou
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730 China
| | - Zhipeng Mai
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730 China
| | - Zhigang Ji
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730 China
| | - Hanzhong Li
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730 China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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