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Lund JÅ, Lydersen S, Aksnessæther B, Solberg A, Wanderås A, Lervåg C, Kaasa S, Tøndel H. Image guided radiotherapy in curative treatment for prostate cancer. 5-year results from a randomized controlled trial (RIC-trial). Radiother Oncol 2024; 196:110309. [PMID: 38670265 DOI: 10.1016/j.radonc.2024.110309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/16/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Between 2012 and 2015 we conducted a randomized controlled trial in prostate cancer patients comparing weekly 2-D portal imaging versus daily 3-D verification. AIM To evaluate the clinical outcomes of image guided radiotherapy by presenting rectal and urinary side effects, health related quality of life and progression free survival after 5-years follow up of a randomized controlled trial. METHODS We randomized 260 men with intermediate or high-risk prostate cancer to weekly 2-D portal imaging with 15 mm margin from CTV to PTV (Arm A) or daily 3-D cone-beam computer tomography with 7 mm margins (Arm B). Prescribed doses were 78 Gy/39 fractions. All patients received hormonal therapy. Primary end point was patient reported bowel symptoms and secondary outcomes were patient reported urinary symptoms, health- related quality of life and progression free survival. RESULTS Of the 216 patients available for analyses at 5 years more than 90 % completed patient reported outcome measures. There were no significant differences between study arms for any single items nor scales evaluating bowel symptoms. There were also no differences in self-reported urinary symptoms nor in health-related quality of life. Symptom scores were low in both study arms. Progression free survival was similar in Arm B as compared to arm A (Hazard ratio 1.01; 95 % CI 0.57 to 1.97). CONCLUSIONS Our results support that both 2-D weekly and 3-D daily image guided radiotherapy are safe and efficient treatments for PC and emphasize the need to evaluate technological progress in clinical trials with long follow-up.
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Affiliation(s)
- Jo-Åsmund Lund
- Clinic for Cancer Treatment and Rehabilitation, Helse Møre and Romsdal Hospital Trust, Ålesund, Norway; Department of Health Sciences, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Ålesund, Norway.
| | - Stian Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology, Trondheim, Norway
| | - Bjørg Aksnessæther
- Clinic for Cancer Treatment and Rehabilitation, Helse Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Arne Solberg
- Cancer Clinic, St. Olavs Hospital Trust, Trondheim University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anne Wanderås
- Cancer Clinic, St. Olavs Hospital Trust, Trondheim University Hospital, Trondheim, Norway
| | - Christoffer Lervåg
- Clinic for Cancer Treatment and Rehabilitation, Helse Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre, Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; European Palliative Care Research Centre, Department of Oncology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Hanne Tøndel
- Cancer Clinic, St. Olavs Hospital Trust, Trondheim University Hospital, Trondheim, Norway
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Chetiyawardana G, Chadwick E, Kordolaimi S, Sundar S. Bladder trigone sparing radiotherapy in prostate cancer treatment. Radiography (Lond) 2024; 30:1201-1209. [PMID: 38905764 DOI: 10.1016/j.radi.2024.06.004] [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: 03/14/2024] [Revised: 05/29/2024] [Accepted: 06/06/2024] [Indexed: 06/23/2024]
Abstract
INTRODUCTION Evidence suggests the bladder trigone to be a potential organ at risk (OAR) in predicting acute and late genitourinary (GU) side effects when treating prostate cancer with radiotherapy. METHODS A search of MEDLINE, Cinahl, EMBASE, PubMed, the Cochrane Database of Systematic Reviews and OpenGrey was conducted and no current or underway systematic reviews or scoping reviews on the topic were identified. A systematic literature review was carried out assessing the quality of this evidence. All evidence that prospectively or retrospectively reviewed radiotherapy or modelled radiotherapy dose to the bladder trigone were included. The search was conducted on the 8th July 2021 with 32 studies included in this review. This was repeated 10th June 2023 and two additional studies were identified. Any evidence published since this date have not been included and are a limitation of this review. RESULTS MRI imaging is recommended to assist in delineating the trigone which has been shown to have a high amount of inter-observer variability and the use of specific training may reduce this. Across all radiotherapy treatment modalities, trigone dose contributed to GU acute and late toxicity symptoms. Trigone motion is relative to prostate motion but further research is required to confirm if the prostate can be used as a reliable surrogate for trigone position. The dose tolerance given for specific trigone related toxicities is debated within the literature, and on analysis the authors of this review suggest bladder trigone dose limits: Dmean < 45.8 Gy, V61.0Gy < 40%, V59.8Gy < 25%, V42.5Gy-V41.0Gy < 91% and V47.4Gy-V43.2Gy < 91% with α/β of 3 Gy to reduce acute and late GU toxicities. CONCLUSION There is evidence to support further research into bladder trigone sparing radiotherapy to improve patient outcomes. IMPLICATION FOR PRACTICE Using the bladder trigone as an organ at risk is possible and the authors are currently seeking funding for a feasibility trial to further investigate this.
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Affiliation(s)
- G Chetiyawardana
- Nottingham University Hospitals, City Campus, Radiotherapy, Hucknall Road, Nottingham, NG5 1PB, UK.
| | - E Chadwick
- Nottingham University Hospitals, City Campus, Radiotherapy, Hucknall Road, Nottingham, NG5 1PB, UK
| | - S Kordolaimi
- Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, UK
| | - S Sundar
- Nottingham University Hospitals, City Campus, Radiotherapy, Hucknall Road, Nottingham, NG5 1PB, UK
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Neilsen BK, Ma TM, Akingbemi WO, Neylon J, Casado MC, Sharma S, Sheng K, Ruan D, Low DA, Yang Y, Valle LF, Steinberg ML, Lamb JM, Cao M, Kishan AU. Impact of Interfractional Bladder and Trigone Displacement and Deformation on Radiation Exposure and Subsequent Acute Genitourinary Toxicity: A Post Hoc Analysis of Patients Treated with Magnetic Resonance Imaging-Guided Prostate Stereotactic Body Radiation Therapy in a Phase 3 Randomized Trial. Int J Radiat Oncol Biol Phys 2024; 118:986-997. [PMID: 37871887 DOI: 10.1016/j.ijrobp.2023.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/08/2023] [Accepted: 10/10/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE Emerging data suggest that trigone dosimetry may be more associated with poststereotactic body radiation therapy (SBRT) urinary toxicity than whole bladder dosimetry. We quantify the dosimetric effect of interfractional displacement and deformation of the whole bladder and trigone during prostate SBRT using on-board, pretreatment 0.35T magnetic resonance images (MRI). METHODS AND MATERIALS Seventy-seven patients treated with MRI-guided prostate SBRT (40 Gy/5 fractions) on the MRI arm of a phase 3 single-center randomized trial were included. Bladder and trigone structures were contoured on images obtained from a 0.35T simulation MRI and 5 on-board pretreatment MRIs. Dice similarity coefficient (DSC) scores and changes in volume between simulation and daily treatments were calculated. Dosimetric parameters including Dmax, D0.03 cc, Dmean, V40 Gy, V39 Gy, V38 Gy, and V20 Gy for the bladder and trigone for the simulation and daily treatments were collected. Both physician-scored (Common Terminology Criteria for Adverse Events, version 4.03 scale) as well as patient-reported (International Prostate Symptom Scores and the Expanded Prostate Cancer Index Composite-26 scores) acute genitourinary (GU) toxicity outcomes were collected and analyzed. RESULTS The average treatment bladder volume was about 30% smaller than the simulation bladder volume; however, the trigone volume remained fairly consistent despite being positively correlated with total bladder volume. Overall, the trigone accounted for <2% of the bladder volume. Median DSC for the bladder was 0.79, whereas the median DSC of the trigone was only 0.33. No statistically significant associations between our selected bladder and trigonal dosimetric parameters and grade ≥2 GU toxicity were identified, although numerically, patients with GU toxicity (grade ≥2) had higher intermediate doses to the bladder (V20 Gy and Dmean) and larger volumes exposed to higher doses in the trigone (V40 Gy, V39 Gy, and V38 Gy). CONCLUSIONS The trigone exhibits little volume change, but considerable interfractional displacement/deformation. As a result, the relative volume of the trigone receiving high doses during prostate SBRT varies substantially between fractions, which could influence GU toxicity and may not be predicted by radiation planning dosimetry.
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Affiliation(s)
- Beth K Neilsen
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Ting Martin Ma
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | | | - Jack Neylon
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Maria C Casado
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Sahil Sharma
- Department of Medicine, Georgetown University, Washington, DC
| | - Ke Sheng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Dan Ruan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Daniel A Low
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Yingli Yang
- Department of Radiology, Ruijin Hospital, Shanghai, China
| | - Luca F Valle
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - James M Lamb
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Minsong Cao
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California.
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Gao X, Ge L, Gao J, Cao Z. Multiscale spatial relationship-based model for predicting bladder wall dose in pelvic radiotherapy. J Appl Clin Med Phys 2024; 25:e14153. [PMID: 37698358 PMCID: PMC10860549 DOI: 10.1002/acm2.14153] [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: 05/22/2023] [Revised: 08/17/2023] [Accepted: 08/28/2023] [Indexed: 09/13/2023] Open
Abstract
PURPOSE This research aimed to develop a prediction model to assess bladder wall dosimetry during radiotherapy for patients with pelvic tumors, thereby facilitating the refinement and evaluation of radiotherapy treatment plans to mitigate bladder toxicity. METHODS Radiotherapy treatment plans of 49 rectal cancer patients and 45 gynecologic cancer patients were collected, and multiple linear regression analyses were used to generate prediction models for bladder wall dose parameters (V 10 - 45 G y ( c m 3 ) ${V_{10 - 45Gy\ }}( {{\mathrm{c}}{{\mathrm{m}}^3}} )$ ,D m e a n ( Gy ) ${D_{mean}}( {{\mathrm{Gy}}} )$ ). These models were based on the multiscale spatial relationship between the planning target volume (PTV) and the bladder or bladder wall. The proportion of bladder or bladder wall volume overlapped by the different distance expansions of the PTV was used as an indicator of the multiscale spatial relationship. The accuracy of these models was verified in a cohort of 12 new patients, with further refinement of radiotherapy treatment plans using the predicted values as optimization parameters. Model accuracy was assessed using root mean square error (RMSE) and mean percentage error (MPE). RESULTS Models derived from individual disease data outperformed those derived from combined datasets. Predicted bladder wall dose parameters were accurate, with the majority of initial calculated values for new patients falling within the 95% confidence interval of the model predictions. There was a robust correlation between the predicted and actual dose metrics, with a correlation coefficient of 0.943. Using the predicted values to optimize treatment plans significantly reduced bladder wall dose (p< $\ < \ $ 0.001), with bladder wallD mean ( G y ) ${D_{{\mathrm{mean}}}}( {Gy} )$ andV 10 - 45 G y ( c m 3 ) ${V_{10 - 45Gy\ }}( {{\mathrm{c}}{{\mathrm{m}}^3}} )$ decreasing by 2.27±0.80 Gy (5.8%±1.8%) and 2.96±2.05 cm3 (7.9%±5.4%), respectively. CONCLUSION The formulated prediction model provides a valuable tool for predicting and minimizing bladder wall dose and for optimizing and evaluating radiotherapy treatment plans for pelvic tumor patients. This approach holds promise for reducing bladder toxicity and potentially improving patient outcomes.
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Affiliation(s)
- Xiang Gao
- Oncology DepartmentHefei First People's HospitalHefeiChina
| | - Lei Ge
- Oncology DepartmentHefei First People's HospitalHefeiChina
| | - Junfeng Gao
- Oncology DepartmentHefei First People's HospitalHefeiChina
| | - Zheng Cao
- Oncology DepartmentHefei First People's HospitalHefeiChina
- National Synchrotron Radiation LaboratoryUniversity of Science and Technology of ChinaHefeiChina
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Aoyama T, Shimizu H, Koide Y, Kitagawa T, Tachibana H, Suzuki K, Kodaira T. Estimation of the risk of secondary cancer in rectum and bladder after radiation therapy for prostate cancer using a feasibility dose-volume histogram. Phys Imaging Radiat Oncol 2023; 27:100468. [PMID: 37520638 PMCID: PMC10384607 DOI: 10.1016/j.phro.2023.100468] [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: 03/13/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 08/01/2023] Open
Abstract
We investigated the risk of secondary cancers in rectum and bladder for prostate cancer radiotherapy using a feasibility assessment tool. We calculated the risk of secondary cancer by generating a dose-volume histogram based on an ideal dose falloff function (f-value). This study found a smaller f-value was associated with a lower secondary cancer risk in the rectum but a higher risk in the bladder. The study suggests setting the f-value at 0-0.1 as the optimization goal for the rectum and 0.4 for the bladder is reasonable and feasible for reducing the risk of secondary cancer and other adverse events.
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Affiliation(s)
- Takahiro Aoyama
- Department of Radiation Oncology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-Ku, Nagoya, Aichi 464-8681, Japan
| | - Hidetoshi Shimizu
- Department of Radiation Oncology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-Ku, Nagoya, Aichi 464-8681, Japan
| | - Yutaro Koide
- Department of Radiation Oncology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-Ku, Nagoya, Aichi 464-8681, Japan
| | - Tomoki Kitagawa
- Department of Radiation Oncology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-Ku, Nagoya, Aichi 464-8681, Japan
| | - Hiroyuki Tachibana
- Department of Radiation Oncology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-Ku, Nagoya, Aichi 464-8681, Japan
| | - Kojiro Suzuki
- Department of Radiology, Aichi Medical University, 1-1 Yazako-karimata, Nagakute, Aichi 480-1195 Japan
| | - Takeshi Kodaira
- Department of Radiation Oncology, Aichi Cancer Center, 1-1 Kanokoden, Chikusa-Ku, Nagoya, Aichi 464-8681, Japan
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Hanke L, Tang H, Schröder C, Windisch P, Kudura K, Shelan M, Buchali A, Bodis S, Förster R, Zwahlen DR. Dose-Volume Histogram Parameters and Quality of Life in Patients with Prostate Cancer Treated with Surgery and High-Dose Volumetric-Intensity-Modulated Arc Therapy to the Prostate Bed. Cancers (Basel) 2023; 15:3454. [PMID: 37444564 DOI: 10.3390/cancers15133454] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
INTRODUCTION Prostate bed radiotherapy (RT) is a major affecter of patients' long-term quality of life (QoL). To ensure the best possible outcome of these patients, dose constraints are key for optimal RT planning and delivery. However, establishing refined dose constraints requires access to patient-level data. Therefore, we aimed to provide such data on the relationship between OAR and gastrointestinal (GI) as well as genitourinary (GU) QoL outcomes of a homogenous patient cohort who received dose-intensified post-operative RT to the prostate bed. Furthermore, we aimed to conduct an exploratory analysis of the resulting data. METHODS Patients who were treated with prostate bed RT between 2010 and 2020 were inquired about their QoL based on the Expanded Prostate Cancer Index Composite (EPIC). Those (n = 99) who received volumetric arc therapy (VMAT) of at least 70 Gy to the prostate bed were included. Dose-volume histogram (DVH) parameters were gathered and correlated with the EPIC scores. RESULTS The median age at the time of prostate bed RT was 68.9 years, and patients were inquired about their QoL in the median 2.3 years after RT. The median pre-RT prostate-specific antigen (PSA) serum level was 0.35 ng/mL. The median duration between surgery and RT was 1.5 years. The median prescribed dose to the prostate bed was 72 Gy. A total of 61.6% received prostate bed RT only. For the bladder, the highest level of statistical correlation (p < 0.01) was seen for V10-20Gy, Dmean and Dmedian with urinary QoL. For bladder wall, the highest level of statistically significant correlation (p < 0.01) was seen for V5-25Gy, Dmean and Dmedian with urinary QoL. Penile bulb V70Gy was statistically significantly correlated with sexual QoL (p < 0.05). A larger rectal volume was significantly correlated with improved bowel QoL (p < 0.05). Sigmoid and urethral DVH parameters as well as the surgical approach were not statistically significantly correlated with QoL. CONCLUSION Specific dose constraints for bladder volumes receiving low doses seem desirable for the further optimization of prostate bed RT. This may be particularly relevant in the context of the aspiration of establishing focal RT of prostate cancer and its local recurrences. Our comprehensive dataset may aid future researchers in achieving these goals.
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Affiliation(s)
- Luca Hanke
- Department of Radiation Oncology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
| | - Hongjian Tang
- Department of Radiation Oncology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
| | - Christina Schröder
- Department of Radiation Oncology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
| | - Paul Windisch
- Department of Radiation Oncology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
| | - Ken Kudura
- Department of Nuclear Medicine, Sankt Clara Hospital, Kleinriehenstrasse 30, 4058 Basel, Switzerland
| | - Mohamed Shelan
- Department of Radiation Oncology, Inselspital, University Hospital Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - André Buchali
- Department of Radiation Oncology, University Hospital Ruppin-Brandenburg, Fehrbelliner Strasse 38, 16816 Neuruppin, Germany
| | - Stephan Bodis
- Department of Radiation Oncology, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Robert Förster
- Department of Radiation Oncology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
| | - Daniel R Zwahlen
- Department of Radiation Oncology, Cantonal Hospital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
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7
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Xu D, Ma TM, Savjani R, Pham J, Cao M, Yang Y, Kishan AU, Scalzo F, Sheng K. Fully automated segmentation of prostatic urethra for MR-guided radiation therapy. Med Phys 2023; 50:354-364. [PMID: 36106703 DOI: 10.1002/mp.15983] [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: 09/05/2022] [Revised: 04/29/2022] [Accepted: 09/01/2022] [Indexed: 01/25/2023] Open
Abstract
PURPOSE Accurate delineation of the urethra is a prerequisite for urethral dose reduction in prostate radiotherapy. However, even in magnetic resonance-guided radiation therapy (MRgRT), consistent delineation of the urethra is challenging, particularly in online adaptive radiotherapy. This paper presented a fully automatic MRgRT-based prostatic urethra segmentation framework. METHODS Twenty-eight prostate cancer patients were included in this study. In-house 3D half fourier single-shot turbo spin-echo (HASTE) and turbo spin echo (TSE) sequences were used to image the Foley-free urethra on a 0.35 T MRgRT system. The segmentation pipeline uses 3D nnU-Net as the base and innovatively combines ground truth and its corresponding radial distance (RD) map during training supervision. Additionally, we evaluate the benefit of incorporating a convolutional long short term memory (LSTM-Conv) layer and spatial recurrent convolution layer (RCL) into nnU-Net. A novel slice-by-slice simple exponential smoothing (SEPS) method specifically for tubular structures was used to post-process the segmentation results. RESULTS The experimental results show that nnU-Net trained using a combination of Dice, cross-entropy and RD achieved a Dice score of 77.1 ± 2.3% in the testing dataset. With SEPS, Hausdorff distance (HD) and 95% HD were reduced to 2.95 ± 0.17 mm and 1.84 ± 0.11 mm, respectively. LSTM-Conv and RCL layers only minimally improved the segmentation precision. CONCLUSION We present the first Foley-free MRgRT-based automated urethra segmentation study. Our method is built on a data-driven neural network with novel cost functions and a post-processing step designed for tubular structures. The performance is consistent with the need for online and offline urethra dose reduction in prostate radiotherapy.
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Affiliation(s)
- Di Xu
- Department of Computer Science, University of California, Los Angeles, California, USA.,Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Ting Martin Ma
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Ricky Savjani
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Jonathan Pham
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Yingli Yang
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Fabien Scalzo
- Department of Computer Science, Pepperdine University, Los Angeles, California, USA
| | - Ke Sheng
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
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Ong ALK, Knight K, Panettieri V, Dimmock M, Tuan JKL, Tan HQ, Wright C. Predictive modelling for late rectal and urinary toxicities after prostate radiotherapy using planned and delivered dose. Front Oncol 2022; 12:1084311. [PMID: 36591496 PMCID: PMC9800591 DOI: 10.3389/fonc.2022.1084311] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022] Open
Abstract
Background and purpose Normal tissue complication probability (NTCP) parameters derived from traditional 3D plans may not be ideal in defining toxicity outcomes for modern radiotherapy techniques. This study aimed to derive parameters of the Lyman-Kutcher-Burman (LKB) NTCP model using prospectively scored clinical data for late gastrointestinal (GI) and genitourinary (GU) toxicities for high-risk prostate cancer patients treated using volumetric-modulated-arc-therapy (VMAT). Dose-volume-histograms (DVH) extracted from planned (DP) and accumulated dose (DA) were used. Material and methods DP and DA obtained from the DVH of 150 prostate cancer patients with pelvic-lymph-nodes irradiation treated using VMAT were used to generate LKB-NTCP parameters using maximum likelihood estimations. Defined GI and GU toxicities were recorded up to 3-years post RT follow-up. Model performance was measured using Hosmer-Lemeshow goodness of fit test and the mean area under the receiver operating characteristics curve (AUC). Bootstrapping method was used for internal validation. Results For mild-severe (Grade ≥1) GI toxicity, the model generated similar parameters based on DA and DP DVH data (DA-D50:71.6 Gy vs DP-D50:73.4; DA-m:0.17 vs DP-m:0.19 and DA/P-n 0.04). The 95% CI for DA-D50 was narrower and achieved an AUC of >0.6. For moderate-severe (Grade ≥2) GI toxicity, DA-D50 parameter was higher and had a narrower 95% CI (DA-D50:77.9 Gy, 95% CI:76.4-79.6 Gy vs DP-D50:74.6, 95% CI:69.1-85.4 Gy) with good model performance (AUC>0.7). For Grade ≥1 late GU toxicity, D50 and n parameters for DA and DP were similar (DA-D50: 58.8 Gy vs DP-D50: 59.5 Gy; DA-n: 0.21 vs DP-n: 0.19) with a low AUC of<0.6. For Grade ≥2 late GU toxicity, similar NTCP parameters were attained from DA and DP DVH data (DA-D50:81.7 Gy vs DP-D50:81.9 Gy; DA-n:0.12 vs DP-n:0.14) with an acceptable AUCs of >0.6. Conclusions The achieved NTCP parameters using modern RT techniques and accounting for organ motion differs from QUANTEC reported parameters. DA-D50 of 77.9 Gy for GI and DA/DP-D50 of 81.7-81.9 Gy for GU demonstrated good predictability in determining the risk of Grade ≥2 toxicities especially for GI derived D50 and are recommended to incorporate as part of the DV planning constraints to guide dose escalation strategies while minimising the risk of toxicity.
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Affiliation(s)
- Ashley Li Kuan Ong
- Division of Radiation Oncology, National Cancer Centre, Singapore, Singapore,Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,*Correspondence: Ashley Li Kuan Ong,
| | - Kellie Knight
- Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
| | - Vanessa Panettieri
- Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,Alfred Health Radiation Oncology, Alfred Hospital, Melbourne, VIC, Australia
| | - Mathew Dimmock
- Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,School of Allied Health Professions, Keele University, Staffordshire, United Kingdom
| | | | - Hong Qi Tan
- Division of Radiation Oncology, National Cancer Centre, Singapore, Singapore
| | - Caroline Wright
- Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
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Yang Y, Rwigema JCM, Vargas C, Yu NY, Keole SR, Wong WW, Schild SE, Bues M, Liu W, Shen J. Technical note: Investigation of dose and LET d effect to rectum and bladder by using non-straight laterals in prostate cancer receiving proton therapy. Med Phys 2022; 49:7428-7437. [PMID: 36208196 DOI: 10.1002/mp.16008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/02/2022] [Accepted: 09/22/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Parallel-opposed lateral beams are the conventional beam arrangements in proton therapy for prostate cancer. However, when considering linear energy transfer (LET) and RBE effects, alternative beam arrangements should be investigated. PURPOSE To investigate the dose and dose averaged LET (LETd ) impact of using new beam arrangements rotating beams 5°-15° posteriorly to the laterals in prostate cancer treated with pencil-beam-scanning (PBS) proton therapy. METHODS Twenty patients with localized prostate cancer were included in this study. Four proton treatment plans for each patient were generated utilizing 0°, 5°, 10°, and 15° posterior oblique beam pairs relative to parallel-opposed lateral beams. Dose-volume histograms (DVHs) from posterior oblique beams were analyzed. Dose-LETd -volume histogram (DLVH) was employed to study the difference in dose and LETd with each beam arrangement. DLVH indices, V ( d , l ) $V( {d,l} )$ , defined as the cumulative absolute volume that has a dose of at least d (Gy[RBE]) and a LETd of at least l (keV/µm), were calculated for both the rectum and bladder to the whole group of patients and two-sub groups with and without hydrogel spacer. These metrics were tested using Wilcoxon signed-rank test. RESULTS Rotating beam angles from laterals to slightly posterior by 5°-15° reduced high LETd volumes while it increased the dose volume in the rectum and increased LETd in bladders. Beam angles rotated five degrees posteriorly from laterals (i.e., gantry in 95° and 265°) are proposed since they achieved the optimal balance of better LETd sparing and minimal dose increase in the rectum. A reduction of V(50 Gy[RBE], 2.6 keV/µm) from 7.41 to 3.96 cc (p < 0.01), and a slight increase of V(50 Gy[RBE], 0 keV/µm) from 20.1 to 21.6 cc (p < 0.01) were observed for the group without hydrogel spacer. The LETd sparing was less effective for the group with hydrogel spacer, which achieved the reduction of V(50 Gy[RBE], 2.6 keV/µm) from 4.28 to 2.10 cc (p < 0.01). CONCLUSIONS Posterior oblique angle plans improved LETd sparing of the rectum while sacrificing LETd sparing in the bladder in the treatment of prostate cancer with PBS. Beam angle modification from laterals to slightly posterior may be a strategy to redistribute LETd and perhaps reduce rectal toxicity risks in prostate cancer patients treated with PBS. However, the effect is reduced for patients with hydrogel spacer.
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Affiliation(s)
- Yunze Yang
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - Carlos Vargas
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Hewson EA, Nguyen DT, Le A, Booth JT, Keall PJ, Mejnertsen L. Optimising multi-target multileaf collimator tracking using real-time dose for locally advanced prostate cancer patients. Phys Med Biol 2022; 67. [DOI: 10.1088/1361-6560/ac8967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/12/2022] [Indexed: 11/11/2022]
Abstract
Abstract
Objective. The accuracy of radiotherapy for patients with locally advanced cancer is compromised by independent motion of multiple targets. To date, MLC tracking approaches have used 2D geometric optimisation where the MLC aperture shape is simply translated to correspond to the target’s motion, which results in sub-optimal delivered dose. To address this limitation, a dose-optimised multi-target MLC tracking method was developed and evaluated through simulated locally advanced prostate cancer treatments. Approach. A dose-optimised multi-target tracking algorithm that adapts the MLC aperture to minimise 3D dosimetric error was developed for moving prostate and static lymph node targets. A fast dose calculation algorithm accumulated the planned dose to the prostate and lymph node volumes during treatment in real time, and the MLC apertures were recalculated to minimise the difference between the delivered and planned dose with the included motion. Dose-optimised tracking was evaluated by simulating five locally advanced prostate plans and three prostate motion traces with a relative interfraction displacement. The same simulations were performed using geometric-optimised tracking and no tracking. The dose-optimised, geometric-optimised, and no tracking results were compared with the planned doses using a 2%/2 mm γ criterion. Main results. The mean dosimetric error was lowest for dose-optimised MLC tracking, with γ-failure rates of 12% ± 8.5% for the prostate and 2.2% ± 3.2% for the nodes. The γ-failure rates for geometric-optimised MLC tracking were 23% ± 12% for the prostate and 3.6% ± 2.5% for the nodes. When no tracking was used, the γ-failure rates were 37% ± 28% for the prostate and 24% ± 3.2% for the nodes. Significance. This study developed a dose-optimised multi-target MLC tracking method that minimises the difference between the planned and delivered doses in the presence of intrafraction motion. When applied to locally advanced prostate cancer, dose-optimised tracking showed smaller errors than geometric-optimised tracking and no tracking for both the prostate and nodes.
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11
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van Gysen K, Kneebone A, Le A, Wu K, Haworth A, Bromley R, Hruby G, O'Toole J, Booth J, Brown C, Pearse M, Sidhom M, Wiltshire K, Tang C, Eade T. Evaluating the utility of knowledge-based planning for clinical trials using the TROG 08.03 post prostatectomy radiation therapy planning data. Phys Imaging Radiat Oncol 2022; 22:91-97. [PMID: 35602546 PMCID: PMC9117914 DOI: 10.1016/j.phro.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 05/05/2022] [Accepted: 05/05/2022] [Indexed: 10/27/2022] Open
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12
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Elisabeth Olsson C, Suresh R, Niemelä J, Akram SU, Valdman A. Autosegmentation based on different-sized training datasets of consistently-curated volumes and impact on rectal contours in prostate cancer radiation therapy. Phys Imaging Radiat Oncol 2022; 22:67-72. [PMID: 35572041 PMCID: PMC9092250 DOI: 10.1016/j.phro.2022.04.007] [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: 09/30/2021] [Revised: 04/20/2022] [Accepted: 04/22/2022] [Indexed: 12/01/2022] Open
Abstract
Background and purpose Autosegmentation techniques are emerging as time-saving means for radiation therapy (RT) contouring, but the understanding of their performance on different datasets is limited. The aim of this study was to determine agreement between rectal volumes by an existing autosegmentation algorithm and manually-delineated rectal volumes in prostate cancer RT. We also investigated contour quality by different-sized training datasets and consistently-curated volumes for retrained versions of this same algorithm. Materials and methods Single-institutional data from 624 prostate cancer patients treated to 50–70 Gy were used. Manually-delineated clinical rectal volumes (clinical) and consistently-curated volumes recontoured to one anatomical guideline (reference) were compared to autocontoured volumes by a commercial autosegmentation tool based on deep-learning (v1; n = 891, multiple-institutional data) and retrained versions using subsets of the curated volumes (v32/64/128/256; n = 32/64/128/256). Evaluations included dose-volume histogram metrics, Dice similarity coefficients, and Hausdorff distances; differences between groups were quantified using parametric or non-parametric hypothesis testing. Results Volumes by v1-256 (76–78 cm3) were larger than reference (75 cm3) and clinical (76 cm3). Mean doses by v1-256 (24.2–25.2 Gy) were closer to reference (24.2 Gy) than to clinical (23.8 Gy). Maximum doses were similar for all volumes (65.7–66.0 Gy). Dice for v1-256 and reference (0.87–0.89) were higher than for v1-256 and clinical (0.86–0.87) with corresponding Hausdorff comparisons including reference smaller than comparisons including clinical (5–6 mm vs. 7–8 mm). Conclusion Using small single-institutional RT datasets with consistently-defined rectal volumes when training autosegmentation algorithms created contours of similar quality as the same algorithm trained on large multi-institutional datasets.
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Fischer AM, Hoskin PJ. Radiotherapy-induced toxicity in prostate cancer patients with hip prostheses. Radiat Oncol 2022; 17:9. [PMID: 35039065 PMCID: PMC8762967 DOI: 10.1186/s13014-021-01975-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/21/2021] [Indexed: 12/25/2022] Open
Abstract
Introduction Acute and late toxicity was analysed for prostate cancer patients with bilateral hip prostheses, who received fixed field intensity modulated radiotherapy (IMRT). The aims were (1) to establish whether toxicity rates differed from those of a control group with normal hips, (2) to develop a volumetric modulated arc therapy (VMAT) approach for patients with prostheses and (3) to compare doses to bladder and rectum for the control group, prostheses group and VMAT replans for the prostheses group. Methods Genitourinary (GU) and gastrointestinal (GI) toxicity was scored using Common Terminology Criteria for Adverse Events version 5.0. The incidence of grade 2 or worse (G2+) toxicity was compared using Fisher’s exact test. Dose volume histograms (DVHs) and mean doses to organs at risk (OARs) were compared using signed rank tests. Results There were 17 patients in the prostheses group and 50 in the control group. Acute and late GU toxicity was similar. G2+ late GI toxicity incidence was 31% for the prostheses group and 14% for the control group (p = 0.14). Significant differences (p < 0.05) were seen between the OAR DVHs of the prostheses group who had IMRT and the control group for a range of intermediate doses. The rectum mean dose was significantly different (p < 0.001), but no difference was seen for the bladder mean dose (p = 0.08). Conclusions No significant differences were seen in GU and GI toxicity incidence between patients with bilateral hip prostheses and a control group. The DVHs for bladder and rectum were significantly higher for patients with prostheses planned with IMRT. Replanning using a VMAT technique significantly reduced doses to the OARs, whilst maintaining good planning target volume coverage.
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Affiliation(s)
- Andrea M Fischer
- Mount Vernon Cancer Centre, Rickmansworth Road, Northwood, HA6 2RN, UK.
| | - Peter J Hoskin
- Mount Vernon Cancer Centre, Rickmansworth Road, Northwood, HA6 2RN, UK.,Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
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Groen VH, van Schie M, Zuithoff NPA, Monninkhof EM, Kunze-Busch M, de Boer JCJ, van der Voort van Zijp J, Pos FJ, Smeenk RJ, Haustermans K, Isebaert S, Draulans C, Depuydt T, Verkooijen HM, van der Heide UA, Kerkmeijer LGW. Urethral and bladder dose-effect relations for late genitourinary toxicity following external beam radiotherapy for prostate cancer in the FLAME trial. Radiother Oncol 2021; 167:127-132. [PMID: 34968470 DOI: 10.1016/j.radonc.2021.12.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 12/16/2021] [Accepted: 12/18/2021] [Indexed: 01/18/2023]
Abstract
PURPOSE or objectives The FLAME trial (NCT01168479) showed that by adding a focal boost to conventional fractionated EBRT in the treatment of localized prostate cancer, the five-year biochemical disease-free survival increased, without significantly increasing toxicity. The aim of the present study was to investigate the association between radiation dose to the bladder and urethra and genitourinary (GU) toxicity grade ≥2 in the entire cohort. MATERIAL AND METHODS The dose-effect relations of the urethra and bladder dose, separately, and GU toxicity grade ≥2 (CTCAE 3.0) up to five years after treatment were assessed. A mixed model analysis for repeated measurements was used, adjusting for age, diabetes mellitus, T-stage, baseline GU toxicity grade ≥1 and institute. Additionally, the association between the dose and separate GU toxicity subdomains were investigated. RESULTS Dose-effect relations were observed for the dose (Gy) to the bladder D2cm3 and urethra D0.1cm3, with adjusted odds ratios of 1.14 (95% CI 1.12-1.16, p<0.0001) and 1.12 (95% CI 1.11-1.14, p<0.0001), respectively. Additionally, associations between the dose to the urethra and bladder and the subdomains urinary frequency, urinary retention and urinary incontinence were observed. CONCLUSION Further increasing the dose to the bladder and urethra will result in a significant increase in GU toxicity following EBRT. Focal boost treatment plans should incorporate a urethral dose-constraint. Further treatment optimization to increase the focal boost dose without increasing the dose to the urethra and other organs at risk should be a focus for future research, as we have shown that a focal boost is beneficial in the treatment of prostate cancer.
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Affiliation(s)
- Veerle H Groen
- University Medical Center Utrecht, Radiation Oncology, Utrecht, The Netherlands
| | - Marcel van Schie
- The Netherlands Cancer Institute, Radiation Oncology, Amsterdam, The Netherlands
| | - Nicolaas P A Zuithoff
- University Medical Center, Julius Center for Health Sciences and Primary Care, Utrecht University, Utrecht, The Netherlands
| | - Evelyn M Monninkhof
- University Medical Center, Julius Center for Health Sciences and Primary Care, Utrecht University, Utrecht, The Netherlands
| | - Martina Kunze-Busch
- Radboud University Medical Center, Radiation Oncology, Nijmegen, The Netherlands
| | | | | | - Floris J Pos
- The Netherlands Cancer Institute, Radiation Oncology, Amsterdam, The Netherlands
| | - Robert Jan Smeenk
- Radboud University Medical Center, Radiation Oncology, Nijmegen, The Netherlands
| | | | - Sofie Isebaert
- University Hospitals Leuven, Radiation Oncology, Leuven, Belgium
| | - Cédric Draulans
- University Hospitals Leuven, Radiation Oncology, Leuven, Belgium
| | - Tom Depuydt
- University Hospitals Leuven, Radiation Oncology, Leuven, Belgium
| | | | | | - Linda G W Kerkmeijer
- University Medical Center Utrecht, Radiation Oncology, Utrecht, The Netherlands; Radboud University Medical Center, Radiation Oncology, Nijmegen, The Netherlands.
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Park J, Park J, Oh S, Yea JW, Lee JE, Park JW. Multi-criteria optimization for planning volumetric-modulated arc therapy for prostate cancer. PLoS One 2021; 16:e0257216. [PMID: 34506581 PMCID: PMC8432831 DOI: 10.1371/journal.pone.0257216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/25/2021] [Indexed: 11/18/2022] Open
Abstract
We aimed to compare the volumetric-modulated arc therapy (VMAT) plans with or without multi-criteria optimization (MCO) on commercial treatment-planning systems (Eclipse, Varian Medical System, Palo Alto, CA, USA) for patients with prostate cancer. We selected 25 plans of patients with prostate cancer who were previously treated on the basis of a VMAT plan. All plans were imported into the Eclipse Treatment Planning System version 15.6, and re-calculation and re-optimization were performed. The MCO plan was then generated. The dosimetric quality of the plans was evaluated using dosimetric parameters and dose indices that account for target coverage and sparing of the organs at risk (OARs). We defined the rectum, bladder, and bilateral femoral heads. The VMAT-MCO plan offers an improvement of gross treatment volume coverage with increased minimal dose and reduced maximal dose. In the planning treatment volume, the Dmean and better gradient, homogeneity, and conformity indexes improved despite the increasing hot and cold spots. When implemented through the MCO plan, a steeper fall off the adjacent OARs in the overlap area was achieved to obtain lower dose parameters. MCO generated better sparing of the rectum and bladder through a tradeoff of the increasing dose to the bilateral femoral heads within the tolerable dose constraints. Compared with re-optimization and re-calculation, respectively, significant dose reductions were observed in the bladder (241 cGy and 254 cGy; p<0.001) and rectum (474 cGy and 604 cGy, p<0.001) with the MCO. Planning evaluation and dosimetric measurements showed that the VMAT-MCO plan using visualized navigation can provide sparing of OAR doses without compromising the target coverage in the same OAR dose constraints.
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Affiliation(s)
- Jongmoo Park
- Department of Radiation Oncology, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | - Jaehyeon Park
- Department of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Sean Oh
- Department of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Ji Woon Yea
- Department of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Jeong Eun Lee
- Department of Radiation Oncology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jae Won Park
- Department of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Republic of Korea
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16
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Groen VH, Zuithoff NPA, van Schie M, Monninkhof EM, Kunze-Busch M, de Boer HCJ, van der Voort van Zyp J, Pos FJ, Smeenk RJ, Haustermans K, Isebaert S, Draulans C, Depuydt T, Verkooijen HM, van der Heide UA, Kerkmeijer LGW. Anorectal dose-effect relations for late gastrointestinal toxicity following external beam radiotherapy for prostate cancer in the FLAME trial. Radiother Oncol 2021; 162:98-104. [PMID: 34214614 DOI: 10.1016/j.radonc.2021.06.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE The phase III FLAME trial (NCT01168479) showed an increase in five-year biochemical disease-free survival, with no significant increase in toxicity when adding a focal boost to external beam radiotherapy (EBRT) for localized prostate cancer [Kerkmeijer et al. JCO 2021]. The aim of this study was to investigate the association between delivered radiation dose to the anorectum and gastrointestinal (GI) toxicity (grade ≥2). MATERIAL AND METHODS All patients in the FLAME trial were analyzed, irrespective of treatment arm. The dose-effect relation of the anorectal dose parameters (D2cm3 and D50%) and GI toxicity grade ≥2 in four years of follow-up was assessed using a mixed model analysis for repeated measurements, adjusted for age, cardiovascular disease, diabetes mellitus, T-stage, baseline toxicity grade ≥1, hormonal therapy and institute. RESULTS A dose-effect relation for D2cm3 and D50% was observed with adjusted odds ratios of 1.17 (95% CI 1.13-1.21, p < 0.0001) and 1.20 (95% CI 1.14-1.25, p < 0.0001) for GI toxicity, respectively. CONCLUSION Although there was no difference in toxicity between study arms, a higher radiation dose to the anorectum was associated with a statistically significant increase in GI toxicity following EBRT for prostate cancer. This dose-effect relation was present for both large and small anorectal volumes. Therefore, further increase in dose to the anorectum should be weighed against the benefit of focal dose escalation for prostate cancer.
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Affiliation(s)
- Veerle H Groen
- University Medical Center Utrecht, Radiation Oncology, The Netherlands
| | - Nicolaas P A Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, The Netherlands
| | - Marcel van Schie
- The Netherlands Cancer Institute, Radiation Oncology, Amsterdam, The Netherlands
| | - Evelyn M Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, The Netherlands
| | - Martina Kunze-Busch
- Radboud University Medical Centre, Radiation Oncology, Nijmegen, The Netherlands
| | - Hans C J de Boer
- University Medical Center Utrecht, Radiation Oncology, The Netherlands
| | | | - Floris J Pos
- The Netherlands Cancer Institute, Radiation Oncology, Amsterdam, The Netherlands
| | - Robert Jan Smeenk
- Radboud University Medical Centre, Radiation Oncology, Nijmegen, The Netherlands
| | | | - Sofie Isebaert
- University Hospitals Leuven, Radiation Oncology, Belgium
| | | | - Tom Depuydt
- University Hospitals Leuven, Radiation Oncology, Belgium
| | | | | | - Linda G W Kerkmeijer
- University Medical Center Utrecht, Radiation Oncology, The Netherlands; Radboud University Medical Centre, Radiation Oncology, Nijmegen, The Netherlands.
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Murgic J, Jaksic B, Prpic M, Kust D, Bahl A, Budanec M, Prgomet Secan A, Franco P, Kruljac I, Spajic B, Babic N, Kruslin B, Zovak M, Zubizarreta E, Rosenblatt E, Fröbe A. Comparison of hypofractionation and standard fractionation for post-prostatectomy salvage radiotherapy in patients with persistent PSA: single institution experience. Radiat Oncol 2021; 16:88. [PMID: 33980277 PMCID: PMC8115388 DOI: 10.1186/s13014-021-01808-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/18/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Hypofractionated post-prostatectomy radiotherapy is emerging practice, however with no randomized evidence so far to support it's use. Additionally, patients with persistent PSA after prostatectomy may have aggressive disease and respond less well on standard salvage treatment. Herein we report outcomes for conventionally fractionated (CFR) and hypofractionated radiotherapy (HFR) in patients with persistent postprostatectomy PSA who received salvage radiotherapy to prostate bed. METHODS Single institution retrospective chart review was performed after Institutional Review Board approval. Between May 2012 and December 2016, 147 patients received salvage postprostatectomy radiotherapy. PSA failure-free and metastasis-free survival were calculated using Kaplan-Meier method. Cox regression analysis was performed to test association of fractionation regimen and other clinical factors with treatment outcomes. Early and late toxicity was assessed using Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0. RESULTS Sixty-nine patients who had persistent PSA (≥ 0.1 ng/mL) after prostatectomy were identified. Median follow-up was 67 months (95% CI 58-106 months, range, 8-106 months). Thirty-six patients (52.2%) received CFR, 66 Gy in 33 fractions, 2 Gy per fraction, and 33 patients (47.8%) received HFR, 52.5 Gy in 20 fractions, 2.63 Gy per fraction. Forty-seven (68%) patients received androgen deprivation therapy (ADT). 5-year PSA failure- and metastasis-free survival rate was 56.9% and 76.9%, respectively. Thirty patients (43%) experienced biochemical failure after salvage radiotherapy and 16 patients (23%) experienced metastatic relapse. Nine patients (13%) developed metastatic castration-resistant disease and died of advanced prostate cancer. Median PSA failure-free survival was 72 months (95% CI; 41-72 months), while median metastasis-free survival was not reached. Patients in HFR group were more likely to experience shorter PSA failure-free survival when compared to CFR group (HR 2.2; 95% CI 1.0-4.6, p = 0.04). On univariate analysis, factors significantly associated with PSA failure-free survival were radiotherapy schedule (CFR vs HFR, HR 2.2, 95% CI 1.0-4.6, p = 0.04), first postoperative PSA (HR 1.02, 95% CI 1.0-1.04, p = 0.03), and concomitant ADT (HR 3.3, 95% CI 1.2-8.6, p = 0.02). On multivariate analysis, factors significantly associated with PSA failure-free survival were radiotherapy schedule (HR 3.04, 95% CI 1.37-6.74, p = 0.006) and concomitant ADT (HR 4.41, 95% CI 1.6-12.12, p = 0.004). On univariate analysis, factors significantly associated with metastasis-free survival were the first postoperative PSA (HR 1.07, 95% CI 1.03-1.12, p = 0.002), seminal vesicle involvement (HR 3.48, 95% CI 1.26-9.6,p = 0.02), extracapsular extension (HR 7.02, 95% CI 1.96-25.07, p = 0.003), and surgical margin status (HR 2.86, 95% CI 1.03-7.97, p = 0.04). The first postoperative PSA (HR 1.04, 95% CI 1.00-1.08, p = 0.02) and extracapsular extension (HR 4.24, 95% CI 1.08-16.55, p = 0.04) remained significantly associated with metastasis-free survival on multivariate analysis. Three patients in CFR arm (8%) experienced late genitourinary grade 3 toxicity. CONCLUSIONS In our experience, commonly used hypofractionated radiotherapy regimen was associated with lower biochemical control compared to standard fractionation in patients with persistent PSA receiving salvage radiotherapy. Reason for this might be lower biological dose in HFR compared to CFR group. However, this observation is limited due to baseline imbalances in ADT use, ADT duration and Grade Group distribution between two radiotherapy cohorts. In patients with persistent PSA post-prostatectomy, the first postoperative PSA is an independent risk factor for treatment failure. Additional studies are needed to corroborate our observations.
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Affiliation(s)
- Jure Murgic
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
| | - Blanka Jaksic
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
| | - Marin Prpic
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
- School of Dental Medicine, University of Zagreb, Gunduliceva 5, 10000, Zagreb, Croatia
| | - Davor Kust
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
| | - Amit Bahl
- University Hospitals Bristol NHS Foundation Trust, Marlborough Street, Bristol, BS13NU, UK
| | - Mirjana Budanec
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
| | - Angela Prgomet Secan
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
| | - Pierfrancesco Franco
- Department of Translational Medicine, University of Eastern Piedmont, 28100, Novara, Italy
- Department of Radiation Oncology, 'Maggiore della Carità' University Hospital, 28100, Novara, Italy
| | - Ivan Kruljac
- Department of Endocrinology, Diabetes and Metabolic Diseases "Mladen Sekso", University Hospital Center Sestre Milosrdnice, University of Zagreb School of Medicine, Vinogradska 29, 10000, Zagreb, Croatia
| | - Borislav Spajic
- Department of Urology, University Hospital Center Sestre Milosrdnice, 10000, Zagreb, Croatia
| | - Nenad Babic
- Department of Radiology, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
| | - Bozo Kruslin
- Ljudevit Jurak Department of Pathology and Cytology, Sestre Milosrdnice University Hospital Centre, Vinogradska 29, 10000, Zagreb, Croatia
| | - Mario Zovak
- Department of Surgery, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia
| | - Eduardo Zubizarreta
- Division of Human Health, International Atomic Energy Agency (IAEA), Wagramer Str. 5, 1220, Vienna, Austria
| | - Eduardo Rosenblatt
- Division of Human Health, International Atomic Energy Agency (IAEA), Wagramer Str. 5, 1220, Vienna, Austria
| | - Ana Fröbe
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Vinogradska 29, 10000, Zagreb, Croatia.
- School of Dental Medicine, University of Zagreb, Gunduliceva 5, 10000, Zagreb, Croatia.
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Herrmann T. [Aloe vera in the prevention and treatment of radiogenic proctitis?]. Strahlenther Onkol 2021; 197:452-454. [PMID: 33665705 PMCID: PMC8062331 DOI: 10.1007/s00066-021-01754-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 11/23/2022]
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Ferini G, Pergolizzi S. A Ten-year-long Update on Radiation Proctitis Among Prostate Cancer Patients Treated With Curative External Beam Radiotherapy. In Vivo 2021; 35:1379-1391. [PMID: 33910815 DOI: 10.21873/invivo.12390] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/07/2021] [Accepted: 02/12/2021] [Indexed: 02/07/2023]
Abstract
This comprehensive synopsis summarizes the most relevant information obtained from a systematic analysis of studies of the last decade on radiation proctitis, one of the most feared radioinduced side effects among prostate cancer patients treated with curative external beam radiotherapy. The present review provides a useful support to radiation oncologists for limiting the onset or improving the treatment of radiation proctitis. This work shows that the past decade was a harbinger of significant new evidence in technological advances and technical tricks to avoid radiation proctitis, in addition to dosimetric perspectives and goals, understanding of pathogenesis, diagnostic work-up and treatment. We believe that a well-rounded knowledge of such an issue is fundamental for its appropriate management.
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Affiliation(s)
| | - Stefano Pergolizzi
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, University of Messina, Messina, Italy
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20
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Boldrini L, Intven M, Bassetti M, Valentini V, Gani C. MR-Guided Radiotherapy for Rectal Cancer: Current Perspective on Organ Preservation. Front Oncol 2021; 11:619852. [PMID: 33859937 PMCID: PMC8042309 DOI: 10.3389/fonc.2021.619852] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/08/2021] [Indexed: 12/18/2022] Open
Abstract
Online MRI-guided radiotherapy (MRgRT) is one of the most recent technological advances in radiotherapy. MRgRT permits the visualization of tumorous and healthy tissue while the patient is on the treatment table and online daily plan adaptations following the observed anatomical changes. In the context of rectal cancer, online MRgRT is a very promising modality due to the pronounced geographical variability of tumor tissues and the surrounding healthy tissues. This current paper will discuss the possible applications of online MRgRT, in particular, in terms of radiotherapy dose escalation and response prediction in organ preservation approaches for rectal cancer.
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Affiliation(s)
- Luca Boldrini
- Unità Operativa Complessa Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Martijn Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Michael Bassetti
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI, United States
| | - Vincenzo Valentini
- Unità Operativa Complessa Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Cihan Gani
- Department of Radiation Oncology, Eberhard Karls Universität Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site, Tübingen, Germany
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21
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Ghate A. Imputing radiobiological parameters of the linear-quadratic dose-response model from a radiotherapy fractionation plan. Phys Med Biol 2020; 65:225009. [PMID: 32937610 DOI: 10.1088/1361-6560/abb935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The objective in cancer radiotherapy is to maximize tumor-kill while limiting toxic effects of radiation dose on nearby organs-at-risk (OAR). Given a fixed number of treatment sessions, planners thus face the problem of finding a dosing sequence that achieves this goal. This is called the fractionation problem, and has received steady attention over a long history in the clinical literature. Mathematical formulations of the resulting optimization problem utilize the linear-quadratic (LQ) framework to characterize radiation dose-response of tumors and OAR. This yields a nonconvex quadratically constrained quadratic program. The optimal dosing plan in this forward problem crucially depends on the parameters of the LQ model. Unfortunately, these parameters are difficult to estimate via in vitro or in vivo studies, and as such, their values are unknown to treatment planners. The clinical literature is thus replete with debates about what parameter values will make specific dosing plans effective. This paper formulates this as an inverse optimization problem. The LQ dose-response parameters appear in the objective function, the left hand side, and the right hand side of the forward problem, and none of the existing generic methods can provide an exact solution of the inverse problem. This paper exploits the structure of the problem and identifies all possible parameter values that render the given dosing plan optimal, in closed-form. This closed-form formula is applied to dosing-plans from three clinical studies published within the last two years.
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Affiliation(s)
- Archis Ghate
- Industrial & Systems Engineering, University of Washington, Seattle, United States of America
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22
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Thompson AB, Hamstra DA. Rectal Spacer Usage with Proton Radiation Therapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2020; 108:644-648. [DOI: 10.1016/j.ijrobp.2020.05.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/11/2020] [Accepted: 05/18/2020] [Indexed: 01/03/2023]
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23
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Chetiyawardana G, Hoskin PJ, Tsang YM. The implementation of an empty bladder filling protocol for localised prostate volumetric modulated arctherapy (VMAT): early results of a single institution service evaluation. Br J Radiol 2020; 93:20200548. [PMID: 32706990 DOI: 10.1259/bjr.20200548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To examine the impact of an empty bladder filling protocol on patients receiving radical RT for localised prostate cancer on post RT toxicity and biochemical progression free survival (bPFS). METHODS AND MATERIALS Records of patients receiving radical external beam RT (EBRT) for localised prostate cancer with a full or empty bladder were reviewed. These included the bladder size on planning CT, daily online image guided RT (IGRT) setup data, treatment time and post treatment follow up data.These included bPFS, gastrointestinal(GI) and genitourinary(GU) toxicity scoring post RT using the CTCAE v4.0 scoring system. All patients included in the study were planned and treated under the same departmental clinical protocol with VMAT and daily online IGRT corrections. RESULTS 90 patients were treated with 60 Gy in 20 fractions with a median follow up of 48 months. At 4 years bPFS in the empty bladder group was 100 and 98% in the full bladder group (p = 0.27). There were no statistically significant differences in cumulative ≥Grade 2GU (p = 0.10) and GI (p = 0.27) toxicity rates between the two bladder filling protocols. No statistically significant differences in the IGRT setup between the two groups of patients. Although the median treatment times per fraction were not statistically different between the two groups (p = 0.47), patients in the full bladder filling group were required to spend a longer time in the RT department per treatment session for bladder filling. CONCLUSION An empty bladder filling protocol has non-inferior bPFS, GI and GU toxicities at 4 years in patients with localised prostate cancer using advanced RT techniques in comparison to a full bladder filling protocol. A longer follow up with a larger sample size is required to validate this approach. ADVANCES IN KNOWLEDGE This study suggests that an empty bladder filling protocol can be used in external beam EBRT for localised prostate cancer with non-inferior treatment outcomes.
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Affiliation(s)
| | - Peter J Hoskin
- Mount Vernon Cancer Centre, Northwood, Middlesex HA6 2RN, UK.,Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Yat Man Tsang
- Mount Vernon Cancer Centre, Northwood, Middlesex HA6 2RN, UK
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24
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Marcello M, Denham JW, Kennedy A, Haworth A, Steigler A, Greer PB, Holloway LC, Dowling JA, Jameson MG, Roach D, Joseph DJ, Gulliford SL, Dearnaley DP, Sydes MR, Hall E, Ebert MA. Increased Dose to Organs in Urinary Tract Associates With Measures of Genitourinary Toxicity in Pooled Voxel-Based Analysis of 3 Randomized Phase III Trials. Front Oncol 2020; 10:1174. [PMID: 32793485 PMCID: PMC7387667 DOI: 10.3389/fonc.2020.01174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 06/09/2020] [Indexed: 12/21/2022] Open
Abstract
Purpose: Dose information from organ sub-regions has been shown to be more predictive of genitourinary toxicity than whole organ dose volume histogram information. This study aimed to identify anatomically-localized regions where 3D dose is associated with genitourinary toxicities in healthy tissues throughout the pelvic anatomy. Methods and Materials: Dose distributions for up to 656 patients of the Trans-Tasman Radiation Oncology Group 03.04 RADAR trial were deformably registered onto a single exemplar CT dataset. Voxel- based multiple comparison permutation dose difference testing, Cox regression modeling and LASSO feature selection were used to identify regions where 3D dose-increase was associated with late grade ≥ 2 genitourinary dysuria, incontinence and frequency, and late grade ≥ 1 haematuria. This was externally validated by registering dose distributions from the RT01 (up to n = 388) and CHHiP (up to n = 247) trials onto the same exemplar and repeating the voxel-based tests on each of these data sets. All three datasets were then combined, and the tests repeated. Results: Voxel-based Cox regression and multiple comparison permutation dose difference testing revealed regions where increased dose was correlated with genitourinary toxicity. Increased dose in the vicinity of the membranous and spongy urethra was associated with dysuria for all datasets. Haematuria was similarly correlated with increased dose at the membranous and spongy urethra, for the RADAR, CHHiP, and combined datasets. Some evidence was found for the association between incontinence and increased dose at the internal and external urethral sphincter for RADAR and the internal sphincter alone for the combined dataset. Incontinence was also strongly correlated with dose from posterior oblique beams. Patients with fields extending inferiorly and posteriorly to the CTV, adjacent to the membranous and spongy urethra, were found to experience increased frequency. Conclusions: Anatomically-localized dose-toxicity relationships were determined for late genitourinary symptoms in the urethra and urinary sphincters. Low-intermediate doses to the extraprostatic urethra were associated with risk of late dysuria and haematuria, while dose to the urinary sphincters was associated with incontinence.
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Affiliation(s)
- Marco Marcello
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Department of Physics, University of Western Australia, Perth, WA, Australia
| | - James W. Denham
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Annette Haworth
- School of Physics, University of Sydney, Sydney, NSW, Australia
| | - Allison Steigler
- Prostate Cancer Trials Group, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Peter B. Greer
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, NSW, Australia
- Department of Radiation Oncology, Calvary Mater Newcastle, Waratah, NSW, Australia
| | - Lois C. Holloway
- Department of Medical Physics, Liverpool Cancer Centre, Liverpool, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia
| | - Jason A. Dowling
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, NSW, Australia
- CSIRO, St Lucia, QLD, Australia
| | - Michael G. Jameson
- Department of Medical Physics, Liverpool Cancer Centre, Liverpool, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia
- Cancer Research Team, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Dale Roach
- Department of Medical Physics, Liverpool Cancer Centre, Liverpool, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia
- Cancer Research Team, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - David J. Joseph
- School of Surgery, University of Western Australia, Perth, WA, Australia
- 5D Clinics, Claremont, WA, Australia
- GenesisCare WA, Wembley, WA, Australia
| | - Sarah L. Gulliford
- Radiotherapy Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - David P. Dearnaley
- Academic UroOncology Unit, The Institute of Cancer Research and the Royal Marsden NHS Trust, London, United Kingdom
| | - Matthew R. Sydes
- MRC Clinical Trials Unit, Medical Research Council, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Martin A. Ebert
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Department of Physics, University of Western Australia, Perth, WA, Australia
- 5D Clinics, Claremont, WA, Australia
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25
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Braide K, Kindblom J, Lindencrona U, Hugosson J, Pettersson N. Salvage radiation therapy in prostate cancer: relationship between rectal dose and long-term, self-reported rectal bleeding. Clin Transl Oncol 2020; 23:397-404. [PMID: 32621207 PMCID: PMC7854429 DOI: 10.1007/s12094-020-02433-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/16/2020] [Indexed: 11/26/2022]
Abstract
Purpose To quantify the relationship between the rectal dose distribution and the prevalence of self-reported rectal bleeding among men treated with salvage radiotherapy (ST) delivered by three-dimensional conformal radiotherapy (3DCRT) for prostate cancer. To use this relationship to estimate the risk of rectal bleeding for a contemporary cohort of patients treated with volumetric modulated arc therapy (VMAT) ST. Methods and patients Rectal bleeding of any grade was reported by 56 (22%) of 255 men in a PROM-survey at a median follow-up of 6.7 years after 3DCRT ST. Treatment plan data were extracted and dose–response relationships for the rectal volumes receiving at least 35 Gy (V35Gy) or 63 Gy (V63Gy) were calculated with logistic regression. These relationships were used to estimate the risk of rectal bleeding for a cohort of 253 patients treated with VMAT ST. Results In the dose–response analysis of patients in the 3DCRT ST cohort, both rectal V35Gy and V63Gy were statistically significant parameters in univariable analysis (p = 0.005 and 0.003, respectively). For the dose–response models using either rectal V35Gy or V63Gy, the average calculated risk of rectal bleeding was 14% among men treated with VMAT ST compared to a reported prevalence of 22% for men treated with 3DCRT ST. Conclusions We identified dose–response relationships between the rectal dose distribution and the risk of self-reported rectal bleeding of any grade in a long-term perspective for men treated with 3DCRT ST. Furthermore, VMAT ST may have the potential to decrease the prevalence of late rectal bleeding.
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Affiliation(s)
- K Braide
- Department of Urology, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden.
- Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - J Kindblom
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - U Lindencrona
- Department of Radiation Physics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - J Hugosson
- Department of Urology, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - N Pettersson
- Department of Radiation Physics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
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26
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Casares-Magaz O, Moiseenko V, Witte M, Rancati T, Muren LP. Towards spatial representations of dose distributions to predict risk of normal tissue morbidity after radiotherapy. Phys Imaging Radiat Oncol 2020; 15:105-107. [PMID: 33458334 PMCID: PMC7807547 DOI: 10.1016/j.phro.2020.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Oscar Casares-Magaz
- Department of Medical Physics - Oncology, Aarhus University/Aarhus University Hospital, Aarhus, Denmark
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Science, University of California San Diego, La Jolla, CA, United States
| | - Marnix Witte
- Cluster Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Ludvig P Muren
- Department of Medical Physics - Oncology, Aarhus University/Aarhus University Hospital, Aarhus, Denmark
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27
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Thor M, Oh JH, Apte AP, Deasy JO. Registering Study Analysis Plans (SAPs) Before Dissecting Your Data—Updating and Standardizing Outcome Modeling. Front Oncol 2020; 10:978. [PMID: 32670879 PMCID: PMC7327097 DOI: 10.3389/fonc.2020.00978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/18/2020] [Indexed: 12/13/2022] Open
Abstract
Public preregistration of study analysis plans (SAPs) is widely recognized for clinical trials, but adopted to a much lesser extent in observational studies. Registration of SAPs prior to analysis is encouraged to not only increase transparency and exactness but also to avoid positive finding bias and better standardize outcome modeling. Efforts to generally standardize outcome modeling, which can be based on clinical trial and/or observational data, have recently spurred. We suggest a three-step SAP concept in which investigators are encouraged to (1) Design the SAP and circulate it among the co-investigators, (2) Log the SAP with a public repository, which recognizes the SAP with a digital object identifier (DOI), and (3) Cite (using the DOI), briefly summarize and motivate any deviations from the SAP in the associated manuscript. More specifically, the SAP should include the scope (brief data and study description, co-investigators, hypotheses, primary outcome measure, study title), in addition to step-by-step details of the analysis (handling of missing data, resampling, defined significance level, statistical function, validation, and variables and parameterization).
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28
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Panettieri V, Rancati T, Onjukka E, Ebert MA, Joseph DJ, Denham JW, Steigler A, Millar JL. External Validation of a Predictive Model of Urethral Strictures for Prostate Patients Treated With HDR Brachytherapy Boost. Front Oncol 2020; 10:910. [PMID: 32596153 PMCID: PMC7300245 DOI: 10.3389/fonc.2020.00910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/11/2020] [Indexed: 12/12/2022] Open
Abstract
Purpose: For prostate cancer treatment, comparable or superior biochemical control was reported when using External-Beam-Radiotherapy (EBRT) with High-Dose-Rate-Brachytherapy (HDRB)-boost, compared to dose-escalation with EBRT alone. The conformal doses produced by HDRB could allow further beneficial prostate dose-escalation, but increase in dose is limited by normal tissue toxicity. Previous works showed correlation between urethral dose and incidence of urinary toxicity, but there is a lack of established guidelines on the dose constraints to this organ. This work aimed at fitting a Normal-Tissue-Complication-Probability model to urethral stricture data collected at one institution and validating it with an external cohort, looking at neo-adjuvant androgen deprivation as dose-modifying factor. Materials and Methods: Clinical and dosimetric data of 258 patients, with a toxicity rate of 12.8%, treated at a single institution with a variety of prescription doses, were collected to fit the Lyman–Kutcher–Burman (LKB) model using the maximum likelihood method. Due to the different fractionations, doses were converted into 2 Gy-equivalent doses (α/β = 5 Gy), and urethral stricture was used as an end-point. For validation, an external cohort of 187 patients treated as part of the TROG (Trans Tasman Radiation Oncology Group) 03.04 RADAR trial with a toxicity rate of 8.7%, was used. The goodness of fit was assessed using calibration plots. The effect of neo-adjuvant androgen deprivation (AD) was analyzed separating patients who had received it prior to treatment from those who did not receive it. Results: The obtained LKB parameters were TD50 = 116.7 Gy and m = 0.23; n was fixed to 0.3, based on numerical optimization of the likelihood. The calibration plot showed a good agreement between the observed toxicity and the probability predicted by the model, confirmed by bootstrapping. For the external validation, the calibration plot showed that the observed toxicity obtained with the RADAR patients was well-represented by the fitted LKB model parameters. When patients were stratified by the use of AD TD50 decreased when AD was not present. Conclusions: Lyman–Kutcher–Burman model parameters were fitted to the risk of urethral stricture and externally validated with an independent cohort, to provide guidance on urethral tolerance doses for patients treated with a HDRB boost. For patients that did not receive AD, model fitting provided a lower TD50 suggesting a protective effect on urethra toxicity.
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Affiliation(s)
- Vanessa Panettieri
- Alfred Health Radiation Oncology, Alfred Hospital, Melbourne, VIC, Australia.,Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
| | - Tiziana Rancati
- Prostate Cancer Program, Scientific Directorate, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Eva Onjukka
- Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Martin A Ebert
- Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Physics, Mathematics and Computing, University of Western Australia, Perth, WA, Australia.,5D Clinics, Claremont, WA, Australia
| | - David J Joseph
- 5D Clinics, Claremont, WA, Australia.,GenesisCare, Subiaco, WA, Australia.,School of Surgery, University of Western Australia, WA, Australia
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Allison Steigler
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Jeremy L Millar
- Alfred Health Radiation Oncology, Alfred Hospital, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
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29
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Variation in Interinstitutional Plan Quality When Adopting a Hypofractionated Protocol for Prostate Cancer External Beam Radiation Therapy. Int J Radiat Oncol Biol Phys 2020; 107:243-252. [DOI: 10.1016/j.ijrobp.2020.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/21/2020] [Accepted: 02/18/2020] [Indexed: 11/20/2022]
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30
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Sanguineti G, Faiella A, Farneti A, D'Urso P, Fuga V, Olivieri M, Giannarelli D, Marzi S, Iaccarino G, Landoni V. Refinement & validation of rectal wall dose volume objectives for prostate hypofractionation in 20 fractions. Clin Transl Radiat Oncol 2020; 21:91-97. [PMID: 32072030 PMCID: PMC7015822 DOI: 10.1016/j.ctro.2020.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/25/2020] [Accepted: 01/29/2020] [Indexed: 02/07/2023] Open
Abstract
LRB was correlated to irradiation technique and several % rectal wall cut points. The predictive role of dosimetric variables relates to the irradiation technique. Dose volume objectives for patients treated with IMRT/VMAT are reported.
Background and purpose Dose-volume objectives for the rectum have been proposed to limit long term toxicity after moderately hypofractionated radiotherapy (MHRT) for localized prostate cancer. The purpose of the present study is to validate and possibly refine dose volume objective for the rectal wall after 20-fraction MHRT. Materials and methods All patients treated by 20-fraction MHRT at a single Institution were identified and relative rectal wall (%RW) DVH retrieved. The endpoint of the study is the development of grade 2+ late rectal bleeding (LRB) according to a modified RTOG scale. Clinical and dosimetric predictors of LRB were investigated at both uni- and multi-variable analysis. Results 293 patients were identified and analyzed. Of them, 35 (12%) developed the endpoint. At univariable analysis, antithrombotic drug usage (yes vs no), technique (3DCRT vs IMRT/VMAT) and several %RW DVH cut-points were significantly correlated with LRB. However, within patients treated by 3DCRT (N = 106), a bi-variable model including anti-thrombotic drug usage and selected %RW dose/volume metrics failed to identify independent dosimetric predictors of LRB. Conversely, within patients treated with intensity modulation (N = 187), the same model showed a progressively higher impact of the percent of RW receiving doses above 40 Gy. Based on this model, we were able to confirm (V32), refine (V60) and identify a novel (V50) cut-point for the %RW. Conclusion We recommend the following dose volume objectives for the %RW in order to minimize the risk of LRB after 20-fraction MHRT: V32 ≤ 50%; V50 ≤ 25.8% and V60 ≤ 10%.
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Affiliation(s)
- Giuseppe Sanguineti
- Departments of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
- Corresponding author at: Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy.
| | - Adriana Faiella
- Departments of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Alessia Farneti
- Departments of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Pasqualina D'Urso
- Departments of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Valentina Fuga
- Departments of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Michela Olivieri
- Departments of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Diana Giannarelli
- Departments of Statistics, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Simona Marzi
- Departments of Physics, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giuseppe Iaccarino
- Departments of Physics, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Valeria Landoni
- Departments of Physics, IRCCS Regina Elena National Cancer Institute, Rome, Italy
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31
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Tsang YM, Vignarajah D, Mcwilliam A, Tharmalingam H, Lowe G, Choudhury A, Hoskin P. A pilot study on dosimetric and radiomics analysis of urethral strictures following HDR brachytherapy as monotherapy for localized prostate cancer. Br J Radiol 2019; 93:20190760. [PMID: 31778319 DOI: 10.1259/bjr.20190760] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE A cohort of high dose-rate (HDR) monotherapy patients was analyzed to (i) establish the frequency of non-malignant urethral stricture; (ii) explore the relation between stricture formation with the dose distribution along the length of the urethra, and MRI radiomics features of the prostate gland. METHODS A retrospective review of treatment records of patients who received 19 Gy single fraction of HDR brachytherapy (BT) was carried out. A matched pair analysis used one control for each stricture case matched with pre-treatment International Prostate Symptom Score (IPSS) score, number of needles used and clinical target volume volume for each stricture case identified.For all data sets, pre-treatment T2 weighted MRI images were used to define regions of interests along the urethra and within the whole prostate gland. MRI textural radiomics features-energy, contrast and homogeneity were selected. Wilcoxon signed-rank test was performed to investigate significant differences in dosimetric parameters and MRI radiomics feature values between cases and controls. RESULTS From Nov 2010 to July 2017, there were 178 patients treated with HDR BT delivering 19 Gy in a single dose. With a median follow-up of 28.2 months, a total of 5/178 (3%) strictures were identified.10 patients were included in the matched pair analysis. The urethral dosimetric parameters investigated were not statistically different between cases and controls (p > 0.05). With regards to MRI radiomics feature analysis, significant differences were found in contrast and homogeneity between cases and controls (p < 0.05). However, this did not apply to the energy feature (p = 0.28). CONCLUSION In this matched pair analysis, no association between post-treatment stricture and urethral dosimetry was identified. Our study generated a preliminary clinical hypothesis suggesting that the MRI radiomics features of homogeneity and contrast of the prostate gland can potentially identify patients who develop strictures after HDR BT. Although the sample size is small, this warrants further validation in a larger patient cohort. ADVANCES IN KNOWLEDGE Urethral stricture has been reported as a specific late effect with prostate HDR brachytherapy. Our study reported a relatively low stricture rate of 3% and no association between post-treatment stricture and urethral dosimetry was identified. MRI radiomics features can potentially identify patients who are more prone to develop strictures.
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Affiliation(s)
- Yat Man Tsang
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | | | - Alan Mcwilliam
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | | | - Gerry Lowe
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Ananya Choudhury
- Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, United Kingdom.,Division of Cancer Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
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Shortall J, Vasquez Osorio E, Chuter R, McWilliam A, Choudhury A, Kirkby K, Mackay R, van Herk M. Assessing localized dosimetric effects due to unplanned gas cavities during pelvic MR-guided radiotherapy using Monte Carlo simulations. Med Phys 2019; 46:5807-5815. [PMID: 31600837 DOI: 10.1002/mp.13857] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/01/2019] [Accepted: 10/01/2019] [Indexed: 01/28/2023] Open
Abstract
PURPOSE It has been proposed that beam modulation and opposing beam configurations can cancel effects of the Electron Return Effect (ERE) during MR-guided radiotherapy (MRgRT). However, this may not always be the case for unplanned gas cavities outside of the target in the pelvic region. We evaluate dosimetric effects, including effects in the rectal wall, due to unplanned spherical air cavities during MRgRT. METHODS Nine virtual cuboid water phantoms containing spherical air cavities (0.5-7.5 cm diameter) and a reference phantom without air were created. Monte Carlo dose calculations of 7 MV photons under the influence of a 1.5 T transverse magnetic field were produced using Monaco 5.19.02 Treatment Planning System (TPS) (Elekta AB, Stockholm, Sweden). Cavities in the path of a single and multiple beam plans were considered. Dose distributions of phantoms with and without air cavities were compared (ΔD% ) using a spherical coordinate system originating in the center of the cavity. Effects in the rectal wall were quantified by comparing dose volume histogram (DVH) parameters for solid and gaseous filling from simulated rectal wall structures. RESULTS Max(ΔD% ) of ~70% and 20% were observed around large cavities in the path of a single and multiple beam plans, respectively. Approximately 45 cm3 of phantom surrounding the largest cavity in a single beam received dose changes of >10%. Dmean in the rectal wall was unchanged when comparing gaseous and solid filling in the path of a single beam; however, D1cc and Dmax increased by up to ~45% and ~63%, respectively. CONCLUSIONS Unplanned gas cavities in the path of a single beam during pelvic MRgRT with a 1.5 T transverse magnetic field cause dose changes which may impact toxicity in the rectal wall, depending on local dose and fractionation. Effects are reduced but not eliminated with a five-beam plan.
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Affiliation(s)
- Jane Shortall
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Eliana Vasquez Osorio
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Robert Chuter
- Department of Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Alan McWilliam
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Department of Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Ananya Choudhury
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Department of Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Karen Kirkby
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Department of Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Ranald Mackay
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Department of Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Marcel van Herk
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Department of Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
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Santos PMG, Barsky AR, Vapiwala N. Proton beam therapy after radical prostatectomy. Cancer 2019; 126:1135-1136. [PMID: 31774555 DOI: 10.1002/cncr.32642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/07/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Patricia Mae G Santos
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew R Barsky
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neha Vapiwala
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Olsson C, Nyholm T, Wieslander E, Onjukka E, Gunnlaugsson A, Reizenstein J, Johnsson S, Kristensen I, Skönevik J, Karlsson M, Isacsson U, Flejmer A, Abel E, Nordström F, Nyström L, Bergfeldt K, Zackrisson B, Valdman A. Initial experience with introducing national guidelines for CT- and MRI-based delineation of organs at risk in radiotherapy. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2019; 11:88-91. [PMID: 33458285 PMCID: PMC7807599 DOI: 10.1016/j.phro.2019.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/30/2019] [Accepted: 08/30/2019] [Indexed: 12/25/2022]
Abstract
A fundamental problem in radiotherapy is the variation of organ at risk (OAR) volumes. Here we present our initial experience in engaging a large Radiation Oncology (RO) community to agree on national guidelines for OAR delineations. Our project builds on associated standardization initiatives and invites professionals from all radiotherapy departments nationwide. Presently, one guideline (rectum) has successfully been agreed on by a majority vote. Reaching out to all relevant parties in a timely manner and motivating funding agencies to support the work represented early challenges. Population-based data and a scalable methodological approach are major strengths of the proposed strategy.
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Affiliation(s)
- Caroline Olsson
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Sweden.,Regional Cancer Centre West, Western Sweden Healthcare Region, Gothenburg, Sweden
| | - Tufve Nyholm
- Department of Radiation Sciences, Umeå University, Sweden
| | - Elinore Wieslander
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Sweden
| | - Eva Onjukka
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | | | - Johan Reizenstein
- Department of Oncology, Örebro University Hospital and Örebro University, Sweden
| | - Stefan Johnsson
- Department of Radiation Physics, Kalmar County Hospital, Sweden
| | - Ingrid Kristensen
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Sweden
| | - Johan Skönevik
- Department of Radiation Sciences, Umeå University, Sweden
| | | | - Ulf Isacsson
- Medical Radiation Physics, Dept. of Biomedical Engineering, Medical Physics and IT, Uppsala University Hospital, Uppsala, Sweden
| | - Anna Flejmer
- Department of Oncology, Linköping University Hospital, Sweden
| | - Edvard Abel
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Fredrik Nordström
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Sweden.,Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Leif Nyström
- Department of Radiation Sciences, Umeå University, Sweden
| | | | | | - Alexander Valdman
- Department of Radiation Therapy, Karolinska University Hospital, Stockholm, Sweden
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Santos PMG, Barsky AR, Hwang WT, Deville C, Wang X, Both S, Bekelman JE, Christodouleas JP, Vapiwala N. Comparative toxicity outcomes of proton-beam therapy versus intensity-modulated radiotherapy for prostate cancer in the postoperative setting. Cancer 2019; 125:4278-4293. [PMID: 31503338 DOI: 10.1002/cncr.32457] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Despite increasing utilization of proton-beam therapy (PBT) in the postprostatectomy setting, no data exist regarding toxicity outcomes relative to intensity-modulated radiotherapy (IMRT). The authors compared acute and late genitourinary (GU) and gastrointestinal (GI) toxicity outcomes in patients with prostate cancer (PC) who received treatment with postprostatectomy IMRT versus PBT. METHODS With institutional review board approval, patients with PC who received adjuvant or salvage IMRT or PBT (70.2 gray with an endorectal balloon) after prostatectomy from 2009 through 2017 were reviewed. Factors including combined IMRT and PBT and/or concurrent malignancies prompted exclusion. A case-matched cohort analysis was performed using nearest-neighbor 3-to-1 matching by age and GU/GI disorder history. Logistic and Cox regressions were used to identify univariate and multivariate associations between toxicities and cohort/dosimetric characteristics. Toxicity-free survival (TFS) was assessed using the Kaplan-Meier method. RESULTS Three hundred seven men (mean ± SD age, 59.7 ± 6.3 years; IMRT, n = 237; PBT, n = 70) were identified, generating 70 matched pairs. The median follow-up was 48.6 and 46.1 months for the IMRT and PBT groups, respectively. Although PBT was superior at reducing low-range (volumes receiving 10% to 40% of the dose, respectively) bladder and rectal doses (all P ≤ .01), treatment modality was not associated with differences in clinician-reported acute or late GU/GI toxicities (all P ≥ .05). Five-year grade ≥2 GU and grade ≥1 GI TFS was 61.1% and 73.7% for IMRT, respectively, and 70.7% and 75.3% for PBT, respectively; and 5-year grade ≥3 GU and GI TFS was >95% for both groups (all P ≥ .05). CONCLUSIONS Postprostatectomy PBT minimized low-range bladder and rectal doses relative to IMRT; however, treatment modality was not associated with clinician-reported GU/GI toxicities. Future prospective investigation and ongoing follow-up will determine whether dosimetric differences between IMRT and PBT confer clinically meaningful differences in long-term outcomes.
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Affiliation(s)
- Patricia Mae G Santos
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew R Barsky
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei-Ting Hwang
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Curtiland Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xingmei Wang
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stefan Both
- Department of Medical Physics, University Medical Center Groningen, Groningen, Netherlands
| | - Justin E Bekelman
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P Christodouleas
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neha Vapiwala
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Gomolka M, Blyth B, Bourguignon M, Badie C, Schmitz A, Talbot C, Hoeschen C, Salomaa S. Potential screening assays for individual radiation sensitivity and susceptibility and their current validation state. Int J Radiat Biol 2019; 96:280-296. [PMID: 31347938 DOI: 10.1080/09553002.2019.1642544] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose: The workshop on 'Individual Radiosensitivity and Radiosusceptibility' organized by MELODI and CONCERT on Malta in 2018, evaluated the current state of assays to identify sensitive and susceptible subgroups. The authors provide an overview on potential screening assays detecting individuals showing moderate to severe early and late radiation reactions or are at increased risk to develop cancer upon radiation exposure.Conclusion: It is necessary to separate clearly between tissue reactions and stochastic effects such as cancer when comparing the existing literature to validate various test systems. Requirements for the assays are set up. The literature is reviewed for assays that are reliable and robust. Sensitivity and specificity of the assays are regarded and scrutinized for modifying factors. Accuracy of an assay system is required to be more than 90% to balance risks of adverse reactions against risk to fail to cure the cancer. No assay/biomarker is in routine use. Assays that have shown predictive potential for radiosensitivity include SNPs, the RILA assay, and the pATM assay. A tree of risk guideline for radiologists is provided to assist medical treatment decisions. Recommendations for effective research include the setup of common retrospective and prospective cohorts/biobanks to validate current and future tests.
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Affiliation(s)
- Maria Gomolka
- Federal Office for Radiation Protection, Neuherberg, Germany
| | - Benjamin Blyth
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | | | - Christophe Badie
- Cancer Mechanisms and Biomarkers Group, Radiation Effects Department Centre for Radiation, Chemical and Environmental Hazards Public Health England, Didcot, United Kingdom
| | - Annette Schmitz
- Institut de Radiobiologie Cellulaire et Moléculaire, Institut de Biologie François Jacob, Direction de la Recherche Fondamentale, CEA, Paris, France
| | - Christopher Talbot
- Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
| | - Christoph Hoeschen
- Faculty of Electrical Engineering and Information Technology, Institute for Medical Technology, Otto-von-Guericke-University, Magdeburg, Germany
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Nakamura K, Konishi K, Komatsu T, Ishiba R. Quality of life after external beam radiotherapy for localized prostate cancer: Comparison with other modalities. Int J Urol 2019; 26:950-954. [PMID: 31131492 DOI: 10.1111/iju.14026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 04/24/2019] [Indexed: 12/29/2022]
Abstract
In external beam radiotherapy for localized prostate cancer, acute toxicities are typically transient and mild. These symptoms will disappear within 4-8 weeks after external beam radiotherapy. Some patients might suffer from proctitis with bloody stools as late rectal toxicity. Therefore, it has been shown that external beam radiotherapy has a more pronounced negative impact on bowel function compared with other treatment modalities. However, the recent development of modern beam delivery techniques, including intensity-modulated radiotherapy, allows us not only to deliver higher doses to the prostate, but also to decrease the doses to the critical organs, resulting in the maintenance of patients' quality of life within satisfactory levels. Patients' quality of life after external beam radiotherapy is also strongly related to the total dose, fractionation regimens, dose parameters of the critical organs and treatment plan quality, with a trade-off between the radicality of external beam radiotherapy and potentially increased toxicity. Radiation oncologists should choose treatment parameters carefully to achieve a reasonable balance between a good oncological outcome and the patient's quality of life.
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Affiliation(s)
- Katsumasa Nakamura
- Department of Radiation Oncology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kenta Konishi
- Department of Radiation Oncology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tetsuya Komatsu
- Department of Radiation Oncology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Ryo Ishiba
- Department of Radiation Oncology, Hamamatsu University School of Medicine, Hamamatsu, Japan
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In Regard to Cicchetti et al. Int J Radiat Oncol Biol Phys 2019; 103:776-777. [DOI: 10.1016/j.ijrobp.2018.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 10/10/2018] [Accepted: 11/02/2018] [Indexed: 11/20/2022]
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Mylona E, Acosta O, Lizee T, Lafond C, Crehange G, Magné N, Chiavassa S, Supiot S, Ospina Arango JD, Campillo-Gimenez B, Castelli J, de Crevoisier R. Voxel-Based Analysis for Identification of Urethrovesical Subregions Predicting Urinary Toxicity After Prostate Cancer Radiation Therapy. Int J Radiat Oncol Biol Phys 2019; 104:343-354. [PMID: 30716523 DOI: 10.1016/j.ijrobp.2019.01.088] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 01/22/2019] [Accepted: 01/26/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE To apply a voxel-based analysis to identify urethrovesical symptom-related subregions (SRSs) associated with acute and late urinary toxicity in prostate cancer radiation therapy. METHODS AND MATERIALS Two hundred seventy-two patients with prostate cancer treated with intensity-modulated radiation therapy/image-guided radiation therapy were analyzed prospectively. Each patient's computed tomography imaging was spatially normalized to a common coordinate system via nonrigid registration. The obtained deformation fields were used to map the dose of each patient to the common coordinate system. A voxel-based statistical analysis was applied to generate 3-dimensional dose-volume maps for different urinary symptoms, allowing the identification of corresponding SRSs with statistically significant dose differences between patients with or without toxicity. Each SRS was propagated back to each individual's native space, and dose-volume histograms (DVHs) for the SRSs and the whole bladder were computed. Logistic and Cox regression were used to estimate the SRS's prediction capability compared with the whole bladder. RESULTS A local dose-effect relationship was found in the bladder and the urethra. SRSs were identified for 5 symptoms: acute incontinence in the urethra, acute retention in the bladder trigone, late retention and dysuria in the posterior part of the bladder, and late hematuria in the superior part of the bladder, with significant dose differences between patients with and without toxicity, ranging from 1.2 to 9.3 Gy. The doses to the SRSs were significantly predictive of toxicity, with maximum areas under the receiver operating characteristic curve of 0.73 for acute incontinence, 0.62 for acute retention, 0.70 for late retention, 0.81 for late dysuria, and 0.67 for late hematuria. The bladder DVH was predictive only for late retention, dysuria, and hematuria (area under the curve, 0.65-0.72). CONCLUSIONS The dose delivered to the urethra and the posterior and superior parts of the bladder was predictive of acute incontinence and retention and of late retention, dysuria, and hematuria. The dose to the whole bladder was moderately predictive.
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Affiliation(s)
- Eugenia Mylona
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI - UMR 1099, F-35000 Rennes, France
| | - Oscar Acosta
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI - UMR 1099, F-35000 Rennes, France
| | - Thibaut Lizee
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI - UMR 1099, F-35000 Rennes, France
| | - Caroline Lafond
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI - UMR 1099, F-35000 Rennes, France
| | - Gilles Crehange
- Department of Radiation Oncology, Centre Georges François Leclerc, Dijon, France
| | - Nicolas Magné
- Department of Radiation Oncology, Lucien Neuwirth Cancer Institute, St Priest en Jarez, France
| | - Sophie Chiavassa
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest, Saint Herblain, France
| | - Stéphane Supiot
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest, Saint Herblain, France
| | - Juan David Ospina Arango
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI - UMR 1099, F-35000 Rennes, France; Universidad Nacional de Colombia, Medellin, Colombia
| | | | - Joel Castelli
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI - UMR 1099, F-35000 Rennes, France
| | - Renaud de Crevoisier
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI - UMR 1099, F-35000 Rennes, France.
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