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Patel KR, van der Heide UA, Kerkmeijer LGW, Schoots IG, Turkbey B, Citrin DE, Hall WA. Target Volume Optimization for Localized Prostate Cancer. Pract Radiat Oncol 2024:S1879-8500(24)00148-6. [PMID: 39019208 DOI: 10.1016/j.prro.2024.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 06/17/2024] [Accepted: 06/26/2024] [Indexed: 07/19/2024]
Abstract
PURPOSE To provide a comprehensive review of the means by which to optimize target volume definition for the purposes of treatment planning for patients with intact prostate cancer with a specific emphasis on focal boost volume definition. METHODS Here we conduct a narrative review of the available literature summarizing the current state of knowledge on optimizing target volume definition for the treatment of localized prostate cancer. RESULTS Historically, the treatment of prostate cancer included a uniform prescription dose administered to the entire prostate with or without coverage of all or part of the seminal vesicles. The development of prostate magnetic resonance imaging (MRI) and positron emission tomography (PET) using prostate-specific radiotracers has ushered in an era in which radiation oncologists are able to localize and focally dose-escalate high-risk volumes in the prostate gland. Recent phase 3 data has demonstrated that incorporating focal dose escalation to high-risk subvolumes of the prostate improves biochemical control without significantly increasing toxicity. Still, several fundamental questions remain regarding the optimal target volume definition and prescription strategy to implement this technique. Given the remaining uncertainty, a knowledge of the pathological correlates of radiographic findings and the anatomic patterns of tumor spread may help inform clinical judgement for the definition of clinical target volumes. CONCLUSION Advanced imaging has the ability to improve outcomes for patients with prostate cancer in multiple ways, including by enabling focal dose escalation to high-risk subvolumes. However, many questions remain regarding the optimal target volume definition and prescription strategy to implement this practice, and key knowledge gaps remain. A detailed understanding of the pathological correlates of radiographic findings and the patterns of local tumor spread may help inform clinical judgement for target volume definition given the current state of uncertainty.
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Affiliation(s)
- Krishnan R Patel
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute (NKI-AVL), Amsterdam, The Netherlands
| | - Linda G W Kerkmeijer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ivo G Schoots
- Department of Radiation Oncology, The Netherlands Cancer Institute (NKI-AVL), Amsterdam, The Netherlands
| | - Baris Turkbey
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Deborah E Citrin
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - William A Hall
- Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
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Mohamad O, Nicosia L, Mathier E, Riggenbach E, Zamboglou C, Aebersold DM, Alongi F, Shelan M. Focal brachytherapy as definitive treatment for localized prostate cancer: A systematic review and meta-analysis. Brachytherapy 2024; 23:309-320. [PMID: 38431441 DOI: 10.1016/j.brachy.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 12/06/2023] [Accepted: 01/18/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE In this systematic review and meta-analysis, we describe the oncologic and toxicity outcomes of definitive focal brachytherapy for prostate cancer. METHODS AND MATERIALS A PROSPERO registered study (CRD42023410170) was conducted following the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines. PubMed, Embase, and The Cochrane Library were searched for studies between 2000 and 2022. Two authors independently performed the initial search. Biochemical recurrence-free survival (bRFS) was defined as the primary endpoint for the meta-analysis. Generalized linear mixed-effects models were conducted to calculate effect size and quantify heterogeneity. We also describe the side effects and local recurrence patterns of focal brachytherapy. RESULTS Ten studies were identified and included 315 patients treated using focal brachytherapy as a definitive treatment. Mean (SD) age was 67.65 (7.9) years and mean (SD) PSA was 7.15 (2.7) ng/mL. Most patients (n = 236, 75%) underwent LDR Brachytherapy and 25% received HDR brachytherapy. Among the participants, 147 (46.5%) had a Gleason score ≤6, and 169 (53.5%) had a Gleason score ≥7. Only 11 (3.5%) patients received ADT. Overall, bRFS rate at median follow-up 4 years (Range: 1-6.42 years) was 91% (95% confidence interval [CI], 82-95%). Acute Grade ≤ 2 GU and GI toxicities were reported in 22 (7%) and 11 (3.5%) patients, respectively. Late Grade ≤ 2 GU and GI toxicity were reported in 6 (2%) and 14 (4.4%) patients, respectively. One case of prostate hemorrhage due to improper foley removal was noted but otherwise no acute or late Grade 3 or higher GI or GU toxicity related to radiotherapy was reported. CONCLUSION Overall, definitive focal brachytherapy has a favorable toxicity profile. Oncologic outcomes are yet to mature. The evidence is limited by the small number of studies with low patients' number, across study heterogeneity, and possibility of publication bias.
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Affiliation(s)
- Osama Mohamad
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Luca Nicosia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, Italy
| | - Etienne Mathier
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Elena Riggenbach
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Constantinos Zamboglou
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; German Oncology Center, University Hospital of the European University, Limassol, Cyprus
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fillipo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, Italy
| | - Mohamed Shelan
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Jonušas J, Patasius A, Trakymas M, Venius J, Janulionis E, Smailyte G, Kincius M. Efficacy of focal high-dose-rate brachytherapy in the treatment of patients diagnosed with low or favourable: intermediate-risk prostate cancer-a protocol for a randomised controlled trial. BMJ Open 2023; 13:e070020. [PMID: 37197816 DOI: 10.1136/bmjopen-2022-070020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
INTRODUCTION Prostate cancer (PCa) is men's second most predominant cancer worldwide. Because the prostate-specific antigen test is used in diagnostics, PCa is more often diagnosed in the early stages, making radical treatment of the disease possible. However, it is estimated that over a million men worldwide suffer from radical treatment-related complications. Thus, focal treatment has been proposed as a solution, which aims to destroy the predominant lesson that determines the progression of the disease. The main objective of our study is to compare the quality of life and efficacy of patients diagnosed with PCa before and after the treatment with focal high-dose-rate brachytherapy and to compare results with focal low-dose-rate brachytherapy and active surveillance. METHODS AND ANALYSIS 150 patients diagnosed with low-risk or favourable intermediate-risk PCa who meet the inclusion criteria will be enrolled in the study. Patients are going to be randomly assigned to the study groups: focal high-dose-rate brachytherapy (group 1), focal low-dose-rate brachytherapy (group 2) and active surveillance (group 3). The study's primary outcomes are quality of life after the procedure and time without biochemical disease recurrence. The secondary outcomes are early and late genitourinary and gastrointestinal reactions after the focal high-dose and low-dose-rate brachytherapies and evaluation of the importance and significance of in vivo dosimetry used for high-dose-rate brachytherapy. ETHICS AND DISSEMINATION Bioethics committee approval was obtained before this study. The trial results will be published in peer-reviewed journals and at conferences. TRIAL REGISTRATION NUMBER Vilnius regional bioethics committee; approval ID 2022/6-1438-911.
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Affiliation(s)
- Justinas Jonušas
- Clinic of Hematology and Oncology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Laboratory of Cancer Epidemiology, National Cancer Institute, Vilnius, Lithuania
| | - Ausvydas Patasius
- Laboratory of Cancer Epidemiology, National Cancer Institute, Vilnius, Lithuania
- Institute of Health Sciences, Vilnius University Faculty of Medicine, Vilnius, Lithuania
| | - Mantas Trakymas
- Department of Radiology, National Cancer Institute, Vilnius, Lithuania
| | - Jonas Venius
- Medical Physics Department, National Cancer Institute, Vilnius, Lithuania
- Laboratory of Biomedical Physics, National Cancer Institute, Vilnius, Lithuania
| | | | - Giedre Smailyte
- Laboratory of Cancer Epidemiology, National Cancer Institute, Vilnius, Lithuania
- Institute of Health Sciences, Vilnius University Faculty of Medicine, Vilnius, Lithuania
| | - Marius Kincius
- Department of Oncourology, National Cancer Institute, Vilnius, Lithuania
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Zeng H, Dai J, Cao D, Wang M, Zhao J, Zeng Y, Xu N, Xie Y, Liu H, Zeng H, Sun G, Shen P. Safety and efficacy associated with single-fraction high-dose-rate brachytherapy in localized prostate cancer: a systematic review and meta-analysis. Strahlenther Onkol 2023; 199:525-535. [PMID: 37093230 DOI: 10.1007/s00066-023-02063-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 02/19/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE Although single-fraction high-dose-rate brachytherapy (SFHDR) for localized prostate cancer has been tried in clinical trials, relevant medical evidence is currently lacking. It is necessary to systematically analyze the safety and efficacy of SFHDR. METHODS Comprehensive and systematic searches for eligible studies were performed in PubMed, Embase, and the Cochrane Library databases. The primary endpoints included safety and efficacy, represented by toxic effects and biochemical recurrence-free survival (bRFS), respectively. The proportion rates were used as the effect measure for each study and were presented with corresponding 95% confidence intervals (CI) and related 95% prediction interval (PI). Restricted maximum-likelihood estimator (REML) and the Hartung-Knapp method were used in the meta-analysis. RESULTS Twenty-five studies met the inclusion criteria for quantitative analysis, including 1440 patients. The median age of patients was 66.9 years old (62-73 years old) and the median follow-up was 47.5 months (12-75 months). The estimates of cumulative occurrence for severe gastrointestinal (GI) and genitourinary (GU) toxic effects were 0.1% (95% CI 0-0.2%) and 0.4% (95% CI 0-1.2%), and for grade 2 toxic effects were 1.6% (95% CI 0.1-4.7%) and 17.1% (95% CI 5.4-33.5%), respectively. The estimate of 3‑year bRFS was 87.5% (95% CI 84.4-90.3%) and 71.0% (95% CI 63.0-78.3%) for 5‑year bRFS. The pooled bRFS rates for low-risk patients were 99.0% (95% CI 85.2-100.0%) at 3 years and 80.9% (95% CI 75.4-85.9%) at 5 years, and the risk group was found to be statistically correlated with bRFS (3-year bRFS, P < 0.01; 5‑year bRFS, P = 0.04). CONCLUSION SFHDR is associated with favorable tolerability and suboptimal clinical benefit in patients with localized prostate cancer. Ongoing and planned high-quality prospective studies are necessary to verify its safety and efficacy.
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Affiliation(s)
- Hong Zeng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Jindong Dai
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Dehong Cao
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Minghao Wang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Jinge Zhao
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuhao Zeng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Nanwei Xu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Yandong Xie
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Haolin Liu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Zeng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Guangxi Sun
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.
| | - Pengfei Shen
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China.
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Jafarieh S, Vishwanath V, Rembielak A. Overview of imaging used to guide management for prostate and bladder malignancy. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2023. [DOI: 10.1111/ijun.12361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Affiliation(s)
- Sarah Jafarieh
- Department of Radiology Royal Oldham Hospital Oldham Manchester UK
| | - Veena Vishwanath
- Department of Radiology Manchester Foundation Trust Manchester UK
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Feasibility of MRI targeted single fraction HDR brachytherapy for localized prostate carcinoma: ProFocAL-study. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04491-3. [DOI: 10.1007/s00432-022-04491-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 11/18/2022] [Indexed: 11/30/2022]
Abstract
Abstract
Purpose
A potential method for focal therapy in locally advanced prostate cancer is focal brachytherapy (F-BT). The purpose of this research was to evaluate midterm F-BT oncologic, functional, and toxicological results in men who had therapy for prostate cancer.
Materials and methods
Between 2016 and 2020, F-BT was used to treat 37 patients with low- to intermediate-risk prostate cancer. The recommended dosage was 20 Gy. Failure was defined as the existence of any prostate cancer that has persisted in-field after treatment. The F-BT oncologic and functional outcomes served as the main and secondary objectives, respectively.
Results
A median 20-month follow-up (range 14–48 months). 37 patients received F-BT and enrolled in the study; no patient experienced a biochemical recurrence in the first 24 months, according to Phoenix criteria. In the control biopsies, only 6 patients showed in-field failure. The median initial IPSS was 6.5, at 6 months was 6.0, and at 24 months was 5.0. When the median ICIQ-SF score was 0 at the baseline, it remained 0 at 6-, 12-, and 24 months. Overall survival and biochemical disease-free survival after 3 years were all at 100% and 86.4%, respectively. There was no notable acute gastro-intestinal (GI) or genitourinary (GU) adverse effects. No intraoperative or perioperative complications occurred.
Conclusions
For selected patients with low- or intermediate-risk localized prostate cancer, F-BT is a safe and effective therapy.
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Kamitani N, Miyaji Y, Tamada T, Yoden E, Kawata Y, Watanabe K, Tokiya R, Nagai A, Katsui K. Feasibility of magnetic resonance imaging-ultrasound guided high-dose-rate brachytherapy for localized prostate cancer: Preliminary results from a prospective study. Int J Urol 2022; 29:725-732. [PMID: 35355325 DOI: 10.1111/iju.14880] [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: 10/27/2021] [Accepted: 03/21/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to investigate preliminary outcomes of a prospective trial of magnetic resonance imaging-ultrasound fusion-guided ultrafocal high-dose-rate brachytherapy in localized prostate cancer. METHODS In our prospective study, data from patients who underwent this treatment between April 1, 2020 and March 31, 2021 were analyzed. In the procedure, the applicator needle was inserted through the perineum to target the lesion on the multiparametric magnetic resonance imaging, which was fused onto the transrectal ultrasound image. The prescription dose was set at a single fraction of 19 Gy. Data from patients who received whole-gland high-dose-rate brachytherapy were extracted and compared with data from patients who received ultrafocal high-dose-rate brachytherapy, to evaluate the frequency of acute adverse events. RESULTS Eight patients underwent ultrafocal high-dose-rate brachytherapy with a median observation period of 7.75 months (range 5.96-15.36 months). No acute genitourinary or gastrointestinal adverse events were observed in this cohort. The planned procedure was completed in all patients, and no unexpected adverse events were observed; however, prostate-specific antigen failure was detected in one patient. In the 25 patients who underwent whole-gland high-dose-rate brachytherapy, acute genitourinary and gastrointestinal adverse events were observed in 88% and 20% of the patients, respectively. Ultrafocal high-dose-rate brachytherapy was a significant factor in avoiding acute adverse genitourinary events in univariate and multivariate analyses (P < 0.001 and P = 0.032, respectively). CONCLUSIONS Magnetic resonance imaging-ultrasound fusion-guided ultrafocal high-dose-rate brachytherapy in localized prostate cancer is a safe and feasible treatment without acute genitourinary and gastrointestinal adverse events. Long-term observation and further investigation are warranted.
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Affiliation(s)
- Nobuhiko Kamitani
- Departments of Radiology, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Yoshiyuki Miyaji
- Department of Urology, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Tsutomu Tamada
- Departments of Radiology, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Eisaku Yoden
- Departments of Radiology, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Yujiro Kawata
- Departments of Radiology, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Kenta Watanabe
- Departments of Radiology, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Ryouji Tokiya
- Departments of Radiology, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Atsushi Nagai
- Department of Urology, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Kuniaki Katsui
- Departments of Radiology, Kawasaki Medical School, Kurashiki, Okayama, Japan
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Liu W, Fakir H, Randhawa G, Alfano R, Corkum M, Kassam Z, Rachinsky I, Chung HT, Chung P, Loblaw A, Morton G, Sexton T, Kapoor A, Ward A, Zukotynski K, Emmett L, Bauman G. Defining radio-recurrent intra-prostatic target volumes using PSMA-targeted PET/CT and multi-parametric MRI. Clin Transl Radiat Oncol 2022; 32:41-47. [PMID: 34841094 PMCID: PMC8606298 DOI: 10.1016/j.ctro.2021.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/08/2021] [Accepted: 11/08/2021] [Indexed: 11/01/2022] Open
Abstract
PURPOSE Our purpose was to evaluate intra-prostatic cancer volumes for salvage radiotherapy in men with recurrent prostate cancer confined to the prostate post-primary radiotherapy using mpMRI and 18F-DCFPyL PET/CT (PET). METHODS Men with biochemical failure post-primary radiotherapy were enrolled in a multi-centre trial investigating mpMRI and PET. All men with isolated intra-prostatic recurrence are included in this secondary analysis. The intra-prostatic gross tumour volume (GTV) was manually delineated on mpMRI and was also delineated on PET using three methods: 1. manually, 2. using a 30% threshold of maximum intra-prostatic standard uptake value (SUVmax), and 3. using a 67% threshold of this SUVmax. Clinical target volumes (CTV) including expansions on each GTV were generated. Conformity indices were performed between the mpMRI CTV and each PET CTV. Correlation with biopsy and clinical outcomes were performed. RESULTS Of the 36 men included, 30 (83%) had disease in two quadrants or less using the combination of mpMRI and PET. Mean target volume (union of CTV on mpMRI and CTV manually delineated on PET) was 12.2 cc (49% of prostate gland volume). 12/36 (33%) men had a biopsy. Per-patient sensitivity was 91% for mpMRI and 82% for PET. CONCLUSIONS mpMRI and PET provide complementary information for delineation of intra-prostatic recurrent disease. Union of CTV on mpMRI and PET is often less than 50% of the prostate, suggesting this imaging could help define a target for focal salvage therapy.
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Affiliation(s)
- Wei Liu
- Department of Oncology, Division of Radiation Oncology, London Health Sciences Centre and Western University, London, Canada
| | - Hatim Fakir
- Department of Oncology and Department of Medical Biophysics, London Health Sciences Centre and Western University, London, Canada
| | | | - Ryan Alfano
- Department of Radiation Oncology, Windsor Regional Cancer Centre, Windsor Regional Hospital, Windsor, Canada
| | - Mark Corkum
- Division of Radiation Oncology, The Ottawa Hospital Cancer Centre and the University of Ottawa, Ottawa, Canada
| | - Zahra Kassam
- Department of Medical Imaging, St. Joseph’s Health Care and Western University, London, Canada
| | - Irina Rachinsky
- Division of Nuclear Medicine, London Health Sciences Centre and Western University, London, Canada
| | - Hans T. Chung
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Peter Chung
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Andrew Loblaw
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Institute of Health Care Policy and Evaluation, University of Toronto, Canada
| | - Gerard Morton
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Tracy Sexton
- Department of Oncology, Division of Radiation Oncology, London Health Sciences Centre and Western University, London, Canada
| | - Anil Kapoor
- Urologic Cancer Centre for Research & Innovation and McMaster University, Hamilton, Canada
| | - Aaron Ward
- Department of Medical Biophysics, Lawson Health Research Institute and Western University, London, Canada
| | - Katherine Zukotynski
- Division of Nuclear Medicine, London Health Sciences Centre and Western University, London, Canada
- Departments of Medicine and Radiology, McMaster University, Hamilton, Canada
| | - Louise Emmett
- Department of Nuclear Medicine and Theranostics, St. Vincent’s Hospital and University of New South Wales, Sydney, Australia
| | - Glenn Bauman
- Department of Oncology, Division of Radiation Oncology, London Health Sciences Centre and Western University, London, Canada
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van Luijtelaar A, Fütterer JJ, Bomers JG. Minimally invasive magnetic resonance image-guided prostate interventions. Br J Radiol 2021; 95:20210698. [PMID: 34723623 PMCID: PMC8978246 DOI: 10.1259/bjr.20210698] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Whole gland prostate cancer treatment, i.e. radical prostatectomy or radiation therapy, is highly effective but also comes with a significant impact on quality of life and possible overtreatment in males with low to intermediate risk disease. Minimal-invasive treatment strategies are emerging techniques. Different sources of energy are used to aim for targeted treatment in order to reduce treatment-related complications and morbidity. Imaging plays an important role in targeting and monitoring of treatment approaches preserving parts of the prostatic tissue. Multiparametric magnetic resonance imaging (mpMRI) is widely used during image-guided interventions due to the multiplanar and real-time anatomical imaging while providing an improved treatment accuracy. This review evaluates the available image-guided prostate cancer treatment options using MRI or magnetic resonance imaging/transrectal ultrasound (MRI/TRUS)-fusion guided imaging. The discussed minimal invasive image-guided prostate interventions may be considered as safe and feasible partial gland ablation in patients with (recurrent) prostate cancer. However, most studies focusing on minimally invasive prostate cancer treatments only report early stages of research and subsequent high-level evidence is still needed. Ensuring a safe and appropriate utilization in patients that will benefit the most, and applied by physicians with relevant training, has become the main challenge in minimally invasive prostate cancer treatments.
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Affiliation(s)
- Annemarijke van Luijtelaar
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jurgen J Fütterer
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joyce Gr Bomers
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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10
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Fiard G, Chowdhury A, Potter AR, Pook CJ, Kelly D, Emberton M, Yap T. Detailing Sexual Outcomes After Focal Therapy for Localised Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Focus 2021; 8:926-941. [PMID: 34580049 DOI: 10.1016/j.euf.2021.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/04/2021] [Accepted: 09/10/2021] [Indexed: 11/04/2022]
Abstract
CONTEXT Focal therapy has emerged as a promising option to treat well-selected men with localised prostate cancer while preserving healthy prostate tissue and key structures, such as the urethral sphincter and neurovascular bundles. However, how this tissue preservation may translate into improved outcomes, particularly into improved sexual outcomes, is still an active research field. OBJECTIVE We conducted a systematic review and meta-analysis of the literature to summarise the existing evidence, in order to provide patients with updated data on what to expect after treatment and help identify gaps in current knowledge that may warrant future research. EVIDENCE ACQUISITION A systematic literature search was conducted on Medline, EMBASE, Scopus, and Web of Science. The search strategy was defined using the "litsearchr" function in R based on a preliminary "naïve" search using the following terms on Medline: (("focal therapy" OR "focal treatment") AND ("prostate cancer") AND ("sexual function" OR "erectile function")). A total of 42 studies, comprising 3117 patients treated and 2352 with available sexual outcomes, were included in the qualitative data synthesis and 26 in a random-effect meta-analysis. EVIDENCE SYNTHESIS The five-item International Index of Erectile Function (IIEF-5) was the most frequently used questionnaire (30/42 studies), with completion rates ranging from 24% to 100% at 18-24 mo. A decrease was noted at 3 mo (IIEF-5 decrease estimate -3.70 [95% confidence interval -4.43, -2.96]), with improvements at 6 mo (-2.18 [-2.91, -1.46]) and 12 mo (-2.14 [-2.96, -1.32]). Studies in which patients had an altered baseline sexual function were more likely to report a significant and durable postoperative decrease in erectile function scores. The patient-reported outcome questionnaires used were not designed for a diverse population. Functional outcomes were not the primary endpoint and have not been reported consistently in most studies considered. CONCLUSIONS Focal therapy led to changes in erectile function in most cases under the significance threshold of the patient-reported outcome questionnaires used. However, patients should be counselled according to their baseline erectile function. More research is warranted to detail aspects other than erectile function, such as ejaculation or orgasm. The early postoperative period appears key to study sexual changes after focal therapy, while only a moderate decrease is expected at 12 mo. PATIENT SUMMARY We reviewed the published literature detailing the sexual consequences of focal therapy for localised prostate cancer using patient-reported outcome questionnaires. Patients were likely to describe a significant decrease in their erectile function at 3 mo, with improvements noted at 6 and 12 mo. The results obtained may not be reproducible in a more diverse population, and further research is warranted to better study aspects other than erectile function, such as ejaculation or orgasm.
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Affiliation(s)
- Gaelle Fiard
- UCL Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK; Department of Urology, Grenoble Alpes University Hospital, Grenoble, France; Université Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, Grenoble, France.
| | - Aminah Chowdhury
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK; GKT School of Medical Education, King's College London, London, UK
| | - Aneirin R Potter
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK; GKT School of Medical Education, King's College London, London, UK
| | - Celina J Pook
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK; GKT School of Medical Education, King's College London, London, UK
| | - Daniel Kelly
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Mark Emberton
- UCL Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Tet Yap
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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11
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Hopstaken JS, Bomers JGR, Sedelaar MJP, Valerio M, Fütterer JJ, Rovers MM. An Updated Systematic Review on Focal Therapy in Localized Prostate Cancer: What Has Changed over the Past 5 Years? Eur Urol 2021; 81:5-33. [PMID: 34489140 DOI: 10.1016/j.eururo.2021.08.005] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 08/12/2021] [Indexed: 11/04/2022]
Abstract
CONTEXT Focal therapy is a promising, minimally invasive strategy to selectively treat localized prostate cancer. A previous systematic review indicated that there is growing evidence for favorable functional outcomes, but that oncological effectiveness was yet to be defined. OBJECTIVE To assess the effectiveness of focal therapy in patients with localized prostate cancer in terms of functional and oncological outcomes. EVIDENCE ACQUISITION PubMed, Embase, and The Cochrane Library were searched for studies between October 2015 and December 31, 2020. In addition, the research stages were acquired according to the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) recommendations. Ongoing studies were identified through clinical trial registries. EVIDENCE SYNTHESIS Seventy-two studies were identified exploring eight different sources of energy to deliver focal therapy in 5827 patients. Twenty-seven studies reported on high-intensity focused ultrasound (HIFU), nine studies on irreversible electroporation, 11 on cryoablation, eight on focal laser ablation and focal brachytherapy, seven on photodynamic therapy (PDT), two on radiofrequency ablation, and one on prostatic artery embolization. The majority of studies were prospective development stage 2a studies (n = 35). PDT and HIFU, both in stage 3, showed promising results. Overall, HIFU studies reported a median of 95% pad-free patients and a median of 85% patients with no clinically significant cancer (CSC) in the treated area. For PDT, no changes in continence were reported and a median of 90% of patients were without CSC. Both treatments were well tolerated. CONCLUSIONS Over the past 5 yr, focal therapy has been studied for eight different energy sources, mostly in single-arm stage 2 studies. Although a first randomized controlled trial in focal therapy has been performed, more high-quality evaluations are needed, preferably via multicenter randomized controlled trials with long-term follow-up and predefined assessment of oncological and functional outcomes and health-related quality-of-life measures. PATIENT SUMMARY Focal treatment (FT) of prostate cancer has potential, considering that it has less impact on continence and potency than radical treatment. Our systematic review indicates that despite the method being studied extensively over the past half decade, the majority of studies remain in an early research stage. The techniques high-intensity focused ultrasound and photodynamic therapy have shown most progression toward advanced research stages and show favorable results. However, more high-quality evidence is required before FT can become available as a standard treatment.
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Affiliation(s)
- Jana S Hopstaken
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Joyce G R Bomers
- Department of Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michiel J P Sedelaar
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Massimo Valerio
- Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Jurgen J Fütterer
- Department of Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maroeska M Rovers
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
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12
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Murgic J, Chung HT. In Regard to van Son et al. Int J Radiat Oncol Biol Phys 2021; 110:617-618. [PMID: 33989586 DOI: 10.1016/j.ijrobp.2021.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/12/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Jure Murgic
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre milosrdnice, Zagreb, Croatia
| | - Hans T Chung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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13
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van Son MJ, Peters M, Moerland MA, van der Voort van Zyp JRN. In Reply to Murgic and Chung. Int J Radiat Oncol Biol Phys 2021; 110:618-619. [PMID: 33989587 DOI: 10.1016/j.ijrobp.2021.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - Max Peters
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marinus A Moerland
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
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14
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van Son MJ, Peters M, Reddy D, Shah TT, Hosking-Jervis F, Robinson S, Lagendijk JJW, Mangar S, Dudderidge T, McCracken S, Hindley RG, Emara A, Nigam R, Persad R, Virdi J, Lewi H, Moore C, Orczyk C, Emberton M, Arya M, Ahmed HU, van der Voort van Zyp JRN, Winkler M, Falconer A. Conventional radical versus focal treatment for localised prostate cancer: a propensity score weighted comparison of 6-year tumour control. Prostate Cancer Prostatic Dis 2021; 24:1120-1128. [PMID: 33934114 DOI: 10.1038/s41391-021-00369-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/14/2021] [Accepted: 04/15/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND For localised prostate cancer, focal therapy offers an organ-sparing alternative to radical treatments (radiotherapy or prostatectomy). Currently, there is no randomised comparative effectiveness data evaluating cancer control of both strategies. METHODS Following the eligibility criteria PSA < 20 ng/mL, Gleason score ≤ 7 and T-stage ≤ T2c, we included 830 radical (440 radiotherapy, 390 prostatectomy) and 530 focal therapy (cryotherapy, high-intensity focused ultrasound or high-dose-rate brachytherapy) patients treated between 2005 and 2018 from multicentre registries in the Netherlands and the UK. A propensity score weighted (PSW) analysis was performed to compare failure-free survival (FFS), with failure defined as salvage treatment, metastatic disease, systemic treatment (androgen deprivation therapy or chemotherapy), or progression to watchful waiting. The secondary outcome was overall survival (OS). Median (IQR) follow-up in each cohort was 55 (28-83) and 62 (42-83) months, respectively. RESULTS At baseline, radical patients had higher PSA (10.3 versus 7.9) and higher-grade disease (31% ISUP 3 versus 11%) compared to focal patients. After PSW, all covariates were balanced (SMD < 0.1). 6-year weighted FFS was higher after radical therapy (80.3%, 95% CI 73.9-87.3) than after focal therapy (72.8%, 95% CI 66.8-79.8) although not statistically significant (p = 0.1). 6-year weighted OS was significantly lower after radical therapy (93.4%, 95% CI 90.1-95.2 versus 97.5%, 95% CI 94-99.9; p = 0.02). When compared in a three-way analysis, focal and LRP patients had a higher risk of treatment failure than EBRT patients (p < 0.001), but EBRT patients had a higher risk of mortality than focal patients (p = 0.008). CONCLUSIONS Within the limitations of a cohort-based analysis in which residual confounders are likely to exist, we found no clinically relevant difference in cancer control conferred by focal therapy compared to radical therapy at 6 years.
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Affiliation(s)
- Marieke J van Son
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK. .,Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK. .,Department of Radiotherapy, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Max Peters
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Deepika Reddy
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Taimur T Shah
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Department of Urology, Sunderland Royal Hospital, City Hospital Foundation Trust, Sunderland, UK
| | - Feargus Hosking-Jervis
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Stephen Robinson
- Division of Clinical Oncology, Department of Radiotherapy, Charing Cross Hospital, Imperial College London Healthcare NHS Trust, London, UK
| | - Jan J W Lagendijk
- Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Stephen Mangar
- Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Tim Dudderidge
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Stuart McCracken
- Department of Urology, Sunderland Royal Hospital, City Hospital Foundation Trust, Sunderland, UK
| | - Richard G Hindley
- Department of Urology, Hampshire Hospitals & Ain Shams University Hospitals, Basingstoke, UK
| | - Amr Emara
- Department of Urology, Hampshire Hospitals & Ain Shams University Hospitals, Basingstoke, UK
| | - Raj Nigam
- BMI Mount Alvernia Hospital, Guildford, Surrey, UK
| | - Raj Persad
- Department of Urology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jaspal Virdi
- Department of Urology, Princes Alexandra Hospital NHS Trust, Harlow, UK.,Rivers Hospital, Essex, UK
| | | | - Caroline Moore
- Department of Surgery and Interventional Sciences, University College London, and University College Hospital London, London, UK.,Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Clement Orczyk
- Department of Surgery and Interventional Sciences, University College London, and University College Hospital London, London, UK.,Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Mark Emberton
- Department of Surgery and Interventional Sciences, University College London, and University College Hospital London, London, UK.,Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Manit Arya
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK.,Department of Urology, Princes Alexandra Hospital NHS Trust, Harlow, UK.,Rivers Hospital, Essex, UK.,Department of Urology, UCLH NHS Foundation Trust, London, UK
| | - Hashim U Ahmed
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Matt Winkler
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Alison Falconer
- Imperial Prostate, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
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15
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Armstrong S, Brown S, Stancliffe M, Ostler P, Hughes R, Hoskin P, Alonzi R. Single dose high-dose-rate brachytherapy with focal dose escalation for prostate cancer: Mature results of a phase 2 clinical trial. Radiother Oncol 2021; 159:67-74. [PMID: 33766703 DOI: 10.1016/j.radonc.2021.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/11/2021] [Accepted: 03/11/2021] [Indexed: 12/27/2022]
Abstract
AIM The dominant intraprostatic lesion (DIL) is the commonest site of relapse after single dose high-dose-rate brachytherapy (HDR-BT) for localised prostate cancer. This study investigated toxicity and clinical outcomes of focal dose escalation to the DIL with dose de-escalation to the remaining prostate. MATERIALS/METHODS Between November 2012 and July 2016, 50 patients with localised prostate adenocarcinoma received single fraction HDR-BT. 21 Gy was prescribed to the DIL, with two de-escalation prescription schedules for the remaining prostate. Primary outcomes included biochemical no evidence of disease (bNED), local recurrence free survival (LRFS), and metastasis free survival (MFS). Secondary outcomes included late genitourinary, gastrointestinal and sexual toxicity. Kaplan-Meier analyses with log rank tests were used to estimate bNED, LRFS and MFS. RESULTS With a median follow up of 70.6 months, 15 patients developed biochemical failure, including 8 in the group that received minor dose de-escalation to the non-DIL prostate (group 1) and 7 in the group that received moderate de-escalation (group 2). Five-year bNED was 88% in group 1 and 76% in group 2 (p = 0.05). Overall 4-year and 5-year FFLF in group 1 was 100% and 96% and in group 2 92% and 84%. These differences were statistically significant (p = 0.03). No acute ≥G3 genitourinary or ≥G2 gastrointestinal toxicity was reported. The median IIEF decreased in the first 6 months improving to a peak median score of 20 at 54 months. CONCLUSION Focal boost to the DIL did not improve biochemical or local control after single-fraction HDR monotherapy compared to what would be expected from 19 Gy single fraction treatment to the whole gland.
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Affiliation(s)
- Shreya Armstrong
- Mount Vernon Cancer Centre, Northwood, UK; Lismore Base Hospital, North Coast Cancer Institute, New South Wales, Australia.
| | | | - May Stancliffe
- West Suffolk Hospital, Bury St Edmunds, UK; Addenbrooke's Hospital, Cambridge, UK
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16
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Ta MH, Nunes-Silva I, Barret E, Renard-Penna R, Rozet F, Mombet A, Cathala N, Sanchez-Salas R, Créhange G, Cathelineau X, Cosset JM. Focal Brachytherapy for Localized Prostate Cancer: Midterm Outcomes. Pract Radiat Oncol 2021; 11:e477-e485. [PMID: 33422681 DOI: 10.1016/j.prro.2020.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/18/2020] [Accepted: 12/24/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Focal brachytherapy (F-BT) is a suitable technique for focal therapy in localized prostate cancer. It has the ability to adapt the seed implantation to the volume and location of the tumor. The aim of this study was to assess F-BT oncologic, functional, and toxicity midterm outcomes in men who underwent prostate cancer treatment. METHODS AND MATERIALS The study included 39 men with low- to intermediate-risk prostate cancer treated with F-BT between 2010 and 2015. The dose prescription was 145 Gy. Failure was defined as the presence of any residual prostate cancer in the treated area. The primary and secondary endpoints were the F-BT oncologic and functional outcomes, respectively. A 2-sided P value < .05 indicated statistical significance. RESULTS The mean follow-up time was 65 months (range, 43-104 months). After 24 months, 34 patients underwent control biopsies and 5 patients refused. The biopsies were negative in 27 cases (79%) and positive in 7 cases (21%), all outside the volume treated. Biochemical relapse-free survival at 5 years, disease-free survival, and overall survival were 96.8% ± 0.032%, 79.5% ± 0.076%, and 100%, respectively. The mean International Prostate Symptom Score at 2 months was significantly higher than initially (P = .0003), with no significant difference later. No late urinary, sexual, or rectal toxicity was observed. Salvage treatment was possible with good tolerance at 3.4 years of follow-up. Limitations of this study include the retrospective nature and lack of randomization. CONCLUSIONS F-BT is a safe and effective treatment for selected patients presenting with low- or intermediate-risk localized prostate cancer.
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Affiliation(s)
- Minh-Hanh Ta
- Radiotherapy Department, SNC Charlebourg, Amethyst Group, La Garenne-Colombes, France
| | - Igor Nunes-Silva
- Urology Department, Institut Mutualiste Montsouris, Paris, France; Urology Department, Arnaldo Vieira de Carvalho Cancer Institute, Sao Paulo, Brazil
| | - Eric Barret
- Urology Department, Institut Mutualiste Montsouris, Paris, France.
| | | | - François Rozet
- Urology Department, Institut Mutualiste Montsouris, Paris, France
| | - Annick Mombet
- Urology Department, Institut Mutualiste Montsouris, Paris, France
| | - Nathalie Cathala
- Urology Department, Institut Mutualiste Montsouris, Paris, France
| | | | - Gilles Créhange
- Urology Department, Institut Mutualiste Montsouris, Paris, France; Oncology/Radiotherapy Department, Institut Curie, Paris, France
| | | | - Jean-Marc Cosset
- Radiotherapy Department, SNC Charlebourg, Amethyst Group, La Garenne-Colombes, France; Urology Department, Institut Mutualiste Montsouris, Paris, France; Oncology/Radiotherapy Department, Institut Curie, Paris, France
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17
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Recommandations françaises du Comité de cancérologie de l’AFU – actualisation 2020–2022 : cancer de la prostate. Prog Urol 2020; 30:S136-S251. [DOI: 10.1016/s1166-7087(20)30752-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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18
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Reddy D, Bedi N, Dudderidge T. Focal therapy, time to join the multi-disciplinary team discussion? Transl Androl Urol 2020; 9:1526-1534. [PMID: 32676440 PMCID: PMC7354327 DOI: 10.21037/tau.2019.09.30] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Organ preserving management is common place in renal cancer, breast cancer and many other solid organ tumours. Current strategies in managing intermediate risk prostate cancer include either whole gland treatment, in the form of radical radiotherapy or radical prostatectomy, or active surveillance. The former is associated with significant post-treatment functional morbidity, whilst the latter associated with the burden of surveillance activity and patient anxiety. Focal therapy would logically fit as a middle ground for suitable patients in whom treatment would be recommended, but where much better functional outcomes may be possible. Ideally this comes without restricting the successful prevention of harm from the cancer. Historically limitations in developing tissue preserving focal therapy strategies in prostate cancer, were due to inaccuracies in tumour characterisation prior to treatment and during follow up. Consequently for example many patients undergoing an active surveillance strategy were being upgraded and upstaged within a short period. Recently high level evidence supporting the use of MRI and targeted biopsies, in particular the PROMIS and PRECISION trials have strengthened clinician confidence in accurate disease characterisation, thus making focal therapy to become a more feasible management option. With improved diagnostic strategies and the publication of reassuring medium term oncological and functional outcomes after focal therapy for intermediate risk prostate cancer, has the time come to require consideration of focal therapy within our multi-disciplinary team (MDT) meetings and with patients? In this review we will consider patient selection and the evidence for the various focal ablation options as well as the surveillance of these patients after treatment. The forthcoming trials to determine comparative effectiveness will be discussed.
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Affiliation(s)
- Deepika Reddy
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Nishant Bedi
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Tim Dudderidge
- Department of Urology, Southampton General Hospital, University Hospital Southampton NHS Trust, Southampton, UK
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19
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Dai X, Lei Y, Zhang Y, Qiu RLJ, Wang T, Dresser SA, Curran WJ, Patel P, Liu T, Yang X. Automatic multi-catheter detection using deeply supervised convolutional neural network in MRI-guided HDR prostate brachytherapy. Med Phys 2020; 47:4115-4124. [PMID: 32484573 DOI: 10.1002/mp.14307] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/19/2020] [Accepted: 05/24/2020] [Indexed: 12/19/2022] Open
Abstract
PURPOSE High-dose-rate (HDR) brachytherapy is an established technique to be used as monotherapy option or focal boost in conjunction with external beam radiation therapy (EBRT) for treating prostate cancer. Radiation source path reconstruction is a critical procedure in HDR treatment planning. Manually identifying the source path is labor intensive and time inefficient. In recent years, magnetic resonance imaging (MRI) has become a valuable imaging modality for image-guided HDR prostate brachytherapy due to its superb soft-tissue contrast for target delineation and normal tissue contouring. The purpose of this study is to investigate a deep-learning-based method to automatically reconstruct multiple catheters in MRI for prostate cancer HDR brachytherapy treatment planning. METHODS Attention gated U-Net incorporated with total variation (TV) regularization model was developed for multi-catheter segmentation in MRI. The attention gates were used to improve the accuracy of identifying small catheter points, while TV regularization was adopted to encode the natural spatial continuity of catheters into the model. The model was trained using the binary catheter annotation images offered by experienced physicists as ground truth paired with original MRI images. After the network was trained, MR images of a new prostate cancer patient receiving HDR brachytherapy were fed into the model to predict the locations and shapes of all the catheters. Quantitative assessments of our proposed method were based on catheter shaft and tip errors compared to the ground truth. RESULTS Our method detected 299 catheters from 20 patients receiving HDR prostate brachytherapy with a catheter tip error of 0.37 ± 1.68 mm and a catheter shaft error of 0.93 ± 0.50 mm. For detection of catheter tips, our method resulted in 87% of the catheter tips within an error of less than ± 2.0 mm, and more than 71% of the tips can be localized within an absolute error of no >1.0 mm. For catheter shaft localization, 97% of catheters were detected with an error of <2.0 mm, while 63% were within 1.0 mm. CONCLUSIONS In this study, we proposed a novel multi-catheter detection method to precisely localize the tips and shafts of catheters in three-dimensional MRI images of HDR prostate brachytherapy. It paves the way for elevating the quality and outcome of MRI-guided HDR prostate brachytherapy.
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Affiliation(s)
- Xianjin Dai
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Yang Lei
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Yupei Zhang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Richard L J Qiu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Tonghe Wang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Sean A Dresser
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Walter J Curran
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Pretesh Patel
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Tian Liu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
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20
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Tourinho-Barbosa RR, Wood BJ, Abreu AL, Nahar B, Shin T, Guven S, Polascik TJ. Current state of image-guided focal therapy for prostate cancer. World J Urol 2020; 39:701-717. [PMID: 32444886 DOI: 10.1007/s00345-020-03254-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/11/2020] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To review the current evidence regarding protocols and outcomes of image-guided focal therapy (FT) for prostate cancer (PCa). METHODS A literature search of the latest published studies assessing primary FT for PCa was carried out in Medline and Cochrane library databases followed by a critical review. FT modalities, follow-up strategies, and oncological and toxicity outcomes were summarized and discussed in this review. RESULTS Twenty-four studies with six different sources of energy met the inclusion criteria. A heterogeneity of patient selection, energy sources, treatment templates, and definitions of failure was found among the studies. While a third of patients may be found to have additional cancer burden over 3-5 years following FT, most patients will remain free of a radical procedure. The vast majority of patients maintain urinary continence and good erectile function after FT. Acute urinary retention is the most common complication, whilst severe complications remain rare. CONCLUSION An increasing number of prospective studies with longer follow-up have been recently published. Acceptable cancer control and low treatment toxicity after FT have been consistently reported. Follow-up imaging and routine biopsy must be encouraged post-FT. While there is no reliable PSA threshold to predict failure after FT, reporting post-FT positive biopsies and retreatment rates appear to be standard when assessing treatment efficacy.
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Affiliation(s)
- Rafael R Tourinho-Barbosa
- Department of Urology, Hospital CardioPulmonar, 157, Ponciano Oliveira Street, Salvador, Bahia, 40170-530, Brazil.
- Department of Urology, Faculdade de Medicina Do ABC (ABC Medical School), São Paulo, Brazil.
| | - Bradford J Wood
- Center for Interventional Oncology, National Cancer Institute, Interventional Radiology, Radiology and Imaging Sciences, NIH Clinical Center, Bethesda, MD, USA
| | - Andre Luis Abreu
- USC Institute of Urology and Catherine & Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Bruno Nahar
- Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Toshitaka Shin
- Department of Urology, Oita University Faculty of Medicine, Oita, Japan
| | - Selcuk Guven
- Department of Urology, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Thomas J Polascik
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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21
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Current status and future prospective of focal therapy for localized prostate cancer: development of multiparametric MRI, MRI-TRUS fusion image-guided biopsy, and treatment modalities. Int J Clin Oncol 2020; 25:509-520. [PMID: 32040781 DOI: 10.1007/s10147-020-01627-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 01/23/2020] [Indexed: 10/25/2022]
Abstract
Multiparametric magnetic resonance imaging (mpMRI) has been increasingly used to diagnose clinically significant prostate cancer (csPC) because of its usefulness in combination with anatomic and functional data. MRI-targeted biopsy, such as MRI-transrectal ultrasound (TRUS) fusion image-guided prostate biopsy, has high accuracy in the detection and localization of csPC. This novel diagnostic technique contributes to the development of tailor-made medicine as focal therapy, which cures the csPC while preserving the anatomical structures related to urinary and sexual function. In the early days of focal therapy, TRUS-guided systematic biopsy was used for patient selection, and treatment was performed for patients with low-risk PC. With the introduction of mpMRI and mapping biopsy, the treatment range is now determined based on individualized cancer localization. In recent prospective studies, 87.4% of treated patients had intermediate- and high-risk PC. However, focal therapy has two main limitations. First, a randomized controlled trial would be difficult to design because of the differences in pathological features between patients undergoing focal therapy and radical treatment. Therefore, pair-matched studies and/or historical controlled studies have been performed to compare focal therapy and radical treatment. Second, no long-term (≥ 10-year) follow-up study has been performed. However, recent prospective studies have encouraged the use of focal therapy as a treatment strategy for localized PC because it contributes to high preservation of continence and erectile function.
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22
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[ 68Ga-]PSMA-11 PET/CT and multiparametric MRI for gross tumor volume delineation in a slice by slice analysis with whole mount histopathology as a reference standard - Implications for focal radiotherapy planning in primary prostate cancer. Radiother Oncol 2019; 141:214-219. [PMID: 31431366 DOI: 10.1016/j.radonc.2019.07.005] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/03/2019] [Accepted: 07/03/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE Focal therapies are a promising approach to treat prostate cancer (PCa) more precisely instead of conventional whole gland treatment. Nowadays, multiparametric MRI (mpMRI) is routinely used for gross tumor volume (GTV) delineation. The aim of our study was to compare PSMA-PET/CT and mpMRI for the delineation of intraprostatic tumor burden by using whole mount histopathology as a reference standard. MATERIAL AND METHODS 17 prospectively enrolled patients with primary PCa underwent [68Ga-]PSMA-11 PET/CT and mpMRI before radical prostatectomy. PSMA-PET/CT, mpMRI and histopathology of the resected specimens were co-registered. Two teams of experts generated GTV contours for mpMRI and PET, respectively. The imaging was validated on a lesion level and slice by slice in quadrants based on the distribution of PCa in histopathology. Overall, 772 quadrants were analyzed with 414 being true positive for tumor (53.6%). RESULTS Median tumor volumes were 10.4 ml for GTV-histo, 10.8 ml for PSMA-PET and 4.5 ml for mpMRI. Median tumor volume in mpMRI was significant (p < 0.05) smaller than GTV-PET and GTV-histo, respectively. The sensitivity and specificity were 86% and 87% for PSMA-PET, 58% and 94% for mpMRI and 91% and 84% for their GTV-union. In 133 quadrants PSMA-PET/CT correctly identified tumor where mpMRI found none. MpMRI identified 19 true positive quadrants exclusively. CONCLUSION Our investigation demonstrates an increased consensus of PSMA-PET with histopathology compared to mpMRI for intraprostatic GTV delineation, especially with a higher sensitivity. Additionally mpMRI contours underestimate tumor volume significantly. Thus PSMA-PET may be a complementary augmentation for GTV delineation in focal therapies.
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David J, Kamrava M. In Regard to Peters et al. Int J Radiat Oncol Biol Phys 2019; 104:1182-1183. [DOI: 10.1016/j.ijrobp.2019.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 04/15/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
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Morton GC, Hoskin PJ. Single Fraction High-Dose-Rate Brachytherapy: Too Good to Be True? Int J Radiat Oncol Biol Phys 2019; 104:1054-1056. [DOI: 10.1016/j.ijrobp.2019.04.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 04/17/2019] [Accepted: 04/28/2019] [Indexed: 10/26/2022]
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