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Fonteyne V, Berghen C, Van Praet C, Vanderstraeten B, Verbeke S, Villeirs G, Colman R, Vanneste B, Ost P, De Meerleer G, Lumen N. Moderate hypofractionated radiotherapy for prostate cancer: 3-year toxicity results of a multicentre randomized phase 3, non-inferiority trial. Radiother Oncol 2024; 193:110089. [PMID: 38278333 DOI: 10.1016/j.radonc.2024.110089] [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: 10/27/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND AND PURPOSE Moderate hypofractionated radiotherapy (HFRT) is a standard treatment for prostate cancer patients. We compared 2 moderate HFRT regimens, with a biologically equivalent dose of 80 Gy in 2 Gy fractions, with a modest simultaneous integrated boost to the dominant intraprostatic lesion. MATERIAL AND METHODS This is a multicenter, non-inferiority, randomized phase 3 trial with acute toxicity as the primary endpoint, comparing: 56 Gy in 4 weeks (16x3.5 Gy, 4 days/week, Arm A) with 67 Gy in 5 weeks (25x2.68 Gy, 5 days/week, Arm B). The H0 hypothesis is that both regimens are equivalent in terms of acute grade ≥ 2 gastro-intestinal toxicity, defined as a difference in acute grade ≥ 2 gastro-intestinal toxicity of ≤ 10 %. Here we report on acute and late toxicity. RESULTS We included 170 patients in Arm A and 172 patients in Arm B. The median follow-up time for all patients was 42 months. Acute grade ≥ 2 gastrointestinal toxicity was reported by 24 % of patients in both groups. Acute grade 2 and 3 urinary toxicity was observed in 52 % and 9 % of patients in Arm A and 53 % and 7 % in Arm B. Late grade 2 and grade ≥ 3 gastrointestinal toxicity occurred in 19 % and 4 % of patients in Arm A compared with 15 % and 4 % in Arm B. Late grade 2 and grade ≥ 3 urinary toxicity was observed in 37 % and 10 % of patients in Arm A and 36 % and 6 % in Arm B. CONCLUSION This analysis confirms that both HFRT regimens are safe and equivalent in terms of acute grade ≥ 2 gastrointestinal toxicity.
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Affiliation(s)
- V Fonteyne
- Department of Radiotherapy Oncology, Ghent University Hospital, Ghent, Belgium; Department Human Structure and Repair, Ghent University, Ghent, Belgium.
| | - C Berghen
- Department of Radiotherapy and Oncology, Leuven University Hospitals, Louvain, Belgium
| | - C Van Praet
- Department of Urology, ERN Accredited Centre, Ghent University Hospital, Ghent, Belgium
| | - B Vanderstraeten
- Department of Radiotherapy Oncology, Ghent University Hospital, Ghent, Belgium; Department Human Structure and Repair, Ghent University, Ghent, Belgium
| | - S Verbeke
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | - G Villeirs
- Department of Radiology, Ghent University Hospital, Ghent, Belgium
| | - R Colman
- Biostatistics Unit, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - B Vanneste
- Department of Radiotherapy Oncology, Ghent University Hospital, Ghent, Belgium; Department Human Structure and Repair, Ghent University, Ghent, Belgium
| | - P Ost
- Department Human Structure and Repair, Ghent University, Ghent, Belgium
| | - G De Meerleer
- Department of Radiotherapy and Oncology, Leuven University Hospitals, Louvain, Belgium
| | - N Lumen
- Department of Urology, ERN Accredited Centre, Ghent University Hospital, Ghent, Belgium
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Gauter-Fleckenstein B, Schönig S, Mertens L, Oppitz H, Siebenlist K, Ehmann M, Fleckenstein J. Effect of simultaneous integrated boost concepts on photoneutron and distant out-of-field doses in VMAT for prostate cancer. Strahlenther Onkol 2024; 200:219-229. [PMID: 37707518 PMCID: PMC10876496 DOI: 10.1007/s00066-023-02138-x] [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: 04/16/2023] [Accepted: 08/08/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND A simultaneous integrated boost (SIB) may result in increased out-of-field (DOOF) and photoneutron (HPN) doses in volumetric modulated arc therapy (VMAT) for prostate cancer (PCA). This work therefore aimed to compare DOOF and HPN in flattened (FLAT) and flattening filter-free (FFF) 6‑MV and 10-MV VMAT treatment plans with and without SIB. METHODS Eight groups of 30 VMAT plans for PCA with 6 MV or 10 MV, with or without FF and with uniform (2 Gy) or SIB target dose (2.5/3.0 Gy) prescriptions (CONV, SIB), were generated. All 240 plans were delivered on a slab-phantom and compared with respect to measured DOOF and HPN in 61.8 cm distance from the isocenter. The 6‑ and 10-MV flattened VMAT plans with conventional fractionation (6- and 10-MV FLAT CONV) served as standard reference groups. Doses were analyzed as a function of delivered monitor units (MU) and weighted equivalent square field size Aeq. Pearson's correlation coefficients between the presented quantities were determined. RESULTS The SIB plans resulted in decreased HPN over an entire prostate RT treatment course (10-MV SIB vs. CONV -38.2%). Omission of the flattening filter yielded less HPN (10-MV CONV -17.2%; 10-MV SIB -22.5%). The SIB decreased DOOF likewise by 39% for all given scenarios, while the FFF mode reduced DOOF on average by 60%. A strong Pearson correlation was found between MU and HPN (r > 0.9) as well as DOOF (0.7 < r < 0.9). CONCLUSION For a complete treatment, SIB reduces both photoneutron and OOF doses to almost the same extent as FFF deliveries. It is recommended to apply moderately hypofractionated 6‑MV SIB FFF-VMAT when considering photoneutron or OOF doses.
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Affiliation(s)
- Benjamin Gauter-Fleckenstein
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany.
| | - Sebastian Schönig
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Lena Mertens
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Hans Oppitz
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Kerstin Siebenlist
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Michael Ehmann
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Jens Fleckenstein
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
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Bano W, Holmes W, Goodburn R, Golbabaee M, Gupta A, Withey S, Tree A, Oelfke U, Wetscherek A. Joint radial trajectory correction for accelerated T 2 * mapping on an MR-Linac. Med Phys 2023; 50:7027-7038. [PMID: 37245075 PMCID: PMC10946747 DOI: 10.1002/mp.16479] [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: 08/04/2022] [Revised: 04/20/2023] [Accepted: 04/28/2023] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND T2 * mapping can characterize tumor hypoxia, which may be associated with resistance to therapy. Acquiring T2 * maps during MR-guided radiotherapy could inform treatment adaptation by, for example, escalating the dose to resistant sub-volumes. PURPOSE The purpose of this work is to demonstrate the feasibility of the accelerated T2 * mapping technique using model-based image reconstruction with integrated trajectory auto-correction (TrACR) for MR-guided radiotherapy on an MR-Linear accelerator (MR-Linac). MATERIALS AND METHODS The proposed method was validated in a numerical phantom, where two T2 * mapping approaches (sequential and joint) were compared for different noise levels (0,0.1,0.5,1) and gradient delays ([1, -1] and [1, -2] in units of dwell time for x- and y-axis, respectively). Fully sampled k-space was retrospectively undersampled using two different undersampling patterns. Root mean square errors (RMSEs) were calculated between reconstructed T2 * maps and ground truth. In vivo data was acquired twice weekly in one prostate and one head and neck cancer patient undergoing treatment on a 1.5 T MR-Linac. Data were retrospectively undersampled and T2 * maps reconstructed, with and without trajectory corrections were compared. RESULTS Numerical simulations demonstrated that, for all noise levels, T2 * maps reconstructed with a joint approach demonstrated less error compared to an uncorrected and sequential approach. For a noise level of 0.1, uniform undersampling and gradient delay [1, -1] (in units of dwell time for x- and y-axis, respectively), RMSEs for sequential and joint approaches were 13.01 and 9.32 ms, respectively, which reduced to 10.92 and 5.89 ms for a gradient delay of [1, 2]. Similarly, for alternate undersampling and gradient delay [1, -1], RMSEs for sequential and joint approaches were 9.80 and 8.90 ms, respectively, which reduced to 9.10 and 5.40 ms for gradient delay [1, 2]. For in vivo data, T2 * maps reconstructed with our proposed approach resulted in less artifacts and improved visual appearance compared to the uncorrected approach. For both prostate and head and neck cancer patients, T2 * maps reconstructed from different treatment fractions showed changes within the planning target volume (PTV). CONCLUSION Using the proposed approach, a retrospective data-driven gradient delay correction can be performed, which is particularly relevant for hybrid devices, where full information on the machine configuration is not available for image reconstruction. T2 * maps were acquired in under 5 min and can be integrated into MR-guided radiotherapy treatment workflows, which minimizes patient burden and leaves time for additional imaging for online adaptive radiotherapy on an MR-Linac.
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Affiliation(s)
- Wajiha Bano
- Joint Department of PhysicsThe Institute of Cancer Research and The Royal Marsden NHS Foundation TrustLondonUK
| | - Will Holmes
- Joint Department of PhysicsThe Institute of Cancer Research and The Royal Marsden NHS Foundation TrustLondonUK
| | - Rosie Goodburn
- Joint Department of PhysicsThe Institute of Cancer Research and The Royal Marsden NHS Foundation TrustLondonUK
| | | | - Amit Gupta
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer ResearchLondonUK
| | - Sam Withey
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer ResearchLondonUK
| | - Alison Tree
- The Royal Marsden NHS Foundation Trust and The Institute of Cancer ResearchLondonUK
| | - Uwe Oelfke
- Joint Department of PhysicsThe Institute of Cancer Research and The Royal Marsden NHS Foundation TrustLondonUK
| | - Andreas Wetscherek
- Joint Department of PhysicsThe Institute of Cancer Research and The Royal Marsden NHS Foundation TrustLondonUK
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Zhao Y, Haworth A, Rowshanfarzad P, Ebert MA. Focal Boost in Prostate Cancer Radiotherapy: A Review of Planning Studies and Clinical Trials. Cancers (Basel) 2023; 15:4888. [PMID: 37835581 PMCID: PMC10572027 DOI: 10.3390/cancers15194888] [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: 08/17/2023] [Revised: 09/28/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Focal boost radiotherapy was developed to deliver elevated doses to functional sub-volumes within a target. Such a technique was hypothesized to improve treatment outcomes without increasing toxicity in prostate cancer treatment. PURPOSE To summarize and evaluate the efficacy and variability of focal boost radiotherapy by reviewing focal boost planning studies and clinical trials that have been published in the last ten years. METHODS Published reports of focal boost radiotherapy, that specifically incorporate dose escalation to intra-prostatic lesions (IPLs), were reviewed and summarized. Correlations between acute/late ≥G2 genitourinary (GU) or gastrointestinal (GI) toxicity and clinical factors were determined by a meta-analysis. RESULTS By reviewing and summarizing 34 planning studies and 35 trials, a significant dose escalation to the GTV and thus higher tumor control of focal boost radiotherapy were reported consistently by all reviewed studies. Reviewed trials reported a not significant difference in toxicity between focal boost and conventional radiotherapy. Acute ≥G2 GU and late ≥G2 GI toxicities were reported the most and least prevalent, respectively, and a negative correlation was found between the rate of toxicity and proportion of low-risk or intermediate-risk patients in the cohort. CONCLUSION Focal boost prostate cancer radiotherapy has the potential to be a new standard of care.
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Affiliation(s)
- Yutong Zhao
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA 6009, Australia; (P.R.); (M.A.E.)
| | - Annette Haworth
- Institute of Medical Physics, School of Physics, The University of Sydney, Camperdown, NSW 2050, Australia;
| | - Pejman Rowshanfarzad
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA 6009, Australia; (P.R.); (M.A.E.)
- Centre for Advanced Technologies in Cancer Research (CATCR), Perth, WA 6000, Australia
| | - Martin A. Ebert
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA 6009, Australia; (P.R.); (M.A.E.)
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia
- 5D Clinics, Claremont, WA 6010, Australia
- School of Medicine and Population Health, University of Wisconsin, Madison WI 53706, USA
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Dmochowska N, Milanova V, Mukkamala R, Chow KK, Pham NTH, Srinivasarao M, Ebert LM, Stait-Gardner T, Le H, Shetty A, Nelson M, Low PS, Thierry B. Nanoparticles Targeted to Fibroblast Activation Protein Outperform PSMA for MRI Delineation of Primary Prostate Tumors. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2023; 19:e2204956. [PMID: 36840671 DOI: 10.1002/smll.202204956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 01/23/2023] [Indexed: 05/25/2023]
Abstract
Accurate delineation of gross tumor volumes remains a barrier to radiotherapy dose escalation and boost dosing in the treatment of solid tumors, such as prostate cancer. Magnetic resonance imaging (MRI) of tumor targets has the power to enable focal dose boosting, particularly when combined with technological advances such as MRI-linear accelerator. Fibroblast activation protein (FAP) is overexpressed in stromal components of >90% of epithelial carcinomas. Herein, the authors compare targeted MRI of prostate specific membrane antigen (PSMA) with FAP in the delineation of orthotopic prostate tumors. Control, FAP, and PSMA-targeting iron oxide nanoparticles were prepared with modification of a lymphotropic MRI agent (FerroTrace, Ferronova). Mice with orthotopic LNCaP tumors underwent MRI 24 h after intravenous injection of nanoparticles. FAP and PSMA nanoparticles produced contrast enhancement on MRI when compared to control nanoparticles. FAP-targeted MRI increased the proportion of tumor contrast-enhancing black pixels by 13%, compared to PSMA. Analysis of changes in R2 values between healthy prostates and LNCaP tumors indicated an increase in contrast-enhancing pixels in the tumor border of 15% when targeting FAP, compared to PSMA. This study demonstrates the preclinical feasibility of PSMA and FAP-targeted MRI which can enable targeted image-guided focal therapy of localized prostate cancer.
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Affiliation(s)
- Nicole Dmochowska
- Future Industries Institute, University of South Australia, Adelaide, South Australia, 5095, Australia
| | - Valentina Milanova
- Future Industries Institute, University of South Australia, Adelaide, South Australia, 5095, Australia
| | - Ramesh Mukkamala
- Department of Chemistry and Institute for Drug Discovery, Purdue University, West Lafayette, IN, 47907, USA
| | - Kwok Keung Chow
- Future Industries Institute, University of South Australia, Adelaide, South Australia, 5095, Australia
| | - Nguyen T H Pham
- Key Centre for Polymers and Colloids, School of Chemistry, The University of Sydney, Sydney, New South Wales, 2006, Australia
| | - Madduri Srinivasarao
- Department of Chemistry and Institute for Drug Discovery, Purdue University, West Lafayette, IN, 47907, USA
| | - Lisa M Ebert
- Centre for Cancer Biology, University of South Australia; SA Pathology; Cancer Clinical Trials Unit, Royal Adelaide Hospital; Adelaide Medical School, University of Adelaide, Adelaide, South Australia, 5000, Australia
| | - Timothy Stait-Gardner
- Nanoscale Organisation and Dynamics Group, Western Sydney University, Sydney, New South Wales, 2560, Australia
| | - Hien Le
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, South Australia, 5000, Australia
| | - Anil Shetty
- Ferronova Pty Ltd, Mawson Lakes, South Australia, 5095, Australia
| | - Melanie Nelson
- Ferronova Pty Ltd, Mawson Lakes, South Australia, 5095, Australia
| | - Philip S Low
- Department of Chemistry and Institute for Drug Discovery, Purdue University, West Lafayette, IN, 47907, USA
| | - Benjamin Thierry
- Future Industries Institute, University of South Australia, Adelaide, South Australia, 5095, Australia
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Li Kuan Ong A, Knight K, Panettieri V, Dimmock M, Kit Loong Tuan J, Qi Tan H, Wright C. Predictors for late genitourinary toxicity in men receiving radiotherapy for high-risk prostate cancer using planned and accumulated dose. Phys Imaging Radiat Oncol 2023; 25:100421. [PMID: 36817981 PMCID: PMC9932727 DOI: 10.1016/j.phro.2023.100421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
Background and purpose Significant deviations between bladder dose planned (DP) and dose accumulated (DA) have been reported in patients receiving radiotherapy for prostate cancer. This study aimed to construct multivariate analysis (MVA) models to predict the risk of late genitourinary (GU) toxicity with clinical and DP or DA as dose-volume (DV) variables. Materials and methods Bladder DA obtained from 150 patients were compared with DP. MVA models were built from significant clinical and DV variables (p < 0.05) at univariate analysis. Previously developed dose-based-region-of-interest (DB-ROI) metrics using expanded ring structures from the prostate were included. Goodness-of-fit test and calibration plots were generated to determine model performance. Internal validation was accomplished using Bootstrapping. Results Intermediate-high DA (V30-65 Gy and DB-ROI-20-50 mm) for bladder increased compared to DP. However, at the very high dose region, DA (D0.003 cc, V75 Gy, and DB-ROI-5-10 mm) were significantly lower. In MVA, single variable models were generated with odds ratio (OR) < 1. DB-ROI-50 mm was predictive of Grade ≥ 1 GU toxicity for DA and DP (DA and DP; OR: 0.96, p: 0.04) and achieved an area under the receiver operating curve (AUC) of > 0.6. Prostate volume (OR: 0.87, p: 0.01) was significant in predicting Grade 2 GU toxicity with a high AUC of 0.81. Conclusions Higher DA (V30-65 Gy) received by the bladder were not translated to higher late GU toxicity. DB-ROIs demonstrated higher predictive power than standard DV metrics in associating Grade ≥ 1 toxicity. Smaller prostate volumes have a minor protective effect on late Grade 2 GU toxicity.
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Affiliation(s)
- Ashley Li Kuan Ong
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore,Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,Corresponding author at: Division of Radiation Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610, Singapore
| | - Kellie Knight
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
| | - Vanessa Panettieri
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,Central Clinical School, Monash University, Melbourne, VIC, Australia,Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Mathew Dimmock
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,School of Allied Health Professions, Keele University, Staffordshire, UK
| | | | - Hong Qi Tan
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Caroline Wright
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
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Tree AC, Satchwell L, Alexander E, Blasiak-Wal I, deSouza NM, Gao A, Greenlay E, McNair H, Parker C, Talbot J, Dearnaley D, Murray J. Standard and Hypofractionated Dose Escalation to Intraprostatic Tumor Nodules in Localized Prostate Cancer: 5-Year Efficacy and Toxicity in the DELINEATE Trial. Int J Radiat Oncol Biol Phys 2023; 115:305-316. [PMID: 36150450 DOI: 10.1016/j.ijrobp.2022.09.058] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 08/25/2022] [Accepted: 09/05/2022] [Indexed: 01/14/2023]
Abstract
PURPOSE Our purpose was to report 5-year efficacy and toxicity of intraprostatic lesion boosting using standard and hypofractionated radiation therapy. METHODS AND MATERIALS DELINEATE (ISRCTN 04483921) is a single center phase 2 multicohort study including standardly fractionated (cohort A: 74 Gy/37F to prostate and seminal vesicles [PSV]; cohort C 74 Gy/37F to PSV plus 60 Gy/37F to pelvic lymph nodes) and moderately hypofractionated (cohort B: 60 Gy/20F to PSV) prostate intensity-modulated radiation therapy patients with National Comprehensive Cancer Network intermediate/high-risk disease. Patients received an integrated boost of 82 Gy (cohorts A and C) or 67 Gy (cohort B) to multiparametric magnetic resonance imaging identified lesion(s). Primary endpoint was late Radiation Therapy Oncology Group (RTOG) gastrointestinal (GI) toxicity at 1 year. Secondary endpoints were acute and late toxicity (clinician and patient reported) and freedom from biochemical/clinical failure at 5 years. RESULTS Two hundred and sixty-five men were recruited and 256 were treated (55 cohort A, 153 cohort B, and 48 cohort C). Median follow-up for each cohort was >5 years. Cumulative late RTOG grade 2+ GI toxicity at 1 year was 3.6% (95% confidence interval [CI], 0.9%-13.8%) (cohort A), 7.2% (95% CI, 4%-12.6%) (cohort B), and 8.4% (95% CI, 3.2%-20.8%) (cohort C). Cumulative late RTOG grade 2+ GI toxicity to 5 years was 12.8% (95% CI, 6.3%-25.1%) (cohort A), 14.6% (95% CI, 9.9%-21.4%) (cohort B), and 20.7% (95% CI, 11.2%-36.2%) (cohort C). Cumulative RTOG grade 2+ genitourinary toxicity to 5 years was 12.9% (95% CI, 6.4%-25.2%) (cohort A), 18.2% (95% CI, 12.8%-25.4%) (cohort B), and 18.2% (95% CI, 9.5%-33.2%) (cohort C). Five-year freedom from biochemical/clinical failure was 98.2% (95% CI, 87.8%-99.7%) (cohort A), 96.7% (95% CI, 91.3%- 98.8%) (cohort B), and 95.1% (95% CI, 81.6-98.7%) (cohort C). CONCLUSIONS The DELINEATE trial has shown safety, tolerability, and feasibility of focal boosting in 20 or 37 fractions. Efficacy results indicate a low chance of prostate cancer recurrence 5 years after radiation therapy. Evidence from ongoing phase 3 randomized trials is awaited.
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Affiliation(s)
- Alison C Tree
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom.
| | - Laura Satchwell
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Emma Alexander
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | | | - Nandita M deSouza
- Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom
| | - Annie Gao
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Emily Greenlay
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Helen McNair
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom
| | - Chris Parker
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom
| | - James Talbot
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - David Dearnaley
- Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom; The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Julia Murray
- The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom
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Holloway N, Ribeiro L, Bosco C, Van Hemelrijck M, Seth J, Nitkunan T, Nicol D, Cahill D, Withington J, Kinsella J, Wong K. Management of men with lower urinary tract symptoms referred for prostate radiotherapy. JOURNAL OF CLINICAL UROLOGY 2022. [DOI: 10.1177/20514158221129952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objective: To report on the experience of the management of lower urinary tract symptoms (LUTS) in men referred for prostate radiotherapy (RT) in a large tertiary referral centre. Methods: Between February and November 2018, 156 men referred for radiotherapy were seen and assessed according to their LUTS history: International Prostate Symptom Score (IPSS), flow rate (FR) and post-void residual (PVR). Patients with LUTS were offered management options depending on severity including lifestyle advice, oral medication or surgery. A subset of patients ( n = 102) were reassessed post-RT, and univariate and multivariate logistic regression was performed to predict symptoms improvement. Results: Prior to referral for RT and assessment at our dedicated LUTS clinic, 65% of men had a documented history of LUTS, 14% had completed an IPSS questionnaire and only 13% had a urinary FR; 17% (27/156) had prior treatment in the form of medication or surgery. In our assessment, 77/156 (49%) had mild, 66/156 (42%) moderate and 13/156 (8%) severe LUTS determined by IPSS. Out of 156, 71 (46%) had a quality-of-life score >3. Of the men, 81% were offered lifestyle advice, 47 patients were started on alpha blockers and 20 (12.8%) went onto Transurethral Resection of the Prostate prior to RT; 6 weeks following RT, 61 (50%) patients had higher IPSS scores. Patients who were started on alpha blockers ( p = 0.022) or had TURP ( p = 0.015) were less likely to have an increase in IPSS score on multivariate analysis. Conclusion: Men undergoing RT for prostate cancer often have co-existing LUTS. Consideration and evaluation of their LUTS and offer of treatment either medication or surgery could improve urinary symptoms in men undergoing prostate radiotherapy in the short term. Longer term data are still needed to understand the full long-term impact on patient’s symptoms and quality of life. We recommend that patients have formal LUTS assessment pre-RT. Level of evidence: Not applicable.
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Affiliation(s)
| | - Luis Ribeiro
- Department of Urology, St George’s University Hospitals NHS Trust, UK
| | - Cecilia Bosco
- Translational Oncology and Urology Research, Faculty of Life Sciences and Medicine, Kings College London, UK
| | - Mieke Van Hemelrijck
- Translational Oncology and Urology Research, Faculty of Life Sciences and Medicine, Kings College London, UK
| | - Jai Seth
- Urology Unit, The Royal Marsden NHS Trust, UK
- Department of Urology, St George’s University Hospitals NHS Trust, UK
- Department of Urology, Epsom and St Helier University Hospitals NHS Trust, UK
| | - Tharani Nitkunan
- Urology Unit, The Royal Marsden NHS Trust, UK
- Department of Urology, Epsom and St Helier University Hospitals NHS Trust, UK
| | - David Nicol
- Urology Unit, The Royal Marsden NHS Trust, UK
| | | | | | - Janette Kinsella
- Urology Unit, The Royal Marsden NHS Trust, UK
- Department of Urology, Epsom and St Helier University Hospitals NHS Trust, UK
| | - Kathie Wong
- Urology Unit, The Royal Marsden NHS Trust, UK
- Department of Urology, Epsom and St Helier University Hospitals NHS Trust, UK
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9
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Magnetic Resonance Imaging–guided Focal Boost to Intraprostatic Lesions Using External Beam Radiotherapy for Localized Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Oncol 2022. [DOI: 10.1016/j.euo.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Liu W, Loblaw A, Laidley D, Fakir H, Mendez L, Davidson M, Kassam Z, Lee TY, Ward A, Thiessen J, Bayani J, Conyngham J, Bailey L, Andrews JD, Bauman G. Imaging Biomarkers in Prostate Stereotactic Body Radiotherapy: A Review and Clinical Trial Protocol. Front Oncol 2022; 12:863848. [PMID: 35494042 PMCID: PMC9043802 DOI: 10.3389/fonc.2022.863848] [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: 01/27/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Advances in imaging have changed prostate radiotherapy through improved biochemical control from focal boost and improved detection of recurrence. These advances are reviewed in the context of prostate stereotactic body radiation therapy (SBRT) and the ARGOS/CLIMBER trial protocol. ARGOS/CLIMBER will evaluate 1) the safety and feasibility of SBRT with focal boost guided by multiparametric MRI (mpMRI) and 18F-PSMA-1007 PET and 2) imaging and laboratory biomarkers for response to SBRT. To date, response to prostate SBRT is most commonly evaluated using the Phoenix Criteria for biochemical failure. The drawbacks of this approach include lack of lesion identification, a high false-positive rate, and delay in identifying treatment failure. Patients in ARGOS/CLIMBER will receive dynamic 18F-PSMA-1007 PET and mpMRI prior to SBRT for treatment planning and at 6 and 24 months after SBRT to assess response. Imaging findings will be correlated with prostate-specific antigen (PSA) and biopsy results, with the goal of early, non-invasive, and accurate identification of treatment failure.
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Affiliation(s)
- Wei Liu
- Department of Oncology, Division of Radiation Oncology, London Health Sciences Centre and Western University, London, ON, Canada
| | - Andrew Loblaw
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre and Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - David Laidley
- Division of Nuclear Medicine, St. Joseph's Health Centre and Western University, London, ON, Canada
| | - Hatim Fakir
- Department of Oncology and Department of Medical Biophysics, London Health Sciences Centre and Western University, London, ON, Canada
| | - Lucas Mendez
- Department of Oncology, Division of Radiation Oncology, London Health Sciences Centre and Western University, London, ON, Canada
| | - Melanie Davidson
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre and Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Zahra Kassam
- Department of Medical Imaging, St. Joseph's Health Care and Western University, London, ON, Canada
| | - Ting-Yim Lee
- Department of Medical Biophysics, Western University and Lawson Health Research Institute, London, ON, Canada
| | - Aaron Ward
- Department of Medical Biophysics, Western University and Lawson Health Research Institute, London, ON, Canada
| | - Jonathan Thiessen
- Department of Medical Biophysics, Western University and Lawson Health Research Institute, London, ON, Canada
| | - Jane Bayani
- Ontario Institute for Cancer Research and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | | | - Laura Bailey
- Clinical Research Unit, London Regional Cancer Program, London, ON, Canada
| | - Joseph D Andrews
- Clinical Research Unit, London Regional Cancer Program, London, ON, Canada
| | - Glenn Bauman
- Department of Oncology, Division of Radiation Oncology, London Health Sciences Centre and Western University, London, ON, Canada
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Feasibility of biology-guided radiotherapy using PSMA-PET to boost to dominant intraprostatic tumour. Clin Transl Radiat Oncol 2022; 35:84-89. [PMID: 35662883 PMCID: PMC9156937 DOI: 10.1016/j.ctro.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 11/23/2022] Open
Abstract
Biology-guided radiation therapy (BGRT) uses PET imaging for online image guidance. PSMA PET uptake is abundant in the dominant intraprostatic lesion (DIL). BgRT boost to PSMA-avid subvolume in the prostate region may be feasible. Suitable targets for BgRT were identified in the ProPSMA clinical trial.
Background Methods Results Conclusions
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12
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Zamboglou DC, Spohn DSK, Ruf PJ, Benndorf DM, Gainey DM, Kamps DM, Jilg PC, Gratzke PC, Adebahr DS, Schmidtmayer-Zamboglou B, Mix PM, Bamberg PF, Zschaeck DS, Ghadjar PP, Baltas PD, Grosu PAL. PSMA-PET- and MRI-based focal dose escalated radiotherapy of primary prostate cancer: planned safety analysis of a non-randomized 2-armed phase II trial (ARO2020-01). Int J Radiat Oncol Biol Phys 2022; 113:1025-1035. [DOI: 10.1016/j.ijrobp.2022.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/24/2022] [Accepted: 04/16/2022] [Indexed: 11/29/2022]
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13
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Spohn SKB, Adebahr S, Huber M, Jenkner C, Wiehle R, Nagavci B, Schmucker C, Carl EG, Chen RC, Weber WA, Mix M, Rühle A, Sprave T, Nicolay NH, Gratzke C, Benndorf M, Wiegel T, Weis J, Baltas D, Grosu AL, Zamboglou C. Feasibility, pitfalls and results of a structured concept-development phase for a randomized controlled phase III trial on radiotherapy in primary prostate cancer patients. BMC Cancer 2022; 22:337. [PMID: 35351058 PMCID: PMC8960686 DOI: 10.1186/s12885-022-09434-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/09/2022] [Indexed: 11/15/2022] Open
Abstract
Objective Failure rate in randomized controlled trials (RCTs) is > 50%, includes safety-problems, underpowered statistics, lack of efficacy, lack of funding or insufficient patient recruitment and is even more pronounced in oncology trials. We present results of a structured concept-development phase (CDP) for a phase III RCT on personalized radiotherapy (RT) in primary prostate cancer (PCa) patients implementing prostate specific membrane antigen targeting positron emission tomography (PSMA-PET). Materials and methods The 1 yr process of the CDP contained five main working packages: (i) literature search and scoping review, (ii) involvement of individual patients, patients’ representatives and patients’ self-help groups addressing the patients’ willingness to participate in the preparation process and the conduct of RCTs as well as the patient informed consent (PIC), (iii) involvement of national and international experts and expert panels (iv) a phase II pilot study investigating the safety of implementation of PSMA-PET for focal dose escalation RT and (v) in-silico RT planning studies assessing feasibility of envisaged dose regimens and effects of urethral sparing in focal dose escalation. Results (i) Systematic literature searches confirmed the high clinical relevance for more evidence on advanced RT approaches, in particular stereotactic body RT, in high-risk PCa patients. (ii) Involvement of patients, patient representatives and randomly selected males relevantly changed the PIC and initiated a patient empowerment project for training of bladder preparation. (iii) Discussion with national and international experts led to adaptions of inclusion and exclusion criteria. (iv) Fifty patients were treated in the pilot trial and in- and exclusion criteria as well as enrollment calculations were adapted accordingly. Parallel conduction of the pilot trial revealed pitfalls on practicability and broadened the horizon for translational projects. (v) In-silico planning studies confirmed feasibility of envisaged dose prescription. Despite large prostate- and boost-volumes of up to 66% of the prostate, adherence to stringent anorectal dose constraints was feasible. Urethral sparing increased the therapeutic ratio. Conclusion The dynamic framework of interdisciplinary working programs in CDPs enhances robustness of RCT protocols and may be associated with decreased failure rates. Structured recommendations are warranted to further define the process of such CDPs in radiation oncology trials. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09434-2.
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Zapatero A, Roch M, Castro Tejero P, Büchser D, Martin de Vidales C, González S, Rodríguez P, San Jose LA, Celada G, Murillo MT. MRI-guided focal boost to dominant intraprostatic lesion using volumetric modulated arc therapy in prostate cancer. Results of a phase II trial. Br J Radiol 2022; 95:20210683. [PMID: 34538073 PMCID: PMC8978233 DOI: 10.1259/bjr.20210683] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To determine morphological and biological control as well as toxicity and quality of life (QoL) of men with localized prostate cancer (PCa) treated with MRI-guided focal boost radiotherapy. MATERIAL AND METHODS 30 patients with PCa and a visible dominant intraprostatic lesion (DIL) identified on mpMRI were included in a prospective Phase II trial. Matching point registration of planning CT and T2W, diffusion-weighted and a gradient-recalled echo (GRE) MRI images made in treatment position was used for prostate and tumour delineation. Treatment consisted on 35 daily fractions of 2.17 Gy with a concomitant focal boost to the DIL of 2.43 Gy using volumetric modulated arc therapy (VMAT) and image-guided radiation therapy (IGRT) with intraprostatic fiducial markers. Biochemical failure was analysed using PSA nadir +2 ng/mL criteria and local control using mpMRI evaluation at 6-9 months following RT. Acute and late toxicity were defined according to CTCAE v.4.0 and RTOG/EORTC scales and QoL was assessed using IPSS, EPIC short-form and UCLA-PCI questionnaires. RESULTS The median radiation dose to the prostate was 77.6 Gy (IQR 77.3-78.1), and to the DIL was 85.5 Gy (IQR 85.0-86.0). With a median follow up of 30.0 months (IQR 25.5-40.27), all patients remain free of biochemical relapse. An mpMRI complete response was observed in 25 patients during the first post-treatment evaluation at 6 months. The remaining five patients achieved a complete disappearance of the DIL both on T2 and DWI on the second mpMRI performed at 9 months following treatment. Six out of 30 (20%) patients presented acute Grade 2 urinary toxicity with no Grade 3 acute complications. Acute rectal toxicity was only found in 2 (6.6%) patients (both Grade 1). Only late Grade 1 urinary and rectal complications were observed in 3/30 patients, respectively, with no Grade 2 or more late toxicity. The urinary, bowel and sexual bother EPIC scores were slightly and insignificantly increased in the first 3 months post-treatment, returning to normal afterwards. CONCLUSIONS mpMRI-guided focal boost using VMAT hypofractionated technique is associated with an excellent morphological and functional response control and a safe toxicity profile. ADVANCES IN KNOWLEDGE In the present trial, we examined the potential role of mpMRI for radiological assessment (functional and morphological) of treatment response in high-risk prostate cancer patients treated with MRI-guided focal radiotherapy dose intensification to dominant Intraprostatic lesion.
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Affiliation(s)
- Almudena Zapatero
- Radiation Oncology Department, Hospital Universitario de la Princesa, Health Research Institute IIS-IP, Madrid, Spain
| | - Maria Roch
- Medical Physics Department, Hospital Universitario de la Princesa, Health Research Institute IIS-IP, Madrid, Spain
| | - Pablo Castro Tejero
- Medical Physics Department, Hospital Universitario de la Princesa, Health Research Institute IIS-IP, Madrid, Spain
| | - David Büchser
- Radiation Oncology Department, Hospital Universitario de la Princesa, Health Research Institute IIS-IP, Madrid, Spain
| | - Carmen Martin de Vidales
- Radiation Oncology Department, Hospital Universitario de la Princesa, Health Research Institute IIS-IP, Madrid, Spain
| | - Saturnino González
- Radiology Department, Hospital Universitario de la Princesa, Health Research Institute IIS-IP, Madrid, Spain
| | - Pablo Rodríguez
- Radiology Department, Hospital Universitario de la Princesa, Health Research Institute IIS-IP, Madrid, Spain
| | - Luis Alberto San Jose
- Urology Department, Hospital Universitario de la Princesa, Health Research Institute IIS-IP, Madrid, Spain
| | - Guillermo Celada
- Urology Department, Hospital Universitario de la Princesa, Health Research Institute IIS-IP, Madrid, Spain
| | - Maria Teresa Murillo
- Radiation Oncology Department, Hospital Universitario de la Princesa, Health Research Institute IIS-IP, Madrid, Spain
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Ohira S, Komiyama R, Kanayama N, Sakai K, Hirata T, Yoshikata K, Ueda Y, Miyazaki M, Nakayama M, Koizumi M, Konishi K. Improvement in bladder volume reproducibility using A-mode portable ultrasound bladder scanner in moderate-hypofractionated volumetric modulated arc therapy for prostate cancer patients. J Appl Clin Med Phys 2022; 23:e13546. [PMID: 35112479 PMCID: PMC8992960 DOI: 10.1002/acm2.13546] [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: 08/22/2021] [Revised: 01/05/2022] [Accepted: 01/16/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose This study introduced an A‐mode portable ultrasound bladder scanner, the Lilium® α‐200 (here after Lilium; Lilium Otsuka, Kanagawa, Japan), for the treatment of prostate cancer patients with hypofractionated volumetric modulated arc therapy to improve the reproducibility of bladder volume (BV). Materials and methods Thirty patients were advised to maintain full BV prior to computed tomography (CT) simulation and daily treatment. Among these, the BV of 15 patients was measured using Lilium until a BV of 80% in the simulation was achieved (with the Lilium group). Daily cone‐beam CT (CBCT) was performed for treatment. The correlation between BV measured by CBCT and Lilium was assessed. The differences in the BV and dosimetric parameters of the bladder in the CBCT versus planning CT were compared between the groups with and without Lilium. Results There was a significantly strong relationship (r = 0.796, p < 0.05) between the BVs measured using CBCT and Lilium. The relative BV ratios to simulation CT < 0.5 and > 2 were observed in 10.3% and 12.7%, respectively, of treatment sessions without Lilium group, while these ratios were 1% and 2.8%, respectively, in the Lilium group. The mean absolute difference in the range of V30Gy to V40Gy without Lilium sessions was significantly larger (p < 0.05) than that in the Lilium group. Conclusion The use of the A‐mode portable ultrasound bladder scanner significantly improved the reproducibility of the BV, resulting in few variations in the dosimetric parameters for the bladder.
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Affiliation(s)
- Shingo Ohira
- Department of Radiation OncologyOsaka International Cancer InstituteOsakaJapan
- Department of Medical Physics and EngineeringOsaka University Graduate School of MedicineSuitaJapan
| | - Riho Komiyama
- Department of Radiation OncologyOsaka International Cancer InstituteOsakaJapan
| | - Naoyuki Kanayama
- Department of Radiation OncologyOsaka International Cancer InstituteOsakaJapan
| | - Kayo Sakai
- Nursing DepartmentOsaka International Cancer InstituteOsakaJapan
| | - Takero Hirata
- Department of Radiation OncologyOsaka University Graduate School of MedicineSuitaJapan
| | - Kento Yoshikata
- Department of Radiation OncologyOsaka International Cancer InstituteOsakaJapan
| | - Yoshihiro Ueda
- Department of Radiation OncologyOsaka International Cancer InstituteOsakaJapan
| | - Masayoshi Miyazaki
- Department of Radiation OncologyOsaka International Cancer InstituteOsakaJapan
| | - Masashi Nakayama
- Department of UrologyOsaka International Cancer InstituteOsakaJapan
| | - Masahiko Koizumi
- Department of Medical Physics and EngineeringOsaka University Graduate School of MedicineSuitaJapan
| | - Koji Konishi
- Department of Radiation OncologyOsaka International Cancer InstituteOsakaJapan
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Finnegan RN, Reynolds HM, Ebert MA, Sun Y, Holloway L, Sykes JR, Dowling J, Mitchell C, Williams SG, Murphy DG, Haworth A. A statistical, voxelised model of prostate cancer for biologically optimised radiotherapy. Phys Imaging Radiat Oncol 2022; 21:136-145. [PMID: 35284663 PMCID: PMC8913349 DOI: 10.1016/j.phro.2022.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/04/2022] Open
Abstract
Background and purpose Radiation therapy (RT) is commonly indicated for treatment of prostate cancer (PC). Biologicallyoptimised RT for PC may improve disease-free survival. This requires accurate spatial localisation and characterisation of tumour lesions. We aimed to generate a statistical, voxelised biological model to complement in vivomultiparametric MRI data to facilitate biologically-optimised RT. Material and methods Ex vivo prostate MRI and histopathological imaging were acquired for 63 PC patients. These data were co-registered to derive three-dimensional distributions of graded tumour lesions and cell density. Novel registration processes were used to map these data to a common reference geometry. Voxelised statistical models of tumour probability and cell density were generated to create the PC biological atlas. Cell density models were analysed using the Kullback–Leibler divergence to compare normal vs. lognormal approximations to empirical data. Results A reference geometry was constructed using ex vivo MRI space, patient data were deformably registered using a novel anatomy-guided process. Substructure correspondence was maintained using peripheral zone definitions to address spatial variability in prostate anatomy between patients. Three distinct approaches to interpolation were designed to map contours, tumour annotations and cell density maps from histology into ex vivo MRI space. Analysis suggests a log-normal model provides a more consistent representation of cell density when compared to a linear-normal model. Conclusion A biological model has been created that combines spatial distributions of tumour characteristics from a population into three-dimensional, voxelised, statistical models. This tool will be used to aid the development of biologically-optimised RT for PC patients.
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Kuisma A, Wright P, Suilamo S, Seppälä J, Koivisto M, Lindholm P, Minn H. Long-term outcome of biologically guided dose-escalated radiotherapy of localized prostate cancer. Acta Oncol 2022; 61:97-103. [PMID: 34772320 DOI: 10.1080/0284186x.2021.1998613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Biologically created subvolumes enable non-uniform dose distributions in prostate cancer radiotherapy (RT) thus potentially improving therapeutic ratio and reducing toxicity. We present the long-term outcome of men receiving focal boosting of carbon-11 acetate (ACE) PET-CT metabolically active areas in prostate carcinoma. MATERIAL AND METHODS Thirty men with hormone naïve localized prostate carcinoma underwent ACE PET/CT for RT planning. There were five low-, 17 intermediate-, and eight high-risk patients. Based on thresholding of the standardized uptake values (SUVs) metabolic target volumes (MTVs) corresponding to intraprostatic lesions (IPLs) were contoured. Two planning target volumes (PTVs) were applied i.e., PTVlow-risk for the whole prostate with 8-10 mm margin and PTVhigh-risk for the MTV. Pelvic nodes were not irradiated. Late toxicity of biologically guided RT was reviewed after a median of 63 months and outcome after a median follow-up of 124 months. RESULTS Median doses to PTVlow-risk, PTVhigh-risk, prostate, and MTV were 72.9 Gy, 79.4 Gy, 76.6 Gy, and 80.4 Gy, respectively, in 38 fractions. The 10-year cancer-specific survival was 86% and the biochemical failure-free ratio 68%, respectively. The median biochemical progression-free survival (PFS) was 37, 108, and 119 months in the high, intermediate, and low-risk groups, respectively, the difference being significant between high and intermediate-risk groups (p = 0.02). One patient (3%) presented with locoregional and 5 (17%) with distant nodal metastases. Five patients (17%) had a biochemical relapse. A larger MTV was associated with shorter PFS (r = -0.41, p = 0.02), but had no influence on OS. No other statistically significant differences in the dose painting parameters were observed between recurrence-free and recurring patients. CONCLUSIONS Biological guidance for dose-escalated prostate RT is feasible with ACE PET/CT. Since a larger MTV may be associated with a higher risk for progression, we encourage further study of dose-escalation to ACE-positive lesions considering the low toxicity of our protocol.
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Affiliation(s)
- Anna Kuisma
- Department of Oncology, Turku University Hospital, Turku, Finland
| | - Pauliina Wright
- Department of Oncology, Turku University Hospital, Turku, Finland
- Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Sami Suilamo
- Department of Oncology, Turku University Hospital, Turku, Finland
- Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Jan Seppälä
- Cancer Center, Kuopio University Hospital, Turku, Finland
| | - Mari Koivisto
- Department of biostatistics, University of Turku, Turku, Finland
| | - Paula Lindholm
- Department of Oncology, Turku University Hospital, Turku, Finland
| | - Heikki Minn
- Department of Oncology, Turku University Hospital, Turku, Finland
- Turku PET Centre, Turku University Hospital, University of Turku, Turku, Finland
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18
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Zhou J, Yang X, Chang CW, Tian S, Wang T, Lin L, Wang Y, Janopaul-Naylor JR, Patel P, Demoor JD, Bohannon D, Stanforth A, Eaton B, McDonald MW, Liu T, Patel SA. Dosimetric Uncertainties in Dominant Intraprostatic Lesion Simultaneous Boost Using Intensity Modulated Proton Therapy. Adv Radiat Oncol 2021; 7:100826. [PMID: 34805623 PMCID: PMC8581277 DOI: 10.1016/j.adro.2021.100826] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 08/27/2021] [Accepted: 09/20/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose While intensity modulated proton therapy can deliver simultaneous integrated boost (SIB) to the dominant intraprostatic lesion (DIL) with high precision, it is sensitive to anatomic changes. We investigated the dosimetric effects from these changes based on pretreatment cone-beam computed tomographic (CBCT) images and identified the most important factors using a multilayer perceptron neural network (MLPNN). Methods and Materials DILs were contoured based on coregistered multiparametric magnetic resonance images for 25 previously treated prostate cancer patients. SIB plans were created with (1) prostate clinical target volume − V70 Gy = 98%; (2) DIL − V98 Gy > 95%; and (3) all organs at risk (OARs)"?> within clinical constraints. SIB plans were applied to daily CBCT-based deformed planning computed tomography (CT)"?>. DIL − V98 Gy, bladder/rectum maximum dose (Dmax) and volume changes, femur shifts, and the distance from DIL to organs at riskOARs"?> in both planning computed tomogramsCT"?> and CBCT were calculated. Wilcoxon signed-ranks tests were used to compare the changes. MLPNNs were used to model the change in ΔDIL − V98 Gy > 10% and bladder/rectum Dmax > 80 Gy, and the relative importance factors for the model were provided. The performances of the models were evaluated with receiver operating characteristic curves. Results Comparing initial plan to the average from evaluation plans, respectively, DIL − V98 Gy was 89.3% ± 19.9% versus 86.2% ± 21.3% (P = .151); bladder Dmax 71.9 ± 0.6 Gy versus 74.5 ± 2.9 Gy (P < .001); and rectum Dmax 70.1 ± 2.4 Gy versus 74.9 ± 9.1Gy (P = .007). Bladder and rectal volumes were 99.6% ± 39.5% and 112.8% ± 27.2%, respectively, of their initial volume. The femur shift was 3.16 ± 2.52 mm. In the modeling of ΔDIL V98 Gy > 10%, DIL to rectum distance changes, DIL to bladder distance changes, and rectum volume changes ratio are the 3 most important factors. The areas under the receiver operating characteristic curves were 0.89, 1.00, and 0.99 for the modeling of ΔDIL − V98 Gy > 10%, and bladder and rectum Dmax > 80 Gy, respectively. Conclusions Dosimetric changes in DIL SIB with intensity modulated proton therapy can be modeled and classified based on anatomic changes on pretreatment images by an MLPNN.
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Affiliation(s)
- Jun Zhou
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Xiaofeng Yang
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Chih-Wei Chang
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Sibo Tian
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Tonghe Wang
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Liyong Lin
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Yinan Wang
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | | | - Pretesh Patel
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - John D Demoor
- Department of Medical Physics, Georgia Institute of Technology, Atlanta, Georgia
| | - Duncan Bohannon
- Department of Medical Physics, Georgia Institute of Technology, Atlanta, Georgia
| | - Alex Stanforth
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Bree Eaton
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Mark W McDonald
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Tian Liu
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Sagar Anil Patel
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
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Hoberück S, Löck S, Borkowetz A, Sommer U, Winzer R, Zöphel K, Fedders D, Michler E, Kotzerke J, Kopka K, Hölscher T, Braune A. Intraindividual comparison of [ 68 Ga]-Ga-PSMA-11 and [ 18F]-F-PSMA-1007 in prostate cancer patients: a retrospective single-center analysis. EJNMMI Res 2021; 11:109. [PMID: 34665337 PMCID: PMC8526666 DOI: 10.1186/s13550-021-00845-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/27/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The analysis aimed to compare the radiotracers [68Ga]-Ga-PSMA-11 and [18F]-F-PSMA-1007 intraindividually in terms of malignant lesions, mi(molecular-imaging)TNM staging and presumable unspecific lesions retrospectively as used in routine clinical practice. METHODS A retrospective analysis of 46 prostate cancer patients (median age: 71 years) who underwent consecutive [68Ga]-Ga-PSMA-11- and [18F]-F-PSMA-1007-PET/CT or PET/MRI within a mean of 12 ± 8.0 days was performed. MiTNM staging was performed in both studies by two nuclear medicine physicians who were blinded to the results of the other tracer. After intradisciplinary and interdisciplinary consensus with two radiologists was reached, differences in both malignant and presumable nonspecific tracer accumulation were analyzed. RESULTS Differences in terms of miTNM stages in both studies occurred in nine of the 46 patients (19.6%). The miT stages differed in five patients (10.9%), the miN stages differed in three patients (6.5%), and different miM stages occurred only in one patient who was upstaged in [18F]-F-PSMA-1007 PET. Concordant miTNM stages were obtained in 37 patients (80.4%). There was no significant difference between [18F]-F-PSMA-1007 and [68Ga]-Ga-PSMA-11 in the SUVmax locally (31.5 vs. 32.7; p = 0.658), in lymph node metastases (28.9 vs. 24.9; p = 0.30) or in bone metastases (22.9 vs. 27.6; p = 0.286). In [18F]-F-PSMA-1007 PET, more patients featured presumable unspecific uptake in the lymph nodes (52.2% vs. 28.3%; p: < 0.001), bones (71.7% vs. 23.9%; p < 0.001) and ganglia (71.7% vs. 43.5%; p < 0.001). Probable unspecific, exclusively [18F]-F-PSMA-1007-positive lesions mainly occurred in the ribs (58.7%), axillary lymph nodes (39.1%) and cervical ganglia (28.3%). CONCLUSION In terms of miTNM staging, both tracers appeared widely exchangeable, as no tracer relevantly outperformed the other. The differences between the two tracers were far more common in presumable unspecific lesions than in malignant spots. A routinely performed two-tracer study could not be shown to be superior. Since it seems at least challenging for most nuclear medicine departments to provide both [18F]-F-PSMA-1007 and [68Ga]-Ga-PSMA-11, it appears reasonable to choose the PSMA radiotracer depending on local availability with attention to the greater occurrence of nonspecific bone findings with [18F]-F-PSMA-1007.
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Affiliation(s)
- Sebastian Hoberück
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany. .,Department of Nuclear Medicine, Helios Klinikum Erfurt, Erfurt, Germany.
| | - Steffen Löck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Angelika Borkowetz
- Department of Urology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Ulrich Sommer
- Department of Pathology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Robert Winzer
- Department of Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Klaus Zöphel
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.,Department of Nuclear Medicine, Klinikum Chemnitz gGmbH, Chemnitz, Germany
| | - Dieter Fedders
- Department of Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Enrico Michler
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Jörg Kotzerke
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Klaus Kopka
- Institute of Radiopharmaceutical Cancer Research, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Dresden, Germany.,Faculty of Chemistry and Food Chemistry, School of Science, TU Dresden, Dresden, Germany
| | - Tobias Hölscher
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Anja Braune
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany
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20
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Fredman E, Traughber B, Kharouta M, Podder T, Lo S, Ponsky L, MacLennan G, Paspulati R, Ellis B, Machtay M, Ellis R. Focal Prostate Stereotactic Body Radiation Therapy With Correlative Pathological and Radiographic-Based Treatment Planning. Front Oncol 2021; 11:744130. [PMID: 34604088 PMCID: PMC8480263 DOI: 10.3389/fonc.2021.744130] [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: 07/19/2021] [Accepted: 08/19/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Advances in multiparametric MRI (mpMRI) combining anatomic and functional imaging can accurately identify foci of adenocarcinoma within the prostate, offering the possibility of partial gland therapy. We performed tandem prospective pilot trials to investigate the feasibility of focal prostate SBRT (f-SBRT) based on correlating diagnostic mpMRI and biopsies with confirmatory pathology in treatment planning. Materials and Methods Patients with pathologic focal Gleason 6–7 disease and a corresponding PIRADS 4–5 lesion on mpMRI underwent targeted and comprehensive biopsies using MRI/ultrasound fusion under electromagnetic sensor navigation. After rigorous analysis for imaging biopsy concordance, five of 18 patients were eligible to proceed to f-SBRT. Chi-squared test was used for differences from expected outcomes, and concordance was estimated with binomial distribution theory and Wilson’s method. Results Six patients had Gleason 6 and 12 had Gleason 3 + 4 disease (mean PSA: 5.8 ng/ml, range: 2.2–8.4). Absolute concordance was 43.8% (95% CI: 0.20, 0.64). Patterns of discordance included additional sites of ipsilateral disease, bilateral disease, and negative target. Five were upstaged to a new NCCN risk category necessitating treatment escalation. The five patients with concordant pathology completed three-fraction f-SBRT with sparing of the surrounding normal structures (including contralateral neurovascular bundle), with no reported grade 2+ toxicities and favorable PSA responses (mean: 41% decrease). Conclusions On our pilot trials of f-SBRT planning using rigorous imaging and pathology concordance, image-guided confirmatory biopsies frequently revealed additional disease, suggesting the need for caution in partial-gland therapy. For truly focal disease, f-SBRT provided excellent dosimetry, minimal toxicity, and encouraging biochemical response. Clinical Trial Registration: www.clinicaltrials.gov, NCT02681614; NCT02163317.
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Affiliation(s)
- Elisha Fredman
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Bryan Traughber
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH, United States.,Department of Radiation Oncology, Penn State University, Milton Hershey Medical Center, Hershey, PA, United States
| | - Michael Kharouta
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Tarun Podder
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Simon Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, United States
| | - Lee Ponsky
- Department of Urology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Gregory MacLennan
- Department of Pathology, University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Raj Paspulati
- Department of Radiology, University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Bradley Ellis
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Mitchell Machtay
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH, United States.,Department of Radiation Oncology, Penn State University, Milton Hershey Medical Center, Hershey, PA, United States
| | - Rodney Ellis
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH, United States.,Department of Radiation Oncology, Penn State University, Milton Hershey Medical Center, Hershey, PA, United States
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21
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Moteabbed M, Harisinghani M, Paganetti H, Trofimov A, Lu HM, Efstathiou JA. Proton vs. photon radiotherapy for MR-guided dose escalation of intraprostatic lesions. Acta Oncol 2021; 60:1283-1290. [PMID: 34282708 DOI: 10.1080/0284186x.2021.1947523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Dose escalation has been associated with improved biochemical control for prostate cancer. Focusing the high dose on the MRI-defined intraprostatic lesions (IL) could spare the surrounding organs at risk and hence allow further escalation. We compare treatment efficacy between state-of-the-art focally-boosted proton and photon-based radiotherapy, and investigate possible predictive guidelines regarding individualized treatment prescriptions. MATERIAL AND METHODS Ten prostate cancer patients with well-defined ILs were selected. Multiparametric MRI was used to delineate ILs, which were transferred to the planning CT via image registration. Pencil beam scanning proton therapy and volumetric modulated arc therapy treatment plans, were created for each patient. Each modality featured 6 plans: (1) moderately hypofractionated dose: 70 Gy to the prostate in 28 fractions, (2)-(6) plan 1 plus additional simultaneous-integrated-boost to ILs to 75.6, 81.2, 86.6, 98 and 112 Gy in 28 fractions. Equivalent dose to 2 Gy-per-fraction (EqD2) was used to calculate tumor control (TCP) and normal tissue complication probabilities (NTCP) for ILs and organs-at-risk. RESULTS For both modalities, the maximum necessary dose to achieve TCP > 99% was 98 Gy for very high-risk ILs. For lower risk ILs lower doses were sufficient. NTCP was <25% and 35% for protons and photons at the maximum dose escalation, respectively. For the cases and beam characteristics considered, proton therapy was dosimetrically superior when IL was >4 cc or located <2.5 mm from the rectum. CONCLUSION This work demonstrated the potential role for proton therapy in the setting of prostate focal dose escalation. We propose that anatomical characteristic could be used as criteria to identify patients who would benefit from proton treatment.
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Affiliation(s)
- Maryam Moteabbed
- Division of Radiation Biophysics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mukesh Harisinghani
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Harald Paganetti
- Division of Radiation Biophysics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Alexei Trofimov
- Division of Radiation Biophysics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Jason A. Efstathiou
- Division of Radiation Biophysics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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22
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Moderately hypofractionated radiotherapy as definitive treatment for localized prostate cancer: Pattern of practice in German-speaking countries : A survey of the Prostate Cancer Expert Panel of the German Society of Radiation Oncology (DEGRO) and the Working Party on Radiation Oncology of the German Cancer Society (DKG-ARO). Strahlenther Onkol 2021; 197:993-1000. [PMID: 34463814 PMCID: PMC8545730 DOI: 10.1007/s00066-021-01820-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 07/02/2021] [Indexed: 11/23/2022]
Abstract
Purpose Various randomized phase III clinical trials have compared moderately hypofractionated to normofractionated radiotherapy (RT). These modalities showed similar effectiveness without major differences in toxicity. This project was conducted by the Prostate Cancer Expert Panel of the German Society of Radiation Oncology (DEGRO) and the Working Party on Radiation Oncology of the German Cancer Society. We aimed to investigate expert opinions on the use of moderately hypofractionated RT as a definitive treatment for localized prostate cancer in German-speaking countries. Methods A 25-item, web-based questionnaire on moderate-hypofractionation RT was prepared by an internal committee. The experts of the DEGRO were asked to complete the questionnaire. Results Fourteen active members of DEGRO completed the questionnaire. The questions described indications for selecting patients eligible to receive moderate hypofractionation based on clinical and pathological factors such as age, urinary symptoms, and risk-group. The questions also collected information on the technical aspects of selection criteria, including the definition of a clinical target volume, the use of imaging, protocols for bladder and rectal filling, the choice of a fractionation schedule, and the use of image guidance. Moreover, the questionnaire collected information on post-treatment surveillance after applying moderately hypofractionated RT. Conclusion Although opinions varied on the use of moderate-hypofractionation RT, the current survey reflected broad agreement on the notion that moderately hypofractionated RT could be considered a standard treatment for localized prostate cancer in German-speaking countries.
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23
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Burgess L, Roy S, Morgan S, Malone S. A Review on the Current Treatment Paradigm in High-Risk Prostate Cancer. Cancers (Basel) 2021; 13:4257. [PMID: 34503067 PMCID: PMC8428221 DOI: 10.3390/cancers13174257] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/16/2021] [Accepted: 08/20/2021] [Indexed: 01/17/2023] Open
Abstract
High-risk prostate cancer is traditionally treated with a combination of radiotherapy (RT) and androgen deprivation therapy (ADT). However, recent advancements in systemic treatment and radiotherapy have widened the spectrum of treatment for this patient population. Use of image guidance and intensity modulation, as well as the incorporation of brachytherapy, has led to safe radiotherapy dose escalation with reduced risk of recurrence. Clinical trials have helped define the role of pelvic nodal radiotherapy, the role of stereotactic ablative radiotherapy, and the optimal duration and sequencing of ADT in combination with radiotherapy. Emerging evidence has redefined the role of surgery in this cohort. Contemporary clinical trials have identified new systemic therapy options in high-risk prostate cancer. Finally, new imaging modalities including multi-parametric MRI and molecular imaging and genomic classifiers have ushered a new era in patient selection, risk stratification, and treatment tailoring.
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Affiliation(s)
- Laura Burgess
- Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, ON K1H 8L6, Canada;
- Radiation Medicine Program, The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
| | - Soumyajit Roy
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL 60605, USA;
| | - Scott Morgan
- Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, ON K1H 8L6, Canada;
- Radiation Medicine Program, The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
| | - Shawn Malone
- Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, ON K1H 8L6, Canada;
- Radiation Medicine Program, The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
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24
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Draulans C, Pos F, Smeenk RJ, Kerkmeijer L, Vogel WV, Nagarajah J, Janssen M, Mai C, Heijmink S, van der Leest M, Zámecnik P, Oyen R, Isebaert S, Maes F, Joniau S, Kunze-Busch M, De Roover R, Defraene G, van der Heide UA, Goffin K, Haustermans K. 68Ga-PSMA-11 PET, 18F-PSMA-1007 PET, and MRI for Gross Tumor Volume Delineation in Primary Prostate Cancer: Intermodality and Intertracer Variability. Pract Radiat Oncol 2021; 11:202-211. [PMID: 33941347 DOI: 10.1016/j.prro.2020.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 10/11/2020] [Accepted: 11/08/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE To assess the intermodality and intertracer variability of gallium-68 (68Ga)- or fluorine-18 (18F)-labeled prostate-specific membrane antigen (PSMA) positron emission tomography (PET) and biparametric magnetic resonance imaging (bpMRI)-based gross tumor volume (GTV) delineation for focal boosting in primary prostate cancer. METHODS Nineteen prospectively enrolled patients with prostate cancer underwent a PSMA PET/MRI scan, divided into a 1:1 ratio between 68Ga-PSMA-11 and 18F-PSMA-1007, before radical prostatectomy (IWT140193). Four delineation teams performed manual contouring of the GTV based on bpMRI and PSMA PET imaging, separately. Index lesion coverage (overlap%) and interobserver variability were assessed. Furthermore, the distribution of the voxelwise normalized standardized uptake values (SUV%) was determined for the majority-voted (>50%) GTV (GTVmajority) and whole prostate gland to investigate intertracer variability. The median patientwise SUV% contrast ratio (SUV%-CR, calculated as median GTVmajority SUV% / median prostate gland without GTVmajority SUV%) was calculated according to the tracer used. RESULTS A significant difference in overlap% favoring PSMA PET compared with bpMRI was found in the 18F subgroup (median, 63.0% vs 53.1%; P = .004) but was not present in the 68Ga subgroup (32.5% vs 50.6%; P = .100). Regarding interobserver variability, measured Sørensen-Dice coefficients (0.58 vs 0.72) and calculated mean distances to agreement (2.44 mm vs 1.22 mm) were statistically significantly lower and higher, respectively, for the 18F cohort compared with the 68Ga cohort. For the bpMRI-based delineations, the median Sørensen-Dice coefficient and mean distance to agreement were 0.63 and 1.76 mm, respectively. Median patientwise SUV%-CRs of 1.8 (interquartile range [IQR], 1.6-2.7) for 18F-PSMA and 3.3 (IQR, 2.7-5.9) for 68Ga-PSMA PET images were found. CONCLUSIONS Both MRI and PSMA PET provided consistent intraprostatic GTV lesion detection. However, the PSMA tracer seems to have a major influence on the contour characteristics, owing to an apparent difference in SUV% distribution in the prostate gland.
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Affiliation(s)
- Cédric Draulans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium; Department of Oncology, KU Leuven, Leuven, Belgium
| | - Floris Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Linda Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Radiation Oncology, University Medical Centre, Utrecht, The Netherlands
| | - Wouter V Vogel
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - James Nagarajah
- Department of Radiology & Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marcel Janssen
- Department of Radiology & Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Cindy Mai
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Stijn Heijmink
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marloes van der Leest
- Department of Radiology & Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Patrik Zámecnik
- Department of Radiology & Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Raymond Oyen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Sofie Isebaert
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium; Department of Oncology, KU Leuven, Leuven, Belgium
| | - Frederik Maes
- Department of Electrical Engineering, ESAT/PSI, KU Leuven, Leuven, Belgium; Medical Imaging Research Centre, University Hospitals Leuven, Leuven, Belgium
| | - Steven Joniau
- Department of Urology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Martina Kunze-Busch
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robin De Roover
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium; Department of Oncology, KU Leuven, Leuven, Belgium
| | - Gilles Defraene
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium; Department of Oncology, KU Leuven, Leuven, Belgium
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Karolien Goffin
- Department of Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium; Department of Oncology, KU Leuven, Leuven, Belgium.
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25
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De Roover R, Crijns W, Poels K, Dewit B, Draulans C, Haustermans K, Depuydt T. Automated treatment planning of prostate stereotactic body radiotherapy with focal boosting on a fast-rotating O-ring linac: Plan quality comparison with C-arm linacs. J Appl Clin Med Phys 2021; 22:59-72. [PMID: 34318996 PMCID: PMC8425873 DOI: 10.1002/acm2.13345] [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: 04/23/2021] [Accepted: 05/26/2021] [Indexed: 11/14/2022] Open
Abstract
Purpose The integration of auto‐segmentation and automated treatment planning methods on a fast‐rotating O‐ring linac may improve the time efficiency of online adaptive radiotherapy workflows. This study investigates whether automated treatment planning of prostate SBRT with focal boosting on the O‐ring linac could generate plans that are of similar quality as those obtained through manual planning on clinical C‐arm linacs. Methods For 20 men with prostate cancer, reference treatment plans were generated on a TrueBeam STx C‐arm linac with HD120 MLC and a TrueBeam C‐arm linac with Millennium 120 MLC using 6 MV flattened dual arc VMAT. Manual planning on the Halcyon fast‐rotating O‐ring linac was performed using 6 MV FFF dual arc VMAT (HA2‐DL10) and triple arc VMAT (HA3‐DL10) to investigate the performance of the dual‐layer MLC system. Automated planning was performed for triple arc VMAT on the Halcyon linac (ET3‐DL10) using the automated planning algorithms of Ethos Treatment Planning. The prescribed dose was 35 Gy to the prostate and 30 Gy to the seminal vesicles in five fractions. The iso‐toxic focal boost to the intraprostatic tumor nodule(s) was aimed to receive up to 50 Gy. Plan deliverability was verified using portal image dosimetry measurements. Results Compared to the C‐arm linacs, ET3‐DL10 shows increased seminal vesicles PTV coverage (D99%) and reduced high‐dose spillage to the bladder (V37Gy) and urethra (D0.035cc) but this came at the cost of increased high‐dose spillage to the rectum (V38Gy) and a higher intermediate dose spillage (D2cm). No statistically significant differences were found when benchmarking HA2‐DL10 and HA3‐DL10 with the C‐arm linacs. All plans passed the patient‐specific QA tolerance limit. Conclusions Automated planning of prostate SBRT with focal boosting on the fast‐rotating O‐ring linac is feasible and achieves similar plan quality as those obtained on clinical C‐arm linacs using manual planning.
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Affiliation(s)
- Robin De Roover
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, KU Leuven, Leuven, Belgium
| | - Wouter Crijns
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, KU Leuven, Leuven, Belgium
| | - Kenneth Poels
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, KU Leuven, Leuven, Belgium
| | - Bertrand Dewit
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, KU Leuven, Leuven, Belgium
| | - Cédric Draulans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, KU Leuven, Leuven, Belgium
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, KU Leuven, Leuven, Belgium
| | - Tom Depuydt
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, KU Leuven, Leuven, Belgium
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26
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Spohn SKB, Sachpazidis I, Wiehle R, Thomann B, Sigle A, Bronsert P, Ruf J, Benndorf M, Nicolay NH, Sprave T, Grosu AL, Baltas D, Zamboglou C. Influence of Urethra Sparing on Tumor Control Probability and Normal Tissue Complication Probability in Focal Dose Escalated Hypofractionated Radiotherapy: A Planning Study Based on Histopathology Reference. Front Oncol 2021; 11:652678. [PMID: 34055621 PMCID: PMC8160377 DOI: 10.3389/fonc.2021.652678] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/08/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose Multiparametric magnetic resonance tomography (mpMRI) and prostate specific membrane antigen positron emission tomography (PSMA-PET/CT) are used to guide focal radiotherapy (RT) dose escalation concepts. Besides improvements of treatment effectiveness, maintenance of a good quality of life is essential. Therefore, this planning study investigates whether urethral sparing in moderately hypofractionated RT with focal RT dose escalation influences tumour control probability (TCP) and normal tissue complication probability (NTCP). Patients and Methods 10 patients with primary prostate cancer (PCa), who underwent 68Ga PSMA-PET/CT and mpMRI followed by radical prostatectomy were enrolled. Intraprostatic tumour volumes (gross tumor volume, GTV) based on both imaging techniques (GTV-MRI and -PET) were contoured manually using validated contouring techniques and GTV-Union was created by summing both. For each patient three IMRT plans were generated with 60 Gy to the whole prostate and a simultaneous integrated boost up to 70 Gy to GTV-Union in 20 fractions by (Plan 1) not respecting and (Plan 2) respecting dose constraints for urethra as well as (Plan 3) respecting dose constraints for planning organ at risk volume for urethra (PRV = urethra + 2mm expansion). NTCP for urethra was calculated applying a Lyman-Kutcher-Burman model. TCP-Histo was calculated based on PCa distribution in co-registered histology (GTV-Histo). Complication free tumour control probability (P+) was calculated. Furthermore, the intrafractional movement was considered. Results Median overlap of GTV-Union and PRV-Urethra was 1.6% (IQR 0-7%). Median minimum distance of GTV-Histo to urethra was 3.6 mm (IQR 2 - 7 mm) and of GTV-Union to urethra was 1.8 mm (IQR 0.0 - 5.0 mm). The respective prescription doses and dose constraints were reached in all plans. Urethra-sparing in Plans 2 and 3 reached significantly lower NTCP-Urethra (p = 0.002) without significantly affecting TCP-GTV-Histo (p = p > 0.28), NTCP-Bladder (p > 0.85) or NTCP-Rectum (p = 0.85), resulting in better P+ (p = 0.006). Simulation of intrafractional movement yielded even higher P+ values for Plans 2 and 3 compared to Plan 1. Conclusion Urethral sparing may increase the therapeutic ratio and should be implemented in focal RT dose escalation concepts.
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Affiliation(s)
- Simon K B Spohn
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ilias Sachpazidis
- Division of Medical Physics, Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rolf Wiehle
- Division of Medical Physics, Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benedikt Thomann
- Division of Medical Physics, Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - August Sigle
- Department of Urology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Bronsert
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Juri Ruf
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Benndorf
- Department of Radiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany
| | - Anca L Grosu
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany
| | - Dimos Baltas
- German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany.,Division of Medical Physics, Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantinos Zamboglou
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK). Partner Site Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Sardaro A, Turi B, Bardoscia L, Ferrari C, Rubini G, Calabrese A, Ammirati F, Grillo A, Leo A, Lorusso F, Santorsola A, Stabile Ianora AA, Scardapane A. The Role of Multiparametric Magnetic Resonance in Volumetric Modulated Arc Radiation Therapy Planning for Prostate Cancer Recurrence After Radical Prostatectomy: A Pilot Study. Front Oncol 2021; 10:603994. [PMID: 33585223 PMCID: PMC7874055 DOI: 10.3389/fonc.2020.603994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/26/2020] [Indexed: 12/25/2022] Open
Abstract
Background and Purpose Volumetric modulated arc radiotherapy (RT) has become pivotal in the treatment of prostate cancer recurrence (RPC) to optimize dose distribution and minimize toxicity, thanks to the high-precision delineation of prostate bed contours and organs at risk (OARs) under multiparametric magnetic resonance (mpMRI) guidance. We aimed to assess the role of pre-treatment mpMRI in ensuring target volume coverage and normal tissue sparing. Material and Methods Patients with post-prostatectomy RPC eligible for salvage RT were prospectively recruited to this pilot study. Image registration between planning CT scan and T2w pre-treatment mpMRI was performed. Two sets of volumes were outlined, and DWI images/ADC maps were used to facilitate precise gross tumor volume (GTV) delineation on morphological MRI scans. Two rival plans (mpMRI-based or not) were drawn up. Results Ten patients with evidence of RPC after prostatectomy were eligible. Preliminary data showed lower mpMRI-based clinical target volumes than CT-based RT planning (p = 0.0003): median volume difference 17.5 cm3. There were no differences in the boost volume coverage nor the dose delivered to the femoral heads and penile bulb, but median rectal and bladder V70Gy was 4% less (p = 0.005 and p = 0.210, respectively) for mpMRI-based segmentation. Conclusions mpMRI provides high-precision target delineation and improves the accuracy of RT planning for post-prostatectomy RPC, ensures better volume coverage with better OARs sparing and allows non-homogeneous dose distribution, with an aggressive dose escalation to the GTV. Randomized phase III trials and wider datasets are needed to fully assess the role of mpMRI in optimizing therapeutic strategies.
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Affiliation(s)
- Angela Sardaro
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Barbara Turi
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Policlinico, Bari, Italy
| | - Lilia Bardoscia
- Radiation Therapy Unit, Department of Oncology and Advanced Technology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Cristina Ferrari
- Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Giuseppe Rubini
- Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Angela Calabrese
- Department of Radiology, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | - Federica Ammirati
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Antonietta Grillo
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Policlinico, Bari, Italy
| | - Annamaria Leo
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Policlinico, Bari, Italy
| | | | - Antonio Santorsola
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Policlinico, Bari, Italy
| | - Antonio Amato Stabile Ianora
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Arnaldo Scardapane
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari "Aldo Moro", Bari, Italy
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Mohajer J, Dunlop A, Mitchell A, Goodwin E, Nill S, Oelfke U, Tree A. Feasibility of MR-guided ultrahypofractionated radiotherapy in 5, 2 or 1 fractions for prostate cancer. Clin Transl Radiat Oncol 2021; 26:1-7. [PMID: 33241129 PMCID: PMC7674276 DOI: 10.1016/j.ctro.2020.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 01/30/2023] Open
Abstract
The drive towards hypofractionated prostate radiotherapy is motivated by a low alpha/beta ratio for prostate cancer (1 to 3 Gy) compared to surrounding organs at risk, implying an improved therapeutic ratio with increasing dose per fraction. Early evidence from studies of ultrahypofractionated (UHF) prostate HDR brachytherapy has shown good tolerability in terms of normal tissue toxicities and clinical outcomes similar to conventional fractionation schedules. MR-guided stereotactic body radiotherapy (SBRT) with online plan adaptation and real-time tumour imaging may enable UHF doses to be delivered to the prostate safely, without the invasiveness of brachytherapy. The feasibility of UHF prostate treatment planning for the Unity MR-Linac (MRL, Elekta AB, Stockholm) was investigated for target prescriptions and planning constraints derived from the HDR brachytherapy and SBRT literature. Monaco 5.40 (Elekta) was used to generate MRL step-and-shoot IMRT plans for three dose fractionation protocols (5, 2 and 1 fractions), for ten randomly selected previously treated prostate cancer patients. Of the ten plans per UHF scheme, all clinical goals were met in all cases for 5 fractions, and in six cases for both 2 and 1 fraction schemes. PTV D95% was compromised by up to 6.4% and 3.9% of the associated target dose for 2 and 1 fraction plans respectively. There were two cases of PTV D95% compromise greater than a 5% dose decrease for the 2 fraction plans. The study suggests feasibility of the UHF treatment planning approaches if combined with real-time motion mitigation strategies.
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Affiliation(s)
- Jonathan Mohajer
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, 15 Cotswold Road, London, Surrey SM2 5NG, UK
| | - Alex Dunlop
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, 15 Cotswold Road, London, Surrey SM2 5NG, UK
| | - Adam Mitchell
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, 15 Cotswold Road, London, Surrey SM2 5NG, UK
| | - Edmund Goodwin
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, 15 Cotswold Road, London, Surrey SM2 5NG, UK
| | - Simeon Nill
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, 15 Cotswold Road, London, Surrey SM2 5NG, UK
| | - Uwe Oelfke
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, 15 Cotswold Road, London, Surrey SM2 5NG, UK
| | - Alison Tree
- Department of Urology, The Royal Marsden NHS Foundation Trust, 15 Cotswold Road, London, Surrey SM2 5NG, UK
- The Institute of Cancer Research, 15 Cotswold Road, London, Surrey SM2 5NG, UK
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29
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Tocco BR, Kishan AU, Ma TM, Kerkmeijer LGW, Tree AC. MR-Guided Radiotherapy for Prostate Cancer. Front Oncol 2020; 10:616291. [PMID: 33363041 PMCID: PMC7757637 DOI: 10.3389/fonc.2020.616291] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 11/09/2020] [Indexed: 01/08/2023] Open
Abstract
External beam radiotherapy remains the primary treatment modality for localized prostate cancer. The radiobiology of prostate carcinoma lends itself to hypofractionation, with recent studies showing good outcomes with shorter treatment schedules. However, the ability to accurately deliver hypofractionated treatment is limited by current image-guided techniques. Magnetic resonance imaging is the main diagnostic tool for localized prostate cancer and its use in the therapeutic setting offers anatomical information to improve organ delineation. MR-guided radiotherapy, with daily re-planning, has shown early promise in the accurate delivery of radiotherapy. In this article, we discuss the shortcomings of current image-guidance strategies and the potential benefits and limitations of MR-guided treatment for prostate cancer. We also recount present experiences of MR-linac workflow and the opportunities afforded by this technology.
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Affiliation(s)
- Boris R. Tocco
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Amar U. Kishan
- University of California, Los Angeles, Los Angeles, CA, United States
| | - Ting Martin Ma
- University of California, Los Angeles, Los Angeles, CA, United States
| | | | - Alison C. Tree
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
- Department of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
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30
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Syndikus I, Cruickshank C, Staffurth J, Tree A, Henry A, Naismith O, Mayles H, Snelson N, Hassan S, Brown S, Porta N, Griffin C, Hall E. PIVOTALboost: A phase III randomised controlled trial of prostate and pelvis versus prostate alone radiotherapy with or without prostate boost (CRUK/16/018). Clin Transl Radiat Oncol 2020; 25:22-28. [PMID: 32995575 PMCID: PMC7508714 DOI: 10.1016/j.ctro.2020.08.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/24/2020] [Indexed: 01/16/2023] Open
Abstract
•PIVOTALboost evaluates benefits/toxicity of pelvic node RT and focal boost dose escalation.•Unfavourable intermediate/high risk and bulky local disease are most likely to benefit.•Functional MRI imaging is used to select patients for different types of dose escalation.•HDR brachytherapy or focal dose escalation with IMRT are used as options.•Training and support is provided to reduce variations of contouring and radiotherapy planning.•The trial is recruiting patients in 38 radiotherapy centres through the UK.
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Affiliation(s)
| | - Clare Cruickshank
- Clinical Trials and Statistics Unit, The Institute of Cancer Research (ICR-CTSU), London, UK
| | | | - Alison Tree
- The Royal Marsden NHS Foundation Trust/The Institute of Cancer Research, London, UK
| | - Ann Henry
- The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Olivia Naismith
- National Radiotherapy Trials Quality Assurance Group, The Royal Marsden NHS Foundation Trust, London, UK
| | - Helen Mayles
- National Radiotherapy Trials Quality Assurance Group, The Clatterbridge Cancer Centre, Wirral. UK
| | - Nicola Snelson
- National Radiotherapy Trials Quality Assurance Group, The Clatterbridge Cancer Centre, Wirral. UK
| | - Shama Hassan
- Clinical Trials and Statistics Unit, The Institute of Cancer Research (ICR-CTSU), London, UK
| | - Stephanie Brown
- Clinical Trials and Statistics Unit, The Institute of Cancer Research (ICR-CTSU), London, UK
| | - Nuria Porta
- Clinical Trials and Statistics Unit, The Institute of Cancer Research (ICR-CTSU), London, UK
| | - Clare Griffin
- Clinical Trials and Statistics Unit, The Institute of Cancer Research (ICR-CTSU), London, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research (ICR-CTSU), London, UK
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31
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Draulans C, De Roover R, van der Heide UA, Kerkmeijer L, Smeenk RJ, Pos F, Vogel WV, Nagarajah J, Janssen M, Isebaert S, Maes F, Mai C, Oyen R, Joniau S, Kunze-Busch M, Goffin K, Haustermans K. Optimal 68Ga-PSMA and 18F-PSMA PET window levelling for gross tumour volume delineation in primary prostate cancer. Eur J Nucl Med Mol Imaging 2020; 48:1211-1218. [PMID: 33025093 DOI: 10.1007/s00259-020-05059-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/27/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE This study proposes optimal tracer-specific threshold-based window levels for PSMA PET-based intraprostatic gross tumour volume (GTV) contouring to reduce interobserver delineation variability. METHODS Nine 68Ga-PSMA-11 and nine 18F-PSMA-1007 PET scans including GTV delineations of four expert teams (GTVmanual) and a majority-voted GTV (GTVmajority) were assessed with respect to a registered histopathological GTV (GTVhisto) as the gold standard reference. The standard uptake values (SUVs) per voxel were converted to a percentage (SUV%) relative to the SUVmax. The statistically optimised SUV% threshold (SOST) was defined as those that maximises accuracy for threshold-based contouring. A leave-one-out cross-validation receiver operating characteristic (ROC) curve analysis was performed to determine the SOST for each tracer. The SOST analysis was performed twice, first using the GTVhisto contour as training structure (GTVSOST-H) and second using the GTVmajority contour as training structure (GTVSOST-MA) to correct for any limited misregistration. The accuracy of both GTVSOST-H and GTVSOST-MA was calculated relative to GTVhisto in the 'leave-one-out' patient of each fold and compared with the accuracy of GTVmanual. RESULTS ROC curve analysis for 68Ga-PSMA-11 PET revealed a median threshold of 25 SUV% (range, 22-27 SUV%) and 41 SUV% (40-43 SUV%) for GTVSOST-H and GTVSOST-MA, respectively. For 18F-PSMA-1007 PET, a median threshold of 42 SUV% (39-45 SUV%) for GTVSOST-H and 44 SUV% (42-45 SUV%) for GTVSOST-MA was found. A significant pairwise difference was observed when comparing the accuracy of the GTVSOST-H contours with the median accuracy of the GTVmanual contours (median, - 2.5%; IQR, - 26.5-0.2%; p = 0.020), whereas no significant pairwise difference was found for the GTVSOST-MA contours (median, - 0.3%; IQR, - 4.4-0.6%; p = 0.199). CONCLUSIONS Threshold-based contouring using GTVmajority-trained SOSTs achieves an accuracy comparable with manual contours in delineating GTVhisto. The median SOSTs of 41 SUV% for 68Ga-PSMA-11 PET and 44 SUV% for 18F-PSMA-1007 PET form a base for tracer-specific window levelling. TRIAL REGISTRATION Clinicaltrials.gov ; NCT03327675; 31-10-2017.
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Affiliation(s)
- Cédric Draulans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.
- Department of Oncology, KU Leuven, Leuven, Belgium.
| | - Robin De Roover
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Linda Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Radiation Oncology, University Medical Centre, Utrecht, The Netherlands
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Floris Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wouter V Vogel
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - James Nagarajah
- Department of Radiology & Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marcel Janssen
- Department of Radiology & Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Sofie Isebaert
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Frederik Maes
- Department of Electrical Engineering, ESAT/PSI, KU Leuven, Leuven, Belgium
- Medical Imaging Research Centre, University Hospitals Leuven, Leuven, Belgium
| | - Cindy Mai
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Raymond Oyen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Steven Joniau
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Martina Kunze-Busch
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Karolien Goffin
- Department of Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.
- Department of Oncology, KU Leuven, Leuven, Belgium.
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32
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Tamihardja J, Schortmann M, Lawrenz I, Weick S, Bratengeier K, Flentje M, Guckenberger M, Polat B. Moderately hypofractionated radiotherapy for localized prostate cancer: updated long-term outcome and toxicity analysis. Strahlenther Onkol 2020; 197:124-132. [PMID: 32833036 PMCID: PMC7840645 DOI: 10.1007/s00066-020-01678-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/03/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE Evaluation of long-term outcome and toxicity of moderately hypofractionated radiotherapy using intensity-modulated radiotherapy (IMRT) with simultaneous integrated boost treatment planning and cone beam CT-based image guidance for localized prostate cancer. METHODS Between 2005 and 2015, 346 consecutive patients with localized prostate cancer received primary radiotherapy using cone beam CT-based image-guided intensity-modulated radiotherapy (IG-IMRT) and volumetric modulated arc therapy (IG-VMAT) with a simultaneous integrated boost (SIB). Total doses of 73.9 Gy (n = 44) and 76.2 Gy (n = 302) to the high-dose PTV were delivered in 32 and 33 fractions, respectively. The low-dose PTV received a dose (D95) of 60.06 Gy in single doses of 1.82 Gy. The pelvic lymph nodes were treated in 91 high-risk patients to 45.5 Gy (D95). RESULTS Median follow-up was 61.8 months. The 5‑year biochemical relapse-free survival (bRFS) was 85.4% for all patients and 93.3, 87.4, and 79.4% for low-, intermediate-, and high-risk disease, respectively. The 5‑year prostate cancer-specific survival (PSS) was 94.8% for all patients and 98.7, 98.9, 89.3% for low-, intermediate-, and high-risk disease, respectively. The 5‑year and 10-year overall survival rates were 83.8 and 66.3% and the 5‑year and 10-year freedom from distant metastasis rates were 92.2 and 88.0%, respectively. Cumulative 5‑year late GU toxicity and late GI toxicity grade ≥2 was observed in 26.3 and 12.1% of the patients, respectively. Cumulative 5‑year late grade 3 GU/GI toxicity occurred in 4.0/1.2%. CONCLUSION Moderately hypofractionated radiotherapy using SIB treatment planning and cone beam CT image guidance resulted in high biochemical control and survival with low rates of late toxicity.
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Affiliation(s)
- Jörg Tamihardja
- Department of Radiation Oncology, University Hospital Wuerzburg, University of Wuerzburg, Wuerzburg, Germany.
| | - Max Schortmann
- Department of Radiation Oncology, University Hospital Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Ingulf Lawrenz
- Department of Radiation Oncology, University Hospital Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Stefan Weick
- Department of Radiation Oncology, University Hospital Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Klaus Bratengeier
- Department of Radiation Oncology, University Hospital Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Michael Flentje
- Department of Radiation Oncology, University Hospital Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Bülent Polat
- Department of Radiation Oncology, University Hospital Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
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Blake SW, Stapleton A, Brown A, Curtis S, Ash-Miles J, Dennis E, Masson S, Bowers D, Hilman S. A study of the clinical, treatment planning and dosimetric feasibility of dose painting in external beam radiotherapy of prostate cancer. Phys Imaging Radiat Oncol 2020; 15:66-71. [PMID: 33458328 PMCID: PMC7807863 DOI: 10.1016/j.phro.2020.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 07/26/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Radiotherapy dose painting is a promising technique which enables dose escalation to areas of higher tumour cell density within the prostate which are associated with radioresistance, known as dominant intraprostatic lesions (DILs). The aim of this study was to determine factors affecting the feasibility of radiotherapy dose painting in patients with high and intermediate risk prostate cancer. MATERIALS & METHODS Twenty patients were recruited into the study for imaging using a 3 T magnetic resonance imaging (MRI) scanner. Identified DILs were outlined and the scan registered with the planning computed tomography (CT) dataset. Intensity-modulated plans were produced and evaluated to determine the effect of the organ-at-risk constraints on the dose that could be delivered to the DILs. Measurements were made to verify that the distribution could be safely delivered. RESULTS MRI scans were obtained for nineteen patients. Fourteen patients had one to two DILs with ten overlapping the urethra and/or rectum. The target boost of 86 Gy was achieved in seven plans but was limited to 80 Gy for five patients whose boost volume overlapped or abutted the urethra. Dosimetric measurements gave a satisfactory gamma pass rate at 3%/3 mm. CONCLUSIONS It was feasible to produce dose-painted plans for a boost of 86 Gy for approximately half the patients with DILs. The main limiting factor was the proximity of the urethra to the boost volumes. For a small proportion of patients, rigid registration between CT and MRI images was not adequate for planning purposes.
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Affiliation(s)
- Steve W. Blake
- Medical Physics, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
| | - Alison Stapleton
- Medical Physics, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
| | - Andrew Brown
- Medical Physics, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
| | - Sian Curtis
- Bioengineering, Innovation & Research Hub, Medical Physics, St Michael's Hospital, Bristol BS2 8EG, UK
- Clinical Research and Imaging Centre (CRICBristol), Bristol BS2 8DX, UK
| | | | - Emma Dennis
- Oncology, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
| | - Susan Masson
- Oncology, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
| | - Dawn Bowers
- Oncology, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
| | - Serena Hilman
- Oncology, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
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Her EJ, Haworth A, Rowshanfarzad P, Ebert MA. Progress towards Patient-Specific, Spatially-Continuous Radiobiological Dose Prescription and Planning in Prostate Cancer IMRT: An Overview. Cancers (Basel) 2020; 12:E854. [PMID: 32244821 PMCID: PMC7226478 DOI: 10.3390/cancers12040854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/12/2020] [Accepted: 03/27/2020] [Indexed: 01/30/2023] Open
Abstract
Advances in imaging have enabled the identification of prostate cancer foci with an initial application to focal dose escalation, with subvolumes created with image intensity thresholds. Through quantitative imaging techniques, correlations between image parameters and tumour characteristics have been identified. Mathematical functions are typically used to relate image parameters to prescription dose to improve the clinical relevance of the resulting dose distribution. However, these relationships have remained speculative or invalidated. In contrast, the use of radiobiological models during treatment planning optimisation, termed biological optimisation, has the advantage of directly considering the biological effect of the resulting dose distribution. This has led to an increased interest in the accurate derivation of radiobiological parameters from quantitative imaging to inform the models. This article reviews the progress in treatment planning using image-informed tumour biology, from focal dose escalation to the current trend of individualised biological treatment planning using image-derived radiobiological parameters, with the focus on prostate intensity-modulated radiotherapy (IMRT).
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Affiliation(s)
- Emily Jungmin Her
- Department of Physics, University of Western Australia, Crawley, WA 6009, Australia
| | - Annette Haworth
- Institute of Medical Physics, University of Sydney, Camperdown, NSW 2050, Australia
| | - Pejman Rowshanfarzad
- Department of Physics, University of Western Australia, Crawley, WA 6009, Australia
| | - Martin A. Ebert
- Department of Physics, University of Western Australia, Crawley, WA 6009, Australia
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia
- 5D Clinics, Claremont, WA 6010, Australia
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