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Le Guévelou J, Zilli T, Ferretti L, Beuzit L, De Hertogh O, Palumbo S, Jolicoeur M, Crehange G, Derashodian T, De Crevoisier R, Chapet O, Terlizzi M, Supiot S, Salembier C, Sargos P. Urinary organs-at-risk for prostate cancer external beam radiotherapy: contouring guidelines on behalf of the Francophone Group of Urological Radiation Therapy (GFRU). Pract Radiat Oncol 2024:S1879-8500(24)00145-0. [PMID: 38986900 DOI: 10.1016/j.prro.2024.05.009] [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: 04/23/2024] [Revised: 05/09/2024] [Accepted: 05/14/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE Occurrence of genitourinary (GU) toxicity is a common adverse event observed after external beam radiotherapy (EBRT) for prostate cancer (PCa). Recent findings suggest that the dose delivered to specific urinary organs-at-risk (OARs) such as ureters, bladder trigone, and urethra is involved in the development of GU toxicity. METHODS AND MATERIALS A multidisciplinary task force including three radiation oncologists, a uroradiologist, and a urologist was created in 2022. First, OARs potentially involved in GU toxicity were identified and discussed. A literature review was performed, addressing several questions relative to urinary OARs: anatomical and radiological definition, radiation-induced injury, dose-volume parameters. Secondly, results were presented and discussed with a panel of radiation oncologists, members of the "Francophone Group of Urological Radiation Therapy" (GFRU). Thereafter, GFRU experts were asked to answer a dedicated questionnaire, including 35 questions on the controversial issues related to the delineation of urinary OARs. RESULTS The following structures were identified as critical for PCa EBRT: ureters, bladder, bladder neck, bladder trigone, urethra (intraprostatic, membranous, spongious), striated sphincter, and post-enucleation or post-transurethral resection of the prostate (TURP) cavity. A consensus was obtained for 32 out of 35 items. CONCLUSION This consensus highlights contemporary urinary structures in both upper and lower urinary tract to be considered for EBRT treatment planning of PCa. The current recommendations also propose a standardized definition of urinary OARs, for both daily practice and future clinical trials.
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Affiliation(s)
- J Le Guévelou
- Department of radiation oncology, Centre Eugène Marquis, Rennes, France.
| | - T Zilli
- Department of radiation oncology, Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - L Ferretti
- Department of urology, MSP Bordeaux Bagatelle, Talence, France
| | - L Beuzit
- Department of radiology, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - O De Hertogh
- Department of radiation oncology, CHR Verviers East Belgium, Verviers, Belgium
| | - S Palumbo
- Department of radiation oncology, Hôpital de Jolimont, La Louvière, Belgium
| | - M Jolicoeur
- Department of radiation oncology, Charles LeMoyne Hospital, CISSS Montérégie-center, Montréal, Quebec, Canada
| | - G Crehange
- Department of radiation oncology, Institut Curie, Saint-Cloud, France
| | - T Derashodian
- Department of radiation oncology, Charles LeMoyne Hospital, CISSS Montérégie-center, Montréal, Quebec, Canada
| | - R De Crevoisier
- Department of radiation oncology, Centre Eugène Marquis, Rennes, France
| | - O Chapet
- Department of radiation oncology, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - M Terlizzi
- Department of radiation oncology, Institut Gustave Roussy, Villejuif, France
| | - S Supiot
- Department of radiation oncology, Institut de Cancérologie de l'Ouest, Nantes Saint-Herblain, France; Unité en Sciences Biologiques et Biotechnologies, University of Nantes, Nantes, France
| | - C Salembier
- Department of radiation oncology, Europe Hospitals Brussels, Brussels, Belgium
| | - P Sargos
- Department of radiation oncology, Institut Bergonié, Bordeaux, France
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Galienne M, Risbourg S, Lacornerie T, Taillez A, Lartigau E, Barthoulot M, Pasquier D. Extreme hypofractionated stereotactic radiotherapy for localized prostate Cancer: Efficacy and late urinary toxicity according to transurethral resection of the prostate history. Clin Transl Radiat Oncol 2024; 46:100779. [PMID: 38681137 PMCID: PMC11047194 DOI: 10.1016/j.ctro.2024.100779] [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: 01/30/2024] [Revised: 04/08/2024] [Accepted: 04/17/2024] [Indexed: 05/01/2024] Open
Abstract
Background and purpose Extreme hypofractionated stereotactic body radiotherapy (SBRT) is a therapeutic alternative for localized low- or intermediate-risk prostate cancer. Despite the availability of several studies, the toxicity profile of SBRT has not been comprehensively described. This real-world evidence study assessed the efficacy and toxicities associated with this regimen, and potential prognosis factors for genitourinary toxicities. Materials and methods This retrospective study included 141 consecutive patients with localized prostatic adenocarcinoma treated with CyberKnife™ SBRT, as primary irradiation, at the Oscar Lambret Center between 2010 and 2020. The prescribed dose was 36.25 Gy in 5 fractions. Acute and late toxicities were graded according to the CTCAE (version 5.0). Biochemical recurrence-free survival (bRFS) and overall survival (OS) were estimated using the Kaplan-Meier method. The cumulative incidence of biochemical recurrence (cBR) was estimated using the Kalbfleisch-Prentice method. Results Among the included patients, 13.5 % had a history of transurethral resection of the prostate (TURP). The median follow-up was 48 months. At 5 years, bRFS, cBR, and OS were 72 % (95 %CI: 61-81), 7 % (95 %CI: 3-14), and 82 % (95 %CI: 73-89), respectively. Twenty-nine patients experienced at least one late toxicity of grade ≥ 2; genitourinary (N = 29), including 3 cases of chronic hematuria, and/or gastrointestinal (N = 1). The cumulative incidence of late urinary toxicity of grade ≥ 2 was 20.6 % at 5 years (95 %CI: 13.9-28.1). Multivariate analysis revealed that a history of TURP was significantly associated with late urinary toxicity of grade ≥ 2, after adjusting for clinical target volume (Odds Ratio = 3.06; 95%CI: 1.05-8.86; P = 0.04). Conclusion Extreme hypofractionated SBRT is effective for localized prostate cancer with a low risk of late toxicity. A history of TURP is associated with a higher risk of late urinary toxicity. These findings may contribute to the optimal management of patients treated with this regimen, particularly those with a history of TURP.
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Affiliation(s)
- Maxime Galienne
- University of Picardie Jules Verne, Amiens, France
- Department of Radiotherapy, Amiens-Picardie University Hospital (South Site), Amiens, France
| | - Séverine Risbourg
- Department of Methodology and Biostatistics, Oscar Lambret Center, Clinical Research and Innovation Directorate, Lille, France
| | | | | | - Eric Lartigau
- Department of Radiotherapy, Oscar Lambret Center, Lille, France
- University of Lille & CRIStAL (Research Center in Computer Science, Signal and Automatic Control of Lille ((UMR 9189), Lille, France
| | - Maël Barthoulot
- Department of Methodology and Biostatistics, Oscar Lambret Center, Clinical Research and Innovation Directorate, Lille, France
| | - David Pasquier
- Department of Radiotherapy, Oscar Lambret Center, Lille, France
- University of Lille & CRIStAL (Research Center in Computer Science, Signal and Automatic Control of Lille ((UMR 9189), Lille, France
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Nachbar M, Lo Russo M, Gani C, Boeke S, Wegener D, Paulsen F, Zips D, Roque T, Paragios N, Thorwarth D. Automatic AI-based contouring of prostate MRI for online adaptive radiotherapy. Z Med Phys 2024; 34:197-207. [PMID: 37263911 PMCID: PMC11156783 DOI: 10.1016/j.zemedi.2023.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/03/2023] [Accepted: 05/02/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND PURPOSE MR-guided radiotherapy (MRgRT) online plan adaptation accounts for tumor volume changes, interfraction motion and thus allows daily sparing of relevant organs at risk. Due to the high interfraction variability of bladder and rectum, patients with tumors in the pelvic region may strongly benefit from adaptive MRgRT. Currently, fast automatic annotation of anatomical structures is not available within the online MRgRT workflow. Therefore, the aim of this study was to train and validate a fast, accurate deep learning model for automatic MRI segmentation at the MR-Linac for future implementation in a clinical MRgRT workflow. MATERIALS AND METHODS For a total of 47 patients, T2w MRI data were acquired on a 1.5 T MR-Linac (Unity, Elekta) on five different days. Prostate, seminal vesicles, rectum, anal canal, bladder, penile bulb, body and bony structures were manually annotated. These training data consisting of 232 data sets in total was used for the generation of a deep learning based autocontouring model and validated on 20 unseen T2w-MRIs. For quantitative evaluation the validation set was contoured by a radiation oncologist as gold standard contours (GSC) and compared in MATLAB to the automatic contours (AIC). For the evaluation, dice similarity coefficients (DSC), and 95% Hausdorff distances (95% HD), added path length (APL) and surface DSC (sDSC) were calculated in a caudal-cranial window of ± 4 cm with respect to the prostate ends. For qualitative evaluation, five radiation oncologists scored the AIC on the possible usage within an online adaptive workflow as follows: (1) no modifications needed, (2) minor adjustments needed, (3) major adjustments/ multiple minor adjustments needed, (4) not usable. RESULTS The quantitative evaluation revealed a maximum median 95% HD of 6.9 mm for the rectum and minimum median 95% HD of 2.7 mm for the bladder. Maximal and minimal median DSC were detected for bladder with 0.97 and for penile bulb with 0.73, respectively. Using a tolerance level of 3 mm, the highest and lowest sDSC were determined for rectum (0.94) and anal canal (0.68), respectively. Qualitative evaluation resulted in a mean score of 1.2 for AICs over all organs and patients across all expert ratings. For the different autocontoured structures, the highest mean score of 1.0 was observed for anal canal, sacrum, femur left and right, and pelvis left, whereas for prostate the lowest mean score of 2.0 was detected. In total, 80% of the contours were rated be clinically acceptable, 16% to require minor and 4% major adjustments for online adaptive MRgRT. CONCLUSION In this study, an AI-based autocontouring was successfully trained for online adaptive MR-guided radiotherapy on the 1.5 T MR-Linac system. The developed model can automatically generate contours accepted by physicians (80%) or only with the need of minor corrections (16%) for the irradiation of primary prostate on the clinically employed sequences.
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Affiliation(s)
- Marcel Nachbar
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Monica Lo Russo
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Simon Boeke
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Daniel Wegener
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany; German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiation Oncology, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | | | - Nikos Paragios
- TheraPanacea, Paris, France; CentraleSupelec, University of Paris-Saclay, Gif-sur-Yvette, France
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany; German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Lee J, Nandalur S, Hazy A, Al-Katib S, Kim K, Ye H, Kolderman N, Dhaliwal A, Krauss D, Quinn T, Marvin K, Nandalur KR. Prostatic Urethral Length on MRI Potentially Predicts Late Genitourinary Toxicity After Prostate Cancer Radiation. Acad Radiol 2024; 31:1950-1958. [PMID: 37858506 DOI: 10.1016/j.acra.2023.09.004] [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: 08/01/2023] [Revised: 08/28/2023] [Accepted: 09/03/2023] [Indexed: 10/21/2023]
Abstract
RATIONALE AND OBJECTIVES The purpose of our study was to evaluate pretreatment prostate quantitative magnetic resonance imaging (MRI) measurements and clinical characteristics in predicting genitourinary (GU) toxicity after radiotherapy (RT) for prostate cancer. MATERIALS AND METHODS In this single-institution retrospective cohort study, we evaluated patients with prostate adenocarcinoma who underwent MRI within 6 months before completing definitive RT and follow-up information in our GU toxicity database from June 2016 to February 2023. MRI measurements included quantitative urethra, prostate, and bladder measurements. GU toxicity was physician-scored using the Common Terminology Criteria for Adverse Events (CTCAE v4.0) with acute toxicity defined as ≤180 days and late defined as >180 days. Multivariable logistic regression model was constructed for grade ≥2 acute toxicity and Cox proportional hazards regression for late toxicity, adjusted for clinical factors and RT method. RESULTS A total of 361 men (median age 68 years, interquartile range [IQR] 62-73) were included; 14.4% (50/347) men experienced grade ≥2 acute toxicity. Brachytherapy (odds ratio [OR]: 2.9, 95% confidence interval [CI]: 1.5-5.8), P < 0.01) was associated with increased odds of acute GU toxicity, and longer MUL (OR: 0.41 [95%CI: 0.18-0.92], P = 0.03) with decreased odds. Median follow-up for late toxicity was 15.0 months (IQR: 9.0-28.0) with approximately 88.7% and 72.0% patients free of toxicity at 1 and 3 years, respectively. Only longer prostatic urethral length (hazard ratio [HR]: 1.6, 95%CI: 1.2-2.1, P < 0.01) was associated with increased risk of late GU toxicity, notably urinary frequency/urgency symptoms (HR: 1.7 [95%CI: 1.3-2.3], P < 0.01). CONCLUSION Longer prostatic urethral length measured on prostate MRI is independently associated with higher risk of developing late grade ≥2 GU toxicity after radiation therapy for prostate cancer. This pretreatment metric may be potentially valuable in risk-stratification models for quality of life following prostate RT.
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Affiliation(s)
- Joseph Lee
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan (J.L., S.N., A.H., H.Y., D.K., T.Q., K.M.); Medical School, Oakland University William Beaumont School of Medicine, Rochester, Michigan (J.L., S.N., A.H., S.A.K., K.K., H.Y., N.K., A.D., D.K., T.Q., K.R.N.)
| | - Sirisha Nandalur
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan (J.L., S.N., A.H., H.Y., D.K., T.Q., K.M.); Medical School, Oakland University William Beaumont School of Medicine, Rochester, Michigan (J.L., S.N., A.H., S.A.K., K.K., H.Y., N.K., A.D., D.K., T.Q., K.R.N.)
| | - Allison Hazy
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan (J.L., S.N., A.H., H.Y., D.K., T.Q., K.M.); Medical School, Oakland University William Beaumont School of Medicine, Rochester, Michigan (J.L., S.N., A.H., S.A.K., K.K., H.Y., N.K., A.D., D.K., T.Q., K.R.N.)
| | - Sayf Al-Katib
- Medical School, Oakland University William Beaumont School of Medicine, Rochester, Michigan (J.L., S.N., A.H., S.A.K., K.K., H.Y., N.K., A.D., D.K., T.Q., K.R.N.); Department of Radiology and Molecular Imaging, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan (S.A.K., N.K., A.D., K.R.N.)
| | - Kyu Kim
- Medical School, Oakland University William Beaumont School of Medicine, Rochester, Michigan (J.L., S.N., A.H., S.A.K., K.K., H.Y., N.K., A.D., D.K., T.Q., K.R.N.)
| | - Hong Ye
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan (J.L., S.N., A.H., H.Y., D.K., T.Q., K.M.); Medical School, Oakland University William Beaumont School of Medicine, Rochester, Michigan (J.L., S.N., A.H., S.A.K., K.K., H.Y., N.K., A.D., D.K., T.Q., K.R.N.)
| | - Nathan Kolderman
- Medical School, Oakland University William Beaumont School of Medicine, Rochester, Michigan (J.L., S.N., A.H., S.A.K., K.K., H.Y., N.K., A.D., D.K., T.Q., K.R.N.); Department of Radiology and Molecular Imaging, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan (S.A.K., N.K., A.D., K.R.N.)
| | - Abhay Dhaliwal
- Medical School, Oakland University William Beaumont School of Medicine, Rochester, Michigan (J.L., S.N., A.H., S.A.K., K.K., H.Y., N.K., A.D., D.K., T.Q., K.R.N.); Department of Radiology and Molecular Imaging, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan (S.A.K., N.K., A.D., K.R.N.)
| | - Daniel Krauss
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan (J.L., S.N., A.H., H.Y., D.K., T.Q., K.M.); Medical School, Oakland University William Beaumont School of Medicine, Rochester, Michigan (J.L., S.N., A.H., S.A.K., K.K., H.Y., N.K., A.D., D.K., T.Q., K.R.N.)
| | - Thomas Quinn
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan (J.L., S.N., A.H., H.Y., D.K., T.Q., K.M.); Medical School, Oakland University William Beaumont School of Medicine, Rochester, Michigan (J.L., S.N., A.H., S.A.K., K.K., H.Y., N.K., A.D., D.K., T.Q., K.R.N.)
| | - Kimberly Marvin
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan (J.L., S.N., A.H., H.Y., D.K., T.Q., K.M.)
| | - Kiran R Nandalur
- Medical School, Oakland University William Beaumont School of Medicine, Rochester, Michigan (J.L., S.N., A.H., S.A.K., K.K., H.Y., N.K., A.D., D.K., T.Q., K.R.N.); Department of Radiology and Molecular Imaging, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan (S.A.K., N.K., A.D., K.R.N.).
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Ratnakumaran R, Mohajer J, Withey SJ, H. Brand D, Lee E, Loblaw A, Tolan S, van As N, Tree AC. Developing and validating a simple urethra surrogate model to facilitate dosimetric analysis to predict genitourinary toxicity. Clin Transl Radiat Oncol 2024; 46:100769. [PMID: 38586079 PMCID: PMC10998036 DOI: 10.1016/j.ctro.2024.100769] [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: 01/17/2024] [Revised: 03/08/2024] [Accepted: 03/23/2024] [Indexed: 04/09/2024] Open
Abstract
Purpose The urethra is a critical structure in prostate radiotherapy planning; however, it is impossible to visualise on CT. We developed a surrogate urethra model (SUM) for CT-only planning workflow and tested its geometric and dosimetric performance against the MRI-delineated urethra (MDU). Methods The SUM was compared against 34 different MDUs (within the treatment PTV) in patients treated with 36.25Gy (PTV)/40Gy (CTV) in 5 fractions as part of the PACE-B trial. To assess the surrogate's geometric performance, the Dice similarity coefficient (DSC), Hausdorff distance (HD), mean distance to agreement (MDTA) and the percentage of MDU outside the surrogate (UOS) were calculated. To evaluate the dosimetric performance, a paired t-test was used to calculate the mean of differences between the MDU and SUM for the D99, D98, D50, D2 and D1. The D(n) is the dose (Gy) to n% of the urethra. Results The median results showed low agreement on DSC (0.32; IQR 0.21-0.41), but low distance to agreement, as would be expected for a small structure (HD 8.4mm (IQR 7.1-10.1mm), MDTA 2.4mm (IQR, 2.2mm-3.2mm)). The UOS was 30% (IQR, 18-54%), indicating nearly a third of the urethra lay outside of the surrogate. However, when comparing urethral dose between the MDU and SUM, the mean of differences for D99, D98 and D95 were 0.12Gy (p=0.57), 0.09Gy (p=0.61), and 0.11Gy (p=0.46) respectively. The mean of differences between the D50, D2 and D1 were 0.08Gy (p=0.04), 0.09Gy (p=0.02) and 0.1Gy (p=0.01) respectively, indicating good dosimetric agreement between MDU and SUM. Conclusion While there were geometric differences between the MDU and SUM, there was no clinically significant difference between urethral dose-volume parameters. This surrogate model could be validated in a larger cohort and then used to estimate the urethral dose on CT planning scans in those without an MRI planning scan or urinary catheter.
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Affiliation(s)
- Ragu Ratnakumaran
- The Royal Marsden NHS Foundation Trust, London, UK
- Radiotherapy and Imaging Division, Institute of Cancer Research, London, UK
| | | | | | - Douglas H. Brand
- Department of Medical Physics and Bioengineering, University College London, UK
| | - Ernest Lee
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Shaun Tolan
- The Clatterbridge Cancer Centre, Liverpool, UK
| | - Nicholas van As
- The Royal Marsden NHS Foundation Trust, London, UK
- Radiotherapy and Imaging Division, Institute of Cancer Research, London, UK
| | - Alison C. Tree
- The Royal Marsden NHS Foundation Trust, London, UK
- Radiotherapy and Imaging Division, Institute of Cancer Research, London, UK
| | - on behalf of the PACE Trial Investigators
- The Royal Marsden NHS Foundation Trust, London, UK
- Radiotherapy and Imaging Division, Institute of Cancer Research, London, UK
- Department of Medical Physics and Bioengineering, University College London, UK
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- The Clatterbridge Cancer Centre, Liverpool, UK
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6
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Huck C, Achard V, Maitre P, Murthy V, Zilli T. Stereotactic body radiation therapy for prostate cancer after surgical treatment of prostatic obstruction: Impact on urinary morbidity and mitigation strategies. Clin Transl Radiat Oncol 2024; 45:100709. [PMID: 38179576 PMCID: PMC10765005 DOI: 10.1016/j.ctro.2023.100709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/03/2023] [Accepted: 12/05/2023] [Indexed: 01/06/2024] Open
Abstract
In the past decade, stereotactic body radiation therapy (SBRT) has emerged as a valid treatment option for patients with localized prostate cancer. Despite the promising results of ultra-hypofractionation in terms of tolerance and disease control, the toxicity profile of SBRT for prostate cancer patients with a history of surgical treatment of benign prostate hyperplasia is still underreported. Here we present an overview of the available data on urinary morbidity for prostate cancer patients treated with SBRT after prior surgical treatments for benign prostate hyperplasia. Technical improvements useful to minimize toxicity and possible treatments for radiation-induced urethritis are discussed.
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Affiliation(s)
- Constance Huck
- Division of Radiation Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Vérane Achard
- Division of Radiation Oncology, Fribourg Cantonal Hospital, Fribourg, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Priyamvada Maitre
- Tata Memorial Hospital and Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Vedang Murthy
- Tata Memorial Hospital and Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Thomas Zilli
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
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7
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Ong WL, Allan Hupman M, Davidson M, Ruschin M, Detsky J, Liu S, Vesprini D, Loblaw A. Urethra contouring on computed tomography urethrogram versus magnetic resonance imaging for stereotactic body radiotherapy in prostate cancer. Clin Transl Radiat Oncol 2024; 45:100722. [PMID: 38234697 PMCID: PMC10792737 DOI: 10.1016/j.ctro.2023.100722] [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: 10/04/2023] [Revised: 12/24/2023] [Accepted: 12/30/2023] [Indexed: 01/19/2024] Open
Abstract
Accurate urethra contouring is critical in prostate SBRT. We compared urethra contouring on CT-urethrogram and T2-weighted MRI. The dice similarity coefficient, Jaccard index, Hausdorff distance and mean distance to agreement were evaluated. All four metrics indicate better agreement and less variability in urethra contouring on CT-urethrogram, compared to T2-weighted MRI.
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Affiliation(s)
- Wee Loon Ong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
- Alfred Health Radiation Oncology, Monash University, Melbourne, Australia
| | - M. Allan Hupman
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Mark Ruschin
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Jay Detsky
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Stanley Liu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Danny Vesprini
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
- Department of Health Policy, Measurement and Evaluation, University of Toronto, Canada
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McGee KP, Cao M, Das IJ, Yu V, Witte RJ, Kishan AU, Valle LF, Wiesinger F, De-Colle C, Cao Y, Breen WG, Traughber BJ. The Use of Magnetic Resonance Imaging in Radiation Therapy Treatment Simulation and Planning. J Magn Reson Imaging 2024. [PMID: 38265188 DOI: 10.1002/jmri.29246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 01/25/2024] Open
Abstract
Ever since its introduction as a diagnostic imaging tool the potential of magnetic resonance imaging (MRI) in radiation therapy (RT) treatment simulation and planning has been recognized. Recent technical advances have addressed many of the impediments to use of this technology and as a result have resulted in rapid and growing adoption of MRI in RT. The purpose of this article is to provide a broad review of the multiple uses of MR in the RT treatment simulation and planning process, identify several of the most used clinical scenarios in which MR is integral to the simulation and planning process, highlight existing limitations and provide multiple unmet needs thereby highlighting opportunities for the diagnostic MR imaging community to contribute and collaborate with our oncology colleagues. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 5.
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Affiliation(s)
- Kiaran P McGee
- Department of Radiology, Mayo Clinic & Foundation, Rochester, Minnesota, USA
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Indra J Das
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Victoria Yu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Robert J Witte
- Department of Radiology, Mayo Clinic & Foundation, Rochester, Minnesota, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Luca F Valle
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | | | - Chiara De-Colle
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - William G Breen
- Department of Radiation Oncology, Mayo Clinic & Foundation, Rochester, Minnesota, USA
| | - Bryan J Traughber
- Department of Radiation Oncology, Mayo Clinic & Foundation, Rochester, Minnesota, USA
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9
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Takagi M, Hasegawa Y, Tateoka K, Takada Y, Hareyama M. Dosimetric Comparison Study of Proton Therapy Using Line Scanning versus Passive Scattering and Volumetric Modulated Arc Therapy for Localized Prostate Cancer. Cancers (Basel) 2024; 16:403. [PMID: 38254892 PMCID: PMC10814771 DOI: 10.3390/cancers16020403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND The proton irradiation modality has transitioned from passive scattering (PS) to pencil beam scanning. Nevertheless, the documented outcomes predominantly rely on PS. METHODS Thirty patients diagnosed with prostate cancer were selected to assess treatment planning across line scanning (LS), PS, and volumetric modulated arc therapy (VMAT). Dose constraints encompassed clinical target volume (CTV) D98 ≥ 73.0 Gy (RBE), rectal wall V65 < 17% and V40 < 35%, and bladder wall V65 < 25% and V40 < 50%. The CTV, rectal wall, and bladder wall dose volumes were calculated and evaluated using the Freidman test. RESULTS The LS technique adhered to all dose limitations. For the rectal and bladder walls, 10 (33.3%) and 21 (70.0%) patients in the PS method and 5 (16.7%) and 1 (3.3%) patients in VMAT, respectively, failed to meet the stipulated requirements. The wide ranges of the rectal and bladder wall volumes (V10-70) were lower with LS than with PS and VMAT. LS outperformed VMAT across all dose-volume rectal and bladder wall indices. CONCLUSION The LS method demonstrated a reduction in rectal and bladder doses relative to PS and VMAT, thereby suggesting the potential for mitigating toxicities.
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Affiliation(s)
- Masaru Takagi
- Department of Radiation Oncology, Sapporo Teishinkai Hospital, Sapporo 065-0033, Japan
| | - Yasuhiro Hasegawa
- Department of Radiation Physics, Sapporo Teishinkai Hospital, Sapporo 065-0033, Japan
| | - Kunihiko Tateoka
- Department of Radiation Physics, Sapporo Teishinkai Hospital, Sapporo 065-0033, Japan
| | - Yu Takada
- Department of Radiation Oncology, Sapporo Teishinkai Hospital, Sapporo 065-0033, Japan
| | - Masato Hareyama
- Department of Radiation Oncology, Sapporo Teishinkai Hospital, Sapporo 065-0033, Japan
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10
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Pham J, Neilsen BK, Liu H, Cao M, Yang Y, Sheng K, Ma TM, Kishan AU, Ruan D. Dosimetric predictors for genitourinary toxicity in MR-guided stereotactic body radiation therapy (SBRT): Substructure with fraction-wise analysis. Med Phys 2024; 51:612-621. [PMID: 38055353 DOI: 10.1002/mp.16878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 11/07/2023] [Accepted: 11/10/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND MR-guided radiation therapy (MRgRT) systems provide superior soft tissue contrast than x-ray based systems and can acquire real-time cine for treatment gating. These features allow treatment planning margins to be reduced, allowing for improved critical structure sparing and reduced treatment toxicity. Despite this improvement, genitourinary (GU) toxicity continues to affect many patients. PURPOSE (1) To identify dosimetric predictors, potentially in combination with clinical parameters, of GU toxicity following SBRT by leveraging MRgRT to accurately monitor daily dose, beyond predicted dose calculated during planning. (2) Improve awareness of toxicity-sensitive bladder substructures, specifically the trigone and urethra. METHODS Sixty-nine prostate cancer patients (NCT04384770 clinical trial) were treated on a ViewRay MRIdian MRgRT system, with 40 Gy prescribed to 95% of the PTV in over five fractions. Overall, 17 (24.6%) prostate patients reported acute grade 2 GU toxicity. The CTV, PTV, bladder, bladder wall, trigone, urethra, rectum, and rectal wall were contoured on the planning and daily treatment MRIs. Planning and daily treatment DVHs (0.1 Gy increments), organ doses (min, max, mean), and organ volumes were recorded. Daily dose was estimated by transferring the planning dose distributions to the daily MRI based on the daily setup alignment. Patients were partitioned into a training (55) and testing set (14). Dose features were pre-filtered using a t-test followed by maximum relevance minimum redundancy (MRMR) algorithm. Logistic regression was investigated with regularization to select dosimetric predictors. Specifically, two approaches: time-group least absolute shrinkage and selection (LASSO), and interactive grouped greedy algorithm (IGA) were investigated. Shared features across the planning and five treatment fractions were grouped to encourage consistency and stability. The conventional flat non-temporally grouped LASSO was also evaluated to provide a solid benchmark. After feature selection, a final logistic regression model was trained. Dosimetric regression models were compared to a clinical regression model with only clinical parameters (age, baseline IPSS, prostate gland size, ADT usage, etc.) and a hybrid model, combining the best performing dosimetric features with the clinical parameters, was evaluated. Final model performance was evaluated on the testing set using accuracy, sensitivity, and specificity determined by the optimal threshold of the training set. RESULTS IGA had the best testing performance with an accuracy/sensitivity/specificity of 0.79/0.67/0.82, selecting 12 groups covering the bladder (V19.8 Gy, V20.5 Gy), bladder wall (19.7 Gy), trigone (15.9, 18.2, 43.3 Gy), urethra (V41.4 Gy, V41.7 Gy), CTV (V41.9 Gy), rectum (V8.5 Gy), and rectal wall (1.2, 44.1 Gy) dose features. Absolute bladder V19.8 Gy and V20.5 Gy were the most important features, followed by relative trigone 15.9 and 18.2 Gy. Inclusion of clinical parameters in the hybrid model with IGA did not significantly change regression performance. CONCLUSION Overall, IGA feature selection resulted in the best GU toxicity prediction performance. This exploratory study demonstrated the feasibility of identification and analysis of dosimetric toxicity predictors with awareness to sensitive substructures and daily dose to potentially provide consistent and stable dosimetric metrics to guide treatment planning. Further patient accruement is warranted to further assess dosimetric predictor and perform validation.
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Affiliation(s)
- Jonathan Pham
- Physics and Biology in Medicine Graduate Program, University of California, Los Angeles, USA
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Beth K Neilsen
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Hengjie Liu
- Physics and Biology in Medicine Graduate Program, University of California, Los Angeles, USA
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Minsong Cao
- Physics and Biology in Medicine Graduate Program, University of California, Los Angeles, USA
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Yingli Yang
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- SJTU-Ruijing-UIH Institute for Medical Imaging Technology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ke Sheng
- Department of Radiation Oncology, University of California, San Francisco, USA
| | - Ting Martin Ma
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Dan Ruan
- Physics and Biology in Medicine Graduate Program, University of California, Los Angeles, USA
- Department of Radiation Oncology, University of California, Los Angeles, USA
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11
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Panizza D, Faccenda V, Arcangeli S, De Ponti E. Treatment Optimization in Linac-Based SBRT for Localized Prostate Cancer: A Single-Arc versus Dual-Arc Plan Comparison. Cancers (Basel) 2023; 16:13. [PMID: 38201441 PMCID: PMC10778084 DOI: 10.3390/cancers16010013] [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: 11/17/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
This study aimed to comprehensively present data on treatment optimization in linac-based SBRT for localized prostate cancer at a single institution. Moreover, the dosimetric quality and treatment efficiency of single-arc (SA) versus dual-arc (DA) VMAT planning and delivery approaches were compared. Re-optimization was performed on twenty low-to-intermediate-risk- (36.25 Gy in 5 fractions) and twenty high-risk (42.7 Gy in 7 fractions) prostate plans initially administered with the DA FFF-VMAT technique in 2021. An SA approach was adopted, incorporating new optimization parameters based on increased planning and clinical experience. Analysis included target coverage, organ-at-risk (OAR) sparing, treatment delivery time, and the pre-treatment verification's gamma analysis-passing ratio. The SA optimization technique has consistently produced superior plans. Rectum and bladder mean doses were significantly reduced, and comparable target coverage and homogeneity were achieved in order to maintain a urethra protection strategy. The mean SA treatment delivery time was reduced by 22%; the mean monitor units increased due to higher plan complexity; and dose measurements demonstrated optimal agreement with calculations. The substantial reduction in treatment delivery time decreased the probability of prostate motion beyond the applied margins, suggesting potential decrease in treatment-related toxicity and improved target coverage in prostate SBRT. Further investigations are warranted to assess the long-term clinical outcomes.
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Affiliation(s)
- Denis Panizza
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (V.F.); (E.D.P.)
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy;
| | - Valeria Faccenda
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (V.F.); (E.D.P.)
| | - Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy;
- Radiation Oncology Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Elena De Ponti
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (V.F.); (E.D.P.)
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy;
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12
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Ong WL, Cheung P, Chung H, Chu W, Detsky J, Liu S, Morton G, Szumacher E, Tseng CL, Vesprini D, Davidson M, Ravi A, McGuffin M, Zhang L, Mamedov A, Deabreu A, Kulasingham-Poon M, Loblaw A. To Boost or Not to Boost: Pooled Analyses From 2-Fraction SABR Trials for Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:1153-1162. [PMID: 37419394 DOI: 10.1016/j.ijrobp.2023.06.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/07/2023] [Accepted: 06/23/2023] [Indexed: 07/09/2023]
Abstract
PURPOSE Focal boost to dominant intraprostatic lesion (DIL) is an approach for dose escalation in prostate radiation therapy. In this study, we aimed to report the outcomes of 2-fraction SABR ± DIL boost. METHODS AND MATERIALS We included 60 patients with low- to intermediate-risk prostate cancer enrolled in 2 phase 2 trials (30 patients in each trial). In the 2STAR trial (NCT02031328), 26 Gy (equivalent dose in 2-Gy fractions = 105.4 Gy) was delivered to the prostate. In the 2SMART trial (NCT03588819), 26 Gy was delivered to the prostate, with up to 32 Gy boost to magnetic resonance imaging-defined DIL (equivalent dose in 2-Gy fractions = 156.4 Gy). The reported outcomes included prostate-specific antigen (PSA) response (ie, <0.4 ng/mL) at 4 years (4yrPSARR), biochemical failure (BF), acute and late toxicities, and quality of life (QOL). RESULTS In 2SMART, median DIL D99% of 32.3 Gy was delivered. Median follow-up was 72.7 months (range, 69.1-75.) in 2STAR and 43.6 months (range, 38.7-49.5) in 2SMART. The 4yrPSARR was 57% (17/30) in 2STAR and 63% (15/24) in 2SMART (P = 0.7). The 4-year cumulative BF was 0% in 2STAR and 8.3% in 2SMART (P = 0.1). The 6-year BF in 2STAR was 3.5%. For genitourinary toxicities, there were differences in grade ≥1 urinary urgency in the acute (0% vs 47%; P < .001) and late settings (10% vs 67%; P < .001) favoring 2STAR. For urinary QOL, no difference was observed in the acute setting, but lower proportion in 2STAR had minimal clinically important changes in urinary QOL score in the late setting (21% vs 50%; P = .03). There were no significant differences in gastrointestinal and sexual toxicities and QOL in both acute and late settings between the 2 trials. CONCLUSIONS This study presents the first prospective data comparing 2-fraction prostate SABR ± DIL boost. The addition of DIL boost resulted in similar medium-term efficacy (in 4yrPSARR and BF), with impact on late urinary QOL outcomes.
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Affiliation(s)
- Wee Loon Ong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Alfred Health Radiation Oncology, Monash University, Melbourne, Victoria, Australia
| | - Patrick Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Hans Chung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Stanley Liu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Gerard Morton
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Ewa Szumacher
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Danny Vesprini
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Ananth Ravi
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; MOLLI Surgical, Toronto, Ontario, Canada
| | - Merrylee McGuffin
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Liying Zhang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alexandre Mamedov
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrea Deabreu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Department of Health Policy, Measurement and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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13
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Zilli T, Jorcano S, Bral S, Symon Z, Rubio C, Bruynzeel AME, Ibrahimov R, Minn H, Oliveira A, Bertaut A, Constantin G, Miralbell R. Every-Other-Day Versus Once-a-Week Urethra-Sparing Prostate Stereotactic Body Radiation Therapy: 5-Year Results of a Randomized Phase 2 Trial. Int J Radiat Oncol Biol Phys 2023; 117:791-798. [PMID: 37001763 DOI: 10.1016/j.ijrobp.2023.03.057] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE The objective of this study was to present the 5-year results from a prospective, multicenter, phase 2 randomized trial of every-other-day (EOD) versus once-a-week (QW) urethra-sparing stereotactic body radiation therapy for localized prostate cancer. METHODS AND MATERIALS Between 2012 and 2015, 170 patients with cT1c-3aN0M0 prostate cancer from 9 European institutions were randomized to 36.25 Gy in 5 fractions (6.5 Gy/fraction to the urethra) delivered either EOD (arm A, n = 84) or QW (arm B, n = 86). The median follow-up was 78 months (interquartile range, 66-89 months) and 77 months (interquartile range, 66-82 months) for arms A and B, respectively. RESULTS Among the 165 patients treated and retained for the final analysis (arm A, n = 82; arm B, n = 83), acute toxicity (National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03 scale) was mild or absent, with no differences between arms. The 5-year grade 2 or greater genitourinary toxicity-free survival was 75.9% and 76.1% for arms A and B, respectively (P = .945), whereas the 5-year grade 2 or greater gastrointestinal toxicity-free survival was 89% and 92% for arms A and B, respectively (P = .596). No changes in European Organisation for Research and Treatment of Cancer QLQ-PR25 scores were observed in both arms for genitourinary, gastrointestinal, and sexual domains at 5-year follow-up compared with baseline. At the last follow-up, biochemical failure was observed in 14 patients in the EOD arm and in 7 patients in the QW arm, with a 5-year biochemical relapse-free survival rate of 92.2% and 93% for arms A and B, respectively (P = .13). CONCLUSIONS Stereotactic body radiation therapy for prostate cancer with a 10% dose reduction to urethra was associated with a minimal effect on urinary function and quality of life regardless of an EOD or QW fractionation schedule. Biochemical control so far has been encouraging and much alike in both study arms, although longer follow-up is probably needed to assess the true value of overall treatment time on disease outcome.
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Affiliation(s)
- Thomas Zilli
- Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland; Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), Bellinzona, Switzerland.
| | - Sandra Jorcano
- Radiation Oncology, Teknon Oncologic Institute, Barcelona, Spain
| | - Samuel Bral
- Radiation Oncology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
| | - Zvi Symon
- Radiation Oncology, Sheba Medical Center, Ramat Gan, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Carmen Rubio
- Radiation Oncology, Hospital Universitario Sanchinarro, Madrid, Spain
| | - Anna M E Bruynzeel
- Radiation Oncology, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Roman Ibrahimov
- Radiation Oncology, Neolife Medical Center, Istanbul, Turkey
| | - Heikki Minn
- Radiation Oncology, University Hospital Turku, Turku, Finland
| | - Angelo Oliveira
- Radiation Oncology, Portuguese Institut of Oncology, Porto, Portugal
| | - Aurélie Bertaut
- Methodology and Biostatistics, Centre Georges-François-Leclerc, Dijon, France
| | | | - Raymond Miralbell
- Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland; Radiation Oncology, Teknon Oncologic Institute, Barcelona, Spain
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14
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Ong WL, Davidson M, Cheung P, Chung H, Chu W, Detsky J, Liu S, Morton G, Szumacher E, Tseng CL, Vesprini D, Ravi A, McGuffin M, Zhang L, Mamedov A, Deabreu A, Kulasingham-Poon M, Loblaw A. Dosimetric correlates of toxicities and quality of life following two-fraction stereotactic ablative radiotherapy (SABR) for prostate cancer. Radiother Oncol 2023; 188:109864. [PMID: 37619656 DOI: 10.1016/j.radonc.2023.109864] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE There is no evidence-based data to guide dose constraints in two-fraction prostate stereotactic ablative radiotherapy (SABR). Using individual patient-data from two prospective trials, we aimed to correlate dosimetric parameters with toxicities and quality of life (QoL) outcomes. MATERIALS AND METHODS We included 60 patients who had two-fraction prostate SABR in the 2STAR (NCT02031328) and 2SMART (NCT03588819) trials. The prescribed dose was 26 Gy to the prostate+/-32 Gy boost to the dominant intraprostatic lesions. Toxicities and QoL data were prospectively collected using CTCAEv4 and EPIC-26 questionnaire. The outcomes evaluated were acute and late grade ≥ 2 toxicities, and late minimal clinical important changes (MCIC) in QoL domains. Dosimetric parameters for bladder, urethra, rectum, and penile bulb were evaluated. RESULTS The median follow-up was 56 months (range: 39-78 months). The cumulative incidence of grade ≥ 2 genitourinary (GU), gastrointestinal (GI), and sexual toxicities were 62%, 3%, and 17% respectively in the acute setting (<3 months), and 57%, 15%, and 52% respectively in late setting (>6 months). There were 36%, 28%, and 29% patients who had late MCIC in urinary, bowel and sexual QoL outcomes respectively. Bladder 0.5 cc was significant predictor for late grade ≥ 2 GU toxicities, with optimal cut-off of 25.5 Gy. Penile bulb D5cc was associated of late grade ≥ 2 sexual toxicities (no optimal cut-off was identified). No dosimetric parameters were identified to be associated with other outcomes. CONCLUSION Using real-life patient data from prospective trials with medium-term follow-up, we identified additional dose constraints that may mitigate the risk of late treatment-related toxicities for two-fraction prostate SABR.
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Affiliation(s)
- Wee Loon Ong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada; Alfred Health Radiation Oncology, Monash University, Melbourne, Australia
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Patrick Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Hans Chung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Jay Detsky
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Stanley Liu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Gerard Morton
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Ewa Szumacher
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Chia-Lin Tseng
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Danny Vesprini
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Ananth Ravi
- Department of Radiation Oncology, University of Toronto, Canada; Molli Surgical, Toronto, Canada
| | - Merrylee McGuffin
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Liying Zhang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Alexandre Mamedov
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Andrea Deabreu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada; Department of Health Policy, Measurement and Evaluation, University of Toronto, Canada.
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15
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Le Guevelou J, Bosetti DG, Castronovo F, Angrisani A, de Crevoisier R, Zilli T. State of the art and future challenges of urethra-sparing stereotactic body radiotherapy for prostate cancer: a systematic review of literature. World J Urol 2023; 41:3287-3299. [PMID: 37668718 PMCID: PMC10632210 DOI: 10.1007/s00345-023-04579-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/11/2023] [Indexed: 09/06/2023] Open
Abstract
PURPOSE Doses delivered to the urethra have been associated with an increased risk to develop long-term urinary toxicity in patients undergoing stereotactic body radiotherapy (SBRT) for prostate cancer (PCa). Aim of the present systematic review is to report on the role of urethra-sparing SBRT (US-SBRT) techniques for prostate cancer, with a focus on outcome and urinary toxicity. METHOD A systematic review of the literature was performed on the PubMed database on May 2023. Based on the urethra-sparing technique, 13 studies were selected for the analysis and classified in the two following categories: "urethra-steering" SBRT (restriction of hotspots to the urethra) and "urethra dose-reduction" SBRT (dose reduction to urethra below the prescribed dose). RESULTS By limiting the urethra Dmax to 90GyEQD2 (α/β = 3 Gy) with urethra-steering SBRT techniques, late genitourinary (GU) grade 2 toxicity remains mild, ranging between 12.1% and 14%. With dose-reduction strategies decreasing the urethral dose below 70 GyEQD2, the risk of late GU toxicity was further reduced (< 8% at 5 years), while maintaining biochemical relapse-free survival rates up to 93% at 5 years. CONCLUSION US-SBRT techniques limiting maximum doses to urethra below a 90GyEQD2 (α/β = 3 Gy) threshold result in a low rate of acute and late grade ≥ 2 GU toxicity. A better understanding of clinical factors and anatomical substructures involved in the development of GU toxicity, as well as the development and use of adapted dose constraints, is expected to further reduce the long-term GU toxicity of prostate cancer patients treated with SBRT.
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Affiliation(s)
| | - Davide Giovanni Bosetti
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, Via Ospedale, 6500, Bellinzona, Switzerland
| | - Francesco Castronovo
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, Via Ospedale, 6500, Bellinzona, Switzerland
| | - Antonio Angrisani
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, Via Ospedale, 6500, Bellinzona, Switzerland
| | | | - Thomas Zilli
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland (IOSI), EOC, Via Ospedale, 6500, Bellinzona, Switzerland.
- Facoltà Di Scienze Biomediche, Università Della Svizzera Italiana (USI), Lugano, Switzerland.
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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16
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Leeman JE, Shin KY, Chen YH, Mak RH, Nguyen PL, D'Amico AV, Martin NE. Acute toxicity comparison of magnetic resonance-guided adaptive versus fiducial or computed tomography-guided non-adaptive prostate stereotactic body radiotherapy: A systematic review and meta-analysis. Cancer 2023; 129:3044-3052. [PMID: 37485697 DOI: 10.1002/cncr.34836] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is gaining wider adoption for prostate cancer management but there remain significant toxicity risks when delivering prostate SBRT with standard techniques. Magnetic resonance-guided daily adaptive SBRT (MRg-A-SBRT) offers technological advantages in precision of radiation dose delivery, but the toxicity profile associated with MRg-A-SBRT compared to more standardly used fiducial or computed tomography-guided non-adaptive prostate SBRT (CT-SBRT) remains unknown. METHODS A meta-analysis to compare acute toxicity rates associated with MRg-A-SBRT and CT-SBRT for prostate cancer was performed in compliance with PRISMA guidelines. MEDLINE (PubMed) and Google Scholar were searched for prospective studies of prostate SBRT that were published between January 1, 2018 and August 31, 2022. Random effects and fixed effects models were used to estimate pooled toxicity rates, and meta-regression was performed to compare toxicity between MRg-A-SBRT and CT-SBRT study groups. RESULTS Twenty-nine prospective studies were identified that met the inclusion criteria and included a total of 2547 patients. The pooled estimates for acute grade 2 or higher (G2+) genitourinary (GU) and gastrointestinal (GI) toxicity for MRg-A-SBRT were 16% (95% confidence interval [CI], 10%-24%) and 4% (95% CI, 2%-7%) and for CT-SBRT they were 28% (95% CI, 23%-33%) and 9% (95% CI, 6%-12%), respectively. On meta-regression, the odds ratios for acute G2+ GU and GI toxicities comparing MRg-A-SBRT and CT-SBRT were 0.56 (95% CI, 0.33-0.97, p = .04) and 0.40 (95% CI, 0.17-0.96, p = .04), respectively. CONCLUSION MRg-A-SBRT is associated with a significantly reduced risk of acute G2+ GU or GI toxicity compared to CT-SBRT. Longer follow-up will be needed to evaluate late toxicity and disease control outcomes. PLAIN LANGUAGE SUMMARY Magnetic resonance imaging-guided daily adaptive prostate stereotactic radiation (MRg-A-SBRT) is a treatment that may allow for delivery of prostate radiation more precisely than other radiotherapy techniques, but it is unknown whether this reduces side effects compared to standardly used computed tomography-guided SBRT (CT-SBRT). In this systematic review and meta-analysis combining data from 29 clinical trials including 2547 patients, it was found that the risk of short-term urinary side effects was reduced by 44% and the risk of short-term bowel side effects was reduced by 60% with MRg-A-SBRT compared to CT-SBRT.
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Affiliation(s)
- Jonathan E Leeman
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kee-Young Shin
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Yu-Hui Chen
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Raymond H Mak
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony V D'Amico
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Neil E Martin
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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17
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Sevillano D, Hervás A, García-Fuentes JD, Vallejo C, López F, Colmenares R, Capuz AB, Morís R, Cámara M, Galiano P, Williamson S, Chillida R, Béjar MJ, Prieto D, García-Vicente F. The use of a thin guide-wire for urethral definition in prostate SBRT treatments with Cyberknife. J Appl Clin Med Phys 2023:e14006. [PMID: 37097754 PMCID: PMC10402662 DOI: 10.1002/acm2.14006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 04/26/2023] Open
Abstract
PURPOSE To study and analyze the effect of the use of a thin guide-wire instead of a Foley catheter for urethral definition in prostate stereotactic body radiation therapy (SBRT) treatments and to compare treatment parameters in both situations. MATERIAL AND METHODS Thirty-seven prostate SBRT patients were employed in this study. A Foley catheter was employed in nine of them, and a guide-wire was employed in the other 28 patients. For each of the 28 patients in which the guide-wire was employed, a comparison between urethral positions in both situations was performed, allowing for a margin definition of the urethra when a Foley catheter was employed. Displacements of the prostate during treatment were obtained, allowing for an analysis of prostate positions in both situations. Also, different treatment parameters such as the number of treatment interruptions, couch movements performed, and x-rays needed were gathered. RESULTS Large differences between urethral positions can be found in the anterior-posterior (AP) directions compared to those in the lateral (LAT) direction. Differences are also larger in areas closer to the base of the prostate, where margins applied in the case of using a Foley catheter are 16 mm with a mean displacement of 6 mm in the posterior direction. No differences in the treatment parameters were found during treatment in both situations. The difference found in absolute prostate pitch rotations suggests that the Foley catheter provokes a shift of the prostate position, which does not occur when employing the guide-wire. CONCLUSIONS Foley catheters shift the urethral position, making them a wrong surrogate of the urethra when no catheters are present. The margins needed to assess uncertainties introduced by the use of a Foley catheter are larger than those usually applied. The use of a Foley catheter did not present any additional difficulty during treatment delivery in terms of images employed or interruptions produced.
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Affiliation(s)
- David Sevillano
- Medical Physics Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Asunción Hervás
- Radiation Oncology Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Juan D García-Fuentes
- Medical Physics Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Carmen Vallejo
- Radiation Oncology Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Fernando López
- Radiation Oncology Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Rafael Colmenares
- Medical Physics Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Ana Belén Capuz
- Medical Physics Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Rafael Morís
- Medical Physics Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Miguel Cámara
- Medical Physics Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Pablo Galiano
- Medical Physics Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Sandra Williamson
- Medical Physics Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Rubén Chillida
- Medical Physics Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - María Josefa Béjar
- Medical Physics Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Daniel Prieto
- Medical Physics Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
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18
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Chuong MD, Palm RF, Tjong MC, Hyer DE, Kishan AU. Advances in MRI-Guided Radiation Therapy. Surg Oncol Clin N Am 2023; 32:599-615. [PMID: 37182995 DOI: 10.1016/j.soc.2023.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Image guidance for radiation therapy (RT) has evolved over the last few decades and now is routinely performed using cone-beam computerized tomography (CBCT). Conventional linear accelerators (LINACs) that use CBCT have limited soft tissue contrast, are not able to image the patient's internal anatomy during treatment delivery, and most are not capable of online adaptive replanning. RT delivery systems that use MRI have become available within the last several years and address many of the imaging limitations of conventional LINACs. Herein, the authors review the technical characteristics and advantages of MRI-guided RT as well as emerging clinical outcomes.
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Affiliation(s)
- Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, 8900 North Kendall Drive, Miami, FL 33176, USA.
| | - Russell F Palm
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Michael C Tjong
- Department of Radiation Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Daniel E Hyer
- Department of Radiation Oncology, University of Iowa, 200 Hawkins Dr, Iowa City, IA 52242, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, 1338 S Hope Street, Los Angeles, CA 90015, USA
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19
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Cubero L, García-Elcano L, Mylona E, Boue-Rafle A, Cozzarini C, Ubeira Gabellini MG, Rancati T, Fiorino C, de Crevoisier R, Acosta O, Pascau J. Deep learning-based segmentation of prostatic urethra on computed tomography scans for treatment planning. Phys Imaging Radiat Oncol 2023; 26:100431. [PMID: 37007914 PMCID: PMC10064422 DOI: 10.1016/j.phro.2023.100431] [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: 11/15/2022] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 04/04/2023] Open
Abstract
Background and purpose The intraprostatic urethra is an organ at risk in prostate cancer radiotherapy, but its segmentation in computed tomography (CT) is challenging. This work sought to: i) propose an automatic pipeline for intraprostatic urethra segmentation in CT, ii) analyze the dose to the urethra, iii) compare the predictions to magnetic resonance (MR) contours. Materials and methods First, we trained Deep Learning networks to segment the rectum, bladder, prostate, and seminal vesicles. Then, the proposed Deep Learning Urethra Segmentation model was trained with the bladder and prostate distance transforms and 44 labeled CT with visible catheters. The evaluation was performed on 11 datasets, calculating centerline distance (CLD) and percentage of centerline within 3.5 and 5 mm. We applied this method to a dataset of 32 patients treated with intensity-modulated radiation therapy (IMRT) to quantify the urethral dose. Finally, we compared predicted intraprostatic urethra contours to manual delineations in MR for 15 patients without catheter. Results A mean CLD of 1.6 ± 0.8 mm for the whole urethra and 1.7 ± 1.4, 1.5 ± 0.9, and 1.7 ± 0.9 mm for the top, middle, and bottom thirds were obtained in CT. On average, 94% and 97% of the segmented centerlines were within a 3.5 mm and 5 mm radius, respectively. In IMRT, the urethra received a higher dose than the overall prostate. We also found a slight deviation between the predicted and manual MR delineations. Conclusion A fully-automatic segmentation pipeline was validated to delineate the intraprostatic urethra in CT images.
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Affiliation(s)
- Lucía Cubero
- Departamento de Bioingeniería, Universidad Carlos III de Madrid, Madrid, Spain
- Université Rennes, CLCC Eugène Marquis, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Laura García-Elcano
- Departamento de Bioingeniería, Universidad Carlos III de Madrid, Madrid, Spain
| | | | - Adrien Boue-Rafle
- Université Rennes, CLCC Eugène Marquis, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Cesare Cozzarini
- Department of Radiation Oncology, San Raffaele Scientific Institute - IRCCS, Milan, Italy
| | | | - Tiziana Rancati
- Science Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Claudio Fiorino
- Department of Medical Physics, San Raffaele Scientific Institute - IRCCS, Milan, Italy
| | - Renaud de Crevoisier
- Université Rennes, CLCC Eugène Marquis, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Oscar Acosta
- Université Rennes, CLCC Eugène Marquis, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Javier Pascau
- Departamento de Bioingeniería, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Corresponding author at: Departamento de Bioingeniería, Universidad Carlos III de Madrid, Madrid, Spain.
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20
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Achard V, Zilli T. Prostate cancer intensity-modulated radiotherapy and long term genitourinary toxicity: an evolving therapeutic landscape. Prostate Cancer Prostatic Dis 2023; 26:1-2. [PMID: 35488121 DOI: 10.1038/s41391-022-00535-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/10/2022] [Accepted: 03/29/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Vérane Achard
- Department of Radiation Oncology, Geneva University Hospital, Geneva, and Faculty of Medicine, Geneva, Switzerland
| | - Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, and Faculty of Medicine, Geneva, Switzerland.
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21
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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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22
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Xu D, Ma TM, Savjani R, Pham J, Cao M, Yang Y, Kishan AU, Scalzo F, Sheng K. Fully automated segmentation of prostatic urethra for MR-guided radiation therapy. Med Phys 2023; 50:354-364. [PMID: 36106703 DOI: 10.1002/mp.15983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 04/29/2022] [Accepted: 09/01/2022] [Indexed: 01/25/2023] Open
Abstract
PURPOSE Accurate delineation of the urethra is a prerequisite for urethral dose reduction in prostate radiotherapy. However, even in magnetic resonance-guided radiation therapy (MRgRT), consistent delineation of the urethra is challenging, particularly in online adaptive radiotherapy. This paper presented a fully automatic MRgRT-based prostatic urethra segmentation framework. METHODS Twenty-eight prostate cancer patients were included in this study. In-house 3D half fourier single-shot turbo spin-echo (HASTE) and turbo spin echo (TSE) sequences were used to image the Foley-free urethra on a 0.35 T MRgRT system. The segmentation pipeline uses 3D nnU-Net as the base and innovatively combines ground truth and its corresponding radial distance (RD) map during training supervision. Additionally, we evaluate the benefit of incorporating a convolutional long short term memory (LSTM-Conv) layer and spatial recurrent convolution layer (RCL) into nnU-Net. A novel slice-by-slice simple exponential smoothing (SEPS) method specifically for tubular structures was used to post-process the segmentation results. RESULTS The experimental results show that nnU-Net trained using a combination of Dice, cross-entropy and RD achieved a Dice score of 77.1 ± 2.3% in the testing dataset. With SEPS, Hausdorff distance (HD) and 95% HD were reduced to 2.95 ± 0.17 mm and 1.84 ± 0.11 mm, respectively. LSTM-Conv and RCL layers only minimally improved the segmentation precision. CONCLUSION We present the first Foley-free MRgRT-based automated urethra segmentation study. Our method is built on a data-driven neural network with novel cost functions and a post-processing step designed for tubular structures. The performance is consistent with the need for online and offline urethra dose reduction in prostate radiotherapy.
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Affiliation(s)
- Di Xu
- Department of Computer Science, University of California, Los Angeles, California, USA.,Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Ting Martin Ma
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Ricky Savjani
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Jonathan Pham
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Yingli Yang
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Fabien Scalzo
- Department of Computer Science, Pepperdine University, Los Angeles, California, USA
| | - Ke Sheng
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
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23
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Five fractions of SBRT for prostate cancer. Lancet Oncol 2022; 23:e530. [DOI: 10.1016/s1470-2045(22)00615-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 11/30/2022]
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24
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Mechanisms, mitigation, and management of urinary toxicity from prostate radiotherapy. Lancet Oncol 2022; 23:e534-e543. [DOI: 10.1016/s1470-2045(22)00544-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/30/2022]
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25
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Greco C, Pares O, Pimentel N, Louro V, Nunes B, Kociolek J, Marques J, Fuks Z. Health-related quality of life of salvage prostate reirradiation using stereotactic ablative radiotherapy with urethral-sparing. Front Oncol 2022; 12:984917. [PMID: 36276100 PMCID: PMC9582606 DOI: 10.3389/fonc.2022.984917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 09/12/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To explore whether prostate motion mitigation using the rectal distension-mediated technique is safe and effective in stereotactic ablative radiation therapy (SABR) salvage treatment of intraprostatic cancer recurrences following initial radiotherapy for primary prostate cancer. MATERIALS AND METHODS Between July 2013 and December 2020, 30 patients received salvage SABR for 68Ga- PSMA-11 PET/CT-detected intra-prostatic relapses. Median time from primary RT to salvage reirradiation was 70.2 (IQR, 51.3-116.0) months. Median PSA at retreatment was 3.6 ng/mL (IQR, 1.9-6.2). Rectal distension-mediated SABR was achieved with a 150-cm3 air-inflated endorectal balloon and a Foley catheter loaded with 3 beacon transponders was used for urethra visualization and on-line tracking. MRI-based planning employed a 2-mm expansion around the planned target volume (PTV), reduced to 0-mm at the interface with critical organs at risk (OARs). Volumetric Modulated Arc Therapy (VMAT) permitted a 20% dose reduction of the urethra. VMAT simultaneous integrated boost (SIB) of the dominant intraprostatic lesion was deployed when indicated. Median SABR dose was 35 Gy (7 Gy per fraction over 5 consecutive days; range 35-40 Gy). Toxicity assessment used CTCAE v.4 criteria. RESULTS Median follow-up was 44 months (IQR, 18-60). The actuarial 3- and 4-year biochemical relapse free survival was 53.4% and 47.5%, respectively. Intraprostatic post-salvage relapse by PSMA PET/CT was 53.3%. Acute grade 2 and 3 genitourinary (GU) toxicities were 20% and 0%, respectively. There were no instances of acute grade ≥2 rectal (GI) toxicity. Late grade 2 and 3 GU toxicities occurred in 13.3% and 0% of patients, respectively. There were no instances of grade ≥2 late rectal toxicity. Patient-reported QOL measures showed an acute transient deterioration in the urinary domain 1 month after treatment but returned to baseline values at 3 months. The median IPSS scores rose over baseline (≥5 points in 53% of patients) between month 6 and 12 post-treatment as a result of urinary symptoms flare, eventually receding at 18 months. The bowel domain metrics had no appreciable changes over time. CONCLUSION Pursuit of local control in intraprostatic failures is feasible and can be achieved with an acceptably low toxicity profile associated with effective OAR sparing.
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Affiliation(s)
- Carlo Greco
- The Champalimaud Centre for the Unknown, Department of Radiation Oncology, Lisbon, Portugal,*Correspondence: Carlo Greco,
| | - Oriol Pares
- The Champalimaud Centre for the Unknown, Department of Radiation Oncology, Lisbon, Portugal
| | - Nuno Pimentel
- The Champalimaud Centre for the Unknown, Department of Radiation Oncology, Lisbon, Portugal
| | - Vasco Louro
- The Champalimaud Centre for the Unknown, Department of Radiation Oncology, Lisbon, Portugal
| | - Beatriz Nunes
- The Champalimaud Centre for the Unknown, Department of Radiation Oncology, Lisbon, Portugal
| | - Justyna Kociolek
- The Champalimaud Centre for the Unknown, Department of Radiation Oncology, Lisbon, Portugal
| | - Joao Marques
- The Champalimaud Centre for the Unknown, Department of Radiation Oncology, Lisbon, Portugal
| | - Zvi Fuks
- The Champalimaud Centre for the Unknown, Department of Radiation Oncology, Lisbon, Portugal,Memorial Sloan Kettering Cancer Department of Radiation Oncology Center, New York, NY, United States
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26
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Tree AC, Ostler P, van der Voet H, Chu W, Loblaw A, Ford D, Tolan S, Jain S, Martin A, Staffurth J, Armstrong J, Camilleri P, Kancherla K, Frew J, Chan A, Dayes IS, Duffton A, Brand DH, Henderson D, Morrison K, Brown S, Pugh J, Burnett S, Mahmud M, Hinder V, Naismith O, Hall E, van As N. Intensity-modulated radiotherapy versus stereotactic body radiotherapy for prostate cancer (PACE-B): 2-year toxicity results from an open-label, randomised, phase 3, non-inferiority trial. Lancet Oncol 2022; 23:1308-1320. [PMID: 36113498 DOI: 10.1016/s1470-2045(22)00517-4] [Citation(s) in RCA: 111] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Localised prostate cancer is commonly treated with external beam radiotherapy and moderate hypofractionation is non-inferior to longer schedules. Stereotactic body radiotherapy (SBRT) allows shorter treatment courses without impacting acute toxicity. We report 2-year toxicity findings from PACE-B, a randomised trial of conventionally fractionated or moderately hypofractionated radiotherapy versus SBRT. METHODS PACE is an open-label, multicohort, randomised, controlled, phase 3 trial conducted at 35 hospitals in the UK, Ireland, and Canada. In PACE-B, men aged 18 years and older with a WHO performance status 0-2 and low-risk or intermediate-risk histologically-confirmed prostate adenocarcinoma (Gleason 4 + 3 excluded) were randomly allocated (1:1) by computerised central randomisation with permuted blocks (size four and six), stratified by centre and risk group to control radiotherapy (CRT; 78 Gy in 39 fractions over 7·8 weeks or, following protocol amendment on March 24, 2016, 62 Gy in 20 fractions over 4 weeks) or SBRT (36·25 Gy in five fractions over 1-2 weeks). Androgen deprivation was not permitted. Co-primary outcomes for this toxicity analysis were Radiation Therapy Oncology Group (RTOG) grade 2 or worse gastrointestinal and genitourinary toxicity at 24 months after radiotherapy. Analysis was by treatment received and included all patients with at least one fraction of study treatment assessed for late toxicity. Recruitment is complete. Follow-up for oncological outcomes continues. The trial is registered with ClinicalTrials.gov, NCT01584258. FINDINGS We enrolled and randomly assigned 874 men between Aug 7, 2012, and Jan 4, 2018 (441 to CRT and 433 to SBRT). In this analysis, 430 patients were analysed in the CRT group and 414 in the SBRT group; a total of 844 (97%) of 874 randomly assigned patients. At 24 months, RTOG grade 2 or worse genitourinary toxicity was seen in eight (2%) of 381 participants assigned to CRT and 13 (3%) of 384 participants assigned to SBRT (absolute difference 1·3% [95% CI -1·3 to 4·0]; p=0·39); RTOG grade 2 or worse gastrointestinal toxicity was seen in 11 (3%) of 382 participants in the CRT group versus six (2%) of 384 participants in the SBRT group (absolute difference -1·3% [95% CI -3·9 to 1·1]; p=0·32). No serious adverse events (defined as RTOG grade 4 or worse) or treatment-related deaths were reported within the analysis timeframe. INTERPRETATION In the PACE-B trial, 2-year RTOG toxicity rates were similar for five fraction SBRT and conventional schedules of radiotherapy. Prostate SBRT was found to be safe and associated with low rates of side-effects. Biochemical outcomes are awaited. FUNDING Accuray.
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Affiliation(s)
- Alison C Tree
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK.
| | | | | | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Daniel Ford
- University Hospitals Birmingham, Birmingham, UK
| | - Shaun Tolan
- The Clatterbridge Cancer Centre, Liverpool, UK
| | | | - Alexander Martin
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - John Armstrong
- Cancer Trials Ireland, Dublin, Ireland; St Luke's Radiation Oncology Network, St Lukes Hospital, Dublin, Ireland
| | | | | | | | - Andrew Chan
- University Hospitals Coventry & Warwickshire, Coventry, UK
| | - Ian S Dayes
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Douglas H Brand
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | | | - Kirsty Morrison
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | | | - Julia Pugh
- The Institute of Cancer Research, London, UK
| | | | | | | | - Olivia Naismith
- The Royal Marsden Hospital, London, UK; Radiotherapy Trials QA Group, London, UK
| | - Emma Hall
- The Institute of Cancer Research, London, UK
| | - Nicholas van As
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
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27
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Pham J, Savjani RR, Yoon SM, Yang T, Gao Y, Cao M, Hu P, Sheng K, Low DA, Steinberg M, Kishan A, Yang Y. Urethral Interfractional Geometric and Dosimetric Variations of Prostate Cancer Patients: A Study Using an Onboard MRI. Front Oncol 2022; 12:916254. [PMID: 35912253 PMCID: PMC9334678 DOI: 10.3389/fonc.2022.916254] [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: 04/09/2022] [Accepted: 06/14/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose For a cohort of prostate cancer patients treated on an MR-guided radiotherapy (MRgRT) system, we retrospectively analyzed urethral interfractional geometric and dosimetric variations based on onboard MRIs acquired at different timepoints and evaluated onboard prostatic urethra visualization for urethra-focused online adaptive RT. Methods Twenty-six prostate cancer patients were prospectively scanned on a 0.35-T MRgRT system using an optimized T2-weighted HASTE sequence at simulation and final fraction. Two radiation oncologists (RO1 and RO2) contoured the urethras on all HASTE images. The simulation and final fraction HASTE images were rigidly registered, and urethral interobserver and interfractional geometric variation was evaluated using the 95th percentile Hausdorff distance (HD95), mean distance to agreement (MDA), center-of-mass shift (COMS), and DICE coefficient. For dosimetric analysis, simulation and final fraction HASTE images were registered to the 3D bSSFP planning MRI and 3D bSSFP final setup MRI, respectively. Both ROs’ urethra contours were transferred from HASTE images for initial treatment plan optimization and final fraction dose estimation separately. Stereotactic body radiotherapy (SBRT) plans, 40 Gy in 5 fractions, were optimized to meet clinical constraints, including urethral V42Gy ≤0.03 cc, on the planning MRI. The initial plan was then forward calculated on the final setup MRI to estimate urethral dose on the final fraction and evaluate urethral dosimetric impact due to anatomy change. Results The average interobserver HD95, MDA, COMS, and DICE were 2.85 ± 1.34 mm, 1.02 ± 0.36 mm, 3.16 ± 1.61 mm, and 0.58 ± 0.15, respectively. The average interfractional HD95, MDA, COMS, and DICE were 3.26 ± 1.54 mm, 1.29 ± 0.54 mm, 3.34 ± 2.01 mm, and 0.49 ± 0.18, respectively. All patient simulation MRgRT plans met all clinical constraints. For RO1 and RO2, 23/26 (88%) and 21/26 (81%) patients’ final fraction estimated urethral dose did not meet the planned constraint. The average urethral V42Gy change was 0.48 ± 0.58 cc. Conclusion Urethral interfractional motion and anatomic change can result in daily treatment violating urethral constraints. Onboard MRI with good visualization of the prostatic urethra can be a valuable tool to help better protect the urethra through patient setup or online adaptive RT.
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Affiliation(s)
- Jonathan Pham
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Ricky R. Savjani
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Stephanie M. Yoon
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Tiffany Yang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Yu Gao
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Peng Hu
- Department of Radiology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Ke Sheng
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Daniel A. Low
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Michael Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Yingli Yang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
- *Correspondence: Yingli Yang,
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Surgical Treatments of Benign Prostatic Hyperplasia and Prostate Cancer Stereotactic Radiotherapy: Impact on Long-Term Genitourinary Toxicity. Clin Oncol (R Coll Radiol) 2022; 34:e392-e399. [PMID: 35715340 DOI: 10.1016/j.clon.2022.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/16/2022] [Accepted: 05/31/2022] [Indexed: 11/20/2022]
Abstract
AIMS Although the results on acute and late toxicity of ultrahypofractionation are encouraging, data on safety in prostate cancer patients with a medical history of transurethral resection of the prostate (TURP) or adenomectomy remain scarce, especially in cases of repeated procedures. The aim of the present study was to report on long-term toxicities after stereotactic body radiotherapy (SBRT) of prostate cancer patients with previous surgical treatment of benign prostatic hyperplasia. MATERIALS AND METHODS Among 150 patients treated with SBRT (median dose 36.25 Gy in five fractions) realised from 2014 to 2019 in a single-centre institution, data of 24 men with a history of TURP (n = 19) or adenomectomy (n = 5) were analysed. Repeated TURP was carried out in three patients, with a median time between surgery and SBRT of 54 months. Genitourinary toxicity was assessed using the Common Terminology Criteria for Adverse Events v4.0 grading scale. RESULTS With a median follow-up of 45 months, 10 of 24 (42%) patients experienced at least one episode of transient haematuria. One patient (4%) with three previous TURP presented a grade 3 acute non-infective cystitis. Late grade 2 and 3 genitourinary toxicities were observed in eight (33%) and four patients (17%) (two treated with adenomectomy, one with multiple TURP and one with a 140 cm3 prostate size), respectively, with no grade ≥4 adverse events. A complete recovery of grade 3 genitourinary toxicities was observed for all patients after hyperbaric oxygen therapy. CONCLUSION Prostate SBRT is feasible and well-tolerated in patients with a medical history of surgical treatments of benign hyperplasia. Patients with prior adenomectomy or multiple TURP are at higher risk of developing severe genitourinary toxicity and should be carefully evaluated before SBRT treatments.
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Diez P, Hanna GG, Aitken KL, van As N, Carver A, Colaco RJ, Conibear J, Dunne EM, Eaton DJ, Franks KN, Good JS, Harrow S, Hatfield P, Hawkins MA, Jain S, McDonald F, Patel R, Rackley T, Sanghera P, Tree A, Murray L. UK 2022 Consensus on Normal Tissue Dose-Volume Constraints for Oligometastatic, Primary Lung and Hepatocellular Carcinoma Stereotactic Ablative Radiotherapy. Clin Oncol (R Coll Radiol) 2022; 34:288-300. [PMID: 35272913 DOI: 10.1016/j.clon.2022.02.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/21/2022] [Accepted: 02/14/2022] [Indexed: 12/25/2022]
Abstract
The use of stereotactic ablative radiotherapy (SABR) in the UK has expanded over the past decade, in part as the result of several UK clinical trials and a recent NHS England Commissioning through Evaluation programme. A UK SABR Consortium consensus for normal tissue constraints for SABR was published in 2017, based on the existing literature at the time. The published literature regarding SABR has increased in volume over the past 5 years and multiple UK centres are currently working to develop new SABR services. A review and update of the previous consensus is therefore appropriate and timely. It is hoped that this document will provide a useful resource to facilitate safe and consistent SABR practice.
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Affiliation(s)
- P Diez
- Radiotherapy Physics, National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Cancer Centre, Northwood, UK
| | - G G Hanna
- Belfast Health and Social Care Trust, Belfast, UK; Queen's University Belfast, Belfast, UK
| | - K L Aitken
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK; Institute of Cancer Research, London, UK
| | - N van As
- Institute of Cancer Research, London, UK; Department of Radiotherapy, Royal Marsden NHS Foundation Trust, Chelsea, London, UK
| | - A Carver
- Department of Medical Physics, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Medical Centre, Edgbaston, Birmingham, UK
| | - R J Colaco
- Department of Clinical Oncology, The Christie Hospital NHS Foundation Trust, Manchester, UK
| | - J Conibear
- Radiotherapy Department, Barts Cancer Centre, London, UK
| | - E M Dunne
- Department of Clinical Oncology, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - D J Eaton
- Radiotherapy Physics, National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Cancer Centre, Northwood, UK; Department of Medical Physics, Guys and St Thomas' NHS Foundation Trust, London, UK; School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - K N Franks
- Department of Clinical Oncology, Leeds Cancer Centre, St James's University Hospitals, Leeds, UK
| | - J S Good
- Department of Clinical Oncology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | - S Harrow
- Department of Clinical Oncology, Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - P Hatfield
- Department of Clinical Oncology, Leeds Cancer Centre, St James's University Hospitals, Leeds, UK
| | - M A Hawkins
- Department of Medical Physics and Biomechanical Engineering, University College London, London, UK; Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - S Jain
- Belfast Health and Social Care Trust, Belfast, UK; Queen's University Belfast, Belfast, UK
| | - F McDonald
- Institute of Cancer Research, London, UK; Department of Radiotherapy, Royal Marsden NHS Foundation Trust, Chelsea, London, UK
| | - R Patel
- Radiotherapy Physics, National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Cancer Centre, Northwood, UK
| | - T Rackley
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, UK
| | - P Sanghera
- Department of Clinical Oncology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | - A Tree
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK; Institute of Cancer Research, London, UK
| | - L Murray
- Department of Clinical Oncology, Leeds Cancer Centre, St James's University Hospitals, Leeds, UK; Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK.
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30
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Zilli T, Achard V, Guevelou JL. Intraprostatic Urethra: The New Kid on the Block for Prostate Cancer Radiation Therapy? Int J Radiat Oncol Biol Phys 2022; 113:92-95. [DOI: 10.1016/j.ijrobp.2022.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/16/2022] [Indexed: 10/18/2022]
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31
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Greco C, Pares O, Pimentel N, Louro V, Nunes B, Kociolek J, Stroom J, Vieira S, Mateus D, Cardoso MJ, Soares A, Marques J, Freitas E, Coelho G, Fuks Z. Urethra Sparing With Target Motion Mitigation in Dose-Escalated Extreme Hypofractionated Prostate Cancer Radiotherapy: 7-Year Results From a Phase II Study. Front Oncol 2022; 12:863655. [PMID: 35433469 PMCID: PMC9012148 DOI: 10.3389/fonc.2022.863655] [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: 02/24/2022] [Indexed: 11/15/2022] Open
Abstract
Purpose To explore whether the rectal distension-mediated technique, harnessing human physiology to achieve intrafractional prostate motion mitigation, enables urethra sparing by inverse dose painting, thus promoting dose escalation with extreme hypofractionated stereotactic ablative radiotherapy (SABR) in prostate cancer. Materials and Methods Between June 2013 and December 2018, 444 patients received 5 × 9 Gy SABR over 5 consecutive days. Rectal distension-mediated SABR was employed via insertion of a 150-cm3 air-inflated endorectal balloon. A Foley catheter loaded with 3 beacon transponders was used for urethra visualization and online tracking. MRI-based planning using Volumetric Modulated Arc Therapy - Image Guided Radiotherapy (VMAT-IGRT) with inverse dose painting was employed in delivering the planning target volume (PTV) dose and in sculpting exposure of organs at risk (OARs). A 2-mm margin was used for PTV expansion, reduced to 0 mm at the interface with critical OARs. All plans fulfilled Dmean ≥45 Gy. Target motion ≥2 mm/5 s motions mandated treatment interruption and target realignment prior to completion of the planned dose delivery. Results Patient compliance to the rectal distension-mediated immobilization protocol was excellent, achieving reproducible daily prostate localization at a patient-specific retropubic niche. Online tracking recorded ≤1-mm intrafractional target deviations in 95% of treatment sessions, while target realignment in ≥2-mm deviations enabled treatment completion as scheduled in all cases. The cumulative incidence rates of late grade ≥2 genitourinary (GU) and gastrointestinal (GI) toxicities were 5.3% and 1.1%, respectively. The favorable toxicity profile was corroborated by patient-reported quality of life (QOL) outcomes. Median prostate-specific antigen (PSA) nadir by 5 years was 0.19 ng/ml. The cumulative incidence rate of biochemical failure using the Phoenix definition was 2%, 16.6%, and 27.2% for the combined low/favorable–intermediate, unfavorable intermediate, and high-risk categories, respectively. Patients with a PSA failure underwent a 68Ga-labeled prostate-specific membrane antigen (68Ga-PSMA) scan showing a 20.2% cumulative incidence of intraprostatic relapses in biopsy International Society of Urological Pathology (ISUP) grade ≥3. Conclusion The rectal distension-mediated technique is feasible and well tolerated. Dose escalation to 45 Gy with urethra-sparing results in excellent toxicity profiles and PSA relapse rates similar to those reported by other dose-escalated regimens. The existence of intraprostatic recurrences in patients with high-risk features confirms the notion of a high α/β ratio in these phenotypes resulting in diminished effectiveness with hypofractionated dose escalation.
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Affiliation(s)
- Carlo Greco
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Oriol Pares
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Nuno Pimentel
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Vasco Louro
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Beatriz Nunes
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Justyna Kociolek
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Joep Stroom
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Sandra Vieira
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Dalila Mateus
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Maria Joao Cardoso
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Ana Soares
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Joao Marques
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Elda Freitas
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Graça Coelho
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Zvi Fuks
- Department of Radiation Oncology, Champalimaud Centre for the Unknown, Lisbon, Portugal.,Memorial Sloan Kettering Cancer Center, New York, NY, United States
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