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Navaratnam A, Cumsky J, Abdul-Muhsin H, Gagneur J, Shen J, Kosiorek H, Golafshar M, Kawashima A, Wong W, Ferrigni R, Humphreys MR. Assessment of Polyethylene Glycol Hydrogel Spacer and Its Effect on Rectal Radiation Dose in Prostate Cancer Patients Receiving Proton Beam Radiation Therapy. Adv Radiat Oncol 2019; 5:92-100. [PMID: 32051895 PMCID: PMC7004937 DOI: 10.1016/j.adro.2019.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 07/15/2019] [Accepted: 08/13/2019] [Indexed: 12/31/2022] Open
Abstract
Purpose To assess the efficacy of placing a polyethylene glycol (PEG) spacing hydrogel in patients undergoing proton beam radiation therapy for prostate cancer. This study also aims to assess the effect on rectal radiation dose of prostate-rectum separation in various anatomic planes. Methods and Materials Seventy-two consecutive prostate cancer patients undergoing conventionally fractionated pencil beam scanning proton radiation therapy with and without hydrogel placement were compared. Magnetic resonance images taken after hydrogel placement measured prostate-rectum separation and were correlated to rectal dosing and rectal toxicity. Univariate analysis of clinical variables and radiation dosing was conducted using nonparametric Wilcoxon rank-sum test with continuity correction between groups (hydrogel spacer vs controls). Spearman's rank correlation coefficient assessed relationships between the various anatomic dimensions of perirectal space and rectal radiation dosing. Results Fifty-one patients had hydrogel placement before therapy and 21 did not. There was a 42.2% reduction in rectal dosing (mL3 rectum) in hydrogel patients (P < .001). Increasing midline sagittal lift resulted in a greater mitigation of total rectal dose (P = .031). The degree of prostate surface area coverage on coronal plane did not correlate with further reductions in rectal radiation dose (P = .673). Patients who had PEG hydrogels placed reported more rectal side effects during treatment compared with those patients who did not (35.3% vs 9.5%, P = .061). At median 9.5-month follow-up, there was no difference in reporting of grade ≤2 rectal toxicity between the 2 groups (7.7% vs 7.1%, P = .145). Conclusions Polyethylene glycol hydrogel placement before pencil proton beam radiation therapy for prostate cancer reduced rectal radiation dose. The most important factor reducing total rectal dose was the degree of sagittal midline separation created by the PEG hydrogel. This is the largest study with the longest follow-up to investigate hydrogel placement in the proton beam radiation setting.
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Affiliation(s)
| | - Jameson Cumsky
- Department of Urology, Mayo Clinic in Arizona, Phoenix, Arizona
| | | | - Justin Gagneur
- Department of Radiation Oncology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Heidi Kosiorek
- Department of Biostatistics, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Michael Golafshar
- Department of Biostatistics, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Akira Kawashima
- Department of Radiology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - William Wong
- Department of Radiation Oncology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Robert Ferrigni
- Department of Urology, Mayo Clinic in Arizona, Phoenix, Arizona
| | - Mitchell R. Humphreys
- Department of Urology, Mayo Clinic in Arizona, Phoenix, Arizona
- Corresponding author: Mitchell R. Humphreys, MD
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Polamraju P, Bagley AF, Williamson T, Zhu XR, Frank SJ. Hydrogel Spacer Reduces Rectal Dose during Proton Therapy for Prostate Cancer: A Dosimetric Analysis. Int J Part Ther 2019; 5:23-31. [PMID: 31773038 DOI: 10.14338/ijpt-18-00041.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 03/18/2019] [Indexed: 12/24/2022] Open
Abstract
Purpose Proton therapy for prostate cancer may reduce bowel dose and risk of bowel symptoms relative to photon-based methods. Here, we determined the effect of using a biodegradable, injectable hydrogel spacer on rectal dose on plans for treating prostate cancer with intensity-modulated proton therapy (IMPT) or passive scattering proton therapy (PSPT). Materials and Methods Pairs of IMPT and PSPT plans for 9 patients were created from fused computed tomography/magnetic resonance imaging scans obtained before and after spacer injection. Calculated values of rectal V40, V60, V70, V80, and maximum dose (Dmax) were compared with Wilcoxon signed rank tests. Displacements at the base (BP), midgland (MP), and apex (AP) of the prostate relative to the anterior rectal wall with the spacer in place were averaged for each patient and correlated with V70 by using linear regression models. Results The presence of a spacer reduced all dosimetric parameters for both PSPT and IMPT, with the greatest difference in V70, which was 81.1% lower for PSPT-with-spacer than for IMPT-without-spacer. Median displacements at BP, MP, and AP were 12 mm (range 7-19), 2 mm (range 0-4), and 1 mm (range 0-5) without the spacer and 19 mm (range 12-23), 10 mm (range 8-16), and 7 mm (range 2-12) with the spacer. Modest linear trends were noted between rectal V70 and displacement for IMPT-with-spacer and PSPT-with-spacer. When displacement was ≥8 mm, V70 was ≤5.1% for IMPT-with-spacer and PSPT-with-spacer. Conclusion Use of biodegradable hydrogel spacers for prostate cancer treatment provides a significant reduction of radiation dose to the rectum with proton therapy. Significant reductions in rectal dose occurred in both PSPT and IMPT plans, with the greatest reduction for IMPT-with-spacer relative to PSPT alone. Prospective studies are ongoing to assess the clinical impact of reducing rectal dose with hydrogel spacers.
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Affiliation(s)
- Praveen Polamraju
- University of Texas Medical Branch at Galveston School of Medicine, Galveston, TX, USA
| | - Alexander F Bagley
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tyler Williamson
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - X Ronald Zhu
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Moteabbed M, Trofimov A, Sharp GC, Wang Y, Zietman AL, Efstathiou JA, Lu HM. Proton therapy of prostate cancer by anterior-oblique beams: implications of setup and anatomy variations. Phys Med Biol 2017; 62:1644-1660. [DOI: 10.1088/1361-6560/62/5/1644] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Chung H, Polf J, Badiyan S, Biagioli M, Fernandez D, Latifi K, Wilder R, Mehta M, Chuong M. Rectal dose to prostate cancer patients treated with proton therapy with or without rectal spacer. J Appl Clin Med Phys 2017; 18:32-39. [PMID: 28291917 PMCID: PMC5689902 DOI: 10.1002/acm2.12001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 09/08/2016] [Indexed: 11/06/2022] Open
Abstract
The purpose of this study was to evaluate whether a spacer inserted in the prerectal space could reduce modeled rectal dose and toxicity rates for patients with prostate cancer treated in silico with pencil beam scanning (PBS) proton therapy. A total of 20 patients were included in this study who received photon therapy (12 with rectal spacer (DuraSeal™ gel) and 8 without). Two PBS treatment plans were retrospectively created for each patient using the following beam arrangements: (1) lateral-opposed (LAT) fields and (2) left and right anterior oblique (LAO/RAO) fields. Dose volume histograms (DVH) were generated for the prostate, rectum, bladder, and right and left femoral heads. The normal tissue complication probability (NTCP) for ≥grade 2 rectal toxicity was calculated using the Lyman-Kutcher-Burman model and compared between patients with and without the rectal spacer. A significantly lower mean rectal DVH was achieved in patients with rectal spacer compared to those without. For LAT plans, the mean rectal V70 with and without rectal spacer was 4.19 and 13.5%, respectively. For LAO/RAO plans, the mean rectal V70 with and without rectal spacer was 5.07 and 13.5%, respectively. No significant differences were found in any rectal dosimetric parameters between the LAT and the LAO/RAO plans generated with the rectal spacers. We found that ≥ 9 mm space resulted in a significant decrease in NTCP modeled for ≥grade 2 rectal toxicity. Rectal spacers can significantly decrease modeled rectal dose and predicted ≥grade 2 rectal toxicity in prostate cancer patients treated in silico with PBS. A minimum of 9 mm separation between the prostate and anterior rectal wall yields the largest benefit.
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Affiliation(s)
- Heeteak Chung
- Department of Radiation OncologyUniversity of MarylandBaltimore School of MedicineBaltimoreMDUSA
| | - Jerimy Polf
- Department of Radiation OncologyUniversity of MarylandBaltimore School of MedicineBaltimoreMDUSA
| | - Shahed Badiyan
- Department of Radiation OncologyUniversity of MarylandBaltimore School of MedicineBaltimoreMDUSA
| | - Matthew Biagioli
- Department of Radiation OncologyFlorida Hospital Cancer InstituteOrlandoFLUSA
| | - Daniel Fernandez
- Department of Radiation OncologyH. Lee Moffitt Cancer CenterTampaFLUSA
| | - Kujtim Latifi
- Department of Radiation OncologyH. Lee Moffitt Cancer CenterTampaFLUSA
| | - Richard Wilder
- Department of Radiation OncologyH. Lee Moffitt Cancer CenterTampaFLUSA
| | - Minesh Mehta
- Department of Radiation OncologyUniversity of MarylandBaltimore School of MedicineBaltimoreMDUSA
| | - Michael Chuong
- Department of Radiation OncologyUniversity of MarylandBaltimore School of MedicineBaltimoreMDUSA
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Müller AC, Mischinger J, Klotz T, Gagel B, Habl G, Hatiboglu G, Pinkawa M. Interdisciplinary consensus statement on indication and application of a hydrogel spacer for prostate radiotherapy based on experience in more than 250 patients. Radiol Oncol 2016; 50:329-36. [PMID: 27679550 PMCID: PMC5024663 DOI: 10.1515/raon-2016-0036] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 04/17/2016] [Indexed: 12/19/2022] Open
Abstract
Background The aim of the study was to reach a consensus on indication and application of a hydrogel spacer based on multicentre experience and give new users important information to shorten the learning curve for this innovative technique. Methods The interdisciplinary meeting was attended by radiation oncologists and urologists, each with experience of 23 – 138 hydrogel injections (SpaceOAR®) in prostate cancer patients before dose-escalated radiotherapy. User experience was discussed and questions were defined to comprise practical information relevant for successful hydrogel injection and treatment. Answers to the defined key questions were generated. Hydrogel-associated side effects were collected to estimate the percentage, treatment and prognosis of potential risks. Results The main indication for hydrogel application was dose-escalated radiotherapy for histologically confirmed low or intermediate risk prostate cancer. It was not recommended in locally advanced prostate cancer. The injection or implantation was performed under transrectal ultrasound guidance via the transperineal approach after prior hydrodissection. The rate of injection-related G2-toxicity was 2% (n = 5) in a total of 258 hydrogel applications. The most frequent complication (n = 4) was rectal wall penetration, diagnosed at different intervals after hydrogel injection and treated conservatively. Conclusions A consensus was reached on the application of a hydrogel spacer. Current experience demonstrated feasibility, which could promote initiation of this method in more centres to reduce radiation-related gastrointestinal toxicity of dose-escalated IGRT. However, a very low rate of a potential serious adverse event could not be excluded. Therefore, the application should carefully be discussed with the patient and be balanced against potential benefits.
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Affiliation(s)
| | | | - Theodor Klotz
- Department of Urology, Hospital Weiden, Weiden, Germany
| | - Bernd Gagel
- Department of Radiation Oncology, Hospital Weiden, Weiden, Germany
| | - Gregor Habl
- Department of Radiation Oncology, Technical University Munich, Munich, Germany
| | - Gencay Hatiboglu
- Department of Urology, University of Heidelberg, Heidelberg, Germany
| | - Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany
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Underwood T, Giantsoudi D, Moteabbed M, Zietman A, Efstathiou J, Paganetti H, Lu HM. Can We Advance Proton Therapy for Prostate? Considering Alternative Beam Angles and Relative Biological Effectiveness Variations When Comparing Against Intensity Modulated Radiation Therapy. Int J Radiat Oncol Biol Phys 2016; 95:454-464. [DOI: 10.1016/j.ijrobp.2016.01.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 01/06/2016] [Accepted: 01/12/2016] [Indexed: 12/27/2022]
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Kubota Y, Kawamura H, Sakai M, Tsumuraya R, Tashiro M, Yusa K, Kubo N, Sato H, Kawahara M, Katoh H, Kanai T, Ohno T, Nakano T. Changes in Rectal Dose Due to Alterations in Beam Angles for Setup Uncertainty and Range Uncertainty in Carbon-Ion Radiotherapy for Prostate Cancer. PLoS One 2016; 11:e0153894. [PMID: 27097041 PMCID: PMC4838308 DOI: 10.1371/journal.pone.0153894] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 04/05/2016] [Indexed: 12/02/2022] Open
Abstract
Background and Purpose Carbon-ion radiotherapy of prostate cancer is challenging in patients with metal implants in one or both hips. Problems can be circumvented by using fields at oblique angles. To evaluate the influence of setup and range uncertainties accompanying oblique field angles, we calculated rectal dose changes with oblique orthogonal field angles, using a device with fixed fields at 0° and 90° and a rotating patient couch. Material and Methods Dose distributions were calculated at the standard angles of 0° and 90°, and then at 30° and 60°. Setup uncertainty was simulated with changes from −2 mm to +2 mm for fields in the anterior-posterior, left-right, and cranial-caudal directions, and dose changes from range uncertainty were calculated with a 1 mm water-equivalent path length added to the target isocenter in each angle. The dose distributions regarding the passive irradiation method were calculated using the K2 dose algorithm. Results The rectal volumes with 0°, 30°, 60°, and 90° field angles at 95% of the prescription dose were 3.4±0.9 cm3, 2.8±1.1 cm3, 2.2±0.8 cm3, and 3.8±1.1 cm3, respectively. As compared with 90° fields, 30° and 60° fields had significant advantages regarding setup uncertainty and significant disadvantages regarding range uncertainty, but were not significantly different from the 90° field setup and range uncertainties. Conclusions The setup and range uncertainties calculated at 30° and 60° field angles were not associated with a significant change in rectal dose relative to those at 90°.
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Affiliation(s)
- Yoshiki Kubota
- Gunma University Heavy Ion Medical Center, Gunma, Japan
- * E-mail:
| | | | - Makoto Sakai
- Gunma University Heavy Ion Medical Center, Gunma, Japan
| | | | | | - Ken Yusa
- Gunma University Heavy Ion Medical Center, Gunma, Japan
| | - Nobuteru Kubo
- Gunma University Heavy Ion Medical Center, Gunma, Japan
| | - Hiro Sato
- Gunma University Heavy Ion Medical Center, Gunma, Japan
| | | | | | | | - Tatsuya Ohno
- Gunma University Heavy Ion Medical Center, Gunma, Japan
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Andrzejewski P, Kuess P, Knäusl B, Pinker K, Georg P, Knoth J, Berger D, Kirisits C, Goldner G, Helbich T, Pötter R, Georg D. Feasibility of dominant intraprostatic lesion boosting using advanced photon-, proton- or brachytherapy. Radiother Oncol 2015; 117:509-14. [DOI: 10.1016/j.radonc.2015.07.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 05/22/2015] [Accepted: 07/21/2015] [Indexed: 11/30/2022]
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Rucinski A, Brons S, Richter D, Habl G, Debus J, Bert C, Haberer T, Jäkel O. Ion therapy of prostate cancer: daily rectal dose reduction by application of spacer gel. Radiat Oncol 2015; 10:56. [PMID: 25886457 PMCID: PMC4399750 DOI: 10.1186/s13014-015-0348-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 02/01/2015] [Indexed: 12/11/2022] Open
Abstract
Background Ion beam therapy represents a promising approach to treat prostate cancer, mainly due to its high conformity and radiobiological effectiveness. However, the presence of prostate motion, patient positioning and range uncertainties may deteriorate target dose and increase exposure of organs at risk. Spacer gel injected between prostate and rectum may increase the safety of prostate cancer (PC) radiation therapy by separating the rectum from the target dose field. The dosimetric impact of the application of spacer gel for scanned carbon ion therapy of PC has been analyzed at Heidelberg Ion-Beam Therapy Center (HIT). Materials and methods The robustness of ion therapy treatment plans was investigated by comparison of two data sets of patients treated with and without spacer gel. A research treatment planning system for ion therapy was used for treatment plan optimization and calculation of daily dose distributions on 2 to 9 Computed Tomography (CT) studies available for each of the 19 patients. Planning and daily dose distributions were analyzed with respect to target coverage, maximal dose to the rectum (excluding 1 ml of the greatest dose; Dmax-1 ml) and the rectal volume receiving dose greater than 90% of prescribed target dose (V90Rectum), respectively. Results The application of spacer gel did substantially diminish rectum dose. Dmax-1 ml on the treatment planning CT was on average reduced from 100.0 ± 1.0% to 90.2 ± 4.8%, when spacer gel was applied. The robustness analysis performed with daily CT studies demonstrated for all analyzed patient cases that application of spacer gel results in a decrease of the daily V90Rectum index, which calculated over all patient cases and CT studies was 10.2 ± 10.4 [ml] and 1.1 ± 2.1 [ml] for patients without and with spacer gel, respectively. Conclusions The dosimetric benefit of increasing the distance between prostate and rectum using spacer gel for PC treatment with carbon ion beams has been quantified. Application of spacer gel substantially reduced rectal exposure to high treatment dose and, therefore, can reduce the hazard of rectal toxicity in ion beam therapy of PC. The results of this study enable modifications of the PC ion therapy protocol such as dose escalation or hypofractionation. Electronic supplementary material The online version of this article (doi:10.1186/s13014-015-0348-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antoni Rucinski
- Heidelberg Ion-Beam Therapy Center (HIT) and Department of Radiation Oncology, University Clinic Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,Now INFN Sezione di Roma, Roma, Italy and Dipartimento di Scienze di Base e Applicate per Ingegneria, Sapienza Universit'a di Roma, Roma, Italy.
| | - Stephan Brons
- Heidelberg Ion-Beam Therapy Center (HIT) and Department of Radiation Oncology, University Clinic Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Daniel Richter
- Biophysics Division, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Planckstraße 1, Darmstadt, Germany. .,Now Friedrich-Alexander Universität Erlangen-Nürnberg and University Clinic Erlangen, Radiation Oncology, Universitätsstraße 27, 91054, Erlangen, Germany.
| | - Gregor Habl
- Heidelberg Ion-Beam Therapy Center (HIT) and Department of Radiation Oncology, University Clinic Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,Now Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany.
| | - Jürgen Debus
- Heidelberg Ion-Beam Therapy Center (HIT) and Department of Radiation Oncology, University Clinic Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Christoph Bert
- Biophysics Division, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Planckstraße 1, Darmstadt, Germany. .,Now Friedrich-Alexander Universität Erlangen-Nürnberg and University Clinic Erlangen, Radiation Oncology, Universitätsstraße 27, 91054, Erlangen, Germany.
| | - Thomas Haberer
- Heidelberg Ion-Beam Therapy Center (HIT) and Department of Radiation Oncology, University Clinic Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Oliver Jäkel
- Heidelberg Ion-Beam Therapy Center (HIT) and Department of Radiation Oncology, University Clinic Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,Deutsches Krebsforschungszentrum, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
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