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Rectal and Urethro-Vesical Subregions for Toxicity Prediction After Prostate Cancer Radiation Therapy: Validation of Voxel-Based Models in an Independent Population. Int J Radiat Oncol Biol Phys 2020; 108:1189-1195. [DOI: 10.1016/j.ijrobp.2020.07.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/01/2020] [Accepted: 07/06/2020] [Indexed: 12/16/2022]
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Nishio T, Nakamura M, Okamoto H, Kito S, Minemura T, Ozawa S, Kumazaki Y, Ishikawa M, Tohyama N, Kurooka M, Nakashima T, Shimizu H, Suzuki R, Ishikura S, Nishimura Y. An overview of the medical-physics-related verification system for radiotherapy multicenter clinical trials by the Medical Physics Working Group in the Japan Clinical Oncology Group-Radiation Therapy Study Group. JOURNAL OF RADIATION RESEARCH 2020; 61:999-1008. [PMID: 32989445 PMCID: PMC7674673 DOI: 10.1093/jrr/rraa089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/25/2020] [Indexed: 05/14/2023]
Abstract
The Japan Clinical Oncology Group-Radiation Therapy Study Group (JCOG-RTSG) has initiated several multicenter clinical trials for high-precision radiotherapy, which are presently ongoing. When conducting multi-center clinical trials, a large difference in physical quantities, such as the absolute doses to the target and the organ at risk, as well as the irradiation localization accuracy, affects the treatment outcome. Therefore, the differences in the various physical quantities used in different institutions must be within an acceptable range for conducting multicenter clinical trials, and this must be verified with medical physics consideration. In 2011, Japan's first Medical Physics Working Group (MPWG) in the JCOG-RTSG was established to perform this medical-physics-related verification for multicenter clinical trials. We have developed an auditing method to verify the accuracy of the absolute dose and the irradiation localization. Subsequently, we credentialed the participating institutions in the JCOG multicenter clinical trials that were using stereotactic body radiotherapy (SBRT) for lungs, intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) for several disease sites, and proton beam therapy (PT) for the liver. From the verification results, accuracies of the absolute dose and the irradiation localization among the participating institutions of the multicenter clinical trial were assured, and the JCOG clinical trials could be initiated.
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Affiliation(s)
- Teiji Nishio
- Corresponding author. Department of Medical Physics, Graduate School of Medicine, Tokyo Women’s Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan. Tel: +81-3-3353-8111; Fax: +81-3-5269-7040;
| | - Mitsuhiro Nakamura
- Division of Medical Physics, Department of Information Technology and Medical Engineering, Human He Sciences, Graduate School of Medicine, Kyoto University, 53 Shogoin-Kawaharacho, Sakyo-ku, Kyoto 606-8507, Japan
- Medical Physics Working Group (MPWG) in Japan Clinical Oncology Group - Radiation Therapy Study Group (JCOG-RTSG), Tokyo, Japan
| | - Hiroyuki Okamoto
- Department of Medical Physics, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045 Japan
- Medical Physics Working Group (MPWG) in Japan Clinical Oncology Group - Radiation Therapy Study Group (JCOG-RTSG), Tokyo, Japan
| | - Satoshi Kito
- Department of Radiology, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Kotobashi, Sumida-ku, Tokyo 130-8575, Japan
- Department of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
- Division of Medical Physics, Department of Information Technology and Medical Engineering, Human He Sciences, Graduate School of Medicine, Kyoto University, 53 Shogoin-Kawaharacho, Sakyo-ku, Kyoto 606-8507, Japan
- Medical Physics Working Group (MPWG) in Japan Clinical Oncology Group - Radiation Therapy Study Group (JCOG-RTSG), Tokyo, Japan
| | - Toshiyuki Minemura
- Division of Medical Support and Partnership, Center for Cancer Control and Information Services, National Cancer Center, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
- Medical Physics Working Group (MPWG) in Japan Clinical Oncology Group - Radiation Therapy Study Group (JCOG-RTSG), Tokyo, Japan
| | - Shuichi Ozawa
- Department of Radiation Oncology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
- Hiroshima High-Precision Radiotherapy Cancer Center, 3-2-2, Futabanosato, Higashi-ku, Hiroshima 732-0057, Japan
- Medical Physics Working Group (MPWG) in Japan Clinical Oncology Group - Radiation Therapy Study Group (JCOG-RTSG), Tokyo, Japan
| | - Yu Kumazaki
- Department of Radiation Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama 350-1298, Japan
- Medical Physics Working Group (MPWG) in Japan Clinical Oncology Group - Radiation Therapy Study Group (JCOG-RTSG), Tokyo, Japan
| | - Masayori Ishikawa
- Faculty of Health Sciences, Hokkaido University, N-12 W-5 Kita-ku, Sapporo, 060-0812, Japan
- Medical Physics Working Group (MPWG) in Japan Clinical Oncology Group - Radiation Therapy Study Group (JCOG-RTSG), Tokyo, Japan
| | - Naoki Tohyama
- Division of Medical Physics, Tokyo Bay Advanced Imaging & Radiation Oncology Makuhari Clinic, 1-17 Toyosuna, Mihama-ku, Chiba, 261-0024, Japan
- Medical Physics Working Group (MPWG) in Japan Clinical Oncology Group - Radiation Therapy Study Group (JCOG-RTSG), Tokyo, Japan
| | - Masahiko Kurooka
- Department of Radiation Therapy, Tokyo Medical University Hospital, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
- Medical Physics Working Group (MPWG) in Japan Clinical Oncology Group - Radiation Therapy Study Group (JCOG-RTSG), Tokyo, Japan
| | - Takeo Nakashima
- Radiation Therapy Section, Department of Clinical Support, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
- Medical Physics Working Group (MPWG) in Japan Clinical Oncology Group - Radiation Therapy Study Group (JCOG-RTSG), Tokyo, Japan
| | - Hidetoshi Shimizu
- Department of Radiation Oncology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi 464-8681, Japan
- Medical Physics Working Group (MPWG) in Japan Clinical Oncology Group - Radiation Therapy Study Group (JCOG-RTSG), Tokyo, Japan
| | - Ryusuke Suzuki
- Department of Medical Physics, Hokkaido University Hospital, North-14, West-5, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan
- Medical Physics Working Group (MPWG) in Japan Clinical Oncology Group - Radiation Therapy Study Group (JCOG-RTSG), Tokyo, Japan
| | - Satoshi Ishikura
- Department of Radiology, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan
- Radiotherapy Committee (RC) in Japan Clinical Oncology Group, Tokyo, Japan
- Japan Clinical Oncology Group - Radiation Therapy Study Group (JCOG-RTSG), Tokyo, Japan
| | - Yasumasa Nishimura
- Department of Radiation Oncology, Kindai University Faculty of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka 589-8511, Japan
- Japan Clinical Oncology Group - Radiation Therapy Study Group (JCOG-RTSG), Tokyo, Japan
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Joseph D, Denham JW, Steigler A, Lamb DS, Spry NA, Stanley J, Shannon T, Duchesne G, Atkinson C, Matthews JH, Turner S, Kenny L, Christie D, Tai KH, Gogna NK, Kearvell R, Murray J, Ebert MA, Haworth A, Delahunt B, Oldmeadow C, Attia J. Radiation Dose Escalation or Longer Androgen Suppression to Prevent Distant Progression in Men With Locally Advanced Prostate Cancer: 10-Year Data From the TROG 03.04 RADAR Trial. Int J Radiat Oncol Biol Phys 2020; 106:693-702. [DOI: 10.1016/j.ijrobp.2019.11.415] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 11/17/2019] [Accepted: 11/21/2019] [Indexed: 10/25/2022]
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Short-term androgen suppression and radiotherapy versus intermediate-term androgen suppression and radiotherapy, with or without zoledronic acid, in men with locally advanced prostate cancer (TROG 03.04 RADAR): 10-year results from a randomised, phase 3, factorial trial. Lancet Oncol 2018; 20:267-281. [PMID: 30579763 DOI: 10.1016/s1470-2045(18)30757-5] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND The optimal duration of androgen suppression for men with locally advanced prostate cancer receiving radiotherapy with curative intent is yet to be defined. Zoledronic acid is effective in preventing androgen suppression-induced bone loss, but its role in preventing castration-sensitive bone metastases in locally advanced prostate cancer is unclear. The RADAR trial assessed whether the addition of 12 months of adjuvant androgen suppression, 18 months of zoledronic acid, or both, can improve outcomes in men with locally advanced prostate cancer who receive 6 months of androgen suppression and prostatic radiotherapy. This report presents 10-year outcomes from this trial. METHODS For this randomised, phase 3, 2 × 2 factorial trial, eligible men were 18 years or older with locally advanced prostate cancer (either T2b-4, N0 M0 tumours or T2a, N0 M0 tumours provided Gleason score was ≥7 and baseline prostate-specific antigen [PSA] concentration was ≥10 μg/L). We randomly allocated participants in a 2 × 2 factorial design by computer-generated randomisation (using the minimisation technique, and stratified by centre, baseline PSA concentration, clinical tumour stage, Gleason score, and use of a brachytherapy boost) in a 1:1:1:1 ratio to four treatment groups. Patients in the control group received 6 months of neoadjuvant androgen suppression with leuprorelin (22·5 mg every 3 months, intramuscularly) and radiotherapy alone (short-term androgen suppression [STAS]); this treatment was either followed by another 12 months of adjuvant androgen suppression with leuprorelin (22·5 mg every 3 months, intramuscularly; intermediate-term androgen suppression [ITAS]), or accompanied by 18 months of zoledronic acid (4 mg every 3 months, intravenously) starting at randomisation (STAS plus zoledronic acid), or both (ITAS plus zoledronic acid). All patients received radiotherapy to the prostate and seminal vesicles, starting from the end of the fifth month of androgen suppression; dosing options were 66, 70, and 74 Gy in 2-Gy fractions per day, or 46 Gy in 2-Gy fractions followed by a high-dose-rate brachytherapy boost dose of 19·5 Gy in 6·5-Gy fractions. Treatment allocation was open label. The primary endpoint was prostate cancer-specific mortality and was analysed according to intention-to-treat using competing-risks methods. The trial is closed to follow-up and this is the final report of the main endpoints. This trial is registered with ClinicalTrials.gov, number NCT00193856. FINDINGS Between Oct 20, 2003, and Aug 15, 2007, 1071 men were enrolled and randomly assigned to STAS (n=268), ITAS (n=268), STAS plus zoledronic acid (n=268), and ITAS plus zoledronic acid (n=267). Median follow-up was 10·4 years (IQR 7·9-11·7). At this 10-year follow-up, no interactions were observed between androgen suppression and zoledronic acid so the treatment groups were collapsed to compare treatments according to duration of androgen suppression: 6 months of androgen suppression plus radiotherapy (6AS+RT) versus 18 months of androgen suppression plus radiotherapy (18AS+RT) and to compare treatments according to whether or not patients received zoledronic acid. The total number of deaths was 375 (200 men receiving 6AS+RT and 175 men receiving 18AS+RT), of which 143 (38%) were attributable to prostate cancer (81 men receiving 6AS+RT and 62 men receiving 18AS+RT). When analysed by duration of androgen suppression, the adjusted cumulative incidence of prostate cancer-specific mortality was 13·3% (95% CI 10·3-16·0) for 6AS+RT versus 9·7% (7·3-12·0) for 18AS+RT, representing an absolute difference of 3·7% (95% CI 0·3-7·1; sub-hazard ratio [sHR] 0·70 [95% CI 0·50-0·98], adjusted p=0·035). The addition of zoledronic acid did not affect prostate cancer-specific mortality; the adjusted cumulative incidence of prostate cancer-specific mortality was 11·2% (95% CI 8·7-13·7) with zoledronic acid vs 11·7% (9·2-14·1) without, representing an absolute difference of -0·5% (95% CI -3·8 to 2·9; sHR 0·95 [95% CI 0·69-1·32], adjusted p=0·78). Although safety analysis was not prespecified for this 10-year analysis, one new serious adverse event (osteonecrosis of the mandible, in a patient who received 18 months of androgen suppression plus zoledronic acid) occurred since our previous report, bringing the total number of cases of this serious adverse event to three (<1% out of 530 patients who received zoledronic acid evaluated for safety) and the total number of drug-related serious adverse events to 12 (1% out of all 1065 patients evaluable for safety). No treatment-related deaths occurred during the study. INTERPRETATION 18 months of androgen suppression plus radiotherapy is a more effective treatment option for locally advanced prostate cancer than 6 months of androgen suppression plus radiotherapy, but the addition of zoledronic acid to this treatment regimen is not beneficial. Evidence from the RADAR and French Canadian Prostate Cancer Study IV trials suggests that 18 months of androgen suppression with moderate radiation dose escalation is an effective but more tolerable option than longer durations of androgen suppression for men with locally advanced prostate cancer including intermediate and high risk elements. FUNDING National Health and Medical Research Council of Australia, Novartis Pharmaceuticals Australia, AbbVie Pharmaceuticals Australia, New Zealand Health Research Council, New Zealand Cancer Society, Cancer Standards Institute New Zealand, University of Newcastle (Australia), Hunter Medical Research Institute, Calvary Mater Newcastle Radiation Oncology Fund, and Maitland Cancer Appeal.
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de Leon JF, Kneebone A, Gebski V, Cross S, Do V, Hayden A, Ngo D, Sidhom M, Turner S. Long-term outcomes in 1121 Australian prostate cancer patients treated with definitive radiotherapy. J Med Imaging Radiat Oncol 2018; 63:116-123. [PMID: 30188601 DOI: 10.1111/1754-9485.12797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 08/07/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Optimal definitive treatment of prostate cancer is controversial, especially in high-risk patients. We report the largest prospective cohort of Australian patients treated with radiotherapy for localised prostate cancer. METHODS One thousand, one hundred and twenty-one patients with prostate cancer were prospectively registered and treated to a dose of 70-74 Gy. Patients were classified as low, intermediate or high risk based on PSA, clinical staging and Gleason score. Intermediate-risk patients were treated with 0-6 months of hormonal therapy (ADT) and high-risk patients were offered neoadjuvant and adjuvant ADT. Overall survival (OS) and biochemical relapse-free survival (bNED) were calculated using the Kaplan-Meier method. RESULTS Median follow-up was 92 months. Eight-year OS and bNED were 78.4% and 68.1% respectively in the entire cohort. OS for the low, intermediate and high-risk groups was 84.5%, 78.4% and 68% respectively. For these risk groups, bNED was 80.3%, 65.7% and 53.7% respectively. In the intermediate and high-risk group, OS and bNED decreased with increasing number of risk factors. CONCLUSION Definitive radiotherapy is an effective treatment for prostate cancer, including in high-risk cases.
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Affiliation(s)
- Jeremiah F de Leon
- Department of Radiation Oncology, Illawarra Cancer Care Centre, Wollongong, New South Wales, Australia
| | - Andrew Kneebone
- Northern Sydney Cancer Centre, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Val Gebski
- University of Sydney, Sydney, New South Wales, Australia.,NHMRC Clinical Trials Centre, Sydney, New South Wales, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Shamira Cross
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Nepean Cancer Centre, Sydney, New South Wales, Australia
| | - Viet Do
- Nepean Cancer Centre, Sydney, New South Wales, Australia.,Liverpool and Macarthur Cancer Therapy Centre, Sydney, New South Wales, Australia.,University of New South Wales, New South Wales, Australia
| | - Amy Hayden
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Nepean Cancer Centre, Sydney, New South Wales, Australia
| | - Diana Ngo
- Liverpool and Macarthur Cancer Therapy Centre, Sydney, New South Wales, Australia
| | - Mark Sidhom
- Liverpool and Macarthur Cancer Therapy Centre, Sydney, New South Wales, Australia.,University of New South Wales, New South Wales, Australia
| | - Sandra Turner
- University of Sydney, Sydney, New South Wales, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
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A virtual dosimetry audit - Towards transferability of gamma index analysis between clinical trial QA groups. Radiother Oncol 2018; 125:398-404. [PMID: 29100698 DOI: 10.1016/j.radonc.2017.10.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 11/22/2022]
Abstract
PURPOSE Quality assurance (QA) for clinical trials is important. Lack of compliance can affect trial outcome. Clinical trial QA groups have different methods of dose distribution verification and analysis, all with the ultimate aim of ensuring trial compliance. The aim of this study was to gain a better understanding of different processes to inform future dosimetry audit reciprocity. MATERIALS Six clinical trial QA groups participated. Intensity modulated treatment plans were generated for three different cases. A range of 17 virtual 'measurements' were generated by introducing a variety of simulated perturbations (such as MLC position deviations, dose differences, gantry rotation errors, Gaussian noise) to three different treatment plan cases. Participants were blinded to the 'measured' data details. Each group analysed the datasets using their own gamma index (γ) technique and using standardised parameters for passing criteria, lower dose threshold, γ normalisation and global γ. RESULTS For the same virtual 'measured' datasets, different results were observed using local techniques. For the standardised γ, differences in the percentage of points passing with γ < 1 were also found, however these differences were less pronounced than for each clinical trial QA group's analysis. These variations may be due to different software implementations of γ. CONCLUSIONS This virtual dosimetry audit has been an informative step in understanding differences in the verification of measured dose distributions between different clinical trial QA groups. This work lays the foundations for audit reciprocity between groups, particularly with more clinical trials being open to international recruitment.
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Marcello M, Ebert M, Haworth A, Steigler A, Kennedy A, Joseph D, Denham J. Association between treatment planning and delivery factors and disease progression in prostate cancer radiotherapy: Results from the TROG 03.04 RADAR trial. Radiother Oncol 2018; 126:249-256. [DOI: 10.1016/j.radonc.2017.10.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 10/16/2017] [Accepted: 10/16/2017] [Indexed: 11/25/2022]
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Radiation Oncology Quality and Safety Considerations in Low-Resource Settings: A Medical Physics Perspective. Semin Radiat Oncol 2017; 27:124-135. [DOI: 10.1016/j.semradonc.2016.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Yahya N, Ebert MA, Bulsara M, House MJ, Kennedy A, Joseph DJ, Denham JW. Statistical-learning strategies generate only modestly performing predictive models for urinary symptoms following external beam radiotherapy of the prostate: A comparison of conventional and machine-learning methods. Med Phys 2017; 43:2040. [PMID: 27147316 DOI: 10.1118/1.4944738] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Given the paucity of available data concerning radiotherapy-induced urinary toxicity, it is important to ensure derivation of the most robust models with superior predictive performance. This work explores multiple statistical-learning strategies for prediction of urinary symptoms following external beam radiotherapy of the prostate. METHODS The performance of logistic regression, elastic-net, support-vector machine, random forest, neural network, and multivariate adaptive regression splines (MARS) to predict urinary symptoms was analyzed using data from 754 participants accrued by TROG03.04-RADAR. Predictive features included dose-surface data, comorbidities, and medication-intake. Four symptoms were analyzed: dysuria, haematuria, incontinence, and frequency, each with three definitions (grade ≥ 1, grade ≥ 2 and longitudinal) with event rate between 2.3% and 76.1%. Repeated cross-validations producing matched models were implemented. A synthetic minority oversampling technique was utilized in endpoints with rare events. Parameter optimization was performed on the training data. Area under the receiver operating characteristic curve (AUROC) was used to compare performance using sample size to detect differences of ≥0.05 at the 95% confidence level. RESULTS Logistic regression, elastic-net, random forest, MARS, and support-vector machine were the highest-performing statistical-learning strategies in 3, 3, 3, 2, and 1 endpoints, respectively. Logistic regression, MARS, elastic-net, random forest, neural network, and support-vector machine were the best, or were not significantly worse than the best, in 7, 7, 5, 5, 3, and 1 endpoints. The best-performing statistical model was for dysuria grade ≥ 1 with AUROC ± standard deviation of 0.649 ± 0.074 using MARS. For longitudinal frequency and dysuria grade ≥ 1, all strategies produced AUROC>0.6 while all haematuria endpoints and longitudinal incontinence models produced AUROC<0.6. CONCLUSIONS Logistic regression and MARS were most likely to be the best-performing strategy for the prediction of urinary symptoms with elastic-net and random forest producing competitive results. The predictive power of the models was modest and endpoint-dependent. New features, including spatial dose maps, may be necessary to achieve better models.
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Affiliation(s)
- Noorazrul Yahya
- School of Physics, University of Western Australia, Western Australia 6009, Australia and School of Health Sciences, National University of Malaysia, Bangi 43600, Malaysia
| | - Martin A Ebert
- School of Physics, University of Western Australia, Western Australia 6009, Australia and Department of Radiation Oncology, Sir Charles Gairdner Hospital, Western Australia 6008, Australia
| | - Max Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Western Australia 6959, Australia
| | - Michael J House
- School of Physics, University of Western Australia, Western Australia 6009, Australia
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Western Australia 6008, Australia
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Western Australia 6008, Australia and School of Surgery, University of Western Australia, Western Australia 6009, Australia
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, New South Wales 2308, Australia
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Yahya N, Ebert MA, House MJ, Kennedy A, Matthews J, Joseph DJ, Denham JW. Modeling Urinary Dysfunction After External Beam Radiation Therapy of the Prostate Using Bladder Dose-Surface Maps: Evidence of Spatially Variable Response of the Bladder Surface. Int J Radiat Oncol Biol Phys 2016; 97:420-426. [PMID: 28068247 DOI: 10.1016/j.ijrobp.2016.10.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 09/27/2016] [Accepted: 10/14/2016] [Indexed: 01/05/2023]
Abstract
PURPOSE We assessed the association of the spatial distribution of dose to the bladder surface, described using dose-surface maps, with the risk of urinary dysfunction. METHODS AND MATERIALS The bladder dose-surface maps of 754 participants from the TROG 03.04-RADAR trial were generated from the volumetric data by virtually cutting the bladder at the sagittal slice, intersecting the bladder center-of-mass through to the bladder posterior and projecting the dose information on a 2-dimensional plane. Pixelwise dose comparisons were performed between patients with and without symptoms (dysuria, hematuria, incontinence, and an International Prostate Symptom Score increase of ≥10 [ΔIPSS10]). The results with and without permutation-based multiple-comparison adjustments are reported. The pixelwise multivariate analysis findings (peak-event model for dysuria, hematuria, and ΔIPSS10; event-count model for incontinence), with adjustments for clinical factors, are also reported. RESULTS The associations of the spatially specific dose measures to urinary dysfunction were dependent on the presence of specific symptoms. The doses received by the anteroinferior and, to lesser extent, posterosuperior surface of the bladder had the strongest relationship with the incidence of dysuria, hematuria, and ΔIPSS10, both with and without adjustment for clinical factors. For the doses to the posteroinferior region corresponding to the area of the trigone, the only symptom with significance was incontinence. CONCLUSIONS A spatially variable response of the bladder surface to the dose was found for symptoms of urinary dysfunction. Limiting the dose extending anteriorly might help reduce the risk of urinary dysfunction.
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Affiliation(s)
- Noorazrul Yahya
- School of Health Sciences, National University of Malaysia, Kuala Lumpur, Malaysia; School of Physics, University of Western Australia, Perth, Western Australia, Australia.
| | - Martin A Ebert
- School of Physics, University of Western Australia, Perth, Western Australia, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Michael J House
- School of Physics, University of Western Australia, Perth, Western Australia, Australia
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - John Matthews
- Department of Radiation Oncology, Auckland City Hospital, Auckland, New Zealand
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; School of Surgery, University of Western Australia, Perth, Western Australia, Australia
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
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Yahya N, Ebert MA, Bulsara M, House MJ, Kennedy A, Joseph DJ, Denham JW. Urinary symptoms following external beam radiotherapy of the prostate: Dose-symptom correlates with multiple-event and event-count models. Radiother Oncol 2015; 117:277-82. [PMID: 26476560 DOI: 10.1016/j.radonc.2015.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 09/30/2015] [Accepted: 10/03/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE This study aimed to compare urinary dose-symptom correlates after external beam radiotherapy of the prostate using commonly utilised peak-symptom models to multiple-event and event-count models which account for repeated events. MATERIALS AND METHODS Urinary symptoms (dysuria, haematuria, incontinence and frequency) from 754 participants from TROG 03.04-RADAR trial were analysed. Relative (R1-R75 Gy) and absolute (A60-A75Gy) bladder dose-surface area receiving more than a threshold dose and equivalent uniform dose using exponent a (range: a ∈[1 … 100]) were derived. The dose-symptom correlates were analysed using; peak-symptom (logistic), multiple-event (generalised estimating equation) and event-count (negative binomial regression) models. RESULTS Stronger dose-symptom correlates were found for incontinence and frequency using multiple-event and/or event-count models. For dysuria and haematuria, similar or better relationships were found using peak-symptom models. Dysuria, haematuria and high grade (⩾ 2) incontinence were associated to high dose (R61-R71 Gy). Frequency and low grade (⩾ 1) incontinence were associated to low and intermediate dose-surface parameters (R13-R41Gy). Frequency showed a parallel behaviour (a=1) while dysuria, haematuria and incontinence showed a more serial behaviour (a=4 to a ⩾ 100). Relative dose-surface showed stronger dose-symptom associations. CONCLUSIONS For certain endpoints, the multiple-event and event-count models provide stronger correlates over peak-symptom models. Accounting for multiple events may be advantageous for a more complete understanding of urinary dose-symptom relationships.
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Affiliation(s)
- Noorazrul Yahya
- School of Physics, University of Western Australia, Australia; School of Health Sciences, National University of Malaysia, Malaysia.
| | - Martin A Ebert
- School of Physics, University of Western Australia, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Australia
| | - Max Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Australia
| | - Michael J House
- School of Physics, University of Western Australia, Australia
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Australia
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Australia; School of Surgery, University of Western Australia, Australia
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, Australia
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Yahya N, Ebert MA, Bulsara M, Haworth A, Kennedy A, Joseph DJ, Denham JW. Dosimetry, clinical factors and medication intake influencing urinary symptoms after prostate radiotherapy: An analysis of data from the RADAR prostate radiotherapy trial. Radiother Oncol 2015; 116:112-8. [PMID: 26163088 DOI: 10.1016/j.radonc.2015.06.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 05/31/2015] [Accepted: 06/08/2015] [Indexed: 01/09/2023]
Abstract
PURPOSE/OBJECTIVE To identify dosimetry, clinical factors and medication intake impacting urinary symptoms after prostate radiotherapy. MATERIAL AND METHODS Data describing clinical factors and bladder dosimetry (reduced with principal component (PC) analysis) for 754 patients treated with external beam radiotherapy accrued by TROG 03.04 RADAR prostate radiotherapy trial were available for analysis. Urinary symptoms (frequency, incontinence, dysuria and haematuria) were prospectively assessed using LENT-SOMA to a median of 72months. The endpoints assessed were prevalence (grade ⩾1) at the end of radiotherapy (representing acute symptoms), at 18-, 36- and 54-month follow-ups (representing late symptoms) and peak late incidence including only grade ⩾2. Impact of factors was assessed using multivariate logistic regression models with correction for over-optimism. RESULTS Baseline symptoms, non-insulin dependent diabetes mellitus, age and PC1 (correlated to the mean dose) impact symptoms at >1 timepoints. Associations at a single timepoint were found for cerebrovascular condition, ECOG status and non-steroidal anti-inflammatory drug intake. Peak incidence analysis shows the impact of baseline, bowel and cerebrovascular condition and smoking status. CONCLUSIONS The prevalence and incidence analysis provide a complementary view for urinary symptom prediction. Sustained impacts across time points were found for several factors while some associations were not repeated at different time points suggesting poorer or transient impact.
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Affiliation(s)
- Noorazrul Yahya
- School of Physics, University of Western Australia, Australia; Faculty of Health Sciences, National University of Malaysia, Bangi, Malaysia.
| | - Martin A Ebert
- School of Physics, University of Western Australia, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Australia
| | - Max Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Australia
| | - Annette Haworth
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Australia
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Australia; School of Surgery, University of Western Australia, Australia
| | - Jim W Denham
- School of Medicine and Public Health, University of Newcastle, Australia
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Elsner K, Francis K, Hruby G, Roderick S. Quality improvement process to assess tattoo alignment, set-up accuracy and isocentre reproducibility in pelvic radiotherapy patients. J Med Radiat Sci 2015; 61:246-252. [PMID: 25598978 PMCID: PMC4282035 DOI: 10.1002/jmrs.79] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 10/06/2014] [Accepted: 10/07/2014] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION This quality improvement study tested three methods of tattoo alignment and isocentre definition to investigate if aligning lateral tattoos to minimise pitch, roll and yaw decreased set-up error, and if defining the isocentre using the lateral tattoos for cranio-caudal (CC) position improved isocentre reproducibility. The study population was patients receiving curative external beam radiotherapy (EBRT) for prostate cancer. The results are applicable to all supine pelvic EBRT patients. METHODS The three sequential cohorts recruited 11, 11 and 10 patients respectively. A data set of 20 orthogonal pairs of electronic portal images (EPI) was acquired for each patient. EPIs were matched offline to digitally reconstructed radiographs. In cohort 1, lateral tattoos were adjusted to minimise roll. The anterior tattoo was used to define the isocentre. In cohort 2, lateral tattoos were aligned to minimise roll and yaw. Isocentre was defined as per cohort 1. In cohort 3, lateral tattoos were aligned as per cohort 2 and the anterior tattoo was adjusted to minimise pitch. Isocentre was defined by the lateral tattoos for CC position and the anterior tattoo for the left-right position. RESULTS Cohort 3 results were superior as CC systematic and random set-up errors reduced from -1.3 mm to -0.5 mm, and 3.1 mm to 1.4 mm respectively, from cohort 1 to cohort 3. Isocentre reproducibility also improved from 86.7% to 92.1% of treatment isocentres within 5 mm of the planned isocentre. CONCLUSION The methods of tattoo alignment and isocentre definition in cohort 3 reduced set-up errors and improved isocentre reproducibility.
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Affiliation(s)
- Kelly Elsner
- Sydney Cancer Centre, Department of Radiation Oncology, Royal Prince Alfred Hospital Sydney, Australia
| | - Kate Francis
- Radiation Oncology, The Canberra Hospital Garran, Australia
| | - George Hruby
- Sydney Cancer Centre, Department of Radiation Oncology, Royal Prince Alfred Hospital Sydney, Australia ; University of Sydney Sydney, Australia
| | - Stephanie Roderick
- Northern Sydney Cancer Centre, Royal North Shore Hospital St Leonards, Australia
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Yahya N, Ebert MA, Bulsara M, Haworth A, Kearvell R, Foo K, Kennedy A, Richardson S, Krawiec M, Joseph DJ, Denham JW. Impact of treatment planning and delivery factors on gastrointestinal toxicity: an analysis of data from the RADAR prostate radiotherapy trial. Radiat Oncol 2014; 9:282. [PMID: 25498565 PMCID: PMC4271488 DOI: 10.1186/s13014-014-0282-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 12/01/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To assess the impact of incremental modifications of treatment planning and delivery technique, as well as patient anatomical factors, on late gastrointestinal toxicity using data from the TROG 03.04 RADAR prostate radiotherapy trial. METHODS The RADAR trial accrued 813 external beam radiotherapy participants during 2003-2008 from 23 centres. Following review and archive to a query-able database, digital treatment plans and data describing treatment technique for 754 patients were available for analysis. Treatment demographics, together with anatomical features, were assessed using uni- and multivariate regression models against late gastrointestinal toxicity at 18-, 36- and 54-month follow-up. Regression analyses were reviewed in the context of dose-volume data for the rectum and anal canal. RESULTS A multivariate analysis at 36-month follow-up shows that patients planned using a more rigorous dose calculation algorithm (DCA) was associated with a lower risk of stool frequency (OR: 0.435, CI: 0.242-0.783, corrected p = 0.04). Patients using laxative as a method of bowel preparation had higher risk of having increased stool frequency compared to patients with no dietary intervention (OR: 3.639, CI: 1.502-8.818, corrected p = 0.04). Despite higher risks of toxicities, the anorectum, anal canal and rectum dose-volume histograms (DVH) indicate patients using laxative had unremarkably different planned dose distributions. Patients planned with a more rigorous DCA had lower median DVH values between EQD23 = 15 Gy and EQD23 = 35 Gy. Planning target volume (PTV), conformity index, rectal width and prescription dose were not significant when adjusted for false discovery rate. Number of beams, beam energy, treatment beam definition, positioning orientation, rectum-PTV separation, rectal length and mean cross sectional area did not affect the risk of toxicities. CONCLUSIONS The RADAR study dataset has allowed an assessment of technical modifications on gastrointestinal toxicity. A number of interesting associations were subsequently found and some factors, previously hypothesised to influence toxicity, did not demonstrate any significant impact. We recommend trial registries be encouraged to record technical modifications introduced during the trial in order for more powerful evidence to be gathered regarding the impact of the interventions.
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Affiliation(s)
- Noorazrul Yahya
- School of Physics, University of Western Australia, Crawley, Western Australia, Australia. .,School of Health Sciences, National University of Malaysia, Bangi, Malaysia.
| | - Martin A Ebert
- School of Physics, University of Western Australia, Crawley, Western Australia, Australia. .,Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.
| | - Max Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Western Australia, Australia.
| | - Annette Haworth
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Victoria, Australia. .,Sir Peter MacCallum Department of Oncology, University of Melbourne, Victoria, Australia.
| | - Rachel Kearvell
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.
| | - Kerwyn Foo
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.
| | - Sharon Richardson
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.
| | - Michele Krawiec
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia. .,School of Surgery, University of Western Australia, Crawley, Western Australia, Australia.
| | - Jim W Denham
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.
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Short-term androgen suppression and radiotherapy versus intermediate-term androgen suppression and radiotherapy, with or without zoledronic acid, in men with locally advanced prostate cancer (TROG 03.04 RADAR): an open-label, randomised, phase 3 factorial trial. Lancet Oncol 2014; 15:1076-89. [PMID: 25130995 DOI: 10.1016/s1470-2045(14)70328-6] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND We investigated whether 18 months of androgen suppression plus radiotherapy, with or without 18 months of zoledronic acid, is more effective than 6 months of neoadjuvant androgen suppression plus radiotherapy with or without zoledronic acid. METHODS We did an open-label, randomised, 2 × 2 factorial trial in men with locally advanced prostate cancer (either T2a N0 M0 prostatic adenocarcinomas with prostate-specific antigen [PSA] ≥10 μg/L and a Gleason score of ≥7, or T2b-4 N0 M0 tumours regardless of PSA and Gleason score). We randomly allocated patients by computer-generated minimisation--stratified by centre, baseline PSA, tumour stage, Gleason score, and use of a brachytherapy boost--to one of four groups in a 1:1:1:1 ratio. Patients in the control group were treated with neoadjuvant androgen suppression with leuprorelin (22·5 mg every 3 months, intramuscularly) for 6 months (short-term) and radiotherapy alone (designated STAS); this procedure was either followed by another 12 months of androgen suppression with leuprorelin (intermediate-term; ITAS) or accompanied by 18 months of zoledronic acid (4 mg every 3 months for 18 months, intravenously; STAS plus zoledronic acid) or by both (ITAS plus zoledronic acid). The primary endpoint was prostate cancer-specific mortality. This analysis represents the first, preplanned assessment of oncological endpoints, 5 years after treatment. Analysis was by intention-to-treat. This trial is registered with ClinicalTrials.gov, number NCT00193856. FINDINGS Between Oct 20, 2003, and Aug 15, 2007, 1071 men were randomly assigned to STAS (n=268), STAS plus zoledronic acid (n=268), ITAS (n=268), and ITAS plus zoledronic acid (n=267). Median follow-up was 7·4 years (IQR 6·5-8·4). Cumulative incidences of prostate cancer-specific mortality were 4·1% (95% CI 2·2-7·0) in the STAS group, 7·8% (4·9-11·5) in the STAS plus zoledronic acid group, 7·4% (4·6-11·0) in the ITAS group, and 4·3% (2·3-7·3) in the ITAS plus zoledronic acid group. Cumulative incidence of all-cause mortality was 17·0% (13·0-22·1), 18·9% (14·6-24·2), 19·4% (15·0-24·7), and 13·9% (10·3-18·8), respectively. Neither prostate cancer-specific mortality nor all-cause mortality differed between control and experimental groups. Cumulative incidence of PSA progression was 34·2% (28·6-39·9) in the STAS group, 39·6% (33·6-45·5) in the STAS plus zoledronic acid group, 29·2% (23·8-34·8) in the ITAS group, and 26·0% (20·8-31·4) in the ITAS plus zoledronic acid group. Compared with STAS, no difference was noted in PSA progression with ITAS or STAS plus zoledronic acid; however, ITAS plus zoledronic acid reduced PSA progression (sub-hazard ratio [SHR] 0·71, 95% CI 0·53-0·95; p=0·021). Cumulative incidence of local progression was 4·1% (2·2-7·0) in the STAS group, 6·1% (3·7-9·5) in the STAS plus zoledronic acid group, 1·5% (0·5-3·7) in the ITAS group, and 3·4% (1·7-6·1) in the ITAS plus zoledronic acid group; no differences were noted between groups. Cumulative incidences of bone progression were 7·5% (4·8-11·1), 14·6% (10·6-19·2), 8·4% (5·5-12·2), and 7·6% (4·8-11·2), respectively. Compared with STAS, STAS plus zoledronic acid increased the risk of bone progression (SHR 1·90, 95% CI 1·14-3·17; p=0·012), but no differences were noted with the other two groups. Cumulative incidence of distant progression was 14·7% (10·7-19·2) in the STAS group, 17·3% (13·0-22·1) in the STAS plus zoledronic acid group, 14·2% (10·3-18·7) in the ITAS group, and 11·1% (7·6-15·2) in the ITAS plus zoledronic acid group; no differences were recorded between groups. Cumulative incidence of secondary therapeutic intervention was 25·6% (20·5-30·9), 28·9% (23·5-34·5), 20·7% (16·1-25·9), and 15·3% (11·3-20·0), respectively. Compared with STAS, ITAS plus zoledronic acid reduced the need for secondary therapeutic intervention (SHR 0·67, 95% CI 0·48-0·95; p=0·024); no differences were noted with the other two groups. An interaction between trial factors was recorded for Gleason score; therefore, we did pairwise comparisons between all groups. Post-hoc analyses suggested that the reductions in PSA progression and decreased need for secondary therapeutic intervention with ITAS plus zoledronic acid were restricted to tumours with a Gleason score of 8-10, and that ITAS was better than STAS in tumours with a Gleason score of 7 or lower. Long-term morbidity and quality-of-life scores were not affected adversely by 18 months of androgen suppression or zoledronic acid. INTERPRETATION Compared with STAS, ITAS plus zoledronic acid was more effective for treatment of prostate cancers with a Gleason score of 8-10, and ITAS alone was effective for tumours with a Gleason score of 7 or lower. Nevertheless, these findings are based on secondary endpoint data and post-hoc analyses and must be regarded cautiously. Long- term follow-up is necessary, as is external validation of the interaction between zoledronic acid and Gleason score. STAS plus zoledronic acid can be ruled out as a potential therapeutic option. FUNDING National Health and Medical Research Council of Australia, Novartis Pharmaceuticals Australia, Abbott Pharmaceuticals Australia, New Zealand Health Research Council, New Zealand Cancer Society, University of Newcastle (Australia), Calvary Health Care (Calvary Mater Newcastle Radiation Oncology Fund), Hunter Medical Research Institute, Maitland Cancer Appeal, Cancer Standards Institute New Zealand.
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Ebert MA, Bulsara M, Haworth A, Kearvell R, Richardson S, Kennedy A, Spry NA, Bydder SA, Joseph DJ, Denham JW. Technical quality assurance during the TROG 03.04 RADAR prostate radiotherapy trial: Are the results reflected in observed toxicity rates? J Med Imaging Radiat Oncol 2014; 59:99-108. [DOI: 10.1111/1754-9485.12212] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 06/15/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Martin A Ebert
- Department of Radiation Oncology; Sir Charles Gairdner Hospital, University of Western Australia; Perth Australia
- School of Physics; University of Western Australia; Perth Australia
| | - Max Bulsara
- School of Health Sciences; University of Notre Dame; Fremantle Western Australia Australia
| | - Annette Haworth
- Department of Physical Sciences; Peter MacCallum Cancer Centre, University of Melbourne; Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
| | - Rachel Kearvell
- Department of Radiation Oncology; Sir Charles Gairdner Hospital, University of Western Australia; Perth Australia
| | - Sharon Richardson
- Department of Radiation Oncology; Sir Charles Gairdner Hospital, University of Western Australia; Perth Australia
| | - Angel Kennedy
- Department of Radiation Oncology; Sir Charles Gairdner Hospital, University of Western Australia; Perth Australia
| | - Nigel A Spry
- Department of Radiation Oncology; Sir Charles Gairdner Hospital, University of Western Australia; Perth Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Australia
| | - Sean A Bydder
- Department of Radiation Oncology; Sir Charles Gairdner Hospital, University of Western Australia; Perth Australia
- School of Surgery; University of Western Australia; Perth Australia
| | - David J Joseph
- Department of Radiation Oncology; Sir Charles Gairdner Hospital, University of Western Australia; Perth Australia
- School of Surgery; University of Western Australia; Perth Australia
| | - James W Denham
- School of Medicine and Public Health; University of Newcastle; Newcastle New South Wales Australia
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Ibbott GS, Haworth A, Followill DS. Quality assurance for clinical trials. Front Oncol 2013; 3:311. [PMID: 24392352 PMCID: PMC3867736 DOI: 10.3389/fonc.2013.00311] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 12/05/2013] [Indexed: 11/13/2022] Open
Abstract
Cooperative groups, of which the Radiation Therapy Oncology Group is one example, conduct national clinical trials that often involve the use of radiation therapy. In preparation for such a trial, the cooperative group prepares a protocol to define the goals of the trial, the rationale for its design, and the details of the treatment procedure to be followed. The Radiological Physics Center (RPC) is one of several quality assurance (QA) offices that is charged with assuring that participating institutions deliver doses that are clinically consistent and comparable. The RPC does this by conducting a variety of independent audits and credentialing processes. The RPC has compiled data showing that credentialing can help institutions comply with the requirements of a cooperative group clinical protocol. Phantom irradiations have been demonstrated to exercise an institution's procedures for planning and delivering advanced external beam techniques (1-3). Similarly, RPC data indicate that a rapid review of patient treatment records or planning procedures can improve compliance with clinical trials (4). The experiences of the RPC are presented as examples of the contributions that a national clinical trials QA center can make to cooperative group trials. These experiences illustrate the critical need for comprehensive QA to assure that clinical trials are successful and cost-effective. The RPC is supported by grants CA 10953 and CA 81647 from the National Cancer Institute, NIH, DHHS.
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Affiliation(s)
- Geoffrey S Ibbott
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center , Houston, TX , USA
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Dosimetric consequences of prostate-based couch shifts on the precision of dose delivery during simultaneous IMRT irradiation of the prostate, seminal vesicles and pelvic lymph nodes. Phys Med 2013; 30:228-33. [PMID: 23860339 DOI: 10.1016/j.ejmp.2013.06.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 06/02/2013] [Accepted: 06/25/2013] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION To evaluate the impact interfraction prostate (CTV1) motion corrections on doses delivered to seminal vesicles (CTV2) and lymph nodes (CTV3), and to determine ideal planning target volume (PTV) margins for these targets with prostate-based position verification. MATERIAL AND METHODS Retrospective analysis based on 253 cone beam computed tomography (CBCT) studies of 28 patients. The isocenter-shift method was used to estimate the interfraction prostate and bony shift effects on the original plan coverage. Friedman's test was used to assess statistical significance between dose-volume histogram (DVH) parameters which were calculated for prostate-based sum plans, bony-based sum plans and original treatment plans. The van Herk formula was used to determine the set-up margin size for prostate-based verification. RESULTS The tracked shifts influenced the minimum, maximum and mean CTV2 and CTV3 doses, with a range differential of 0.17%-2.63% (prostate shifts) and 0.13%-1.92% (bony shifts) compared to the corresponding original parameters. Friedman's test revealed significant differences in the minimum doses to the CTV3 and maximum doses to both the CTV2 and CTV3. The calculated set-up margins of 1.22 cm (vertical), 0.19 cm (longitudinal) and 0.39 cm (lateral) should be added to CTV3 while performing prostate-based positioning. CONCLUSION To avoid geographical miss during simultaneous irradiation of independently moving targets (CTV1-3) appropriate margins should be used in accordance with the position verification method used. Based on our findings the following margin sizes should be used: 0.7 cm for the CTV1, 0.8-0.9 cm for the CTV2 , and asymmetric 1.0 cm (vertically) and 0.5 cm (other axes) for the CTV3.
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A methodology for dosimetry audit of rotational radiotherapy using a commercial detector array. Radiother Oncol 2013; 108:78-85. [DOI: 10.1016/j.radonc.2013.05.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 04/29/2013] [Accepted: 05/18/2013] [Indexed: 11/17/2022]
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Kron T, Haworth A, Williams I. Dosimetry for audit and clinical trials: challenges and requirements. ACTA ACUST UNITED AC 2013. [DOI: 10.1088/1742-6596/444/1/012014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Quality assurance in radiotherapy on a national level; experience from Norway: the KVIST initiative. JOURNAL OF RADIOTHERAPY IN PRACTICE 2013; 13:35-44. [PMID: 24611030 PMCID: PMC3942814 DOI: 10.1017/s1460396912000544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 09/14/2012] [Accepted: 10/08/2012] [Indexed: 11/13/2022]
Abstract
Background and purpose In radiotherapy (RT), there are high requirements for quality assurance (QA) in all the steps of the process. Development of QA systems are demanding in terms of financial and human resources. A national QA programme (KVIST) has been established in Norway to facilitate implementation of QA activity on hospital level. Method The KVIST organisation comprises the KVIST team, the reference group (RG) and the working groups (WGs). The KVIST team is multidisciplinary and are employed in permanent positions. The RG acts as an advisory body for the KVIST team in defining and ranking the priority of projects. Relevant national QA projects are identified in collaboration with the RG, and WGs are established to carry out the various projects. Result Several national consensus documents have been prepared by the various WGs. Systems for incident handling and activity reporting have been established and clinical audits have been implemented in Norwegian RT. Guidelines for RT of various diagnoses have also been prepared in collaboration with National Cancer groups. Conclusion The KVIST programme has been very well acknowledged in the Norwegian RT community. It has succeeded in creating a positive attitude towards QA and improved the communication between centres and the various professions.
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Kearvell R, Haworth A, Ebert MA, Murray J, Hooton B, Richardson S, Joseph DJ, Lamb D, Spry NA, Duchesne G, Denham JW. Quality improvements in prostate radiotherapy: Outcomes and impact of comprehensive quality assurance during the TROG 03.04 ‘RADAR’ trial. J Med Imaging Radiat Oncol 2013; 57:247-57. [DOI: 10.1111/1754-9485.12025] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 10/01/2012] [Indexed: 11/27/2022]
Affiliation(s)
- Rachel Kearvell
- Department of Radiation Oncology; Sir Charles Gairdner Hospital; Nedlands; Western Australia; Australia
| | | | | | - Judy Murray
- Department of Pathology and Molecular Medicine; University of Otago; Wellington; New Zealand
| | - Ben Hooton
- Department of Radiation Oncology; Sir Charles Gairdner Hospital; Nedlands; Western Australia; Australia
| | - Sharon Richardson
- Department of Radiation Oncology; Sir Charles Gairdner Hospital; Nedlands; Western Australia; Australia
| | | | - David Lamb
- Department of Pathology and Molecular Medicine; University of Otago; Wellington; New Zealand
| | | | | | - James W Denham
- School of Medicine and Public Health; University of Newcastle; Callaghan; New South Wales; Australia
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Denham JW, Wilcox C, Joseph D, Spry NA, Lamb DS, Tai KH, Matthews J, Atkinson C, Turner S, Christie D, Gogna NK, Kenny L, Duchesne G, Delahunt B, McElduff P. Quality of life in men with locally advanced prostate cancer treated with leuprorelin and radiotherapy with or without zoledronic acid (TROG 03.04 RADAR): secondary endpoints from a randomised phase 3 factorial trial. Lancet Oncol 2012; 13:1260-70. [DOI: 10.1016/s1470-2045(12)70423-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Miles E, Venables K. Radiotherapy Quality Assurance: Facilitation of Radiotherapy Research and Implementation of Technology. Clin Oncol (R Coll Radiol) 2012; 24:710-2. [DOI: 10.1016/j.clon.2012.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 06/21/2012] [Indexed: 10/28/2022]
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Denham JW, Wilcox C, Lamb DS, Spry NA, Duchesne G, Atkinson C, Matthews J, Turner S, Kenny L, Tai KH, Gogna NK, Ebert M, Delahunt B, McElduff P, Joseph D. Rectal and urinary dysfunction in the TROG 03.04 RADAR trial for locally advanced prostate cancer. Radiother Oncol 2012; 105:184-92. [DOI: 10.1016/j.radonc.2012.09.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 09/20/2012] [Accepted: 09/29/2012] [Indexed: 01/03/2023]
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QA makes a clinical trial stronger: Evidence-based medicine in radiation therapy. Radiother Oncol 2012; 105:4-8. [DOI: 10.1016/j.radonc.2012.08.008] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 08/15/2012] [Accepted: 08/16/2012] [Indexed: 11/17/2022]
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Adamczyk M, Piotrowski T, Adamiak E. Evaluation of combining bony anatomy and soft tissue position correction strategies for IMRT prostate cancer patients. Rep Pract Oncol Radiother 2012; 17:104-9. [PMID: 24377008 PMCID: PMC3863327 DOI: 10.1016/j.rpor.2012.01.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 11/15/2011] [Accepted: 01/13/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Radiotherapy treatment requires delivering high homogenous dose to target volume while sparing organs at risk. That is why accurate patient positioning is one of the most important steps during the treatment process. It reduces set-up errors which have a strong influence on the doses given to the target and surrounding tissues. AIM The aim of this study was to investigate the efficiency of combining bony anatomy and soft tissue imaging position correction strategies for patients with prostate cancer. MATERIALS AND METHODS The study based on pre-treatment position verification results determined for 10 patients using kV images and CBCT match. At the same patients' position, two orthogonal kV images and set of CT scans were acquired. Both verification methods gave the information about patients' position changes in vertical, longitudinal and lateral directions. RESULTS For 93 verifications, the mean values of kV shifts in vertical, longitudinal and lateral directions equaled: -0.11 ± 0.54 cm, 0.26 ± 0.38 cm and -0.06 ± 0.47 cm, respectively. The same values achieved for CBCT matching equaled: 0.07 ± 0.62 cm, 0.22 ± 0.36 cm and -0.02 ± 0.45 cm. Statistically significant changes between the values of shifts received during the first week of treatment and the rest time of the irradiation process were found for 2 patients in the lateral direction and 2 patients in vertical direction among kV results and for 3 patients in the longitudinal direction among CBCT results. A significant difference between kV and CBCT match results was found in the vertical direction. CONCLUSIONS In clinical practice, CBCT combined with kV or even portal imaging improves precision and effectiveness of prostate cancer treatment accuracy.
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Affiliation(s)
- Marta Adamczyk
- Department of Medical Physics, Greater Poland Cancer Centre, 15 Garbary St., 61-866 Poznań, Poland
| | - Tomasz Piotrowski
- Department of Medical Physics, Greater Poland Cancer Centre, 15 Garbary St., 61-866 Poznań, Poland
| | - Ewa Adamiak
- Radiotherapy Ward I, Greater Poland Cancer Centre, 15 Garbary St., 61-866 Poznań, Poland
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Quality assurance for prospective EORTC radiation oncology trials: The challenges of advanced technology in a multicenter international setting. Radiother Oncol 2011; 100:150-6. [DOI: 10.1016/j.radonc.2011.05.073] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 05/23/2011] [Accepted: 05/29/2011] [Indexed: 11/20/2022]
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Sanuki N, Ishikura S, Shinoda M, Ito Y, Hayakawa K, Ando N. Radiotherapy quality assurance review for a multi-center randomized trial of locally advanced esophageal cancer: the Japan Clinical Oncology Group (JCOG) trial 0303. Int J Clin Oncol 2011; 17:105-11. [PMID: 21667354 DOI: 10.1007/s10147-011-0264-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 05/24/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to evaluate the radiotherapy (RT) quality assurance (QA) for JCOG 0303. METHODS AND MATERIALS JCOG 0303 was a multi-center phase II/III trial that compared two types of chemotherapy administered concomitantly with RT for locally advanced esophageal cancer. RT requirements included a total dose of 60 Gy in 30 fractions and CTV with a 2-cm margin cranio-caudally to the primary tumor. The QA assessment was given as per protocol (PP), deviation acceptable (DA), violation unacceptable (VU), and incomplete/not evaluable following predefined criteria for quality parameters. RESULTS A total of 142 cases were accrued. After excluding 36 incomplete/not evaluable, 106 (75%) were fully evaluable for RT quality review. Of these 106, there were 4 VU (4%) and overall RT compliance (PP + DA) was 96%. Comparing the incidence of VU based on the numbers enrolled by institution, the highest quarter of enrollment (≥7 cases) had no VU, while all VU (4; 11%) were from institutions enrolling <7 patients. CONCLUSIONS The results of the RTQA assessment for JCOG 0303 were sufficient to provide reliable results. Additional improvements will be needed for institutions with low accrual rates.
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Affiliation(s)
- Naoko Sanuki
- Center for Cancer Control and Information Services, National Cancer Center, Tokyo, Japan
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Johnston ML, Vial P, Wiltshire KL, Bell LJ, Blome S, Kerestes Z, Morgan GW, O'Driscoll D, Shakespeare TP, Eade TN. Daily online bony correction is required for prostate patients without fiducial markers or soft-tissue imaging. Clin Oncol (R Coll Radiol) 2011; 23:454-9. [PMID: 21470835 DOI: 10.1016/j.clon.2011.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 01/24/2011] [Accepted: 01/25/2011] [Indexed: 11/25/2022]
Abstract
AIM To compare online position verification strategies with offline correction protocols for patients undergoing definitive prostate radiotherapy. MATERIALS AND METHODS We analysed 50 patients with implanted fiducial markers undergoing curative prostate radiation treatment, all of whom underwent daily kilovoltage imaging using an on-board imager. For each treatment, patients were set-up initially with skin tattoos and in-room lasers. Orthogonal on-board imager images were acquired and the couch shift to match both bony anatomy and the fiducial markers recorded. The set-up error using skin tattoos and offline bone correction was compared with online bone correction. The fiducial markers were used as the reference. RESULTS Data from 1923 fractions were analysed. The systematic error was ≤1 mm for all protocols. The average random error was 2-3mm for online bony correction and 3-5mm for skin tattoos or offline-bone. Online-bone showed a significant improvement compared with offline-bone in the number of patients with >5mm set-up errors for >10% (P<0.001) and >20% (P<0.003) of their fractions. CONCLUSIONS Online correction to bony anatomy reduces both systematic and random set-up error in patients undergoing prostate radiotherapy, and is superior to offline correction methods for those patients not suitable for fiducial markers or daily soft-tissue imaging.
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Affiliation(s)
- M L Johnston
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW, Australia
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Dal Pra A, Cury FL, Souhami L. Radiation therapy and androgen deprivation in the management of high risk prostate cancer. Int Braz J Urol 2011; 37:161-75; discussion 176-9. [DOI: 10.1590/s1677-55382011000200003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2010] [Indexed: 02/01/2023] Open
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Dal Pra A, Cury FL, Souhami L. Combining radiation therapy and androgen deprivation for localized prostate cancer-a critical review. ACTA ACUST UNITED AC 2010; 17:28-38. [PMID: 20975876 DOI: 10.3747/co.v17i5.632] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Interest has been increasing in the use of androgen deprivation therapy (ADT) combined with radiation therapy (RT) in the management of localized prostate cancer. Preclinical studies have provided some rationale for the use of this combination. In patients with high-risk disease, the benefit of a combined approach, with the addition of adjuvant hormonal therapy, is supported by results of randomized trials. In contrast, for patients with low-risk disease, there is no obvious therapeutic advantage except for cytoreduction. The usefulness of short-term hormonal therapy in association with rt for intermediate-risk patients is still debatable, particularly in the context of doseescalated RT. The optimal timing and duration of ADT, in the neoadjuvant and adjuvant settings alike, are still under investigation. In view of the potential side effects with ADT, further studies are being performed to better identify subsets of patients who will definitely benefit from this therapy in combination with rt.
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Affiliation(s)
- A Dal Pra
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, Montreal, QC
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Patient setup for PET/CT acquisition in radiotherapy planning. Radiother Oncol 2010; 96:298-301. [DOI: 10.1016/j.radonc.2010.07.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Revised: 07/17/2010] [Accepted: 07/29/2010] [Indexed: 11/18/2022]
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Delahunt B, Lamb DS, Srigley JR, Murray JD, Wilcox C, Samaratunga H, Atkinson C, Spry NA, Joseph D, Denham JW. Gleason scoring: a comparison of classical and modified (International Society of Urological Pathology) criteria using nadir PSA as a clinical end point. Pathology 2010; 42:339-43. [DOI: 10.3109/00313021003787924] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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