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Moreno A, Solanki AA, Xu T, Lin R, Palta J, Daugherty E, Hong D, Hong J, Kamran SC, Katsoulakis E, Brock K, Feng M, Fuller C, Mayo C, Consortium BDSCPC. Identification of Key Elements in Prostate Cancer for Ontology Building via a Multidisciplinary Consensus Agreement. Cancers (Basel) 2023; 15:3121. [PMID: 37370731 PMCID: PMC10295832 DOI: 10.3390/cancers15123121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/25/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Clinical data collection related to prostate cancer (PCa) care is often unstructured or heterogeneous among providers, resulting in a high risk for ambiguity in its meaning when sharing or analyzing data. Ontologies, which are shareable formal (i.e., computable) representations of knowledge, can address these challenges by enabling machine-readable semantic interoperability. The purpose of this study was to identify PCa-specific key data elements (KDEs) for standardization in clinic and research. METHODS A modified Delphi method using iterative online surveys was performed to report a consensus agreement on KDEs by a multidisciplinary panel of 39 PCa specialists. Data elements were divided into three themes in PCa and included (1) treatment-related toxicities (TRT), (2) patient-reported outcome measures (PROM), and (3) disease control metrics (DCM). RESULTS The panel reached consensus on a thirty-item, two-tiered list of KDEs focusing mainly on urinary and rectal symptoms. The Expanded Prostate Cancer Index Composite (EPIC-26) questionnaire was considered most robust for PROM multi-domain monitoring, and granular KDEs were defined for DCM. CONCLUSIONS This expert consensus on PCa-specific KDEs has served as a foundation for a professional society-endorsed, publicly available operational ontology developed by the American Association of Physicists in Medicine (AAPM) Big Data Sub Committee (BDSC).
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Affiliation(s)
- Amy Moreno
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Abhishek A. Solanki
- Department of Radiation Oncology, Loyola University Medical Center, Berwyn, IL 60402, USA;
| | - Tianlin Xu
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (T.X.); (R.L.)
| | - Ruitao Lin
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (T.X.); (R.L.)
| | - Jatinder Palta
- Department of Medical Physics, Virginia Commonwealth University, Richmond, VA 23284, USA;
| | - Emily Daugherty
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA;
| | - David Hong
- Department of Radiation Oncology, University of Southern California, Los Angeles, CA 90089, USA;
| | - Julian Hong
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA 93701, USA; (J.H.); (M.F.)
| | - Sophia C. Kamran
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02129, USA;
| | - Evangelia Katsoulakis
- Department of Radiation Oncology, James A Haley VA Medical Center, Tampa, FL 33612, USA;
| | - Kristy Brock
- Department of Imaging Physics, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Mary Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA 93701, USA; (J.H.); (M.F.)
| | - Clifton Fuller
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Charles Mayo
- Department of Radiation Physics, University of Michigan, Ann Arbor, MI 48109, USA;
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Ahmad Khalil D, Wulff J, Jazmati D, Geismar D, Bäumer C, Kramer PH, Steinmeier T, Schleithoff SS, Tschirdewahn S, Hadaschik B, Timmermann B. Is an Endorectal Balloon Beneficial for Rectal Sparing after Spacer Implantation in Prostate Cancer Patients Treated with Hypofractionated Intensity-Modulated Proton Beam Therapy? A Dosimetric and Radiobiological Comparison Study. Curr Oncol 2023; 30:758-768. [PMID: 36661707 PMCID: PMC9857887 DOI: 10.3390/curroncol30010058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/21/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The aim of this study is to examine the dosimetric influence of endorectal balloons (ERB) on rectal sparing in prostate cancer patients with implanted hydrogel rectum spacers treated with dose-escalated or hypofractionated intensity-modulated proton beam therapy (IMPT). METHODS Ten patients with localized prostate cancer included in the ProRegPros study and treated at our center were investigated. All patients underwent placement of hydrogel rectum spacers before planning. Two planning CTs (with and without 120 cm3 fluid-filled ERB) were applied for each patient. Dose prescription was set according to the h strategy, with 72 Gray (Gy)/2.4 Gy/5× weekly to prostate + 1 cm of the seminal vesicle, and 60 Gy/2 Gy/5× weekly to prostate + 2 cm of the seminal vesicle. Planning with two laterally opposed IMPT beams was performed in both CTs. Rectal dosimetry values including dose-volume statistics and normal tissue complication probability (NTCP) were compared for both plans (non-ERB plans vs. ERB plans). RESULTS For ERB plans compared with non-ERB, the reductions were 8.51 ± 5.25 Gy (RBE) (p = 0.000) and 15.76 ± 11.11 Gy (p = 0.001) for the mean and the median rectal doses, respectively. No significant reductions in rectal volumes were found after high dose levels. The use of ERB resulted in significant reduction in rectal volume after receiving 50 Gy (RBE), 40 Gy (RBE), 30 Gy (RBE), 20 Gy (RBE), and 10 Gy (RBE) with p values of 0.034, 0.008, 0.003, 0.001, and 0.001, respectively. No differences between ERB and non-ERB plans for the anterior rectum were observed. ERB reduced posterior rectal volumes in patients who received 30 Gy (RBE), 20 Gy (RBE), or 10 Gy (RBE), with p values of 0.019, 0.003, and 0.001, respectively. According to the NTCP models, no significant reductions were observed in mean or median rectal toxicity (late rectal bleeding ≥ 2, necrosis or stenosis, and late rectal toxicity ≥ 3) when using the ERB. CONCLUSION ERB reduced rectal volumes exposed to intermediate or low dose levels. However, no significant reduction in rectal volume was observed in patients receiving high or intermediate doses. There was no benefit and also no disadvantage associated with the use of ERB for late rectal toxicity, according to available NTCP models.
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Affiliation(s)
- Dalia Ahmad Khalil
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), 45147 Essen, Germany
| | - Jörg Wulff
- Faculty of Physics, TU Dortmund University, 44227 Dortmund, Germany
| | - Danny Jazmati
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), 45147 Essen, Germany
| | - Dirk Geismar
- Faculty of Physics, TU Dortmund University, 44227 Dortmund, Germany
| | - Christian Bäumer
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), 45147 Essen, Germany
| | | | - Theresa Steinmeier
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), 45147 Essen, Germany
| | | | - Stephan Tschirdewahn
- Department of Urology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Boris Hadaschik
- Department of Urology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), 45147 Essen, Germany
- Faculty of Physics, TU Dortmund University, 44227 Dortmund, Germany
- German Cancer Consortium (DKTK), 45147 Essen, Germany
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3
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Peng X, Zhou S, Liu S, Li J, Huang S, Jiang X, Lin M, Huang S, Lin C, Qian C, Liu M, He L. Dose-volume analysis of predictors for acute anal toxicity after radiotherapy in prostate cancer patients. Radiat Oncol 2019; 14:174. [PMID: 31601249 PMCID: PMC6785897 DOI: 10.1186/s13014-019-1374-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 09/05/2019] [Indexed: 12/24/2022] Open
Abstract
Background This study aimed to evaluate the clinical and dosimetric factors predictive of acute anal toxicity (AAT) after radiotherapy in prostate cancer (PCa) patients with or without hemorrhoids. Methods We analyzed data from 347 PCa patients (248 cases treated from July 2013 to November 2017 for training cohort and 99 cases treated in 2018 for validation cohort) treated with pelvic radiotherapy at a single institution. Anal canal dose–volume histogram was used to determine the prescribed dose. Univariate and multivariate analyses were used to evaluate the risk of AAT as a function of clinical and dosimetric factors. Results Totally, 39.5% (98/248) and 31.3% (31/99) of the PCa patients developed AAT in training and validation cohorts, respectively. The incidence of AAT was much higher in patients with hemorrhoids than in those without hemorrhoids in both training and validation cohorts. Hemorrhoids and volume received more than 20 Gy (V20) were valuated as independent factors for predicting AAT in training cohort. Similar results were also observed in our validation cohort. The combination of hemorrhoids and high anal canal V20 (> 74.93% as determined by ROC curves) showed the highest specificity and positive predictive values for predicting AAT in both training and validation cohorts. Conclusions AAT occurs commonly in PCa patients with hemorrhoids during and after pelvic radiotherapy. Hemorrhoids and anal canal V20 are independent predictors of AAT. These factors should be carefully considered during treatment planning to minimize the incidence of AAT.
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Affiliation(s)
- Xingsi Peng
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Sha Zhou
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shiliang Liu
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Jibin Li
- Department of Clinical Research, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Sijuan Huang
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Xiaobo Jiang
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Maosheng Lin
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shaomin Huang
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Chengguang Lin
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Chaonan Qian
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Mengzhong Liu
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.
| | - Liru He
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.
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Rectal wall delineation in patients with a rectal displacement device in place during prostate cancer radiotherapy. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s13566-019-00378-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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5
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Leiker AJ, Desai NB, Folkert MR. Rectal radiation dose-reduction techniques in prostate cancer: a focus on the rectal spacer. Future Oncol 2018; 14:2773-2788. [PMID: 29939069 DOI: 10.2217/fon-2018-0286] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Prostate cancer is the most common cancer in men. External beam radiotherapy by a variety of methods is a standard treatment option with excellent disease control. However, acute and late rectal side effects remain a limiting concern in intensification of therapy in higher-risk patients and in efforts to reduce treatment burden in others. A number of techniques have emerged that allow for high-radiation dose delivery to the prostate with reduced risk of rectal toxicity, including image-guided intensity-modulated radiation therapy, endorectal balloons and various forms of rectal spacers. Image-guided radiation therapy, either intensity-modulated radiation therapy or stereotactic ablative radiation therapy, in conjunction with a rectal spacer, is an efficacious means to reduce acute and long-term rectal toxicity.
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Affiliation(s)
- Andrew J Leiker
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
| | - Neil B Desai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
| | - Michael R Folkert
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390-9303, USA
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Dubouloz A, Rouzaud M, Tsvang L, Verbakel W, Björkqvist M, Linthout N, Lencart J, Pérez-Moreno JM, Ozen Z, Escude L, Zilli T, Miralbell R. Urethra-sparing stereotactic body radiotherapy for prostate cancer: how much can the rectal wall dose be reduced with or without an endorectal balloon? Radiat Oncol 2018; 13:114. [PMID: 29921291 PMCID: PMC6008922 DOI: 10.1186/s13014-018-1059-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 06/13/2018] [Indexed: 11/20/2022] Open
Abstract
Background This is a dosimetric comparative study intended to establish appropriate low-to-intermediate dose-constraints for the rectal wall (Rwall) in the context of a randomized phase-II trial on urethra-sparing stereotactic body radiotherapy (SBRT) for prostate cancer. The effect of plan optimization on low-to-intermediate Rwall dose and the potential benefit of an endorectal balloon (ERB) are investigated. Methods Ten prostate cancer patients, simulated with and without an ERB, were planned to receive 36.25Gy (7.25Gyx5) to the planning treatment volume (PTV) and 32.5Gy to the urethral planning risk volume (uPRV). Reference plans with and without the ERB, optimized with respect to PTV and uPRV coverage objectives and the organs at risk dose constraints, were further optimized using a standardized stepwise approach to push down dose constraints to the Rwall in the low to intermediate range in five sequential steps to obtain paired plans with and without ERB (Vm1 to Vm5). Homogeneity index for the PTV and the uPRV, and the Dice similarity coefficient (DSC) for the PTV were analyzed. Dosimetric parameters for Rwall including the median dose and the dose received by 10 to 60% of the Rwall, bladder wall (Bwall) and femoral heads (FHeads) were compared. The monitor units (MU) per plan were recorded. Results Vm4 reduced by half D30%, D40%, D50%, and Dmed for Rwall and decreased by a third D60% while HIPTV, HIuPRV and DSC remained stable with and without ERB compared to Vmref. HIPTV worsened at Vm5 both with and without ERB. No statistical differences were observed between paired plans on Rwall, Bwall except a higher D2% for Fheads with and without an ERB. Conclusions Further optimization to the Rwall in the context of urethra sparing prostate SBRT is feasible without compromising the dose homogeneity to the target. Independent of the use or not of an ERB, low-to-intermediate doses to the Rwall can be significantly reduced using a four-step sequential optimization approach.
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Affiliation(s)
- Angèle Dubouloz
- Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1205, Genève, Switzerland. .,Radiation Oncology Department, Geneva University Hospital, CH-1211, 14, Geneva, Switzerland.
| | - Michel Rouzaud
- Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1205, Genève, Switzerland
| | - Lev Tsvang
- Department of Radiation Oncology, Chaim Sheba Medical Center, Tel-Hashomer, 52621, Ramat Gan, Israel
| | - Wilko Verbakel
- Department of Radiation Oncology, VU medical center, De Boelelaan 1117, P.O. Box 7057, 1007, MB, Amsterdam, The Netherlands
| | - Mikko Björkqvist
- Department of Oncology and Radiotherapy, Turku University Hospital, PO Box 52, 20521, Turku, Finland.,Department of Medical Physics, Turku University Hospital, PO Box 52, 20521, Turku, Finland
| | - Nadine Linthout
- Onze-Lieve-Vrouw Ziekenhuis, Moorselbaan 164, 9300, Aalst, Belgium
| | - Joana Lencart
- Serviço de Radioterapia Externa, Instituto Portugues de Oncologia, Rua Dr Antonio Bernardino de Almeida, 4200-072, Porto, Portugal
| | - Juan María Pérez-Moreno
- Servicio de Oncología Radioterápica, Centro Integral Oncológico "Clara Campal", Hospital Universitario Madrid Sanchinarro, C/ Oña 10, 28050, Madrid, Spain
| | - Zeynep Ozen
- Neolife Medical Center, Nisbetiye Mah. Yucel Sokak, No: 6 Besiktas, 34340, Istanbul, Turkey
| | - Lluís Escude
- Servei de Radiooncologia, Institut Oncològic Teknon, C/ Vilana 12, 08022, Barcelona, Spain
| | - Thomas Zilli
- Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1205, Genève, Switzerland
| | - Raymond Miralbell
- Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1205, Genève, Switzerland.,Servei de Radiooncologia, Institut Oncològic Teknon, C/ Vilana 12, 08022, Barcelona, Spain
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7
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Krol R, McColl GM, Hopman WPM, Smeenk RJ. Anal and rectal function after intensity-modulated prostate radiotherapy with endorectal balloon. Radiother Oncol 2018; 128:364-368. [PMID: 29716753 DOI: 10.1016/j.radonc.2018.03.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/27/2018] [Accepted: 03/29/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE Late anorectal toxicity influences quality of life after external beam radiotherapy (EBRT) for prostate cancer. A daily inserted endorectal balloon (ERB) during EBRT aims to reduce anorectal toxicity. Our goal is to objectify anorectal function over time after prostate intensity-modulated radiotherapy (IMRT) with ERB. MATERIAL AND METHODS Sixty men, irradiated with IMRT and an ERB, underwent barostat measurements and anorectal manometry prior to EBRT and 6 months, one year and 2 years after radiotherapy. Primary outcome measures were rectal distensibility and rectal sensibility in response to stepwise isobaric distensions and anal pressures. RESULTS Forty-eight men completed all measurements. EBRT reduced maximal rectal capacity 2 years after EBRT (250 ± 10 mL vs. 211 ± 10 mL; p < 0.001), area under the pressure-volume curve (2878 ± 270 mL mmHg vs. 2521 ± 305 mL mmHg; p = 0.043) and rectal compliance (NS). Sensory pressure thresholds for first sense and first urge (both p < 0.01) increased. Anal maximum pressure diminished after IMRT (p = 0.006). CONCLUSIONS Rectal capacity and sensory function are increasingly affected over time after radiotherapy. There is an indication that these reductions are affected less with IMRT + ERB compared to conventional radiation techniques.
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Affiliation(s)
- Robin Krol
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Gill M McColl
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Wim P M Hopman
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Robert J Smeenk
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
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8
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Wortel RC, Heemsbergen WD, Smeenk RJ, Witte MG, Krol SDG, Pos FJ, Incrocci L. Local Protocol Variations for Image Guided Radiation Therapy in the Multicenter Dutch Hypofractionation (HYPRO) Trial: Impact of Rectal Balloon and MRI Delineation on Anorectal Dose and Gastrointestinal Toxicity Levels. Int J Radiat Oncol Biol Phys 2017; 99:1243-1252. [PMID: 28943074 DOI: 10.1016/j.ijrobp.2017.07.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/14/2017] [Accepted: 07/31/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The phase 3 HYpofractionated irradiation for PROstate cancer (HYPRO) trial randomized patients with intermediate- to high-risk localized prostate cancer to conventionally fractionated (78 Gy in 39 fractions) or hypofractionated (64.6 Gy in 19 fractions) radiation therapy. Differences in techniques and treatment protocols were present between participating centers. This study aimed to compare dose parameters and patient-reported gastrointestinal symptoms between these centers. METHODS AND MATERIALS From the trial population, we selected patients (N=572) from 4 treatment centers who received image guided (IG) intensity modulated radiation therapy (IMRT). Center A (n=242) applied planning target volume (PTV) margins of 5 to 6 mm and was considered the reference center. In center B (n=170, 7-mm margins), magnetic resonance imaging (MRI) was integrated in treatment planning. An endorectal balloon (ERB) was applied in center C (n=85, 7-mm margins). Center D (n=75) applied the largest PTV margins of 8 mm. The study protocol provided identical anorectal dose constraints, and local protocols were applied for further treatment optimization. Anorectal dose-surface histograms were compared by applying t tests. Rectal complaints during follow-up (6 months to 4 years) were compared in a generalized linear model, adjusting for age, follow-up, treatment arm, and hormone therapy. RESULTS Favorable anorectal dose distributions were found for center B (MRI delineation) and center C (ERB application) as compared with centers A and D. These were associated with significantly lower incidences of patient-reported complaints of rectal incontinence, use of incontinence pads, and rectal discomfort in these centers. Furthermore, lower incidences of increased stool frequency (≥4 per day) and mucous loss were observed for center C. CONCLUSIONS Despite comparable IG-IMRT techniques and predefined dose constraints, pronounced differences in dose distributions and toxicity rates were observed. MRI delineation and ERB application were associated with favorable rectal dose parameters and toxicity profiles, whereas a 2- to 3-mm difference in PTV margins did not translate into observed differences. We conclude that choices for treatment optimization of IG-IMRT are important and clinically relevant for patients since these affect symptoms experienced in daily life.
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Affiliation(s)
- Ruud C Wortel
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Wilma D Heemsbergen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Robert Jan Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marnix G Witte
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Stijn D G Krol
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
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9
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The effect of endorectal balloon on anorectal dose during postoperative volumetric arc radiotherapy of prostate cancer. Radiother Oncol 2017; 123:454-458. [PMID: 28464996 DOI: 10.1016/j.radonc.2017.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 04/11/2017] [Accepted: 04/11/2017] [Indexed: 11/23/2022]
Abstract
PURPOSE To evaluate the impact of endorectal balloon (ERB) on anorectal dose during postoperative VMAT of prostate cancer. METHODS In ten patients referred for salvage radiotherapy CTs were obtained without ERB and with air-filled ERB of 50ml and 100ml. CTs were repeated weekly (4-6 control CTs) and registered to the respective planning CT. For each planning CT, a VMAT plan was made with defined anorectal dose constraints and propagated on the respective control CTs. The dose volumes V40Gy, V60Gy and V65Gy of the rectal and anal wall (Rwall and Awall, respectively) and the ERB position were obtained from each plan. RESULTS In plans with ERB, the mean Rwall dose volumes V40Gy, V60Gy and V65Gy were higher by 8%, 5% and 2% (ERB 50ml) and 2%, 3% and 3% (ERB 100ml) in comparison to plans without ERB. The respective Awall dose volume differences were 2%, 0%, -1% (ERB 50ml), and -3%, -2%, -2% (ERB 100ml). The dose volume variability of the Rwall was comparable with and without ERB, but was slightly reduced by ERB for the Awall. The mean ERB position variability was >2mm in anterior-posterior and inferior-superior directions. CONCLUSION The use of ERB during post-operative VMAT has no advantages for anorectal dose.
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10
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Xiang HF, Lu HM, Efstathiou JA, Zietman AL, De Armas R, Harris K, Bloch BN, Qureshi MM, Keohan S, Hirsch AE. Dosimetric impacts of endorectal balloon in CyberKnife stereotactic body radiation therapy (SBRT) for early-stage prostate cancer. J Appl Clin Med Phys 2017; 18:37-43. [PMID: 28407345 PMCID: PMC5689864 DOI: 10.1002/acm2.12063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/24/2017] [Accepted: 02/07/2017] [Indexed: 11/12/2022] Open
Abstract
PURPOSE In SBRT for prostate cancer, higher fractional dose to the rectum is a major toxicity concern due to using smaller PTV margin and hypofractionation. We investigate the dosimetric impact on rectum using endorectal balloon (ERB) in prostate SBRT. MATERIALS AND METHODS Twenty prostate cancer patients were included in a retrospective study, ten with ERB and 10 without ERB. Optimized SBRT plans were generated on CyberKnife MultiPlan for 5 × 7.25 Gy to PTV under RTOG-0938 protocol for early-stage prostate cancer. For the rectum and the anterior half rectum, mean dose and percentage of volumes receiving 50%, 80%, 90%, and 100% prescription dose were compared. RESULTS Using ERB, mean dose to the rectum was 62 cGy (P = 0.001) lower per fraction, and 50 cGy (P = 0.024) lower per fraction for the anterior half rectum. The average V50% , V80% , V90% , and V100% were lower by 9.9% (P = 0.001), 5.3% (P = 0.0002), 3.4% (P = 0.0002), and 1.2% (P = 0.005) for the rectum, and lower by 10.4% (P = 0.009), 8.3% (P = 0.0004), 5.4% (P = 0.0003), and 2.1% (P = 0.003) for the anterior half rectum. CONCLUSIONS Significant reductions of dose to the rectum using ERB were observed. This may lead to improvement of the rectal toxicity profiles in prostate SBRT.
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Affiliation(s)
- Hong F Xiang
- Department of Radiation Oncology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA.,Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Hsiao-Ming Lu
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony L Zietman
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ricardo De Armas
- Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Kathryn Harris
- Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - B Nicolas Bloch
- Department of Radiation Oncology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Muhammad Mustafa Qureshi
- Department of Radiation Oncology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Sean Keohan
- Department of Radiation Oncology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Ariel E Hirsch
- Department of Radiation Oncology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA.,Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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11
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Zaorsky NG, Showalter TN, Ezzell GA, Nguyen PL, Assimos DG, D'Amico AV, Gottschalk AR, Gustafson GS, Keole SR, Liauw SL, Lloyd S, McLaughlin PW, Movsas B, Prestidge BR, Taira AV, Vapiwala N, Davis BJ. ACR Appropriateness Criteria ® external beam radiation therapy treatment planning for clinically localized prostate cancer, part I of II. Adv Radiat Oncol 2016; 2:62-84. [PMID: 28740916 PMCID: PMC5514238 DOI: 10.1016/j.adro.2016.10.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/12/2016] [Indexed: 12/24/2022] Open
Affiliation(s)
| | | | | | - Gary A Ezzell
- Mayo Clinic, Phoenix, Arizona (research author, contributing)
| | - Paul L Nguyen
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts (panel vice-chair)
| | - Dean G Assimos
- University of Alabama School of Medicine, Birmingham, Alabama (American Urological Association)
| | - Anthony V D'Amico
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts (American Society of Clinical Oncology)
| | | | | | | | | | - Shane Lloyd
- Huntsman Cancer Hospital, Salt Lake City, Utah
| | | | | | | | - Al V Taira
- Mills Peninsula Hospital, San Mateo, California
| | - Neha Vapiwala
- University of Pennsylvania, Philadelphia, Pennsylvania
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12
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Yeoh EK, Krol R, Dhillon VS, Botten R, Di Matteo A, Butters J, Brock AR, Esterman A, Salisbury C, Fenech M. Predictors of radiation-induced gastrointestinal morbidity: A prospective, longitudinal study following radiotherapy for carcinoma of the prostate. Acta Oncol 2016; 55:604-10. [PMID: 27046049 DOI: 10.3109/0284186x.2015.1118658] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background Chronic gastrointestinal (GI) morbidity occurs in ≥50% of patients after external beam radiotherapy (EBRT) for carcinoma of prostate (CaP). This prospective, longitudinal study examines which baseline measurements of: 1) homocysteine and micronutrients in plasma; 2) chromosome damage/misrepair biomarkers; and 3) anal and rectal dose volume metrics predict GI morbidity after EBRT. Patients and methods In total, 106 patients with CaP had evaluations of GI symptoms (modified LENT-SOMA questionnaires) before EBRT and at one month, one, two and three years after its completion. Other variables measured before EBRT were: 1) plasma concentrations of homocysteine and micronutrients including caroteinoids and selenium; 2) chromosome damage/DNA misrepair (micronuclei/nucleoplasmic bridge) indices; and 3) mean anal and rectal wall doses and volumes of anal and rectal walls receiving ≥40 Gy and ≥60 Gy. Univariate and multivariate analyzes examined the relationships among: 1) plasma levels of homocysteine and micronutrients; 2) indices of chromosome damage/DNA misrepair; and 3) mean anal and rectal wall doses and volumes of anal and rectal walls receiving ≥40 Gy and ≥60 Gy and total GI symptom scores from one month to three years after EBRT. Results Increased frequency and urgency of defecation, rectal mucous discharge and bleeding after EBRT resulted in sustained rises in total GI symptom scores above baseline at three years. On univariate analysis, total GI symptom scores were significantly associated with: 1) plasma selenium and α tocopherol; 2) micronuclei indices of DNA damage; 3) mean anal and rectal wall doses; and 4) volumes of anal and rectal wall receiving ≥40 Gy and ≥60 Gy (p = 0.08-<0.001). On multivariate analysis, only volume of anal wall receiving ≥40 Gy was significant for increased GI symptoms after EBRT (p < 0.001). Conclusion The volume of anal wall receiving ≥40 Gy predicts chronic GI morbidity after EBRT for CaP.
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Affiliation(s)
- Eric K. Yeoh
- Department of Radiation Oncology, Royal Adelaide Hospital (RAH) and Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Robin Krol
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Varinderpal S. Dhillon
- Genome Health and Personalised Nutrition Laboratory, Commonwealth Scientific and Industrial Research Organisation (CSIRO), Division of Food and Nutrition and School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Rochelle Botten
- Department of Radiation Oncology, Royal Adelaide Hospital (RAH) and Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Addolorata Di Matteo
- Department of Radiation Oncology, Royal Adelaide Hospital (RAH) and Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Julie Butters
- Department of Radiation Oncology, Royal Adelaide Hospital (RAH) and Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Aleisha R. Brock
- Samson Institute of Health Research, University of South Australia, Adelaide, Australia
| | - Adrian Esterman
- Samson Institute of Health Research, University of South Australia, Adelaide, Australia
| | - Carolyn Salisbury
- Genome Health and Personalised Nutrition Laboratory, Commonwealth Scientific and Industrial Research Organisation (CSIRO), Division of Food and Nutrition and School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Michael Fenech
- Genome Health and Personalised Nutrition Laboratory, Commonwealth Scientific and Industrial Research Organisation (CSIRO), Division of Food and Nutrition and School of Health Sciences, University of South Australia, Adelaide, Australia
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13
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Dose-surface maps identifying local dose-effects for acute gastrointestinal toxicity after radiotherapy for prostate cancer. Radiother Oncol 2015; 117:515-20. [PMID: 26522060 DOI: 10.1016/j.radonc.2015.10.020] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 10/05/2015] [Accepted: 10/20/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE We evaluated dose distributions in the anorectum and its relation to acute gastrointestinal toxicities using dose surface maps in an image-guided (IG) IMRT and 3D-conformal radiotherapy (3D-CRT) population. MATERIAL AND METHODS For patients treated to 78 Gy with IG-IMRT (n=260) or 3D-CRT (n=215), for whom acute toxicity data were available, three types of surface maps were calculated: (1) total anorectum using regular intervals along a central axis with perpendicular slices, (2) the rectum next to the prostate, and (3) the anal canal (horizontal slicing). For each toxicity, an average dose map was calculated for patients with and without the toxicity and subsequently dose difference maps were constructed, 3D-CRT and IG-IMRT separately. P-values were based on permutation tests. RESULTS Dose distributions in patients with grade ⩾2 acute proctitis were significantly different from dose distributions in patients without toxicity, for IG-IMRT and 3D-CRT. At the cranial and posterior rectal site, in areas receiving moderate dose levels (≈25-50 Gy), dose differences up to 10 Gy were identified for IG-IMRT. For pain, cramps, incontinence, diarrhea and mucus loss significant differences were found as well. CONCLUSIONS We demonstrated significant relationships between acute rectal toxicity and local dose distributions. This may serve as a basis for subsequent dose-effect modeling in IG-IMRT, and improved dose constraints in current clinical practice.
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14
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Wortel RC, Incrocci L, Pos FJ, Lebesque JV, Witte MG, van der Heide UA, van Herk M, Heemsbergen WD. Acute toxicity after image-guided intensity modulated radiation therapy compared to 3D conformal radiation therapy in prostate cancer patients. Int J Radiat Oncol Biol Phys 2015; 91:737-44. [PMID: 25752386 DOI: 10.1016/j.ijrobp.2014.12.017] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 12/03/2014] [Accepted: 12/08/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE Image-guided intensity modulated radiation therapy (IG-IMRT) allows significant dose reductions to organs at risk in prostate cancer patients. However, clinical data identifying the benefits of IG-IMRT in daily practice are scarce. The purpose of this study was to compare dose distributions to organs at risk and acute gastrointestinal (GI) and genitourinary (GU) toxicity levels of patients treated to 78 Gy with either IG-IMRT or 3D-CRT. METHODS AND MATERIALS Patients treated with 3D-CRT (n=215) and IG-IMRT (n=260) receiving 78 Gy in 39 fractions within 2 randomized trials were selected. Dose surface histograms of anorectum, anal canal, and bladder were calculated. Identical toxicity questionnaires were distributed at baseline, prior to fraction 20 and 30 and at 90 days after treatment. Radiation Therapy Oncology Group (RTOG) grade ≥1, ≥2, and ≥3 endpoints were derived directly from questionnaires. Univariate and multivariate binary logistic regression analyses were applied. RESULTS The median volumes receiving 5 to 75 Gy were significantly lower (all P<.001) with IG-IMRT for anorectum, anal canal, and bladder. The mean dose to the anorectum was 34.4 Gy versus 47.3 Gy (P<.001), 23.6 Gy versus 44.6 Gy for the anal canal (P<.001), and 33.1 Gy versus 43.2 Gy for the bladder (P<.001). Significantly lower grade ≥2 toxicity was observed for proctitis, stool frequency ≥6/day, and urinary frequency ≥12/day. IG-IMRT resulted in significantly lower overall RTOG grade ≥2 GI toxicity (29% vs 49%, respectively, P=.002) and overall GU grade ≥2 toxicity (38% vs 48%, respectively, P=.009). CONCLUSIONS A clinically meaningful reduction in dose to organs at risk and acute toxicity levels was observed in IG-IMRT patients, as a result of improved technique and tighter margins. Therefore reduced late toxicity levels can be expected as well; additional research is needed to quantify such reductions.
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Affiliation(s)
- Ruud C Wortel
- Department of Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Joos V Lebesque
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marnix G Witte
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Uulke A van der Heide
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marcel van Herk
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wilma D Heemsbergen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
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15
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Argon plasma coagulation therapy versus topical formalin for intractable rectal bleeding and anorectal dysfunction after radiation therapy for prostate carcinoma. Int J Radiat Oncol Biol Phys 2013; 87:954-9. [PMID: 24113059 DOI: 10.1016/j.ijrobp.2013.08.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Revised: 08/23/2013] [Accepted: 08/25/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate and compare the effect of argon plasma coagulation (APC) and topical formalin for intractable rectal bleeding and anorectal dysfunction associated with chronic radiation proctitis. METHODS AND MATERIALS Thirty men (median age, 72 years; range, 49-87 years) with intractable rectal bleeding (defined as ≥1× per week and/or requiring blood transfusions) after radiation therapy for prostate carcinoma were randomized to treatment with APC (n=17) or topical formalin (n=13). Each patient underwent evaluations of (1) anorectal symptoms (validated questionnaires, including modified Late Effects in Normal Tissues-Subjective, Objective, Management, and Analytic and visual analogue scales for rectal bleeding); (2) anorectal motor and sensory function (manometry and graded rectal balloon distension); and (3) anal sphincteric morphology (endoanal ultrasound) before and after the treatment endpoint (defined as reduction in rectal bleeding to 1× per month or better, reduction in visual analogue scales to ≤25 mm, and no longer needing blood transfusions). RESULTS The treatment endpoint was achieved in 94% of the APC group and 100% of the topical formalin group after a median (range) of 2 (1-5) sessions of either treatment. After a follow-up duration of 111 (29-170) months, only 1 patient in each group needed further treatment. Reductions in rectal compliance and volumes of sensory perception occurred after APC, but no effect on anorectal symptoms other than rectal bleeding was observed. There were no differences between APC and topical formalin for anorectal symptoms and function, nor for anal sphincteric morphology. CONCLUSIONS Argon plasma coagulation and topical formalin had comparable efficacy in the durable control of rectal bleeding associated with chronic radiation proctitis but had no beneficial effect on anorectal dysfunction.
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16
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Tree A, Alexander E, Van As N, Dearnaley D, Khoo V. Biological Dose Escalation and Hypofractionation: What is There to be Gained and How Will it Best be Done? Clin Oncol (R Coll Radiol) 2013; 25:483-98. [DOI: 10.1016/j.clon.2013.05.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 05/09/2013] [Indexed: 12/12/2022]
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17
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Valdagni R, Rancati T. Reducing rectal injury during external beam radiotherapy for prostate cancer. Nat Rev Urol 2013; 10:345-57. [PMID: 23670182 DOI: 10.1038/nrurol.2013.96] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Rectal bleeding and faecal incontinence are serious injuries that men with prostate cancer who receive radiotherapy can experience. Although technical advances--including the use of intensity-modulated radiotherapy coupled with image-guided radiotherapy--have enabled the delivery of dose distributions that conform to the shape of the tumour target with steep dose gradients that reduce the dose given to surrounding tissues, radiotherapy-associated toxicity can not be avoided completely. Many large-scale prospective studies have analysed the correlations of patient-related and treatment-related parameters with acute and late toxicity to optimize patient selection and treatment planning. The careful application of dose-volume constraints and the tuning of these constraints to the individual patient's characteristics are now considered the most effective ways of reducing rectal morbidity. Additionally, the use of endorectal balloons (to reduce the margins between the clinical target volume and planning target volume) and the insertion of tissue spacers into the region between the prostate and anterior rectal wall have been investigated as means to further reduce late rectal injury. Finally, some drugs and other compounds are also being considered to help protect healthy tissue. Overall, a number of approaches exist that must be fully explored in large prospective trials to address the important issue of rectal toxicity in prostate cancer radiotherapy.
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Affiliation(s)
- Riccardo Valdagni
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan 20133, Italy
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18
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Krol R, Smeenk RJ, van Lin ENJT, Hopman WPM. Impact of late anorectal dysfunction on quality of life after pelvic radiotherapy. Int J Colorectal Dis 2013; 28:519-26. [PMID: 23080344 DOI: 10.1007/s00384-012-1593-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE Anorectal dysfunction is common after pelvic radiotherapy. This study aims to explore the relationship of subjective and objective anorectal function with quality of life (QoL) and their relative impact in patients irradiated for prostate cancer. METHODS Patients underwent anal manometry, rectal barostat measurement, and completed validated questionnaires, at least 1 year after prostate radiotherapy (range 1-7 years). QoL was measured by the Fecal Incontinence Quality of Life scale (FIQL) and the Expanded Prostate Cancer Index Composite Bowel domain (EPICB)-bother subscale. Severity of symptoms was rated by the EPICB function subscale. RESULTS Anorectal function was evaluated in 85 men. Sixty-three percent suffered from one or more anorectal symptoms. Correlations of individual symptoms ranged from r = 0.23 to r = 0.53 with FIQL domains and from r = 0.36 to r = 0.73 with EPICB bother scores. They were strongest for fecal incontinence and urgency. Correlations of anal sphincter pressures, rectal capacity, and sensory thresholds ranged from r = 0.00 to r = 0.42 with FIQL domains and from r = 0.15 to r = 0.31 with EPICB bother scores. Anal resting pressure correlated most strongly. Standardized regression coefficients for QoL outcomes were largest for incontinence, urgency, and anal resting pressure. Regression models with subjective parameters explained a larger amount (range 26-92 %) of variation in QoL outcome than objective parameters (range 10-22 %). CONCLUSIONS Fecal incontinence and rectal urgency are the symptoms with the largest influence on QoL. Impaired anal resting pressure is the objective function parameter with the largest influence. Therefore, sparing the structures responsible for an adequate fecal continence is important in radiotherapy planning.
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Affiliation(s)
- Robin Krol
- 455 Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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19
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Smeenk RJ, van Lin ENJT. Application of anorectal sparing devices in prostate radiotherapy. Radiother Oncol 2013; 106:155-6. [PMID: 23474285 DOI: 10.1016/j.radonc.2013.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 02/11/2013] [Accepted: 02/11/2013] [Indexed: 11/27/2022]
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20
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Yeoh EK, Holloway RH, Fraser RJ, Botten RJ, Di Matteo AC, Butters J. Pathophysiology and Natural History of Anorectal Sequelae Following Radiation Therapy for Carcinoma of the Prostate. Int J Radiat Oncol Biol Phys 2012; 84:e593-9. [DOI: 10.1016/j.ijrobp.2012.06.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 06/12/2012] [Accepted: 06/19/2012] [Indexed: 10/28/2022]
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21
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Klein D, Briere TM, Kudchadker R, Archambault L, Beaulieu L, Lee A, Beddar S. In-phantom dose verification of prostate IMRT and VMAT deliveries using plastic scintillation detectors. RADIAT MEAS 2012. [PMID: 23180976 DOI: 10.1016/j.radmeas.2012.08.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The goal of this work was to demonstrate the feasibility of using a plastic scintillation detector (PSD) incorporated into a prostate immobilization device to verify doses in vivo delivered during intensity-modulated radiation therapy (IMRT) and volumetric modulated-arc therapy (VMAT) for prostate cancer. The treatment plans for both modalities had been developed for a patient undergoing prostate radiation therapy. First, a study was performed to test the dependence, if any, of PSD accuracy on the number and type of calibration conditions. This study included PSD measurements of each treatment plan being delivered under quality assurance (QA) conditions using a rigid QA phantom. PSD results obtained under these conditions were compared to ionization chamber measurements. After an optimal set of calibration factors had been found, the PSD was combined with a commercial endorectal balloon used for rectal distension and prostate immobilization during external beam radiotherapy. This PSD-enhanced endorectal balloon was placed inside of a deformable anthropomorphic phantom designed to simulate male pelvic anatomy. PSD results obtained under these so-called "simulated treatment conditions" were compared to doses calculated by the treatment planning system (TPS). With the PSD still inserted in the pelvic phantom, each plan was delivered once again after applying a shift of 1 cm anterior to the original isocenter to simulate a treatment setup error.The mean total accumulated dose measured using the PSD differed the TPS-calculated doses by less than 1% for both treatment modalities simulated treatment conditions using the pelvic phantom. When the isocenter was shifted, the PSD results differed from the TPS calculations of mean dose by 1.2% (for IMRT) and 10.1% (for VMAT); in both cases, the doses were within the dose range calculated over the detector volume for these regions of steep dose gradient. Our results suggest that the system could benefit prostate cancer patient treatment by providing accurate in vivo dose reports during treatment and verify in real-time whether treatments are being delivered according to the prescribed plan.
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Affiliation(s)
- David Klein
- Department of Radiation Physics, Unit 94, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030
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22
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Abdel-Wahab M, Mahmoud O, Merrick G, Hsu ICJ, Arterbery VE, Ciezki JP, Frank SJ, Mohler JL, Moran BJ, Rosenthal SA, Rossi CJ, Yamada Y. ACR Appropriateness Criteria® external-beam radiation therapy treatment planning for clinically localized prostate cancer. J Am Coll Radiol 2012; 9:233-8. [PMID: 22469373 DOI: 10.1016/j.jacr.2011.12.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 12/19/2011] [Indexed: 12/20/2022]
Abstract
Image-based radiation treatment planning and localization have contributed to better targeting of the prostate and sparing of normal tissues. Guidelines are needed to address radiation dose delivery, including patient setup and immobilization, target volume definition, treatment planning, treatment delivery methods, and target localization. Guidelines for external-beam radiation treatment planning have been updated and are presented here. The use of appropriate doses, simulation techniques, and verification of field setup are essential for the accurate delivery of radiation therapy. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
- May Abdel-Wahab
- Cleveland Clinic Foundation, Taussig Comprehensive Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA.
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Krol R, Hopman WPM, Smeenk RJ, Van Lin ENJT. Increased rectal wall stiffness after prostate radiotherapy: relation with fecal urgency. Neurogastroenterol Motil 2012; 24:339-e166. [PMID: 22235913 DOI: 10.1111/j.1365-2982.2011.01858.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Late anorectal toxicity is a frequent adverse event of external beam radiotherapy (EBRT) for prostate cancer. The pathophysiology of anorectal toxicity remains unknown, but we speculate that rectal distensibility is impaired due to fibrosis. Our goal was to determine whether EBRT induces changes of rectal distensibility as measured by an electronic barostat and to explore whether anorectal complaints are related to specific changes of anorectal function. METHODS Thirty-two men, irradiated for localized prostate carcinoma, underwent barostat measurements, anorectal manometry, and completed a questionnaire prior to and 1 year after radiotherapy. The primary outcome measure was rectal distensibility in response to stepwise isobaric distensions. In addition, we assessed sensory thresholds, anal pressures, and anorectal complaints. KEY RESULTS External beam radiotherapy reduced maximal rectal capacity (227 ± 14 mL vs 277 ± 15 mL; P < 0.001), area under the pressure-volume curve (3212 ± 352 mL mmHg vs 3969 ± 413 mL mmHg; P < 0.005), and rectal compliance (15.7 ± 1.2 mL mmHg(-1) vs 17.6 ± 0.9 mL mmHg(-1) ; P = 0.12). Sensory pressure thresholds did not significantly change. Sixteen of the 32 patients (50%) had one or more anorectal complaints. Patients with urgency (n = 10) had a more reduced anal squeeze and maximum pressure (decrease 29 ± 11 mmHg vs 1 ± 7 mmHg; P < 0.05 and 31 ± 12 mmHg vs 2 ± 8 mmHg; P < 0.05 respectively) compared with patients without complaints, indicating a deteriorated external anal sphincter function. CONCLUSIONS & INFERENCES Irradiation for prostate cancer leads to reduced rectal distensibility. In patients with urgency symptoms, anal sphincter function was also impaired.
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Affiliation(s)
- R Krol
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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24
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Smeenk RJ, Hoffmann AL, Hopman WPM, van Lin ENJT, Kaanders JHAM. Dose-effect relationships for individual pelvic floor muscles and anorectal complaints after prostate radiotherapy. Int J Radiat Oncol Biol Phys 2011; 83:636-44. [PMID: 22137024 DOI: 10.1016/j.ijrobp.2011.08.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 06/28/2011] [Accepted: 08/08/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE To delineate the individual pelvic floor muscles considered to be involved in anorectal toxicity and to investigate dose-effect relationships for fecal incontinence-related complaints after prostate radiotherapy (RT). METHODS AND MATERIALS In 48 patients treated for localized prostate cancer, the internal anal sphincter (IAS) muscle, the external anal sphincter (EAS) muscle, the puborectalis muscle (PRM), and the levator ani muscles (LAM) in addition to the anal wall (Awall) and rectal wall (Rwall) were retrospectively delineated on planning computed tomography scans. Dose parameters were obtained and compared between patients with and without fecal urgency, incontinence, and frequency. Dose-effect curves were constructed. Finally, the effect of an endorectal balloon, which was applied in 28 patients, was investigated. RESULTS The total volume of the pelvic floor muscles together was about three times that of the Awall. The PRM was exposed to the highest RT dose, whereas the EAS received the lowest dose. Several anal and rectal dose parameters, as well as doses to all separate pelvic floor muscles, were associated with urgency, while incontinence was associated mainly with doses to the EAS and PRM. Based on the dose-effect curves, the following constraints regarding mean doses could be deduced to reduce the risk of urgency: ≤ 30 Gy to the IAS; ≤ 10 Gy to the EAS; ≤ 50 Gy to the PRM; and ≤ 40 Gy to the LAM. No dose-effect relationships for frequency were observed. Patients treated with an endorectal balloon reported significantly less urgency and incontinence, while their treatment plans showed significantly lower doses to the Awall, Rwall, and all pelvic floor muscles. CONCLUSIONS Incontinence-related complaints show specific dose-effect relationships to individual pelvic floor muscles. Dose constraints for each muscle can be identified for RT planning. When only the Awall is delineated, substantial components of the continence apparatus are excluded.
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Affiliation(s)
- Robert Jan Smeenk
- Department of Radiation Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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25
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Smeenk RJ, van Lin ENJT, van Kollenburg P, McColl GM, Kunze-Busch M, Kaanders JHAM. Endorectal balloon reduces anorectal doses in post-prostatectomy intensity-modulated radiotherapy. Radiother Oncol 2011; 101:465-70. [PMID: 21872953 DOI: 10.1016/j.radonc.2011.07.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 07/25/2011] [Accepted: 07/26/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND PURPOSE To investigate the effect of an endorectal balloon (ERB) on anal wall (Awall) and rectal wall (Rwall) doses in high-dose post-prostatectomy intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS For 20 patients, referred for salvage IMRT after prostatectomy for prostate cancer, two planning CT-scans were performed: one with and one without an air-filled ERB. A planning target volume (PTV) was defined, using international guidelines. Furthermore, the Awall and Rwall were delineated. In both the scans, IMRT plans were generated with a prescribed dose of 70 Gy. The mean dose (D(mean)), maximum dose, minimum dose, and volumes exposed to doses ranging from ≥ 20 to ≥ 70 Gy (V(20)-V(70)) to the Awall and Rwall were calculated. Finally, inner Rwall surface areas exposed to doses ranging from ≥ 20 to ≥ 70 Gy (A(20)-A(70)) were calculated. Dose-parameters were compared between plans with and without ERB. RESULTS All Awall parameters, except V(70), were significantly reduced by the ERB with an overall D(mean) reduction of 6 Gy. Absolute reductions in dose-volume parameters varied from 5% to 11%. Significantly reduced Rwall V(30), V(40), and A(40) were observed with ERB, irrespective of the target volume size. CONCLUSION ERB application significantly reduces Awall and to a lesser degree Rwall doses in high-dose post-prostatectomy IMRT.
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Affiliation(s)
- Robert Jan Smeenk
- Department of Radiation Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Smeenk RJ, Hopman WPM, Hoffmann AL, van Lin ENJT, Kaanders JHAM. Differences in radiation dosimetry and anorectal function testing imply that anorectal symptoms may arise from different anatomic substrates. Int J Radiat Oncol Biol Phys 2010; 82:145-52. [PMID: 20950951 DOI: 10.1016/j.ijrobp.2010.08.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 08/19/2010] [Accepted: 08/19/2010] [Indexed: 11/28/2022]
Abstract
PURPOSE To explore the influence of functional changes and dosimetric parameters on specific incontinence-related anorectal complaints after prostate external beam radiotherapy and to estimate dose-effect relations for the anal wall and rectal wall. METHODS AND MATERIALS Sixty patients, irradiated for localized prostate cancer, underwent anorectal manometry and barostat measurements to evaluate anal pressures, rectal capacity, and rectal sensory functions. In addition, 30 untreated men were analyzed as a control group. In 36 irradiated patients, the anal wall and rectal wall were retrospectively delineated on planning computed tomography scans, and dosimetric parameters were retrieved from the treatment plans. Functional and dosimetric parameters were compared between patients with and without complaints, focusing on urgency, incontinence, and frequency. RESULTS After external beam radiotherapy, reduced anal pressures and tolerated rectal volumes were observed, irrespective of complaints. Patients with urgency and/or incontinence showed significantly lower anal resting pressures (mean 38 and 39 vs. 49 and 50 mm Hg) and lower tolerated rectal pressures (mean 28 and 28 vs. 33 and 34 mm Hg), compared to patients without these complaints. In patients with frequency, almost all rectal parameters were reduced. Several dosimetric parameters to the anal wall and rectal wall were predictive for urgency (e.g., anal D(mean)>38 Gy), whereas some anal wall parameters correlated to incontinence and no dose-effect relation for frequency was found. CONCLUSIONS Anorectal function deteriorates after external beam radiotherapy. Different incontinence-related complaints show specific anorectal dysfunctions, suggesting different anatomic and pathophysiologic substrates: urgency and incontinence seem to originate from both anal wall and rectal wall, whereas frequency seems associated with rectal wall dysfunction. Also, dose-effect relations differed between these complaints. This implies that anal wall and rectal wall should be considered separate organs in radiotherapy planning.
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Affiliation(s)
- Robert Jan Smeenk
- Department of Radiation Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Baumann M, Hölscher T, Denham J. Fractionation in prostate cancer – Is it time after all? Radiother Oncol 2010; 96:1-5. [DOI: 10.1016/j.radonc.2010.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 06/02/2010] [Indexed: 01/08/2023]
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Smeenk RJ, Teh BS, Butler EB, van Lin EN, Kaanders JH. Is there a role for endorectal balloons in prostate radiotherapy? A systematic review. Radiother Oncol 2010; 95:277-82. [DOI: 10.1016/j.radonc.2010.04.016] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Revised: 01/21/2010] [Accepted: 04/07/2010] [Indexed: 10/19/2022]
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