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Sagara T, Kato T, Murakami M. Biological impact of dosimetric perturbations of a fiducial marker and the daily number of fields in proton therapy for prostate cancer. Biomed Phys Eng Express 2021; 7:025007. [PMID: 33522497 DOI: 10.1088/2057-1976/abd9d4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this study was to estimate the biological impact of dosimetric perturbations of a fiducial marker and the daily number of fields in proton therapy for prostate cancer. Using a linear-quadratic model, normalized total doses (NTDs) of points where deposited dose was reduced from the prescribed dose by dosimetric perturbation of a fiducial marker were calculated in two hypothetical prostate cancer treatment schedules: a) irradiation of both parallel-opposed lateral fields and b) irradiation of alternate field in each daily treatment. The impact of hypofractionation and sublethal damage repair between irradiation on NTD was also estimated. The NTD of two fields/day schedule becomes lower than that of one field/day schedule. The difference becomes larger as dose reduction from one of two fields becomes more enhanced. The NTD reduction from the total dose in the two fields/day schedule is largest (30% of total dose) where the dose from one beam is completely lost by a fiducial marker. In contrast, the NTD reduction from the total dose in the one field/day schedule is largest (9% of total dose) where the half dose from one beam is decreased by a fiducial marker. In addition, the NTD reduction becomes larger as the fractional dose increases in a hypofractionated regimen, and when the effect of sublethal damage repair was incorporated. These influences become significant in prostate cancer since the radiobiological sensitivity α/β of prostate cancer is lower than other cancer types and normal tissues late complication. Treating with one alternate field in a daily treatment can improve a deteriorating treatment effect by dosimetric distortion of a fiducial marker in prostate cancer treatment. However, the choice of the number of beams in a fraction must also be determined by considering the sparing of normal tissues and patient-specific status.
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Affiliation(s)
- Tatstuhiko Sagara
- Department of Radiation Physics and Technology, Southern Tohoku Proton Therapy Center, Fukushima, Japan
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2
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Schiller K, Geier M, Duma MN, Nieder C, Molls M, Combs SE, Geinitz H. Definitive, intensity modulated tomotherapy with a simultaneous integrated boost for prostate cancer patients - Long term data on toxicity and biochemical control. Rep Pract Oncol Radiother 2019; 24:315-321. [PMID: 31193851 DOI: 10.1016/j.rpor.2019.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/29/2019] [Accepted: 05/11/2019] [Indexed: 10/26/2022] Open
Abstract
Aim To report long-term data regarding biochemical control and late toxicity of simultaneous integrated boost intensity modulated radiotherapy (SIB-IMRT) with tomotherapy in patients with localized prostate cancer. Background Dose escalation improves cancer control after curative intended radiation therapy (RT) to patients with localized prostate cancer, without increasing toxicity, if IMRT is used. Materials and methods In this retrospective analysis, we evaluated long-term toxicity and biochemical control of the first 40 patients with intermediate risk prostate cancer receiving SIB-IMRT. Primary target volume (PTV) 1 including the prostate and proximal third of the seminal vesicles with safety margins was treated with 70 Gy in 35 fractions. PTV 2 containing the prostate with smaller safety margins was treated as SIB to a total dose of 76 Gy with 2.17 Gy per fraction. Toxicity was evaluated using an adapted CTCAE-Score (Version 3). Results Median follow-up of living patients was 66 (20-78) months. No late genitourinary toxicity higher than grade 2 has been reported. Grade 2 genitourinary toxicity rates decreased from 58% at the end of the treatment to 10% at 60 months. Late gastrointestinal (GI) toxicity was also moderate, though the prescribed PTV Dose of 76 Gy was accepted at the anterior rectal wall. 74% of patients reported any GI toxicity during follow up and no toxicity rates higher than grade 2 were observed. Grade 2 side effects were reported by 13% of the patients at 60 months. 5-year freedom from biochemical failure was 95% at our last follow up. Conclusion SIB-IMRT using daily MV-CT guidance showed excellent long-term biochemical control and low toxicity rates.
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Affiliation(s)
- Kilian Schiller
- Klinik und Poliklinik für Strahlentherapie und RadioOnkologie, Technische Universität München, München, Germany
| | - Michael Geier
- Klinik und Poliklinik für Strahlentherapie und RadioOnkologie, Technische Universität München, München, Germany.,Abteilung für Radioonkologie; Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Marciana Nona Duma
- Klinik und Poliklinik für Strahlentherapie und RadioOnkologie, Technische Universität München, München, Germany.,Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum, Friedrich-Schiller-Universität, Jena, Germany
| | - Carsten Nieder
- Department of Oncology and Palliative Care, Nordland Hospital, Nordland Hospital Trust, Bodø, Norway.,Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Michael Molls
- Klinik und Poliklinik für Strahlentherapie und RadioOnkologie, Technische Universität München, München, Germany
| | - Stephanie E Combs
- Klinik und Poliklinik für Strahlentherapie und RadioOnkologie, Technische Universität München, München, Germany.,Institut für Innovative Radiotherapie (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München (HMGU), Oberschleißheim, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Germany
| | - Hans Geinitz
- Klinik und Poliklinik für Strahlentherapie und RadioOnkologie, Technische Universität München, München, Germany.,Abteilung für Radioonkologie; Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
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3
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Quel rapport alpha/bêta pour le cancer prostatique en 2019 ? Cancer Radiother 2019; 23:342-345. [DOI: 10.1016/j.canrad.2019.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/29/2018] [Accepted: 01/06/2019] [Indexed: 12/13/2022]
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Wang S, Zhou L, Xue J, Lan J, Deng L, Yi T, Lu Y. Comparison of biologically effective dose for treatment planning in the fixed-beam intensity-modulated radiotherapy and the volumetric-modulated arc therapy for the typical types of cancer. Radiat Phys Chem Oxf Engl 1993 2019. [DOI: 10.1016/j.radphyschem.2018.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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5
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Adams Q, Hopfensperger KM, Kim Y, Wu X, Xu W, Shukla H, McGee J, Caster JM, Flynn RT. Effectiveness of Rotating Shield Brachytherapy for Prostate Cancer Dose Escalation and Urethral Sparing. Int J Radiat Oncol Biol Phys 2018; 102:1543-1550. [PMID: 30092333 PMCID: PMC6363898 DOI: 10.1016/j.ijrobp.2018.07.2015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/08/2018] [Accepted: 07/26/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE To compare single-fraction 153Gd-based rotating shield brachytherapy (RSBT) for prostate cancer with conventional 192Ir-based high-dose-rate brachytherapy (HDR-BT) in a planning study that radiobiologically accounts for dose rate and relative biological effectiveness. RSBT was used for planning target volume (PTV) dose escalation without increasing urethral dose for monotherapy, or for urethral sparing without decreasing PTV dose as a boost to external beam radiation therapy. METHODS AND MATERIALS Twenty-six patients were studied. PTV doses were expressed as equivalent dose delivered in 2 Gy fractions (EQD2), accounting for relative biological effectiveness (1.00 for 192Ir and 1.15 for 153Gd), dose protraction (114-minute repair half-time), and tumor dose response (α/β of 3.41 Gy). HDR-BT dose was prescribed such that 90% of the PTV received 110% of the prescription dose of 19 Gy for dose escalation and 15 Gy for urethral sparing, corresponding to EQD290% values (minimum EQD2 to the hottest 90% of the PTV) of 93.9 GyEQD2 and 60.7 GyEQD2, respectively. Twenty 90.95 GBq 153Gd RSBT sources and one 370 GBq 192Ir HDR-BT source were modeled. RESULTS For dose escalation with fresh sources, RSBT increased PTV EQD290% by 42.5% ± 8.4% (average ± standard deviation) without increasing urethral D10%, with treatment times of 216.8 ± 28.9 minutes versus 15.1 ± 2.1 minutes. After 1 half-life (240.4 days for 153Gd and 73.8 days for 192Ir), EQD290% increased 20.5% ± 9.1%. For urethral sparing with fresh sources, RSBT decreased urethral D10% by 26.0% ± 3.4% without decreasing PTV EQD290%, with treatment times of 133.6 ± 16.5 minutes versus 12.0 ± 1.7 minutes. After 1 half-life, urethral D10% decreased 20.2% ± 4.8%. CONCLUSIONS RSBT can increase PTV EQD90% or decrease urethral D10% relative to HDR-BT at the cost of increased treatment time. Source aging reduces RSBT benefit, but RSBT remains theoretically superior to HDR-BT by >20% after 1 half-life has elapsed.
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Affiliation(s)
- Quentin Adams
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa.
| | | | - Yusung Kim
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa
| | - Xiaodong Wu
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa; Department of Electrical and Computer Engineering, University of Iowa, Iowa City, Iowa
| | - Weiyu Xu
- Department of Electrical and Computer Engineering, University of Iowa, Iowa City, Iowa
| | | | - James McGee
- OSF Saint Francis Medical Center, Peoria, Illinois
| | - Joseph M Caster
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa
| | - Ryan T Flynn
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa
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6
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Her EJ, Reynolds HM, Mears C, Williams S, Moorehouse C, Millar JL, Ebert MA, Haworth A. Radiobiological parameters in a tumour control probability model for prostate cancer LDR brachytherapy. Phys Med Biol 2018; 63:135011. [PMID: 29799812 DOI: 10.1088/1361-6560/aac814] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
To provide recommendations for the selection of radiobiological parameters for prostate cancer treatment planning. Recommendations were based on validation of the previously published values, parameter estimation and a consideration of their sensitivity within a tumour control probability (TCP) model using clinical outcomes data from low-dose-rate (LDR) brachytherapy. The proposed TCP model incorporated radiosensitivity (α) heterogeneity and a non-uniform distribution of clonogens. The clinical outcomes data included 849 prostate cancer patients treated with LDR brachytherapy at four Australian centres between 1995 and 2012. Phoenix definition of biochemical failure was used. Validation of the published values from four selected literature and parameter estimation was performed with a maximum likelihood estimation method. Each parameter was varied to evaluate the change in calculated TCP to quantify the sensitivity of the model to its radiobiological parameters. Using a previously published parameter set and a total clonogen number of 196 000 provided TCP estimates that best described the patient cohort. Fitting of all parameters with a maximum likelihood estimation was not possible. Variations in prostate TCP ranged from 0.004% to 0.67% per 1% change in each parameter. The largest variation was caused by the log-normal distribution parameters for α (mean, [Formula: see text], and standard deviation, σ α ). Based on the results using the clinical cohort data, we recommend a previously published dataset is used for future application of the TCP model with inclusion of a patient-specific, non-uniform clonogen density distribution which could be derived from multiparametric imaging. The reduction in uncertainties in these parameters will improve the confidence in using biological models for clinical radiotherapy planning.
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Affiliation(s)
- E J Her
- School of Physics and Astrophysics, University of Western Australia, Perth, Australia
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van Leeuwen CM, Oei AL, Crezee J, Bel A, Franken NAP, Stalpers LJA, Kok HP. The alfa and beta of tumours: a review of parameters of the linear-quadratic model, derived from clinical radiotherapy studies. Radiat Oncol 2018. [PMID: 29769103 DOI: 10.1186/s13014a018-1040-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Prediction of radiobiological response is a major challenge in radiotherapy. Of several radiobiological models, the linear-quadratic (LQ) model has been best validated by experimental and clinical data. Clinically, the LQ model is mainly used to estimate equivalent radiotherapy schedules (e.g. calculate the equivalent dose in 2 Gy fractions, EQD2), but increasingly also to predict tumour control probability (TCP) and normal tissue complication probability (NTCP) using logistic models. The selection of accurate LQ parameters α, β and α/β is pivotal for a reliable estimate of radiation response. The aim of this review is to provide an overview of published values for the LQ parameters of human tumours as a guideline for radiation oncologists and radiation researchers to select appropriate radiobiological parameter values for LQ modelling in clinical radiotherapy. METHODS AND MATERIALS We performed a systematic literature search and found sixty-four clinical studies reporting α, β and α/β for tumours. Tumour site, histology, stage, number of patients, type of LQ model, radiation type, TCP model, clinical endpoint and radiobiological parameter estimates were extracted. Next, we stratified by tumour site and by tumour histology. Study heterogeneity was expressed by the I2 statistic, i.e. the percentage of variance in reported values not explained by chance. RESULTS A large heterogeneity in LQ parameters was found within and between studies (I2 > 75%). For the same tumour site, differences in histology partially explain differences in the LQ parameters: epithelial tumours have higher α/β values than adenocarcinomas. For tumour sites with different histologies, such as in oesophageal cancer, the α/β estimates correlate well with histology. However, many other factors contribute to the study heterogeneity of LQ parameters, e.g. tumour stage, type of LQ model, TCP model and clinical endpoint (i.e. survival, tumour control and biochemical control). CONCLUSIONS The value of LQ parameters for tumours as published in clinical radiotherapy studies depends on many clinical and methodological factors. Therefore, for clinical use of the LQ model, LQ parameters for tumour should be selected carefully, based on tumour site, histology and the applied LQ model. To account for uncertainties in LQ parameter estimates, exploring a range of values is recommended.
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Affiliation(s)
- C M van Leeuwen
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - A L Oei
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
- Laboratory for Experimental Oncology and Radiobiology (LEXOR)/Center for Experimental Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - J Crezee
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - A Bel
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - N A P Franken
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
- Laboratory for Experimental Oncology and Radiobiology (LEXOR)/Center for Experimental Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - L J A Stalpers
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - H P Kok
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands.
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8
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van Leeuwen CM, Oei AL, Crezee J, Bel A, Franken NAP, Stalpers LJA, Kok HP. The alfa and beta of tumours: a review of parameters of the linear-quadratic model, derived from clinical radiotherapy studies. Radiat Oncol 2018; 13:96. [PMID: 29769103 PMCID: PMC5956964 DOI: 10.1186/s13014-018-1040-z] [Citation(s) in RCA: 267] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/30/2018] [Indexed: 12/16/2022] Open
Abstract
Background Prediction of radiobiological response is a major challenge in radiotherapy. Of several radiobiological models, the linear-quadratic (LQ) model has been best validated by experimental and clinical data. Clinically, the LQ model is mainly used to estimate equivalent radiotherapy schedules (e.g. calculate the equivalent dose in 2 Gy fractions, EQD2), but increasingly also to predict tumour control probability (TCP) and normal tissue complication probability (NTCP) using logistic models. The selection of accurate LQ parameters α, β and α/β is pivotal for a reliable estimate of radiation response. The aim of this review is to provide an overview of published values for the LQ parameters of human tumours as a guideline for radiation oncologists and radiation researchers to select appropriate radiobiological parameter values for LQ modelling in clinical radiotherapy. Methods and materials We performed a systematic literature search and found sixty-four clinical studies reporting α, β and α/β for tumours. Tumour site, histology, stage, number of patients, type of LQ model, radiation type, TCP model, clinical endpoint and radiobiological parameter estimates were extracted. Next, we stratified by tumour site and by tumour histology. Study heterogeneity was expressed by the I2 statistic, i.e. the percentage of variance in reported values not explained by chance. Results A large heterogeneity in LQ parameters was found within and between studies (I2 > 75%). For the same tumour site, differences in histology partially explain differences in the LQ parameters: epithelial tumours have higher α/β values than adenocarcinomas. For tumour sites with different histologies, such as in oesophageal cancer, the α/β estimates correlate well with histology. However, many other factors contribute to the study heterogeneity of LQ parameters, e.g. tumour stage, type of LQ model, TCP model and clinical endpoint (i.e. survival, tumour control and biochemical control). Conclusions The value of LQ parameters for tumours as published in clinical radiotherapy studies depends on many clinical and methodological factors. Therefore, for clinical use of the LQ model, LQ parameters for tumour should be selected carefully, based on tumour site, histology and the applied LQ model. To account for uncertainties in LQ parameter estimates, exploring a range of values is recommended. Electronic supplementary material The online version of this article (10.1186/s13014-018-1040-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C M van Leeuwen
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - A L Oei
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands.,Laboratory for Experimental Oncology and Radiobiology (LEXOR)/Center for Experimental Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - J Crezee
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - A Bel
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - N A P Franken
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands.,Laboratory for Experimental Oncology and Radiobiology (LEXOR)/Center for Experimental Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - L J A Stalpers
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - H P Kok
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands.
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9
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Cosset JM. [Hypofractionated irradiation of prostate cancer: What is the radiobiological understanding in 2017?]. Cancer Radiother 2017; 21:447-453. [PMID: 28847464 DOI: 10.1016/j.canrad.2017.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 06/16/2017] [Indexed: 01/10/2023]
Abstract
For prostate cancer, hypofractionation has been based since 1999 on radiobiological data, which calculated a very low alpha/beta ratio (1.2 to 1.5Gy). This suggested that a better local control could be obtained, without any toxicity increase. Consequently, two types of hypofractionated schemes were proposed: "moderate" hypofractionation, with fractions of 2.5 to 4Gy, and "extreme" hypofractionation, utilizing stereotactic techniques, with fractions of 7 to 10Gy. For moderate hypofractionation, the linear-quadratic (LQ) model has been used to calculate the equivalent doses of the new protocols. The available trials have often shown a "non-inferiority", but no advantage, while the equivalent doses calculated for the hypofractionated arms were sometimes very superior to the doses of the conventional arms. This finding could suggest either an alpha/beta ratio lower than previously calculated, or a negative impact of other radiobiological parameters, which had not been taken into account. For "extreme" hypofractionation, the use of the LQ model is discussed for high dose fractions. Moreover, a number of radiobiological questions are still pending. The reduced overall irradiation time could be either a positive point (better local control) or a negative one (reduced reoxygenation). The prolonged duration of the fractions could lead to a decrease of efficacy (because allowing for reparation of sublethal lesions). Finally, the impact of the large fractions on the microenvironment and/or immunity remains discussed. The reported series appear to show encouraging short to mid-term results, but the results of randomized trials are still awaited. Today, it seems reasonable to only propose those extreme hypofractionated schemes to well-selected patients, treating small volumes with high-level stereotactic techniques.
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Affiliation(s)
- J-M Cosset
- GIE Charlebourg, groupe Amethyst, 65, avenue Foch, 92250 La Garenne-Colombes, France.
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10
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Rasmusson E, Gunnlaugsson A, Kjellén E, Nilsson P, Einarsdottir M, Wieslander E, Fransson P, Ahlgen G, Blom R. Low-dose rate brachytherapy with I-125 seeds has an excellent 5-year outcome with few side effects in patients with low-risk prostate cancer. Acta Oncol 2016; 55:1016-21. [PMID: 27174603 DOI: 10.1080/0284186x.2016.1175659] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Low-dose rate brachytherapy (LDR-BT) has been used in Sweden for more than a decade for treatment of low-risk prostate cancer. This study presents the outcome for patients treated with LDR-BT at a single institution with focus on the association between dose and biochemical failure-free survival (BFFS). METHODS In total 195 patients were treated with LDR-BT between 2004 and 2008. The patients were followed systematically for side effects for at least one year. PSA levels were followed regularly from three months and for at least five years. Outcome was analyzed in relation to clinical variables at baseline and to radiotherapy data. RESULTS Kaplan-Meier estimated BFFS at five years was 95.7%. Dose to the prostate in terms of D90% was significantly associated with BFFS [HR 0.90 (95%CI 0.83-0.96), p = 0.002]. CONCLUSION Out data confirmed that absorbed dose is a predictive factor for BFFS for low-risk patients without androgen deprivation therapy. With our treatment routines and dosimetry, a D90% in the range of 170-180 Gy gives excellent outcomes with acceptable toxicity for patients with low-risk prostate cancer.
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Affiliation(s)
- Elisabeth Rasmusson
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
| | - Adalsteinn Gunnlaugsson
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
| | - Elisabeth Kjellén
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
| | - Per Nilsson
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
| | - Margret Einarsdottir
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
| | - Elinore Wieslander
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
| | - Per Fransson
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Göran Ahlgen
- Department of Surgery and Urology, Skåne University Hospital, Malmö, Sweden
| | - René Blom
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
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11
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Boonstra PS, Taylor JMG, Smolska-Ciszewska B, Behrendt K, Dworzecki T, Gawkowska-Suwinska M, Bialas B, Suwinski R. Alpha/beta (α/β) ratio for prostate cancer derived from external beam radiotherapy and brachytherapy boost. Br J Radiol 2016; 89:20150957. [PMID: 26903392 DOI: 10.1259/bjr.20150957] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE There is disagreement regarding the value of the α/β ratio for prostate cancer. Androgen deprivation therapy (ADT) may dominate the effects of dose fractionation on prostate-specific antigen (PSA) response and confound estimates of the α/β ratio. We estimate this ratio from combined data on external beam radiation therapy (EBRT) and brachytherapy (BT)-treated patients, providing a range of doses per fraction, while accounting for the effects of ADT. METHODS We analyse data on 289 patients with local prostate cancer treated with EBRT (2 Gy per fraction) or EBRT plus one or two BT boosts of 10 Gy each. The timing of ADT was heterogeneous. We develop statistical models to estimate the α/β ratio based upon PSA measurements at 1 year as a surrogate for the surviving fraction of cancer cells as well as combined biochemical + clinical recurrence-free survival (bcRFS), controlling for ADT. RESULTS For the PSA-based end point, the α/β ratio estimate is 7.7 Gy [95% confidence interval (CI): 4.1 to 12.5]. Based on the bcRFS end point, the estimate is 18.0 Gy (95% CI: 8.2 to ∞). CONCLUSION Our model-based estimates of the α/β ratio, which account for the effects of ADT and other important confounders, are higher than some previous estimates. ADVANCES IN KNOWLEDGE Although dose inhomogeneities and other limitations may limit the scope of our findings, the data suggest caution regarding the assumptions of the α/β ratio for prostate cancer in some clinical environments.
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Affiliation(s)
- Philip S Boonstra
- 1 Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Jeremy M G Taylor
- 1 Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Beata Smolska-Ciszewska
- 2 Radiotherapy Clinic and Teaching Hospital, M. Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
| | - Katarzyna Behrendt
- 2 Radiotherapy Clinic and Teaching Hospital, M. Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
| | - Tomasz Dworzecki
- 2 Radiotherapy Clinic and Teaching Hospital, M. Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
| | - Marzena Gawkowska-Suwinska
- 2 Radiotherapy Clinic and Teaching Hospital, M. Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
| | - Brygida Bialas
- 3 Department of Brachytherapy, M. Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
| | - Rafal Suwinski
- 2 Radiotherapy Clinic and Teaching Hospital, M. Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
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12
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Smolska-Ciszewska B, Miszczyk L, Białas B, Fijałkowski M, Plewicki G, Gawkowska-Suwińska M, Giglok M, Behrendt K, Nowicka E, Zajusz A, Suwiński R. The effectiveness and side effects of conformal external beam radiotherapy combined with high-dose-rate brachytherapy boost compared to conformal external beam radiotherapy alone in patients with prostate cancer. Radiat Oncol 2015; 10:60. [PMID: 25884489 PMCID: PMC4356106 DOI: 10.1186/s13014-015-0366-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 02/20/2015] [Indexed: 01/19/2023] Open
Abstract
Background Clinical data that compare external-beam radiotherapy (EBRT) combined with high-dose-rate brachytherapy (HDR-BT) boost versus EBRT alone are scarce. The analysis of published studies suggest that biochemical relapse-free survival in combined EBRT and HDR-BT may be superior compared to EBRT alone. We retrospectively examined the effectiveness and tolerance of both schemes in a single center study. Methods Between March 2003 and December 2004, 229 patients were treated for localized T1-T2N0M0 prostate cancer. Median age was 66 years (range, 49 – 83 years). PSA level ranged from 0.34 to 64 ng/ml (median 12.3 ng/ml) and Gleason score ranged from 2 to 10. The analysis included 99 patients who underwent EBRT with HDR-BT (group A) and 130 patients who were treated with EBRT alone (group B). Results Median follow-up was 6 years. Biochemical relapses occurred in 34% vs. 22% (p = 0.002), local recurrences in 17% vs. 5% (p = 0.002), and distant metastases in 11% vs. 6% (p = 0.179) of patients in groups A and B, respectively. Five-year biochemical relapse-free survival was 67% vs. 81% (p = 0.005), local recurrence-free survival 95% vs. 99% (p = 0.002), metastases-free survival 95% vs. 94% (p = 0.302) for groups A and B, respectively. Five-year overall survival was 85% in both groups (p = 0.596). Grade 2/3 late GI complications appeared in 9.2% and 24.8% (p = 0.003), respectively. Grade 2/3 late GU symptoms occurred in 12% in both groups. Conclusions Although because of the retrospective character of the study and nonrandomized selection of fractionation schedule the present conclusions had limitations EBRT alone appeared more effective than EBRT combined with HDR-BT. It was likely the result of the less frequent use of androgen deprivation therapy (ADT) for combined scheme group, too low dose in a single BT fraction or inadequate assumptions regarding fractionation sensitivity of prostate cancer.
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Affiliation(s)
- Beata Smolska-Ciszewska
- Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Ul. Wybrzeże Armii Krajowej 15, Gliwice, 44-100, Poland.
| | - Leszek Miszczyk
- Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Ul. Wybrzeże Armii Krajowej 15, Gliwice, 44-100, Poland.
| | - Brygida Białas
- Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Ul. Wybrzeże Armii Krajowej 15, Gliwice, 44-100, Poland.
| | - Marek Fijałkowski
- Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Ul. Wybrzeże Armii Krajowej 15, Gliwice, 44-100, Poland.
| | - Grzegorz Plewicki
- Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Ul. Wybrzeże Armii Krajowej 15, Gliwice, 44-100, Poland.
| | - Marzena Gawkowska-Suwińska
- Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Ul. Wybrzeże Armii Krajowej 15, Gliwice, 44-100, Poland.
| | - Monika Giglok
- Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Ul. Wybrzeże Armii Krajowej 15, Gliwice, 44-100, Poland.
| | - Katarzyna Behrendt
- Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Ul. Wybrzeże Armii Krajowej 15, Gliwice, 44-100, Poland.
| | - Elżbieta Nowicka
- Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Ul. Wybrzeże Armii Krajowej 15, Gliwice, 44-100, Poland.
| | - Aleksander Zajusz
- Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Ul. Wybrzeże Armii Krajowej 15, Gliwice, 44-100, Poland.
| | - Rafał Suwiński
- Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Ul. Wybrzeże Armii Krajowej 15, Gliwice, 44-100, Poland.
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Tree AC, Khoo VS, van As NJ, Partridge M. Is biochemical relapse-free survival after profoundly hypofractionated radiotherapy consistent with current radiobiological models? Clin Oncol (R Coll Radiol) 2014; 26:216-29. [PMID: 24529742 DOI: 10.1016/j.clon.2014.01.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 12/19/2013] [Accepted: 01/02/2014] [Indexed: 11/25/2022]
Abstract
AIMS The α/β ratio for prostate cancer is thought to be low and less than for the rectum, which is usually the dose-limiting organ. Hypofractionated radiotherapy should therefore improve the therapeutic ratio, increasing cure rates with less toxicity. A number of models for predicting biochemical relapse-free survival have been developed from large series of patients treated with conventional and moderately hypofractionated radiotherapy. The purpose of this study was to test these models when significant numbers of patients treated with profoundly hypofractionated radiotherapy were included. MATERIALS AND METHODS A systematic review of the literature with regard to hypofractionated radiotherapy for prostate cancer was conducted, focussing on data recently presented on prostate stereotactic body radiotherapy. For the work described here, we have taken published biochemical control rates for a range of moderately and profoundly fractionated schedules and plotted these together with a range of radiobiological models, which are described. RESULTS The data reviewed show consistency between the various radiobiological model predictions and the currently observed data. CONCLUSION Current radiobiological models provide accurate predictions of biochemical relapse-free survival, even when profoundly hypofractionated patients are included in the analysis.
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Affiliation(s)
- A C Tree
- Royal Marsden NHS Foundation Trust, London, UK.
| | - V S Khoo
- Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer Research, London, UK
| | - N J van As
- Royal Marsden NHS Foundation Trust, London, UK
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Cosset JM, Mornex F, Eschwège F. Hypofractionnement en radiothérapie : l’éternel retour. Cancer Radiother 2013; 17:355-62. [DOI: 10.1016/j.canrad.2013.06.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 06/05/2013] [Indexed: 10/26/2022]
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15
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Hennequin C, Dubray B. [Alpha/beta ratio revisited in the era of hypofractionation]. Cancer Radiother 2013; 17:344-8. [PMID: 23972468 DOI: 10.1016/j.canrad.2013.06.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Revised: 06/10/2013] [Accepted: 06/14/2013] [Indexed: 11/26/2022]
Abstract
Large doses per fraction are not recommended in daily radiotherapy due to a higher risk of late normal tissue injury. The technical refinements of modern radiotherapy and suggestions that some tumors could be sensitive to dose per fraction have renewed the interest in hypofractionated schedules. The estimation of α/β ratio value requires large samples of carefully evaluated patients in whom total and fractional doses have varied independently. Tumor repopulation has to be considered when the treatment duration is altered. Without setting aside conflicting publication, the α/β ratio values for prostate and breast (after lumpectomy) cancers could be as low as 2.5 Gy and 4 Gy, respectively. While it is too early to change our routine protocols, the time has come to conduct clinical trials comparing different fractionation schedules.
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Affiliation(s)
- C Hennequin
- Service de cancérologie-radiothérapie, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefeaux, 75475 Paris, France; Université Paris Diderot Paris VII, 75475 Paris, France.
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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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Riou O, Regnault de la Mothe P, Azria D, Aillères N, Dubois JB, Fenoglietto P. Simultaneous integrated boost plan comparison of volumetric-modulated arc therapy and sliding window intensity-modulated radiotherapy for whole pelvis irradiation of locally advanced prostate cancer. J Appl Clin Med Phys 2013; 14:4094. [PMID: 23835376 PMCID: PMC5714536 DOI: 10.1120/jacmp.v14i4.4094] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Revised: 02/27/2013] [Accepted: 02/26/2013] [Indexed: 12/25/2022] Open
Abstract
Concurrent radiotherapy to the pelvis plus a prostate boost with long-term androgen deprivation is a standard of care for locally advanced prostate cancer. IMRT has the ability to deliver highly conformal dose to the target while lowering irradiation of critical organs around the prostate. Volumetric-modulated arc therapy is able to reduce treatment time, but its impact on organ sparing is still controversial when compared to static gantry IMRT. We compared the two techniques in simultaneous integrated boost plans. Ten patients with locally advanced prostate cancer were included. The planning target volume (PTV) 1 was defined as the pelvic lymph nodes, the prostate, and the seminal vesicles plus setup margins. The PTV2 consisted of the prostate with setup margins. The prescribed doses to PTV1 and PTV2 were 54 Gy in 37 fractions and 74 Gy in 37 fractions, respectively. We compared simultaneous integrated boost plans by means of either a seven coplanar static split fields IMRT, or a one-arc (RA1) and a two-arc (RA2) RapidArc planning. All three techniques allowed acceptable homogeneity and PTV coverage. Static IMRT enabled a better homogeneity for PTV2 than RapidArc techniques. Sliding window IMRT and VMAT permitted to maintain doses to OAR within acceptable levels with a low risk of side effects for each organ. VMAT plans resulted in a clinically and statistically significant reduction in doses to bladder (mean dose IMRT: 50.1 ± 4.6Gy vs. mean dose RA2: 47.1 ± 3.9 Gy, p = 0.037), rectum (mean dose IMRT: 44± 4.5 vs. mean dose RA2: 41.6 ± 5.5 Gy, p = 0.006), and small bowel (V30 IMRT: 76.47 ± 14.91% vs. V30 RA2: 47.49 ± 16.91%, p = 0.002). Doses to femoral heads were higher with VMAT but within accepted constraints. Our findings suggest that simultaneous integrated boost plans using VMAT and sliding window IMRT allow good OAR sparing while maintaining PTV coverage within acceptable levels.
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Affiliation(s)
- Olivier Riou
- Radiation Oncology Department, Montpellier Cancer Institute, Montpellier, France.
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Nickers P, Blanchard P, Hannoun-Lévi JM, Bossi A, Chapet O, Guérif S. Curiethérapie prostatique de haut débit de dose. Cancer Radiother 2013; 17:118-24. [DOI: 10.1016/j.canrad.2013.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 02/27/2013] [Indexed: 10/27/2022]
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Oliveira SM, Teixeira NJ, Fernandes L. What do we know about the α/β for prostate cancer? Med Phys 2012; 39:3189-201. [DOI: 10.1118/1.4712224] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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20
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Geier M, Astner ST, Duma MN, Jacob V, Nieder C, Putzhammer J, Winkler C, Molls M, Geinitz H. Dose-escalated simultaneous integrated-boost treatment of prostate cancer patients via helical tomotherapy. Strahlenther Onkol 2012; 188:410-6. [PMID: 22367410 DOI: 10.1007/s00066-012-0081-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 01/20/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE The goal of this work was to assess the feasibility of moderately hypofractionated simultaneous integrated-boost intensity-modulated radiotherapy (SIB-IMRT) with helical tomotherapy in patients with localized prostate cancer regarding acute side effects and dose-volume histogram data (DVH data). METHODS Acute side effects and DVH data were evaluated of the first 40 intermediate risk prostate cancer patients treated with a definitive daily image-guided SIB-IMRT protocol via helical tomotherapy in our department. The planning target volume including the prostate and the base of the seminal vesicles with safety margins was treated with 70 Gy in 35 fractions. The boost volume containing the prostate and 3 mm safety margins (5 mm craniocaudal) was treated as SIB to a total dose of 76 Gy (2.17 Gy per fraction). Planning constraints for the anterior rectal wall were set in order not to exceed the dose of 76 Gy prescribed to the boost volume. Acute toxicity was evaluated prospectively using a modified CTCAE (Common Terminology Criteria for Adverse Events) score. RESULTS SIB-IMRT allowed good rectal sparing, although the full boost dose was permitted to the anterior rectal wall. Median rectum dose was 38 Gy in all patients and the median volumes receiving at least 65 Gy (V65), 70 Gy (V70), and 75 Gy (V75) were 13.5%, 9%, and 3%, respectively. No grade 4 toxicity was observed. Acute grade 3 toxicity was observed in 20% of patients involving nocturia only. Grade 2 acute intestinal and urological side effects occurred in 25% and 57.5%, respectively. No correlation was found between acute toxicity and the DVH data. CONCLUSION This institutional SIB-IMRT protocol using daily image guidance as a precondition for smaller safety margins allows dose escalation to the prostate without increasing acute toxicity.
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Affiliation(s)
- M Geier
- Klinik und Poliklinik für Strahlentherapie und Radiologische Onkologie, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
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Trotz geringer dosislimitierender Toxizität ist Vorsicht bei der extrem hypofraktionierten Dosiseskalation mithilfe Körperstereotaxie (SBRT) bei frühen Prostatakarzinomen mit niedrigem oder intermediärem Risikoprofil geboten. Strahlenther Onkol 2012; 188:192-3. [DOI: 10.1007/s00066-011-0033-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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22
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Valdagni R, Nahum AE, Magnani T, Italia C, Lanceni A, Montanaro P, Rancati T, Avuzzi B, Fiorino C. Long-term biochemical control of prostate cancer after standard or hyper-fractionation: Evidence for different outcomes between low–intermediate and high risk patients. Radiother Oncol 2011; 101:454-9. [DOI: 10.1016/j.radonc.2011.07.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Revised: 07/14/2011] [Accepted: 07/24/2011] [Indexed: 11/27/2022]
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23
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Faria S, Pra AD, Cury F, David M, Duclos M, Freeman CR, Souhami L. Treating intermediate-risk prostate cancer with hypofractionated external beam radiotherapy alone. Radiother Oncol 2011; 101:486-9. [DOI: 10.1016/j.radonc.2011.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 06/21/2011] [Accepted: 07/07/2011] [Indexed: 11/29/2022]
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Haie-Meder C, Siebert FA, Pötter R. Image guided, adaptive, accelerated, high dose brachytherapy as model for advanced small volume radiotherapy. Radiother Oncol 2011; 100:333-43. [PMID: 21963284 DOI: 10.1016/j.radonc.2011.09.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 09/15/2011] [Indexed: 11/16/2022]
Abstract
Brachytherapy has consistently provided a very conformal radiation therapy modality. Over the last two decades this has been associated with significant improvements in imaging for brachytherapy applications (prostate, gynecology), resulting in many positive advances in treatment planning, application techniques and clinical outcome. This is emphasized by the increased use of brachytherapy in Europe with gynecology as continuous basis and prostate and breast as more recently growing fields. Image guidance enables exact knowledge of the applicator together with improved visualization of tumor and target volumes as well as of organs at risk providing the basis for very individualized 3D and 4D treatment planning. In this commentary the most important recent developments in prostate, gynecological and breast brachytherapy are reviewed, with a focus on European recent and current research aiming at the definition of areas for important future research. Moreover the positive impact of GEC-ESTRO recommendations and the highlights of brachytherapy physics are discussed what altogether presents a full overview of modern image guided brachytherapy. An overview is finally provided on past and current international brachytherapy publications focusing on "Radiotherapy and Oncology". These data show tremendous increase in almost all research areas over the last three decades strongly influenced recently by translational research in regard to imaging and technology. In order to provide high level clinical evidence for future brachytherapy practice the strong need for comprehensive prospective clinical research addressing brachytherapy issues is high-lighted.
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