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Ramot Y, Levin-Harrus T, Ezratty A, Steiner M, Ezov N, Domb AJ, Abdel-Haq M, Shohat S, Aperman L, Adler L, Dolkart O, Nyska A. Assessment of Bioprotect's Biodegradable Balloon System as a Rectal Spacer in Radiotherapy: An Animal Study on Tissue Response and Biocompatibility. Pharmaceutics 2023; 15:2744. [PMID: 38140085 PMCID: PMC10747072 DOI: 10.3390/pharmaceutics15122744] [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: 10/13/2023] [Revised: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023] Open
Abstract
Prostate cancer is a significant health concern for men, emphasizing the need for effective treatment strategies. Dose-escalated external beam radiotherapy shows promise in improving outcomes but presents challenges due to radiation effects on nearby structures, such as the rectum. Innovative techniques, including rectal spacers, have emerged to mitigate these effects. This study comprehensively assessed tissue responses following the implantation of the Bioprotect biodegradable fillable balloon as a rectal spacer in a rat model. Evaluation occurred at multiple time points (4, 26, and 52 weeks) post-implantation. Results revealed localized tissue responses consistent with the expected reaction to biodegradable materials, characterized by mild to moderate fibrotic reactions and encapsulation, underscoring the safety and biocompatibility of the balloon. Importantly, no other adverse events occurred, and the animals remained healthy throughout the study. These findings support its potential clinical utility in radiotherapy treatments to enhance patient outcomes and minimize long-term implant-related complications, serving as a benchmark for future similar studies and offering valuable insights for researchers in the field. In conclusion, the findings from this study highlight the safety, biocompatibility, and potential clinical applicability of the Bioprotect biodegradable fillable balloon as a promising rectal spacer in mitigating radiation-induced complications during prostate cancer radiotherapy.
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Affiliation(s)
- Yuval Ramot
- Department of Dermatology, Hadassah Medical Center, Jerusalem 9112001, Israel;
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel
| | - Tal Levin-Harrus
- Envigo CRS Israel Limited, Ness Ziona 7414001, Israel; (T.L.-H.); (A.E.); (M.S.); (N.E.)
| | - Adva Ezratty
- Envigo CRS Israel Limited, Ness Ziona 7414001, Israel; (T.L.-H.); (A.E.); (M.S.); (N.E.)
| | - Michal Steiner
- Envigo CRS Israel Limited, Ness Ziona 7414001, Israel; (T.L.-H.); (A.E.); (M.S.); (N.E.)
| | - Nati Ezov
- Envigo CRS Israel Limited, Ness Ziona 7414001, Israel; (T.L.-H.); (A.E.); (M.S.); (N.E.)
| | - Abraham J. Domb
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (A.J.D.); (M.A.-H.)
| | - Muhammad Abdel-Haq
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (A.J.D.); (M.A.-H.)
| | - Shaul Shohat
- BioProtect, Tzur Yigal 4486200, Israel; (S.S.); (L.A.); (L.A.)
| | - Liron Aperman
- BioProtect, Tzur Yigal 4486200, Israel; (S.S.); (L.A.); (L.A.)
| | - Lee Adler
- BioProtect, Tzur Yigal 4486200, Israel; (S.S.); (L.A.); (L.A.)
| | - Oleg Dolkart
- Assuta Ashdod University Hospital, Ben-Gurion University of the Negev, Beer Sheba 8410501, Israel;
| | - Abraham Nyska
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6200515, Israel
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2
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Kos M, Nurani R, Costa P, Dabkowski M, da Silva JVF, Zimberg S, Keane J. Multicenter, dual fractionation scheme, single core lab comparison of rectal volume dose reduction following injection of two biodegradable perirectal spacers. J Appl Clin Med Phys 2023; 24:e14086. [PMID: 37376868 PMCID: PMC10562021 DOI: 10.1002/acm2.14086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023] Open
Abstract
PURPOSE A multicenter, double-arm, central core lab, retrospective study was performed to compare the rectal dosimetry of patients implanted with two injectable, biodegradable perirectal spacers, in conventional fractionation (CF), as well as ultrahypofractionation (UH) treatment plans. METHODS AND MATERIALS Fifty-nine patients were enrolled into the study in five centers: two centers in Europe, which implanted a biodegradable balloon spacer in a total of 24 subjects and three centers in the US, which implanted the SpaceOAR in 35 subjects. Anonymized CTs (pre and post-implantation) were reviewed by the central core lab. For VMAT CF plans rectal V50, V60, V70, and V80 were calculated. For UH plans, a corresponding rectal V22.6, V27.1, V31.37, and V36.25 were established representing 62.5%, 75%, 87.5%, and 100% of the 36.25 Gy prescribed dose. RESULTS For CF VMAT, a comparison between the balloon spacer and the SpaceOAR revealed a significant difference of 33.4% decrease in mean rectal V50 (71.9% vs. 38.5%, p < 0.001), 27.7% in mean rectal V60 (79.6% vs. 51.9%, p < 0.001), 17.1% difference in mean rectal V70 (84.1% vs. 67.0%, p = 0.001), and a significant difference of 3.0% (p = 0.019) in mean rectal V80 (87.2% vs. 84.2%). With UH analysis, the mean rectal dose reduction for the balloon spacer compared to the SpaceOAR was 79.2% and 53.3% for V27.1 (p < 0.001), 84.1% and 68.1% for V31.71 (p = 0.001), and 89.7% and 84.8% for V36.25 (p = 0.012), respectively. CONCLUSION Rectal dosimetry is more favorable for treatment with the balloon spacer compared with SpaceOAR. Further research, particularly in the context of a prospective randomized clinical trial design, is needed to assess the acute and late toxicity experience as well as physician satisfaction with achieving symmetrical implantation, and ease of use in light of increasing clinical use.
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Affiliation(s)
- Michael Kos
- Northern NV Radiation OncologySpokaneWashingtonUSA
| | | | - Paulo Costa
- CUF Porto InstitutoRua Fonte das Sete BicasPortoPortugal
| | | | | | - Shawn Zimberg
- Advanced Radiation Centers of New YorkLake SuccessNew YorkUSA
| | - John Keane
- Advanced Radiation Centers of New YorkLake SuccessNew YorkUSA
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3
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Yu H, Wang C, Wu L, Zhou Z, Wang Y, Li W, Yuan H, Lu Z, Yan D, Chen S, Wang X, Yan S. A novel hydrogel orthotopic injection model in moderately hypofractionated radiation therapy for prostate cancer: Adaptive degradation and durable imaging. Front Oncol 2023; 12:1077900. [PMID: 36713508 PMCID: PMC9880553 DOI: 10.3389/fonc.2022.1077900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 12/29/2022] [Indexed: 01/15/2023] Open
Abstract
Purpose Moderately hypofractionated radiotherapy (MHRT) holds an important position in prostate cancer management. Existing hydrogel spacers can protect the rectum from radiation damage, but need improvement. We explored the application of a novel hydrogel in MHRT with adaptive degradation and durable imaging functions. Methods and materials The hydrogels were irradiated with 6MV x-ray to detect the radio-resistance property. Male SD rats (n=45) underwent hydrogel injection between the prostate and rectum. CT was used for investigating the novel spacer's degradation and imaging functions over three months. The hydrogel's radiation-attenuation properties and biocompatibility were further assessed. Results Hydrogel weight and volume remained stable for six weeks post-injection. After MHRT ended, the hydrogel showed accelerated degradation characteristics and remained in the body for at most three months. CT values of hydrogels exceeded 300 Hounsfield units (HU) throughout treatment, significantly higher than in surrounding normal tissues. A significant dose drop behind the hydrogel was observed post-implantation. Biocompatibility tests of hydrogel found it safe enough for living organisms. Conclusions The novel hydrogel application was fully adaptable to prostate cancer MHRT modalities, largely stable during treatment, rapidly degraded after radiotherapy ended, and consistently maintained superior imaging performance and biocompatibility. This novel spacer will be an effective tool in the era of hypofractionated radiotherapy.
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Affiliation(s)
- Hao Yu
- Department of Radiation Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Cheng Wang
- College of Materials Science & Engineering, Zhejiang University of Technology, Hangzhou, Zhejiang, China
| | - Lingyun Wu
- Department of Radiation Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Ziyang Zhou
- Department of Radiation Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yiqi Wang
- Department of Radiation Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Wenxiang Li
- Department of Radiation Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Huili Yuan
- College of Materials Science & Engineering, Zhejiang University of Technology, Hangzhou, Zhejiang, China
| | - Zeyi Lu
- Department of Urology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Danfang Yan
- Department of Radiation Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Si Chen
- College of Materials Science & Engineering, Zhejiang University of Technology, Hangzhou, Zhejiang, China,*Correspondence: Senxiang Yan, ; Xu Wang, ; Si Chen,
| | - Xu Wang
- College of Materials Science & Engineering, Zhejiang University of Technology, Hangzhou, Zhejiang, China,*Correspondence: Senxiang Yan, ; Xu Wang, ; Si Chen,
| | - Senxiang Yan
- Department of Radiation Oncology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China,*Correspondence: Senxiang Yan, ; Xu Wang, ; Si Chen,
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Björeland U, Notstam K, Fransson P, Söderkvist K, Beckman L, Jonsson J, Nyholm T, Widmark A, Thellenberg Karlsson C. Hyaluronic acid spacer in prostate cancer radiotherapy: dosimetric effects, spacer stability and long-term toxicity and PRO in a phase II study. Radiat Oncol 2023; 18:1. [PMID: 36593460 PMCID: PMC9809044 DOI: 10.1186/s13014-022-02197-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/30/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Perirectal spacers may be beneficial to reduce rectal side effects from radiotherapy (RT). Here, we present the impact of a hyaluronic acid (HA) perirectal spacer on rectal dose as well as spacer stability, long-term gastrointestinal (GI) and genitourinary (GU) toxicity and patient-reported outcome (PRO). METHODS In this phase II study 81 patients with low- and intermediate-risk prostate cancer received transrectal injections with HA before external beam RT (78 Gy in 39 fractions). The HA spacer was evaluated with MRI four times; before (MR0) and after HA-injection (MR1), at the middle (MR2) and at the end (MR3) of RT. GI and GU toxicity was assessed by physician for up to five years according to the RTOG scale. PROs were collected using the Swedish National Prostate Cancer Registry and Prostate cancer symptom scale questionnaires. RESULTS There was a significant reduction in rectal V70% (54.6 Gy) and V90% (70.2 Gy) between MR0 and MR1, as well as between MR0 to MR2 and MR3. From MR1 to MR2/MR3, HA thickness decreased with 28%/32% and CTV-rectum space with 19%/17% in the middle level. The cumulative late grade ≥ 2 GI toxicity at 5 years was 5% and the proportion of PRO moderate or severe overall bowel problems at 5 years follow-up was 12%. Cumulative late grade ≥ 2 GU toxicity at 5 years was 12% and moderate or severe overall urinary problems at 5 years were 10%. CONCLUSION We show that the HA spacer reduced rectal dose and long-term toxicity.
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Affiliation(s)
- Ulrika Björeland
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Radiation Physics, Umeå University, 901 87 Umeå, Sweden
| | - Kristina Notstam
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
| | - Per Fransson
- grid.12650.300000 0001 1034 3451Department of Nursing, Umeå University, 901 87 Umeå, Sweden
| | - Karin Söderkvist
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
| | - Lars Beckman
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
| | - Joakim Jonsson
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Radiation Physics, Umeå University, 901 87 Umeå, Sweden
| | - Tufve Nyholm
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Radiation Physics, Umeå University, 901 87 Umeå, Sweden
| | - Anders Widmark
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
| | - Camilla Thellenberg Karlsson
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Oncology, Umeå University, 901 87 Umeå, Sweden
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5
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See AW, Bowden P, Wells G, Appu S, Lawrentschuk N, Liodakis P, Pandeli C, Aarons Y, Smyth LML, McKenzie DP. Dose-escalated radiotherapy to 82 Gy for prostate cancer following insertion of a peri-rectal hydrogel spacer: 3-year outcomes from a phase II trial. Radiat Oncol 2022; 17:131. [PMID: 35879722 PMCID: PMC9316359 DOI: 10.1186/s13014-022-02103-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/11/2022] [Indexed: 12/03/2022] Open
Abstract
Background Dose-escalation to above 80 Gy during external beam radiotherapy for localised prostate cancer leads to improved oncological outcomes but also substantially increased rectal toxicity. The aim of this study was to demonstrate the safety and efficacy of escalating the dose to 82 Gy following insertion of a peri-rectal hydrogel spacer (HS) prior to radiotherapy. Methods This was a single arm, open-label, prospective study of men with localised prostate cancer who were prescribed a course of intensity modulated radiotherapy escalated to 82 Gy in 2 Gy fractions following insertion of the SpaceOAR™ HS (Boston Scientific, Marlborough, MA). Patients were prescribed a standard course of 78 Gy in 2 Gy fractions where rectal dose constraints could not be met for the 82 Gy plan. The co-primary endpoints were the rate of grade 3 gastrointestinal (GI) and genitourinary (GU) adverse events (CTCAE, v4), and patient-reported quality of life (QoL) (EORTC QLQ-C30 and PR25 modules), up to 37.5 months post-treatment. Results Seventy patients received treatment on the study, with 64 (91.4%) receiving an 82 Gy treatment course. The median follow-up time post-treatment was 37.4 months. The rate of radiotherapy-related grade 3 GI and GU adverse events was 0% and 2.9%, respectively. There were 2 (2.9%) grade 3 adverse events related to insertion of the HS. Only small and transient declines in QoL were observed; there was no clinically or statistically significant decline in QoL beyond 13.5 months and up to 37.5 months post-treatment, compared to baseline. No late RTOG-defined grade ≥ 2 GI toxicity was observed, with no GI toxicity observed in any patient at 37.5 months post-treatment. Nine (12.9%) patients met criteria for biochemical failure within the follow-up period. Conclusions Dose-escalation to 82 Gy, facilitated by use of a hydrogel spacer, is safe and feasible, with minimal toxicity up to 37.5 months post-treatment when compared to rates of rectal toxicity in previous dose-escalation trials up to 80 Gy. Trials with longer follow-up of oncological and functional outcomes are required to robustly demonstrate a sustained widening of the therapeutic window. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12621000056897, 22/01/2021. Retrospectively registered.
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Affiliation(s)
| | | | - Geoffrey Wells
- Urology Department, Eastern Health, Box Hill Hospital, Box Hill, Australia
| | - Sree Appu
- Department of Surgery, Monash University, Melbourne, Australia.,Cabrini Health, Malvern, Australia.,Department of Urology, Austin Health, Heidelberg, Australia
| | - Nathan Lawrentschuk
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Urology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Surgery, University of Melbourne, Melbourne, Australia.,EJ Whitten Centre for Prostate Cancer Research, Epworth Healthcare, Melbourne, Australia
| | - Peter Liodakis
- Department of Urology, Austin Health, Heidelberg, Australia.,North Eastern Urology, Heidelberg, Australia
| | | | | | - Lloyd M L Smyth
- Icon Institute of Innovation and Research, South Brisbane, Australia
| | - Dean P McKenzie
- Research Development and Governance Unit, Epworth HealthCare, Richmond, Australia.,Department of Health Sciences and Biostatistics, Swinburne University of Technology, Hawthorn, Australia
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Repka MC, Creswell M, Lischalk JW, Carrasquilla M, Forsthoefel M, Lee J, Lei S, Aghdam N, Kataria S, Obayomi-Davies O, Collins BT, Suy S, Hankins RA, Collins SP. Rationale for Utilization of Hydrogel Rectal Spacers in Dose Escalated SBRT for the Treatment of Unfavorable Risk Prostate Cancer. Front Oncol 2022; 12:860848. [PMID: 35433457 PMCID: PMC9008358 DOI: 10.3389/fonc.2022.860848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
In this review we outline the current evidence for the use of hydrogel rectal spacers in the treatment paradigm for prostate cancer with external beam radiation therapy. We review their development, summarize clinical evidence, risk of adverse events, best practices for placement, treatment planning considerations and finally we outline a framework and rationale for the utilization of rectal spacers when treating unfavorable risk prostate cancer with dose escalated Stereotactic Body Radiation Therapy (SBRT).
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Affiliation(s)
- Michael C Repka
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Michael Creswell
- Georgetown University School of Medicine, Washington, DC, United States
| | - Jonathan W Lischalk
- Department of Radiation Oncology at New York University (NYU) Long Island School of Medicine, Perlmutter Cancer Center at NYCyberKnife, New York, NY, United States
| | - Michael Carrasquilla
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Matthew Forsthoefel
- Department of Radiation Oncology, Radiotherapy Centers of Kentuckiana, Louisville, KY, United States
| | - Jacqueline Lee
- Georgetown University School of Medicine, Washington, DC, United States
| | - Siyuan Lei
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Nima Aghdam
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Shaan Kataria
- Department of Radiation Oncology, Arlington & Reston Radiation Oncology, Arlington, VA, United States
| | - Olusola Obayomi-Davies
- Department of Radiation Oncology, Wellstar Kennestone Hospital, Marietta, GA, United States
| | - Brian T Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Ryan A Hankins
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
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7
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Barros S, Roseira J, Caldeira P, Vaz AM, Guerreiro H, Codon O. Rectal Perforation by a Balloon Spacer: A Rare Cause of Rectal Perforation Addressed Endoscopically. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2021; 28:416-419. [PMID: 34901449 DOI: 10.1159/000511647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/14/2020] [Indexed: 12/12/2022]
Abstract
Prostate cancer is the second most frequent cancer in men worldwide. Dose escalation is currently the standard of care for the treatment of prostate cancer with radiation therapy. However, the rectum tends to be the dose-limiting structure when treating prostate cancer, given its proximity. The injection of biodegradable spacers between the prostate and the rectum may optimize radiotherapy treatment delivery for patients with localized disease. Nevertheless, although the overall complication rate of spacers is marginal, the benefits of spacer technologies need to be evaluated against the complication risks such as rectum perforation/necrosis. We report a case of a 59-year-old man with a diagnosis of prostate adenocarcinoma for whom hormonal treatment followed by intensity modulated radiation therapy (IMRT) was proposed. A biodegradable and expandable balloon (BioProtect®) was injected into the perirectal space without detectable immediate complications. One month later, the patient presented with a 3-day persistent rectal bleeding. The investigation confirmed a rectal perforation by the balloon spacer system.
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Affiliation(s)
- Sónia Barros
- Gastroenterology Department, Algarve University Medical Center, Faro, Portugal
| | - Joana Roseira
- Gastroenterology Department, Algarve University Medical Center, Faro, Portugal
| | - Paulo Caldeira
- Gastroenterology Department, Algarve University Medical Center, Faro, Portugal
| | - Ana Margarida Vaz
- Gastroenterology Department, Algarve University Medical Center, Faro, Portugal
| | - Horácio Guerreiro
- Gastroenterology Department, Algarve University Medical Center, Faro, Portugal
| | - Oscar Codon
- Radiation Oncology Department, Algarve Radio-Oncology Clinic, Faro, Portugal
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8
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Latorzeff I, Bruguière E, Bogart E, Le Deley MC, Lartigau E, Marre D, Pasquier D. Use of a Biodegradable, Contrast-Filled Rectal Spacer Balloon in Intensity-Modulated Radiotherapy for Intermediate-Risk Prostate Cancer Patients: Dosimetric Gains in the BioPro-RCMI-1505 Study. Front Oncol 2021; 11:701998. [PMID: 34513681 PMCID: PMC8427159 DOI: 10.3389/fonc.2021.701998] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/21/2021] [Indexed: 01/12/2023] Open
Abstract
Background/purpose Dose-escalated external beam radiotherapy (RT) is effective in the control of prostate cancer but is associated with a greater incidence of rectal adverse events. We assessed the dosimetric gain and safety profile associated with implantation of a new biodegradable rectal spacer balloon. Materials/methods Patients scheduled for image-guided, intensity-modulated RT for intermediate-risk prostate cancer were prospectively included in the French multicenter BioPro-RCMI-1505 study (NCT02478112). We evaluated the dosimetric gain, implantation feasibility, adverse events (AEs), and prostate-cancer-specific quality of life associated with use of the balloon spacer. Results After a scheduled review of the initial recruitment target of 50 patients by the study's independent data monitoring committee (IDMC), a total of 24 patients (including 22 with dosimetry data) were included by a single center between November 2016 and May 2018. The interventional radiologist who implanted the balloons considered that 86% of the procedures were easy. 20 of the 24 patients (83.3%) received IMRT and 4 (16.7%) received volumetric modulated arc therapy (78-80 Gy delivered in 39 fractions). The dosimetric gains associated with spacer implantation were highly significant (p<0.001) for most variables. For the rectum, the median (range) relative gain ranged from 15.4% (-9.2-47.5) for D20cc to 91.4% (36.8-100.0) for V70 Gy (%). 15 patients (62%) experienced an acute grade 1 AE, 8 (33%) experienced a late grade 1 AE, 1 (4.2%) experienced an acute grade 2 AE, and 3 experienced a late grade 2 AE. No grade 3 AEs were reported. Quality of life was good at baseline (except for sexual activity) and did not markedly worsen during RT and up to 24 months afterwards. Conclusion The use of a biodegradable rectal spacer balloon is safe, effective and associated with dosimetric gains in modern RT for intermediate-risk prostate cancer.
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Affiliation(s)
- Igor Latorzeff
- Department of Radiotherapy, Clinique Pasteur, Toulouse, France
| | - Eric Bruguière
- Department of Imaging, Clinique Pasteur, Toulouse, France
| | - Emilie Bogart
- Methodology and Biostatistics Unit, Centre Oscar Lambret, Lille, France
| | | | - Eric Lartigau
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France.,CRIStAL UMR CNRS 9189, Lille University, Lille, France
| | - Delphine Marre
- Department of Physics, Clinique Pasteur, Toulouse, France
| | - David Pasquier
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France.,CRIStAL UMR CNRS 9189, Lille University, Lille, France
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9
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Wang X, Zhang B, He Q, Kong Y, Dai Z, Meng H, Huang F, Zhang S, Zhu Y, Tan X, Zhen X. Rectum Protection by Rectal Gel Injection in Cervical Cancer Brachytherapy: A Dosimetric Study via Deformable Surface Dose Accumulation and Machine-Learning-Based Discriminative Modeling. Front Oncol 2021; 11:657208. [PMID: 33937068 PMCID: PMC8085420 DOI: 10.3389/fonc.2021.657208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose This retrospective study aimed to evaluate the dosimetric effects of a rectal insertion of Kushen Ningjiao on rectal protection using deformable dose accumulation and machine learning–based discriminative modelling. Materials and Methods Sixty-two patients with cervical cancer enrolled in a clinical trial, who received a Kushen Ningjiao injection of 20 g into their rectum for rectal protection via high–dose rate brachytherapy (HDR-BT, 6 Gy/f), were studied. The cumulative equivalent 2-Gy fractional rectal surface dose was deformably summed using an in-house-developed topography-preserved point-matching deformable image registration method. The cumulative three-dimensional (3D) dose was flattened and mapped to a two-dimensional (2D) plane to obtain the rectal surface dose map (RSDM). For analysis, the rectal dose (RD) was further subdivided as follows: whole, anterior, and posterior 3D-RD and 2D-RSDM. The dose–volume parameters (DVPs) were extracted from the 3D-RD, while the dose geometric parameters (DGPs) and textures were extracted from the 2D-RSDM. These features were fed into 192 classification models (built with 8 classifiers and 24 feature selection methods) for discriminating the dose distributions between pre-Kushen Ningjiao and pro-Kushen Ningjiao. Results The rectal insertion of Kushen Ningjiao dialated the rectum in the ambilateral direction, with the rectal column increased from pre-KN 15 cm3 to post-KN 18 cm3 (P < 0.001). The characteristics of DGPs accounted for the largest portions of the top-ranked features. The top-ranked dosimetric features extracted from the posterior rectum were more reliable indicators of the dosimetric effects/changes introduced by the rectal insertion of Kushen Ningjiao. A significant dosimetric impact was found on the dose–volume parameters D1.0cc–D2.5cc extracted on the posterior rectal wall. Conclusions The rectal insertion of Kushen Ningjiao incurs significant dosimetric changes on the posterior rectal wall. Whether this effect is eventually translated into clinical gains requires further long-term follow-up and more clinical data for confirmation.
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Affiliation(s)
- Xuetao Wang
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Bailin Zhang
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qiang He
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yilin Kong
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhenhui Dai
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Haoyu Meng
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fangjun Huang
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
| | - Shengfeng Zhang
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuanhu Zhu
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiang Tan
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xin Zhen
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
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10
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Wang C, Wu L, Li W, Fei J, Xu J, Chen S, Yan S, Wang X. An injectable double-crosslinking iodinated composite hydrogel as a potential radioprotective spacer with durable imaging function. J Mater Chem B 2021; 9:3346-3356. [PMID: 33881426 DOI: 10.1039/d0tb02953j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Prostate cancer is one of the leading causes of cancer incidence among males worldwide. Radiotherapy can achieve similar oncological outcomes to those of radical prostatectomy. One concern is, however, radiation damage to the rectum because of the extreme proximity between the two organs. Inserting a biomaterial to separate the prostate and rectum is a promising strategy, and an injectable hydrogel is regarded to be the preferred spacer after screening of various materials. Nevertheless, there exist shortcomings for the currently available injectable hydrogel that cannot fully meet the unique requirements in clinical practice. In this work, a novel injectable hydrogel spacer based on carboxymethyl chitosan (CMC), aldehyde guar gum (AG), and aldehyde iohexol (DHQ) with an imaging function is fabricated. Contrast agent DHQ is chemically attached to CMC-AG network to form a double-crosslinking network to obtain a controlled degradation rate and high strength as well as durable CT imaging function. The hydrogel is injected subcutaneously into rats, where rapid gelation occurs and it serves as a hydrogel spacer. During the month-long in vivo studies, the spacer exhibits remarkable radiation dose attenuation and sustainable imaging function, as well as excellent toxicity profiles. This novel hydrogel shows excellent potential in the protection of critical organs during prostate cancer radiotherapy.
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Affiliation(s)
- Cheng Wang
- College of Materials Science & Engineering, Zhejiang University of Technology, China.
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11
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Turner BE, Schüler E, Chang SD, Harsh GR, Soltys SG. Intracranial Autograft Fat Placement to Separate the Optic Chiasm from Tumor to Improve Stereotactic Radiotherapy Dosimetry. World Neurosurg 2020; 146:80-84. [PMID: 33130141 DOI: 10.1016/j.wneu.2020.10.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Radiation therapy for intracranial lesions is constrained by dose to neurologic organs at risk. CASE DESCRIPTION We report 2 cases, a newly diagnosed chondrosarcoma and a previously irradiated meningioma, with tumors that abutted the optic chiasm following subtotal resection. Definitive radiotherapy would have required either undercoverage of the tumor or treatment of the chiasm with doses posing an unacceptable risk of blindness. Therefore, the patients underwent open surgery with placement of an abdominal fat autograft to provide space between the tumor and the optic structures at risk. Patients received definitive fractionated stereotactic radiotherapy. For each patient, we retrospectively compared the treated plan (with fat autograft) to a second plan generated using the pre-autograft imaging, maintaining similar tumor coverage. For the chondrosarcoma, the fat autograft reduced the optic chiasm maximum dose by 21% (70.4 Gy to 55.3 Gy). For the reirradiated peri-optic meningioma, the optic chiasm maximum dose was reduced by 10% (50.8 Gy to 45.9 Gy), the left optic nerve by 17% (48.9 Gy to 40.4 Gy), and the right optic nerve by 30% (32.3 Gy to 22.6 Gy). CONCLUSIONS We demonstrate the utility of abdominal fat autograft placement to maximize coverage of tumor while minimizing dose to intracranial organs at risk.
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Affiliation(s)
- Brandon E Turner
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California, USA
| | - Emil Schüler
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford School of Medicine, Stanford, California, USA
| | - Griffith R Harsh
- Department of Neurosurgery, University of California, Davis, Davis, California, USA
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California, USA.
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12
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Lehrich BM, Barnes L, Mesa A, Singh K, Tokita KM. Response to "Is there a role for hydrogel spacer in post-prostatectomy radiotherapy setting?". Radiol Med 2019; 124:1304-1305. [PMID: 31428959 DOI: 10.1007/s11547-019-01071-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 08/06/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Brandon M Lehrich
- Department of Radiation Oncology, Cancer Center of Irvine, 16100 Sand Canyon Ste #130, Irvine, CA, 92618, USA.
| | - Lucy Barnes
- Department of Radiation Oncology, Cancer Center of Irvine, 16100 Sand Canyon Ste #130, Irvine, CA, 92618, USA
| | - Albert Mesa
- Department of Radiation Oncology, Cancer Center of Irvine, 16100 Sand Canyon Ste #130, Irvine, CA, 92618, USA
| | - Karan Singh
- Department of Radiation Oncology, Cancer Center of Irvine, 16100 Sand Canyon Ste #130, Irvine, CA, 92618, USA
| | - Kenneth M Tokita
- Department of Radiation Oncology, Cancer Center of Irvine, 16100 Sand Canyon Ste #130, Irvine, CA, 92618, USA.
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13
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Autologous fat as a rectal–prostate spacer for prostate brachytherapy: Results at 6 months. Brachytherapy 2019; 18:462-469. [DOI: 10.1016/j.brachy.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 12/13/2022]
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14
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Schörghofer A, Drerup M, Kunit T, Lusuardi L, Holzinger J, Karner J, Groher M, Zoubek C, Forstner R, Sedlmayer F, Wolf F. Rectum-spacer related acute toxicity - endoscopy results of 403 prostate cancer patients after implantation of gel or balloon spacers. Radiat Oncol 2019; 14:47. [PMID: 30876433 PMCID: PMC6419822 DOI: 10.1186/s13014-019-1248-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 03/04/2019] [Indexed: 12/15/2022] Open
Abstract
Background Rectal spacers are used to limit dose to the anterior rectal wall in high dose external beam radiation therapy of the prostate and have been shown to reduce radiation induced toxicity. Here we report the complication rate and toxicity of the implantation procedure in a large cohort of patients who have either received a gel- or balloon-type spacer. Methods In total, 403 patients received rectal spacing, 264 with balloon, 139 with gel. Allocation was non-randomized. Two hundred seventy-six patients were treated with normofractionated regimen, the remaining 125 patients in moderate hypofractionation. Spacer related acute and late rectal toxicity was prospectively assessed by endoscopy using a mucosa scoring system (Vienna Rectoscopy Score) as well as CTCAE V.4. For the balloon subgroup, position and rotation of balloon spacers were additionally correlated to incidence and grade of rectal reactions in a post-hoc analysis of post-implant planning MRIs. Results Overall rectal toxicity was very low with average VRS scores of 0.06 at the day after implantation, 0.10 at the end of RT, 0.31 at 6 months and 0.42 at 12 months follow up. Acute Grade 3 toxicity (rectum perforation and urethral damage) directly related to the implantation procedure occurred in 1.49% (n = 6) and was seen exclusively in patients who had received the spacer balloon. Analysis of post implant MR imaging did not identify abnormal or mal-rotated positions of this spacer to be a predictive factors for the occurrence of spacer related G3 toxicities. Conclusions Spacer technology is an effective means to minimize dose to the anterior rectal wall. However, the benefits in terms of dose sparing need to be weighed against the low, but possible risks of complications such as rectum perforation.
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Affiliation(s)
- Andreas Schörghofer
- Dapartment of Radiotherapy and Radio-Oncology, LKH Salzburg University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Martin Drerup
- Department of Urology, LKH Salzburg University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Thomas Kunit
- Department of Urology, LKH Salzburg University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Lukas Lusuardi
- Department of Urology, LKH Salzburg University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Josef Holzinger
- Department of Surgery, LKH Salzburg University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Josef Karner
- Dapartment of Radiotherapy and Radio-Oncology, LKH Salzburg University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Michael Groher
- Dapartment of Radiotherapy and Radio-Oncology, LKH Salzburg University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Christoph Zoubek
- Department of Radiology, LKH Salzburg University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Rosemarie Forstner
- Department of Radiology, LKH Salzburg University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Felix Sedlmayer
- Dapartment of Radiotherapy and Radio-Oncology, LKH Salzburg University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Frank Wolf
- Dapartment of Radiotherapy and Radio-Oncology, LKH Salzburg University Clinics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria.
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Vanneste BG, Buettner F, Pinkawa M, Lambin P, Hoffmann AL. Ano-rectal wall dose-surface maps localize the dosimetric benefit of hydrogel rectum spacers in prostate cancer radiotherapy. Clin Transl Radiat Oncol 2019; 14:17-24. [PMID: 30456317 PMCID: PMC6234617 DOI: 10.1016/j.ctro.2018.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/31/2018] [Accepted: 10/31/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND PURPOSE To evaluate spatial differences in dose distributions of the ano-rectal wall (ARW) using dose-surface maps (DSMs) between prostate cancer patients receiving intensity-modulated radiation therapy with and without implantable rectum spacer (IMRT+IRS; IMRT-IRS, respectively), and to correlate this with late gastro-intestinal (GI) toxicities using validated spatial and non-spatial normal-tissue complication probability (NTCP) models. MATERIALS AND METHODS For 26 patients DSMs of the ARW were generated. From the DSMs various shape-based dose measures were calculated at different dose levels: lateral extent, longitudinal extent, and eccentricity. The contiguity of the ARW dose distribution was assessed by the contiguous-DSH (cDSH). Predicted complication rates between IMRT+IRS and IMRT-IRS plans were assessed using a spatial NTCP model and compared against a non-spatial NTCP model. RESULTS Dose surface maps are generated for prostate radiotherapy using an IRS. Lateral extent, longitudinal extent and cDSH were significantly lower in IMRT+IRS than for IMRT-IRS at high-dose levels. Largest significant differences were observed for cDSH at dose levels >50 Gy, followed by lateral extent at doses >57 Gy, and longitudinal extent in anterior and superior-inferior directions. Significant decreases (p = 0.01) in median rectal and anal NTCPs (respectively, Gr 2 late rectal bleeding and subjective sphincter control) were predicted when using an IRS. CONCLUSIONS Local-dose effects are predicted to be significantly reduced by an IRS. The spatial NTCP model predicts a significant decrease in Gr 2 late rectal bleeding and subjective sphincter control. Dose constraints can be improved for current clinical treatment planning.
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Affiliation(s)
| | | | - Michael Pinkawa
- Department of Radiation Oncology, MediClin Robert Janker Klinik, Bonn, Germany
| | - Philippe Lambin
- The D-Lab, GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Aswin L. Hoffmann
- MAASTRO Clinic, Maastricht, The Netherlands
- Institute of Radiooncology, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Radiotherapy, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
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Tang Q, Zhao F, Yu X, Wu L, Lu Z, Yan S. The role of radioprotective spacers in clinical practice: a review. Quant Imaging Med Surg 2018; 8:514-524. [PMID: 30050786 DOI: 10.21037/qims.2018.06.06] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The delivery of high dose radiotherapy to tumors is often limited by the proximity of the surrounding radiosensitive normal tissues, even using modern techniques such as intensity modulated radiation therapy (IMRT). Previous studies have reported that placement of a spacer can effectively displace normal tissues. So that they are some distance away from the lesion, thus allowing for the safe delivery of high-dose radiation. The application of radioprotective spacers was first reported 30 years ago regarding radiotherapy of tongue and abdominal cancers; more recently, they are increasingly being used in prostate cancer. This review focuses on the published data concerning the features of different types of spacers and their application in various tumor sites. Placement-related complications and the cost-effectiveness of the spacers are also discussed. With the increasing use of high-precision radiotherapy in clinical practice, especially the paradigm-changing stereotactic body radiotherapy (SBRT), more robust studies are warranted to further establish the role of radioprotective spacers through materials development and novel placement techniques.
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Affiliation(s)
- Qiuying Tang
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Feng Zhao
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Xiaokai Yu
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Lingyun Wu
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Zhongjie Lu
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Senxiang Yan
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
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17
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BioPro-RCMI-1505 trial: multicenter study evaluating the use of a biodegradable balloon for the treatment of intermediate risk prostate cancer by intensity modulated radiotherapy; study protocol. BMC Cancer 2018; 18:566. [PMID: 29769060 PMCID: PMC5956854 DOI: 10.1186/s12885-018-4492-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 05/08/2018] [Indexed: 02/03/2023] Open
Abstract
Background Prospective trials have demonstrated the advantage of dose-escalated radiotherapy for the biochemical and clinical control of intermediate risk prostate cancer. Dose escalation improves outcomes but increases risks of urinary and bowel toxicity. Recently the contribution of “spacers” positioned in the septum between the rectum and the prostate could improve the functional results of intensity modulated radiation therapy (IMRT). To date most of the evaluated devices were polyethylen glycol (PEG) and hyaluronic acid (HA). Men on the Spacer arm had decreased bowel toxicity and less decline in both urinary and bowel quality of life as compared to Control men in a randomized trial. Methods This is an interventional, multi-center study to evaluate the use of biodegradable inflatable balloon for patients with intermediate risk prostate cancer treated by IMRT (74 to 80 Gy, 2 Gy/fraction) with daily image guided radiotherapy. Discussion This multicenter prospective study will yield new data regarding dosimetric gain and implantation stages of Bioprotect balloon. Acute and late toxicities and quality of life will be registered too. Trial registration NCT02478112, date of registration: 15/06/2015.
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18
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Vanneste BGL, van De Beek K, Lutgens L, Lambin P. Implantation of a biodegradable rectum balloon implant: tips, Tricks and Pitfalls. Int Braz J Urol 2018; 43:1033-1042. [PMID: 28338306 PMCID: PMC5734065 DOI: 10.1590/s1677-5538.ibju.2016.0494] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/20/2016] [Indexed: 12/18/2022] Open
Abstract
Introduction: A rectum balloon implant (RBI) is a new device to spare rectal structures during prostate cancer radiotherapy. The theoretical advantages of a RBI are to reduce the high radiation dose to the anterior rectum wall, the possibility of a post-implant correction, and their predetermined shape with consequent predictable position. Objective: To describe, step-by-step, our mini-invasive technique for hands-free transperineal implantation of a RBI before start of radiotherapy treatment. Materials and Methods: We provide step-by-step instructions for optimization of the transperineal implantation procedure performed by urologists and/or radiation oncologists experienced with prostate brachytherapy and the use of the real-time bi-plane transrectal ultrasonography (TRUS) probe. A RBI was performed in 15 patients with localised prostate cancer. Perioperative side-effects were reported. Results: We provide ‘tips and tricks’ for optimizing the procedure and proper positioning of the RBI. Please watch the animation, see video in https://vimeo.com/205852376/789df4fae4. The side-effects included mild discomfort to slight pain at the perineal region in 8 out of 15 patients. Seven patients (47%) had no complaints at all. Two patients developed redness of the skin, where prompt antibiotic regimen was started with no further sequelae. One patient revealed a temporary urine retention, which resolved in a few hours following conservative treatment. Further no perioperative complications occurred. Conclusion: This paper describes in detail the implantation procedure for an RBI. It is a feasible, safe and very well-tolerated procedure.
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Affiliation(s)
- Ben G L Vanneste
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Kees van De Beek
- Department of Urology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Ludy Lutgens
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, Netherlands
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19
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Padmanabhan R, Pinkawa M, Song DY. Hydrogel spacers in prostate radiotherapy: a promising approach to decrease rectal toxicity. Future Oncol 2017; 13:2697-2708. [DOI: 10.2217/fon-2017-0073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
High-dose radiation is a well-established method of treatment for prostate cancer. The main limiting structure for dose escalation is the rectum. The risk of rectal toxicity is related to dose received by the rectum. Several strategies for reducing dose to rectum have been explored; these include endorectal balloons as well as injection of rectal spacers like hydrogels. They create greater distance between rectal wall and prostate to confer a dosimetric advantage to the rectum. Early clinical studies with hydrogels have shown favorable outcomes. A low incidence of major procedural adverse effects with hydrogel use has been reported and it is well tolerated by patients. Hydrogel holds promise in establishing itself as an adjunct to standard of care in prostate radiation.
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Affiliation(s)
- Ranjani Padmanabhan
- Department of Radiation Oncology, INOVA Health System Fairfax, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Pauwelsstrasse 30, 52057 Aachen, Germany
| | - Daniel Y Song
- Johns Hopkins Medicine, Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University, 401 N Broadway, Baltimore, MD 21231, USA
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Vanneste BGL, van Wijk Y, Lutgens LC, Van Limbergen EJ, van Lin EN, van de Beek K, Lambin P, Hoffmann AL. Dynamics of rectal balloon implant shrinkage in prostate VMAT : Influence on anorectal dose and late rectal complication risk. Strahlenther Onkol 2017; 194:31-40. [PMID: 29038832 PMCID: PMC5752748 DOI: 10.1007/s00066-017-1222-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 09/19/2017] [Indexed: 01/20/2023]
Abstract
PURPOSE To assess the effect of a shrinking rectal balloon implant (RBI) on the anorectal dose and complication risk during the course of moderately hypofractionated prostate radiotherapy. METHODS In 15 patients with localized prostate cancer, an RBI was implanted. A weekly kilovolt cone-beam computed tomography (CBCT) scan was acquired to measure the dynamics of RBI volume and prostate-rectum separation. The absolute anorectal volume encompassed by the 2 Gy equieffective 75 Gy isodose (V75Gy) was recalculated as well as the mean anorectal dose. The increase in estimated risk of grade 2-3 late rectal bleeding (LRB) between the start and end of treatment was predicted using nomograms. The observed acute and late toxicities were evaluated. RESULTS A significant shrinkage of RBI volumes was observed, with an average volume of 70.4% of baseline at the end of the treatment. Although the prostate-rectum separation significantly decreased over time, it remained at least 1 cm. No significant increase in V75Gy of the anorectum was observed, except in one patient whose RBI had completely deflated in the third week of treatment. No correlation between mean anorectal dose and balloon deflation was found. The increase in predicted LRB risk was not significant, except in the one patient whose RBI completely deflated. The observed toxicities confirmed these findings. CONCLUSIONS Despite significant decrease in RBI volume the high-dose rectal volume and the predicted LRB risk were unaffected due to a persistent spacing between the prostate and the anterior rectal wall.
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Affiliation(s)
- Ben G L Vanneste
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands.
| | - Y van Wijk
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - L C Lutgens
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - E J Van Limbergen
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - E N van Lin
- Radiotherapy Bonn-Rhein-Sieg, Troisdorf, Germany
| | - K van de Beek
- Department of Urology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - P Lambin
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - A L Hoffmann
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
- Institute of Radiooncology - OncoRay, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Radiotherapy, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
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Serrano NA, Kalman NS, Anscher MS. Reducing rectal injury in men receiving prostate cancer radiation therapy: current perspectives. Cancer Manag Res 2017; 9:339-350. [PMID: 28814898 PMCID: PMC5546182 DOI: 10.2147/cmar.s118781] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Dose escalation is now the standard of care for the treatment of prostate cancer with radiation therapy. However, the rectum tends to be the dose-limiting structure when treating prostate cancer, given its close proximity. Early and late toxicities can occur when the rectum receives large doses of radiation therapy. New technologies allow for prevention of these toxicities. In this review, we examine the evidence that supports various dose constraints employed to prevent these rectal injuries from occurring. We also examine the use of intensity-modulated radiation therapy and how this compares to older radiation therapy techniques that allow for further sparing of the rectum during a radiation therapy course. We then review the literature on endorectal balloons and the effects of their daily use throughout a radiation therapy course. Tissue spacers are now being investigated in greater detail; these devices are injected into the rectoprostatic fascia to physically increase the distance between the prostate and the anterior rectal wall. Last, we review the use of systemic drugs, specifically statin medications and antihypertensives, as well as their impact on rectal toxicity.
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Affiliation(s)
- Nicholas A Serrano
- Department of Radiation Oncology, Virginia Commonwealth University - Massey Cancer Center, Richmond, VA
| | - Noah S Kalman
- Department of Radiation Oncology, Virginia Commonwealth University - Massey Cancer Center, Richmond, VA
| | - Mitchell S Anscher
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Boissier R, Udrescu C, Rebillard X, Terrier JE, Faix A, Chapet O, Azria D, Devonec M, Paparel P, Ruffion A. Technique of Injection of Hyaluronic Acid as a Prostatic Spacer and Fiducials Before Hypofractionated External Beam Radiotherapy for Prostate Cancer. Urology 2017; 99:265-269. [DOI: 10.1016/j.urology.2016.09.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 09/21/2016] [Accepted: 09/30/2016] [Indexed: 12/25/2022]
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23
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Prostate Cancer Radiation Therapy: What Do Clinicians Have to Know? BIOMED RESEARCH INTERNATIONAL 2016; 2016:6829875. [PMID: 28116302 PMCID: PMC5225325 DOI: 10.1155/2016/6829875] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/18/2016] [Accepted: 10/31/2016] [Indexed: 12/11/2022]
Abstract
Radiotherapy (RT) for prostate cancer (PC) has steadily evolved over the last decades, with improving biochemical disease-free survival. Recently population based research also revealed an association between overall survival and doses ≥ 75.6 Gray (Gy) in men with intermediate- and high-risk PC. Examples of improved RT techniques are image-guided RT, intensity-modulated RT, volumetric modulated arc therapy, and stereotactic ablative body RT, which could facilitate further dose escalation. Brachytherapy is an internal form of RT that also developed substantially. New devices such as rectum spacers and balloons have been developed to spare rectal structures. Newer techniques like protons and carbon ions have the intrinsic characteristics maximising the dose on the tumour while minimising the effect on the surrounding healthy tissue, but clinical data are needed for confirmation in randomised phase III trials. Furthermore, it provides an overview of an important discussion issue in PC treatment between urologists and radiation oncologists: the comparison between radical prostatectomy and RT. Current literature reveals that all possible treatment modalities have the same cure rate, but a different toxicity pattern. We recommend proposing the possible different treatment modalities with their own advantages and side-effects to the individual patient. Clinicians and patients should make treatment decisions together (shared decision-making) while using patient decision aids.
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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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Who will benefit most from hydrogel rectum spacer implantation in prostate cancer radiotherapy? A model-based approach for patient selection. Radiother Oncol 2016; 121:118-123. [DOI: 10.1016/j.radonc.2016.08.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 08/05/2016] [Accepted: 08/29/2016] [Indexed: 12/11/2022]
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Basu A, Haim-Zada M, Domb AJ. Biodegradable inflatable balloons for tissue separation. Biomaterials 2016; 105:109-116. [DOI: 10.1016/j.biomaterials.2016.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/03/2016] [Accepted: 08/03/2016] [Indexed: 11/27/2022]
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Pinkawa M, Berneking V, König L, Frank D, Bretgeld M, Eble MJ. Hydrogel injection reduces rectal toxicity after radiotherapy for localized prostate cancer. Strahlenther Onkol 2016; 193:22-28. [DOI: 10.1007/s00066-016-1040-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 08/12/2016] [Indexed: 12/11/2022]
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Trifiletti DM, Garda AE, Showalter TN. Implanted spacer approaches for pelvic radiation therapy. Expert Rev Med Devices 2016; 13:633-40. [DOI: 10.1080/17434440.2016.1195682] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Daniel M. Trifiletti
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Allison E. Garda
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Timothy N. Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
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Decision analysis model evaluating the cost of a temporary hydrogel rectal spacer before prostate radiation therapy to reduce the incidence of rectal complications. Urol Oncol 2016; 34:291.e19-26. [PMID: 27038698 DOI: 10.1016/j.urolonc.2016.02.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 02/24/2016] [Accepted: 02/28/2016] [Indexed: 12/15/2022]
Abstract
PURPOSE We conducted a decision analysis to evaluate the cost effectiveness of a newly Food and Drug Administration approved rectal spacer gel (SpaceOAR, Augmenix) for the reduction of rectal toxicity of prostate radiation therapy (RT). METHODS A decision tree model (TreeAge Pro) was used to compare the strategy of pretherapy placement of a spacing hydrogel before RT to RT alone. The model compared costs associated with rectal complications because of rectal toxicity over a 10-year period across 3 different RT modalities. Rectal toxicity rates were estimated from studies on conformal RT dose escalation, high-dose stereotactic body radiotherapy (SBRT) and low-dose SBRT. Rectal toxicity reduction rates (baseline reduction 70%) were estimated from recently published 15 month data using a rectal spacer. Direct and indirect cost estimates for established grades of rectal toxicity were based on national and institutional costs. Reduction in short-term complications were assumed to carry forward to a reduction in long-term toxicity. One-way and two-way sensitivity analyses were performed. RESULTS The overall standard management cost for conformal RT was $3,428 vs. $3,946 with rectal spacer for an incremental cost of $518 over 10 years. A 1-way sensitivity analyses showed the breakeven cost of spacer at $2,332 or a breakeven overall risk reduction of 86% at a cost of $2,850. For high-dose SBRT, spacer was immediately cost effective with a savings of $2,640 and breakeven risk reduction at 36%. However, 2-way spacer cost to risk reduction sensitivity analyses were performed. CONCLUSION The use of a rectal spacer for conformal RT results in a marginal cost increase with a significant reduction in rectal toxicity assuming recently published 15 month rectal toxicity reduction is maintained over 10 years. For high-dose SBRT it was cost effective. Further studies would be necessary to validate the long-term benefits of rectal spacers.
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Kanda T, Fukuda S, Fukui N, Ohkubo Y, Kazumoto T, Saito Y, Ishikawa A, Kurosumi M, Kageyama Y, Fujii Y, Kihara K. Favorable outcome of intraoperative radiotherapy to the primary site in patients with metastatic prostate cancer. Int J Clin Oncol 2016; 21:764-772. [DOI: 10.1007/s10147-016-0947-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 01/03/2016] [Indexed: 10/22/2022]
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Pinkawa M. Current role of spacers for prostate cancer radiotherapy. World J Clin Oncol 2015; 6:189-193. [PMID: 26677428 PMCID: PMC4675900 DOI: 10.5306/wjco.v6.i6.189] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/12/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
Radiotherapy is an established curative treatment method for prostate cancer. Optimal tumor control rates can only be achieved with high local doses, associated with a considerable risk of rectal toxicity. Apart from already widely adapted technical advances, as intensity-modulated radiation therapy, the application of spacers placed between the prostate and rectum has been increasingly used in the last years. Biodegradable spacers, including hydrogel, hyaluronic acid, collagen or an implantable balloon, can be injected or inserted in a short procedure under transrectal ultrasound guidance via a transperineal approach. A distance of about 1.0-1.5 cm is usually achieved between the rectum and prostate, excluding the rectal wall from the high isodoses. Several studies have shown well tolerated injection procedures and treatments. Apart from considerable reduction of rectal irradiation, a prospective randomized trial demonstrated a reduction of rectal toxicity after hydrogel injection in men undergoing prostate image-guided intensity-modulated radiation therapy. The results are encouraging for continuing evaluation in dose escalation, hypofractionation, stereotactic radiotherapy or re-irradiation trials in the future.
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Systematic Review of the Relationship between Acute and Late Gastrointestinal Toxicity after Radiotherapy for Prostate Cancer. Prostate Cancer 2015; 2015:624736. [PMID: 26697225 PMCID: PMC4677238 DOI: 10.1155/2015/624736] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 11/15/2015] [Indexed: 12/24/2022] Open
Abstract
A small but meaningful percentage of men who are treated with external beam radiation therapy for prostate cancer will develop late gastrointestinal toxicity. While numerous strategies to prevent gastrointestinal injury have been studied, clinical trials concentrating on late toxicity have been difficult to carry out. Identification of subjects at high risk for late gastrointestinal injury could allow toxicity prevention trials to be performed using reasonable sample sizes. Acute radiation therapy toxicity has been shown to predict late toxicity in several organ systems. Late toxicities may occur as a consequential effect of acute injury. In this systematic review of published reports, we found that late gastrointestinal toxicity following prostate radiotherapy seems to be statistically and potentially causally related to acute gastrointestinal morbidity as a consequential effect. We submit that acute gastrointestinal toxicity may be used to identify at-risk patients who may benefit from additional attention for medical interventions and close follow-up to prevent late toxicity. Acute gastrointestinal toxicity could also be explored as a surrogate endpoint for late effects in prospective trials.
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Vanneste BGL, Van De Voorde L, de Ridder RJ, Van Limbergen EJ, Lambin P, van Lin EN. Chronic radiation proctitis: tricks to prevent and treat. Int J Colorectal Dis 2015; 30:1293-303. [PMID: 26198994 PMCID: PMC4575375 DOI: 10.1007/s00384-015-2289-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2015] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of this study was to give an overview of the measures used to prevent chronic radiation proctitis (CRP) and to provide an algorithm for the treatment of CRP. METHODS Medical literature databases including PubMed and Medline were screened and critically analyzed for relevance in the scope of our purpose. RESULTS CRP is a relatively frequent late side effect (5-20%) and mainly dependent on the dose and volume of irradiated rectum. Radiation treatment (RT) techniques to prevent CRP are constantly improving thanks to image-guided RT and intensity-modulated RT. Also, newer techniques like protons and new devices such as rectum spacers and balloons have been developed to spare rectal structures. Biopsies do not contribute to diagnosing CRP and should be avoided because of the risk of severe rectal wall damage, such as necrosis and fistulas. There is no consensus on the optimal treatment of CRP. A variety of possibilities is available and includes topical and oral agents, hyperbaric oxygen therapy, and endoscopic interventions. CONCLUSIONS CRP has a natural history of improving over time, even without treatment. This is important to take into account when considering these treatments: first be conservative (topical and oral agents) and be aware that invasive treatments can be very toxic.
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Affiliation(s)
- Ben G L Vanneste
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands.
| | - Lien Van De Voorde
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Evert J Van Limbergen
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - Emile N van Lin
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
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How can the aetiological factors of rectal distension be managed to reduce interfraction prostate motion during a course of radiotherapy treatment. JOURNAL OF RADIOTHERAPY IN PRACTICE 2015. [DOI: 10.1017/s1460396915000436] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractAimDuring radiotherapy of the prostate it is important to minimise interfraction prostate motion to allow dose escalation and reduce normal tissue damage. Rectal volume has been identified as playing a significant role in prostate motion with various methods used to reduce it. The aim was to systematically review published literature to allow evidence based recommendations to be made to current practice to reduce interfraction prostate motion.Materials and methodsA systematic search of CINAHL, Medline, PubMed, Science Direct, NHS Evidence and The Cochrane Library was performed. Limited searches of The Society of Radiographers website, OpenGrey and COPAC were undertaken, alongside manual searches of cross references of eligible articles. The quality of included papers was measured using a pre-existing tool. The causes, consequences and solutions to manage rectal volume and its effect on prostate position were extracted, compared and evaluated to extract solutions to be implemented into clinical practice.ResultsOf the 2,339 unique articles systematically retrieved, 23 met the inclusion criteria, 15 of which discuss radiotherapy, five constipation and three flatulence.FindingsA combined medicinal and dietary approach adaptable to departmental workflow is required to manage rectal volume, with special consideration to patients with pre-existing extrinsic factors.
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Wolf F, Gaisberger C, Ziegler I, Krenn E, Scherer P, Hruby S, Schätz T, Forstner R, Holzinger J, Vaszi A, Kametriser G, Steininger P, Deutschmann H, Sedlmayer F. Comparison of two different rectal spacers in prostate cancer external beam radiotherapy in terms of rectal sparing and volume consistency. Radiother Oncol 2015; 116:221-5. [PMID: 26232129 DOI: 10.1016/j.radonc.2015.07.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 07/03/2015] [Accepted: 07/05/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE In external beam radiation (EBRT) of the prostate, the rectum is the dose-limiting organ at risk, and sparing of the anterior rectal wall is a prerequisite for safe delivery of doses beyond 70 Gy. Spatial sparing of the rectum can be achieved by introducing a spacer material into the retroprostatic space, thus separating the anterior rectal wall from the PTV. MATERIALS AND METHODS Two spacer technologies, Spacer OAR, a polyethylene glycol gel and ProSpace, a saline inflated balloon, were compared in terms of spacer volume, stability, and dose reduction to the anterior rectum wall in 78 patients. RESULTS Both spacer systems significantly reduced the rectum surface encompassed by the 95% isodose (gel: -35%, p<0.01; balloon -63.4%, p<0.001) compared to a control group. The balloon spacer was superior in reducing rectum dose (-27.7%, p=0.034), but exhibited an average volume loss of >50% during the full course of treatment of 37-40 fractions, while the volume of gel spacers remained fairly constant. CONCLUSIONS In choosing between the two spacer technologies, the advantageous dose reduction of the balloon needs to be weighed up against the better volume consistency of the gel spacer with respect to the duration of hypofractionated vs normofractionated regimens.
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Affiliation(s)
- Frank Wolf
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria.
| | - Christoph Gaisberger
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Ingrid Ziegler
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Elisabeth Krenn
- Salzburg University of Applied Sciences, Paracelsus Medical University of Salzburg, Austria
| | - Philipp Scherer
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Stephan Hruby
- Dpt. of Urology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Tobias Schätz
- Dpt. of Urology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Rosemarie Forstner
- Dpt. of Radiology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Josef Holzinger
- Dept. of Surgery, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Andrea Vaszi
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Gerhard Kametriser
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Philipp Steininger
- Institute for Research and Development on Advanced Radiation Technologies (radART), St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Heinz Deutschmann
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria; Institute for Research and Development on Advanced Radiation Technologies (radART), St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
| | - Felix Sedlmayer
- Dpt. of Radiation Oncology, St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria; Institute for Research and Development on Advanced Radiation Technologies (radART), St. Johanns-Spital, Paracelsus Medical University of Salzburg, Austria
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Chapet O, Decullier E, Bin S, Faix A, Ruffion A, Jalade P, Fenoglietto P, Udrescu C, Enachescu C, Azria D. Prostate hypofractionated radiation therapy with injection of hyaluronic acid: acute toxicities in a phase 2 study. Int J Radiat Oncol Biol Phys 2015; 91:730-6. [PMID: 25752385 DOI: 10.1016/j.ijrobp.2014.11.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 11/17/2014] [Accepted: 11/18/2014] [Indexed: 12/11/2022]
Abstract
PURPOSE Hypofractionated radiation therapy (RT) in prostate cancer can be developed only if the risk of rectal toxicity is controlled. In a multicenter phase 2 trial, hypofractionated irradiation was combined with an injection of hyaluronic acid (HA) to preserve the rectal wall. Tolerance of the injection and acute toxicity rates are reported. METHODS AND MATERIALS The study was designed to assess late grade 2 toxicity rates. The results described here correspond to the secondary objectives. Acute toxicity was defined as occurring during RT or within 3 months after RT and graded according to the Common Terminology Criteria for Adverse Events version 4.0. HA tolerance was evaluated with a visual analog scale during the injection and 30 minutes after injection and then by use of the Common Terminology Criteria at each visit. RESULTS From 2010 to 2012, 36 patients with low-risk to intermediate-risk prostate cancer were included. The HA injection induced a mean pain score of 4.6/10 ± 2.3. Thirty minutes after the injection, 2 patients still reported pain (2/10 and 3/10), which persisted after the intervention. Thirty-three patients experienced at least 1 acute genitourinary toxicity and 20 patients at least 1 acute gastrointestinal toxicity. Grade 2 toxicities were reported for 19 patients with urinary obstruction, frequency, or both and for 1 patient with proctitis. No grade 3 or 4 toxicities were reported. At the 3-month visit, 4 patients described grade 2 obstruction or frequency, and no patients had any grade 2 gastrointestinal toxicities. CONCLUSIONS The injection of HA makes it possible to deliver hypofractionated irradiation over 4 weeks with a dose per fraction of > 3 Gy, with limited acute rectal toxicity.
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Affiliation(s)
- Olivier Chapet
- Department of Radiation Oncology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Benite, France; EMR3738, Université Lyon 1, Lyon, France.
| | - Evelyne Decullier
- Pole Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France; Université Lyon 1, Lyon, France; EA SIS, Université de Lyon, Lyon, France
| | - Sylvie Bin
- Pole Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France; Université Lyon 1, Lyon, France; EA SIS, Université de Lyon, Lyon, France
| | - Antoine Faix
- Department of Urology, Clinique Beausoleil, Montpellier, France
| | - Alain Ruffion
- Université Lyon 1, Lyon, France; Department of Urology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - Patrice Jalade
- Department of Medical Physics, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - Pascal Fenoglietto
- Department of Radiation Oncology and Physics, Institut du Cancer de Montpellier, Montpellier, France
| | - Corina Udrescu
- Department of Radiation Oncology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - Ciprian Enachescu
- Department of Radiation Oncology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - David Azria
- Department of Radiation Oncology and Physics, Institut du Cancer de Montpellier, Montpellier, France
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A review of rectal toxicity following permanent low dose-rate prostate brachytherapy and the potential value of biodegradable rectal spacers. Prostate Cancer Prostatic Dis 2015; 18:96-103. [PMID: 25687401 DOI: 10.1038/pcan.2015.4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/02/2014] [Accepted: 12/10/2014] [Indexed: 01/15/2023]
Abstract
Permanent radioactive seed implantation provides highly effective treatment for prostate cancer that typically includes multidisciplinary collaboration between urologists and radiation oncologists. Low dose-rate (LDR) prostate brachytherapy offers excellent tumor control rates and has equivalent rates of rectal toxicity when compared with external beam radiotherapy. Owing to its proximity to the anterior rectal wall, a small portion of the rectum is often exposed to high doses of ionizing radiation from this procedure. Although rare, some patients develop transfusion-dependent rectal bleeding, ulcers or fistulas. These complications occasionally require permanent colostomy and thus can significantly impact a patient's quality of life. Aside from proper technique, a promising strategy has emerged that can help avoid these complications. By injecting biodegradable materials behind Denonviller's fascia, brachytherpists can increase the distance between the rectum and the radioactive sources to significantly decrease the rectal dose. This review summarizes the progress in this area and its applicability for use in combination with permanent LDR brachytherapy.
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Vanneste BGL, Pijls-Johannesma M, Van De Voorde L, van Lin EN, van de Beek K, van Loon J, Ramaekers BL, Lambin P. Spacers in radiotherapy treatment of prostate cancer: is reduction of toxicity cost-effective? Radiother Oncol 2015; 114:276-81. [PMID: 25616537 DOI: 10.1016/j.radonc.2015.01.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 01/05/2015] [Accepted: 01/06/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE To compare the cost-effectiveness of treating prostate cancer patients with intensity-modulated radiation therapy and a spacer (IMRT+S) versus IMRT-only without a spacer (IMRT-O). MATERIALS AND METHODS A decision-analytic Markov model was constructed to examine the effect of late rectal toxicity and compare the costs and quality-adjusted Life Years (QALYs) of IMRT-O and IMRT+S. The main assumption of this modeling study was that disease progression, genito-urinary toxicity and survival were equal for both comparators. RESULTS For all patients, IMRT+S revealed a lower toxicity than IMRT-O. Treatment follow-up and toxicity costs for IMRT-O and IMRT+S amounted to €1604 and €1444, respectively, thus saving €160 on the complication costs at an extra charge of €1700 for the spacer in IMRT+S. The QALYs yielded for IMRT-O and IMRT+S were 3.542 and 3.570, respectively. This results in an incremental cost-effectiveness ratio (ICER) of €55,880 per QALY gained. For a ceiling ratio of €80,000, IMRT+S had a 77% probability of being cost-effective. CONCLUSION IMRT+S is cost-effective compared to IMRT-O based on its potential to reduce radiotherapy-related toxicity.
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Affiliation(s)
- Ben G L Vanneste
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, The Netherlands.
| | - Madelon Pijls-Johannesma
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, The Netherlands; Health insurance company CZ, Tilburg, The Netherlands
| | - Lien Van De Voorde
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, The Netherlands
| | | | - Kees van de Beek
- Department of Urology, Maastricht University Medical Center+, The Netherlands
| | - Judith van Loon
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, The Netherlands
| | - Bram L Ramaekers
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, The Netherlands; Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, The Netherlands
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Abstract
Definitive radiotherapy is a well-recognized treatment option for localized prostate cancer. Rectum toxicity is the dose-limiting toxicity. Dose-volume correlations have been reported in many studies. The application of a spacer to increase the distance between the prostate and anterior rectal wall is an innovative technique, considerably reducing the dose to the rectum. Hyaluronic acid, human collagen, an inflatable balloon or hydrogel are potential materials to create the desired effect. The number of clinical studies is rapidly increasing. Well-tolerated injection or implantation techniques and low rectal treatment-related toxicity have been demonstrated in prospective studies. Long-term clinical results and the results of randomized studies are needed to better define the beneficial effect for the patient.
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Affiliation(s)
- Michael Pinkawa
- *Department of Radiation Oncology, Rheinisch-Westfaelische Technische Hochschule Aachen University, Pauwelsstrasse 30, 52057 Aachen, Germany;
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Mok G, Benz E, Vallee JP, Miralbell R, Zilli T. Optimization of radiation therapy techniques for prostate cancer with prostate-rectum spacers: a systematic review. Int J Radiat Oncol Biol Phys 2014; 90:278-88. [PMID: 25304788 DOI: 10.1016/j.ijrobp.2014.06.044] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/12/2014] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
Abstract
Dose-escalated radiation therapy for localized prostate cancer improves disease control but is also associated with worse rectal toxicity. A spacer placed between the prostate and rectum can be used to displace the anterior rectal wall outside of the high-dose radiation regions and potentially minimize radiation-induced rectal toxicity. This systematic review focuses on the published data regarding the different types of commercially available prostate-rectum spacers. Dosimetric results and preliminary clinical data using prostate-rectum spacers in patients with localized prostate cancer treated by curative radiation therapy are compared and discussed.
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Affiliation(s)
- Gary Mok
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Department of Radiation Oncology, Centre Intégré de Cancérologie de Laval, Centre de Santé et de Services Sociaux de Laval, Laval, Québec, Canada; Department of Radiology, Radiation Oncology, and Nuclear Medicine, Centre Hospitalier Universitaire de Montréal, Montréal, Québec, Canada
| | - Eileen Benz
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Jean-Paul Vallee
- Department of Radiology, Geneva University Hospital, Geneva, Switzerland
| | - Raymond Miralbell
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland.
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Pinkawa M, Schubert C, Escobar-Corral N, Holy R, Eble MJ. Application of a hydrogel spacer for postoperative salvage radiotherapy of prostate cancer. Strahlenther Onkol 2014; 191:375-9. [PMID: 25339311 DOI: 10.1007/s00066-014-0769-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 10/03/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND In contrast to primary radiotherapy, no reports are available for a hydrogel spacer application in postoperative salvage radiotherapy for prostate cancer. CASE REPORT A 77-year-old patient presented 20 years after radical prostatectomy with a digitally palpable local recurrence at the urethrovesical anastomosis (PSA 5.5 ng/ml). The hydrogel spacer (10 ml, SpaceOAR™) was injected between the local recurrence and rectal wall under transrectal ultrasound guidance. Treatment planning was performed with an intensity-modulated technique up to a total dose of 76 Gy in 2-Gy fractions. The same planning was performed based on computed tomography before spacer injection for comparison. RESULTS The local recurrence, initially directly on the rectal wall, could be displaced more than 1 cm from the rectal wall after hydrogel injection. With a mean total dose of 76 Gy to the planning target volume, rectal wall volumes included in the 70 Gy, 60 Gy, 50 Gy isodoses were 0 cm(3), 0 cm(3), and 0.4 cm(3) with a spacer and 2.9 cm(3), 4.5 cm(3), and 6.2 cm(3) without a spacer, respectively. The patient reported rectal urgency during radiotherapy, completely resolving after the end of treatment. The PSA level was 5.4 ng/ml a week before the end of radiotherapy and dropped to 0.9 ng/ml 5 months after radiotherapy. CONCLUSION A hydrogel spacer was successfully applied for dose-escalated radiotherapy in a patient with macroscopic local prostate cancer recurrence at the urethrovesical anastomosis to decrease the dose at the rectal wall. This option can be considered in specifically selected patients.
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Affiliation(s)
- Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Pauwelsstrasse 30, 52057, Aachen, Germany,
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[Prostate-rectum spacers: optimization of prostate cancer irradiation]. Cancer Radiother 2014; 18:215-21; quiz 243-4, 247. [PMID: 24746454 DOI: 10.1016/j.canrad.2014.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/03/2014] [Accepted: 03/03/2014] [Indexed: 12/20/2022]
Abstract
In the curative radiotherapy of localized prostate cancer, improvements in biochemical control observed with dose escalation have been counterbalanced by an increase in radiation-induced toxicity. The injection of biodegradable spacers between prostate and rectum represents a new frontier in the optimization of radiotherapy treatments for patients with localized disease. Transperineal injection of different types of spacers under transrectal ultrasound guidance allows creating a 7-to-20 mm additional space between the prostate and the anterior rectal wall lasting 3 to 12 months. Dosimetrically, a relative reduction in the rectal volume receiving at least 70 Gy (V70) in the order of 43% to 84% is observed with all types of spacers, regardless of the radiotherapy technique used. Preliminary clinical results show for all spacers a good tolerance and a possible reduction in the acute side effects rate. The aim of the present systematic review of the literature is to report on indications as well as dosimetric and clinical advantages of the different types of prostate-rectum spacers commercially available (hydrogel, hyaluronic acid, collagen, biodegradable balloon).
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Ng M, Brown E, Williams A, Chao M, Lawrentschuk N, Chee R. Fiducial markers and spacers in prostate radiotherapy: current applications. BJU Int 2014; 113 Suppl 2:13-20. [DOI: 10.1111/bju.12624] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Michael Ng
- Radiation Oncology Victoria; Melbourne VIC Australia
| | - Elizabeth Brown
- Department of Radiation Oncology; Princess Alexandra Hospital; Brisbane QLD Australia
| | - Andrew Williams
- Department of Urology; Auckland City Hospital; Auckland New Zealand
| | - Michael Chao
- Radiation Oncology Victoria; Melbourne VIC Australia
| | - Nathan Lawrentschuk
- Department of Surgery and Ludwig Institute for Cancer Research; Austin Hospital; University of Melbourne; Melbourne VIC Australia
| | - Raphael Chee
- Genesis Cancer Care Western Australia; Joondalup WA Australia
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Improved long-term outcomes with IMRT: is it better technology or better physics? Int J Radiat Oncol Biol Phys 2014; 87:867-8. [PMID: 24267964 DOI: 10.1016/j.ijrobp.2013.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 09/05/2013] [Accepted: 09/05/2013] [Indexed: 11/20/2022]
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Pinkawa M, Klotz J, Djukic V, Schubert C, Escobar-Corral N, Caffaro M, Piroth MD, Holy R, Eble MJ. Learning curve in the application of a hydrogel spacer to protect the rectal wall during radiotherapy of localized prostate cancer. Urology 2013; 82:963-8. [PMID: 24074991 DOI: 10.1016/j.urology.2013.07.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 06/03/2013] [Accepted: 07/07/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the effect of increasing experience on hydrogel dimensions, rectal dose, and acute toxicity, and to discuss important technical issues gained from this experience. METHODS Sixty-four consecutive patients with prostate cancer were included in this analysis (G1/G2 corresponding to first/second 32 patients) after injection of 10 mL spacer gel. All patients were treated with a 5-field intensity-modulated radiotherapy technique to 76-78 Gy. Treatment toxicity was evaluated with a validated quality of life questionnaire (expanded prostate cancer index composite) before and after radiotherapy. RESULTS Rectum volume could be entirely excluded from the planning target volume in 31% in G1 vs 56% in G2 (P = .04). Increasing symmetry was detected comparing the first 15 patients to the subsequent rest, with mean differences between right and left of 0.6 cm vs 0.3 cm at the midgland (P = .03). Mean distance between prostate and anterior rectal wall increased from 0.8 cm/1.1 cm/0.8 cm (G1) at the base/middle/apex to 1.3 cm/1.5 cm/1.2 cm (G2), respectively, so that the dose to the rectum decreased significantly (6% vs 2% of the volume inside the 70 Gy isodose; P <.01). Bowel function and bother score changes were smaller comparing baseline with last day of radiotherapy levels (mean 16/18 in G1 vs 9/12 in G2). CONCLUSION A learning curve could be demonstrated in our patient population, respecting improved and more symmetrical spacer placement, improved treatment planning, and less treatment-related acute toxicity. Several important technical aspects need to be considered.
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Affiliation(s)
- Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany.
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Pinkawa M, Bornemann C, Escobar-Corral N, Piroth MD, Holy R, Eble MJ. Treatment planning after hydrogel injection during radiotherapy of prostate cancer. Strahlenther Onkol 2013; 189:796-800. [PMID: 23836063 DOI: 10.1007/s00066-013-0388-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 05/22/2013] [Indexed: 12/31/2022]
Abstract
PURPOSE Imaging for treatment planning shortly after hydrogel injection is optimal for practical purposes, reducing the number of appointments. The aim was to evaluate the actual difference between early and late imaging. PATIENTS AND METHODS Treatment planning computed tomography (CT) was performed shortly after injection of 10 ml hydrogel (CT1) and 1-2 weeks later (CT2) for 3 patients. The hydrogel was injected via the transperineal approach after dissecting the space between the prostate and rectum with a saline/lidocaine solution of at least 20-ml. Hydrogel volume and distances between the prostate and rectal wall were compared. Intensity-modulated radiotherapy (IMRT) plans up to a dose of 78 Gy were generated (rectum V70 < 20 %, rectum V50 < 50 %; with the rectum including hydrogel volume for planning). RESULTS A mean planning treatment volume of 104 cm(3) resulted for a prostate volume of 37 cm(3). Hydrogel volumes of 30 and 10 cm(3) were determined in CT1 and CT2, respectively. Distances between the prostate and rectal wall at the levels of the base, middle, and apex were 1.7 cm, 1.6 cm, 1.5 cm in CT1 and 1.3 cm, 1.2 cm, 0.8 cm in CT2, respectively, corresponding to a mean decrease of 24, 25, and 47 %. A small overlap between the PTV and the rectum was found only in 1 patient in CT2 (0.2 cm(3)). The resulting mean rectum (without hydrogel) V75, V70, V60, V50 increased from 0 %, 0 %, 0.6 %, 10 % in CT1 to 0.1 %, 1.2 %, 6 %, 20 % in CT2, respectively. CONCLUSION Treatment planning based on imaging shortly after hydrogel injection overestimates the actual hydrogel volume during the treatment as a result of not-yet-absorbed saline solution and air bubbles.
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Affiliation(s)
- M Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Pauwelsstr. 30, 52072, Aachen, Germany.
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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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