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Millot JC, Arenas-Gallo C, Silver E, Goldman M, Picciotto S, Jia AY, Zaorsky NG, Spratt DE, Fredman ET, Shoag JE. Major Complications and Adverse Events Related to Use of SpaceOAR Hydrogel for Prostate Cancer Radiotherapy. Urology 2024; 188:94-100. [PMID: 38458325 DOI: 10.1016/j.urology.2023.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/11/2023] [Accepted: 12/20/2023] [Indexed: 03/10/2024]
Abstract
OBJECTIVE To determine the prevalence and severity of SpaceOAR-related adverse events using the Manufacturer and User Facility Device Experience (MAUDE) database. METHODS We analyzed SpaceOAR-related adverse event reports in the Manufacturer and User Facility Device Experience (MAUDE) database from January 2015 to May 2023. For each report, the event type, associated device and patient problems, event description, event timing, and event severity stratified by the Common Terminology Criteria for Adverse Events version 5.0 (CTCAE) grading system were recorded. RESULTS From 2015 to 2022, 206,619 SpaceOAR devices were sold. From January 2015 to May 2023, we identified 981 reports describing 990 SpaceOAR-related adverse events. Malfunctions were the most common event type (N = 626), followed by patient injuries (N = 350) with few reported deaths (N = 5). Device positioning problems were the most frequent device issue (N = 686). Pain was the most reported patient problem (N = 216). Abscesses and fistulas related to the device were each reported in 91 events. A noteworthy portion of relevant adverse events occurred before the initiation of radiation (N = 35, 22.4%), suggesting the device, rather than the radiation, was responsible. In total, 470 (50.2%) and 344 (36.7%) of the adverse events were CTCAE grade 1 and 2, respectively. There were 123 (13.1%) events that were CTCAE grade ≥3. CONCLUSION We identified multiple reports of SpaceOAR-related adverse events, many of which are more serious than have been reported in clinical trials. While SpaceOAR use is common, suggesting these events are rare, these data highlight the need for continued postmarket surveillance.
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Affiliation(s)
- Jack C Millot
- Department of Urology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Camilo Arenas-Gallo
- Department of Urology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Esther Silver
- Department of Neuroscience, Ohio State University, Columbus, OH
| | | | - Shany Picciotto
- Department of Urology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Angela Y Jia
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Elisha T Fredman
- Department of Radiation Oncology, Davidoff Cancer Center, Beilinson Hospital, Petah Tikva, Israel
| | - Jonathan E Shoag
- Department of Urology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Urology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, NY.
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Kashihara T, Urago Y, Okamoto H, Takemori M, Nakayama H, Mikasa S, Nakaichi T, Iijima K, Chiba T, Kuwahara J, Nakamura S, Chang W, Matsui Y, Igaki H. A preliminary study on rectal dose reduction associated with hyaluronic acid implantation in brachytherapy for prostate cancer. Asian J Urol 2024; 11:286-293. [PMID: 38680582 PMCID: PMC11053323 DOI: 10.1016/j.ajur.2022.08.006] [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: 03/17/2022] [Accepted: 08/28/2022] [Indexed: 02/05/2023] Open
Abstract
Objectives Hydrogel spacer (HS) was developed to reduce rectal toxicities caused by radiotherapy, but has been reported to cause major adverse events. Our institute has attempted to introduce a hyaluronic acid (HA) as an alternative spacer. This study aimed to compare rectal doses and geometric distributions between the HS and HA implantation in prostate cancer. Methods HS and HA were inserted in 20 and 18 patients undergoing high-dose brachytherapy, respectively. The rectum spacer volumes injected were 10 mL and 22 mL, respectively. In the treatment planning system, 13.5 Gy was administered with common catheter positions. The rectal dose indices were assessed between the spacer groups for dosimetry evaluation. Distances between the prostate and rectum and configurations of the spacers were compared. Results The mean doses irradiated to 0.1 and 2 mL of the rectum were 10.45 Gy and 6.71 Gy for HS, and 6.73 Gy and 4.90 Gy for HA (p<0.001). The mean minimum distances between the prostate and rectum were 1.23 cm and 1.79 cm for HS and HA, respectively (p<0.05). Geometrical configuration comparisons revealed that HA has a higher ability to expand the space than HS. Conclusion The rectal dose reduction ability of HA is significantly greater than that of HS, suggesting its potential as a new spacer.
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Affiliation(s)
- Tairo Kashihara
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Yuka Urago
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
- Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, 7-2-10 Higashi-Ogu, Arakawa-ku, Tokyo, Japan
| | - Hiroyuki Okamoto
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Mihiro Takemori
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
- Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, 7-2-10 Higashi-Ogu, Arakawa-ku, Tokyo, Japan
| | - Hiroki Nakayama
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
- Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, 7-2-10 Higashi-Ogu, Arakawa-ku, Tokyo, Japan
| | - Shohei Mikasa
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Tetsu Nakaichi
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Kotaro Iijima
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Takahito Chiba
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Junichi Kuwahara
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
- Department of Radiological Technology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Satoshi Nakamura
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Weishan Chang
- Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, 7-2-10 Higashi-Ogu, Arakawa-ku, Tokyo, Japan
| | - Yoshiyuki Matsui
- Department of Urological Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
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Dose Distribution of High Dose-Rate and Low Dose-Rate Prostate Brachytherapy at Different Intervals-Impact of a Hydrogel Spacer and Prostate Volume. Cancers (Basel) 2023; 15:cancers15051396. [PMID: 36900188 PMCID: PMC10000179 DOI: 10.3390/cancers15051396] [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: 01/20/2023] [Revised: 02/13/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
The study aimed to compare the dose distribution in permanent low-dose-rate brachytherapy (LDR-BT) and high-dose-rate brachytherapy (HDR-BT), specifically focusing on the impact of a spacer and prostate volume. The relative dose distribution of 102 LDR-BT patients (prescription dose 145 Gy) at different intervals was compared with the dose distribution of 105 HDR-BT patients (232 HDR-BT fractions with prescription doses of 9 Gy, n = 151, or 11.5 Gy, n = 81). A hydrogel spacer (10 mL) was only injected before HDR-BT. For the analysis of dose coverage outside the prostate, a 5 mm margin was added to the prostate volume (PV+). Prostate V100 and D90 of HDR-BT and LDR-BT at different intervals were comparable. HDR-BT was characterized by a considerably more homogenous dose distribution and lower doses to the urethra. The minimum dose in 90% of PV+ was higher for larger prostates. As a consequence of the hydrogel spacer in HDR-BT patients, the intraoperative dose at the rectum was considerably lower, especially in smaller prostates. However, prostate volume dose coverage was not improved. The dosimetric results well explain clinical differences between these techniques reported in the literature review, specifically comparable tumor control, higher acute urinary toxicity rates in LDR-BT in comparison to HDR-BT, decreased rectal toxicity after spacer placement, and improved tumor control after HDR-BT in larger prostate volumes.
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AUA/ASTRO 2022 Guidelines: "Scrutinized". Pract Radiat Oncol 2023; 13:172-174. [PMID: 36882350 DOI: 10.1016/j.prro.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/11/2022] [Accepted: 01/06/2023] [Indexed: 02/05/2023]
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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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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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Payne HA, Jain S, Peedell C, Edwards A, Thomas JA, Das P, Hansson Hedblom A, Woodward E, Saunders R, Bahl A. Delphi study to identify consensus on patient selection for hydrogel rectal spacer use during radiation therapy for prostate cancer in the UK. BMJ Open 2022; 12:e060506. [PMID: 35858729 PMCID: PMC9305805 DOI: 10.1136/bmjopen-2021-060506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To identify consensus on patient prioritisation for rectal hydrogel spacer use during radiation therapy for the treatment of prostate cancer in the UK. DESIGN Delphi study consisting of two rounds of online questionnaires, two virtual advisory board meetings and a final online questionnaire. SETTING Radical radiation therapy for localised and locally advanced prostate cancer in the UK. PARTICIPANTS Six leading clinical oncologists and one urologist from across the UK. INTERVENTIONS Rectal hydrogel spacer. PRIMARY AND SECONDARY OUTCOME MEASURES None reported. RESULTS The panel reached consensus on the importance of minimising toxicity for treatments with curative intent and that even low-grade toxicity-related adverse events can significantly impact quality of life. There was agreement that despite meeting rectal dose constraints, too many patients experience rectal toxicity and that rectal hydrogel spacers in eligible patients significantly reduces toxicity-related adverse events. However, as a consequence of funding limitations, patients need to be prioritised for spacer use. A higher benefit of spacers can be expected in patients on anticoagulation and in patients with diabetes or inflammatory bowel disease, but consensus could not be reached regarding patient groups expected to benefit less. While radiation therapy regimen is not a main factor determining prioritisation, higher benefit is expected in ultrahypofractionated regimens. CONCLUSION There is a strong and general agreement that all patients with prostate cancer undergoing radical radiation therapy have the potential to benefit from hydrogel spacers. Currently, not all patients who could potentially benefit can access hydrogel spacers, and access is unequal. Implementation of the consensus recommendations would likely help prioritise and equalise access to rectal spacers for patients in the UK.
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Affiliation(s)
- Heather Ann Payne
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Suneil Jain
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Clive Peedell
- Department of Radiotherapy and Oncology, James Cook University Hospital, Middlesbrough, UK
| | | | | | - Prantik Das
- Department of Oncology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | - Emily Woodward
- Health Economics, Boston Scientific AG, Solothurn, Switzerland
| | | | - Amit Bahl
- Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Zhang H, Wang L, Riegel AC, Antone J, Potters L, Lee L, Cao Y. Biological effective dose in analysis of rectal dose in prostate cancer patients who underwent a combination therapy of VMAT and LDR with hydrogel spacer insertion. J Appl Clin Med Phys 2022; 23:e13584. [PMID: 35285578 PMCID: PMC9194986 DOI: 10.1002/acm2.13584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/01/2022] [Accepted: 02/24/2022] [Indexed: 11/25/2022] Open
Abstract
This study aimed to evaluate rectal dose reduction in prostate cancer patients who underwent a combination of volumetric modulated arc therapy (VMAT) and low‐dose‐rate (LDR) brachytherapy with insertion of hydrogel spacer (SpaceOAR). For this study, 35 patients receiving hydrogel spacer and 30 patients receiving no spacer were retrospectively enrolled. Patient was treated to doses of 45 Gy to the primary tumor site and nodal regions over 25 fractions using VMAT and 100 Gy to the prostate using prostate seed implant (PSI). In VMAT plans of patients with no spacer, mean doses of rectal wall were 43.6, 42.4, 40.1, and 28.8 Gy to the volume of 0.5, 1, 2, and 5 cm3, respectively. In patients with SpaceOAR, average rectal wall doses decreased to 39.0, 36.9, 33.5, and 23.9 Gy to the volume of 0.5, 1, 2, and 5 cm3, respectively (p < 0.01). In PSI plans, rectal wall doses were on average 78.5, 60.9, 41.8, and 14.8 Gy to the volume of 0.5, 1, 2, and 5 cm3, respectively, in patients without spacer. In contrast, the doses decreased to 34.5, 28.4, 20.6 (p < 0.01), and 8.5 Gy (p < 0.05) to rectal wall volume of 0.5, 1, 2, and 5 cm3, respectively, in patient with SpaceOAR. To demonstrate rectal sum dose sparing, dose‐biological effective dose (BED) calculation was accomplished in those patients who showed >60% overlap of rectal volumetric doses between VMAT and PSI. In patients with SpaceOAR, average BEDsum was decreased up to 34%, which was 90.1, 78.9, 65.9, and 40.8 Gy to rectal volume of 0.5, 1, 2, and 5 cm3, respectively, in comparison to 137.4, 116.7, 93.0, and 50.2 Gy to the volume of 0.5, 1, 2, and 5 cm3, respectively, in those with no spacer. Our result suggested a significant reduction of rectal doses in those patients who underwent a combination of VMAT and LDR with hydrogel spacer placement.
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Affiliation(s)
- Honglai Zhang
- Department of Radiation Medicine Northwell Health Cancer Institute, Lake Success New York USA
| | - Lin Wang
- Department of Radiation Medicine Northwell Health Cancer Institute, Lake Success New York USA
- Department of Radiation Medicine Zucker School of Medicine at Northwell/Hofstra Hempstead New York USA
| | - Adam C. Riegel
- Department of Radiation Medicine Northwell Health Cancer Institute, Lake Success New York USA
- Department of Radiation Medicine Zucker School of Medicine at Northwell/Hofstra Hempstead New York USA
| | - Jeffrey Antone
- Department of Radiation Medicine Northwell Health Cancer Institute, Lake Success New York USA
| | - Louis Potters
- Department of Radiation Medicine Northwell Health Cancer Institute, Lake Success New York USA
- Department of Radiation Medicine Zucker School of Medicine at Northwell/Hofstra Hempstead New York USA
| | - Lucille Lee
- Department of Radiation Medicine Northwell Health Cancer Institute, Lake Success New York USA
- Department of Radiation Medicine Zucker School of Medicine at Northwell/Hofstra Hempstead New York USA
| | - Yijian Cao
- Department of Radiation Medicine Northwell Health Cancer Institute, Lake Success New York USA
- Department of Radiation Medicine Zucker School of Medicine at Northwell/Hofstra Hempstead New York USA
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Lazo A, de la Torre-Luque A, Arregui G, Rivas D, Serradilla A, Gómez J, Jurado F, Núñez MI, López E. Long-Term Outcomes of Dose-Escalated Hypofractionated Radiotherapy in Localized Prostate Cancer. BIOLOGY 2022; 11:435. [PMID: 35336808 PMCID: PMC8945092 DOI: 10.3390/biology11030435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/02/2022] [Accepted: 03/09/2022] [Indexed: 06/14/2023]
Abstract
This retrospective study aimed to provide some clinical outcomes regarding effectiveness, toxicity, and quality of life in PCa patients treated with dose-escalated moderately hypofractionated radiation therapy (HFRT). Patients received HFRT to a total dose of 66 Gy in 22 fractions (3 Gy/fraction) delivered via volume modulated arc therapy (VMAT) in 2011-2016. Treatment effectiveness was measured by the biochemical failure-free survival rate. Toxicity was assessed according to the criteria of the Radiation Therapy Oncology Group (RTOG) and quality of life according to the criteria of the European Organization for Research and Treatment of Cancer (EORTC). In this regard, quality of life (QoL) was measured longitudinally, at a median of 2 and 5 years after RT. Enrolled patients had low-risk (40.2%), intermediate-risk (47.5%), and high-risk (12.3%) PCa. Median follow-up was 75 months. The biochemical failure-free survival rate was 94.2%. The incidence of acute grade 2 or higher gastrointestinal (GI) and genitourinary (GU) toxicity was 9.84% and 28.69%, respectively. The incidence rate of late grade 2 or higher GI and GU toxicity was 1.64% and 4.10%, respectively. Expanded Prostate Cancer Index Composite (EPIC) scores showed that the majority of patients maintained their QoL. HFRT to 66 Gy with VMAT was associated with adequate biochemical control, low toxicity and good reported GU and GI quality of life.
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Affiliation(s)
- Antonio Lazo
- Department of Radiation Oncology, San Cecilio Clinical University Hospital, 18016 Granada, Spain;
| | - Alejandro de la Torre-Luque
- Department of Legal Medicine, Psychiatry and Pathology, CIBERSAM, Complutense University of Madrid, 28040 Madrid, Spain
| | | | - Daniel Rivas
- Department of Radiation Oncology, GenesisCare, 29018 Malaga, Spain;
| | - Ana Serradilla
- Department of Radiation Oncology, GenesisCare, 18004 Granada, Spain;
| | - Joaquin Gómez
- Department of Radiation Oncology, Torrecardenas Hospitalary Complex, 04009 Almeria, Spain;
| | - Francisca Jurado
- Department of Radiation Oncology, GenesisCare, 14012 Cordoba, Spain;
| | - María Isabel Núñez
- Department of Radiology and Physical Medicine, Granada University, 18012 Granada, Spain
- Biopathology and Regenerative Medicine Institute (IBIMER), Centre for Biomedical Research, Granada University, 18016 Granada, Spain
- Biosanitary Research Institute, ibs. Granada, 18012 Granada, Spain
| | - Escarlata López
- Department of Radiation Oncology, GenesisCare, 28043 Madrid, Spain;
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10
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Thomas C, Dregely I, Oksuz I, Urbano TG, Greener T, King AP, Barrington SF. Neural-network dose-prediction for rectal spacer stratification in dose-escalated prostate radiotherapy. Med Phys 2022; 49:2172-2182. [PMID: 35218024 PMCID: PMC9311720 DOI: 10.1002/mp.15575] [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: 08/23/2021] [Revised: 01/22/2022] [Accepted: 02/14/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose To develop a knowledge‐based decision‐support system capable of stratifying patients for rectal spacer (RS) insertion based on neural network predicted rectal dose, reducing the need for time‐ and resource‐intensive radiotherapy (RT) planning. Methods Forty‐four patients treated for prostate cancer were enrolled into a clinical trial (NCT03238170). Dose‐escalated prostate RT plans were manually created for 30 patients with simulated boost volumes using a conventional treatment planning system (TPS) and used to train a hierarchically dense 3D convolutional neural network to rapidly predict RT dose distributions. The network was used to predict rectal doses for 14 unseen test patients, with associated toxicity risks calculated according to published data. All metrics obtained using the network were compared to conventionally planned values. Results The neural network stratified patients with an accuracy of 100% based on optimal rectal dose–volume histogram constraints and 78.6% based on mandatory constraints. The network predicted dose‐derived grade 2 rectal bleeding risk within 95% confidence limits of ‐1.9% to +1.7% of conventional risk estimates (risk range 3.5%–9.9%) and late grade 2 fecal incontinence risk within ‐0.8% to +1.5% (risk range 2.3%–5.7%). Prediction of high‐resolution 3D dose distributions took 0.7 s. Conclusions The feasibility of using a neural network to provide rapid decision support for RS insertion prior to RT has been demonstrated, and the potential for time and resource savings highlighted. Directly after target and healthy tissue delineation, the network is able to (i) risk stratify most patients with a high degree of accuracy to prioritize which patients would likely derive greatest benefit from RS insertion and (ii) identify patients close to the stratification threshold who would require conventional planning.
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Affiliation(s)
- Christopher Thomas
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK.,Medical Physics Department, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Isabel Dregely
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK.,Computer Science, UAS Technikum Wien, Vienna, Austria
| | - Ilkay Oksuz
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK.,Computer Engineering Department, Istanbul Technical University, Istanbul, Turkey
| | | | - Tony Greener
- Medical Physics Department, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Andrew P King
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Sally F Barrington
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK.,King's College London and Guy's and St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, King's College London, King's Health Partners, London, UK
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11
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Vanneste BGL, Van Limbergen EJ, Marcelissen T, Reynders K, Melenhorst J, van Roermund JGH, Lutgens L. Is prostate cancer radiotherapy using implantable rectum spacers safe and effective in inflammatory bowel disease patients? Clin Transl Radiat Oncol 2021; 27:121-125. [PMID: 33604459 PMCID: PMC7875819 DOI: 10.1016/j.ctro.2021.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 12/12/2022] Open
Abstract
Radiotherapy in patients with inflammatory bowel disease remains controversial. A biodegradable balloon is inserted between the prostate and the rectal wall. The balloon pushes the anterior rectal wall outside of the high-dose area. No grade 3 or more rectal toxicities were observed.
Background Prostate cancer radiotherapy (RT) in patients with (active) inflammatory bowel disease (IBD) remains controversial. We hypothesized that RT in combination with a biodegradable prostate-rectum spacer balloon implantation, might be a safe treatment approach with acceptable toxicities for these high risk for rectal toxicity patients. Materials and methods We report on a small prospective mono-centric series of 8 patients with all-risk prostate cancer with the comorbidity of an IBD. Four patients had Crohn’s disease and 4 patients had ulcerative colitis. One out of four had an active status of IBD. All patients were intended to be treated with curative high-dose RT: 5 patients were treated with external beam RT (70 Gray (Gy) in 28 fractions), and 3 patients were treated with 125I-implant (145 Gy). Toxicities were scored according to the CTCAE v4.03: acute side effects occur up to 3 months after RT, and late side effects start after 3 months. Results Median follow-up was 13 months (range: 3–42 months). Only one acute grade 2 gastro-intestinal (GI) toxicity was observed: an increased diarrhea (4–6 above baseline) during RT, which resolved completely 6 weeks after treatment. No late grade 3 or more GI toxicity was reported, and no acute and late grade ≥2 genitourinary toxicity events were observed. Conclusion Prostate cancer patients with IBD are a challenge to treat with RT. Our results suggest that RT in combination with a balloon implant in selective patients with (active) IBD may be promising, however additional validation is needed.
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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, the Netherlands
| | - Evert J Van Limbergen
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Tom Marcelissen
- Department of Urology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Kobe Reynders
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Joep G H van Roermund
- Department of Urology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Ludy Lutgens
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
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12
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Quinn TJ, Daignault-Newton S, Bosch W, Mariados N, Sylvester J, Shah D, Gross E, Hudes R, Beyer D, Kurtzman S, Bogart J, Hsi RA, Kos M, Ellis R, Logsdon M, Zimberg S, Forsythe K, Zhang H, Soffen E, Francke P, Mantz C, DeWeese T, Gay HA, Michalski J, Hamstra DA. Who Benefits From a Prostate Rectal Spacer? Secondary Analysis of a Phase III Trial. Pract Radiat Oncol 2020; 10:186-194. [DOI: 10.1016/j.prro.2019.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 11/07/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
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13
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Paetkau O, Gagne IM, Alexander A. SpaceOAR© hydrogel rectal dose reduction prediction model: a decision support tool. J Appl Clin Med Phys 2020; 21:15-25. [PMID: 32250042 PMCID: PMC7324696 DOI: 10.1002/acm2.12860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 02/10/2020] [Accepted: 03/04/2020] [Indexed: 12/12/2022] Open
Abstract
Prostate cancer external beam radiation therapy can result in toxicity due to organ at risk (OAR) dose, potentially impairing quality of life. A polyethylene glycol-based spacer, SpaceOAR© hydrogel (SOH), implanted between prostate gland and rectum may significantly reduce dose received by the rectum and hence risk of rectal toxicity. SOH implant is not equally effective in all patients. Determining patients in which the implant will offer most benefit, in terms of rectal dose reduction, allows for effective management of SOH resources. Several factors have been shown to be correlated with reduction in rectal dose including distance between rectum and planning treatment volume (PTV), volume of rectum in the PTV, and change in rectum volume pre- to post-SOH. Several of these factors along with other pre-SOH CT metrics were able to predict reduction in rectal dose associated with SOH implant. Rectal V55Gy metric, was selected as the dose level of interest in the context of 60 Gy in 20 fraction treatment plans. Models were produced to predict change in RV55Gy and pre-SOH hydrogel RV55Gy. These models offered R-squared between 0.81 and 0.88 with statistical significance in each model. Applying an ω 1 = 3% lower limit of pre-SOH RV55 Gy and an ω 2 = 3.5% lower limit on change in RV55 Gy, retained 60% of patients experiencing the largest rectal dose reduction from the hydrogel. This may offer a clinically useful tool in deciding which patients should receive SOH implant given limited resources. Predictive models, nomograms, and a workflow diagram were produced for clinical management of SOH implant.
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Affiliation(s)
- Owen Paetkau
- Department of Physics and Astronomy, University of Victoria, Victoria, BC, Canada
| | - Isabelle M Gagne
- Department of Physics and Astronomy, University of Victoria, Victoria, BC, Canada.,Department of Medical Physics, BC Cancer - Victoria, Victoria, BC, Canada
| | - Abraham Alexander
- Department of Radiation Oncology, BC Cancer - Victoria, Victoria, BC, Canada.,Department of Surgery, University of British Columbia, Vancouver, BC, Canada
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14
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Jones S, Hargrave C, Deegan T, Holt T, Mengersen K. Comparison of statistical machine learning models for rectal protocol compliance in prostate external beam radiation therapy. Med Phys 2020; 47:1452-1459. [DOI: 10.1002/mp.14044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/23/2019] [Accepted: 01/08/2020] [Indexed: 12/14/2022] Open
Affiliation(s)
- Scott Jones
- Radiation Oncology Princess Alexandra Hospital Raymond Terrace Brisbane Qld 4101 Australia
- Science and Engineering Faculty Queensland University of Technology Brisbane Qld 4000 Australia
| | - Catriona Hargrave
- Radiation Oncology Princess Alexandra Hospital Raymond Terrace Brisbane Qld 4101 Australia
- School of Clinical Sciences Faculty of Health Queensland University of Technology Brisbane Qld 4000 Australia
| | - Timothy Deegan
- Radiation Oncology Princess Alexandra Hospital Raymond Terrace Brisbane Qld 4101 Australia
- School of Clinical Sciences Faculty of Health Queensland University of Technology Brisbane Qld 4000 Australia
| | - Tanya Holt
- Radiation Oncology Princess Alexandra Hospital Raymond Terrace Brisbane Qld 4101 Australia
- University of Queensland Brisbane Qld 4072 Australia
| | - Kerrie Mengersen
- Science and Engineering Faculty Queensland University of Technology Brisbane Qld 4000 Australia
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15
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What is the quality of hydrogel spacer insertions? and which patients will benefit? A literature review. JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s1460396919000979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractAim:To evaluate the quality of rectal hydrogel spacer (HS) insertions from literature in patients undergoing radical radiotherapy for prostate cancer. The secondary aim is to assess the benefit of HSs in patients with risk factors more likely to have rectal complications, such as non-conventional radiotherapy dose fractionations and high-risk disease.Method and materials:A literature search of peer-reviewed electronic articles was carried out using Boolean connectors and Medical Subject Headings in the databases. Databases searched included ScienceDirect, Medline and Cinahl. The articles were assessed using relevant critical appraisal skills programme tools.Results:From the 26 studies used, HS showed a clinically significant relative reduction in rectal planning dose volumes for both high- and low-risk prostate cancer patients in a range of radiotherapy treatment modalities including volumetric modulated arc therapy, intensity-modulated radiotherapy, intensity-modulated proton therapy, stereotactic ablative body radiotherapy and brachytherapy. Spacer placements were successfully inserted in 99% of patients. However, rectal wall infiltration occurrence was 6% and ≥2 cm unsymmetrical placements in 2%.Findings:A spacer scoring system based on the HS symmetry has provided evidence of the quality of the position inserted, which was visually aided by T2-wieghted MRIs. Despite optimal HS placements ranging from 62 to 72%, HS had a clinically significant reduction of ≥25% in planned rectal V70 dose in 97% of patients.
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16
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Sanmamed N, Glicksman RM, Helou J, Chung P, Berlin A. Case series illustrating the synergistic use of hydrogel spacer and MR-guidance to increase the radiotherapeutic index for localized prostate cancer. Tech Innov Patient Support Radiat Oncol 2019; 11:22-25. [PMID: 32095546 PMCID: PMC7033779 DOI: 10.1016/j.tipsro.2019.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 07/24/2019] [Accepted: 08/30/2019] [Indexed: 12/13/2022] Open
Abstract
Polyethylene glycol hydrogel spacer allows radiotherapy in challenging scenarios. Polyethylene glycol hydrogel material properties may limit broader applicability. MRI-guided brachytherapy unique scenario to use PEG without compromising prostate resolution.
Background The risk of gastrointestinal (GI) toxicity may limit the use of curative-intent radical radiotherapy (RT) for prostate cancer (PCa) in circumstances where morbidity of treatment may exceed an acceptable threshold. Rectal spacers are used to expand the distance between the anterior rectal wall and the prostate, consequently sparing the rectum from the high-dose region. Case presentations We report three clinical scenarios of PCa patients treated at our institution, where risk of RT-associated rectal toxicity may be increased: inflammatory bowel disease (IBD), salvage brachytherapy (BT) after previous external beam RT (EBRT), and tailored dose-escalation with focal BT to the gross tumor volume followed by stereotactic body RT. Prior to RT, a polyethylene glycol (PEG) hydrogel spacer was successfully placed in all cases. Treatment comprised magnetic resonance (MR) guided high dose-rate BT ± EBRT. All patients completed treatment uneventfully, without any significant GI toxicity at last follow-up. Conclusions These cases illustrate the utility of PEG hydrogel spacer, where concerns of radiation induced toxicity may have previously limited the application of radiotherapy. The synergistic use of these novel devices together with MR-guided BT may expand the indications and therapeutic index of curative-intent RT-based treatments, while minimizing the risks of GI toxicity.
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Affiliation(s)
- Noelia Sanmamed
- Department of Radiation Oncology, University of Toronto, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | | | - Joelle Helou
- Department of Radiation Oncology, University of Toronto, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Peter Chung
- Department of Radiation Oncology, University of Toronto, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada.,Techna Institute, University Health Network, Canada
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17
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Te Velde BL, Westhuyzen J, Awad N, Wood M, Shakespeare TP. Late toxicities of prostate cancer radiotherapy with and without hydrogel SpaceAOR insertion. J Med Imaging Radiat Oncol 2019; 63:836-841. [PMID: 31520465 DOI: 10.1111/1754-9485.12945] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 07/29/2019] [Indexed: 12/30/2022]
Abstract
INTRODUCTION To investigate whether the implantation of a hydrogel spacer (SpaceOAR) reduces long-term rectal toxicity for prostate cancer patients treated with intensity-modulated radiotherapy (IMRT). METHODS Patients with localised prostate cancer treated with 81 Gy in 45 fx of IMRT over 9 weeks were retrospectively compared: 65 patients with SpaceOAR and 56 patients without SpaceOAR. Planning aims restricted rectal doses to V40 Gy < 35%, V65 Gy < 17%, V75 Gy < 10%. Toxicities were evaluated between 3 months and 3 years after the completion of radiotherapy and were based on the common terminology criteria for adverse events (CTCAE) assessment tool for diarrhoea, haemorrhoids, faecal incontinence and proctitis. RESULTS The cumulative incidence of low-grade diarrhoea (G1) was significantly higher in the non-SpaceOAR group (21.4% vs 6.2%; P = 0.016). The cumulative incidence of proctitis (grades G1 and G2) was also higher in the non-SpaceOAR group (26.7% vs 9.2%; P = 0.015); the cumulative incidence of G2 proctitis was higher in the latter group (P = 0.043). There were no differences between the treatment groups for cumulative incidences of faecal incontinence and/or haemorrhoids. Three years after IMRT, diarrhoea and proctitis were higher in the non-SpaceOAR group, without reaching statistical significance. This finding was unchanged after correcting for baseline symptoms. CONCLUSION SpaceOAR is of benefit in reducing the cumulative incidence of low-grade diarrhoea and proctitis for up to 3 years after intensity-modulated radiotherapy.
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Affiliation(s)
- Bridget L Te Velde
- Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Justin Westhuyzen
- Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Nader Awad
- Urology Centre, Port Macquarie, New South Wales, Australia
| | - Maree Wood
- Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Thomas P Shakespeare
- Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
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18
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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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19
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Rectal retractor application during image-guided dose-escalated prostate radiotherapy. Strahlenther Onkol 2019; 195:923-933. [PMID: 30824942 DOI: 10.1007/s00066-019-01445-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 02/08/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To investigate efficacy of a rectal retractor (RR) on rectal dose during image-guided dose-escalated prostate three-dimensional conformal radiotherapy (3DCRT). PATIENTS AND METHODS In all, 21 patients with localized prostate cancer were treated with a RR for 3DCRT in 40 × 2 Gy. Patient underwent two scans for radiotherapy planning, without and with RR. RR was used for the first half of the treatment sessions. Two plans were created for each patient to compare the effect of RR on rectal doses. PTW-31014 Pinpoint chamber embedded within RR was used for in vivo dosimetry in 6 of 21 patients. The patient tolerance and acute rectal toxicity were surveyed during radiotherapy using Common Terminology Criteria for Adverse Events (CTCAE) v.4.0. RESULTS Patients tolerated the RR well during 20 fractions with mild degree of anal irritation. Using a RR significantly reduced the rectal wall (RW), anterior RW and posterior RW dose-volume parameters. The average RW Dmean was 29.4 and 43.0 Gy for plans with and without RR, respectively. The mean discrepancy between the measured dose and planned dose was -3.8% (±4.9%). Grade 1 diarrhea, rectal urgency and proctitis occurred in 4, 2 and 3 cases, respectively. There were no grade ≥2 acute rectal toxicities during the treatment. CONCLUSION Rectal retraction resulted in a significant reduction of rectal doses with a safe toxicity profile, which may reduce rectal toxicity. Dosimeter inserted into the RR providing a practical method for in vivo dosimetric verification. Further prospective clinical studies will be necessary to demonstrate the clinical advantage of RR.
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20
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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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21
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Rohr A, Werth K, Shen X, Collins Z, Fishback S, Jones J, Ash R, Williams V. MRI findings of absorbable hydrogel spacer for prostate cancer therapy: a pictorial review. Abdom Radiol (NY) 2019; 44:247-251. [PMID: 29967983 DOI: 10.1007/s00261-018-1685-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Prior studies have shown that dose-escalated radiation therapy for prostate cancer improves clinical outcomes. However, this is associated with increased rectal toxicity. Hydrogel spacer for prostate cancer therapy is an effective way of decreasing rectal toxicity in the late post-therapeutic stages. In some occasions, the gel spacer may not be placed symmetrically between the rectum and prostate. There are several forms of a malpositioned spacer, including lateral displacement, rectal wall infiltration, and prostate capsule infiltration. This manuscript is aimed at evaluating appropriately positioned and malpositioned gel spacers, primarily via magnetic resonance imaging. There are limited educational imaging guides that address what radiologists should evaluate on post-spacer placement imaging. This pictorial review will specifically evaluate post-injection pitfalls such as asymmetry, rectal wall infiltration, and subcapsular injection.
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Affiliation(s)
- Aaron Rohr
- Department of Interventional Radiology, University of Stanford, 300 Pasteur Drive, H3531, Stanford, CA, 94305, USA.
| | - Kyle Werth
- Department of Radiology, University of Kansas Health Systems, Kansas City, USA
| | - Xinglei Shen
- Department of Radiation Oncology, University of Kansas Health Systems, Kansas City, USA
| | - Zachary Collins
- Department of Radiology, University of Kansas Health Systems, Kansas City, USA
| | - Shelby Fishback
- Department of Radiology, University of Kansas Health Systems, Kansas City, USA
| | - Jill Jones
- Department of Radiology, University of Kansas Health Systems, Kansas City, USA
| | - Ryan Ash
- Department of Radiology, University of Kansas Health Systems, Kansas City, USA
| | - Vanessa Williams
- Department of Radiology, University of Kansas Health Systems, Kansas City, USA
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22
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van Wijk Y, Vanneste BGL, Jochems A, Walsh S, Oberije CJ, Pinkawa M, Ramaekers BLT, Vega A, Lambin P. Development of an isotoxic decision support system integrating genetic markers of toxicity for the implantation of a rectum spacer. Acta Oncol 2018; 57:1499-1505. [PMID: 29952681 DOI: 10.1080/0284186x.2018.1484156] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Previous studies revealed that dose escalated radiotherapy for prostate cancer patients leads to higher tumor control probabilities (TCP) but also to higher rectal toxicities. An isotoxic model was developed to maximize the given dose while controlling the toxicity level. This was applied to analyze the effect of an implantable rectum spacer (IRS) and extended with a genetic test of normal tissue radio-sensitivity. A virtual IRS (V-IRS) was tested using this method. We hypothesized that the patients with increased risk of toxicity would benefit more from an IRS. MATERIAL AND METHODS Sixteen localized prostate cancer patients implanted with an IRS were included in the study. Treatment planning was performed on computed tomography (CT) images before and after the placement of the IRS and with a V-IRS. The normal tissue complication probability (NTCP) was calculated using a QUANTEC reviewed model for Grade > =2 late rectal bleeding and the number of fractions of the plans were adjusted until the NTCP value was under 5%. The resulting treatment plans were used to calculate the TCP before and after placement of an IRS. This was extended by adding the effect of two published genetic single nucleotide polymorphisms (SNP's) for late rectal bleeding. RESULTS The median TCP resulting from the optimized plans in patients before the IRS was 75.1% [32.6-90.5%]. With IRS, the median TCP is significantly higher: 98.9% [80.8-99.9%] (p < .01). The difference in TCP between the V-IRS and the real IRS was 1.8% [0.0-18.0%]. Placing an IRS in the patients with SNP's improved the TCP from 49.0% [16.1-80.8%] and 48.9% [16.0-72.8%] to 96.3% [67.0-99.5%] and 90.1% [49.0-99.5%] (p < .01) respectively for either SNP. CONCLUSION This study was a proof-of-concept for an isotoxic model with genetic biomarkers with a V-IRS as a multifactorial decision support system for the decision of a placement of an IRS.
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Affiliation(s)
- Yvonka van Wijk
- The D‐Lab: Decision Support for Precision Medicine, GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Ben G. L. Vanneste
- Department of Radiation Oncology (MAASTRO), GROW – School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Arthur Jochems
- The D‐Lab: Decision Support for Precision Medicine, GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Sean Walsh
- The D‐Lab: Decision Support for Precision Medicine, GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Cary J. Oberije
- The D‐Lab: Decision Support for Precision Medicine, GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany
- Department of Radiation Oncology, MediClin Robert Janker Klinik, Bonn, Germany
| | - Bram L. T. Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Ana Vega
- Fundación Pública Galega de Medicina Xenómica-SERGAS, Grupo de Medicina Xenómica-USC, CIBERER, IDIS, Santiago de Compostela, Spain
| | - Philippe Lambin
- The D‐Lab: Decision Support for Precision Medicine, GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
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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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King RB, Osman SO, Fairmichael C, Irvine DM, Lyons CA, Ravi A, O'Sullivan JM, Hounsell AR, Mitchell DM, McGarry CK, Jain S. Efficacy of a rectal spacer with prostate SABR-first UK experience. Br J Radiol 2018; 91:20170672. [PMID: 29182384 DOI: 10.1259/bjr.20170672] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE This study assessed the use of implanted hydrogel rectal spacers for stereotactic ablative radiotherapy-volumetric modulated arc therapy (SABR-VMAT) patients, investigating practicality, dosimetric impact, normal tissue complication probability (NTCP) and early toxicity. METHODS Data from the first 6 patients treated within a prostate SABR and rectal spacer trial were examined to determine spacer insertion tolerability, resultant changes in treatment planning and dosimetry and early toxicity effects. CT scans acquired prior to spacer insertion were used to generate SABR plans which were compared to post-insertion plans. Plans were evaluated for target coverage, conformity, and organs at risk doses with NTCPs also determined from resultant dose fluences. Early toxicity data were also collected. RESULTS All patients had successful spacer insertion under local anaesthetic with maximal Grade 1 toxicity. All plans were highly conformal, with no significant differences in clinical target volume dose coverage between pre- and post-spacer plans. Substantial improvements in rectal dose metrics were observed in post-spacer plans, e.g. rectal volume receiving 36 Gy reduced by ≥42% for all patients. Median NTCP for Grade 2 + rectal bleeding significantly decreased from 4.9 to 0.8% with the use of a rectal spacer (p = 0.031). To date, two episodes of acute Grade 1 proctitis have been reported following treatment. CONCLUSION The spacer resulted in clinically and statistically significant reduction in rectal doses for all patients. Advances in knowledge: This is one of the first studies to investigate the efficacy of a hydrogel spacer in prostate SABR treatments. Observed dose sparing of the rectum is predicted to result in meaningful clinical benefit.
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Affiliation(s)
- Raymond B King
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Sarah Os Osman
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Ciaran Fairmichael
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Denise M Irvine
- 2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Ciara A Lyons
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland.,4 Department of Clinical Oncology, North West Cancer Centre, Altnagelvin Area Hospital , Londonderry , Northern Ireland
| | - Ananth Ravi
- 5 Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre , Toronto , Canada
| | - Joe M O'Sullivan
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Alan R Hounsell
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Darren M Mitchell
- 3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Conor K McGarry
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,2 Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
| | - Suneil Jain
- 1 Centre for Cancer Research and Cell Biology, Queen's University Belfast , Belfast , Ireland.,3 Department of Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital , Belfast , Ireland
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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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Development of a virtual spacer to support the decision for the placement of an implantable rectum spacer for prostate cancer radiotherapy: Comparison of dose, toxicity and cost-effectiveness. Radiother Oncol 2017; 125:107-112. [DOI: 10.1016/j.radonc.2017.07.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/12/2017] [Accepted: 07/25/2017] [Indexed: 02/06/2023]
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Long-term outcomes of a phase II trial of moderate hypofractionated image-guided intensity modulated radiotherapy (IG-IMRT) for localized prostate cancer. Radiother Oncol 2017; 122:93-98. [DOI: 10.1016/j.radonc.2016.10.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 10/14/2016] [Accepted: 10/24/2016] [Indexed: 11/23/2022]
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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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Hamstra DA, Mariados N, Sylvester J, Shah D, Karsh L, Hudes R, Beyer D, Kurtzman S, Bogart J, Hsi RA, Kos M, Ellis R, Logsdon M, Zimberg S, Forsythe K, Zhang H, Soffen E, Francke P, Mantz C, Rossi P, DeWeese T, Daignault-Newton S, Fischer-Valuck BW, Chundury A, Gay H, Bosch W, Michalski J. Continued Benefit to Rectal Separation for Prostate Radiation Therapy: Final Results of a Phase III Trial. Int J Radiat Oncol Biol Phys 2016; 97:976-985. [PMID: 28209443 DOI: 10.1016/j.ijrobp.2016.12.024] [Citation(s) in RCA: 241] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/01/2016] [Accepted: 12/15/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE SpaceOAR, a Food and Drug Administration-approved hydrogel intended to create a rectal-prostate space, was evaluated in a single-blind phase III trial of image guided intensity modulated radiation therapy. A total of 222 men were randomized 2:1 to the spacer or control group and received 79.2 Gy in 1.8-Gy fractions to the prostate with or without the seminal vesicles. The present study reports the final results with a median follow-up period of 3 years. METHODS AND MATERIALS Cumulative (Common Terminology Criteria for Adverse Events, version 4.0) toxicity was evaluated using the log-rank test. Quality of life (QOL) was examined using the Expanded Prostate Cancer Index Composite (EPIC), and the mean changes from baseline in the EPIC domains were tested using repeated measures models. The proportions of men with minimally important differences (MIDs) in each domain were tested using repeated measures logistic models with prespecified thresholds. RESULTS The 3-year incidence of grade ≥1 (9.2% vs 2.0%; P=.028) and grade ≥2 (5.7% vs 0%; P=.012) rectal toxicity favored the spacer arm. Grade ≥1 urinary incontinence was also lower in the spacer arm (15% vs 4%; P=.046), with no difference in grade ≥2 urinary toxicity (7% vs 7%; P=0.7). From 6 months onward, bowel QOL consistently favored the spacer group (P=.002), with the difference at 3 years (5.8 points; P<.05) meeting the threshold for a MID. The control group had a 3.9-point greater decline in urinary QOL compared with the spacer group at 3 years (P<.05), but the difference did not meet the MID threshold. At 3 years, more men in the control group than in the spacer group had experienced a MID decline in bowel QOL (41% vs 14%; P=.002) and urinary QOL (30% vs 17%; P=.04). Furthermore, the control group were also more likely to have experienced large declines (twice the MID) in bowel QOL (21% vs 5%; P=.02) and urinary QOL (23% vs 8%; P=.02). CONCLUSIONS The benefit of a hydrogel spacer in reducing the rectal dose, toxicity, and QOL declines after image guided intensity modulated radiation therapy for prostate cancer was maintained or increased with a longer follow-up period, providing stronger evidence for the benefit of hydrogel spacer use in prostate radiation therapy.
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Affiliation(s)
| | - Neil Mariados
- Associated Medical Professionals of NY, PLLC, Syracuse, New York
| | - John Sylvester
- 21st Century Oncology, Inc, Lakewood Ranch, East Bradenton, Florida
| | - Dhiren Shah
- Western New York Urology Associates, LLC, Doing Business as Cancer Care of WNY, Cheektowaga, New York
| | | | - Richard Hudes
- Chesapeake Urology Associates, Doing Business as Chesapeake Urology Research Associates (The Prostate Center), Owings Mills, Maryland
| | - David Beyer
- Arizona Oncology Services Foundation, Phoenix, Arizona
| | - Steven Kurtzman
- Urological Surgeons of Northern California Inc, Campbell, California
| | - Jeffrey Bogart
- The Research Foundation of State University of New York/State University of New York Upstate Medical University, Syracuse, New York
| | - R Alex Hsi
- Peninsula Cancer Center, Poulsbo, Washington
| | | | - Rodney Ellis
- University Hospitals Case Medical Center, Cleveland, Ohio
| | - Mark Logsdon
- Sutter Health Sacramento Sierra Region, Doing Business as Sutter Institute for Medical Research, Sacramento, California
| | - Shawn Zimberg
- Advanced Radiation Centers of New York, Lake Success, New York
| | | | - Hong Zhang
- University of Rochester, Rochester, New York
| | | | - Patrick Francke
- Carolina Regional Cancer Center, LLC, 21st Century Oncology, Inc, Myrtle Beach, South Carolina
| | | | | | | | | | | | | | - Hiram Gay
- Washington University School of Medicine, St Louis, Missouri
| | - Walter Bosch
- Washington University School of Medicine, St Louis, Missouri
| | - Jeff Michalski
- Washington University School of Medicine, St Louis, Missouri
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