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Mohamad O, Zamboglou C, Zilli T, Murthy V, Aebersold DM, Loblaw A, Guckenberger M, Shelan M. Safety of Ultrahypofractionated Pelvic Nodal Irradiation in the Definitive Management of Prostate Cancer: Systematic Review and Meta-analysis. Int J Radiat Oncol Biol Phys 2024; 118:998-1010. [PMID: 37863241 DOI: 10.1016/j.ijrobp.2023.09.053] [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: 07/31/2023] [Revised: 09/15/2023] [Accepted: 09/29/2023] [Indexed: 10/22/2023]
Abstract
PURPOSE This systematic review and meta-analysis aimed to evaluate the evidence for ultrahypofractionated pelvic nodal irradiation in patients with prostate cancer, with a focus on reported acute and late toxicities. METHODS AND MATERIALS A comprehensive search was conducted in 5 electronic databases (PubMed, Scopus, Web of Science, Cochrane Library, ClinicalTrials.gov) from inception until March 23, 2023. Eligible publications included patients with intermediate- and high-risk and node-positive prostate cancer who underwent elective or therapeutic ultrahypofractionated pelvic nodal irradiation. Primary outcomes included the presence of grade ≥2 rates of acute and late gastrointestinal and genitourinary toxicity based on the Common Terminology Criteria for Adverse Events or Radiation Therapy Oncology Group scales. Quality assessment was performed using National Institutes of Health tools for noncontrolled beforeand after (single arm) clinical trials, as well as single-arm observational studies. Because all outcomes were categorical variables, proportion was calculated to estimate the effect size and compare the outcomes after the intervention. RESULTS We identified 16 publications that reported the use of ultrahypofractionated radiation therapy to treat the pelvis in prostate cancer. Seven publications met our criteria and were included in the meta-analysis, including 417 patients. The median total dose to the pelvic lymph nodes was 25 Gy (range, 25-28.5 Gy), with a median of 5 fractions. The prostate received a median dose of 40 Gy (range, 35-47.5 Gy). All studies used androgen deprivation therapy for a median duration of 18 months. The median follow-up period was 3 years (range, 0.5-5.6 years). The rates of acute grade ≥2 gastrointestinal and genitourinary toxicity were 8% (95% CI, 1%-15%) and 29% (95% CI, 18%-41%), respectively. For late grade ≥2 gastrointestinal and genitourinary toxicity, the rates were 13% (95% CI, 5%-21%) and 29% (95% CI, 17%-42%), respectively. CONCLUSIONS Ultrahypofractionated pelvic nodal irradiation appears to be a safe approach in terms of acute and late genitourinary and gastrointestinal toxicity.
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Affiliation(s)
- Osama Mohamad
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Constantinos Zamboglou
- Department of Radiation Oncology, Medical Center - Uwniversity of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Oncology Center, European University Cyprus, Limassol, Cyprus
| | - Thomas Zilli
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Vedang Murthy
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre and Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Mohamed Shelan
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland.
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Wu J, Ran X, Wang T, Xiong K, Long S, Hao Y, Wang P, Wang A. Enteric α-Defensin Contributes to Recovery of Radiation-Induced Intestinal Injury by Modulating Gut Microbiota and Fecal Metabolites. Radiat Res 2024; 201:160-173. [PMID: 38124379 DOI: 10.1667/rade-23-00071.1] [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: 04/24/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023]
Abstract
The effect of ionizing radiation on the gastrointestinal tract is a common complication of abdominal and pelvic radiotherapy. However, the pathological features of radiation enteropathy and its effective medical intervention regimen is still a global challenge. Here, we explored the role and mechanism of enteric alpha-defensins (EαDs) in protecting against radiation enteropathy. To address this, we utilized EαDs-deficiency mice, in which the matrix metallopeptidase 7 to activate Paneth cell α-defensins was knockout (KO) mice, and the complementary wild-type (WT) control mice for this study. Remarkably, the KO mice were more susceptible to 5.0 Gy total-body irradiation, resulting in worse clinic scores and lower survival rate, compared with the wild-type mice. Histological examination indicated that the KO mice were subjected to slow recovery of intestinal villus and mucosa function, characterized by the reduced expression of TFF3, Glut1 and Muc2. In addition, compared with the wild-type controls, the KO mice experienced serious inflammation response in intestinal tissue, indicated by the remarkably increased expression level of IL-1β, IL-6 and IL-12. Using high-throughput sequencing analysis, we found that the intestinal bacterial community of the KO mice was more prone to dysbiosis than that of the WT mice, with significantly increased abundance of opportunistic pathogenic bacteria, such as Streptococcus sp. and Escherichia-Shigella sp., whereas remarkably decreased probiotics harboring Lactobacillus sp., Desulfovibrio sp. etc. Fecal metabolomics analysis indicated that the relative abundance of 31 metabolites arose significantly different between WT and KO mice on day 10 after radiation exposure. A subset of differential metabolites to regulate host metabolism and immunity, such as acetic acid, acetate, butanoic acid, was negatively correlated with the alteration of gut microbiota in the irradiated KO mice. This study provides new insight into EαDs contribution to the recovery of radiation-induced intestinal damage, and suggests a potential novel target to prevent the adverse effects of radiotherapy.
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Affiliation(s)
- Jie Wu
- Department of Frigid Zone Medicine, College of High Altitude Military Medicine, Army Medical University, Chongqing 400038, China
- Department of Radiation Medicine, College of Preventive Medicine, Army Medical University, Chongqing 400038, China
| | - Xi Ran
- Department of Clinical Laboratory, the Second Affiliated Hospital of Army Medical University, Chongqing 400037, China
| | - Tao Wang
- Department of Radiation Medicine, College of Preventive Medicine, Army Medical University, Chongqing 400038, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Chongqing 400038, China
| | - Kun Xiong
- Department of Frigid Zone Medicine, College of High Altitude Military Medicine, Army Medical University, Chongqing 400038, China
| | - Shuang Long
- Department of Radiation Medicine, College of Preventive Medicine, Army Medical University, Chongqing 400038, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Chongqing 400038, China
| | - Yuhui Hao
- Department of Radiation Medicine, College of Preventive Medicine, Army Medical University, Chongqing 400038, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Chongqing 400038, China
| | - Peng Wang
- Department of Oncology, Southwest Hospital, Army Medical University
| | - Aiping Wang
- Department of Frigid Zone Medicine, College of High Altitude Military Medicine, Army Medical University, Chongqing 400038, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Chongqing 400038, China
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Beaudry M, Carignan D, Foster W, Lavallee M, Aubin S, Lacroix F, Poulin E, Lachance B, Després P, Beaulieu L, Vigneault E, Martin A. Comparison of four-year toxicities and local control of ultra-hypofractionated vs moderate-hypofractionated image guided prostate radiation with HDR brachytherapy boost: A phase I-II single institution trial. Clin Transl Radiat Oncol 2023; 40:100593. [PMID: 36875870 PMCID: PMC9974413 DOI: 10.1016/j.ctro.2023.100593] [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: 10/31/2022] [Revised: 02/03/2023] [Accepted: 02/05/2023] [Indexed: 02/10/2023] Open
Abstract
Purpose/Objectives To analyze the long term efficacy and safety of an ultra-hypofractionated (UHF) radiation therapy prostate treatment regimen with HDR brachytherapy boost (BB) and compare it to moderate-hypofractionated regimens (MHF). Materials/Methods In this single arm, prospective monocentric study, 28 patients with intermediate risk prostate cancer were recruited in an experimental treatment arm of 25 Gy in 5 fractions plus a 15 Gy HDR BB. They were then compared to two historical control groups, treated with either 36 Gy in 12 fractions or 37.5 Gy in 15 fractions with a similar HDR BB. The control groups included 151 and 311 patients respectively. Patient outcomes were reported using the International Prostate Symptom Score (IPSS) and Expanded Prostate Index Composite (EPIC-26) questionnaires at baseline and at each follow-up visit. Results Median follow-up for the experimental arm was 48.5 months compared to 47 months and 60 months compared to the 36/12 and 37,5/15 groups respectively. The IPSS and EPIC scores did not demonstrate any significant differences in the gastrointestinal or genitourinary domains between the three groups over time. No biochemical recurrence occurred in the UHF arm as defined by the Phoenix criterion. Conclusion The UHF treatment scheme with HDR BB seems equivalent to standard treatment arms in terms of toxicities and local control. Randomized control trials with larger cohorts are ongoing and needed to further confirm our findings.
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Affiliation(s)
- M.M. Beaudry
- CHU de Québec-Université Laval, Service de radio-oncologie, Québec, QC, Canada
| | - D. Carignan
- Centre de recherche sur le cancer, Université Laval, Québec, QC, Canada
| | - W. Foster
- CHU de Québec-Université Laval, Service de radio-oncologie, Québec, QC, Canada
| | - M.C. Lavallee
- CHU de Québec-Université Laval, Service de radio-oncologie, Québec, QC, Canada
| | - S. Aubin
- CHU de Québec-Université Laval, Service de radio-oncologie, Québec, QC, Canada
| | - F. Lacroix
- CHU de Québec-Université Laval, Service de radio-oncologie, Québec, QC, Canada
| | - E. Poulin
- CHU de Québec-Université Laval, Service de radio-oncologie, Québec, QC, Canada
| | - B. Lachance
- CHU de Québec-Université Laval, Service de radio-oncologie, Québec, QC, Canada
| | - P. Després
- CHU de Québec-Université Laval, Service de radio-oncologie, Québec, QC, Canada
- Centre de recherche sur le cancer, Université Laval, Québec, QC, Canada
| | - L. Beaulieu
- CHU de Québec-Université Laval, Service de radio-oncologie, Québec, QC, Canada
- Centre de recherche sur le cancer, Université Laval, Québec, QC, Canada
| | - E. Vigneault
- CHU de Québec-Université Laval, Service de radio-oncologie, Québec, QC, Canada
- Centre de recherche sur le cancer, Université Laval, Québec, QC, Canada
| | - A.G. Martin
- CHU de Québec-Université Laval, Service de radio-oncologie, Québec, QC, Canada
- Centre de recherche sur le cancer, Université Laval, Québec, QC, Canada
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Two-fraction stereotactic ablative radiotherapy with simultaneous boost to MRI-defined dominant intra-prostatic lesion - Results from the 2SMART phase 2 trial. Radiother Oncol 2023; 181:109503. [PMID: 36754232 DOI: 10.1016/j.radonc.2023.109503] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE This is the first report of the 2SMART Phase II trial evaluating the safety of two-fraction stereotactic ablative radiotherapy (SABR) with focal boost to magnetic resonance imaging (MRI) defined dominant intra-prostatic lesion (DIL) for localised prostate cancer. MATERIALS AND METHODS Men with low or intermediate risk prostate cancer were eligible for the study. The gross tumour volume (GTV) was MRI-defined DIL, and the clinical target volume (CTV) was entire prostate gland. The planning target volume (PTV) was a 2 mm expansion anteroposterior and lateral, and 2.5 mm superoinferior. The prescribed dose was 32 Gy to GTV, and 26 Gy to CTV. Primary endpoint was minimal clinically important change (MCIC) in quality of life (QOL) within 3-months of SABR, assessed using the EPIC-26 questionnaire. Secondary endpoints were acute and late toxicities (assessed using CTCAEv4), PSA nadir, and biochemical failure (based on Phoenix criteria). RESULTS Thirty men were enrolled in the study - 2 (7%) had low-risk and 28 (93%) had intermediate risk prostate cancer. The median follow-up was 44 months (range:39-49 months). The median PSA nadir was 0.25 ng/mL, with median time to nadir of 37 months. One patient (3%) had biochemical failure at 44 months post-treatment. Ten (33%), six (20%), and three (10%) men had acute MCIC in urinary, bowel, and sexual QOL domains respectively. No acute or late grade ≥ 3 urinary or bowel toxicities were observed. CONCLUSION This novel protocol of two-fraction prostate SABR with MRI-defined DIL boost is a safe approach for dose-escalation, with minimal impact on acute QOL and no grade ≥ 3 toxicities.
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Murthy V, Adsul K, Maitre P, Singhla A, Singh P, Panigrahi G, Raveendran V, Phurailatpam R. Acute and late toxicity of prostate-only or pelvic SBRT in prostate cancer: A Comparative Study. Int J Radiat Oncol Biol Phys 2022; 114:275-282. [PMID: 35724773 DOI: 10.1016/j.ijrobp.2022.05.050] [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: 03/15/2022] [Revised: 05/13/2022] [Accepted: 05/28/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare the urinary and gastrointestinal toxicity with or without the inclusion of pelvic nodal regions in patients treated with extreme hypofractionated stereotactic radiotherapy (SBRT) for prostate cancer. METHODS Patients treated with definitive SBRT for non-metastatic adenocarcinoma prostate were identified from prospectively maintained institutional database, and details of radiotherapy volume, dose, acute and late adverse effects were analyzed. Symptoms of acute (within 90 days of completing SBRT) and late gastrointestinal and urinary toxicities were graded using CTCAE version 5.0. Each symptom was scored according to the worst reported grading during treatment and follow-up period. Cumulative toxicity rates between prostate-only SBRT (PO-SBRT) and whole pelvic SBRT (WP-SBRT) were compared using chi-square test. RESULTS Total 220 patients were analyzed (PO-SBRT=118, WP-SBRT=102), with a median follow-up of 28 months (IQR 14-40). Most patients had locally advanced disease (PO-SBRT 60% high risk and 40% intermediate risk, WP-SBRT 79% node positive and 21% high risk). Median SBRT dose was 36.25Gy (IQR 35-36.25) to the prostate (EQD2=90.6Gy, a/b=1.5Gy) and simultaneous integrated 25Gy to the pelvis (EQD2=46.3Gy) in five fractions on alternate days. No grade 3-4 acute toxicities were observed except one grade 3 urinary obstruction (PO-SBRT). WP-SBRT was associated with significantly higher acute grade 2 gastrointestinal toxicity (29.4% vs 14.7%, p=0.008) and late grade 2 urinary toxicity (45.6% vs 25.0%, p=0.003). Both the groups had low incidence of late grade 3 toxicities (urinary 2.5%, gastrointestinal 1%). CONCLUSION WP-SBRT was associated with significantly higher acute gastrointestinal and late urinary toxicity as compared to PO-SBRT, though overall incidence of severe toxicity was low.
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Affiliation(s)
| | | | | | | | | | | | - Vysakh Raveendran
- Department of Medical Physics, Tata Memorial Hospital and Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Reena Phurailatpam
- Department of Medical Physics, Tata Memorial Hospital and Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, India
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Glicksman RM, Liu SK, Cheung P, Vesprini D, Chu W, Chung HT, Morton G, Deabreu A, Davidson M, Ravi A, Musunuru HB, Helou J, Ho L, Zhang L, Loblaw A. Elective nodal ultra hypofractionated radiation for prostate cancer: Safety and efficacy from four prospective clinical trials. Radiother Oncol 2021; 163:159-164. [PMID: 34487764 DOI: 10.1016/j.radonc.2021.08.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/19/2021] [Accepted: 08/25/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE The role of elective nodal irradiation (ENI) in localized prostate cancer (PCa) is controversial. With increasing use of SBRT to the prostate, data is needed regarding the safety and efficacy of ENI using ultra-hypofractionated radiation (UHRT). MATERIALS AND METHODS Between 2013-2020, 4 prospective clinical trials of intermediate or high-risk PCa receiving dose-escalated RT to the prostate (via HDR brachytherapy or SBRT boost) and ENI using UHRT (25 Gy in 5 weekly fractions) were conducted. Primary endpoints included acute genitourinary and gastrointestinal toxicities (CTCAE v3.0/4.0), and secondary endpoints included late genitourinary and gastrointestinal toxicities, patient-reported quality of life (EPIC) and biochemical failure (Phoenix definition). RESULTS One-hundred sixty-five patients were enrolled, of whom 98 (59%) had high-risk disease. ADT was used in 141 (85%). Median follow-up was 38 months (IQR 10-63). The worst acute genitourinary and gastrointestinal toxicities respectively were 48% and 7.5% for grade 2, and 2.7% and 0% for grade 3. Cumulative incidence of late grade 2+ genitourinary and gastrointestinal toxicities at 36 months were 58% and 11.3% and for late grade 3+ toxicities were 1% and 0%, respectively. No grade 4+ acute or late toxicities were observed. Bowel and sexual toxicity significantly worsened up to 1-year compared to baseline. Over time, urinary (p < 0.0001), bowel (p = 0.0018) and sexual (p < 0.0001) scores significantly improved. The 3-year biochemical recurrence-free survival was 98%. CONCLUSION ENI using UHRT is associated with low incidence of grade 3+ toxicity, while grade 1-2 acute genitourinary and gastrointestinal toxicity is common. Randomized phase 3 trials are needed.
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Affiliation(s)
| | - Stanley K Liu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Patrick Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Danny Vesprini
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Hans T Chung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Gerard Morton
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Andrea Deabreu
- Clinical Trials and Epidemiology Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Ananth Ravi
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | | | - Joelle Helou
- Department of Radiation Oncology, University of Toronto, Canada; Princess Margaret Cancer Centre, Canada
| | - Ling Ho
- Department of Radiation Oncology, University of Toronto, Canada
| | - Liying Zhang
- Clinical Trials and Epidemiology Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Canada; Institute of Health Policy, Management and Evaluation, Canada.
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