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Kim S, Kong JH, Lee Y, Lee JY, Kang TW, Kong TH, Kim MH, You SH. Dose-escalated radiotherapy for clinically localized and locally advanced prostate cancer. Cochrane Database Syst Rev 2023; 3:CD012817. [PMID: 36884035 PMCID: PMC9994460 DOI: 10.1002/14651858.cd012817.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
BACKGROUND Treatments for clinically localized prostate cancer include radical prostatectomy, external beam radiation therapy, brachytherapy, active surveillance, hormonal therapy, and watchful waiting. For external beam radiation therapy, oncological outcomes may be expected to improve as the dose of radiotherapy (RT) increases. However, radiation-mediated side effects on surrounding critical organs may also increase. OBJECTIVES To assess the effects of dose-escalated RT in comparison with conventional dose RT for curative treatment of clinically localized and locally advanced prostate cancer. SEARCH METHODS We performed a comprehensive search using multiple databases including trial registries and other sources of grey literature, up until 20 July 2022. We applied no restrictions on publication language or status. SELECTION CRITERIA We included parallel-arm randomized controlled trials (RCTs) of definitive RT in men with clinically localized and locally advanced prostate adenocarcinoma. RT was dose-escalated RT (equivalent dose in 2 Gy [EQD2] ≥ 74 Gy, lesser than 2.5 Gy per fraction) versus conventional RT (EQD2 < 74 Gy, 1.8 Gy or 2.0 Gy per fraction). Two review authors independently classified studies for inclusion or exclusion. DATA COLLECTION AND ANALYSIS Two review authors independently abstracted data from the included studies. We performed statistical analyses by using a random-effects model and interpreted them according to the Cochrane Handbook for Systematic Reviews of Interventions. We used GRADE guidance to rate the certainty of the evidence of RCTs. MAIN RESULTS We included nine studies with 5437 men in an analysis comparing dose-escalated RT versus conventional dose RT for the treatment of prostate cancer. The mean participant age ranged from 67 to 71 years. Almost all men had localized prostate cancer (cT1-3N0M0). Primary outcomes Dose-escalated RT probably results in little to no difference in time to death from prostate cancer (hazard ratio [HR] 0.83, 95% CI 0.66 to 1.04; I2 = 0%; 8 studies; 5231 participants; moderate-certainty evidence). Assuming a risk of death from prostate cancer of 4 per 1000 at 10 years in the conventional dose RT group, this corresponds to 1 fewer men per 1000 (1 fewer to 0 more) dying of prostate cancer in the dose-escalated RT group. Dose-escalated RT probably results in little to no difference in severe RT toxicity of grade 3 or higher late gastrointestinal (GI) toxicity (RR 1.72, 95% CI 1.32 to 2.25; I2 = 0%; 8 studies; 4992 participants; moderate-certainty evidence); 23 more men per 1000 (10 more to 40 more) in the dose-escalated RT group assuming severe late GI toxicity as 32 per 1000 in the conventional dose RT group. Dose-escalated RT probably results in little to no difference in severe late genitourinary (GU) toxicity (RR 1.25, 95% CI 0.95 to 1.63; I2 = 0%; 8 studies; 4962 participants; moderate-certainty evidence); 9 more men per 1000 (2 fewer to 23 more) in the dose-escalated RT group assuming severe late GU toxicity as 37 per 1000 in the conventional dose RT group. Secondary outcomes Dose-escalated RT probably results in little to no difference in time to death from any cause (HR 0.98, 95% CI 0.89 to 1.09; I2 = 0%; 9 studies; 5437 participants; moderate-certainty evidence). Assuming a risk of death from any cause of 101 per 1000 at 10 years in the conventional dose RT group, this corresponds to 2 fewer men per 1000 (11 fewer to 9 more) in the dose-escalated RT group dying of any cause. Dose-escalated RT probably results in little to no difference in time to distant metastasis (HR 0.83, 95% CI 0.57 to 1.22; I2 = 45%; 7 studies; 3499 participants; moderate-certainty evidence). Assuming a risk of distant metastasis of 29 per 1000 in the conventional dose RT group at 10 years, this corresponds to 5 fewer men per 1000 (12 fewer to 6 more) in the dose-escalated RT group developing distant metastases. Dose-escalated RT may increase overall late GI toxicity (RR 1.27, 95% CI 1.04 to 1.55; I2 = 85%; 7 studies; 4328 participants; low-certainty evidence); 92 more men per 1000 (14 more to 188 more) in the dose-escalated RT group assuming overall late GI toxicity as 342 per 1000 in the conventional dose RT group. However, dose-escalated RT may result in little to no difference in overall late GU toxicity (RR 1.12, 95% CI 0.97 to 1.29; I2 = 51%; 7 studies; 4298 participants; low-certainty evidence); 34 more men per 1000 (9 fewer to 82 more) in the dose-escalated RT group assuming overall late GU toxicity as 283 per 1000 in the conventional dose RT group. Based on long-term follow-up (up to 36 months), dose-escalated RT may result or probably results in little to no difference in the quality of life using 36-Item Short Form Survey; physical health (MD -3.9, 95% CI -12.78 to 4.98; 1 study; 300 participants; moderate-certainty evidence) and mental health (MD -3.6, 95% CI -83.85 to 76.65; 1 study; 300 participants; low-certainty evidence), respectively. AUTHORS' CONCLUSIONS Compared to conventional dose RT, dose-escalated RT probably results in little to no difference in time to death from prostate cancer, time to death from any cause, time to distant metastasis, and RT toxicities (except overall late GI toxicity). While dose-escalated RT may increase overall late GI toxicity, it may result, or probably results, in little to no difference in physical and mental quality of life, respectively.
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Affiliation(s)
- Sunghyun Kim
- Department of Radation Oncology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Jee Hyun Kong
- Department of Hematology-Oncology, Division of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea, South
- Center of Evidence Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea, South
| | - YoHan Lee
- Department of Radation Oncology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Jun Young Lee
- Center of Evidence Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea, South
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Tae Wook Kang
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Tae Hoon Kong
- Department of Otorhinolaryngology Head and neck surgery, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Myung Ha Kim
- Yonsei Wonju Medical Library, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Sei Hwan You
- Department of Radation Oncology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
- Center of Evidence Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea, South
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Turna M, Akboru H, Ermis E, Oskeroglu S, Dincer S, Altin S. Stereotactic body radiotherapy as a boost after external beam radiotherapy for high-risk prostate cancer patients. Indian J Cancer 2020; 58:518-524. [PMID: 33402584 DOI: 10.4103/ijc.ijc_377_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background The effect of high-dose-rate (HDR) brachytherapy after external radiation in high-risk prostate cancer patients has been proven. Stereotactic body radiotherapy as a less invasive method has similar dosimetric results with HDR brachytherapy. This study aims to evaluate the prostate-specific antigen (PSA) response, acute side effects, and quality of life of patients who underwent stereotactic body radiotherapy (SBRT) as a boost after pelvic radiotherapy (RT). Methods A total of 34 patients diagnosed with high-risk prostate cancer treated with SBRT boost (21 Gy in three fractions) combined with whole pelvic RT (50 Gy in 25 fractions) were evaluated. Biochemical control has been evaluated with PSA before, and after treatment, acute adverse events were evaluated with radiation therapy oncology group (RTOG) grading scale and quality of life with the Expanded Prostate Cancer Index Composite (EPIC) scoring system. Results The mean follow-up of 34 patients was 41.2 months (range 7-52). The mean initial PSA level was 22.4 ng/mL. None of the patients had experienced a biochemical or clinical relapse of the disease. Grade 2 and higher acute gastrointestinal (GI) was observed in 14%, and genitourinary (GU) toxicity was observed in 29%. None of the patients had grade 3-4 late toxicity. Conclusions SBRT boost treatment after pelvic irradiation has been used with a good biochemical control and acceptable toxicity in high-risk prostate cancer patients. More extensive randomized trial results are needed on the subject.
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Affiliation(s)
- Menekse Turna
- Radiation Oncology Department, Okmeydani Research and Education Hospital, Sisli, Istanbul, Turkey
| | - Halil Akboru
- Radiation Oncology Department, Okmeydani Research and Education Hospital, Sisli, Istanbul, Turkey
| | - Ekin Ermis
- Radiation Oncology Department, Okmeydani Research and Education Hospital, Sisli, Istanbul, Turkey
| | - Sedenay Oskeroglu
- Radiation Oncology Department, Okmeydani Research and Education Hospital, Sisli, Istanbul, Turkey
| | - Selvi Dincer
- Radiation Oncology Department, Okmeydani Research and Education Hospital, Sisli, Istanbul, Turkey
| | - Suleyman Altin
- Radiation Oncology Department, Okmeydani Research and Education Hospital, Sisli, Istanbul, Turkey
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Alexander EJ, Murray JR, Morgan VA, Giles SL, Riches SF, Hazell S, Thomas K, Sohaib SA, Thompson A, Gao A, Dearnaley DP, DeSouza NM. Validation of T2- and diffusion-weighted magnetic resonance imaging for mapping intra-prostatic tumour prior to focal boost dose-escalation using intensity-modulated radiotherapy (IMRT). Radiother Oncol 2019; 141:181-187. [PMID: 31493904 PMCID: PMC6908966 DOI: 10.1016/j.radonc.2019.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/22/2019] [Accepted: 07/25/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE To assess the diagnostic accuracy and inter-observer agreement of T2-weighted (T2W) and diffusion-weighted (DW) magnetic resonance imaging (MRI) for mapping intra-prostatic tumour lesions (IPLs) for the purpose of focal dose-escalation in prostate cancer radiotherapy. MATERIALS AND METHODS Twenty-six men selected for radical treatment with radiotherapy were recruited prospectively and underwent pre-treatment T2W+DW-MRI and 5 mm spaced transperineal template-guided mapping prostate biopsies (TTMPB). A 'traffic-light' system was used to score both data sets. Radiologically suspicious lesions measuring ≥0.5 cm3 were classified as red; suspicious lesions 0.2-0.5 cm3 or larger lesions equivocal for tumour were classified as amber. The histopathology assessment combined pathological grade and tumour length on biopsy (red = ≥4 mm primary Gleason grade 4/5 or ≥6 mm primary Gleason grade 3). Two radiologists assessed the MRI data and inter-observer agreement was measured with Cohens' Kappa co-efficient. RESULTS Twenty-five of 26 men had red image-defined IPLs by both readers, 24 had red pathology-defined lesions. There was a good correlation between lesions ≥0.5 cm3 classified "red" on imaging and "red" histopathology in biopsies (Reader 1: r = 0.61, p < 0.0001, Reader 2: r = 0.44, p = 0.03). Diagnostic accuracy for both readers for red image-defined lesions was sensitivity 85-86%, specificity 93-98%, positive predictive value (PPV) 79-92% and negative predictive value (NPV) 96%. Inter-observer agreement was good (Cohen's Kappa 0.61). CONCLUSIONS MRI is accurate for mapping clinically significant prostate cancer; diffusion-restricted lesions ≥0.5 cm3 can be confidently identified for radiation dose boosting.
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Affiliation(s)
- E J Alexander
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
| | - J R Murray
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
| | - V A Morgan
- The Institute of Cancer Research, Sutton, UK.
| | - S L Giles
- The Institute of Cancer Research, Sutton, UK.
| | - S F Riches
- The Institute of Cancer Research, Sutton, UK.
| | - S Hazell
- The Royal Marsden NHS Foundation Trust, Sutton, UK.
| | - K Thomas
- The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - S A Sohaib
- The Royal Marsden NHS Foundation Trust, Sutton, UK.
| | - A Thompson
- The Royal Marsden NHS Foundation Trust, Sutton, UK.
| | - A Gao
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
| | - D P Dearnaley
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
| | - N M DeSouza
- The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK.
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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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McPartlin A, Kershaw L, McWilliam A, Taylor MB, Hodgson C, van Herk M, Choudhury A. Changes in prostate apparent diffusion coefficient values during radiotherapy after neoadjuvant hormones. Ther Adv Urol 2018; 10:359-364. [PMID: 30574195 DOI: 10.1177/1756287218798748] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/30/2018] [Indexed: 01/21/2023] Open
Abstract
Background Changes in prostate cancer apparent diffusion coefficient (ADC) derived from diffusion-weighted magnetic resonance imaging (MRI) provide a noninvasive method for assessing radiotherapy response. This may be attenuated by neoadjuvant hormone therapy (NA-HT). We investigate ADC values measured before, during and after external beam radiotherapy (EBRT) following NA-HT. Methods Patients with ⩾T2c biopsy-proven prostate cancer receiving 3 months of NA-HT plus definitive radiotherapy were prospectively identified. All underwent ADC-MRI scans in the week before EBRT, in the third week of EBRT and 8 weeks after its completion. Imaging was performed at 1.5 T. The tumour, peripheral zone (PZ) and central zone (CZ) of the prostate gland were identified and median ADC calculated for each region and time point. Results Between September and December 2014, 15 patients were enrolled (median age 68.3, range 57-78) with a median Gleason score of 7 (6-9) and prostate-specific antigen (PSA) at diagnosis 14 (3-197) ng/ml. Median period of NA-HT prior to first imaging was 96 days (69-115). All patients completed treatment. Median follow up was 25 months (7-34), with one patient relapsing in this time. Thirteen patients completed all imaging as intended, one withdrew after one scan and another missed the final imaging. PZ and CZ could not be identified in one patient. Median tumour ADC before, during and post radiotherapy was 1.24 × 10-3 mm2/s (interquartile range 0.16 × 10-3 mm2/s), 1.31 × 10-3 mm2/s (0.22 × 10-3 mm2/s), then 1.32 × 10-3 mm2/s (0.13 × 10-3 mm2/s) respectively (p > 0.05). There was no significant difference between median tumour and PZ or CZ ADC at any point. Gleason score did not correlate with ADC values. Conclusions Differences in ADC parameters of normal and malignant tissue during EBRT appear attenuated by prior NA-HT. The use of changes in ADC as a predictive tool in this group may have limited utility.
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Affiliation(s)
- Andrew McPartlin
- The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
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Åström L, Grusell E, Sandin F, Turesson I, Holmberg L. Two decades of high dose rate brachytherapy with external beam radiotherapy for prostate cancer. Radiother Oncol 2018; 127:81-87. [DOI: 10.1016/j.radonc.2017.12.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 12/18/2017] [Accepted: 12/20/2017] [Indexed: 10/17/2022]
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Soumarová R, Homola L, Perková H, Stursa M. Three-Dimensional Conformal External Beam Radiotherapy versus the Combination of External Radiotherapy with High-Dose Rate Brachytherapy in Localized Carcinoma of the Prostate: Comparison of Acute Toxicity. TUMORI JOURNAL 2018; 93:37-44. [PMID: 17455870 DOI: 10.1177/030089160709300108] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background Radiotherapy represents one of the basic therapeutic methods in treatment of localized carcinoma of the prostate. Optimal irradiation dose is the cornerstone of a successful treatment. Along with local control of the disease and overall survival of the patient, possible acute and long-term side effects need to be monitored very closely. Methods A non-randomized prospective study comparing the acute genitourinary and gastrointestinal toxicity in patients irradiated for localized carcinoma of the prostate. Fifty-seven patients were treated with three-dimensional conformal external beam radiotherapy alone, and in the second treatment arm a combination of external beam radiotherapy and high-dose rate brachytherapy was employed in 40 patients. Results Three-dimensional conformai external beam radiotherapy. Acute G1 genitourinary toxicity was recorded in 35.1% of patients, G2 in 22.8%, and G2-3 in one patient (1.7%). Acute gastrointestinal toxicity was experienced by 54.4% of patients, G1 in 28.1%, G2 in 17.5%, and G3 in 8.8%. Three-dimensional conformal external beam radiotherapy + brachytherapy. Acute G1 genitourinary toxicity was recorded in 37.5% and grade 2 in 15% of the patients. Only G1 acute gastrointestinal toxicity was recorded in 40% of the patients. Conclusions Acute G1 genitourinary toxicity was experienced by a similar percentage of patients in both treatment arms. Acute G2 genitourinary toxicity was more frequent in the three-dimensional conformal radiotherapy arm. Higher acute genitourinary toxicity, G3 or G4, was recorded only in one patient per treatment arm. Acute gastrointestinal toxicity was more frequent in the three-dimensional conformal radiotherapy arm. Higher acute gastrointestinal toxicity, G2 and G3, was only observed in the three-dimensional conformal radiotherapy arm. The acute toxicity observed was of a low grade. The combination of external beam radiotherapy with brachytherapy resulted in a lower incidence of gastrointestinal toxicity than external beam radiotherapy alone.
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Affiliation(s)
- Renata Soumarová
- JG Mendel Cancer Center Nový Jicín, Hospital Nový Jicín, Czech Republic.
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Nitsche M, Brannath W, Brückner M, Wagner D, Kaltenborn A, Temme N, Hermann RM. Comparison of different contouring definitions of the rectum as organ at risk (OAR) and dose-volume parameters predicting rectal inflammation in radiotherapy of prostate cancer: which definition to use? Br J Radiol 2016; 90:20160370. [PMID: 27936891 DOI: 10.1259/bjr.20160370] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE The objective of this retrospective planning study was to find a contouring definition for the rectum as an organ at risk (OAR) in curative three-dimensional external beam radiotherapy (EBRT) for prostate cancer (PCa) with a predictive correlation between the dose-volume histogram (DVH) and rectal toxicity. METHODS In a pre-study, the planning CT scans of 23 patients with PCa receiving definitive EBRT were analyzed. The rectum was contoured according to 13 different definitions, and the dose distribution was correlated with the respective rectal volumes by generating DVH curves. Three definitions were identified to represent the most distinct differences in the shapes of the DVH curves: one anatomical definition recommended by the Radiation Therapy Oncology Group (RTOG) and two functional definitions based on the target volume. In the main study, the correlation between different relative DVH parameters derived from these three contouring definitions and the occurrence of rectal toxicity during and after EBRT was studied in two consecutive collectives. The first cohort consisted of 97 patients receiving primary curative EBRT and the second cohort consisted of 66 patients treated for biochemical recurrence after prostatectomy. Rectal toxicity was investigated by clinical investigation and scored according to the Common Terminology Criteria for Adverse Events. Candidate parameters were the volume of the rectum, mean dose, maximal dose, volume receiving at least 60 Gy (V60), area under the DVH curve up to 25 Gy and area under the DVH curve up to 75 Gy in dependence of each chosen rectum definition. Multivariable logistic regression considered other clinical factors such as pelvine lymphatics vs local target volume, diabetes, prior rectal surgery, anticoagulation or haemorrhoids too. RESULTS In Cohort 1 (primary EBRT), the mean rectal volumes for definitions "RTOG", planning target volume "(PTV)-based" and "PTV-linked" were 100 cm3 [standard deviation (SD) 43 cm3], 60 cm3 (SD 26 cm3) and 74 cm3 (SD 31 cm3), respectively (p < 0.01; analysis of variance). The mean rectal doses according to these definitions were 35 Gy (SD 8 Gy), 48 Gy (SD 4 Gy) and 44 Gy (SD 5 Gy) (p < 0.01). In Cohort 2 (salvage EBRT), the mean rectal volumes were 114 cm3 (SD 47 cm3), 64 cm3 (SD 26 cm3) and 81 cm3 (SD 30 cm3) (p < 0.01) and the mean doses received by the rectum were 36 Gy (SD 8 Gy), 49 Gy (SD 5 Gy) and 44 Gy (SD 5 Gy) (p < 0.01). Acute or subacute rectal inflammation occurred in 69 (71.9%) patients in Cohort 1 and in 43 (70.5%) in Cohort 2. We did not find a correlation between all investigated DVH parameters and rectal toxicity, irrespective of the investigated definition. By adding additional variables in multivariate analysis, the predictive ability was substantially improved. Still, there was essentially no difference in the probability of predicting rectal inflammation occurrence between the tested contouring definitions. CONCLUSION The RTOG anatomy-based recommendations are questionable in comparison with functional definitions, as they result in higher variances in several relative DVH parameters. Moreover, the anatomy-based definition is no better and no worse in the predictive value concerning clinical end points. Advances in knowledge: Functional definitions for the rectum as OAR are easier to apply, faster to contour, have smaller variances and do not offer less information than the anatomy-based RTOG definition.
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Affiliation(s)
- Mirko Nitsche
- 1 Zentrum für Strahlentherapie und Radioonkologie, Bremen, Germany.,2 Klinik für Strahlentherapie, Karl-Lennert Krebscentrum, Universität Kiel, Kiel, Germany
| | - Werner Brannath
- 3 Abteilung Biometrie, Kompetenzzentrum für Klinische Studien, Universität Bremen, Bremen, Germany
| | - Matthias Brückner
- 3 Abteilung Biometrie, Kompetenzzentrum für Klinische Studien, Universität Bremen, Bremen, Germany
| | - Dirk Wagner
- 1 Zentrum für Strahlentherapie und Radioonkologie, Bremen, Germany
| | - Alexander Kaltenborn
- 4 Abteilung für Unfallchirurgie und Orthopädie, Bundeswehrkrankenhaus Westerstede, Westerstede, Germany.,5 Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Medizinische Hochschule Hannover, Hannover, Germany
| | - Nils Temme
- 1 Zentrum für Strahlentherapie und Radioonkologie, Bremen, Germany
| | - Robert M Hermann
- 1 Zentrum für Strahlentherapie und Radioonkologie, Bremen, Germany.,6 Strahlentherapie und Spezielle Onkologie, Medizinische Hochschule Hannover, Hannover, Germany
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Results of multiparametric transrectal ultrasound-based focal high-dose-rate dose escalation combined with supplementary external beam irradiation in intermediate- and high-risk localized prostate cancer patients. Brachytherapy 2016; 16:277-281. [PMID: 27964906 DOI: 10.1016/j.brachy.2016.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/01/2016] [Accepted: 11/01/2016] [Indexed: 11/23/2022]
Abstract
PURPOSE Clinical results of a biologic information-based focused dose escalation combined with dose de-escalation for the whole organ in external beam radiotherapy + high-dose-rate brachytherapy (HDR-BT) boost application for localized prostate cancer in a consecutively treated patient cohort. METHODS AND MATERIALS One hundred thirty patients were treated with external beam radiotherapy (50 Gy) complementary to two multiparametric transrectal ultrasound-guided 15 Gy HDR-BT fractions. Real-time multiparametric transrectal ultrasound-based biologic planning for high-dose-rate boost dose planning used the summation of gray scale and Doppler sonography imaging + biopsy information. Target subvolumes received HDR-BT dose escalation up to 60 Gy/fraction. Dose-volume histogram parameters, organ at risks doses, and toxicity results were investigated. RESULTS The median followup was 4.3 years, the median age was 68.62 years, and the mean initial prostate-specific antigen was 18.69 ng/mL. Low-, intermediate-, and high-risk constituted 69%, 21%, and 10% of the patients, respectively. The mean peripheral dose was 3.9 Gy per fraction. Prostate-specific antigen nadir was in 93% of the patients ≤1 ng/mL. Quality parameters were as follows: D90: 6.58 Gy, V100: 30.36%, V150: 9.96%, V200: 3.16%, uD0.1: 7.34 Gy, uD2: 9.34 Gy, rD01: 10.56 Gy, and rD2: 8.32 Gy, respectively. We observed G1, G2, G3 urinary toxicity in 17/130, 11/130, and 2/130 patients, respectively. Rectal toxicity: G1 and G2 occurred in 19/130 and 2/130 patients with mean dose values G1: 8.2 Gy and G2: 8.76 Gy. Analysis of variance test resulted in no correlation between toxicities and any other investigated factors. CONCLUSIONS Focused extreme dose escalation with low prostate mean peripheral dose results in excellent long-term outcome data and very high focal boost doses and is causing no enhancement in late treatment toxicity.
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McPartlin AJ, Glicksman R, Pintilie M, Tsuji D, Mok G, Bayley A, Chung P, Bristow RG, Gospodarowicz MK, Catton CN, Milosevic M, Warde PR. PMH 9907: Long-term outcomes of a randomized phase 3 study of short-term bicalutamide hormone therapy and dose-escalated external-beam radiation therapy for localized prostate cancer. Cancer 2016; 122:2595-603. [PMID: 27219522 DOI: 10.1002/cncr.30093] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/06/2016] [Accepted: 04/12/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND The role of hormone therapy (HT) with dose-escalated external-beam radiotherapy (DE-EBRT) in the treatment of intermediate-risk prostate cancer (IRPC) remains controversial. The authors report the long-term outcome of a phase 3 study of DE-EBRT with or without HT for patients with localized prostate cancer (LPC). METHODS From 1999 to 2006, 252 of an intended 338 patients with LPC were randomized to receive DE-EBRT with or without 5 months of neoadjuvant and concurrent bicalutamide 150 mg once daily. The study was closed early because of contemporary concerns surrounding bicalutamide. The primary outcome was biochemical failure (BF) incidence, and the secondary endpoints were overall survival (OS), local control (LC), and quality of life. The BF and OS rates were estimated using the cumulative incidence function and Kaplan-Meier methods and were compared using the Gray test and the log-rank test. RESULTS Eleven patients were excluded from analysis. Characteristics were well balanced in each treatment arm. Ninety-five percent of patients had IRPC. The prescribed dose increased from 75.6 grays (Gy) in 42 fractions to 78 Gy in 39 fractions over the period. At a median follow-up of 9.1 years, 98 BFs occurred, with no significant effect of HT versus no HT on the BF rate (40% vs 47%; P = .32), the OS rate (82% vs 86%; P = .37), the LC rate (52% vs 48 %; P = .32) or quality of life, in the patients who completed the questionnaires. Dose escalation to 75.6 Gy versus >75.6 Gy reduced the BF rate by 26% (P = .004). CONCLUSIONS For patients who predominantly have IRPC, the addition of HT to DE-EBRT did not significantly affect BF, OS, or LC. Bicalutamide appeared to be well tolerated. The conclusions from the study are limited by incomplete recruitment. Cancer 2016;122:2595-603. © 2016 American Cancer Society.
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Affiliation(s)
- Andrew J McPartlin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rachel Glicksman
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Melania Pintilie
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Debbie Tsuji
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Gary Mok
- Department of Radiology, Radiation Oncology, and Nuclear Medicine, University Hospital Center of Montreal, Montreal, Quebec, Canada
| | - Andrew Bayley
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Peter Chung
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Robert G Bristow
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Mary K Gospodarowicz
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Charles N Catton
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael Milosevic
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Padraig R Warde
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
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11
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Wolff RF, Ryder S, Bossi A, Briganti A, Crook J, Henry A, Karnes J, Potters L, de Reijke T, Stone N, Burckhardt M, Duffy S, Worthy G, Kleijnen J. A systematic review of randomised controlled trials of radiotherapy for localised prostate cancer. Eur J Cancer 2015; 51:2345-67. [DOI: 10.1016/j.ejca.2015.07.019] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 07/06/2015] [Accepted: 07/16/2015] [Indexed: 12/30/2022]
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12
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Three linked nomograms for predicting biochemical failure in prostate cancer treated with radiotherapy plus androgen deprivation therapy. Strahlenther Onkol 2015; 191:792-800. [PMID: 26156249 DOI: 10.1007/s00066-015-0866-7] [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: 02/23/2015] [Accepted: 06/06/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Nomograms were established to predict biochemical recurrence (BCR) after radiotherapy (RT) with a low weight of the characteristic variables of RT and androgen deprivation therapy (ADT). Our aim is to provide a new stratified tool for predicting BCR at 4 and 7 years in patients treated using RT with radical intent. MATERIALS AND METHODS A retrospective, nonrandomized analysis was performed on 5044 prostate cancer (PCa) patients with median age 70 years, who received RT-with or without ADT-between November 1992 and May 2007. Median follow-up was 5.5 years. BCR was defined as a rise in serum prostate-specific antigen (PSA) of 2 ng/ml over the post-treatment PSA nadir. Univariate association between predictor variables and BCR was assessed by the log-rank test, and three linked nomograms were created for multivariate prognosis of BCR-free survival. Each nomogram corresponds to a category of the Gleason score-either 6,7, or 8-10-and all of them were created from a single proportional hazards regression model stratified also by months of ADT (0, 1-6, 7-12, 13-24, 25-36, 36-60). The performance of this model was analyzed by calibration, discrimination, and clinical utility. RESULTS Initial PSA, clinical stage, and RT dose were significant variables (p < 0.01). The model showed a good calibration. The concordance probability was 0.779, improving those obtained with other nomograms (0.587, 0.571, 0.554) in the database. Survival curves showed best clinical utility in a comparison with National Comprehensive Cancer Network (NCCN) risk groups. CONCLUSION For each Gleason score category, the nomogram provides information on the benefit of adding ADT to a specific RT dose.
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Mok G, Benz E, Vallee JP, Miralbell R, Zilli T. Optimization of radiation therapy techniques for prostate cancer with prostate-rectum spacers: a systematic review. Int J Radiat Oncol Biol Phys 2014; 90:278-88. [PMID: 25304788 DOI: 10.1016/j.ijrobp.2014.06.044] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/12/2014] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
Abstract
Dose-escalated radiation therapy for localized prostate cancer improves disease control but is also associated with worse rectal toxicity. A spacer placed between the prostate and rectum can be used to displace the anterior rectal wall outside of the high-dose radiation regions and potentially minimize radiation-induced rectal toxicity. This systematic review focuses on the published data regarding the different types of commercially available prostate-rectum spacers. Dosimetric results and preliminary clinical data using prostate-rectum spacers in patients with localized prostate cancer treated by curative radiation therapy are compared and discussed.
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Affiliation(s)
- Gary Mok
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland; Department of Radiation Oncology, Centre Intégré de Cancérologie de Laval, Centre de Santé et de Services Sociaux de Laval, Laval, Québec, Canada; Department of Radiology, Radiation Oncology, and Nuclear Medicine, Centre Hospitalier Universitaire de Montréal, Montréal, Québec, Canada
| | - Eileen Benz
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Jean-Paul Vallee
- Department of Radiology, Geneva University Hospital, Geneva, Switzerland
| | - Raymond Miralbell
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland.
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14
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Mahal BA, Ziehr DR, Hyatt AS, Neubauer-Sugar EH, O'Farrell DA, O'Leary MP, Steele GS, Niedermayr TR, Beard CJ, Martin NE, Orio PF, D'Amico AV, Devlin PM, Nguyen PL. Use of a rectal spacer with low-dose-rate brachytherapy for treatment of prostate cancer in previously irradiated patients: Initial experience and short-term results. Brachytherapy 2014; 13:442-9. [DOI: 10.1016/j.brachy.2014.05.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/19/2014] [Accepted: 05/01/2014] [Indexed: 11/16/2022]
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15
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Acevedo-Henao CM, Lopez Guerra JL, Matute R, Puebla F, Russo M, Rivin E, Sanchez-Reyes A, Ortiz MJ, Azinovic I. Image-guided radiation therapy based on helical tomotherapy in prostate cancer: minimizing toxicity. Oncol Res Treat 2014; 37:324-30. [PMID: 24903763 DOI: 10.1159/000362858] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 03/24/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND We report the clinical results and prognostic factors of image-guided radiation therapy (RT) with helical tomotherapy (HT) for localized and recurrent prostate cancer (PC). PATIENTS AND METHODS We evaluated 70 patients with PC (primary diagnosis, n = 48; adjuvant, n = 5; salvage, n = 17) treated with HT from May 2006 through January 2011. The dose prescribed to the prostate/surgical bed ranged between 60 and 78 Gy. Potential risk factors for genitourinary (GU) and gastrointestinal (GI) toxicity were assessed. RESULTS The median age was 68 years (range 51-87 years). The median follow-up was 37 months (range 3-74 months). The rates of acute grade 2 GI and GU toxicities were 10 and 13%, respectively. Only 1 patient experienced acute grade 3 GU toxicity. The rates of late grade ≥ 2 GI and GU toxicities were 1% each. Multivariate analysis showed an association between rectum mean dose > median (39 Gy) and bladder median dose > median (46 Gy) with a higher grade of acute GI (p = 0.017) and GU (p = 0.019) toxicity, respectively. Additionally, older age was associated with late GU toxicity (p = 0.026). CONCLUSION Toxicity with HT is low and is associated with higher median/mean doses in organs at risk as well as with older age. A prospective validation would be necessary to confirm these results.
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Affiliation(s)
- Catalina M Acevedo-Henao
- Máster en Aplicaciones tecnológicas avanzadas en Oncología Radioterápica, Universidad de Murcia y Fundación Grupo IMO, Madrid, Spain
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16
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[Prostate-rectum spacers: optimization of prostate cancer irradiation]. Cancer Radiother 2014; 18:215-21; quiz 243-4, 247. [PMID: 24746454 DOI: 10.1016/j.canrad.2014.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/03/2014] [Accepted: 03/03/2014] [Indexed: 12/20/2022]
Abstract
In the curative radiotherapy of localized prostate cancer, improvements in biochemical control observed with dose escalation have been counterbalanced by an increase in radiation-induced toxicity. The injection of biodegradable spacers between prostate and rectum represents a new frontier in the optimization of radiotherapy treatments for patients with localized disease. Transperineal injection of different types of spacers under transrectal ultrasound guidance allows creating a 7-to-20 mm additional space between the prostate and the anterior rectal wall lasting 3 to 12 months. Dosimetrically, a relative reduction in the rectal volume receiving at least 70 Gy (V70) in the order of 43% to 84% is observed with all types of spacers, regardless of the radiotherapy technique used. Preliminary clinical results show for all spacers a good tolerance and a possible reduction in the acute side effects rate. The aim of the present systematic review of the literature is to report on indications as well as dosimetric and clinical advantages of the different types of prostate-rectum spacers commercially available (hydrogel, hyaluronic acid, collagen, biodegradable balloon).
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17
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De Bari B, Fiorentino A, Arcangeli S, Franco P, D'Angelillo RM, Alongi F. From radiobiology to technology: what is changing in radiotherapy for prostate cancer. Expert Rev Anticancer Ther 2014; 14:553-64. [DOI: 10.1586/14737140.2014.883282] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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18
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Jones BL, Gan G, Kavanagh B, Miften M. Effect of endorectal balloon positioning errors on target deformation and dosimetric quality during prostate SBRT. Phys Med Biol 2013; 58:7995-8006. [PMID: 24169860 DOI: 10.1088/0031-9155/58/22/7995] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An inflatable endorectal balloon (ERB) is often used during stereotactic body radiation therapy (SBRT) for treatment of prostate cancer in order to reduce both intrafraction motion of the target and risk of rectal toxicity. However, the ERB can exert significant force on the prostate, and this work assessed the impact of ERB position errors on deformation of the prostate and treatment dose metrics. Seventy-one cone-beam computed tomography (CBCT) image datasets of nine patients with clinical stage T1cN0M0 prostate cancer were studied. An ERB (Flexi-Cuff, EZ-EM, Westbury, NY) inflated with 60 cm(3) of air was used during simulation and treatment, and daily kilovoltage (kV) CBCT imaging was performed to localize the prostate. The shape of the ERB in each CBCT was analyzed to determine errors in position, size, and shape. A deformable registration algorithm was used to track the dose received by (and deformation of) the prostate, and dosimetric values such as D95, PTV coverage, and Dice coefficient for the prostate were calculated. The average balloon position error was 0.5 cm in the inferior direction, with errors ranging from 2 cm inferiorly to 1 cm superiorly. The prostate was deformed primarily in the AP direction, and tilted primarily in the anterior-posterior/superior-inferior plane. A significant correlation was seen between errors in depth of ERB insertion (DOI) and mean voxel-wise deformation, prostate tilt, Dice coefficient, and planning-to-treatment prostate inter-surface distance (p < 0.001). Dosimetrically, DOI is negatively correlated with prostate D95 and PTV coverage (p < 0.001). For the model of ERB studied, error in ERB position can cause deformations in the prostate that negatively affect treatment, and this additional aspect of setup error should be considered when ERBs are used for prostate SBRT. Before treatment, the ERB position should be verified, and the ERB should be adjusted if the error is observed to exceed tolerable values.
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Affiliation(s)
- Bernard L Jones
- Department of Radiation Oncology, University of Colorado School of Medicine 1665 Aurora Ct, MSF706, Aurora, CO 80045, USA
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19
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Prabhakar R. Real-time dosimetry in external beam radiation therapy. World J Radiol 2013; 5:352-355. [PMID: 24179630 PMCID: PMC3812446 DOI: 10.4329/wjr.v5.i10.352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 08/02/2013] [Accepted: 10/12/2013] [Indexed: 02/06/2023] Open
Abstract
With growing complexity in radiotherapy treatment delivery, it has become mandatory to check each and every treatment plan before implementing clinically. This process is currently administered by an independent secondary check of all treatment parameters and as a pre-treatment quality assurance (QA) check for intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy treatment plans. Although pre-treatment IMRT QA is aimed to ensure the correct dose is delivered to the patient, it does not necessarily predict the clinically relevant patient dose errors. During radiotherapy, treatment uncertainties can affect tumor control and may increase complications to surrounding normal tissues. To combat this, image guided radiotherapy is employed to help ensure the plan conditions are mimicked on the treatment machine. However, it does not provide information on actual delivered dose to the tumor volume. Knowledge of actual dose delivered during treatment aid in confirming the prescribed dose and also to replan/reassess the treatment in situations where the planned dose is not delivered as expected by the treating physician. Major accidents in radiotherapy would have been averted if real time dosimetry is incorporated as part of the routine radiotherapy procedure. Of late real-time dosimetry is becoming popular with complex treatments in radiotherapy. Real-time dosimetry can be either in the form of point doses or planar doses or projected on to a 3D image dataset to obtain volumetric dose. They either provide entrance dose or exit dose or dose inside the natural cavities of a patient. In external beam radiotherapy, there are four different established platforms whereby the delivered dose information can be obtained: (1) Collimator; (2) Patient; (3) Couch; and (4) Electronic Portal Imaging Device. Current real-time dosimetric techniques available in radiotherapy have their own advantages and disadvantages and a combination of one or more of these methods provide vital information about the actual dose delivered to radiotherapy patients.
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20
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Polf JC, Panthi R, Mackin DS, McCleskey M, Saastamoinen A, Roeder BT, Beddar S. Measurement of characteristic prompt gamma rays emitted from oxygen and carbon in tissue-equivalent samples during proton beam irradiation. Phys Med Biol 2013; 58:5821-31. [PMID: 23920051 DOI: 10.1088/0031-9155/58/17/5821] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this work was to characterize how prompt gamma (PG) emission from tissue changes as a function of carbon and oxygen concentration, and to assess the feasibility of determining elemental concentration in tissues irradiated with proton beams. For this study, four tissue-equivalent water-sucrose samples with differing densities and concentrations of carbon, hydrogen, and oxygen were irradiated with a 48 MeV proton pencil beam. The PG spectrum emitted from each sample was measured using a high-purity germanium detector, and the absolute detection efficiency of the detector, average beam current, and delivered dose distribution were also measured. Changes to the total PG emission from (12)C (4.44 MeV) and (16)O (6.13 MeV) per incident proton and per Gray of absorbed dose were characterized as a function of carbon and oxygen concentration in the sample. The intensity of the 4.44 MeV PG emission per incident proton was found to be nearly constant for all samples regardless of their carbon concentration. However, we found that the 6.13 MeV PG emission increased linearly with the total amount (in grams) of oxygen irradiated in the sample. From the measured PG data, we determined that 1.64 × 10(7) oxygen PGs were emitted per gram of oxygen irradiated per Gray of absorbed dose delivered with a 48 MeV proton beam. These results indicate that the 6.13 MeV PG emission from (16)O is proportional to the concentration of oxygen in tissue irradiated with proton beams, showing that it is possible to determine the concentration of oxygen within tissues irradiated with proton beams by measuring (16)O PG emission.
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Affiliation(s)
- Jerimy C Polf
- Department of Physics, Oklahoma State University, Stillwater, OK 74078, USA.
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21
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Bernchou U, Agergaard SN, Brink C. Radiopaque marker motion during pre-treatment CBCT as a predictor of intra-fractional prostate movement. Acta Oncol 2013; 52:1168-74. [PMID: 23244674 DOI: 10.3109/0284186x.2012.747698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED The intra-fractional movement of the prostate constitutes a hindrance for the reduction of the planning target volume margin for prostate cancer patients. Monitoring the movement of the prostate during treatment is a promising but in most centres not feasible solution. However, the projection images of the pre-treatment cone-beam computed tomography (CBCT) provide information about the motion of the target immediately preceding the treatment. This motion information can be extracted from any standard CBCT scan which is available in many institutions. In this study we measure the motion of the prostate during the pre-treatment CBCT and investigate whether this motion is correlated with the intra-fractional movement of the prostate. MATERIAL AND METHODS Pre- and post-treatment CBCT scans were made during a number of the fractions (average 11 range 8-12) for 13 prostate cancer patients during the radiation treatment course. The displacement of the post-treatment CBCT scans relative to the pre-treatment position was used to assess the intra-fractional motion. Automated image analysis was used to track the 2D position of radiopaque markers in the projection images of the scans. The most probable 3D trajectory of the markers during the CBCT scan was estimated based on a probability density function which was established for each individual scan. RESULTS The accuracy of the tracking algorithm was found satisfactory and the motion of the markers during the CBCT scans was successfully extracted from the projection images. This motion was generally small and uncorrelated with the subsequent intra-fractional movement of the prostate. The correlation coefficients were 20.05, 0.07, and 20.05 in the LR, AP, and CC direction, respectively. CONCLUSION It is tempting to exploit the pre-treatment CBCT to predict the intra-fractional movement of the prostate but, unfortunately, we have found no correlation between the intra-fractional movement and the motion of the prostate immediately prior to treatment.
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Affiliation(s)
- Uffe Bernchou
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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22
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Gill S, Pham D, Dang K, Bressel M, Kron T, Siva S, Tran PK, Tai KH, Foroudi F. Plan of the day selection for online image-guided adaptive post-prostatectomy radiotherapy. Radiother Oncol 2013; 107:165-70. [DOI: 10.1016/j.radonc.2013.04.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Revised: 03/29/2013] [Accepted: 04/05/2013] [Indexed: 11/30/2022]
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Wala J, Craft D, Paly J, Zietman A, Efstathiou J. Maximizing dosimetric benefits of IMRT in the treatment of localized prostate cancer through multicriteria optimization planning. Med Dosim 2013; 38:298-303. [PMID: 23540492 DOI: 10.1016/j.meddos.2013.02.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 01/23/2013] [Accepted: 02/21/2013] [Indexed: 12/25/2022]
Abstract
We examine the quality of plans created using multicriteria optimization (MCO) treatment planning in intensity-modulated radiation therapy (IMRT) in treatment of localized prostate cancer. Nine random cases of patients receiving IMRT to the prostate were selected. Each case was associated with a clinically approved plan created using Corvus. The cases were replanned using MCO-based planning in RayStation. Dose-volume histogram data from both planning systems were presented to 2 radiation oncologists in a blinded evaluation, and were compared at a number of dose-volume points. Both physicians rated all 9 MCO plans as superior to the clinically approved plans (p<10(-5)). Target coverage was equivalent (p = 0.81). Maximum doses to the prostate and bladder and the V50 and V70 to the anterior rectum were reduced in all MCO plans (p<0.05). Treatment planning time with MCO took approximately 60 minutes per case. MCO-based planning for prostate IMRT is efficient and produces high-quality plans with good target homogeneity and sparing of the anterior rectum, bladder, and femoral heads, without sacrificing target coverage.
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Walsh S, van der Putten W. A TCP model for external beam treatment of intermediate-risk prostate cancer. Med Phys 2013; 40:031709. [DOI: 10.1118/1.4790469] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Eckert F, Alloussi S, Paulsen F, Bamberg M, Zips D, Spillner P, Gani C, Kramer U, Thorwarth D, Schilling D, Müller AC. Prospective evaluation of a hydrogel spacer for rectal separation in dose-escalated intensity-modulated radiotherapy for clinically localized prostate cancer. BMC Cancer 2013; 13:27. [PMID: 23336502 PMCID: PMC3558402 DOI: 10.1186/1471-2407-13-27] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 01/18/2013] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND As dose-escalation in prostate cancer radiotherapy improves cure rates, a major concern is rectal toxicity. We prospectively assessed an innovative approach of hydrogel injection between prostate and rectum to reduce the radiation dose to the rectum and thus side effects in dose-escalated prostate radiotherapy. METHODS Acute toxicity and planning parameters were prospectively evaluated in patients with T1-2 N0 M0 prostate cancer receiving dose-escalated radiotherapy after injection of a hydrogel spacer. Before and after hydrogel injection, we performed MRI scans for anatomical assessment of rectal separation. Radiotherapy was planned and administered to 78 Gy in 39 fractions. RESULTS From eleven patients scheduled for spacer injection the procedure could be performed in ten. In one patient hydrodissection of the Denonvillier space was not possible. Radiation treatment planning showed low rectal doses despite dose-escalation to the target. In accordance with this, acute rectal toxicity was mild without grade 2 events and there was complete resolution within four to twelve weeks. CONCLUSIONS This prospective study suggests that hydrogel injection is feasible and may prevent rectal toxicity in dose-escalated radiotherapy of prostate cancer. Further evaluation is necessary including the definition of patients who might benefit from this approach. TRIAL REGISTRATION German Clinical Trials Register DRKS00003273.
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Affiliation(s)
- Franziska Eckert
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Saladin Alloussi
- Department of Urology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Michael Bamberg
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Daniel Zips
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Patrick Spillner
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Cihan Gani
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Ulrich Kramer
- Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - David Schilling
- Department of Urology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
| | - Arndt-Christian Müller
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, Tübingen, 72076, Germany
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Abou-Elenein HS, Attalla EM, Ammar H, Eldesoky I, Farouk M, Zaghloul MS. Megavoltage cone beam computed tomography: Commissioning and evaluation of patient dose. J Med Phys 2012; 36:205-12. [PMID: 22228929 PMCID: PMC3249731 DOI: 10.4103/0971-6203.89969] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 07/15/2011] [Accepted: 07/26/2011] [Indexed: 11/04/2022] Open
Abstract
The improvement in conformal radiotherapy techniques enables us to achieve steep dose gradients around the target which allows the delivery of higher doses to a tumor volume while maintaining the sparing of surrounding normal tissue. One of the reasons for this improvement was the implementation of intensity-modulated radio therapy (IMRT) by using linear accelerators fitted with multi-leaf collimator (MLC), Tomo therapy and Rapid arc. In this situation, verification of patient set-up and evaluation of internal organ motion just prior to radiation delivery become important. To this end, several volumetric image-guided techniques have been developed for patient localization, such as Siemens OPTIVUE/MVCB and MVision megavoltage cone beam CT (MV-CBCT) system. Quality assurance for MV-CBCT is important to insure that the performance of the Electronic portal image device (EPID) and MV-CBCT is suitable for the required treatment accuracy. In this work, the commissioning and clinical implementation of the OPTIVUE/MVCB system was presented. The geometry and gain calibration procedures for the system were described. The image quality characteristics of the OPTIVUE/MVCB system were measured and assessed qualitatively and quantitatively, including the image noise and uniformity, low-contrast resolution, and spatial resolution. The image reconstruction and registration software were evaluated. Dose at isocenter from CBCT and the EPID were evaluated using ionization chamber and thermo-luminescent dosimeters; then compared with that calculated by the treatment planning system (TPS- XiO 4.4). The results showed that there are no offsets greater than 1 mm in the flat panel alignment in the lateral and longitudinal direction over 18 months of the study. The image quality tests showed that the image noise and uniformity were within the acceptable range, and that a 2 cm large object with 1% electron density contrast can be detected with the OPTIVUE/MVCB system with 5 monitor units (MU) protocol. The registration software was accurate within 2 mm in the anterior-posterior, left-right, and superior-inferior directions. The additional dose to the patient from MV-CBCT study set with 5 MU at the isocenter of the treatment plan was 5 cGy. For Electronic portal image device (EPID) verification using two orthogonal images with 2 MU per image the additional dose to the patient was 3.8 cGy. These measured dose values were matched with that calculated by the TPS-XiO, where the calculated doses were 5.2 cGy and 3.9 cGy for MVCT and EPID respectively.
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Hypofractionated helical tomotherapy using 2.5-2.6 Gy daily fractions for localized prostate cancer. Clin Transl Oncol 2012; 15:271-7. [PMID: 22855189 DOI: 10.1007/s12094-012-0907-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 07/03/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The purpose of this study is to evaluate the tolerability of hypofractionated helical tomotherapy (HT) in the treatment of localized prostate cancer. MATERIALS AND METHODS We evaluated 48 patients with primary adenocarcinoma of the prostate (cT1-T3N0M0) who were treated with hypofractionated HT from August 2008 through July 2011. Hypofractionated regimens included: 68.04 Gy at 2.52 Gy/fraction, 70 Gy at 2.5 Gy/fraction, and 70.2 Gy at 2.6 Gy/fraction. Genitourinary (GU) and gastrointestinal (GI) toxicity was scored using the Radiation Therapy Oncology Group scoring system. RESULTS Thirty-two patients were treated with 68.04 Gy, 5 patients with 70 Gy, and 11 with 70.2 Gy. The median age at diagnosis was 69 years (range 49-87) and the median follow-up 11 months (range 7-40). Grade 2 acute GI toxicity occurred in 9 patients (19 %). No grade 3 or higher acute GI toxicity was observed. Grade 2 and 3 acute GU toxicities occurred in 19 and 6 % of patients, respectively. The incidence of late grade 2 GI and GU toxicity was 4 and 2 %, respectively. No grade 3 or higher late toxicities were observed. Multivariate analysis showed that patients treated at 2.6 Gy/fraction or those who received a total radiation dose ≥70 Gy had higher rates of grade ≥2 acute GU toxicity (P = 0.004 and P = 0.048, respectively). CONCLUSION Hypofractionated HT in the treatment of localized prostate cancer is well tolerated with no grade 3 or higher early or late GI and GU toxicities. Further research is needed to assess definitive late toxicity and tumor control.
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Reese AC, Cowan JE, Brajtbord JS, Harris CR, Carroll PR, Cooperberg MR. The quantitative Gleason score improves prostate cancer risk assessment. Cancer 2012; 118:6046-54. [DOI: 10.1002/cncr.27670] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Revised: 03/01/2012] [Accepted: 03/30/2012] [Indexed: 11/08/2022]
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Shen X, Zaorsky NG, Mishra MV, Foley KA, Hyslop T, Hegarty S, Pizzi LT, Dicker AP, Showalter TN. Comparative effectiveness research for prostate cancer radiation therapy: current status and future directions. Future Oncol 2012; 8:37-54. [PMID: 22149034 DOI: 10.2217/fon.11.131] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Comparative effectiveness research aims to help clinicians, patients and policymakers make informed treatment decisions under real-world conditions. Prostate cancer patients have multiple treatment options, including active surveillance, androgen deprivation therapy, surgery and multiple modalities of radiation therapy. Technological innovations in radiation therapy for prostate cancer have been rapidly adopted into clinical practice despite relatively limited evidence for effectiveness showing the benefit for one modality over another. Comparative effectiveness research has become an essential component of prostate cancer research to help define the benefits, risks and effectiveness of the different radiation therapy modalities currently in use for prostate cancer treatment.
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Affiliation(s)
- Xinglei Shen
- Department of Radiation Oncology, Kimmel Cancer Center & Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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Dias RS, Giordani AJ, Souhami L, Segreto RA, Segreto HRC. Rectal planning risk volume correlation with acute and late toxicity in 3-dimensional conformal radiation therapy for prostate cancer. Technol Cancer Res Treat 2012; 10:585-90. [PMID: 22066598 DOI: 10.1177/153303461101000608] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The purpose of this study was to evaluate rectum motion during 3-Dimensional conformal radiation therapy (3D-CRT) in prostate cancer patients, to derive a planning volume at risk (PRV) and to correlate the PRV dose-volume histograms (DVH) with treatment complications.This study was conducted in two phases. Initially, the PRV was defined prospectively in 50 consecutive prostate cancer patients (Group 1) who received a radical course of 3-D CRT. Then, the obtained PRV was used in the radiotherapy planning of these same 50 patients plus another 59 prostate cancer patients (Group 2) previously treated between 2004 and 2008. All these patients' data, including the rectum and PRV DVHs, were correlated to acute and late complications, according to the Common Toxicity Criteria (CTC) v4.0.The largest displacement occurred in the anterior axis. Long-term gastrointestinal (GI) complications grade ≥ 2 were seen in 9.2% of the cases. Factors that influenced acute GI reactions were: doses at 25% (p 5 0.011) and 40% (p 5 0.005) of the rectum volume and at 40% of the PRV (p 5 0.012). The dose at 25% of the rectum volume (p 5 0.033) and acute complications ≥ grade 2 (p 5 0.018) were prognostic factors for long-term complications. The PRV DVH did not correlate with late toxicity. The rectum showed a significant inter-fraction motion during 3D-CRT for prostate cancer. PRV dose correlated with acute gastrointestinal complications and may be a useful tool to predict and reduce their occurrence.
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Affiliation(s)
- R S Dias
- Department of Clinical and Experimental Oncology, Division of Radiation Oncology, Universidade Federal de Sao Paulo, Rua Napoleao de Barros 715, Sao Paulo, SP, Brazil
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Alexander EJ, Harris VA, Sohaib A, Dearnaley D. Reducing the side effects of external beam radiotherapy in prostate cancer: role of imaging techniques. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/iim.11.65] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Smeenk RJ, Hoffmann AL, Hopman WPM, van Lin ENJT, Kaanders JHAM. Dose-effect relationships for individual pelvic floor muscles and anorectal complaints after prostate radiotherapy. Int J Radiat Oncol Biol Phys 2011; 83:636-44. [PMID: 22137024 DOI: 10.1016/j.ijrobp.2011.08.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 06/28/2011] [Accepted: 08/08/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE To delineate the individual pelvic floor muscles considered to be involved in anorectal toxicity and to investigate dose-effect relationships for fecal incontinence-related complaints after prostate radiotherapy (RT). METHODS AND MATERIALS In 48 patients treated for localized prostate cancer, the internal anal sphincter (IAS) muscle, the external anal sphincter (EAS) muscle, the puborectalis muscle (PRM), and the levator ani muscles (LAM) in addition to the anal wall (Awall) and rectal wall (Rwall) were retrospectively delineated on planning computed tomography scans. Dose parameters were obtained and compared between patients with and without fecal urgency, incontinence, and frequency. Dose-effect curves were constructed. Finally, the effect of an endorectal balloon, which was applied in 28 patients, was investigated. RESULTS The total volume of the pelvic floor muscles together was about three times that of the Awall. The PRM was exposed to the highest RT dose, whereas the EAS received the lowest dose. Several anal and rectal dose parameters, as well as doses to all separate pelvic floor muscles, were associated with urgency, while incontinence was associated mainly with doses to the EAS and PRM. Based on the dose-effect curves, the following constraints regarding mean doses could be deduced to reduce the risk of urgency: ≤ 30 Gy to the IAS; ≤ 10 Gy to the EAS; ≤ 50 Gy to the PRM; and ≤ 40 Gy to the LAM. No dose-effect relationships for frequency were observed. Patients treated with an endorectal balloon reported significantly less urgency and incontinence, while their treatment plans showed significantly lower doses to the Awall, Rwall, and all pelvic floor muscles. CONCLUSIONS Incontinence-related complaints show specific dose-effect relationships to individual pelvic floor muscles. Dose constraints for each muscle can be identified for RT planning. When only the Awall is delineated, substantial components of the continence apparatus are excluded.
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Affiliation(s)
- Robert Jan Smeenk
- Department of Radiation Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Improvement of prostate treatment by anterior proton fields. Int J Radiat Oncol Biol Phys 2011; 83:408-18. [PMID: 22133626 DOI: 10.1016/j.ijrobp.2011.06.1974] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 05/19/2011] [Accepted: 06/14/2011] [Indexed: 12/20/2022]
Abstract
PURPOSE We performed a treatment planning study to demonstrate the potential dosimetric benefits of anterior-oriented fields for prostate irradiation by proton beam. A novel in vivo beam range control method shows millimeter accuracy, suggesting that such fields could be safely used to spare the rectum given the sharp distal penumbra of protons. METHODS AND MATERIALS Ten prostate patients treated with water-filled endorectal balloon were selected. Bilateral fields were planned following the conventional treatment protocol. Three anterior-oriented fields (0, +30, -30°) were planned, with the range compensators manually adjusted to improve rectal sparing. Dose distributions to the clinical target volume, rectum, anterior rectal wall (ARW), bladder, bladder wall (BW), and femoral heads were compared for: A) equally weighted bilateral fields, B) a single straight anterior field, and C) two equally weighted anterior-oblique fields. RESULTS The anterior-oriented fields required much less beam energy, ∼10 cm water equivalent path length less than lateral fields. For ARW, the V(95%) for Plans A, B, and C were 39%, 8%, and 6%, respectively; the corresponding V(80%) were 59%, 27%, and 26%, respectively (p = 0.002 when Plan A was compared with B or C). Plan B irradiated a larger volume of BW than did Plan A by 3% at V(95%), 11% at V(80%), and 16% at V(50%) (p = 0.002), whereas Plan C differs little from Plan A for BW at these dose levels. The femoral heads received ∼40% of the prescription dose in Plan A, but negligible dose in Plans B and C. CONCLUSIONS Compared to lateral fields, anterior-oriented fields can significantly reduce dose to the ARW, particularly at high dose levels. These fields alone, or in combination with lateral fields, allow for the possibility of either reducing treatment toxicity at current prescription doses or further dose escalation in the treatment of prostate cancer.
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Zilli T, Jorcano S, Rouzaud M, Dipasquale G, Nouet P, Toscas JI, Casanova N, Wang H, Escudé L, Mollà M, Linero D, Weber DC, Miralbell R. Twice-Weekly Hypofractionated Intensity-Modulated Radiotherapy for Localized Prostate Cancer With Low-Risk Nodal Involvement: Toxicity and Outcome From a Dose Escalation Pilot Study. Int J Radiat Oncol Biol Phys 2011; 81:382-9. [DOI: 10.1016/j.ijrobp.2010.05.057] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Revised: 05/15/2010] [Accepted: 05/25/2010] [Indexed: 11/29/2022]
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Brown S, Lehman M, Ferrari-Anderson J, Glyde A, Burmeister E, Nicol D. Assessment of prostatic fiducial marker introduction: Patient morbidity, staff satisfaction and improved treatment field placement. J Med Imaging Radiat Oncol 2011; 55:417-24. [DOI: 10.1111/j.1754-9485.2011.02278.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kishi K, Sato M, Shirai S, Sonomura T, Yamama R. Reirradiation of prostate cancer with rectum preservation: eradicative high-dose-rate brachytherapy with natural type hyaluronate injection. Brachytherapy 2011; 11:144-8. [PMID: 21820975 DOI: 10.1016/j.brachy.2011.06.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 05/05/2011] [Accepted: 06/28/2011] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Reirradiation of locally recurrent prostate cancer after radiotherapy is limited because of its toxicity to the rectum that is closely adjacent to the prostate. To solve geometric anatomic constraints, including rectal size and distance from the prostate, we developed a technique that modifies the geometry by noninvasive direct intervention. METHODS AND MATERIALS In a patient with local recurrence of prostate cancer at 18 months after initial radiotherapy of 61.8 GyE(LQ2,3) (gray equivalent in 2 Gy/fraction at α/β=3 calculated with linear quadratic [LQ] model) to the prostate, we prescribed 16 Gy (60.8 GyE(LQ2,3) or 78.2 GyE(LQ2,1.6)) of reirradiation by high-dose-rate brachytherapy, using a bolus injection of native-type hyaluronate to create and maintain a distance between the prostate and the rectum and decrease rectal size during treatment. RESULTS The procedure was achieved in 10min, without complications. Rectal D(2cc) of the reirradiation was 5.58 Gy (9.58 GyE(LQ2,3)). Compared with the initial radiation, the gel injection resulted in an improved therapeutic ratio. The patient was regularly followed up at our clinic; at over 3.5 years after reirradiation, there was no evidence of recurrence or radiation-related toxicities greater than Grade 2, maintaining a nadir prostate-specific antigen level of 0.03 ng/mL without hormonal therapy. CONCLUSION We consider that this technique is useful for achieving safe and curative reirradiation of prostate cancer.
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Affiliation(s)
- Kazushi Kishi
- Department of Radiation Oncology, Tumor Center, Wakayama Medical University Hospital, Wakayama City, Wakayama, Japan.
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Feasibility study on effect and stability of adaptive radiotherapy on kilovoltage cone beam CT. Radiol Oncol 2011; 45:220-6. [PMID: 22933960 PMCID: PMC3423744 DOI: 10.2478/v10019-011-0024-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 03/24/2011] [Indexed: 12/03/2022] Open
Abstract
Background We have analyzed the stability of CT to density curve of kilovoltage cone-beam computerized tomography (kV CBCT) imaging modality over the period of six months. We also, investigated the viability of using image value to density table (IVDT) generated at different time, for adaptive radiotherapy treatment planning. The consequences of target volume change and the efficacy of kV CBCT for adaptive planning issues is investigated. Materials and methods. Standard electron density phantom was used to establish CT to electron density calibrations curve. The CT to density curve for the CBCT images were observed for the period of six months. The kV CBCT scans used for adaptive planning was acquired with an on-board imager system mounted on a “Trilogy” linear accelerator. kV CBCT images were acquired for daily setup registration. The effect of variations in CT to density curve was studied on two clinical cases: prostate and lung. Results The soft tissue contouring is superior in kV CBCT scans in comparison to mega voltage CT (MVCT) scans. The CT to density curve for the CBCT images was found steady over six months. Due to difficulty in attaining the reproducibility in daily setup for the prostate treatment, there is a day-to-day difference in dose to the rectum and bladder. Conclusions There is no need for generating a new CT to density curve for the adaptive planning on the kV CBCT images. Also, it is viable to perform the adaptive planning to check the dose to target and organ at risk (OAR) without performing a new kV CT scan, which will reduce the dose to the patient.
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Olsen JR, Noel CE, Baker K, Santanam L, Michalski JM, Parikh PJ. Practical method of adaptive radiotherapy for prostate cancer using real-time electromagnetic tracking. Int J Radiat Oncol Biol Phys 2011; 82:1903-11. [PMID: 21470786 DOI: 10.1016/j.ijrobp.2011.01.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Revised: 01/11/2011] [Accepted: 01/26/2011] [Indexed: 11/18/2022]
Abstract
PURPOSE We have created an automated process using real-time tracking data to evaluate the adequacy of planning target volume (PTV) margins in prostate cancer, allowing a process of adaptive radiotherapy with minimal physician workload. We present an analysis of PTV adequacy and a proposed adaptive process. METHODS AND MATERIALS Tracking data were analyzed for 15 patients who underwent step-and-shoot multi-leaf collimation (SMLC) intensity-modulated radiation therapy (IMRT) with uniform 5-mm PTV margins for prostate cancer using the Calypso® Localization System. Additional plans were generated with 0- and 3-mm margins. A custom software application using the planned dose distribution and structure location from computed tomography (CT) simulation was developed to evaluate the dosimetric impact to the target due to motion. The dose delivered to the prostate was calculated for the initial three, five, and 10 fractions, and for the entire treatment. Treatment was accepted as adequate if the minimum delivered prostate dose (D(min)) was at least 98% of the planned D(min). RESULTS For 0-, 3-, and 5-mm PTV margins, adequate treatment was obtained in 3 of 15, 12 of 15, and 15 of 15 patients, and the delivered D(min) ranged from 78% to 99%, 96% to 100%, and 99% to 100% of the planned D(min). Changes in D(min) did not correlate with magnitude of prostate motion. Treatment adequacy during the first 10 fractions predicted sufficient dose delivery for the entire treatment for all patients and margins. CONCLUSIONS Our adaptive process successfully used real-time tracking data to predict the need for PTV modifications, without the added burden of physician contouring and image analysis. Our methods are applicable to other uses of real-time tracking, including hypofractionated treatment.
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Affiliation(s)
- Jeffrey R Olsen
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
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Tucker SL, Thames HD, Michalski JM, Bosch WR, Mohan R, Winter K, Cox JD, Purdy JA, Dong L. Estimation of α/β for late rectal toxicity based on RTOG 94-06. Int J Radiat Oncol Biol Phys 2011; 81:600-5. [PMID: 21377288 DOI: 10.1016/j.ijrobp.2010.11.080] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 10/27/2010] [Accepted: 11/16/2010] [Indexed: 01/24/2023]
Abstract
PURPOSE To estimate α/β, the parameter ratio from the linear-quadratic (LQ) model, for Grade ≥2 late rectal toxicity among patients treated on Radiation Therapy Oncology Group (RTOG) protocol 94-06; and to determine whether correcting the rectal dose-volume histogram (DVH) for differences in dose per fraction, based on the LQ model, significantly improves the fit to these data of the Lyman-Kutcher-Burman (LKB) normal-tissue complication probability (NTCP) model. METHODS AND MATERIALS The generalized LKB model was fitted to the Grade ≥2 late rectal toxicity data in two ways: by using DVHs representing physical dose to rectum, and by using a modified approach in which dose bins in the rectal DVH were corrected for differences in dose per fraction using the LQ model, with α/β estimated as an additional unknown parameter. The analysis included only patients treated with the same treatment plan throughout radiotherapy, so that the dose per fraction to each voxel of rectum could be determined from the DVH. The likelihood ratio test was used to assess whether the fit of the LQ-corrected model was significantly better than the fit of the LKB model based on physical doses to rectum. RESULTS The analysis included 509 of the 1,084 patients enrolled on RTOG 94-06. The estimate of α/β from the LQ-corrected LKB model was 4.8 Gy, with 68% confidence interval 0.6 Gy to 46 Gy. The fit was not significantly different from the fit of the LKB model based on physical dose to rectum (p = 0.236). CONCLUSIONS The estimated fractionation sensitivity for Grade ≥2 late rectal toxicity is consistent with values of α/β for rectum found previously in human beings and in rodents. However, the confidence interval is large, and there is no evidence that LQ correction of the rectal DVH significantly changes the fit or predictions of the LKB model for this endpoint.
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Affiliation(s)
- Susan L Tucker
- Department of Bioinformatics and Computational Biology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77230-1402, USA.
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Ferrandis C, March J, Martínez J, Hernández J, Diez N, Morillo V, García F, Chuan P. [Combined external radiotherapy and hormone therapy in patients with locally advanced prostate cancer: predictive factors of genitourinary toxicity]. Actas Urol Esp 2011; 35:146-51. [PMID: 21334103 DOI: 10.1016/j.acuro.2010.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Revised: 08/14/2010] [Accepted: 08/31/2010] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Radiotherapy and androgen deprivation are an established treatment option for locally advanced prostate cancer. We evaluate outcomes in efficacy and toxicity for patients treated with this combined therapy at our institution. METHODS A retrospective study of 80 patients with locally advanced prostate cancer treated with radiotherapy combined with neo-adjuvant (2 months) and adjuvant (24 months) androgen deprivation. We studied the clinical variables and side effects. We evaluated treatment outcomes using PSA nadir and biochemical failure, and recorded acute and late gastrointestinal and urinary toxicity. We assessed the correlation between clinical variables and urinary toxicity by means of univariate and multivariate analyses (multiple logistic regression). RESULTS The mean patient age was 68 ± 5.81 years; the initial PSA was 20.05 ± 16.27 ng/ ml and the mean prostate volume 43.7 ± 27.57 cc. The clinical stage was T3a in 33% and T3b in 66%. The Gleason score was <7 in 39%, 7 in 46% and ≥8 in 15%. The mean follow-up was 44.4 months and biochemical failure was observed in 3 cases. Acute urinary toxicity was recorded in 90% of the patients (chronic in 35%) and acute gastrointestinal toxicity in 75% (late in 32%). In a univariate analysis, prostate volume and urinary symptoms were statistically correlated to acute and late urinary toxicity. Both prostate volume and urinary symptoms were independently associated with an increase in urinary toxicity in the logistic regression analysis. CONCLUSIONS Hormone-radiotherapy is a valid option to locally treat advanced prostate cancer with optimal short-term outcomes, although it is not devoid of side effects. Prostate volume and urinary symptoms before treatment can predict genitourinary toxicity.
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Nguyen PL, Chen RC, Hoffman KE, Trofimov A, Efstathiou JA, Coen JJ, Shipley WU, Zietman AL, Talcott JA. Rectal Dose–Volume Histogram Parameters Are Associated With Long-Term Patient-Reported Gastrointestinal Quality of Life After Conventional and High-Dose Radiation for Prostate Cancer: A Subgroup Analysis of a Randomized Trial. Int J Radiat Oncol Biol Phys 2010; 78:1081-5. [DOI: 10.1016/j.ijrobp.2009.09.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 09/13/2009] [Accepted: 09/14/2009] [Indexed: 11/15/2022]
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Miralbell R, Mollà M, Rouzaud M, Hidalgo A, Toscas JI, Lozano J, Sanz S, Ares C, Jorcano S, Linero D, Escudé L. Hypofractionated Boost to the Dominant Tumor Region With Intensity Modulated Stereotactic Radiotherapy for Prostate Cancer: A Sequential Dose Escalation Pilot Study. Int J Radiat Oncol Biol Phys 2010; 78:50-7. [PMID: 19910135 DOI: 10.1016/j.ijrobp.2009.07.1689] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 06/18/2009] [Accepted: 07/18/2009] [Indexed: 10/20/2022]
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Wilder RB, Barme GA, Gilbert RF, Holevas RE, Kobashi LI, Reed RR, Solomon RS, Walter NL, Chittenden L, Mesa AV, Agustin J, Lizarde J, Macedo J, Ravera J, Tokita KM. Cross-linked hyaluronan gel reduces the acute rectal toxicity of radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys 2010; 77:824-30. [PMID: 20510195 DOI: 10.1016/j.ijrobp.2009.05.069] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 05/28/2009] [Accepted: 05/29/2009] [Indexed: 12/11/2022]
Abstract
PURPOSE To prospectively analyze whether cross-linked hyaluronan gel reduces the mean rectal dose and acute rectal toxicity of radiotherapy for prostate cancer. METHODS AND MATERIALS Between September 2008 and March 2009, we transperitoneally injected 9 mL of cross-linked hyaluronan gel (Hylaform; Genzyme Corporation, Cambridge, MA) into the anterior perirectal fat of 10 early-stage prostate cancer patients to increase the separation between the prostate and rectum by 8 to 18 mm at the start of radiotherapy. Patients then underwent high-dose rate brachytherapy to 2,200 cGy followed by intensity-modulated radiation therapy to 5,040 cGy. We assessed acute rectal toxicity using the National Cancer Institute Common Terminology Criteria for Adverse Events v3.0 grading scheme. RESULTS Median follow-up was 3 months. The anteroposterior dimensions of Hylaform at the start and end of radiotherapy were 13 +/- 3mm (mean +/- SD) and 10 +/- 4mm, respectively. At the start of intensity-modulated radiation therapy, daily mean rectal doses were 73 +/- 13 cGy with Hylaform vs. 106 +/- 20 cGy without Hylaform (p = 0.005). There was a 0% incidence of National Cancer Institute Common Terminology Criteria for Adverse Events v3.0 Grade 1, 2, or 3 acute diarrhea in 10 patients who received Hylaform vs. a 29.7% incidence (n = 71) in 239 historical controls who did not receive Hylaform (p = 0.04). CONCLUSIONS By increasing the separation between the prostate and rectum, Hylaform decreased the mean rectal dose. This led to a significant reduction in the acute rectal toxicity of radiotherapy for prostate cancer.
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Smeenk RJ, Teh BS, Butler EB, van Lin EN, Kaanders JH. Is there a role for endorectal balloons in prostate radiotherapy? A systematic review. Radiother Oncol 2010; 95:277-82. [DOI: 10.1016/j.radonc.2010.04.016] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Revised: 01/21/2010] [Accepted: 04/07/2010] [Indexed: 10/19/2022]
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A Prospective Study of Intrafraction Prostate Motion in the Prone vs. Supine Position. Int J Radiat Oncol Biol Phys 2010; 77:165-70. [DOI: 10.1016/j.ijrobp.2009.04.041] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Revised: 04/22/2009] [Accepted: 04/23/2009] [Indexed: 11/20/2022]
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Buyyounouski MK, Price RA, Harris EER, Miller R, Tomé W, Schefter T, Parsai EI, Konski AA, Wallner PE. Stereotactic body radiotherapy for primary management of early-stage, low- to intermediate-risk prostate cancer: report of the American Society for Therapeutic Radiology and Oncology Emerging Technology Committee. Int J Radiat Oncol Biol Phys 2010; 76:1297-304. [PMID: 20338473 DOI: 10.1016/j.ijrobp.2009.09.078] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Accepted: 09/08/2009] [Indexed: 12/30/2022]
Affiliation(s)
- Mark K Buyyounouski
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA.
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Pinkawa M, Piroth MD, Fischedick K, Nussen S, Klotz J, Holy R, Eble MJ. Self-assessed bowel toxicity after external beam radiotherapy for prostate cancer--predictive factors on irritative symptoms, incontinence and rectal bleeding. Radiat Oncol 2009; 4:36. [PMID: 19772568 PMCID: PMC2753361 DOI: 10.1186/1748-717x-4-36] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Accepted: 09/21/2009] [Indexed: 11/22/2022] Open
Abstract
Background The aim of the study was to evaluate self-assessed bowel toxicity after radiotherapy (RT) for prostate cancer. In contrast to rectal bleeding, information concerning irritative symptoms (rectal urgency, pain) and incontinence after RT has not been adequately documented and reported in the past. Methods Patients (n = 286) have been surveyed prospectively before (A), at the last day (70.2-72.0 Gy; B), a median time of two (C) and 16 months after RT (D) using a validated questionnaire (Expanded Prostate Cancer Index Composite). Bowel domain score changes were analyzed and patient-/dose-volume-related factors tested for a predictive value on three separate factors (subscales): irritative symptoms, incontinence and rectal bleeding. Results Irritative symptoms were most strongly affected in the acute phase, but the scores of all subscales remained slightly lower at time D in comparison to baseline scores. Good correlations (correlation indices >0.4; p < 0.001 for all) were found between irritative and incontinence function/bother scores at times B-D, suggesting the presence of an urge incontinence for the majority of patients who reported uncontrolled leakage of stool. Planning target volume (PTV), haemorrhoids and stroke in past history were found to be independent predictive factors for rectal bleeding at time D. Chronic renal failure predisposed for lower irritative scores at time D. Paradoxically, patients with greater rectum volumes inside higher isodose levels presented with higher quality of life scores in the irritative and incontinence subscales. Conclusion PTV and specific comorbidities are important predictive factors on adverse bowel quality of life changes after RT for prostate cancer. However, greater rectum volumes inside high isodose levels have not been found to be associated with lower quality of life scores.
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Affiliation(s)
- Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Pauwelsstrasse 30, 52072 Aachen, Germany.
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Concordance in the perception of couples recovering from primary surgical treatment of prostate cancer. Int J Impot Res 2009; 21:253-60. [DOI: 10.1038/ijir.2009.23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Conformal Arc Radiotherapy for Prostate Cancer: Increased Biochemical Failure in Patients With Distended Rectum on the Planning Computed Tomogram Despite Image Guidance by Implanted Markers. Int J Radiat Oncol Biol Phys 2009; 74:388-91. [DOI: 10.1016/j.ijrobp.2008.08.007] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Revised: 08/06/2008] [Accepted: 08/07/2008] [Indexed: 11/24/2022]
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