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Zhao Y, Haworth A, Reynolds HM, Williams SG, Finnegan R, Rowshanfarzad P, Ebert MA. Towards optimal heterogeneous prostate radiotherapy dose prescriptions based on patient-specific or population-based biological features. Med Phys 2024; 51:3766-3781. [PMID: 38224317 DOI: 10.1002/mp.16936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND Escalation of prescribed dose in prostate cancer (PCa) radiotherapy enables improvement in tumor control at the expense of increased toxicity. Opportunities for reduction of treatment toxicity may emerge if more efficient dose escalation can be achieved by redistributing the prescribed dose distribution according to the known heterogeneous, spatially-varying characteristics of the disease. PURPOSE To examine the potential benefits, limitations and characteristics of heterogeneous boost dose redistribution in PCa radiotherapy based on patient-specific and population-based spatial maps of tumor biological features. METHOD High-resolution prostate histology images, from a cohort of 63 patients, annotated with tumor location and grade, provided patient-specific "maps" and a population-based "atlas" of cell density and tumor probability. Dose prescriptions were derived for each patient based on a heterogeneous redistribution of the boost dose to the intraprostatic lesions, with the prescription maximizing patient tumor control probability (TCP). The impact on TCP was assessed under scenarios where the distribution of population-based biological data was ignored, partially included, or fully included in prescription generation. Heterogeneous dose prescriptions were generated for three combinations of maps and atlas, and for conventional fractionation (CF), extreme hypo-fractionation (EH), moderate hypo-fractionation (MH), and whole Pelvic RT + SBRT Boost (WPRT + SBRT). The predicted efficacy of the heterogeneous prescriptions was compared with equivalent homogeneous dose prescriptions. RESULTS TCPs for heterogeneous dose prescriptions were generally higher than those for homogeneous dose prescriptions. TCP escalation by heterogeneous dose prescription was the largest for CF. When only using population-based atlas data, the generated heterogeneous dose prescriptions of 55 to 58 patients (out of 63) had a higher TCP than for the corresponding homogeneous dose prescriptions. The TCPs of the heterogeneous dose prescriptions generated with the population-based atlas and tumor probability maps did not differ significantly from those using patient-specific biological information. The generated heterogeneous dose prescriptions achieved significantly higher TCP than homogeneous dose prescriptions in the posterior section of the prostate. CONCLUSION Heterogeneous dose prescriptions generated via biologically-optimized dose redistribution can produce higher TCP than the homogeneous dose prescriptions for the majority of the patients in the studied cohort. For scenarios where patient-specific biological information was unavailable or partially available, the generated heterogeneous dose prescriptions can still achieve TCP improvement relative to homogeneous dose prescriptions.
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Affiliation(s)
- Yutong Zhao
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, Western Australia, Australia
| | - Annette Haworth
- Institute of Medical Physics, School of Physics, The University of Sydney, Camperdown, New South Wales, Australia
| | - Hayley M Reynolds
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Scott G Williams
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Robert Finnegan
- Institute of Medical Physics, School of Physics, The University of Sydney, Camperdown, New South Wales, Australia
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Pejman Rowshanfarzad
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, Western Australia, Australia
| | - Martin A Ebert
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, Western Australia, Australia
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- 5D Clinics, Claremont, Western Australia, Australia
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Sawayanagi S, Yamashita H, Ogita M, Kawai T, Sato Y, Kume H. In Curative Stereotactic Body Radiation Therapy for Prostate Cancer, There Is a High Possibility That 45 Gy in Five Fractions Will Not Be Tolerated without a Hydrogel Spacer. Cancers (Basel) 2024; 16:1472. [PMID: 38672553 PMCID: PMC11048095 DOI: 10.3390/cancers16081472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/07/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
The purpose of this study was to determine the maximum tolerated dose (MTD) for stereotactic body radiation therapy (SBRT) in the treatment of non-metastatic prostate cancer. This study was a phase 1 dose escalation trial conducted in Japan. Patients with histologically proven prostate cancer without lymph nodes or distant metastases were enrolled. The prescribed doses were 42.5, 45, or 47.5 Gy in five fractions. Dose-limiting toxicity (DLT) was defined as grade (G) 3+ gastrointestinal or genitourinary toxicity within 180 days after SBRT completion, and a 6 plus 6 design was used as the method of dose escalation. A total of 16 patients were enrolled, with 6 in the 42.5 Gy group and 10 in the 45 Gy group. No DLT was observed in the 42.5 Gy group. In the 45 Gy group, one patient experienced G3 rectal hemorrhage, and another had G4 rectal perforation, leading to the determination of 42.5 Gy as the MTD. None of the patients experienced biochemical recurrence or death during the follow-up period. We concluded that SBRT for non-metastatic prostate cancer at 42.5 Gy in five fractions could be safely performed, but a total dose of 45 Gy increased severe toxicity.
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Affiliation(s)
- Subaru Sawayanagi
- Department of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; (S.S.); (M.O.)
| | - Hideomi Yamashita
- Department of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; (S.S.); (M.O.)
| | - Mami Ogita
- Department of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; (S.S.); (M.O.)
| | - Taketo Kawai
- Department of Urology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; (T.K.); (Y.S.); (H.K.)
- Department of Urology, School of Medicine, Teikyo University, 2-11-1, Kaga, Itabashi-ku, Tokyo 173-8606, Japan
| | - Yusuke Sato
- Department of Urology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; (T.K.); (Y.S.); (H.K.)
- Department of Urology, Tokyo Metropolitan Tama Medical Center, 2-8-29, Musashidai, Fuchu 183-8524, Japan
| | - Haruki Kume
- Department of Urology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; (T.K.); (Y.S.); (H.K.)
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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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Dose-escalation in prostate cancer: Results of randomized trials. Cancer Radiother 2022; 26:899-904. [PMID: 36030191 DOI: 10.1016/j.canrad.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 11/22/2022]
Abstract
In 1998, an editorial from the International Journal of Radiation Oncology - Biology - Physics (IJROBP) on the occasion of the publication of Phase I by Zelefsky et al. on 3D radiotherapy dose escalation asked the question: "will more prove better?". More than 20 years later, several prospective studies have supported the authors' conclusions, making dose escalation a new standard in prostate cancer. The data from prospective randomized studies were ultimately disappointing in that they failed to show an overall survival benefit from dose escalation. However, there is a clear and consistent benefit in biochemical recurrence-free survival, which must be weighed on an individual patient basis against the potential additional toxicity of dose escalation. Techniques and concepts have become more and more precise, such as intensity modulated irradiation, simultaneous integrated boost, hypofractionated dose-escalation, pelvic irradiation with involved node boost or focal dose-escalation on gross recurrence after prostatectomy. The objective here was to summarize the prospective data on dose escalation in prostate cancer and in particular on recent advances in the field. In 2022, can we finally say that more has proven better?
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Spencer KL, Tree AC. Commentary on Cost-Effectiveness of Metastasis-Directed Therapy in Oligorecurrent Hormone-Sensitive Prostate Cancer. Int J Radiat Oncol Biol Phys 2020; 108:927-929. [PMID: 33069354 DOI: 10.1016/j.ijrobp.2020.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 11/22/2022]
Affiliation(s)
- Katie L Spencer
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom; Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust, London, United Kingdom The Institute of Cancer Research, London, United Kingdom
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Eren MF, Çolpan Öksüz D, Sayan M, Karaçam S, Vergalasova I, Ay Eren A, Öner Dinçbaş F. Comparison of kV Orthogonal Radiographs and kV-Cone-Beam Computed Tomography Image-Guided Radiotherapy Methods With and Without Implanted Fiducials in Prostate Cancer. Cureus 2020; 12:e9916. [PMID: 32850264 PMCID: PMC7445001 DOI: 10.7759/cureus.9916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction The aim of this study is to investigate the performance of kilovoltage (kV) cone-beam computed tomography (CBCT)-based adjustments with respect to kV-orthogonal fiducial marker-based matching in a group of patients with prostate cancer. Methods Twenty prostate cancer patients were evaluated retrospectively: 10 with implanted fiducial markers and 10 without. Daily orthogonal kV imaging was recorded prior to radiation delivery. Images were evaluated in the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) directions by matching either the implanted fiducials or going off bony anatomy, depending on the presence or absence of markers, respectively. Cone-beam computed tomography (CBCT) imaging was also subsequently acquired and images were aligned with the planning CT. The couch shifts were calculated and the patient's position was adjusted accordingly. Standard deviations and random errors were also computed. Pearson correlation and Bland-Altman analysis were performed to evaluate relationships between the datasets. Results A total of 240 images were evaluated. The Pearson correlation coefficient for shifts applied to patients with markers using kV and CBCT was 88.3%, 87.8%, and 94.5% for the LR, AP, and SI directions, respectively. For those without markers, the respective values for the LR, AP, and SI directions were: 39.3%, 22.4%, and 3.7%. A Bland-Altman analysis comparing kV and CBCT in patients with markers, revealed R2 values of 0.152, 0.282, and 0.097 in the LR, AP, and SI directions, respectively. The R2 values for patients without markers were 0.008, 0.01, and 0.057, in the LR, AP, and SI directions, respectively. Conclusions Our data suggest that CBCT can be a viable option for image-guidance in clinical settings where fiducial markers are unavailable such as situations of inaccessibility or medical contraindications.
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Affiliation(s)
- Mehmet F Eren
- Radiation Oncology, Marmara University Pendik Education and Research Hospital, Istanbul, TUR
| | - Didem Çolpan Öksüz
- Radiation Oncology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, TUR
| | - Mutlay Sayan
- Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, USA
| | - Songül Karaçam
- Radiation Oncology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, TUR
| | - Irina Vergalasova
- Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, USA
| | - Ayfer Ay Eren
- Radiation Oncology, Saglik Bilimleri University, Kartal Dr. Lutfi Kirdar Education and Research Hospital, Istanbul, TUR
| | - Fazilet Öner Dinçbaş
- Radiation Oncology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, TUR
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Beckmann K, Garmo H, Nilsson P, Franck Lissbrant I, Widmark A, Stattin P. Radical radiotherapy for prostate cancer: patterns of care in Sweden 1998-2016. Acta Oncol 2020; 59:549-557. [PMID: 32122185 DOI: 10.1080/0284186x.2020.1730003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Radiotherapy is an established treatment option for prostate cancer (PCa), both as primary treatment and secondary treatment after radical prostatectomy (RP). Since 1998, detailed data on radiotherapy delivered to Swedish men with PCa (e.g. treatment modalities, absorbed doses, fractionation) have been collated within PCa data Base Sweden (PCBaSe). This study reports patterns of radical radiotherapy for PCa in Sweden over the past two decades.Materials and methods: All men with non-metastatic PCa (1998-2016) who received external beam radiotherapy (EBRT) or high or low dose-rate brachytherapy (HDR-BT/LDR-BT) were identified in PCBaSe. Analyses included: trends in radiation techniques, fractionation patterns and total doses over time; PCa-specific survival comparing treatment in 2007-2017 with 1998-2006; and regional variation in type of primary radiotherapy.Results: About 20,876 men underwent primary radiotherapy. The main treatment modalities include conventionally fractionated (2.0 Gy/fraction) EBRT (51%), EBRT with HDR-BT boost (27%) and hypofractionated (>2.4 Gy/fraction) EBRT (11%). EBRT with photon or proton boost and HDR-BT and LDR-BT monotherapies were each used minimally. Use of dose-escalated EBRT (>74 Gy) and moderate hypofractionation increased over time, while use of HDR-BT declined. Considerable regional variation in treatment modalities was apparent. Risk of PCa death following primary radiotherapy had declined for intermediate-risk (HR: 0.60; 95%CI 0.47-0.87) and high-risk PCa (HR: 0.72; 95%CI 0.61-0.86).Discussion: Increased use of dose escalation and hypofractionated EBRT has occurred in Sweden over the past two decades, reflecting current evidence and practice guidelines. Disease-specific outcomes have also improved. Data collected in PCBaSe provide an excellent resource for further research into RT use in PCa management.
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Affiliation(s)
- Kerri Beckmann
- Translational Oncology and Urology Research (TOUR), School of Cancer and Pharmaceutical Studies, King’s College London, London, UK
- University of South Australia Cancer Research Institute, University of South Australia, Adelaide, Australia
| | - Hans Garmo
- Regional Cancer Centre Uppsala, Uppsala University Hospital, Uppsala, Sweden
| | - Per Nilsson
- Department of Oncology and Radiation Physics, Skane University Hospital and Lund University, Lund, Sweden
| | | | - Anders Widmark
- Department of Radiation Sciences, Umea University, Umea, Sweden
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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Preisser F, Cooperberg MR, Crook J, Feng F, Graefen M, Karakiewicz PI, Klotz L, Montironi R, Nguyen PL, D'Amico AV. Intermediate-risk Prostate Cancer: Stratification and Management. Eur Urol Oncol 2020; 3:270-280. [PMID: 32303478 DOI: 10.1016/j.euo.2020.03.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/02/2020] [Accepted: 03/23/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT Intermediate-risk prostate cancer consists of a highly heterogeneous group of patients. Owing to this heterogeneity and variable prognoses, it is challenging to provide uniform treatment recommendations for men in this group. OBJECTIVE To review the current literature regarding the best available evidence for stratification and treatment of intermediate-risk prostate cancer patients. EVIDENCE ACQUISITION We searched Medline and EMBASE, through September 2019 without year or language restriction, supplemented with hand search. EVIDENCE SYNTHESIS Different treatment options with good long-term oncological outcomes are available for intermediate-risk prostate cancer patients. Best available evidence with long follow-up exists for radical prostatectomy and dose-escalated radiotherapy with short-term androgen deprivation. In favorable intermediate-risk patients, active surveillance and brachy-monotherapy also represent two valid treatment options. In carefully selected men, partial gland ablation represents a reasonable option. Patient preferences and comorbidities should also be considered. CONCLUSIONS Treatment options for intermediate-risk patients range from active surveillance to partial gland ablation, radical prostatectomy, and various radiotherapy methods. The best stratification and the optimal treatment remain controversial. Classification systems, such as the National Cancer Comprehensive Network guidelines, stratify this large cohort into subgroups with favorable or unfavorable disease, which may simplify treatment recommendations but still leave substantial variability within strata. Advanced imaging may further improve current stratification systems of intermediate-risk patients. PATIENT SUMMARY In this review, we assessed the current literature regarding the best available evidence for stratification and treatment of intermediate-risk prostate cancer patients.
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Affiliation(s)
- Felix Preisser
- Department of Urology, University Hospital Frankfurt, Frankfurt, Germany.
| | - Matthew R Cooperberg
- Department of Urology, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Juanita Crook
- BCCA Center for the Southern Interior, University of British Columbia, Kelowna, BC, Canada
| | - Felix Feng
- Department of Radiation Oncology, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada
| | - Laurence Klotz
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rodolfo Montironi
- Section of Pathological Anatomy, Marche Polytechnic University, School of Medicine, United Hospitals, Ancona, Italy
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Anthony V D'Amico
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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9
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Buwenge M, Perrone M, Siepe G, Capocaccia I, Woldemariam AA, Wondemagegnhu T, Uddin KAFM, Sumon MA, Galofaro E, Macchia G, Deodato F, Cilla S, Morganti AG. Definition of fields margins for the optimized 2D radiotherapy of prostate carcinoma. Mol Clin Oncol 2019; 11:37-42. [PMID: 31289675 PMCID: PMC6535634 DOI: 10.3892/mco.2019.1855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/15/2019] [Indexed: 12/03/2022] Open
Abstract
Prostate cancer (PCa) is one of the most common malignancies in men both in western and developing countries. Radiotherapy (RT) is an important therapeutic option. New technologies (including 3D, intensity modulated RT, image-guided RT and, volumetric modulated arc therapy) have been introduced in the last few decades with progressive improvement of clinical outcomes. However, in many developing countries, the only treatment option is the traditional two-dimensional (2D) technique based on standard simulation. The guidelines for 2D field definition are still based on expert's opinions. The aim of the present study was to propose new practical guidelines for 2D fields definition based on 3D simulation in PCa. A total of 20 patients were enrolled. Computed tomography-simulation and pelvic magnetic resonance images were merged to define the prostate volumes. Clinical Target Volume (CTV) was defined using the European Organisation for Research and Treatment of Cancer guidelines in consideration of the four risk categories: Low, intermediate, and high risk with or without seminal vesicles involvement, respectively. Planning Target Volume (PTV) was defined by adding 10 mm to the CTV. For each category, two treatment plans were calculated using a cobalt source or 10 MV photons. Progressive optimization was achieved by evaluating 3D dose distribution. Finally, the optimal distances between field margins and radiological landmarks (bones and rectum with contrast medium) were defined. The results were reported in tabular form. Both field margins (PTV D98% >95%) needed to adequately irradiate all patients and to achieve a similar result in 95% of the enrolled patients are reported. Using a group of patients with PCa and based on a 3D planning analysis, we propose new practical guidelines for PCa 2D-RT based on current criteria for risk category and CTV, and PTV definition.
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Affiliation(s)
- Milly Buwenge
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy
| | - Mariangela Perrone
- Radiotherapy Unit, Fondazione di Ricerca e Cura 'Giovanni Paolo II', Catholic University of Sacred Heart, I-86100 Campobasso, Italy
| | - Giambattista Siepe
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy
| | - Ilaria Capocaccia
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy
| | | | | | - Kamal A F M Uddin
- Radiation Oncology Department, United Hospital Limited, Gulshan, Dhaka 1212, Bangladesh
| | - Mostafa A Sumon
- Radiation Oncology Department, United Hospital Limited, Gulshan, Dhaka 1212, Bangladesh
| | - Elena Galofaro
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy
| | - Gabriella Macchia
- Radiotherapy Unit, Fondazione di Ricerca e Cura 'Giovanni Paolo II', Catholic University of Sacred Heart, I-86100 Campobasso, Italy
| | - Francesco Deodato
- Radiotherapy Unit, Fondazione di Ricerca e Cura 'Giovanni Paolo II', Catholic University of Sacred Heart, I-86100 Campobasso, Italy
| | - Savino Cilla
- Medical Physic Unit, Fondazione di Ricerca e Cura 'Giovanni Paolo II', Catholic University of Sacred Heart, I-86100 Campobasso, Italy
| | - Alessio G Morganti
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy
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10
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Reis Ferreira M, Khan A, Thomas K, Truelove L, McNair H, Gao A, Parker CC, Huddart R, Bidmead M, Eeles R, Khoo V, van As NJ, Hansen VN, Dearnaley DP. Phase 1/2 Dose-Escalation Study of the Use of Intensity Modulated Radiation Therapy to Treat the Prostate and Pelvic Nodes in Patients With Prostate Cancer. Int J Radiat Oncol Biol Phys 2017; 99:1234-1242. [PMID: 28939224 PMCID: PMC5697895 DOI: 10.1016/j.ijrobp.2017.07.041] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 06/21/2017] [Accepted: 07/26/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE To investigate the feasibility of dose escalation and hypofractionation of pelvic lymph node intensity modulated radiation therapy (PLN-IMRT) in prostate cancer (PCa). METHODS AND MATERIALS In a phase 1/2 study, patients with advanced localized PCa were sequentially treated with 70 to 74 Gy to the prostate and dose-escalating PLN-IMRT at doses of 50 Gy (cohort 1), 55 Gy (cohort 2), and 60 Gy (cohort 3) in 35 to 37 fractions. Two hypofractionated cohorts received 60 Gy to the prostate and 47 Gy to PLN in 20 fractions over 4 weeks (cohort 4) and 5 weeks (cohort 5). All patients received long-course androgen deprivation therapy. Primary outcome was late Radiation Therapy Oncology Group toxicity at 2 years after radiation therapy for all cohorts. Secondary outcomes were acute and late toxicity using other clinician/patient-reported instruments and treatment efficacy. RESULTS Between August 9, 2000, and June 9, 2010, 447 patients were enrolled. Median follow-up was 90 months. The 2-year rates of grade 2+ bowel/bladder toxicity were as follows: cohort 1, 8.3%/4.2% (95% confidence interval 2.2%-29.4%/0.6%-26.1%); cohort 2, 8.9%/5.9% (4.1%-18.7%/2.3%-15.0%); cohort 3, 13.2%/2.9% (8.6%-20.2%/1.1%-7.7%); cohort 4, 16.4%/4.8% (9.2%-28.4%/1.6%-14.3%); cohort 5, 12.2%/7.3% (7.6%-19.5%/3.9%-13.6%). Prevalence of bowel and bladder toxicity seemed to be stable over time. Other scales mirrored these results. The biochemical/clinical failure-free rate was 71% (66%-75%) at 5 years for the whole group, with pelvic lymph node control in 94% of patients. CONCLUSIONS This study shows the safety and tolerability of PLN-IMRT. Ongoing and planned phase 3 studies will need to demonstrate an increase in efficacy using PLN-IMRT to offset the small increase in bowel side effects compared with prostate-only IMRT.
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Affiliation(s)
- Miguel Reis Ferreira
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Atia Khan
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Karen Thomas
- Research Data Management and Statistics Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Lesley Truelove
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Helen McNair
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
| | - Annie Gao
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Chris C Parker
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Robert Huddart
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Margaret Bidmead
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden Hospital, London, United Kingdom
| | - Ros Eeles
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Vincent Khoo
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Nicholas J van As
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Vibeke N Hansen
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden Hospital, London, United Kingdom
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom.
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11
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Daoud MA, Aboelnaga EM, Alashry MS, Fathy S, Aletreby MA. Clinical outcome and toxicity evaluation of simultaneous integrated boost pelvic IMRT/VMAT at different dose levels combined with androgen deprivation therapy in prostate cancer patients. Onco Targets Ther 2017; 10:4981-4988. [PMID: 29066917 PMCID: PMC5644603 DOI: 10.2147/ott.s141224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The role of dose escalation in patients receiving long-term androgen deprivation therapy (ADT) is still a controversial issue. The aim of the current study was to evaluate whether dose escalation for ≥76–80 Gy had any advantage in terms of biochemical disease-free survival (BDFS), distant metastasis-free survival (DMFS), or overall survival outcomes over the dose levels from 70 to <76 Gy. Patients and methods The study included a cohort of 24 patients classified with high- and intermediate-risk localized prostate cancer. All patients received ADT, starting at 4–6 months before radiation therapy and continued for a total period of 12–24 months in high-risk patients. The treatment plan was given in two phases. In the first phase, the nodal planning target volume (PTV) and the prostate PTV received 48.6 and 54 Gy, respectively, over 27 fractions. The treatment was applied through intensity-modulated radiation therapy or volumetric modulated arc therapy with a simultaneous integrated boost technique. Results More than half of the patients were in T3–T4 stage, 79.1% of the patients were in the high-risk category, and all patients received ADT. The rate of acute grade II gastrointestinal and genitourinary toxicities in all patients were 41.7% and 62.5%, respectively. The rate of freedom from grade II rectal toxicity at 2 years was 89% and 83% for patients treated with dose levels <76 and ≥76 Gy, respectively. The rate of BDFS at 2 years was 90% and 85% for doses <76 and ≥76 Gy, respectively. The DMFS at 2 years was 100% and 76% for dose levels <76 and ≥76 Gy, respectively. Conclusion In the current study, there were no significant differences in the BDFS and DMFS between patients treated with a dose of <76 and ≥76 Gy, including elective pelvic lymph nodes irradiation combined with ADT.
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Affiliation(s)
- Mohamed A Daoud
- Department of Clinical Oncology and Nuclear Medicine, Mansoura Faculty of Medicine, Mansoura University, Mansoura.,Department of Oncology, Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Engy M Aboelnaga
- Department of Clinical Oncology and Nuclear Medicine, Mansoura Faculty of Medicine, Mansoura University, Mansoura
| | - Mohamed S Alashry
- Department of Clinical Oncology and Nuclear Medicine, Mansoura Faculty of Medicine, Mansoura University, Mansoura
| | - Salwa Fathy
- Department of Radiation, Oncology and Nuclear Medicine, South Egypt Cancer Institute, Assiut University, Assiut
| | - Mostafa A Aletreby
- Department of Oncology, Fakeeh Hospital, Jeddah, Saudi Arabia.,Department of Medical Physics, Kasr Alainy Faculty of Medicine, Al Manial, Egypt
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12
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Henríquez I, Rodríguez-Antolín A, Cassinello J, Gonzalez San Segundo C, Unda M, Gallardo E, López-Torrecilla J, Juarez A, Arranz J. Consensus statement on definition, diagnosis, and management of high-risk prostate cancer patients on behalf of the Spanish Groups of Uro-Oncology Societies URONCOR, GUO, and SOGUG. Clin Transl Oncol 2017; 20:392-401. [PMID: 28785912 DOI: 10.1007/s12094-017-1726-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 07/26/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Prostate cancer (PCa) is the most prevalent malignancy in men and the second cause of mortality in industrialized countries. METHODS Based on Spanish Register of PCa, the incidence of high-risk PCa is 29%, approximately. In spite of the evidence-based beneficial effect of radiotherapy and androgen deprivation therapy in high-risk PCa, these patients (pts) are still a therapeutic challenge for all specialists involved, in part due to the absence of comparative studies to establish which of the present disposable treatments offer better results. RESULTS Nowadays, high-risk PCa definition is not well consensual through the published oncology guides. Clinical stage, tumour grade, and number of risk factors are relevant to be considered on PCa prognosis. However, these factors are susceptible to change depending on when surgical or radiation therapy is considered to be the treatment of choice. Other factors, such as reference pathologist, different diagnosis biopsy schedules, surgical or radiotherapy techniques, adjuvant treatments, biochemical failures, and follow-up, make it difficult to compare the results between different therapeutic options. CONCLUSIONS This article reviews important issues concerning high-risk PCa. URONCOR, GUO, and SOGUG on behalf of the Spanish Groups of Uro-Oncology Societies have reached a consensus addressing a practical recommendation on definition, diagnosis, and management of high-risk PCa.
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Affiliation(s)
- I Henríquez
- Radiation Oncology Department, Hospital Universitario of Sant Joan, Institute d'Investigació Sanitaria Pere Virgili (IISPV), Josep Laporte 2, 43204, Reus, Spain.
| | | | - J Cassinello
- Medical Oncology Department, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | | | - M Unda
- Urology Department, Hospital Barakaldo, Bilbao, Spain
| | - E Gallardo
- Medical Oncology Department, Hospital Parc Taulí, Sabadell, Spain
| | | | - A Juarez
- Urology Department, Hospital Cádiz, Andalucía, Spain
| | - J Arranz
- Medical Oncology Department, Hospital Gregorio Marañón, Madrid, Spain
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13
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Dayes IS, Parpia S, Gilbert J, Julian JA, Davis IR, Levine MN, Sathya J. Long-Term Results of a Randomized Trial Comparing Iridium Implant Plus External Beam Radiation Therapy With External Beam Radiation Therapy Alone in Node-Negative Locally Advanced Cancer of the Prostate. Int J Radiat Oncol Biol Phys 2017; 99:90-93. [PMID: 28816169 DOI: 10.1016/j.ijrobp.2017.05.013] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/27/2017] [Accepted: 05/09/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To determine the impact on long-term survival from the addition of brachytherapy to external beam radiation therapy (EBRT) in patients with prostate cancer. METHODS AND MATERIALS Between 1992 and 1997, 104 men with cT2-3, surgically staged node-negative prostate cancer were randomized to receive either EBRT (40 Gy/20 fractions) with iridium implant (35 Gy/48 hours) or EBRT alone (66 Gy/33 fractions) to the prostate. According to T stage, Gleason score, and prostate-specific antigen level, 60% of patients had high-risk disease. Substantial improvements in biochemical control at 8 years have previously been reported. Additional follow-up was collected on deaths and metastases. RESULTS Median follow-up was 14 years. Five patients were lost to follow-up. All other patients have been followed a minimum of 13 years. There have been 75 deaths, including 21 from prostate cancer and 25 from second cancers. No patients developing a second cancer have died from prostate cancer. There was no difference in overall survival between the 2 treatment groups: 34 deaths (67%) in the implant arm and 41 (77%) in the EBRT arm (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.63-1.59). Similarly, there was no difference in prostate cancer-specific deaths: 9 (18%) patients in the implant arm compared with 12 (23%) in the EBRT arm (HR 0.79, 95% CI 0.34-1.87). There was no statistically significant difference in the number of patients developing metastatic disease: 10 (20%) in the implant arm and 15 (28%) in the EBRT arm (HR 0.70, 95% CI 0.32-1.57). Improvements in biochemical control were maintained (HR 0.53, 95% CI 0.31-0.88). CONCLUSIONS Despite a dramatic reduction of biochemical recurrence rates, the addition of iridium implant to EBRT did not translate into improved overall survival or prostate cancer-specific survival.
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Affiliation(s)
- Ian S Dayes
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada.
| | - Sameer Parpia
- Ontario Clinical Oncology Group, Juravinski Hospital, Hamilton, Ontario, Canada
| | - Jaclyn Gilbert
- Department of Anaesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Jim A Julian
- Ontario Clinical Oncology Group, Juravinski Hospital, Hamilton, Ontario, Canada
| | - Ian R Davis
- Department of Urology, St. Joseph's Health Centre, Hamilton, Ontario, Canada
| | - Mark N Levine
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Ontario Clinical Oncology Group, Juravinski Hospital, Hamilton, Ontario, Canada
| | - Jinka Sathya
- Department of Oncology, Memorial University, St. John's, Newfoundland, Canada
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14
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Abstract
We reviewed the literature on the use of margins in radiotherapy of patients with prostate cancer, focusing on different options for image guidance (IG) and technical issues. The search in PubMed database was limited to include studies that involved external beam radiotherapy of the intact prostate. Post-prostatectomy studies, brachytherapy and particle therapy were excluded. Each article was characterized according to the IG strategy used: positioning on external marks using room lasers, bone anatomy and soft tissue match, usage of fiducial markers, electromagnetic tracking and adapted delivery. A lack of uniformity in margin selection among institutions was evident from the review. In general, introduction of pre- and in-treatment IG was associated with smaller planning target volume (PTV) margins, but there was a lack of definitive experimental/clinical studies providing robust information on selection of exact PTV values. In addition, there is a lack of comparative research regarding the cost-benefit ratio of the different strategies: insertion of fiducial markers or electromagnetic transponders facilitates prostate gland localization but at a price of invasive procedure; frequent pre-treatment imaging increases patient in-room time, dose and labour; online plan adaptation should improve radiation delivery accuracy but requires fast and precise computation. Finally, optimal protocols for quality assurance procedures need to be established.
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Affiliation(s)
- Slav Yartsev
- 1 London Regional Cancer Program, London Health Sciences Centre, London, ON, Canada.,2 Departments of Oncology and Medical Biophysics, Western University, London, ON, Canada
| | - Glenn Bauman
- 1 London Regional Cancer Program, London Health Sciences Centre, London, ON, Canada.,2 Departments of Oncology and Medical Biophysics, Western University, London, ON, Canada
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15
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Shakespeare TP, Wilcox SW, Aherne NJ. Can we avoid high levels of dose escalation for high-risk prostate cancer in the setting of androgen deprivation? Onco Targets Ther 2016; 9:2819-24. [PMID: 27274277 PMCID: PMC4869660 DOI: 10.2147/ott.s105174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Aim Both dose-escalated external beam radiotherapy (DE-EBRT) and androgen deprivation therapy (ADT) improve outcomes in patients with high-risk prostate cancer. However, there is little evidence specifically evaluating DE-EBRT for patients with high-risk prostate cancer receiving ADT, particularly for EBRT doses >74 Gy. We aimed to determine whether DE-EBRT >74 Gy improves outcomes for patients with high-risk prostate cancer receiving long-term ADT. Patients and methods Patients with high-risk prostate cancer were treated on an institutional protocol prescribing 3–6 months neoadjuvant ADT and DE-EBRT, followed by 2 years of adjuvant ADT. Between 2006 and 2012, EBRT doses were escalated from 74 Gy to 76 Gy and then to 78 Gy. We interrogated our electronic medical record to identify these patients and analyzed our results by comparing dose levels. Results In all, 479 patients were treated with a 68-month median follow-up. The 5-year biochemical disease-free survivals for the 74 Gy, 76 Gy, and 78 Gy groups were 87.8%, 86.9%, and 91.6%, respectively. The metastasis-free survivals were 95.5%, 94.5%, and 93.9%, respectively, and the prostate cancer-specific survivals were 100%, 94.4%, and 98.1%, respectively. Dose escalation had no impact on any outcome in either univariate or multivariate analysis. Conclusion There was no benefit of DE-EBRT >74 Gy in our cohort of high-risk prostate patients treated with long-term ADT. As dose escalation has higher risks of radiotherapy-induced toxicity, it may be feasible to omit dose escalation beyond 74 Gy in this group of patients. Randomized studies evaluating dose escalation for high-risk patients receiving ADT should be considered.
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Affiliation(s)
- Thomas P Shakespeare
- Department of Radiation Oncology, North Coast Cancer Institute, University of New South Wales, Coffs Harbour, NSW, Australia; Rural Clinical School, Faculty of Medicine, University of New South Wales, Coffs Harbour, NSW, Australia
| | - Shea W Wilcox
- Department of Radiation Oncology, North Coast Cancer Institute, University of New South Wales, Coffs Harbour, NSW, Australia
| | - Noel J Aherne
- Department of Radiation Oncology, North Coast Cancer Institute, University of New South Wales, Coffs Harbour, NSW, Australia; Rural Clinical School, Faculty of Medicine, University of New South Wales, Coffs Harbour, NSW, Australia
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16
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Shakespeare TP, Wilcox SW, Aherne NJ. Can we avoid dose escalation for intermediate-risk prostate cancer in the setting of short-course neoadjuvant androgen deprivation? Onco Targets Ther 2016; 9:1635-9. [PMID: 27073327 PMCID: PMC4806761 DOI: 10.2147/ott.s102327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Both dose-escalated external beam radiotherapy (DE-EBRT) and androgen deprivation therapy (ADT) improve the outcomes in patients with intermediate-risk prostate cancer. Despite this, there are only few reports evaluating DE-EBRT for patients with intermediate-risk prostate cancer receiving neoadjuvant ADT, and virtually no studies investigating dose escalation >74 Gy in this setting. We aimed to determine whether DE-EBRT >74 Gy improved the outcomes for patients with intermediate-risk prostate cancer who received neoadjuvant ADT. Findings In our institution, patients with intermediate-risk prostate cancer were treated with neoadjuvant ADT and DE-EBRT, with doses sequentially increasing from 74 Gy to 76 Gy and then to 78 Gy between 2006 and 2012. We identified 435 patients treated with DE-EBRT and ADT, with a median follow-up of 70 months. For the 74 Gy, 76 Gy, and 78 Gy groups, five-year biochemical disease-free survival rates were 95.0%, 97.8%, and 95.3%, respectively; metastasis-free survival rates were 99.1%, 100.0%, and 98.6%, respectively; and prostate cancer-specific survival rate was 100% for all three dose levels. There was no significant benefit for dose escalation either on univariate or multivariate analysis for any outcome. Conclusion There was no benefit for DE-EBRT >74 Gy in our cohort of intermediate-risk prostate cancer patients treated with neoadjuvant ADT. Given the higher risks of toxicity associated with dose escalation, it may be feasible to omit dose escalation in this group of patients. Randomized studies evaluating dose de-escalation should be considered.
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Affiliation(s)
- Thomas P Shakespeare
- Department of Radiation Oncology, North Coast Cancer Institute, The University of New South Wales, Coffs Harbour, New South Wales, Australia; Faculty of Medicine, Rural Clinical School, The University of New South Wales, Coffs Harbour, New South Wales, Australia
| | - Shea W Wilcox
- Department of Radiation Oncology, North Coast Cancer Institute, The University of New South Wales, Coffs Harbour, New South Wales, Australia
| | - Noel J Aherne
- Department of Radiation Oncology, North Coast Cancer Institute, The University of New South Wales, Coffs Harbour, New South Wales, Australia; Faculty of Medicine, Rural Clinical School, The University of New South Wales, Coffs Harbour, New South Wales, Australia
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17
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Brachytherapy improves biochemical failure-free survival in low- and intermediate-risk prostate cancer compared with conventionally fractionated external beam radiation therapy: a propensity score matched analysis. Int J Radiat Oncol Biol Phys 2015; 91:505-16. [PMID: 25596107 DOI: 10.1016/j.ijrobp.2014.11.018] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 11/06/2014] [Accepted: 11/11/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare, in a retrospective study, biochemical failure-free survival (bFFS) and overall survival (OS) in low-risk and intermediate-risk prostate cancer patients who received brachytherapy (BT) (either low-dose-rate brachytherapy [LDR-BT] or high-dose-rate brachytherapy with external beam radiation therapy [HDR-BT+EBRT]) versus external beam radiation therapy (EBRT) alone. METHODS AND MATERIALS Patient data were obtained from the ProCaRS database, which contains 7974 prostate cancer patients treated with primary radiation therapy at four Canadian cancer institutions from 1994 to 2010. Propensity score matching was used to obtain the following 3 matched cohorts with balanced baseline prognostic factors: (1) low-risk LDR-BT versus EBRT; (2) intermediate-risk LDR-BT versus EBRT; and (3) intermediate-risk HDR-BT+EBRT versus EBRT. Kaplan-Meier survival analysis was performed to compare differences in bFFS (primary endpoint) and OS in the 3 matched groups. RESULTS Propensity score matching created acceptable balance in the baseline prognostic factors in all matches. Final matches included 2 1:1 matches in the intermediate-risk cohorts, LDR-BT versus EBRT (total n=254) and HDR-BT+EBRT versus EBRT (total n=388), and one 4:1 match in the low-risk cohort (LDR-BT:EBRT, total n=400). Median follow-up ranged from 2.7 to 7.3 years for the 3 matched cohorts. Kaplan-Meier survival analysis showed that all BT treatment options were associated with statistically significant improvements in bFFS when compared with EBRT in all cohorts (intermediate-risk EBRT vs LDR-BT hazard ratio [HR] 4.58, P=.001; intermediate-risk EBRT vs HDR-BT+EBRT HR 2.08, P=.007; low-risk EBRT vs LDR-BT HR 2.90, P=.004). No significant difference in OS was found in all comparisons (intermediate-risk EBRT vs LDR-BT HR 1.27, P=.687; intermediate-risk EBRT vs HDR-BT+EBRT HR 1.55, P=.470; low-risk LDR-BT vs EBRT HR 1.41, P=.500). CONCLUSIONS Propensity score matched analysis showed that BT options led to statistically significant improvements in bFFS in low- and intermediate-risk prostate cancer patient populations.
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18
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Hou Z, Li G, Bai S. High dose versus conventional dose in external beam radiotherapy of prostate cancer: a meta-analysis of long-term follow-up. J Cancer Res Clin Oncol 2014; 141:1063-71. [PMID: 25173623 DOI: 10.1007/s00432-014-1813-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 08/18/2014] [Indexed: 02/05/2023]
Abstract
PURPOSE To assess the efficacy and toxicity between high-dose radiotherapy (HDRT) and conventional-dose radiotherapy (CDRT) by collecting randomized controlled trials of long-term follow-ups. METHODS Unrestricted by language, we searched Ovid MEDLINE, Ovid EMBASE, Cochrane Library, Science Citation Index (Web of Science) and ClinicalTrials.gov for the following end points: biochemical failure (BF), overall survival (OS), prostate cancer-specific survival (PCSS) and side effects. The meta-analysis was performed by using Review Manager 5.2 and Stata version 12.0 software packages. Results were expressed as the odds ratio (OR) with the corresponding 95 % confidence interval (CI). RESULTS Six randomized controlled trials, with a total population of 2,822, were eligible. In terms of 10-year efficacy relative to CDRT, the HDRT was associated with almost an equivalent OS (73.4 vs. 74.3 %, OR 1.05, 95 % CI 0.86-1.28; p = 0.64) and PCSS (90.7 vs. 91.6 %, OR 1.11, 95 % CI 0.83-1.49; p = 0.47), but a significant decrease in the BF (34.0 vs. 24.7 %, OR 0.61, 95 % CI 0.51-0.74; p < 0.00001). In terms of toxicity, HDRT significantly increased the late Grade 2 or higher (G ≥ 2) gastrointestinal toxicity (28.0 vs. 18.6 %, OR 1.72, 95 % CI 1.42-2.08; p < 0.00001) and late G ≥ 2 genitourinary (GU) toxicity (22.6 vs. 19.5 %, OR 1.24, 95 % CI 1.01-1.52; p = 0.04). In the subgroup analysis, trials with or without androgen deprivation therapy both had a significant decrease in the BF at 10 years. With regard to quality of life, there was no significant difference between HDRT and CDRT (p > 0.05). CONCLUSION This was the first meta-analysis of trials with long-term follow-up to indicate that HDRT is superior to CDRT in terms of preventing BF in localized prostate cancer patients. However, this advantage did not translate into an improvement in OS and PCSS. This was also the first meta-analysis to suggest that the HDRT in three-dimensional conformal radiotherapy (3D-CRT) significantly increases the late G ≥ 2 GU toxicity. Thus, the dose escalation in 3D-CRT should be discreetly used in the treatment of prostate cancer due to the increase in late toxicities.
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Affiliation(s)
- Zan Hou
- West China Hospital Cancer Center, Sichuan University, Chengdu, People's Republic of China
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19
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Chang AJ, Autio KA, Roach M, Scher HI. High-risk prostate cancer-classification and therapy. Nat Rev Clin Oncol 2014; 11:308-23. [PMID: 24840073 DOI: 10.1038/nrclinonc.2014.68] [Citation(s) in RCA: 296] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Approximately 15% of patients with prostate cancer are diagnosed with high-risk disease. However, the current definitions of high-risk prostate cancer include a heterogeneous group of patients with a range of prognoses. Some have the potential to progress to a lethal phenotype that can be fatal, while others can be cured with treatment of the primary tumour alone. The optimal management of this patient subgroup is evolving. A refined classification scheme is needed to enable the early and accurate identification of high-risk disease so that more-effective treatment paradigms can be developed. We discuss several principles established from clinical trials, and highlight other questions that remain unanswered. This Review critically evaluates the existing literature focused on defining the high-risk population, the management of patients with high-risk prostate cancer, and future directions to optimize care.
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Affiliation(s)
- Albert J Chang
- Department of Radiation Oncology, University of California, San Francisco, 1600 Divisadero Street, Suite H-1031, San Francisco, CA 94115, USA
| | - Karen A Autio
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, Weill Cornell Medical College, New York, NY 10065, USA
| | - Mack Roach
- Department of Radiation Oncology, University of California, San Francisco, 1600 Divisadero Street, Suite H-1031, San Francisco, CA 94115, USA
| | - Howard I Scher
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, Weill Cornell Medical College, New York, NY 10065, USA
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20
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Dearnaley DP, Jovic G, Syndikus I, Khoo V, Cowan RA, Graham JD, Aird EG, Bottomley D, Huddart RA, Jose CC, Matthews JHL, Millar JL, Murphy C, Russell JM, Scrase CD, Parmar MKB, Sydes MR. Escalated-dose versus control-dose conformal radiotherapy for prostate cancer: long-term results from the MRC RT01 randomised controlled trial. Lancet Oncol 2014; 15:464-73. [PMID: 24581940 DOI: 10.1016/s1470-2045(14)70040-3] [Citation(s) in RCA: 337] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The aim of this trial was to compare dose-escalated conformal radiotherapy with control-dose conformal radiotherapy in patients with localised prostate cancer. Preliminary findings reported after 5 years of follow-up showed that escalated-dose conformal radiotherapy improved biochemical progression-free survival. Based on the sample size calculation, we planned to analyse overall survival when 190 deaths occurred; this target has now been reached, after a median 10 years of follow-up. METHODS RT01 was a phase 3, open-label, international, randomised controlled trial enrolling men with histologically confirmed T1b-T3a, N0, M0 prostate cancer with prostate specific antigen of less than 50 ng/mL. Patients were randomly assigned centrally in a 1:1 ratio, using a computer-based minimisation algorithm stratifying by risk of seminal vesicle invasion and centre to either the control group (64 Gy in 32 fractions, the standard dose at the time the trial was designed) or the escalated-dose group (74 Gy in 37 fractions). Neither patients nor investigators were masked to assignment. All patients received neoadjuvant androgen deprivation therapy for 3-6 months before the start of conformal radiotherapy, which continued until the end of conformal radiotherapy. The coprimary outcome measures were biochemical progression-free survival and overall survival. All analyses were done on an intention-to-treat basis. Treatment-related side-effects have been reported previously. This trial is registered, number ISRCTN47772397. FINDINGS Between Jan 7, 1998, and Dec 20, 2001, 862 men were registered and 843 subsequently randomly assigned: 422 to the escalated-dose group and 421 to the control group. As of Aug 2, 2011, 236 deaths had occurred: 118 in each group. Median follow-up was 10·0 years (IQR 9·1-10·8). Overall survival at 10 years was 71% (95% CI 66-75) in each group (hazard ratio [HR] 0·99, 95% CI 0·77-1·28; p=0·96). Biochemical progression or progressive disease occurred in 391 patients (221 [57%] in the control group and 170 [43%] in the escalated-dose group). At 10 years, biochemical progression-free survival was 43% (95% CI 38-48) in the control group and 55% (50-61) in the escalated-dose group (HR 0·69, 95% CI 0·56-0·84; p=0·0003). INTERPRETATION At a median follow-up of 10 years, escalated-dose conformal radiotherapy with neoadjuvant androgen deprivation therapy showed an advantage in biochemical progression-free survival, but this advantage did not translate into an improvement in overall survival. These efficacy data for escalated-dose treatment must be weighed against the increase in acute and late toxicities associated with the escalated dose and emphasise the importance of use of appropriate modern radiotherapy methods to reduce side-effects. FUNDING UK Medical Research Council.
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Affiliation(s)
- David P Dearnaley
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | - Gordana Jovic
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | | | - Vincent Khoo
- The Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | | | | | | | | | - Robert A Huddart
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London and Sutton, UK
| | | | | | | | - Claire Murphy
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | | | | | - Mahesh K B Parmar
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Matthew R Sydes
- Medical Research Council Clinical Trials Unit at University College London, London, UK.
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