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Mahadevan A, Warnecke B, Chiao E, Nafissi N, Parajuli K, Rijal N, Parajuli R. Goserelin-Induced Chemical Burn: A Case Report and Review of the Literature. Cureus 2023; 15:e45692. [PMID: 37745751 PMCID: PMC10513001 DOI: 10.7759/cureus.45692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 09/26/2023] Open
Abstract
A chemical burn resulting from luteinizing hormone-releasing hormone agonists (LHRHa) is a rare adverse effect that has not been well-documented in prior literature. In this case report, we report a partial-thickness burn that developed following a single subcutaneous injection of goserelin. To our knowledge, this is the first description of goserelin-induced chemical burn in the literature. The importance of early identification and treatment of LHRHa-associated cutaneous reactions must be highlighted to ensure optimal oncologic management and patient comfort.
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Affiliation(s)
- Aditya Mahadevan
- Department of Hematology and Oncology, University of California Irvine School of Medicine, Orange, USA
| | - Brian Warnecke
- Department of Hematology and Oncology, University of California Irvine Medical Center, Orange, USA
| | - Elaine Chiao
- Department of Hematology and Oncology, University of California Irvine School of Medicine, Orange, USA
| | - Nellie Nafissi
- Department of Hematology and Oncology, University of California Irvine Medical Center, Orange, USA
| | - Kritisha Parajuli
- Department of Medicine, Nepal Medical College and Teaching Hospital, Kathmandu, NPL
| | - Nejina Rijal
- Department of Medicine, Kathmandu Medical College, Kathmandu, NPL
| | - Ritesh Parajuli
- Department of Hematology and Oncology, University of California Irvine Medical Center, Orange, USA
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High-Risk Localized Prostate Cancer. Urol Oncol 2022. [DOI: 10.1007/978-3-030-89891-5_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Hussain S, Gunnell D, Donovan J, McPhail S, Hamdy F, Neal D, Albertsen P, Verne J, Stephens P, Trotter C, Martin RM. Secular trends in prostate cancer mortality, incidence and treatment: England and Wales, 1975-2004. BJU Int 2008; 101:547-55. [PMID: 18190630 DOI: 10.1111/j.1464-410x.2007.07338.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To aid the interpretation of the trends in prostate cancer mortality, which declined in the UK in the early 1990 s for unknown reasons, by investigating prostate cancer death rates, incidence and treatments in England and Wales in 1975-2004. METHODS Join-point regression was used to assess secular trends in mortality and incidence (source: Office of National Statistics), radical prostatectomy and orchidectomy (source: Hospital Episode Statistics database) and androgen-suppression drugs (source: Intercontinental Medical Statistics). RESULTS Prostate cancer mortality declined from 1992 (95% confidence interval, CI, 1990-94). The relative decline in mortality to 2004 was greater and more sustained amongst men aged 55-74 years (annual percentage mortality reduction 2.75%; 95% CI 2.33-3.18%) than amongst those aged >or=75 years (0.71%, 0.26-1.15%). The use of radical prostatectomy increased between 1991 (89 operations) and 2004 (2788) amongst men aged 55-74 years. The prescribing of androgen suppression increased between 1987 (33,000 prescriptions) and 2004 (470,000). CONCLUSIONS The decrease in prostate cancer mortality was greater amongst men aged 55-74 years than in those aged >or=75 years, but pre-dated the substantial use of prostate-specific antigen screening and radical prostatectomy in the UK. An increase in radical therapy amongst younger groups with localized cancers and screen-detected low-volume locally advanced disease as a result of stage migration, as well as prolonged survival from increased medical androgen suppression therapy, might partly explain recent trends.
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Affiliation(s)
- Sabina Hussain
- Department of Social Medicine, University of Bristol, Bristol, UK
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Abstract
External beam radiotherapy (RT) has been used as a curative treatment of prostate cancer for more than 5 decades, with the "modern" era emerging more than 3 decades ago. Its history is marked by gradual improvements punctuated by several quantum leaps that are increasingly driven by advancements in the computer and imaging sciences and by its integration with complementary forms of treatment. Consequently, the contemporary use of external beam RT barely resembles its earliest form, and this must be appreciated in the context of current patient care. The influence of predictive factors on the use and outcomes of external beam RT is presented, as is a selected review of the methods and outcomes of external beam RT as a single therapeutic intervention, in association with androgen suppression, or as a postoperative adjunct. Thus, the "state of the (radiotherapeutic) art" is presented to enhance the understanding of this treatment approach with the hope that this information will serve as a useful resource to physicians as they care for patients with prostate cancer.
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Affiliation(s)
- Thomas M Pisansky
- Division of Radiation Oncology, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905, USA
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Abstract
It is important that treatment decisions be based upon scientific data, as opposed to anecdotal experience and expert opinion. The goal of this article is to provide an update on phase III clinical trials in localized and locoregional prostate cancer. Studies comparing surgery and observation for localized disease are reviewed, as are studies comparing various forms of radiotherapy. The effectiveness of certain neoadjuvant and adjuvant therapies is also addressed. Although there are numerous phase III studies ongoing in these areas, there are still large gaps in our understanding of the treatment of localized disease, and additional clinical trials are needed.
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Affiliation(s)
- David F Penson
- Urology and Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA.
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Pisansky TM. Use of neoadjuvant and adjuvant therapy to prevent or delay recurrence of prostate cancer in patients undergoing radiation treatment for prostate cancer. Urology 2003; 62 Suppl 1:36-45. [PMID: 14747040 DOI: 10.1016/j.urology.2003.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Multiple oncologic treatment modalities are often integrated into the curative treatment approach for the patient with a newly established diagnosis of cancer. The combination of neoadjuvant and adjuvant therapies with radiotherapy for the care of the patient with prostate cancer is no exception. There is clear evidence that neoadjuvant androgen suppression reduces the volume of tumor in preparation for radiotherapy, and it is an effective addition to conventional-dose external radiotherapy in patients with large-volume primary prostatic tumors. Adjuvant androgen suppression improves local and systemic tumor control and improves survival duration compared with radiotherapy alone for patients with locally advanced or node-positive prostate cancer, particularly in those with high-grade disease. The role of neoadjuvant and adjuvant therapies is under intense scrutiny as several randomized clinical trials seek to optimize the combination of androgen suppression, chemotherapy, and radiotherapy. The historical precedent for combining androgen suppression with radiotherapy is described, as are the results of prior definitive trials and ongoing studies in this setting.
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Affiliation(s)
- Thomas M Pisansky
- Division of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
BACKGROUND An increased awareness of prostate cancer has led to a rise in the detection of this disease at a clinically localized stage at presentation. This article discusses the role of neoadjuvant hormonal ablation at this earlier stage to decrease tumor bulk and thus enhance survival. METHODS Outcomes from each primary modality for localized treatment of prostate cancer with and without neoadjuvant androgen deprivation (NAAD) are reviewed. RESULTS Survival benefit using NAAD has not yet been demonstrated from prostatectomy. Long-term hormonal deprivation provides an improved time to progression and has decreased distant metastatic and biochemical failure for poor-risk patients undergoing external-beam radiation. The toxicities of brachytherapy can be decreased with NAAD. CONCLUSIONS NAAD with radical prostatectomy is considered to be investigational. The duration of NAAD needs to be delineated for poor-prognosis patients who are treated with external-beam radiation therapy, but the approach improves the local toxicity of brachytherapy.
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Affiliation(s)
- J A Kish
- Genitourinary Oncology Program, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, MCC-UROPROG, 12902 Magnolia Drive, Tampa, FL 33612, USA.
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DeWeese TL, Song DY. Current evidence for the role of combined androgen suppression and radiation in the treatment of adenocarcinoma of the prostate. Urology 2000; 55:169-74. [PMID: 10688072 DOI: 10.1016/s0090-4295(99)00419-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- T L DeWeese
- Johns Hopkins Oncology Center, Division of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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9
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Messing EM, Manola J, Sarosdy M, Wilding G, Crawford ED, Trump D. Immediate hormonal therapy compared with observation after radical prostatectomy and pelvic lymphadenectomy in men with node-positive prostate cancer. N Engl J Med 1999; 341:1781-8. [PMID: 10588962 DOI: 10.1056/nejm199912093412401] [Citation(s) in RCA: 848] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Because the optimal timing of the institution of antiandrogen therapy for prostate cancer is controversial, we compared immediate and delayed treatment in patients who had minimal residual disease after radical prostatectomy. METHODS Ninety-eight men who underwent radical prostatectomy and pelvic lymphadenectomy and who were found to have nodal metastases were randomly assigned to receive immediate antiandrogen therapy, with either goserelin, a synthetic agonist of gonadotropin-releasing hormone, or bilateral orchiectomy, or to be followed until disease progression. The patients were assessed quarterly during the first year and then semiannually. RESULTS After a median of 7.1 years of follow-up, 7 of 47 men who received immediate antiandrogen treatment had died, as compared with 18 of 51 men in the observation group (P=0.02). The cause of death was prostate cancer in 3 men in the immediate-treatment group and in 16 men in the observation group (P<0.01). At the time of the last follow-up, 36 men in the immediate-treatment group (77 percent) and 9 men in the observation group (18 percent) were alive and had no evidence of recurrent disease, including undetectable serum prostate-specific antigen levels (P<0.001). In the observation group, the disease recurred in 42 men; 13 of the 36 who were treated had a complete response to local treatment or hormonal therapy (or both), 16 died of prostate cancer, and 1 died of another disease. The remaining men in this group were alive with progressive disease at the time of the last follow-up or had had a recent relapse. Except for the treatment group (immediate therapy or observation), no clinical or histologic characteristic significantly influenced the outcome. CONCLUSIONS Immediate antiandrogen therapy after radical prostatectomy and pelvic lymphadenectomy improves survival and reduces the risk of recurrence in patients with node-positive prostate cancer.
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Affiliation(s)
- E M Messing
- University of Rochester Medical Center, NY, USA.
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Atkinson G, Hall SJ. Prodrug activation gene therapy and external beam irradiation in the treatment of prostate cancer. Urology 1999; 54:1098-104. [PMID: 10604717 DOI: 10.1016/s0090-4295(99)00295-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Gene therapy may represent a new avenue for the development of multimodal treatment for men with locally advanced prostate cancer. This study explores the potential benefits of combining adenovirus-mediated (ADV) herpes simplex virus thymidine kinase gene (HSV-tk) transduction and ganciclovir (GCV) therapy with external beam radiation therapy (XRT) to enhance the therapeutic efficacy of each treatment alone. METHODS ADV/HSV-tk-transduced mouse prostate cancer cells, RM-1, were irradiated as single-cell suspensions at escalating doses in a cesium source (4.4 Gy/min). HSV-tk-expressing cells were randomized to receive varying doses and varying chronologies of GCV therapy in relation to XRT to fully evaluate potential cooperative activities. End points were determined in a clonogenic assay by counting colonies with greater than 50 cells 7 days after replating. The potential role of apoptosis as a mediator of enhanced cell killing was addressed by a TUNEL assay 12 and 24 hours after therapy. RESULTS Neither ADV infection nor GCV alone affected XRT killing. However, the combination of ADV/HSV-tk+GCV plus XRT maintained the 1 log of cell kill from gene therapy alone through escalating doses of radiation. Radiation sensitization was noted at higher doses of radiation (8.8 Gy or more). Although decreasing the GCV dose had a profound negative influence on HSV-tk+GCV-mediated killing, combination therapy continued to maintain the degree of HSV-tk+GCV killing through escalating doses of XRT in an additive fashion but did not result in radiosensitization. Changing the chronology of GCV exposure in relation to XRT did not significantly alter the additive activities of combination therapy. Studies of apoptosis noted a doubling of apoptotic activity with HSV-tk+GCV compared with HSV-tk+PBS with or without XRT. However, there was no significant change in apoptotic activity in combination therapy over HSV-tk+GCV alone within the 24-hour period after GCV exposure. CONCLUSIONS The combination of ADV/HSV-tk+GCV and XRT appears to result in at least additive, and with higher doses of radiation, synergistic killing activities, indicating a potential usefulness of this treatment strategy for patients with prostate cancer.
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Affiliation(s)
- G Atkinson
- Institute for Gene Therapy and Molecular Medicine and Department of Urology, Mount Sinai School of Medicine, New York, New York 10029, USA
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Abstract
The rising incidence of and mortality from prostate cancer has generated great interest in improving the results of current methods of treatment. It is well-established that large tumour volumes and positive surgical margins are correlated with higher rates of local failure and distant metastasis. Significant decreases in both tumour volume and the rates of positive surgical margins are seen with NHT. Follow-up data from one randomized trial of hormonal therapy before RT have shown significantly improved disease-free survival, but so far there has been no benefit in overall survival. However, the addition of adjuvant hormonal therapy has been reported to improve survival. The results suggest that neoadjuvant and adjuvant hormonal therapy may be a viable option in men with locally advanced prostate cancer in whom cure is probably impossible, but disease progression can potentially be slowed. What remains to be determined is whether hormonal therapy alone can produce the same results. For younger men with clinically localized prostate cancer, radical prostatectomy is increasingly the treatment of choice. Prospective randomized trials of NHT have produced impressive statistics for decreasing the incidence of positive surgical margins, but the potential to down-stage tumours remains controversial. Follow-up serum PSA measurements have thus far shown no benefit from neoadjuvant therapy. The possibility that patients who fail biochemically, whether they are from the pretreated or control group, may simply represent a subgroup with aggressive tumours that may not respond to androgen withdrawal, has yet to be proved. As more follow-up data are analysed within the next several years, there must be a clear survival advantage if NHT is to be offered as a treatment option. Despite the potential of neoadjuvant therapy, the use of androgen withdrawal before definitive surgical treatment should be limited to clinical trials until a clearer picture emerges. Some may argue that although there is no evidence of a true advantage for NHT, neither is there evidence of harm. However, it must be recognized that androgen withdrawal therapy has side-effects and adds significantly to the overall cost of treatment. Furthermore, NHT delays definitive treatment; clearly, this can be a source of anxiety for the patient and the impact on survival is unknown. Currently, the rates of pathologically organ-confined disease are high in some subsets of patients (e.g. low-stage, low-grade and low PSA) so that NHT is unlikely to have great additional benefit. Although the influence of hormones on prostate growth has been known for many decades, we are only now elucidating the biological mechanisms of hormonal therapy. Although androgen ablation therapy has been used in men with metastatic prostate cancer for more than 50 years, further research at the cellular and molecular level is essential if we are to refine treatment modalities for both localized and advanced disease. Furthermore, until we have more follow-up data from randomized clinical trials of NHT, it cannot be considered part of the standard treatment for carcinoma of the prostate. There are still too many unknown factors; only time will tell if the initial promise of NHT will be fulfilled.
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Affiliation(s)
- H H Lee
- Department of Surgery, The Toronto Hospital and University of Toronto, Ontario, Canada
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Vicini FA, Kini VR, Spencer W, Diokno A, Martinez AA. The role of androgen deprivation in the definitive management of clinically localized prostate cancer treated with radiation therapy. Int J Radiat Oncol Biol Phys 1999; 43:707-13. [PMID: 10098424 DOI: 10.1016/s0360-3016(98)00513-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE Multiple studies exploring the use of androgen deprivation given in combination with radiotherapy (RT) for localized prostate cancer have reported significant improvements in the rates of local, regional, and biochemical control (BC). The impact of this therapeutic strategy on overall and cancer specific survival (CSS) has not been established, however. We performed a MEDLINE search of all available studies on this topic to determine if any conclusions could be reached on the efficacy of this treatment approach and the patients most suitable for its application. MATERIALS AND METHODS A MEDLINE search was conducted to obtain all articles in the English language on the use of androgen deprivation in combination with RT for the treatment of localized prostate cancer. The medical subject headings (MeSH) used to search the MEDLINE database included: a) prostatic neoplasms; b) prostatic neoplasms/radiotherapy; c) prostatic neoplasms/androgen deprivation; d) hormone therapy; e) English; and f) 1980 to 1998. RESULTS A total of 14 retrospective studies were identified that compared some form of androgen deprivation given in combination with RT. Most studies showed significant improvements in various measures of local/regional control and disease-free survival (DFS). Three of four studies that analyzed BC rates showed significant improvements in this endpoint but conflicting results were obtained for overall survival (OS). No study showed an improvement in CSS. Six prospective randomized trials were identified that directly compared RT with or without androgen deprivation. Again, all six studies showed improvements in some measure of local/regional control or DFS but only two studies showed an improvement in OS. One study reported a statistically significant improvement in CSS and another study showed an improvement in the rate of negative biopsies with combined treatment. CONCLUSIONS When all available literature on androgen withdrawal given in combination with RT for the definitive treatment of localized prostate cancer was reviewed, no definite conclusions could be reached on the impact of this treatment approach on OS and CSS. However, local/regional control, DFS, and BC were almost uniformly improved with the use of androgen withdrawal suggesting that these impressive early results may translate into improved cure rates. Data from recently initiated and completed randomized trials will be needed, however, to define the impact of this approach on cancer specific mortality and the patients most suitable for it's use.
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Affiliation(s)
- F A Vicini
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073, USA.
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Pollack A, Zagars GK. Androgen ablation in addition to radiation therapy for prostate cancer: is there true benefit? Semin Radiat Oncol 1998; 8:95-106. [PMID: 9516590 DOI: 10.1016/s1053-4296(98)80005-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Prostate cancer patients may now be identified as having a high risk of failing single-modality treatment based on pretreatment prostate specific antigen (PSA), Gleason score, and palpable stage. In particular, a PSA greater than 20 ng/mL portends a biochemical failure rate of 50% to 80% when radiation therapy, surgery, or androgen ablation is administered individually. A number of randomized trials as well as retrospective data show that failure rates are significantly reduced by combining androgen ablation and radiation. The improved results, however, are complicated by the ability to salvage radiation alone-treated patients with androgen ablation and the possibility of less effective salvage (or no effective salvage in the case of permanent androgen ablation) for patients treated with androgen ablation plus radiation. Thus, survival, which is obscured by high rates of intercurrent deaths in this elderly population, is the most important end point in such studies. Two randomized trials, one from the Radiation Therapy Oncology Group (RTOG) and one from the European Organization for Research on Treatment for Cancer (EORTC), of radiation therapy plus adjuvant (as opposed to neoadjuvant) androgen ablation have reported survival gains over radiation therapy alone. In contrast, one neoadjuvant trial from the RTOG failed to show a survival benefit when androgen ablation was added to radiation therapy. In this study, however, androgen ablation was administered for only 4 to 5 months, which may be insufficient. The weight of the evidence to date indicates a true benefit with androgen ablation plus radiation therapy over radiation therapy alone. There are clearly many unanswered questions concerning the optimal timing of androgen ablation and radiation therapy (neoadjuvant versus adjuvant), length of time that androgen ablation should be administered (6 months versus 3 years versus permanent), type of androgen ablation (total androgen ablation or not), and appropriate patient population (definition of high risk). The planned future clinical trials will address many of these issues; however, the full potential of this approach requires an understanding of the fundamental mechanisms involved.
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Affiliation(s)
- A Pollack
- Department of Radiotherapy, M. D. Anderson Cancer Center, Houston, TX 77030, USA
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Yang FE, Vaida F, Ignacio L, Awan A, Culbert H, Nautiyal J, Kolker J, Sutton H, Halpern H, Weichselbaum RR, Chen GT, Vijayakumar S. Acute toxicity in radiotherapy of prostate cancer:Results of a randomized study with and without beam's-eye view three-dimensional conformal therapy. ACTA ACUST UNITED AC 1996. [DOI: 10.1002/(sici)1520-6823(1996)4:5<231::aid-roi5>3.0.co;2-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Yang FE, Chen GT, Ray P, Vaida F, Chiru P, Hamilton RJ, Spelbring D, Abellera M, Vijayakumar S. The potential for normal tissue dose reduction with neoadjuvant hormonal therapy in conformal treatment planning for stage C prostate cancer. Int J Radiat Oncol Biol Phys 1995; 33:1009-17. [PMID: 7493827 DOI: 10.1016/0360-3016(95)02064-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE Preirradiation hormonal cytoreduction of prostate cancer has been proven to reduce exposure of normal structures by decreasing the size of the target volume. Dose-volume histogram (DVH) analysis, however, does not always appear to demonstrate a strong positive benefit with the use of neoadjuvant hormone therapy. This study analyzes various other factors influencing dose to normal organs, which may determine the success or failure of neoadjuvant hormonal therapy in achieving its goals. METHODS AND MATERIALS Patients with bulky clinical Stage C adenocarcinoma of the prostate were given 3 months of hormone treatment consisting of oral Flutamide and monthly Zoladex injections prior to irradiation. Computerized tomography (CT) scans of the pelvis were obtained both prior to and following hormonal treatment. Treatment plans were generated by three-dimensional (3D) conformal treatment planning. The change in the volume of the prostate was assessed along with the percentage of prescribed dose delivered to the rectum and bladder. Various factors such as prostate size, bladder/rectum size, and organ shape were studied. Both dose-volume histograms (DVH) and dose-surface area histograms (DSH) were used for analysis. RESULTS Six of seven patients had reduction in the size of their prostates. The mean volumes of the prostate before and after hormonal manipulation were 129.1 +/- 32.9 standard deviation (SD) cm3 and 73.0 +/- 29.5 SD cm3, respectively (p = 0.0059). The volume of rectum receiving 80% of the prescribed dose was reduced in five of seven patients from a mean of 83.2 to 59.9 cm3 (p = 0.045). The volume of bladder receiving 80% of the prescribed dose was also reduced in five out of seven patients from a mean of 74.5 to 40.2 cm3 (p = 0.098). Correlation between the size of the prostate and volume of rectum and bladder treated was not always consistent: greater reduction in prostate size did not necessarily result in large decreases in dose to bladder or rectum. The total size of the bladder and rectum were found to be important factors in normal tissue radiation exposure; the benefits of hormone therapy may be lost if the bladder and rectum are allowed to decrease in size. Also, the bladder may be prone to sagging into the pelvis of some patients following hormone therapy, resulting in a less optimal therapeutic ratio. CONCLUSION Reduction in prostate size by neoadjuvant hormonal manipulation does decrease the amount of normal tissue irradiated in most patients. However, the correlation between the reduction in prostate size and amount of rectum or bladder treated is not linear if other variables are not controlled. Factors such as the shape of the organs, as well as the distensible nature of the bladder and rectum, play major roles in dose to normal tissues. These facts may mask the benefits of cytoreduction and could be obstacles in realizing consistent benefits from preirradiation hormonal treatment in the clinical setting if they are ignored.
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Affiliation(s)
- F E Yang
- Department of Radiation and Cellular Oncology, Michael Reese/University of Chicago, IL, USA
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Pilepich MV, Krall JM, al-Sarraf M, John MJ, Doggett RL, Sause WT, Lawton CA, Abrams RA, Rotman M, Rubin P. Androgen deprivation with radiation therapy compared with radiation therapy alone for locally advanced prostatic carcinoma: a randomized comparative trial of the Radiation Therapy Oncology Group. Urology 1995; 45:616-23. [PMID: 7716842 DOI: 10.1016/s0090-4295(99)80053-3] [Citation(s) in RCA: 404] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Androgen deprivation therapy before and during radiation therapy could, by reducing tumor volume, increase local tumor control, disease-free survival, and overall survival in patients with locally advanced adenocarcinomas of the prostate. METHODS In a randomized controlled clinical trial, patients with large T2, T3, and T4 prostate tumors, but no evidence of osseous metastasis, were randomized to receive goserelin 3.6 mg subcutaneously every 4 weeks and flutamide 250 mg orally three times daily 2 months before and during the radiation therapy course (Arm I) compared with radiation therapy alone (Arm II). Pelvic irradiation was administered with 1.8 to 2.0 Gy per day to a total dose of 45 +/- 1 Gy followed by a boost to the prostate target volume to a total dose of 65 to 70 Gy. RESULTS Of 471 randomized patients, 456 were evaluable, 226 on Arm I and 230 on Arm II. With a median potential follow-up of 4.5 years, the cumulative incidence of local progression at 5 years was 46% in Arm I and 71% in Arm II (P < 0.001). The 5-year incidence of distant metastasis on Arms I and II was 34% and 41%, respectively (P = 0.09). Progression-free survival rates including normal prostate-specific antigen (PSA) levels for 396 patients with at least one PSA recorded were 36% in Arm I and 15% in Arm II at 5 years (P < 0.001). At this time, no significant difference in overall survival could be detected (P = 0.7). CONCLUSIONS Short-term androgen deprivation with radiation therapy results in a marked increase in local control and disease-free survival compared with pelvic irradiation alone in patients with locally advanced carcinoma of the prostate. Long-term surveillance is required to assess effects on overall survival.
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Affiliation(s)
- W J Catalona
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110
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