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Varga L, Besenyi Z, Paczona VR, Farkas I, Urbán S, Sipka G, Pávics L, Varga Z, Fodor E, Hideghéty K, Olah J, Bajory Z, Maráz A. Prostate-specific membrane antigen-based imaging for stereotactic irradiation of low-volume progressive prostate cancer: a single-center experience. Front Oncol 2023; 13:1166665. [PMID: 37637070 PMCID: PMC10448522 DOI: 10.3389/fonc.2023.1166665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/03/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction Prostate-specific membrane antigen (PSMA) is a transmembrane protein that may be expressed on the surface of prostate cancer (PC) cells. It enables a more sensitive and specific diagnosis PC, compared to conventional anatomical imaging. Aim The integration of PSMA-based imaging in the personalized radiotherapy of PC patients and the evaluation of its impact on target volume definition if stereotactic body radiotherapy (SBRT) is planned for locally recurrent or oligometastatic disease. Patients and methods The data from 363 examinations were analyzed retrospectively. Inclusion criteria were histologically verified PC and clinical data suggesting local recurrence or distant metastasis. Whole-body 99mTc-PSMA-I&S single-photon emission computed tomography (SPECT)/CT or 18F-JK-PSMA-7 positron emission tomography/computer tomography (PET/CT) was carried out, and the evaluation of the scans and biological tumor volume contouring was performed at the Department of Nuclear Medicine. The target volume delineation on topometric CT (TCT) scan was performed at the Department of Oncotherapy. The comparison of the two volumes was performed by image fusion and registration. Results From 363 PSMA isotope-based examinations, 84 lesions of 64 patients were treated with SBRT. In 50 patients, 70 lesions were examined for intermodality comparison. The target volume defined by the PSMA density was significantly smaller than the tumor size defined by the TCT scan: GTVCT (gross tumor volume on the TCT), 27.58 ± 46.07 cm3; BTVPSMA (biological target volume on the PSMA-based examination), 16.14 ± 29.87 cm3. During geometrical analyses, the Dice similarity coefficient (DSC) was 0.56 ± 0.20 (0.07-0.85). Prostate-specific antigen (PSA) control was performed to evaluate the response: mean pre-radiotherapy (pre-RT) PSA was 16.98 ng/ml ( ± SD: 33.81), and post-RT PSA at 3 months after SBRT was 11.19 ng/ml ( ± SD: 32.85). Three-month post-therapy PSMA-based imaging was performed in 14 cases, in which we observed a decrease or cessation of isotope uptake. Conventional imaging control was performed in 42 cases (65.6% of all cases): 22 (52.4%) complete remissions, 14 (33.3%) partial remissions, four (9.5%) stable diseases, and two (4.8%) progressive diseases were described. Conclusion PSMA-based imaging is a promising diagnostic method for specifying the stage and detecting the low-volume progression. Our results suggest that PSMA-based hybrid imaging can influence treatment decisions and target volume delineation for SBRT.
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Affiliation(s)
- Linda Varga
- Department of Oncotherapy, University of Szeged, Szeged, Hungary
| | - Zsuzsanna Besenyi
- Department of Nuclear Medicine, University of Szeged, Szeged, Hungary
| | | | - István Farkas
- Department of Nuclear Medicine, University of Szeged, Szeged, Hungary
| | - Szabolcs Urbán
- Department of Nuclear Medicine, University of Szeged, Szeged, Hungary
| | - Gábor Sipka
- Department of Nuclear Medicine, University of Szeged, Szeged, Hungary
| | - László Pávics
- Department of Nuclear Medicine, University of Szeged, Szeged, Hungary
| | - Zoltan Varga
- Department of Oncotherapy, University of Szeged, Szeged, Hungary
| | - Emese Fodor
- Department of Oncotherapy, University of Szeged, Szeged, Hungary
| | | | - Judit Olah
- Department of Oncotherapy, University of Szeged, Szeged, Hungary
| | - Zoltán Bajory
- Department of Urology, University of Szeged, Szeged, Hungary
| | - Anikó Maráz
- Department of Oncotherapy, University of Szeged, Szeged, Hungary
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Li Kuan Ong A, Knight K, Panettieri V, Dimmock M, Kit Loong Tuan J, Qi Tan H, Wright C. Predictors for late genitourinary toxicity in men receiving radiotherapy for high-risk prostate cancer using planned and accumulated dose. Phys Imaging Radiat Oncol 2023; 25:100421. [PMID: 36817981 PMCID: PMC9932727 DOI: 10.1016/j.phro.2023.100421] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
Background and purpose Significant deviations between bladder dose planned (DP) and dose accumulated (DA) have been reported in patients receiving radiotherapy for prostate cancer. This study aimed to construct multivariate analysis (MVA) models to predict the risk of late genitourinary (GU) toxicity with clinical and DP or DA as dose-volume (DV) variables. Materials and methods Bladder DA obtained from 150 patients were compared with DP. MVA models were built from significant clinical and DV variables (p < 0.05) at univariate analysis. Previously developed dose-based-region-of-interest (DB-ROI) metrics using expanded ring structures from the prostate were included. Goodness-of-fit test and calibration plots were generated to determine model performance. Internal validation was accomplished using Bootstrapping. Results Intermediate-high DA (V30-65 Gy and DB-ROI-20-50 mm) for bladder increased compared to DP. However, at the very high dose region, DA (D0.003 cc, V75 Gy, and DB-ROI-5-10 mm) were significantly lower. In MVA, single variable models were generated with odds ratio (OR) < 1. DB-ROI-50 mm was predictive of Grade ≥ 1 GU toxicity for DA and DP (DA and DP; OR: 0.96, p: 0.04) and achieved an area under the receiver operating curve (AUC) of > 0.6. Prostate volume (OR: 0.87, p: 0.01) was significant in predicting Grade 2 GU toxicity with a high AUC of 0.81. Conclusions Higher DA (V30-65 Gy) received by the bladder were not translated to higher late GU toxicity. DB-ROIs demonstrated higher predictive power than standard DV metrics in associating Grade ≥ 1 toxicity. Smaller prostate volumes have a minor protective effect on late Grade 2 GU toxicity.
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Affiliation(s)
- Ashley Li Kuan Ong
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore,Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,Corresponding author at: Division of Radiation Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610, Singapore
| | - Kellie Knight
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
| | - Vanessa Panettieri
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,Central Clinical School, Monash University, Melbourne, VIC, Australia,Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Mathew Dimmock
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,School of Allied Health Professions, Keele University, Staffordshire, UK
| | | | - Hong Qi Tan
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Caroline Wright
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
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Ong A, Knight K, Panettieri V, Dimmock M, Tuan JKL, Tan HQ, Master Z, Wright C. Application of an automated dose accumulation workflow in high-risk prostate cancer - validation and dose-volume analysis between planned and delivered dose. Med Dosim 2021; 47:92-97. [PMID: 34740517 DOI: 10.1016/j.meddos.2021.09.004] [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: 05/21/2021] [Revised: 07/28/2021] [Accepted: 09/09/2021] [Indexed: 10/19/2022]
Abstract
Inter-fraction organ variations cause deviations between planned and delivered doses in patients receiving radiotherapy for prostate cancer. This study compared planned (DP) vs accumulated doses (DA) obtained from daily cone-beam computed tomography (CBCT) scans in high-risk- prostate cancer with pelvic lymph nodes irradiation. An intensity-based deformable image registration algorithm used to estimate contours for DA was validated using geometrical agreement between radiation oncologist's and deformable image registration algorithm propagated contours. Spearman rank correlations (rs) between geometric measures and changes in organ volumes were evaluated for 20 cases. Dose-volume (DV) differences between DA and DP were compared (Wilcoxon rank test, p < 0.05). A novel region-of-interest (ROI) method was developed and mean doses were analyzed. Geometrical measures for the prostate and organ-at-risk contours were within clinically acceptable criteria. Inter-group mean (± SD) CBCT volumes for the rectum were larger compared to planning CT (pCT) (51.1 ± 11.3 cm3vs 46.6 ± 16.1 cm3), and were moderately correlated with variations in pCT volumes, rs = 0.663, p < 0.01. Mean rectum DV for DA was higher at V30-40 Gy and lower at V70-75 Gy, p < 0.05. Mean bladder CBCT volumes were smaller compared to pCT (198.8 ± 55 cm3vs 211.5 ± 89.1 cm3), and was moderately correlated with pCT volumes, rs = 0.789, p < 0.01. Bladder DA was higher at V30-65 Gy and lower at V70-75 Gy (p < 0.05). For the ROI method, rectum and bladder DA were lower at 5 to 10 mm (p < 0.01) as compared to DP, whilst bladder DA was higher than DP at 20 to 50 mm (p < 0.01). Generated DA demonstrated significant differences in organ-at-risk doses as compared to DP. A well-constructed workflow incorporating a ROI DV-extraction method has been validated in terms of efficiency and accuracy designed for seamless integration in the clinic to guide future plan adaptation.
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Affiliation(s)
- Ashley Ong
- National Cancer Centre Singapore, Division of Radiation Oncology, Singapore; Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia.
| | - Kellie Knight
- Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia
| | - Vanessa Panettieri
- Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia; Alfred Hospital, Alfred Health Radiation Oncology, Melbourne, Australia
| | - Mathew Dimmock
- Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia
| | | | - Hong Qi Tan
- National Cancer Centre Singapore, Division of Radiation Oncology, Singapore
| | - Zubin Master
- National Cancer Centre Singapore, Division of Radiation Oncology, Singapore
| | - Caroline Wright
- Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia
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Okamoto K. Ten-step method of high-dose LDR 125 I brachytherapy for intermediate-risk prostate cancer. J Appl Clin Med Phys 2021; 22:172-182. [PMID: 33939267 PMCID: PMC8200501 DOI: 10.1002/acm2.13224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 02/02/2021] [Accepted: 02/20/2021] [Indexed: 11/08/2022] Open
Abstract
Dose escalation is key for improved outcomes in intermediate‐risk prostate cancer, including unfavorable intermediate‐risk (UIR) cases. This educational report is designed to provide information about our quality high‐dose 125I seed implantation monotherapy technique in which a biologically effective dose (BED) ≧ 200 Gy is applied for treatment of intermediate‐risk prostate cancer. This protocol is named the “Ten‐step Method,” where the rationale and principle of the method are based on the following four goals: (1) The entire prostate should be covered by the prescription isodose distribution with a sufficient margin from the prostatic capsule, achieving high D90 and V100 values by 125I seed implantation. (2) The high‐dose cloud (240 Gy) should not invade the urethra or rectum. (3) In order to achieve goals (1) and (2), make the high‐dose cloud intentionally along the periphery (bilateral wall to anterior wall) away from the urethra and rectum. (4) In order to achieve goal (3), seeds at the periphery, except those anterior to the rectal wall, should be placed just 1mm inside the capsule. The data obtained from a total of 137 patients with intermediate‐risk prostate cancer treated with low‐dose‐rate (LDR) monotherapy are shown. The dosimetry parameters were monitored at 1 month after seed implantation by using CT and MRI fusion guidance. The data at 1 month after LDR were: Average D90, BED, and V100 of 125I LDR monotherapy were 194.1 Gy, 207.3 Gy, and 99%, respectively. This ten‐step method was reproducible in 137 patients with intermediate‐risk prostate cancer, allowing administration of high‐dose monotherapy with excellent clinical outcomes.
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Affiliation(s)
- Keisei Okamoto
- Department of Brachytherapy for Prostate Cancer, Shiga University of Medical Science, Shiga, Japan
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Royce TJ, Mavroidis P, Wang K, Falchook AD, Sheets NC, Fuller DB, Collins SP, El Naqa I, Song DY, Ding GX, Nahum AE, Jackson A, Grimm J, Yorke E, Chen RC. Tumor Control Probability Modeling and Systematic Review of the Literature of Stereotactic Body Radiation Therapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2020; 110:227-236. [PMID: 32900561 DOI: 10.1016/j.ijrobp.2020.08.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/02/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE Dose escalation improves localized prostate cancer disease control, and moderately hypofractionated external beam radiation is noninferior to conventional fractionation. The evolving treatment approach of ultrahypofractionation with stereotactic body radiation therapy (SBRT) allows possible further biological dose escalation (biologically equivalent dose [BED]) and shortened treatment time. METHODS AND MATERIALS The American Association of Physicists in Medicine Working Group on Biological Effects of Hypofractionated Radiation Therapy/SBRT included a subgroup to study the prostate tumor control probability (TCP) with SBRT. We performed a systematic review of the available literature and created a dose-response TCP model for the endpoint of freedom from biochemical relapse. Results were stratified by prostate cancer risk group. RESULTS Twenty-five published cohorts were identified for inclusion, with a total of 4821 patients (2235 with low-risk, 1894 with intermediate-risk, and 446 with high-risk disease, when reported) treated with a variety of dose/fractionation schemes, permitting dose-response modeling. Five studies had a median follow-up of more than 5 years. Dosing regimens ranged from 32 to 50 Gy in 4 to 5 fractions, with total BED (α/β = 1.5 Gy) between 183.1 and 383.3 Gy. At 5 years, we found that in patients with low-intermediate risk disease, an equivalent doses of 2 Gy per fraction (EQD2) of 71 Gy (31.7 Gy in 5 fractions) achieved a TCP of 90% and an EQD2 of 90 Gy (36.1 Gy in 5 fractions) achieved a TCP of 95%. In patients with high-risk disease, an EQD2 of 97 Gy (37.6 Gy in 5 fractions) can achieve a TCP of 90% and an EQD2 of 102 Gy (38.7 Gy in 5 fractions) can achieve a TCP of 95%. CONCLUSIONS We found significant variation in the published literature on target delineation, margins used, dose/fractionation, and treatment schedule. Despite this variation, TCP was excellent. Most prescription doses range from 35 to 40 Gy, delivered in 4 to 5 fractions. The literature did not provide detailed dose-volume data, and our dosimetric analysis was constrained to prescription doses. There are many areas in need of continued research as SBRT continues to evolve as a treatment modality for prostate cancer, including the durability of local control with longer follow-up across risk groups, the efficacy and safety of SBRT as a boost to intensity modulated radiation therapy (IMRT), and the impact of incorporating novel imaging techniques into treatment planning.
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Affiliation(s)
- Trevor J Royce
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Panayiotis Mavroidis
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kyle Wang
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Nathan C Sheets
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Donald B Fuller
- Division of Genesis Healthcare Partners Inc, Genesis CyberKnife, San Diego, California
| | - Sean P Collins
- Department of Radiation Oncology, Georgetown University, Washington, DC
| | - Issam El Naqa
- Machine Learning Department, Moffitt Cancer Center, Tampa, Florida
| | - Daniel Y Song
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - George X Ding
- Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Alan E Nahum
- Department of Physics, University of Liverpool, United Kingdom and Henley-on-Thames, United Kingdom
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Jimm Grimm
- Department of Radiation Oncology, Geisinger Health System, Danville, Pennsylvania; Department of Medical Imaging and Radiation Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Ronald C Chen
- Department of Radiation Oncology, University of Kansas, Kansas City, Kansas
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Vuolukka K, Auvinen P, Tiainen E, Palmgren JE, Heikkilä J, Seppälä J, Aaltomaa S, Kataja V. Stereotactic body radiotherapy for localized prostate cancer - 5-year efficacy results. Radiat Oncol 2020; 15:173. [PMID: 32664981 PMCID: PMC7362647 DOI: 10.1186/s13014-020-01608-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/30/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The use of stereotactic body radiotherapy (SBRT) as the primary treatment modality in clinically localized prostate cancer (PCa) is emerging. The aim of the study was to analyze the long-term results of PCa patients treated with SBRT. METHODS This non-selected, real-life patient cohort included 213 patients with localized PCa treated with a robotic SBRT device during 2012-2015. RESULTS The median follow-up was 64 months (range, 10-85 months), and all risk-groups were represented as 47 (22.1%), 56 (26.3%) and 110 (51.6%) patients were classified into D'Amico risk stratification of low, intermediate and high-risk groups, respectively. Androgen deprivation therapy (ADT) was administered to 64.3% of the patients. At cut-off, the biochemical relapse-free survival (bRFS) was 100, 87.5 and 80.0% for patients at low, intermediate and high-risk (p = 0.004), and 92.5, 84.2 and 66.7% for patients with Gleason score ≤ 6, 7 and ≥ 8, respectively (p = 0.001). The actuarial 5-year overall survival (OS) rates were 97.9, 96.4 and 88.6% in the low, intermediate and high-risk groups, respectively, and at the cut-off, the disease-specific survival (DSS) rate of the whole cohort was high (99.1%), as only two high-risk patients died due to PCa. CONCLUSION Our present results of SBRT delivered with CyberKnife produced excellent long-term bRFS, OS and DSS outcomes among patients with localized PCa. We conclude that SBRT provides an efficient and convenient treatment option for patients with localized PCa, irrespective of the risk-group.
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Affiliation(s)
- Kristiina Vuolukka
- Cancer Center, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland.
| | - Päivi Auvinen
- Cancer Center, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland.,University of Eastern Finland, Kuopio, Finland
| | | | - Jan-Erik Palmgren
- Cancer Center, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland
| | - Janne Heikkilä
- Cancer Center, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland
| | - Jan Seppälä
- Cancer Center, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland
| | - Sirpa Aaltomaa
- Department of Urology, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland
| | - Vesa Kataja
- University of Eastern Finland, Kuopio, Finland.,Central Finland Health Care District, Adm Bldg 6/2, FI-40620, Jyväskylä, Finland
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Heterogenous Dose-escalated Prostate Stereotactic Body Radiation Therapy for All Risk Prostate Cancer: Quality of Life and Clinical Outcomes of an Institutional Pilot Study. Am J Clin Oncol 2020; 43:469-476. [PMID: 32349020 DOI: 10.1097/coc.0000000000000693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Previous prostate stereotactic body radiation therapy studies delivered uniform doses of 35 to 40 Gy/5 fx. Attempts at uniform dose escalation to 50 Gy caused high rates of gastrointestinal (GI) toxicity. We hypothesize that heterogeneous dose escalation to regions nonadjacent to sensitive structures (urethra, rectum, and bladder) is safe and efficacious. MATERIALS AND METHODS Patients were enrolled on a prospective pilot study. The primary endpoint was treatment-related GI and genitourinary (GU) toxicity. The secondary endpoints included quality of life (QOL) assessed by the EPIC-26 questionnaire and biochemical control. The target volume received 36.25 Gy/5 fx. The target >3 mm from sensitive was dose escalated to 50 Gy/5 fx. RESULTS Thirty-five patients were enrolled. Three patients had low, 14 intermediate, and 18 high-risk disease. The mean initial prostate specific antigen was 15.1 ng/mL. Androgen deprivation therapy was given to 19 patients. Median follow-up was 46 months. Urinary irritation/obstructive and urinary bother scores declined by minimal clinically important difference threshold from baseline at 6 weeks, but subsequently recovered by 4 months. No differences in QOL scores were observed for urinary incontinence, bowel domain, bloody stools, or sexual domain. One patient developed acute grade 4 GU toxicity and acute grade 4 GI toxicity. The incidence of late high grade toxicity was 1/35 for GU toxicity and 2/35 for GI toxicity. Freedom from biochemical failure at 3 years was 88.0%. CONCLUSIONS Heterogeneous dose-escalated prostate stereotactic body radiation therapy is feasible with low rates of acute and late toxicities and favorable QOL outcomes in patients with predominantly intermediate-risk and high-risk prostate cancer.
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Clinical outcomes of low-dose-rate brachytherapy based radiotherapy for intermediate risk prostate cancer. J Contemp Brachytherapy 2020; 12:6-11. [PMID: 32190064 PMCID: PMC7073334 DOI: 10.5114/jcb.2020.92405] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/15/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose To monitor the outcomes for intermediate-risk prostate cancer patients treated with biologically effective dose (BED) ≥ 200 Gy radiotherapy using low-dose-rate (LDR) brachytherapy. Material and methods Between 2005 and 2016, a total of 397 patients with intermediate-risk prostate cancer were treated by LDR-based radiotherapy with a BED ≥ 200 Gy. Treatments consisted of LDR brachytherapy alone (177 cases) or LDR and external beam radiotherapy (EBRT) (220 cases). Short-term androgen deprivation therapy (ADT) was used in 186 patients (46.9%). The median follow-up period was 72 months (range 29-165 months). Dosimetric parameters and BED were studied in each case. The numbers of intermediate-risk features were: 163 patients with 1 intermediate-risk feature (41%), 169 patients with 2 intermediate-risk features (43%), and 65 patients with 3 intermediate-risk features (16%). A total of 145 cases were diagnosed as having primary Gleason pattern 4: Gleason score 4 + 3 (36.5%). Results Three patients developed biochemical failure, thus providing a 7-year actual biochemical failure-free survival (BFFS) rate of 99.1%. Biochemical failure was observed exclusively in cases with distant metastasis: two cases with lymph node metastasis and one case with bone metastasis, thus yielding a 7-year freedom from clinical failure (FFCF) rate of 99.1%. We observed eight deaths, but there was no death from prostate cancer, thus yielding a 7-year cause-specific survival (CSS) rate of 100%, and an overall survival (OS) rate of 98.4%. Conclusions This study highlights excellent outcomes for intermediate-risk prostate cancer patients, including unfavorable intermediate-risk cases, treated with BED ≥ 200 Gy radiotherapy using LDR brachytherapy. LDR alone with a BED of 200 Gy may be an optimal treatment for both favorable and unfavorable intermediate-risk prostate cancer patients, although a longer follow-up is mandatory to confirm the present findings.
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Stone NN, Stock RG. Stage T3b prostate cancer diagnosed by seminal vesicle biopsy and treated with neoadjuvant hormone therapy, permanent brachytherapy and external beam radiotherapy. BJU Int 2018; 123:277-283. [PMID: 29956864 DOI: 10.1111/bju.14464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To report the long-term results of prostate brachytherapy followed by external beam radiotherapy (EBRT) in men with a positive seminal vesicle biopsy (+SVB). PATIENTS AND METHODS In all, 1081 men with localised prostate cancer were treated with permanent brachytherapy, of which 615 had staging SVB and 53 (9.4%) were positive. Higher stage, Gleason score and PSA level were associated with a +SVB (P < 0.001). Patients with +SVB and negative laparoscopic pelvic lymph node dissection, bone and CT scans had 3 months of androgen-deprivation therapy (ADT) followed by 103 Pd implant to the prostate (dose 100 Gy) and proximal SVs, and 2 months later 45 Gy EBRT. ADT was continued for a median of 6 months (total ADT 9 months). The mean (range) follow-up was 9 (5-22) years. RESULTS Biochemical freedom from failure (computed by the Phoenix definition), freedom from metastasis, and cause-specific survival (CSS) for patients with a negative SVB (-SVB) vs +SVB at 15 years, was 76.3% vs 60.6% (P = 0.001), 95.4% vs 78.2% (P < 0.001), and 95% vs 70.4% (P < 0.001), respectively. Prostate cancer death occurred in 45 of 590 (7.6%) men with a -SVB vs eight of 25 (32%) with a +SVB (odds ratio 5.7, 95% confidence interval 2.35-13.9, P < 0.001). Cox proportion hazard rates (HRs) demonstrated Gleason score (P < 0.001, HR 1.9), stage (P = 0.010, HR 1.42), RT dose (P = 0.013, HR 0.991), and +SVB (P = 0.001, HR 4.48), as significantly associated with CSS. CONCLUSIONS Men with a +SVB have inferior CSS compared to those with a -SVB. However, a strategy that included a SVB in high-risk patients and implantation of the SVs in men undergoing combined therapy still yields favourable long-term results.
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Affiliation(s)
- Nelson N Stone
- Department of Urology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Radiation Oncology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard G Stock
- Department of Urology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Radiation Oncology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Prone Positioning on a Belly Board Decreases Rectal and Bowel Doses in Pelvic Intensity-Modulated Radiation Therapy (IMRT) for Prostate Cancer. Pathol Oncol Res 2018; 25:995-1002. [PMID: 29882196 DOI: 10.1007/s12253-018-0436-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 05/29/2018] [Indexed: 12/13/2022]
Abstract
The presence of normal tissues in the irradiated volume limits dose escalation during pelvic radiotherapy (RT) for prostate cancer. Supine and prone positions on a belly board were compared by analyzing the exposure of organs at risk (OARs) using intensity modulated RT (IMRT). The prospective trial included 55 high risk, localized or locally advanced prostate cancer patients, receiving definitive image-guided RT. Computed tomography scanning for irradiation planning was carried out in both positions. Gross tumor volume, clinical and planning target volumes (PTV) and OARs were delineated, defining subprostatic and periprostatic rectal subsegments. At the height of the largest antero-posterior (AP) diameter of the prostate, rectal diameters and distance from the posterior prostate wall were measured. IMRT plans were generated. Normal tissue exposure and structure volumes were compared between supine and prone plans using paired t-test. In the volumes of the prostate, PTV, colon and small bowel, no significant differences were found. In prone position, all rectal volumes, diameters, and rectum-prostate distance were significantly higher, the irradiated colon and small bowel volume was lower in dose ranges of 20-40 Gy, and the exposure to all rectal segments was more favorable in 40-75 Gy dose ranges. No significant difference was found in the exposure of other OARs. Prone positioning on a belly board is an appropriate positioning method aiming rectum and bowel protection during pelvic IMRT of prostate cancer. The relative reduction in rectal exposure might be a consequence of the slight departure between the prostate and rectal wall.
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Amiya Y, Yamada Y, Sugiura M, Sasaki M, Shima T, Suzuki N, Nakatsu H, Murakami S, Shimazaki J. Treatment of locally advanced prostate cancer (Stage T3). Jpn J Clin Oncol 2017; 47:257-261. [PMID: 28096182 DOI: 10.1093/jjco/hyw186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Indexed: 01/10/2023] Open
Abstract
Objective Formerly, locally advanced prostate cancer exhibited poorly prognosis. In the late 1990s, new surgical and radiation technologies were introduced in combination with androgen deprivation. To evaluate respective strategies, outcomes were examined. Patients and methods Between 2001 and 2010, 224 patients with T3N0M0 (10.9% of all prostate cancer cases) were treated with prostatectomy, external beam radiation therapy with/without androgen deprivation or hormone alone. Complete records were obtained by the end of 2015. Results Operation group first started without adjuvant treatment and prostate-specific antigen (PSA) relapse occurred in 39% of cases. Radiation therapy group was alternatively divided into two subgroups, that received either monotherapy or combination with androgen deprivation, and PSA relapse rates were 65 and 16%, respectively. High rates of PSA relapse in both the operation and radiation therapy groups were observed in patients without adjuvant therapy, but after relapse androgen deprivation proceeded favorable outcomes. In the radiation subgroups, PSA relapse rates were different, but both subsequent survival rates were the same. This may be due to the effect of androgen deprivation after relapse, indicating effect of delayed therapy. PSA relapse rate in the hormone therapy group was 25% and after relapse, patients applied to treatment with other hormonal and anticancer drugs. Overall survival rates were 91, 88 and 67% in the operation, radiation therapy and hormone therapy groups, respectively. Conclusion Aggressive treatment with short-term androgen deprivation for locally advanced prostate cancer could be beneficial and not harmful when suitable candidates are selected. Delayed androgen deprivation was effective for no adjuvant patients after PSA relapse.
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Affiliation(s)
| | | | | | - Makoto Sasaki
- Department of Urology, Asahi General Hospital, Asahi
| | | | | | | | | | - Jun Shimazaki
- Department of Urology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Krishna S, Lim CS, McInnes MDF, Flood TA, Shabana WM, Lim RS, Schieda N. Evaluation of MRI for diagnosis of extraprostatic extension in prostate cancer. J Magn Reson Imaging 2017; 47:176-185. [PMID: 28387981 DOI: 10.1002/jmri.25729] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/23/2017] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To assess the ability of magnetic resonance imaging (MRI) to diagnose extraprostatic extension (EPE) in prostate cancer. MATERIALS AND METHODS With Institutional Review Board (IRB) approval, 149 men with 170 ≥0.5 mL tumors underwent preoperative 3T MRI followed by radical prostatectomy (RP) between 2012-2015. Two blinded radiologists (R1/R2) assessed tumors using Prostate Imaging Reporting and Data System (PI-RADS) v2, subjectively evaluated for the presence of EPE, measured tumor size, and length of capsular contact (LCC). A third blinded radiologist, using MRI-RP-maps, measured whole-lesion: apparent diffusion coefficient (ADC) mean/centile and histogram features. Comparisons were performed using chi-square, logistic regression, and receiver operator characteristic (ROC) analysis. RESULTS The subjective EPE assessment showed high specificity (SPEC = 75.4/91.3% [R1/R2]), low sensitivity (SENS = 43.3/43.6% [R1/R2]), and area-under (AU) ROC curve = 0.67 (confidence interval [CI] 0.61-0.73) R1 and 0.61 (CI 0.53-0.70) R2; (k = 0.33). PI-RADS v2 scores were strongly associated with EPE (P < 0.001 / P = 0.008; R1/R2) with AU-ROC curve = 0.72 (0.64-0.79) R1 and 0.61 (0.53-0.70) R2; (k = 0.44). Tumors with EPE were larger (18.8 ± 7.8 [median 17, range 6-51] vs. 18.8 ± 4.9 [12, 6-28] mm) and had greater LCC (21.1 ± 14.9 [16, 1-85] vs. 13.6 ± 6.1 [11.5, 4-30] mm); P < 0.001 and 0.002, respectively. AU-ROC for size was 0.73 (0.64-0.80) and LCC was 0.69 (0.60-0.76), respectively. Optimal SENS/SPEC for diagnosis of EPE were: size ≥15 mm = 67.7/66.7% and LCC ≥11 mm = 84.9/44.8%. 10th -centile ADC and ADC entropy were both associated with EPE (P = 0.02 and < 0.001), with AU-ROC = 0.56 (0.47-0.65) and 0.76 (0.69-0.83), respectively. Optimal SENS/SPEC for diagnosis of EPE with entropy ≥6.99 was 63.3/75.0%. 25th -centile ADC trended towards being significantly lower with EPE (P = 0.06) with no difference in other ADC metrics (P = 0.25-0.88). Size, LCC, and ADC entropy improved sensitivity but reduced specificity compared with subjective analysis with no difference in overall accuracy (P = 0.38). CONCLUSION Measurements of tumor size, capsular contact, and ADC entropy improve sensitivity but reduce specificity for diagnosis of EPE compared to subjective assessment. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:176-185.
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Affiliation(s)
- Satheesh Krishna
- Department of Medical Imaging, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Christopher S Lim
- Department of Medical Imaging, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Matthew D F McInnes
- Department of Medical Imaging, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Trevor A Flood
- Department of Anatomical Pathology, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Wael M Shabana
- Department of Medical Imaging, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Robert S Lim
- Department of Medical Imaging, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Nicola Schieda
- Department of Medical Imaging, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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High biologically effective dose radiation therapy using brachytherapy in combination with external beam radiotherapy for high-risk prostate cancer. J Contemp Brachytherapy 2017; 9:1-6. [PMID: 28344597 PMCID: PMC5346610 DOI: 10.5114/jcb.2017.66072] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 01/24/2017] [Indexed: 11/17/2022] Open
Abstract
Purpose To evaluate the outcomes of high-risk prostate cancer patients treated with biologically effective dose (BED) ≥ 220 Gy of high-dose radiotherapy, using low-dose-rate (LDR) brachytherapy in combination with external beam radiotherapy (EBRT) and short-term androgen deprivation therapy (ADT). Material and methods From 2005 to 2013, a total of 143 patients with high-risk prostate cancer were treated by radiotherapy of BED ≥ 220 Gy with a combination of LDR brachytherapy, EBRT, and androgen deprivation therapy (ADT). The high-risk patients in the present study included both high-risk and very high-risk prostate cancer. The number of high-risk features were: 60 patients with 1 high-risk factor (42%), 61 patients with 2 high-risk factors (43%), and 22 patients with 3 high-risk factors (15%) including five N1 disease. External beam radiotherapy fields included prostate and seminal vesicles only or whole pelvis depending on the extension of the disease. Biochemical failure was defined by the Phoenix definition. Results Six patients developed biochemical failure, thus providing a 5-year actual biochemical failure-free survival (BFFS) rate of 95.2%. Biochemical failure was observed exclusively in cases with distant metastasis in the present study. All six patients with biochemical relapse had clinical failure due to bone metastasis, thus yielding a 5-year freedom from clinical failure (FFCF) rate of 93.0%. None of the cases with N1 disease experienced biochemical failure. We observed four deaths, including one death from prostate cancer, therefore yielding a cause-specific survival (CSS) rate of 97.2%, and an overall survival (OS) rate of 95.5%. Conclusions High-dose (BED ≥ 220 Gy) radiotherapy by LDR in combination with EBRT has shown an excellent outcome on BFFS in high-risk and very high-risk cancer, although causal relationship between BED and BFFS remain to be explained further.
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Taneja SS. Management of prostate cancer: NYU Case of the Month, July 2017. Rev Urol 2017; 19:180-184. [PMID: 29302241 PMCID: PMC5737345 DOI: 10.3909/riu0771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Samir S Taneja
- Department of Urology, NYU Langone Medical CenterNew York, NY
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