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Pepin A, Shah S, Pernia M, Lei S, Ayoob M, Danner M, Yung T, Collins BT, Suy S, Aghdam N, Collins SP. Bleeding Risk Following Stereotactic Body Radiation Therapy for Localized Prostate Cancer in Men on Baseline Anticoagulant or Antiplatelet Therapy. Front Oncol 2021; 11:722852. [PMID: 34604059 PMCID: PMC8485025 DOI: 10.3389/fonc.2021.722852] [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: 06/09/2021] [Accepted: 08/09/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose Patients on anticoagulant/antiplatelet medications are at a high risk of bleeding following external beam radiation therapy for localized prostate cancer. SBRT may reduce the bleeding risk by decreasing the volume of bladder/rectum receiving high doses. This retrospective study sought to evaluate the rates of hematuria and hematochezia following SBRT in these patients. Methods Localized prostate cancer patients treated with SBRT from 2007 to 2017 on at least one anticoagulant/antiplatelet at baseline were included. The minimum follow-up was 3 years with a median follow-up of 72 months. Patients who had a rectal spacer placed prior to SBRT were excluded. Radiotherapy was delivered in 5 fractions to a dose of 35 Gy or 36.25 Gy utilizing the CyberKnife system. Hematuria and hematochezia were prospectively assessed before and after treatment using the Expanded Prostate Cancer Index Composite (EPIC-26). Toxicities were scored using the CTCAE v4. Cystoscopy and colonoscopy findings were retrospectively reviewed. Results Forty-four men with a median age of 72 years with a history of taking at least one anticoagulant and/or antiplatelet medication received SBRT. Warfarin (46%), clopidogrel (34%) and rivaroxaban (9%) were the most common medications. Overall, 18.2% experienced hematuria with a median time of 10.5 months post-SBRT. Altogether, 38.6% experienced hematochezia with a median time of 6 months post-SBRT. ≥ Grade 2 hematuria and hematochezia occurred in 4.6% and 2.5%, respectively. One patient required bladder neck fulguration and one patient underwent rectal cauterization for multiple non-confluent telangiectasia. There were no grade 4 or 5 toxicities. Cystoscopy revealed bladder cancer (40%) and benign prostatic bleeding (40%) as the most common hematuria etiology. Colonoscopy demonstrated hemorrhoids (54.5%) and radiation proctitis (9.1%) as the main causes of hematochezia. There was no significant change from the mean baseline EPIC-26 hematuria and hematochezia scores at any point during follow up. Conclusion In patients with baseline anticoagulant usage, moderate dose prostate SBRT was well tolerated without rectal spacing. High grade bleeding toxicities were uncommon and resolved with time. Baseline anticoagulation usage should not be considered a contraindication to prostate SBRT.
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Affiliation(s)
- Abigail Pepin
- George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Sarthak Shah
- George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Monica Pernia
- George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Brian T Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Nima Aghdam
- Department of Radiation Medicine, Harvard, Boston, MA, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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Ippolito E, Guido A, Macchia G, Deodato F, Giaccherini L, Farioli A, Arcelli A, Cuicchi D, Frazzoni L, Cilla S, Buwenge M, Mantini G, Alitto AR, Nuzzo M, Valentini V, Ingrosso M, Morganti AG, Fuccio L. Predictive Factors of Late-onset Rectal Mucosal Changes After Radiotherapy of Prostate Cancer. ACTA ACUST UNITED AC 2018; 31:961-966. [PMID: 28882966 DOI: 10.21873/invivo.11154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 07/03/2017] [Accepted: 07/06/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND/AIM The Vienna Rectoscopy Score (VRS; from 0, absence of rectal mucosal changes, to 5) assessed 1 year after radiotherapy is a surrogate end-point of late rectal toxicity. The aim of this study was to investigate the association between treatment-related factors and 1-year VRS. PATIENTS AND METHODS We performed a retrospective analysis of prospectively collected data. Patients with prostate adenocarcinoma treated with definitive or postoperative radiotherapy (RT) underwent endoscopy 1 year after RT. Relationships between VRS of 2 or more and treatment parameters were investigated by univariate and multivariate logistic analyses. RESULTS One hundred and ninety-five patients (mean age=69 years; range=43-81 years) were considered eligible for the study. At univariate analysis, patients treated with hypofractionation plus radiosurgery boost (p<0.001) and an equivalent dose in 2 Gy per fraction (EQD2) (α/β=3) ≥75 Gy (p<0.001) was associated with a significantly higher incidence of VRS ≥2 after 1 year of follow-up. At multivariate analysis, radiosurgery boost was an independent risk factor for developing rectal mucosal lesions (VRS ≥2), yielding an odds ratio (OR) of 4.14 (95% confidence interval (CI)=1.2-13.8), while pelvic surgery was inversely associated with VRS ≥2 (OR=0.39; 95% CI=0.17-0.94). CONCLUSION Hypofractionation followed by radiosurgery boost significantly increased the risk of developing late-onset rectal mucosal changes. Therefore, special care and preventative treatment strategies are needed when using radiosurgery boost after hypofractionated RT.
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Affiliation(s)
- Edy Ippolito
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Alessandra Guido
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine DIMES, University of Bologna, Bologna, Italy
| | - Gabriella Macchia
- Radiotherapy Unit, Giovanni Paolo II Research and Care Foundation, Campobasso, Italy
| | - Francesco Deodato
- Radiotherapy Unit, Giovanni Paolo II Research and Care Foundation, Campobasso, Italy
| | - Lucia Giaccherini
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine DIMES, University of Bologna, Bologna, Italy
| | - Andrea Farioli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Alessandra Arcelli
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine DIMES, University of Bologna, Bologna, Italy
| | - Dajana Cuicchi
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Savino Cilla
- Medical Physics Unit, Giovanni Paolo II Research and Care Foundation, Campobasso, Italy
| | - Milly Buwenge
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine DIMES, University of Bologna, Bologna, Italy
| | - Giovanna Mantini
- Department of Radiotherapy, A. Gemelli Hospital, Sacred Heart Catholic University, Rome, Italy
| | - Anna R Alitto
- Department of Radiotherapy, A. Gemelli Hospital, Sacred Heart Catholic University, Rome, Italy
| | - Marianna Nuzzo
- Radiotherapy Unit, Giovanni Paolo II Research and Care Foundation, Campobasso, Italy
| | - Vincenzo Valentini
- Department of Radiotherapy, A. Gemelli Hospital, Sacred Heart Catholic University, Rome, Italy
| | - Marcello Ingrosso
- Endoscopy Unit, Giovanni Paolo II Research and Care Foundation, Campobasso, Italy
| | - Alessio G Morganti
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine DIMES, University of Bologna, Bologna, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
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Reading SR, Porter KR, Slezak JM, Harrison TN, Gelfond JS, Chien GW, Jacobsen SJ. Racial and Ethnic Variation in Health-Related Quality of Life Scores Prior to Prostate Cancer Treatment. Sex Med 2017; 5:e219-e228. [PMID: 28827045 PMCID: PMC5693455 DOI: 10.1016/j.esxm.2017.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/23/2017] [Accepted: 07/10/2017] [Indexed: 11/24/2022] Open
Abstract
Introduction Many men diagnosed with prostate cancer are concerned with how the disease and its course of treatment could affect their health-related quality of life (HRQOL). To aid in the decision-making process on a course of treatment and to better understand how these treatments can affect HRQOL, knowledge of pretreatment HRQOL is essential. Aims To assess the racial and ethnic variations in HRQOL scores in men newly diagnosed with prostate cancer before electing a course of treatment. Methods Male members of the Kaiser Permanente of Southern California health plan who were newly diagnosed with prostate cancer completed the five-domain specific Expanded Prostate Index Composite–26 (EPIC-26) HRQOL questionnaire from March 1, 2011 through August 31, 2013 (N = 2,579). Domain scores were compared across racial and ethnic subgroups and multiple logistic regression analyses were used to assess the association after adjusting for sociodemographic and clinical characteristics. Main Outcome Measures The five EPIC-26 domain scores (sexual, bowel, hormonal, urinary incontinence, and urinary irritation and obstruction). Results Results from the fully adjusted analyses indicated that non-Hispanic black men were more likely to be above the sample median on the sexual (odds ratio [OR] = 1.43, 95% CI = 1.09–1.88), hormonal (OR = 1.35, 95% CI = 1.03–1.77), and urinary irritation and obstruction (OR = 1.34, 95% CI = 1.03–1.74) domains compared with non-Hispanic white men. The Asian or Pacific Islander men were less likely to be above the sample median on the sexual domain (OR = 0.60, 95% CI = 0.44–0.83) compared with non-Hispanic white men. No additional statistically significant differences were identified. Conclusions Within an integrated health care organization, we found minimal racial and ethnic differences, aside from sexual function, in pretreatment HRQOL in men newly diagnosed with prostate cancer. These findings provide important insight with which to interpret HRQOL changes in men newly diagnosed with prostate cancer during and after prostate cancer treatment. Reading SR, Porter KR, Slezak JM, et al. Racial and Ethnic Variation in Health-Related Quality of Life Scores Prior to Prostate Cancer Treatment. Sex Med 2017;5:e219–e228.
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Affiliation(s)
- Stephanie R Reading
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Kimberly R Porter
- Division of Chronic Disease and Injury Prevention, Department of Public Health Los Angeles County, Los Angeles, CA, USA
| | - Jeffrey M Slezak
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Teresa N Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Joy S Gelfond
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Gary W Chien
- Department of Urology, Kaiser Permanente Southern California, Los Angeles, CA, USA
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.
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Paydar I, Cyr RA, Yung TM, Lei S, Collins BT, Chen LN, Suy S, Dritschilo A, Lynch JH, Collins SP. Proctitis 1 Week after Stereotactic Body Radiation Therapy for Prostate Cancer: Implications for Clinical Trial Design. Front Oncol 2016; 6:167. [PMID: 27489794 PMCID: PMC4951492 DOI: 10.3389/fonc.2016.00167] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 06/28/2016] [Indexed: 01/14/2023] Open
Abstract
Background Proctitis following prostate cancer radiation therapy is a primary determinant of quality of life (QOL). While previous studies have assessed acute rectal morbidity at 1 month after stereotactic body radiotherapy (SBRT), little data exist on the prevalence and severity of rectal morbidity within the first week following treatment. This study reports the acute bowel morbidity 1 week following prostate SBRT. Materials and methods Between May 2013 and August 2014, 103 patients with clinically localized prostate cancer were treated with 35–36.25 Gy in five fractions using robotic SBRT delivered on a prospective clinical trial. Bowel toxicity was graded using the Common Terminology Criteria for Adverse Events version 4.0 (CTCAEv.4). Bowel QOL was assessed using the EPIC-26 questionnaire bowel domain at baseline, 1 week, 1 month, and 3 months. Time-dependent changes in bowel symptoms were statistically compared using the Wilcoxon signed-rank test. Clinically significant change was assessed by the minimally important difference (MID) in EPIC score. This was defined as a change of 1/2 standard deviation (SD) from the baseline score. Results One-hundred and three patients with a minimum of 3 months of follow-up were analyzed. The cumulative incidence of acute grade 2 gastrointestinal (GI) toxicity was 23%. There were no acute ≥ grade 3 bowel toxicities. EPIC bowel summary scores maximally declined at 1 week after SBRT (−13.9, p < 0.0001) before returning to baseline at 3 months after SBRT (+0.03, p = 0.94). Prior to treatment, 4.9% of men reported that their bowel bother was a moderate to big problem. This increased to 28.4% (p < 0.0001) 1 week after SBRT and returned to baseline at 3 months after SBRT (0.0%, p = 0.66). Only the bowel summary and bowel bother score declines at 1 week met the MID threshold for clinically significant change. Conclusion The rate and severity of acute proctitis following prostate SBRT peaked at 1 week after treatment and returned to baseline by 3 months. Toxicity assessment at 1 week can therefore minimize recall bias and should aid in the design of future clinical trials focused on accurately capturing and minimizing acute morbidity following SBRT.
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Affiliation(s)
- Ima Paydar
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Robyn A Cyr
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Thomas M Yung
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Brian Timothy Collins
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Leonard N Chen
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - Anatoly Dritschilo
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
| | - John H Lynch
- Department of Urology, Georgetown University Hospital , Washington, DC , USA
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital , Washington, DC , USA
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Stereotactic Body Radiation Therapy Salvage Reirradiation of Radiorecurrent Prostatic Carcinoma Relapsed in the Prostatic Bed. TUMORI JOURNAL 2015; 101:e57-9. [DOI: 10.5301/tj.5000251] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2014] [Indexed: 12/30/2022]
Abstract
A 67-year-old man presented with a slow increase of prostate-specific antigen value after radical prostatectomy and postoperative radiotherapy for prostate cancer. The patient had received 3D conformal radiotherapy to a total dose of 66 Gy in 33 fractions of 2 Gy each on the prostatic bed. Three years later, a macroscopic local failure was diagnosed at the apical region. The patient could not receive androgenic deprivation therapy or other types of treatment owing to comorbid conditions. Thus, stereotactic body radiation therapy with helical image-guided tomotherapy was administered. The total dose was 30 Gy in 5 consecutive fractions of 6 Gy each to the site of the local failure. The treatment was preceded by a transperineal-guided injection of a self-absorbable hydrogel into the prostatic bed, between rectum and bladder, in order to preserve the rectal wall, which already had received significant doses from the first radiation course. Radiation therapy was well-tolerated. After a follow-up period of 6 months, the patient remains healthy, and there has been no further evidence of metastatic spread or recurrence.
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Joh DY, Chen LN, Porter G, Bhagat A, Sood S, Kim JS, Moures R, Yung T, Lei S, Collins BT, Ju AW, Suy S, Carroll J, Lynch JH, Dritschilo A, Collins SP. Proctitis following stereotactic body radiation therapy for prostate cancer. Radiat Oncol 2014; 9:277. [PMID: 25497602 PMCID: PMC4272823 DOI: 10.1186/s13014-014-0277-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 11/26/2014] [Indexed: 11/26/2022] Open
Abstract
Background Proctitis after radiation therapy for prostate cancer remains an ongoing clinical challenge and critical quality of life issue. SBRT could minimize rectal toxicity by reducing the volume of rectum receiving high radiation doses and offers the potential radiobiologic benefits of hypofractionation. This study sought to evaluate the incidence and severity of proctitis following SBRT for prostate cancer. Methods Between February 2008 and July 2011, 269 men with clinically localized prostate cancer were treated definitively with SBRT monotherapy at Georgetown University Hospital. All patients were treated to 35-36.25Gy in 5 fractions delivered with the CyberKnife Radiosurgical System (Accuray). Rectal bleeding was recorded and scored using the CTCAE v.4. Telangiectasias were graded using the Vienna Rectoscopy Score (VRS). Proctitis was assessed via the Bowel domain of the Expanded Prostate Index Composite (EPIC)-26 at baseline and at 1, 3, 6, 9, 12, 18 and 24 months post-SBRT. Results The median age was 69 years with a median prostate volume of 39 cc. The median follow-up was 3.9 years with a minimum follow-up of two years. The 2-year actuarial incidence of late rectal bleeding ≥ grade 2 was 1.5%. Endoscopy revealed VRS Grade 2 rectal telangiectasias in 11% of patients. All proctitis symptoms increased at one month post-SBRT but returned to near-baseline with longer follow-up. The most bothersome symptoms were bowel urgency and frequency. At one month post-SBRT, 11.2% and 8.5% of patients reported a moderate to big problem with bowel urgency and frequency, respectively. The EPIC bowel summary scores declined transiently at 1 month and experienced a second, more protracted decline between 6 months and 18 months before returning to near-baseline at two years post-SBRT. Prior to treatment, 4.1% of men felt their bowel function was a moderate to big problem which increased to 11.5% one month post-SBRT but returned to near-baseline at two years post-SBRT. Conclusions In this single institution cohort, the rate and severity of proctitis observed following SBRT is low. QOL decreased on follow-up; however, our results compare favorably to those reported for patients treated with alternative radiation modalities. Future prospective randomized studies are needed to confirm these observations.
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Affiliation(s)
- Daniel Y Joh
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Leonard N Chen
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Gerald Porter
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Aditi Bhagat
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Sumit Sood
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Joy S Kim
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Rudy Moures
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Thomas Yung
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Brian T Collins
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Andrew W Ju
- Department of Radiation Oncology, East Carolina University, Greenville, NC, 27834, USA.
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - John Carroll
- Department of Gastroenterology, Georgetown University Hospital, Washington, DC, 20007, USA.
| | - John H Lynch
- Department of Urology, Georgetown University Hospital, Washington, DC, 20007, USA.
| | - Anatoly Dritschilo
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Medical Center, 3800 Reservoir Road, N.W, Washington, DC, 20007, USA.
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Retreatment for prostate cancer with stereotactic body radiation therapy (SBRT): Feasible or foolhardy? Rep Pract Oncol Radiother 2014; 20:425-9. [PMID: 26696782 DOI: 10.1016/j.rpor.2014.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 06/26/2014] [Accepted: 08/06/2014] [Indexed: 11/21/2022] Open
Abstract
The most popular therapeutic option in the management of radio-recurrent prostatic carcinoma is represented by the androgen deprivation therapy, that however should be considered only palliative and hampered by potential adverse effects of testosterone suppression. Local therapies such as surgery, cryoablation or brachytherapy might be curative choices for patients in good conditions and with a long-life expectancy, but at cost of significant risk of failure and severe toxicity. The administration of stereotactic body radiation therapy (SBRT) in this setting have come about because of tremendous technologic advances in image guidance and treatment delivery techniques that enable the delivery of large doses to tumor with reduced margins and high gradients outside the target, thereby reducing the volume of rectum which already received significant doses from primary radiotherapy. So far, very modest data are available to support its employment. Rationale, clinical experience, and challenges are herein reviewed and discussed.
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