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Wegener E, Sidhom M, Pryor D, Bucci J, Yeoh K, Richardson M, Greer P, Wilton L, Gallagher S, Schmidt L, Arumugam S, Keats S, Brown S, Glyde A, Martin JM. Prostate Virtual High-dose-rate Brachytherapy Boost: 5-Year Results from the PROMETHEUS Prospective Multicentre Trial. Eur Urol Oncol 2024:S2588-9311(24)00033-6. [PMID: 38302321 DOI: 10.1016/j.euo.2024.01.008] [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: 12/19/2023] [Accepted: 01/12/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND AND OBJECTIVE Despite the high efficacy of high-dose-rate brachytherapy boost (HDRB) in the management of prostate cancer (PC), use of this approach is declining. Similar dosimetry can be achieved using stereotactic body radiotherapy or "virtual HDRB" (vHDRB). The aim of the multicentre, single-arm, phase 2 PROMETHEUS trial (ACTRN12615000223538) was to evaluate the safety and efficacy of vHDRB in patients with PC. METHODS Patients with intermediate-risk PC or selected patients with high-risk PC were eligible for inclusion. vHDRB was given as 19-20 Gy in two fractions, delivered 1 wk apart, followed by conventionally fractionated external beam radiotherapy (EBRT) at 46 Gy in 23 fractions or 36 Gy in 12 fractions. The primary endpoint was the biochemical/clinical relapse-free rate (bcRFR). Toxicity was graded using Common Terminology Criteria for Adverse Events version 4 and quality of life (QoL) data were collected used the Expanded Prostate Cancer Index Composite-26 questionnaire. KEY FINDINGS AND LIMITATIONS From March 2014 to December 2018, 151 patients (74% intermediate risk, 26% high risk) with a median age of 69 yr were treated across five centres. Median follow-up was 60 mo. The 5-yr bcRFR was 94.1% (95% confidence interval [CI] 90-98%) and the local control rate was 98.7%. Acute grade 2 gastrointestinal (GI) and genitourinary (GU) toxicity occurred in 6.6% and 23.2% of patients, respectively, with no acute grade 3 toxicity. At 60 mo after treatment, the prevalence of late grade ≥2 GI toxicity was 1.7% (95% CI 0.3-6.5%) and the prevalence of late grade ≥2 GU toxicity was 3.3% (95% CI 1.1-8.8%). Between baseline and 60 mo, QoL improved for urinary obstructive and hormonal domains, was stable for the bowel domain, and deteriorated slightly for the sexual and urinary incontinence domains. CONCLUSIONS Delivery of gantry-based vHDRB followed by conventionally fractionated EBRT is feasible in a multicentre setting, with high 5-yr bcRFR and low toxicity. This approach is being compared with prostate ultrahypofractionated radiotherapy in the TROG 18.01 NINJA randomised trial (ACTRN12618001806257). PATIENT SUMMARY The PROMETHEUS trial investigated noninvasive high-dose precision radiotherapy combined with conventional radiotherapy in patients with prostate cancer. We found that this new technique was well tolerated and resulted in better cancer control outcomes than historically reported.
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Affiliation(s)
- Eric Wegener
- GenesisCare Maitland, Maitland, Australia; University of Newcastle, Newcastle, Australia
| | - Mark Sidhom
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia; University of New South Wales, Sydney, Australia
| | - David Pryor
- Princess Alexandra Hospital, Brisbane, Australia; Queensland University of Technology, Brisbane, Australia
| | - Joseph Bucci
- University of New South Wales, Sydney, Australia; Cancer Care Centre, St. George Hospital, Sydney, Australia
| | - Kenway Yeoh
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, Australia
| | - Matthew Richardson
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, Australia
| | - Peter Greer
- University of Newcastle, Newcastle, Australia; Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, Australia
| | - Lee Wilton
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, Australia
| | - Sarah Gallagher
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, Australia
| | - Laurel Schmidt
- Cancer Care Centre, St. George Hospital, Sydney, Australia
| | - Sankar Arumugam
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia; University of New South Wales, Sydney, Australia
| | - Sarah Keats
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
| | - Simon Brown
- Princess Alexandra Hospital, Brisbane, Australia
| | - Alan Glyde
- Princess Alexandra Hospital, Brisbane, Australia
| | - Jarad M Martin
- GenesisCare Maitland, Maitland, Australia; University of Newcastle, Newcastle, Australia; Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, Australia.
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Takayesu JSK, Heckman P, Short E, Hurley P, Narayana V, McLaughlin PW. Quality rectal hydrogel placement allows for gel-enabled dose-escalated EBRT (GEDE-EBRT) without rectal interference in prostate cancer. Med Dosim 2023; 48:286-292. [PMID: 37666707 DOI: 10.1016/j.meddos.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/29/2023] [Accepted: 07/31/2023] [Indexed: 09/06/2023]
Abstract
Multiple trials have shown that dose-escalation of radiation for prostate cancer provides a biochemical progression-free survival benefit (bPFS); however, rectal constraints are often limiting. In this dosimetric study, we hypothesized that a well-placed rectal hydrogel (RH) would permit improved dose-escalation and target coverage. We selected patients with good-quality RH and created plans with and without RH, prescribing 70 Gy in 28 fractions to the prostate and proximal seminal vesicles (PSV), and a peripheral zone (PZ) boost to 84 Gy, 98 Gy, or 112 Gy. We then compared plans with and without RH, prescribing a 112 Gy boost to 1 to 2 cm simulated dominant intraprostatic lesions (DIL). In the 18 plans created with a PZ boost, the PTV_boost D95% was higher in RH plans compared to non-RH plans (median 98.5 Gy vs 75.53 Gy, p < 0.01). The PSV planning target volume (PTV_PSV) D95% was also marginally higher with RH (71.87 Gy vs 71.04 Gy, p < 0.01). All rectal metrics were improved with RH. For the 32 plans created for simulated DILs treated to 112 Gy, the PTV_boost coverage (median D95% 112.48 Gy vs 102.63 Gy, p < 0.01) and rectal metrics were improved with RH. Four non-RH plans with at least a 4 mm rectal-PTV_boost gap achieved D95% > 98% of the prescription dose for the PTV_boost. Our study showed that placement of a high-quality RH allowed for GEDE-EBRT up to 112 Gy in 28 fractions (EQD2 160 Gy with α/β = 2.5). This concept should be tested prospectively, particularly to assess for increases in nonrectal toxicities.
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Affiliation(s)
- Jamie S K Takayesu
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
| | - Paul Heckman
- Department of Radiation Oncology, Assarian Cancer Center, Ascension Providence Hospital, Novi, MI, USA
| | - Eric Short
- Department of Radiation Oncology, Assarian Cancer Center, Ascension Providence Hospital, Novi, MI, USA
| | - Patrick Hurley
- Department of Urology, Ascension Providence Hospital, Novi, MI, USA
| | - Vrinda Narayana
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
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Min H, Dowling J, Jameson MG, Cloak K, Faustino J, Sidhom M, Martin J, Cardoso M, Ebert MA, Haworth A, Chlap P, de Leon J, Berry M, Pryor D, Greer P, Vinod SK, Holloway L. Clinical target volume delineation quality assurance for MRI-guided prostate radiotherapy using deep learning with uncertainty estimation. Radiother Oncol 2023; 186:109794. [PMID: 37414257 DOI: 10.1016/j.radonc.2023.109794] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/19/2023] [Accepted: 06/30/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND AND PURPOSE Previous studies on automatic delineation quality assurance (QA) have mostly focused on CT-based planning. As MRI-guided radiotherapy is increasingly utilized in prostate cancer treatment, there is a need for more research on MRI-specific automatic QA. This work proposes a clinical target volume (CTV) delineation QA framework based on deep learning (DL) for MRI-guided prostate radiotherapy. MATERIALS AND METHODS The proposed workflow utilized a 3D dropblock ResUnet++ (DB-ResUnet++) to generate multiple segmentation predictions via Monte Carlo dropout which were used to compute an average delineation and area of uncertainty. A logistic regression (LR) classifier was employed to classify the manual delineation as pass or discrepancy based on the spatial association between the manual delineation and the network's outputs. This approach was evaluated on a multicentre MRI-only prostate radiotherapy dataset and compared with our previously published QA framework based on AN-AG Unet. RESULTS The proposed framework achieved an area under the receiver operating curve (AUROC) of 0.92, a true positive rate (TPR) of 0.92 and a false positive rate of 0.09 with an average processing time per delineation of 1.3 min. Compared with our previous work using AN-AG Unet, this method generated fewer false positive detections at the same TPR with a much faster processing speed. CONCLUSION To the best of our knowledge, this is the first study to propose an automatic delineation QA tool using DL with uncertainty estimation for MRI-guided prostate radiotherapy, which can potentially be used for reviewing prostate CTV delineation in multicentre clinical trials.
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Affiliation(s)
- Hang Min
- CSIRO Australian e-Health Research Centre, Herston, Queensland, Australia; Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia; South Western Clinical Campuses, University of New South Wales, Australia.
| | - Jason Dowling
- CSIRO Australian e-Health Research Centre, Herston, Queensland, Australia; South Western Clinical Campuses, University of New South Wales, Australia; Centre for Medical Radiation Physics, University of Wollongong, New South Wales, Australia; Institute of Medical Physics, The University of Sydney, New South Wales, Australia; School of Mathematical and Physical Sciences, University of Newcastle, New South Wales, Australia
| | - Michael G Jameson
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Australia; GenesisCare, Sydney, New South Wales, Australia; Liverpool and Macarthur Cancer therapy Centres, Liverpool Hospital, New South Wales, Australia
| | - Kirrily Cloak
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia; South Western Clinical Campuses, University of New South Wales, Australia
| | - Joselle Faustino
- Liverpool and Macarthur Cancer therapy Centres, Liverpool Hospital, New South Wales, Australia
| | - Mark Sidhom
- South Western Clinical Campuses, University of New South Wales, Australia; Liverpool and Macarthur Cancer therapy Centres, Liverpool Hospital, New South Wales, Australia
| | - Jarad Martin
- Calvary Mater Newcastle Hospital, Radiation Oncology, Newcastle, Australia
| | - Michael Cardoso
- Liverpool and Macarthur Cancer therapy Centres, Liverpool Hospital, New South Wales, Australia
| | - Martin A Ebert
- Centre for Medical Radiation Physics, University of Wollongong, New South Wales, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; School of Physics Mathematics and Computing, University of Western Australia, Perth, Western Australia, Australia
| | - Annette Haworth
- Institute of Medical Physics, The University of Sydney, New South Wales, Australia
| | - Phillip Chlap
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia; South Western Clinical Campuses, University of New South Wales, Australia; Liverpool and Macarthur Cancer therapy Centres, Liverpool Hospital, New South Wales, Australia
| | - Jeremiah de Leon
- GenesisCare, Sydney, New South Wales, Australia; Illawarra Cancer Care Centre, Wollongong, Australia
| | - Megan Berry
- Liverpool and Macarthur Cancer therapy Centres, Liverpool Hospital, New South Wales, Australia
| | - David Pryor
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Peter Greer
- School of Mathematical and Physical Sciences, University of Newcastle, New South Wales, Australia; Calvary Mater Newcastle Hospital, Radiation Oncology, Newcastle, Australia
| | - Shalini K Vinod
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia; South Western Clinical Campuses, University of New South Wales, Australia; Liverpool and Macarthur Cancer therapy Centres, Liverpool Hospital, New South Wales, Australia
| | - Lois Holloway
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia; South Western Clinical Campuses, University of New South Wales, Australia; Centre for Medical Radiation Physics, University of Wollongong, New South Wales, Australia; Institute of Medical Physics, The University of Sydney, New South Wales, Australia; Liverpool and Macarthur Cancer therapy Centres, Liverpool Hospital, New South Wales, Australia
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Kaur G, Lehmann J, Greer PB, Martin J, Simpson J. Clinical validation of the Varian Truebeam intra-fraction motion review (IMR) system for prostate treatment guidance. Phys Eng Sci Med 2023; 46:131-140. [PMID: 36472802 DOI: 10.1007/s13246-022-01204-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
This study quantified the performance of Intra-fraction Motion Review (IMR) during prostate Stereotactic Body Radiotherapy (SBRT) treatments. IMR was evaluated using prostate motion data from patients treated in an SBRT clinical trial (PROMETHEUS, NCT00587990).IMR measured prostate displacements were compared to those of two 3D motion management methods: Kilovoltage Intra-fraction Motion management (KIM) and MV/kV triangulation. A planning study assessing the impact of a defined prostate motion (2-5 mm) on the PTV coverage with and without IMR was performed. A clinically relevant IMR search region for prostate cancer SBRT treatments was determined using a customised anthropomorphic pelvis phantom with implanted gold seeds and a motion platform. IMR showed submillimeter agreement with corresponding 2D projections from both KIM and MV/kV triangulation. However, IMR detected actual displacements consistently in considerably fewer frames than KIM (3D), with the actual numbers depending on the settings. The Default Search Region (DSR) method employing a circular search region proved superior to user-contoured structures in detecting clinically relevant prostate motion. Reducing the DSR search region radius can reduce the impact of the 2D nature of IMR and improve the detectability of actual motion (by 10% per 0.5 mm reduction) but must be balanced against increased beam interruptions from minor, clinically irrelevant motion. The use of IMR for SBRT prostate treatments has the potential to improve target dose coverage (minimum dose to 98% of the PTV, D98%) by > 20% compared to treatment without IMR. Calculated D98% of IMR monitored treatments with motion was within 1.5% of plans without motion.
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Affiliation(s)
- Guneet Kaur
- Department of Radiation Oncology, The Mater Hospital, Rocklands Road, Crows Nest, Sydney, NSW, 2065, Australia.
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia.
| | - Joerg Lehmann
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
- School of Information and Physical Sciences, College of Engineering, Science and Environment, University of Newcastle, Newcastle, NSW, Australia
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW, Australia
| | - Peter B Greer
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
- School of Information and Physical Sciences, College of Engineering, Science and Environment, University of Newcastle, Newcastle, NSW, Australia
| | - Jarad Martin
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
| | - John Simpson
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
- School of Information and Physical Sciences, College of Engineering, Science and Environment, University of Newcastle, Newcastle, NSW, Australia
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Mechanisms, mitigation, and management of urinary toxicity from prostate radiotherapy. Lancet Oncol 2022; 23:e534-e543. [DOI: 10.1016/s1470-2045(22)00544-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/30/2022]
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Min H, Dowling J, Jameson MG, Cloak K, Faustino J, Sidhom M, Martin J, Ebert MA, Haworth A, Chlap P, de Leon J, Berry M, Pryor D, Greer P, Vinod SK, Holloway L. Automatic radiotherapy delineation quality assurance on prostate MRI with deep learning in a multicentre clinical trial. Phys Med Biol 2021; 66. [PMID: 34507305 DOI: 10.1088/1361-6560/ac25d5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 09/10/2021] [Indexed: 11/11/2022]
Abstract
Volume delineation quality assurance (QA) is particularly important in clinical trial settings where consistent protocol implementation is required, as outcomes will affect future as well current patients. Currently, where feasible, this is conducted manually, which is time consuming and resource intensive. Although previous studies mostly focused on automating delineation QA on CT, magnetic resonance imaging (MRI) is being increasingly used in radiotherapy treatment. In this work, we propose to perform automatic delineation QA on prostate MRI for both the clinical target volume (CTV) and organs-at-risk (OARs) by using delineations generated by 3D Unet variants as benchmarks for QA. These networks were trained on a small gold standard atlas set and applied on a multicentre radiotherapy clinical trial dataset to generate benchmark delineations. Then, a QA stage was designed to recommend 'pass', 'minor correction' and 'major correction' for each manual delineation in the trial set by thresholding its Dice similarity coefficient to the network generated delineation. Among all 3D Unet variants explored, the Unet with anatomical gates in an AtlasNet architecture performed the best in delineation QA, achieving an area under the receiver operating characteristics curve of 0.97, 0.92, 0.89 and 0.97 for identifying unacceptable (major correction) delineations with a sensitivity of 0.93, 0.73, 0.74 and 0.90 at a specificity of 0.93, 0.86, 0.86 and 0.95 for bladder, prostate CTV, rectum and gel spacer respectively. To the best of our knowledge, this is the first study to propose automated delineation QA for a multicentre radiotherapy clinical trial with treatment planning MRI. The methods proposed in this work can potentially improve the accuracy and consistency of CTV and OAR delineation in radiotherapy treatment planning.
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Affiliation(s)
- Hang Min
- CSIRO Australian e-Health Research Centre, Herston, Queensland, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Australia
| | - Jason Dowling
- CSIRO Australian e-Health Research Centre, Herston, Queensland, Australia.,South Western Clinical School, University of New South Wales, Australia.,Centre for Medical Radiation Physics, University of Wollongong, New South Wales, Australia.,Institute of Medical Physics, The University of Sydney, New South Wales, Australia.,School of Mathematical and Physical Sciences, University of Newcastle, New South Wales, Australia
| | - Michael G Jameson
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Australia.,GenesisCare, Sydney, New South Wales, Australia
| | - Kirrily Cloak
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Australia
| | - Joselle Faustino
- Liverpool and Macarthur Cancer therapy Centres, Liverpool Hospital, New South Wales, Australia
| | - Mark Sidhom
- South Western Clinical School, University of New South Wales, Australia.,Liverpool and Macarthur Cancer therapy Centres, Liverpool Hospital, New South Wales, Australia
| | - Jarad Martin
- Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Martin A Ebert
- Centre for Medical Radiation Physics, University of Wollongong, New South Wales, Australia.,Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,School of Physics Mathematics and Computing, University of Western Australia, Perth, Western Australia, Australia
| | - Annette Haworth
- Institute of Medical Physics, The University of Sydney, New South Wales, Australia
| | - Phillip Chlap
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Australia.,Liverpool and Macarthur Cancer therapy Centres, Liverpool Hospital, New South Wales, Australia
| | - Jeremiah de Leon
- GenesisCare, Sydney, New South Wales, Australia.,Illawarra Cancer Care Centre, Wollongong, Australia
| | - Megan Berry
- South Western Clinical School, University of New South Wales, Australia.,Liverpool and Macarthur Cancer therapy Centres, Liverpool Hospital, New South Wales, Australia
| | - David Pryor
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Peter Greer
- School of Mathematical and Physical Sciences, University of Newcastle, New South Wales, Australia.,Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Shalini K Vinod
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Australia.,Liverpool and Macarthur Cancer therapy Centres, Liverpool Hospital, New South Wales, Australia
| | - Lois Holloway
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Australia.,Centre for Medical Radiation Physics, University of Wollongong, New South Wales, Australia.,Institute of Medical Physics, The University of Sydney, New South Wales, Australia.,Liverpool and Macarthur Cancer therapy Centres, Liverpool Hospital, New South Wales, Australia
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de Chavez R, Grogan G, Hug B, Howe K, Grigg A, Waterhouse D, Lane J, Glyde A, Brown E, Bydder S, Pryor D, Hargrave C, Charles PH, Hellyer J, Ebert MA. Assessment of HDR brachytherapy-replicating prostate radiotherapy planning for tomotherapy, cyberknife and VMAT. Med Dosim 2021; 47:61-69. [PMID: 34551879 DOI: 10.1016/j.meddos.2021.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/13/2021] [Accepted: 08/19/2021] [Indexed: 11/19/2022]
Abstract
A dosimetric study was undertaken to assess the ability of Cyberknife (CK), Volumetric Modulated Arc Therapy (VMAT), and TomoTherapy (Tomo) to generate treatment plans that mimic the dosimetry of high dose-rate brachytherapy (HDR BT) for prostate cancer. The project aimed to assess the potential of using stereotactic body radiotherapy (SBRT) for boost treatment of high-risk prostate cancer patients where HDR BT in combination with conformal external beam radiotherapy (EBRT) is the standard of care. The datasets of 6 prostate patients previously treated with HDR BT were collated. VMAT, CK, and TomoTherapy treatment plans were generated for each dataset using the target and organ-at-risk structures as defined by the Radiation Oncologist during the HDR BT treatment process. The HDR BT plan isodoses were also converted into planning structures to assist the other modalities to achieve a HDR BT-like dose distribution. CK plans were created using both the iris collimator (IC) and a multileaf collimator (MLC). Comparison of the techniques was made based on dose-volume indices. Each plan was created at centres experienced using the respective treatment planning systems (TPS). Planning target volume (PTV V100%), i.e., the volume of the planning target volume (PTV) receiving 100% of the relative dose, in VMAT and TomoTherapy SBRT plans was higher than HDR BT plans. PTV V150% and V200%, i.e., volume of the PTV receiving 150% and 200% of the relative dose, were approached on all the CK MLC and TomoTherapy SBRT plans. However, it is not presently achievable for "virtual brachytherapy" SBRT to replicate the same high intraprostatic doses as HDR BT while meeting the constraints on the organs-at-risk (OARs). Half of the CK IC plans achieved PTV V150% but this was at the expense of high rectal dose. TomoTherapy and CK MLC plans achieved PTV V150% and V200% but the bladder dose was higher compared to CK IC plans. VMAT exhibited excellent PTV coverage based on V100 and OAR sparing, but without any ability to achieve the high intra-prostatic doses of HDR (V150% and V200%). SBRT techniques can be used to deliver hypofractionated radiotherapy to the PTV V100%. Based on the comparison of "physical" dose distributions, SBRT cannot presently achieve the same high intraprostatic doses as HDR BT while respecting the OAR constraints. SBRT still remains an attractive treatment option for delivering hypofractionated treatments for prostate cancer compared to HDR BT, in particular as it is less invasive and less resource intensive. Long-term outcomes of clinical trials comparing HDR BT and SBRT "prostate boosts" may show whether the high intraprostatic doses are clinically significant and correlate with outcomes.
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Affiliation(s)
- Romena de Chavez
- Princess Alexandra Hospital, Brisbane, Australia; GenesisCare, Australia.
| | - Garry Grogan
- Sir Charles Gairdner Hospital, Perth, Australia.
| | - Ben Hug
- 5D Clinics, Perth, Australia.
| | - Kate Howe
- Princess Alexandra Hospital, Brisbane, Australia.
| | - Alice Grigg
- Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - David Waterhouse
- Sir Charles Gairdner Hospital, Perth, Australia; GenesisCare, Australia.
| | | | - Alan Glyde
- Princess Alexandra Hospital, Brisbane, Australia.
| | | | - Sean Bydder
- Sir Charles Gairdner Hospital, Perth, Australia; 5D Clinics, Perth, Australia.
| | - David Pryor
- Princess Alexandra Hospital, Brisbane, Australia.
| | - Cathy Hargrave
- Princess Alexandra Hospital, Brisbane, Australia; Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Paul H Charles
- Princess Alexandra Hospital, Brisbane, Australia; Royal Brisbane and Women's Hospital, Brisbane, Australia; Queensland University of Technology, Brisbane, Australia; Herston Biofabrication Institute, Brisbane, Australia; School of Information Technology and Electrical Engineering, University of Queensland, St Lucia, Brisbane, Australia; School of Chemistry and Physics, Queensland University of Technology, Brisbane, Australia.
| | | | - Martin A Ebert
- Sir Charles Gairdner Hospital, Perth, Australia; 5D Clinics, Perth, Australia; University of Western Australia, Perth, Australia.
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Richardson M, Skehan K, Wilton L, Sams J, Samuels J, Goodwin J, Greer P, Sridharan S, Martin J. Visualising the urethra for prostate radiotherapy planning. J Med Radiat Sci 2021; 68:282-288. [PMID: 34028976 PMCID: PMC8424315 DOI: 10.1002/jmrs.485] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 05/01/2021] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION The prostatic urethra is an organ at risk for prostate radiotherapy with genitourinary toxicities a common side effect. Many external beam radiation therapy protocols call for urethral sparing, and with modulated radiotherapy techniques, the radiation dose distribution can be controlled so that maximum doses do not fall within the prostatic urethral volume. Whilst traditional diagnostic MRI sequences provide excellent delineation of the prostate, uncertainty often remains as to the true path of the urethra within the gland. This study aims to assess if a high-resolution isotropic 3D T2 MRI series can reduce inter-observer variability in urethral delineation for radiotherapy planning. METHODS Five independent observers contoured the prostatic urethra for ten patients on three data sets; a 2 mm axial CT, a diagnostic 3 mm axial T2 TSE MRI and a 0.9 mm isotropic 3D T2 SPACE MRI. The observers were blinded from each other's contours. A Dice Similarity Coefficient (DSC) score was calculated using the intersection and union of the five observer contours vs an expert reference contour for each data set. RESULTS The mean DSC of the observer vs reference contours was 0.47 for CT, 0.62 for T2 TSE and 0.78 for T2 SPACE (P < 0.001). CONCLUSIONS The introduction of a 0.9 mm isotropic 3D T2 SPACE MRI for treatment planning provides improved urethral visualisation and can lead to a significant reduction in inter-observer variation in prostatic urethral contouring.
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Affiliation(s)
- Matthew Richardson
- Department of Radiation OncologyCalvary Mater NewcastleWaratahNew South WalesAustralia
| | - Kate Skehan
- Department of Radiation OncologyCalvary Mater NewcastleWaratahNew South WalesAustralia
| | - Lee Wilton
- Department of Radiation OncologyCalvary Mater NewcastleWaratahNew South WalesAustralia
| | - Joshua Sams
- Department of Radiation OncologyCalvary Mater NewcastleWaratahNew South WalesAustralia
| | - Justin Samuels
- Department of Radiation OncologyCalvary Mater NewcastleWaratahNew South WalesAustralia
| | - Jonathan Goodwin
- Department of Radiation OncologyCalvary Mater NewcastleWaratahNew South WalesAustralia
- School of Mathematical and Physical ScienceUniversity of NewcastleCallaghanNew South WalesAustralia
| | - Peter Greer
- Department of Radiation OncologyCalvary Mater NewcastleWaratahNew South WalesAustralia
- School of Mathematical and Physical ScienceUniversity of NewcastleCallaghanNew South WalesAustralia
| | - Swetha Sridharan
- Department of Radiation OncologyCalvary Mater NewcastleWaratahNew South WalesAustralia
| | - Jarad Martin
- Department of Radiation OncologyCalvary Mater NewcastleWaratahNew South WalesAustralia
- School of Medicine and Public HealthUniversity of NewcastleCallaghanNew South WalesAustralia
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Wang K, Mavroidis P, Royce TJ, Falchook AD, Collins SP, Sapareto S, Sheets NC, Fuller DB, El Naqa I, Yorke E, Grimm J, Jackson A, Chen RC. Prostate Stereotactic Body Radiation Therapy: An Overview of Toxicity and Dose Response. Int J Radiat Oncol Biol Phys 2020; 110:237-248. [PMID: 33358229 DOI: 10.1016/j.ijrobp.2020.09.054] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/26/2020] [Indexed: 01/10/2023]
Abstract
PURPOSE Ultrahypofractionationed radiation therapy for prostate cancer is increasingly studied and adopted. The American Association of Physicists in Medicine Working Group on Biological Effects of Hypofractionated Radiotherapy therefore aimed to review studies examining toxicity and quality of life after stereotactic body radiation therapy (SBRT) for prostate cancer and model its effect. METHODS AND MATERIALS We performed a systematic PubMed search of prostate SBRT studies published between 2001 and 2018. Those that analyzed factors associated with late urinary, bowel, or sexual toxicity and/or quality of life were included and reviewed. Normal tissue complication probability modelling was performed on studies that contained detailed dose/volume and outcome data. RESULTS We found 13 studies that examined urinary effects, 6 that examined bowel effects, and 4 that examined sexual effects. Most studies included patients with low-intermediate risk prostate cancer treated to 35-40 Gy. Most patients were treated with 5 fractions, with several centers using 4 fractions. Endpoints were heterogeneous and included both physician-scored toxicity and patient-reported quality of life. Most toxicities were mild-moderate (eg, grade 1-2) with a very low overall incidence of severe toxicity (eg, grade 3 or higher, usually <3%). Side effects were associated with both dosimetric and non-dosimetric factors. CONCLUSIONS Prostate SBRT appears to be overall well tolerated, with determinants of toxicity that include dosimetric factors and patient factors. Suggested dose constraints include bladder V(Rx Dose)Gy <5-10 cc, urethra Dmax <38-42 Gy, and rectum Dmax <35-38 Gy, though current data do not offer firm guidance on tolerance doses. Several areas for future research are suggested.
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Affiliation(s)
- Kyle Wang
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Panayiotis Mavroidis
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Trevor J Royce
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | | | - Sean P Collins
- Department of Radiation Oncology, Georgetown University Hospital, Washington, DC
| | - Stephen Sapareto
- Department of Medical Physics, Banner Health System, Phoenix, Arizona
| | - Nathan C Sheets
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | | | - Issam El Naqa
- Department of Machine Learning, Moffitt Cancer Center, Tampa, Florida
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, 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
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ronald C Chen
- Department of Radiation Oncology, University of Kansas, Kansas City, Kansas.
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Mostafaei F, Dougherty ST, Hamilton RJ. Preliminary Clinical Evaluation of Intrafraction Prostate Displacements for Two Immobilization Systems. Cureus 2020; 12:e10206. [PMID: 33033682 PMCID: PMC7532867 DOI: 10.7759/cureus.10206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Immobilization systems and their corresponding set-up errors influence the clinical target volume to the planning target volume (CTV-PTV) margins, which is critical for hypofractionated prostate stereotactic body radiotherapy (SBRT). This preliminary study evaluates intrafraction prostate displacement for two immobilization systems (A and B). Six consecutive patients having localized prostate cancer and implanted prostate marker seeds were studied. Planar X-ray images were acquired pre- and post-treatment to find the intrafraction prostate displacement. The average absolute displacements (lateral, longitudinal, vertical) were 0.9 ± 0.4 mm, 1.7 ± 0.1 mm, 1.3 ± 0.3 mm (system A), and 0.5 ± 0.2 mm, 0.6 ± 0.1 mm, 0.8 ± 0.3 mm (system B), with average three-dimensional displacements of 2.6 ± 0.2 mm (system A) and 1.3 ± 0.2 mm (system B). The computed CTV-PTV margins (lateral, longitudinal, vertical) were 2.5 mm, 2.5 mm, 3.6 mm and 1.4 mm, 1.6 mm, 2.4 mm for systems A and B, respectively. This suggests that the immobilization system influences intrafraction prostate displacement and, therefore, the margins applied. However, the margins found for both systems are comparable to the margins used for hypofractionated prostate SBRT.
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11
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Martin J, Keall P, Siva S, Greer P, Christie D, Moore K, Dowling J, Pryor D, Chong P, McLeod N, Raman A, Lynam J, Smart J, Oldmeadow C, Tang CI, Murphy DG, Millar J, Tai KH, Holloway L, Reeves P, Hayden A, Lim T, Holt T, Sidhom M. TROG 18.01 phase III randomised clinical trial of the Novel Integration of New prostate radiation schedules with adJuvant Androgen deprivation: NINJA study protocol. BMJ Open 2019; 9:e030731. [PMID: 31434782 PMCID: PMC6707760 DOI: 10.1136/bmjopen-2019-030731] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Stereotactic body radiotherapy (SBRT) is a non-invasive alternative to surgery for the treatment of non-metastatic prostate cancer (PC). The objectives of the Novel Integration of New prostate radiation schedules with adJuvant Androgen deprivation (NINJA) clinical trial are to compare two emerging SBRT regimens for efficacy with technical substudies focussing on MRI only planning and the use of knowledge-based planning (KBP) to assess radiotherapy plan quality. METHODS AND ANALYSIS Eligible patients must have biopsy-proven unfavourable intermediate or favourable high-risk PC, have an Eastern Collaborative Oncology Group (ECOG) performance status 0-1 and provide written informed consent. All patients will receive 6 months in total of androgen deprivation therapy. Patients will be randomised to one of two SBRT regimens. The first will be 40 Gy in five fractions given on alternating days (SBRT monotherapy). The second will be 20 Gy in two fractions given 1 week apart followed 2 weeks later by 36 Gy in 12 fractions given five times per week (virtual high-dose rate boost (HDRB)). The primary efficacy outcome will be biochemical clinical control at 5 years. Secondary endpoints for the initial portion of NINJA look at the transition of centres towards MRI only planning and the impact of KBP on real-time (RT) plan assessment. The first 150 men will demonstrate accrual feasibility as well as addressing the KBP and MRI planning aims, prior to proceeding with total accrual to 472 patients as a phase III randomised controlled trial. ETHICS AND DISSEMINATION NINJA is a multicentre cooperative clinical trial comparing two SBRT regimens for men with PC. It builds on promising results from several single-armed studies, and explores radiation dose escalation in the Virtual HDRB arm. The initial component includes novel technical elements, and will form an important platform set for a definitive phase III study. TRIAL REGISTRATION NUMBER ANZCTN 12615000223538.
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Affiliation(s)
- Jarad Martin
- Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Paul Keall
- Radiation Physics Laboratory, University of Sydney, Sydney, New South Wales, Australia
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter Greer
- Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, New South Wales, Australia
| | | | - Kevin Moore
- Department of Medical Physics, University of California San Diego, La Jolla, California, USA
| | - Jason Dowling
- The Australian e-Health Research Centre, CSIRO, Canberra, Australian Capital Territory, Australia
| | - David Pryor
- Department of Radiation Oncology, Princess Alexandra Hospital Health Service District, Woolloongabba, Queensland, Australia
| | - Peter Chong
- Department of Urology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Nicholas McLeod
- Department of Urology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Avi Raman
- Department of Urology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - James Lynam
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Joanne Smart
- Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | | | - Colin I Tang
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Declan G Murphy
- Urological Service Team, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jeremy Millar
- Department of Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Keen Hun Tai
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Lois Holloway
- Department of Radiation Oncology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Penny Reeves
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Department of Health Research Economics, University of Newcastle Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Amy Hayden
- Department of Radiation Oncology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Tee Lim
- Genesis Care, Perth, Western Australia, Australia
| | - Tanya Holt
- Radiation Oncology Princess Alexandra Raymond Terrace, Brisbane, Queensland, Australia
| | - Mark Sidhom
- Department of Radiation Oncology, Liverpool Hospital, Liverpool, New South Wales, Australia
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12
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Wolf J, Nicholls J, Hunter P, Nguyen DT, Keall P, Martin J. Dosimetric impact of intrafraction rotations in stereotactic prostate radiotherapy: A subset analysis of the TROG 15.01 SPARK trial. Radiother Oncol 2019; 136:143-147. [DOI: 10.1016/j.radonc.2019.04.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/26/2019] [Accepted: 04/07/2019] [Indexed: 12/26/2022]
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13
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de Leon J, Jameson MG, Rivest-Henault D, Keats S, Rai R, Arumugam S, Wilton L, Ngo D, Liney G, Moses D, Dowling J, Martin J, Sidhom M. Reduced motion and improved rectal dosimetry through endorectal immobilization for prostate stereotactic body radiotherapy. Br J Radiol 2019; 92:20190056. [PMID: 30912956 PMCID: PMC6592081 DOI: 10.1259/bjr.20190056] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/19/2019] [Accepted: 03/21/2019] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE PROMETHEUS (ACTRN12615000223538) is a multicentre clinical trial investigating the feasibility of 19 Gy in 2 fractions of stereotactic body radiotherapy (SBRT) as a boost technique for prostate cancer. The objective of this substudy was to evaluate intrafraction motion using cine MRI and assess the dosimetric impact of using a rectal displacement device (RDD). METHODS The initial 10 patients recruited underwent planning CT and MRI, with and without a RDD. Cine MRI images were captured using an interleaved T2 HASTE sequence in sagittal and axial planes with a temporal resolution of 5.2 s acquired over 4.3 min. Points of interest (POIs) were defined and a validated tracking algorithm measured displacement of these points over the 4.3 min in the anteroposterior, superior-inferior and left-right directions. Plans were generated with and without a RDD to examine the impact on dosimetry. RESULTS There was an overall trend for increasing displacement in all directions as time progressed when no RDD was in situ . points of interest remained comparatively stable with the RDD. In the sagittal plane, the RDD resulted in statistically significant improvement in the range of anteroposterior displacement for the rectal wall, anterior prostate, prostate apex and base. Dosimetrically, the use of a RDD significantly reduced rectal V16, V14 and Dmax, as well as the percentage of posterior rectal wall receiving 8.5 Gy. CONCLUSION The RDD used in stereotactic prostate radiotherapy leads to reduced intrafraction motion of the prostate and rectum, with increasing improvement with time. It also results in significant improvement in rectal wall dosimetry. ADVANCES IN KNOWLEDGE It was found that the rectal displacement device improved prostate stabilization significantly, improved rectum stabilization and dosimetry significantly. The rectal displacement device did not improve target volume dosimetry.
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Affiliation(s)
| | | | | | - Sarah Keats
- Liverpool Cancer Therapy Centre, Liverpool, Australia
| | - Robba Rai
- Liverpool Cancer Therapy Centre, Liverpool, Australia
| | | | - Lee Wilton
- Calvary Mater Newcastle, Newcastle, Australia
| | - Diana Ngo
- Liverpool Cancer Therapy Centre, Liverpool, Australia
| | | | - Daniel Moses
- Faculty of Medicine, University of New South Wales, Australia
| | - Jason Dowling
- Australian e-Health Research Centre, CSIRO, Herston, Australia
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14
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Pryor D, Sidhom M, Arumugam S, Bucci J, Gallagher S, Smart J, Grand M, Greer P, Keats S, Wilton L, Martin J. Phase 2 Multicenter Study of Gantry-Based Stereotactic Radiotherapy Boost for Intermediate and High Risk Prostate Cancer (PROMETHEUS). Front Oncol 2019; 9:217. [PMID: 31001481 PMCID: PMC6454110 DOI: 10.3389/fonc.2019.00217] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/12/2019] [Indexed: 12/17/2022] Open
Abstract
Objectives: To report feasibility, early toxicity, and PSA kinetics following gantry-based, stereotactic radiotherapy (SBRT) boost within a prospective, phase 2, multicenter study (PROMETHEUS: ACTRN12615000223538). Methods: Patients were treated with gantry-based SBRT, 19–20 Gy in two fractions delivered 1 week apart, followed by conventionally fractionated IMRT (46 Gy in 23 fractions). The study mandated MRI fusion for RT planning, rectal displacement, and intrafraction image guidance. Toxicity was prospectively graded using the Common Terminology Criteria for Adverse Events version 4.0 (CTCAE v4). Results: Between March 2014 and July 2018, 135 patients (76% intermediate, 24% high-risk) with a median age of 70 years (range 53–81) were treated across five centers. Short course (≤6 months) androgen deprivation therapy (ADT) was used in 36% and long course in 18%. Rectal displacement method was SpaceOAR in 59% and Rectafix in 41%. Forty-two and ninety-three patients were treated at the 19 Gy and 20 Gy dose levels, respectively. Median follow-up was 24 months. Acute grade 2 gastrointestinal (GI) and urinary toxicity occurred in 4.4 and 26.6% with no acute grade 3 toxicity. At 6, 12, 18, 24, and 36 months post-treatment the prevalence of late grade ≥2 gastrointestinal toxicity was 1.6, 3.7, 2.2, 0, and 0%, respectively, and the prevalence of late grade ≥2 urinary toxicity was 0.8, 11, 12, 7.1, and 6.3%, respectively. Three patients experienced grade 3 late toxicity at 12 to 18 months which subsequently resolved to grade 2 or less. For patients not receiving ADT the median PSA value pre-treatment was 7.6 ug/L (1.1–20) and at 12, 24, and 36 months post-treatment was 0.86, 0.36, and 0.20 ug/L. Conclusions: Delivery of a gantry-based SBRT boost is feasible in a multicenter setting, is well-tolerated with low rates of early toxicity and is associated with promising PSA responses. A second transient peak in urinary toxicity was observed at 18 months which subsequently resolved. Follow-up is ongoing to document late toxicity, long-term patient reported outcomes, and tumor control with this approach.
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Affiliation(s)
- David Pryor
- Princess Alexandra Hospital, Brisbane, QLD, Australia.,Queensland University of Technology, Brisbane, QLD, Australia
| | - Mark Sidhom
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
| | - Sankar Arumugam
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia.,Ingham Institute, Sydney, NSW, Australia
| | - Joseph Bucci
- University of New South Wales, Sydney, NSW, Australia.,St George Hospital, Cancer Care Centre, Sydney, NSW, Australia
| | - Sarah Gallagher
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
| | - Joanne Smart
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
| | - Melissa Grand
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia.,Ingham Institute, Sydney, NSW, Australia
| | - Peter Greer
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia.,University of Newcastle, Newcastle, NSW, Australia
| | - Sarah Keats
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, NSW, Australia
| | - Lee Wilton
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
| | - Jarad Martin
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia.,University of Newcastle, Newcastle, NSW, Australia
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Affiliation(s)
- Jarad Martin
- Jarad Martin, PhD, MD, University of Newcastle, Newcastle, New South Wales, Australia; Himu Lukka, MBBCh, McMaster University Hamilton, Ontario, Canada; and Charles Catton, MD, University of Toronto, Toronto, Ontario, Canada
| | - Himu Lukka
- Jarad Martin, PhD, MD, University of Newcastle, Newcastle, New South Wales, Australia; Himu Lukka, MBBCh, McMaster University Hamilton, Ontario, Canada; and Charles Catton, MD, University of Toronto, Toronto, Ontario, Canada
| | - Charles Catton
- Jarad Martin, PhD, MD, University of Newcastle, Newcastle, New South Wales, Australia; Himu Lukka, MBBCh, McMaster University Hamilton, Ontario, Canada; and Charles Catton, MD, University of Toronto, Toronto, Ontario, Canada
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