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Swensen S, Liao JJ, Chen JJ, Kim K, Ma TM, Weg ES. The expanding role of radiation oncology across the prostate cancer continuum. Abdom Radiol (NY) 2024; 49:2693-2705. [PMID: 38900319 DOI: 10.1007/s00261-024-04408-3] [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: 03/31/2024] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024]
Abstract
Radiotherapy is used in the treatment of prostate cancer in a variety of disease states with significant reliance on imaging to guide clinical decision-making and radiation delivery. In the definitive setting, the choice of radiotherapy treatment modality, dose, and fractionation for localized prostate cancer is determined by the patient's initial risk stratification and other clinical considerations. Radiation is also an option as salvage therapy in patients with locoregionally recurrent disease after prior definitive radiation or surgery. In recent years, the role of radiation has expanded for patients with metastatic disease, including prostate-directed radiotherapy in de novo low volume metastatic disease, metastasis-directed therapy for oligorecurrent disease, and palliative management of symptomatic metastases in the advanced setting. Here we review the expanding role of radiation in the treatment of prostate cancer in the definitive, locoregionally recurrent, and metastatic settings, as well as highlight the role of imaging in clinical reasoning, radiation planning, and treatment delivery.
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Affiliation(s)
- Sasha Swensen
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Jay J Liao
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Jonathan J Chen
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Katherine Kim
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Ting Martin Ma
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Emily S Weg
- Department of Radiation Oncology, University of Washington, Fred Hutchinson Cancer Center, 1959 NE Pacific St, Seattle, WA, 98195, USA.
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2
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Takano S, Tomita N, Niwa M, Torii A, Takaoka T, Kita N, Uchiyama K, Nakanishi-Imai M, Ayakawa S, Iida M, Tsuzuki Y, Otsuka S, Manabe Y, Nomura K, Ogawa Y, Miyakawa A, Miyamoto A, Takemoto S, Yasui T, Hiwatashi A. Impact of radiation doses on clinical relapse of biochemically recurrent prostate cancer after prostatectomy. Sci Rep 2024; 14:113. [PMID: 38167430 PMCID: PMC10761985 DOI: 10.1038/s41598-023-50434-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
The relationship between radiation doses and clinical relapse in patients receiving salvage radiotherapy (SRT) for biochemical recurrence (BCR) after radical prostatectomy (RP) remains unclear. We identified 292 eligible patients treated with SRT between 2005 and 2018 at 15 institutions. Clinical relapse-free survival (cRFS) between the ≥ 66 Gy (n = 226) and < 66 Gy groups (n = 66) were compared using the Log-rank test, followed by univariate and multivariate analyses and a subgroup analysis. After a median follow-up of 73 months, 6-year biochemical relapse-free survival, cRFS, cancer-specific survival, and overall survival rates were 58, 92, 98, and 94%, respectively. Six-year cRFS rates in the ≥ 66 Gy and < 66 Gy groups were 94 and 87%, respectively (p = 0.022). The multivariate analysis revealed that Gleason score ≥ 8, seminal vesicle involvement, PSA at BCR after RP ≥ 0.5 ng/ml, and a dose < 66 Gy correlated with clinical relapse (p = 0.015, 0.012, 0.024, and 0.0018, respectively). The subgroup analysis showed the consistent benefit of a dose ≥ 66 Gy in patients across most subgroups. Doses ≥ 66 Gy were found to significantly, albeit borderline, increase the risk of late grade ≥ 2 GU toxicity compared to doses < 66 Gy (14% vs. 3.2%, p = 0.055). This large multi-institutional retrospective study demonstrated that a higher SRT dose (≥ 66 Gy) resulted in superior cRFS.
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Affiliation(s)
- Seiya Takano
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Natsuo Tomita
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan.
| | - Masanari Niwa
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Akira Torii
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Taiki Takaoka
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Nozomi Kita
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Kaoru Uchiyama
- Department of Radiology, Kariya Toyota General Hospital, 5-15 Sumiyoshi-Cho, Kariya, Aichi, 448-8505, Japan
| | - Mikiko Nakanishi-Imai
- Department of Radiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myoken-Cho, Showa-Ku, Nagoya, Aichi, 466-8650, Japan
| | - Shiho Ayakawa
- Department of Radiology, Japan Community Health Care Organization Chukyo Hospital, 1-1-10 Sanjo, Minami-Ku, Nagoya, Aichi, 457-8510, Japan
| | - Masato Iida
- Department of Radiation Oncology, Suzuka General Hospital, 1275-53 Yamanoue, Yasuzuka-Cho, Suzuka, Mie, 513-0818, Japan
| | - Yusuke Tsuzuki
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, 1-1-1 Hirate-Cho, Kita-Ku, Nagoya, Aichi, 462-8508, Japan
| | - Shinya Otsuka
- Department of Radiology, Okazaki City Hospital, 3-1 Goshoai, Koryuji-Cho, Okazaki, Aichi, 444-8553, Japan
| | - Yoshihiko Manabe
- Department of Radiation Oncology, Nanbu Tokushukai General Hospital, 171-1 Hokama, Yaese-Cho, Shimajiri, Okinawa, 901-0493, Japan
| | - Kento Nomura
- Department of Radiotherapy, Nagoya City West Medical Center, 1-1-1 Hirate-Cho, Kita-Ku, Nagoya, Aichi, 462-8508, Japan
| | - Yasutaka Ogawa
- Department of Radiation Oncology, Kasugai Municipal Hospital, 1-1-1 Takaki-Cho, Kasugai, Aichi, 486-8510, Japan
| | - Akifumi Miyakawa
- Department of Radiation Oncology, National Hospital Organization Nagoya Medical Center, 4-1-1, Sannomaru, Naka-Ku, Nagoya, Aichi, 460-0001, Japan
| | - Akihiko Miyamoto
- Department of Radiation Oncology, Hokuto Hospital, 7-5 Kisen, Inada-Cho, Obihiro, Hokkaido, 080-0833, Japan
| | - Shinya Takemoto
- Department of Radiation Oncology, Fujieda Heisei Memorial Hospital, 123-1 Mizukami-Cho, Fujieda, Shizuoka, 426-8662, Japan
| | - Takahiro Yasui
- Department of Urology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
| | - Akio Hiwatashi
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, Aichi, 467-8601, Japan
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Le Guevelou J, Magne N, Counago F, Magsanoc JM, Vermeille M, De Crevoisier R, Benziane-Ouaritini N, Ost P, Niazi T, Supiot S, Sargos P. Stereotactic body radiation therapy after radical prostatectomy: current status and future directions. World J Urol 2023; 41:3333-3344. [PMID: 37725131 DOI: 10.1007/s00345-023-04605-7] [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: 07/18/2023] [Accepted: 08/28/2023] [Indexed: 09/21/2023] Open
Abstract
PURPOSE Around 40% of men with intermediate-risk or high-risk prostate cancer will experience a biochemical recurrence after radical prostatectomy (RP). The aim of this review is to describe both toxicity and oncological outcomes following stereotactic body radiation therapy (SBRT) delivered to the prostate bed (PB). METHOD In april 2023, we performed a systematic review of studies published in MEDLINE or ClinicalTrials.gov according to Preferred Reporting Items for Systematic Reviews, using the keywords "stereotactic radiotherapy" AND "postoperative" AND "prostate cancer". RESULTS A total of 14 studies assessing either adjuvant or salvage SBRT to the whole PB or macroscopic local recurrence (MLR) within the PB, and SBRT on radiorecurrent MLR within the PB were included. Doses delivered to either whole PB or MLR between 30 to 40 Gy are associated with a low rate of late grade ≥ 2 genitourinary (GU) toxicity, ranging from 2.2 to 15.1%. Doses above 40 Gy are associated with increased rate of late GU toxicity, raising up to 38%. Oncological outcomes should be interpreted with caution, due to both short follow-up, heterogeneous populations and androgen deprivation therapy (ADT) use. CONCLUSION PB or MLR SBRT delivered at doses up to 40 Gy appears safe with relatively low late severe GU toxicity rates. Caution is needed with dose-escalated RT schedules above 40 Gy. Further prospective trials are eagerly awaited in this disease setting.
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Affiliation(s)
| | - Nicolas Magne
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
| | - Felipe Counago
- Radiation Oncology Department, GenesisCare Madrid Clinical Director, San Francisco de Asis and La Milagrosa Hospitals, National Chair of Research and Clinical Trials, GenesisCare, Madrid, Spain
| | | | - Matthieu Vermeille
- Radiation Oncology Department, Genolier Swiss Radio-Oncology Network, Genolier, Switzerland
| | | | | | - Piet Ost
- Radiation Oncology Department, Iridium Network, Antwerp, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Tamim Niazi
- Department of Radiation Oncology, Jewish General Hospital, Montreal, QC, Canada
| | - Stéphane Supiot
- Radiation Oncology Department, Institut de Cancérologie de L'Ouest, Nantes, France
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France.
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Benziane-Ouaritini N, Zilli T, Giraud A, Ingrosso G, Di Staso M, Trippa F, Pommier P, Meyer E, Francolini G, Schick U, Pasquier D, Marc Cosset J, Magne N, Martin E, Gnep K, Renard-Penna R, Anger E, Achard V, Giraud N, Aristei C, Ferrari V, Pasquier C, Zaine H, Osman O, Detti B, Perennec T, Mihoci I, Supiot S, Latorzeff I, Sargos P. Prostatectomy Bed Image-guided Dose-escalated Salvage Radiotherapy (SPIDER): An International Multicenter Retrospective Study. Eur Urol Oncol 2023:S2588-9311(23)00067-6. [PMID: 37059627 DOI: 10.1016/j.euo.2023.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 02/13/2023] [Accepted: 02/22/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Management of macroscopic local recurrence (MLR) after radical prostatectomy is a challenging situation with no standardized approach. OBJECTIVE The objective of our study was to assess the efficacy and safety of functional image-guided salvage radiotherapy (SRT) in patients with MLR in the prostate bed. DESIGN, SETTING, AND PARTICIPANTS In this international multicenter retrospective study across 16 European centers, eligible patients were initially treated by radical prostatectomy (RP) with or without pelvic lymph node dissection for localized or locally advanced adenocarcinoma of the prostate. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Prostate-specific antigen (PSA) measured 4 wk after RP was <0.1 ng/ml. All patients presented a biochemical relapse after RP defined by an increase in PSA level of ≥0.2 ng/ml on two successive measures. Only patients with an MLR lesion in the prostatectomy bed visualized on functional imaging (multiparametric magnetic resonance imaging, positron emission tomography/computed tomography [PET/CT] choline, or PET/CT prostate-specific membrane antigen) were eligible. Patients with lymph node, bone, or visceral dissemination at restaging imaging (CT and/or bone scintigraphy and/or magnetic resonance imaging and/or PET) were excluded. Dose escalation was defined as a dose of >66 Gy prescribed to the prostate bed or to MLR. Toxicities were classified using the Common Terminology Criteria for Adverse Events scale, version 4.03. The primary endpoint was progression-free survival (PFS). Secondary outcomes were metastasis-free survival (MPFS), biochemical progression-free survival, and overall survival. Genitourinary (GU) and gastrointestinal (GI) toxicities were analyzed. RESULTS AND LIMITATIONS Between January 2000 and December 2019, 310 patients received at least one dose escalation on MLR and 25 patients did not receive any dose escalation. The median PSA level before SRT was 0.63 ng/ml (interquartile range [IQR], 0.27-1.7). The median follow-up was 54 mo (IQR, 50-56). Five-year PFS and MPFS were 70% (95% confidence interval [CI]: [64; 75]) and 84% (95% CI: [78; 88]), respectively. Grade ≥2 GU and GI late toxicities were observed in 43 (12%) and 11 (3%) patients, respectively. When the prescribed dose on the MLR lesion was ≥72 Gy, an improvement in 5-yr PFS was found for patients received at least one dose escalation (73% [95% CI: 65-79]) vs 60% [95% CI: 48; 70]; p = 0.03). CONCLUSIONS In this contemporary study integrating functional imaging data, we found potential efficacy of SRT with dose escalation ≥72 Gy for patients with MLR in the prostate bed and with an acceptable toxicity profile. Prospective data exploring this MLR dose escalation strategy are awaited. PATIENT SUMMARY In this report, we looked at the outcomes from salvage radiotherapy for prostate cancer and macroscopic relapse in a large European population. We found that outcomes varied with prostate-specific antigen at relapse, Gleason score, and dose escalation. We found potential efficacy of salvage radiotherapy with dose escalation for macroscopic relapse in the prostate bed, with an acceptable toxicity profile.
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Affiliation(s)
| | - Thomas Zilli
- Department of Radiotherapy, University of Geneva, Geneva, Switzerland
| | - Antoine Giraud
- Department of Radiotherapy, Bergonie Institute, Bordeaux, France
| | - Gianluca Ingrosso
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Mario Di Staso
- Department of Clinical Medicine Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Fabio Trippa
- Department of Radiotherapy, Saint Maria Hospital, Terni, Italy
| | - Pascal Pommier
- Department of Radiotherapy, Centre Léon Bérard, Lyon, France
| | - Emmanuel Meyer
- Department of Radiotherapy, Centre Francois Baclesse, Caen, France
| | | | - Ulrike Schick
- Department of Radiotherapy, Morvan Hospital Brest, France
| | - David Pasquier
- Department of Radiotherapy, Oscar Lambret Cancer Centre, Lille, France
| | | | - Nicolas Magne
- Department of Radiotherapy, St Etienne University, St Etienne, France
| | - Etienne Martin
- Department of Radiotherapy, Georges-François Leclerc Centre, Dijon, France
| | - Kémara Gnep
- Department of Radiotherapy, Eugene Marquis Cancer Institute, Rennes, France
| | - Raphaelle Renard-Penna
- Department of Radiology, Sorbonne University, AP-HP, Hopital Pitié-Salpétrière Hospital, Paris, France
| | - Ewen Anger
- Department of Radiotherapy, Eugene Marquis Cancer Institute, Rennes, France
| | - Vérane Achard
- Department of Radiotherapy, University of Geneva, Geneva, Switzerland
| | - Nicolas Giraud
- Department of Radiotherapy, Bergonie Institute, Bordeaux, France
| | | | - Victoria Ferrari
- Department of Medical Oncology, Antoine-Lacassagne Centre, Nice, France
| | - Corentin Pasquier
- Department of Radiotherapy, University Hospital Centre Toulouse, Toulouse, France
| | - Hind Zaine
- Department of Radiotherapy, Oscar Lambret Cancer Centre, Lille, France
| | - Osman Osman
- Department of Radiotherapy, Centre Léon Bérard, Lyon, France
| | | | - Tanguy Perennec
- Department of Radiotherapy, Institute of Cancer Research Western France, St Herblain, France
| | - Inga Mihoci
- Department of Clinical Medicine Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Stéphane Supiot
- Department of Radiotherapy, Institute of Cancer Research Western France, St Herblain, France
| | - Igor Latorzeff
- Department of Radiotherapy, Pasteur Clinic, Toulouse, France
| | - Paul Sargos
- Department of Radiotherapy, Bergonie Institute, Bordeaux, France.
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Padayachee J, Chaudhary S, Shim B, So J, Lim R, Raman S. Utilizing clinical, pathological and radiological information to guide postoperative radiotherapy in prostate cancer. Expert Rev Anticancer Ther 2023; 23:293-305. [PMID: 36795862 DOI: 10.1080/14737140.2023.2181795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
INTRODUCTION A detectable and rising PSA following radical prostatectomy is indicative of recurrent prostate cancer. Salvage radiotherapy (SRT) with/without androgen deprivation therapy represents the main treatment option for these patients and has been historically associated with a biochemical control rate of ~70%. To determine the optimal timing, diagnostic workup, radiotherapy dosefractionation, treatment volume, and use of systemic therapy, several informative studies have been conducted in the last decade. AREAS COVERED This review examines the recent evidence to guide radiotherapy decision making in the SRT setting. Key topics include adjuvant vs salvage RT, utilization of molecular imaging and genomic classifiers, length of androgen deprivation therapy, inclusion of elective pelvic volume, and emerging role for hypofractionation. EXPERT OPINION Recently reported trials, conducted in an era prior to the routine use of molecular imaging and genomic classifiers, have been pivotal in establishing the current standard of care for SRT in prostate cancer. However, decisions about radiation treatment and systemic therapy may be tailored based on available prognostic and predictive biomarkers. Data from contemporary clinical trials are awaited to define and establish individualized, biomarker-driven approaches for SRT.
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Affiliation(s)
- Jerusha Padayachee
- Department of Radiation Oncology, Auckland City Hospital, Auckland, New Zealand
| | - Simone Chaudhary
- Princess Margaret Hospital Cancer Centre, Radiation Medicine Program, Toronto, ON, Canada
| | - Brian Shim
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jonathan So
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Remy Lim
- Mercy PET/CT Epsom, Auckland, New Zealand.,Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Srinivas Raman
- Princess Margaret Hospital Cancer Centre, Radiation Medicine Program, Toronto, ON, Canada
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6
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Liu J, Dong L, Zhu Y, Dong B, Sha J, Zhu HH, Pan J, Xue W. Prostate cancer treatment - China's perspective. Cancer Lett 2022; 550:215927. [PMID: 36162714 DOI: 10.1016/j.canlet.2022.215927] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 09/07/2022] [Accepted: 09/21/2022] [Indexed: 11/02/2022]
Abstract
Prostate cancer (PCa) incidence and mortality have rapidly increased in China. Notably, unique epidemiological characteristics of PCa are found in the Chinese PCa population, including a low but rising incidence and an inferior but improving disease prognosis. Consequently, the current treatment landscape of PCa in China demonstrates distinct features. Establishing a more thorough understanding of the characteristics of Chinese patients may help provide novel insights into potential treatment strategies for PCa patients. Herein, we review the epidemiological status and differences in treatment modalities of Chinese PCa patients. In addition, we discuss the underlying socioeconomic and biological factors that contribute to such diversity and further propose directions for future efforts in optimizing the PCa treatment in China.
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Affiliation(s)
- Jiazhou Liu
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Liang Dong
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Yinjie Zhu
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Baijun Dong
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Jianjun Sha
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Helen He Zhu
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China; State Key Laboratory of Oncogenes and Related Genes, Renji-Med-X Stem Cell Research Center, Department of Urology, Ren Ji Hospital, School of Medicine and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Jiahua Pan
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China.
| | - Wei Xue
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China.
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7
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Bottero M, Faiella A, Giannarelli D, Farneti A, D'Urso P, Bertini L, Landoni V, Vici P, Sanguineti G. A prospective study assessing the pattern of response of local disease at DCE-MRI after salvage radiotherapy for prostate cancer. Clin Transl Radiat Oncol 2022; 35:21-26. [PMID: 35516461 PMCID: PMC9065465 DOI: 10.1016/j.ctro.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/18/2022] [Accepted: 04/25/2022] [Indexed: 10/29/2022] Open
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8
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Lasserre M, Sargos P, Barret E, Beauval JB, Brureau L, Créhange G, Dariane C, Fiard G, Fromont G, Mathieu R, Renard-Penna R, Roubaud G, Ruffion A, Rouprêt M, Ploussard G, Gauthé M. Narrative review of PET/CT performances at biochemical recurrence in prostate cancer after radical prostatectomy and impact on patient disease management: Revue narrative à propos des performances de la TEP/TDM en cas de récidive biochimique après prostatectomie radicale dans le cancer de la prostate et impact sur la prise en charge des patients. Prog Urol 2022; 32:6S33-6S42. [PMID: 36719645 DOI: 10.1016/s1166-7087(22)00173-7] [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] [Indexed: 02/03/2023]
Abstract
Patients treated by radical prostatectomy (RP) for localized prostate cancer (PCa) may experience biochemical recurrence (BCR) in approximately 30% of cases. Recently, advances in imaging modalities and in particular Positron-Emission Tomography with computed tomography (PET/CT) imaging allow for better detection and characterization of lesions outside the prostatic bed at recurrence. Thus, treatment at BCR can be significantly improved by a tailored strategy based on new generation imaging. A more precise and accurate staging of the disease at recurrence paves the way to more appropriate treatment, potentially translating into better survival outcomes of these patients. This review therefore highlights the interest of PET/CT at the time of BCR, its superiority over standard imaging in terms of staging, and its impact on guiding the different therapeutic possibilities depending on the site, number, and volumes of recurrence. Indeed, we will discuss below about different strategies and their indications: salvage radiotherapy of the prostate bed, systemic therapies, stereotactic body radiotherapy and others therapeutical strategies. The various innovative approaches based on PET/CT implementation are partly underway within protocol trials to prove their benefits on clinically meaningful endpoints. © 2022 Elsevier Masson SAS. All rights reserved.
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Affiliation(s)
- M Lasserre
- Department of Medical oncology, Institut Bergonié, Bordeaux
| | - P Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux.
| | - E Barret
- Department of Urology, Institut Mutualiste Montsouris, 75014 Paris
| | - J-B Beauval
- Department of Urology, La Croix du Sud Hospital, 31445 Quint Fonsegrives, France
| | - L Brureau
- Department of Urology, CHU de Pointe-à-Pitre, University of Antilles, Inserm, EHESP, Irset-UMR_S 1085, 97110 Pointe-à-Pitre, France
| | - G Créhange
- Department of Radiation Oncology Curie Institute, 75005 Paris
| | - C Dariane
- Department of Urology, Hôpital européen Georges-Pompidou, APHP, Paris-Paris University-U1151 Inserm-INEM, Necker, 75015 Paris
| | - G Fiard
- Department of Urology, Grenoble Alpes University Hospital, Université Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, 38000 Grenoble, France
| | - G Fromont
- Department of Pathology, CHRU, 37000 Tours, France
| | - R Mathieu
- Department of Urology, CHU Rennes, 35000 Rennes, France
| | - R Renard-Penna
- Radiology, Pitie-Salpetriere Hospital, Sorbonne University, AP-HP, 75013 Paris, France
| | - G Roubaud
- Department of Medical oncology, Institut Bergonié, Bordeaux
| | - A Ruffion
- Service d'urologie Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Equipe 2 - Centre d'Innovation en cancérologie de Lyon (EA 3738 CICLY) - Faculté de médecine Lyon Sud - Université Lyon 1, 69000 Lyon, France
| | - M Rouprêt
- GRC 5 Predictive Onco-Uro, Urology, Pitie-Salpetriere Hospital, Sorbonne University, AP-HP, 75013 Paris
| | - G Ploussard
- Department of Urology, La Croix du Sud Hospital, 31445 Quint Fonsegrives, France; Department of Urology, CHU de Pointe-à-Pitre, University of Antilles, Inserm, EHESP, Irset-UMR_S 1085, 97110 Pointe-à-Pitre, France; Department of Radiation Oncology Curie Institute, 75005 Paris; Department of Urology, Hôpital européen Georges-Pompidou, APHP, Paris-Paris University-U1151 Inserm-INEM, Necker, 75015 Paris; Department of Urology, Grenoble Alpes University Hospital, Université Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, 38000 Grenoble, France; Department of Pathology, CHRU, 37000 Tours, France; Department of Urology, CHU Rennes, 35000 Rennes, France; Radiology, Pitie-Salpetriere Hospital, Sorbonne University, AP-HP, 75013 Paris, France; Service d'urologie Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Equipe 2 - Centre d'Innovation en cancérologie de Lyon (EA 3738 CICLY) - Faculté de médecine Lyon Sud - Université Lyon 1, 69000 Lyon, France; GRC 5 Predictive Onco-Uro, Urology, Pitie-Salpetriere Hospital, Sorbonne University, AP-HP, 75013 Paris; Institut Universitaire du Cancer Oncopole, 31000 Toulouse, France
| | - M Gauthé
- Department of Nuclear medicine, Scintep, 38000 Grenoble
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Pollack A, Karrison TG, Balogh AG, Gomella LG, Low DA, Bruner DW, Wefel JS, Martin AG, Michalski JM, Angyalfi SJ, Lukka H, Faria SL, Rodrigues GB, Beauchemin MC, Lee RJ, Seaward SA, Allen AM, Monitto DC, Seiferheld W, Sartor O, Feng F, Sandler HM. The addition of androgen deprivation therapy and pelvic lymph node treatment to prostate bed salvage radiotherapy (NRG Oncology/RTOG 0534 SPPORT): an international, multicentre, randomised phase 3 trial. Lancet 2022; 399:1886-1901. [PMID: 35569466 PMCID: PMC9819649 DOI: 10.1016/s0140-6736(21)01790-6] [Citation(s) in RCA: 115] [Impact Index Per Article: 57.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 07/02/2021] [Accepted: 07/29/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND In men with a detectable prostate-specific antigen (PSA) level after prostatectomy for prostate cancer, salvage prostate bed radiotherapy (PBRT) results in about 70% of patients being free of progression at 5 years. A three-group randomised trial was designed to determine whether incremental gains in patient outcomes can be achieved by adding either 4-6 months of short-term androgen deprivation therapy (ADT) to PBRT, or both short-term ADT and pelvic lymph node radiotherapy (PLNRT) to PBRT. METHODS The international, multicentre, randomised, controlled SPPORT trial was done at 283 radiation oncology cancer treatment centres in the USA, Canada, and Israel. Eligible patients (aged ≥18 years) were those who after prostatectomy for adenocarcinoma of the prostate had a persistently detectable or an initially undetectable and rising PSA of between 0·1 and 2·0 ng/mL. Patients with and without lymphadenectomy (N0/Nx) were eligible if there was no clinical or pathological evidence of lymph node involvement. Other eligibility criteria included pT2 or pT3 disease, prostatectomy Gleason score of 9 or less, and a Zubrod performance status of 0-1. Eligible patients were randomly assigned to receive PBRT alone at a dose of 64·8-70·2 Gy at 1·8 Gy per fraction daily (group 1), PBRT plus short-term ADT (group 2), or PLNRT (45 Gy at 1·8 Gy per fraction, and then a volume reduction made to the planning target volume for the remaining 19·8-25 ·2 Gy) plus PBRT plus short-term ADT (group 3). The primary endpoint was freedom from progression, in which progression was defined as biochemical failure according to the Phoenix definition (PSA ≥2 ng/mL over the nadir PSA), clinical failure (local, regional, or distant), or death from any cause. A planned interim analysis of 1191 patents with minimum potential follow-up time of 5 years applied a Haybittle-Peto boundary of p<0·001 (one sided) for comparison of 5-year freedom from progression rates between the treatment groups. This trial is registered with ClinicalTrials.gov, NCT00567580. The primary objectives of the trial have been completed, although long-term follow-up is continuing. FINDINGS Between March 31, 2008, and March 30, 2015, 1792 eligible patients were enrolled and randomly assigned to the three treatment groups (592 to group 1 [PBRT alone], 602 to group 2 [PBRT plus short-term ADT], and 598 to group 3 [PLNRT plus PBRT plus short-term ADT]). 76 patients subsequently found to be ineligible were excluded from the analyses; thus, the evaluable patient population comprised 1716 patients. At the interim analysis (n=1191 patients; data cutoff May 23, 2018), the Haybittle-Peto boundary for 5-year freedom from progression was exceeded when group 1 was compared with group 3 (difference 17·9%, SE 2·9%; p<0·0001). The difference between groups 2 and 3 did not exceed the boundary (p=0·0063). With additional follow-up beyond the interim analysis (the final planned analysis; data cutoff May 26, 2021), at a median follow-up among survivors of 8·2 years (IQR 6·6-9·4), the 5-year freedom from progression rates in all 1716 eligible patients were 70·9% (95% CI 67·0-74·9) in group 1, 81·3% (78·0-84·6) in group 2, and 87·4% (84·7-90·2) in group 3. Per protocol criteria, freedom from progression in group 3 was superior to groups 1 and 2. Acute (≤3 months after radiotherapy) grade 2 or worse adverse events were significantly more common in group 3 (246 [44%] of 563 patients) than in group 2 (201 [36%] of 563; p=0·0034), which, in turn, were more common than in group 1 (98 [18%] of 547; p<0·0001). Similar findings were observed for grade 3 or worse adverse events. However, late toxicity (>3 months after radiotherapy) did not differ significantly between the groups, apart from more late grade 2 or worse blood or bone marrow events in group 3 versus group 2 (one-sided p=0·0060) attributable to the addition of PLNRT in this group. INTERPRETATION The results of this randomised trial establish the benefit of adding short-term ADT to PBRT to prevent progression in prostate cancer. To our knowledge, these are the first such findings to show that extending salvage radiotherapy to treat the pelvic lymph nodes when combined with short-term ADT results in meaningful reductions in progression after prostatectomy in patients with prostate cancer. FUNDING National Cancer Institute.
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Affiliation(s)
- Alan Pollack
- Department of Radiation Oncology, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA.
| | - Theodore G Karrison
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA; NRG Oncology, Philadelphia, PA, USA
| | | | - Leonard G Gomella
- Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel A Low
- Department of Radiation Oncology, University of California at Los Angeles, Los Angeles, CA, USA
| | - Deborah W Bruner
- Nell Hodgson Woodruff School of Nursing, and Winship Cancer Institute at Emory University, Atlanta, GA, USA
| | - Jeffrey S Wefel
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andre-Guy Martin
- CHU de Quebec-Université Laval (L'Hotel-Dieu de Quebec), Quebec, QC, Canada
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - Steve J Angyalfi
- Tom Baker Cancer Center, University of Calgary, Calgary, AB, Canada
| | - Himanshu Lukka
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - George B Rodrigues
- Department of Oncology, London Regional Cancer Program, Western University, London, ON, Canada
| | - Marie-Claude Beauchemin
- Department of Radiation Oncology, CHUM-Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - R Jeffrey Lee
- Intermountain Medical Center, Salt Lake City, UT, USA
| | | | - Aaron M Allen
- Davidoff Center, Rabin Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Drew C Monitto
- Spartanburg Regional Medical Center, Spartanburg, SC, USA
| | | | - Oliver Sartor
- Department of Medicine, Tulane University, New Orleans, LA, USA
| | - Felix Feng
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, CA , USA
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Lengana T, Lawal I, Janse Van Rensburg C, Mokoala K, Moshokoa E, Mazibuko S, Van de Wiele C, Maes A, Vorster M, Sathekge MM. The Diagnostic Performance of 18F-PSMA-1007 PET/CT in Prostate Cancer Patients with Early Recurrence after Definitive Therapy with a PSA <10 ng/ml. Nuklearmedizin 2022; 61:120-129. [PMID: 35421900 DOI: 10.1055/a-1759-1603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AIM The prostate bed is one of the common sites of early recurrence of prostate cancer. The currently used PSMA ligands (68Ga-PSMA-11 and 99mTc-PSMA) undergo early urinary clearance resulting in interfering physiological activity within and surrounding the prostate. This can result in sites of cancer recurrence being obscured. 18F-PSMA-1007 has an advantage of delayed urinary clearance thus the prostate region is reviewed without any interfering physiological activity. The aim of this study was to determine the diagnostic performance of 18F-PSMA-1007 PET/CT in patients with early biochemical recurrence after definitive therapy. METHODS Forty-six Prostate cancer (mean age 66.7±7.5, range 48-87 years) presenting with biochemical recurrence (median PSA 1.6ng/ml, range 0.1-10.0) underwent non-contrast-enhanced 18F-PSMA-1007 PET/CT. PET/CT findings were evaluated qualitatively and semiquantitatively (SUVmax) and compared to the results of histology, Gleason grade, and conventional imaging. RESULTS Twenty-four of the 46 (52.2%) patients demonstrated a site of recurrence on 18F-PSMA-1007 PET/CT. Oligometastatic disease was detected in 15 (32.6%) of these patients. Of these 10 (37.5%) demonstrated intra-prostatic recurrence, lymph node disease was noted in 11 (45.8%) whilst two patients demonstrated skeletal metastases. The detection rates for PSA levels 0-<0.5, 0.5-<1, 1-2, >2 were 31.3%, 33.3%, 55.6% and 72.2% respectively. 7 (29.2%) of the positive patients had been described as negative or equivocal on conventional imaging. An optimal PSA cut-off level of 1.3ng/ml was found. CONCLUSION 18F-PSMA-1007 demonstrated good diagnostic performance detecting sites of recurrence. Its ability to detect sites of recurrence in the setting of early biochemical recurrence will have a significant impact on patient management.
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Affiliation(s)
- Thabo Lengana
- Nuclear Medicine, University of Pretoria, Pretoria, South Africa
| | - Ismaheel Lawal
- Nuclear Medicine, University of Pretoria, Pretoria, South Africa
| | - Charl Janse Van Rensburg
- Biostatistics Unit, Pretoria MRC, South African Medical Research Council, Pretoria, South Africa
| | - Kgomotso Mokoala
- Nuclear Medicine, University of Pretoria, Pretoria, South Africa
| | | | | | - Christophe Van de Wiele
- Nuclear Medicine, Universiteit Gent Faculteit Geneeskunde en Gezondheidswetenschappen, Gent, Belgium
| | - Alex Maes
- Department Nuclear Medicine, University Hospital Leuven, Kortrijk, Belgium
| | - Mariza Vorster
- Nuclear Medicine, University of Pretoria, Pretoria, South Africa
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11
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Staal FHE, Janssen J, Brouwer CL, Langendijk JA, Ng Wei Siang K, Schuit E, de Jong IJ, Verzijlbergen JF, Smeenk RJ, Aluwini S. Phase III randomised controlled trial on PSMA PET/CT guided hypofractionated salvage prostate bed radiotherapy of biochemical failure after radical prostatectomy for prostate cancer (PERYTON-trial): study protocol. BMC Cancer 2022; 22:416. [PMID: 35428210 PMCID: PMC9013125 DOI: 10.1186/s12885-022-09493-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background Salvage external beam radiotherapy (sEBRT) for patients with a biochemical recurrence (BCR) after radical prostatectomy provides a 5-year biochemical progression-free survival up to 60%. Multiple studies have shown that dose escalation to the primary prostate tumour improves treatment outcome. However, data is lacking on the role of dose escalation in the recurrent salvage setting. The main objective of the PERYTON-trial is to investigate whether treatment outcome of sEBRT for patients with a BCR after prostatectomy can be improved by increasing the biological effective radiation dose using hypofractionation. Moreover, patients will be staged using the PSMA PET/CT scan, which is superior to conventional imaging modalities in detecting oligometastases. Methods The PERYTON-study is a prospective multicentre open phase III randomised controlled trial. We aim to include 538 participants (269 participants per treatment arm) with a BCR after prostatectomy, a PSA-value of < 1.0 ng/mL and a recent negative PSMA PET/CT scan. Participants will be randomised in a 1:1 ratio between the conventional fractionated treatment arm (35 × 2 Gy) and the experimental hypofractionated treatment arm (20 × 3 Gy). The primary endpoint is the 5-year progression-free survival after treatment. The secondary endpoints include toxicity, quality of life and disease specific survival. Discussion Firstly, the high rate of BCR after sEBRT may be due to the presence of oligometastases, for which local sEBRT is inappropriate. With the use of the PSMA PET/CT before sEBRT, patients with oligometastases will be excluded from intensive local treatment to avoid unnecessary toxicity. Secondly, the currently applied radiation dose for sEBRT may be too low to achieve adequate local control, which may offer opportunity to enhance treatment outcome of sEBRT by increasing the biologically effective radiotherapy dose to the prostate bed. Trial registration This study is registered at ClinicalTrials.gov (Identifier: NCT04642027). Registered on 24 November 2020 – Retrospectively registered. The study protocol was approved by the accredited Medical Ethical Committee (METc) of all participating hospitals (date METc review: 23-06-2020, METc registration number: 202000239). Written informed consent will be obtained from all participants. • This is the first PSMA PET/CT based study addressing the role of hypofractionation in salvage external beam radiation therapy (sEBRT); • Participants will be randomised 1:1 to conventional fractionated sEBRT (35 × 2 Gy) or hypofractionated sEBRT (20 × 3 Gy); • The PSMA PET/CT-scan will be used for staging of all participants at baseline; • The primary endpoint is 5-year progression-free survival after treatment; • All participants will receive early sEBRT (PSA < 1.0 ng/mL) without the use of androgen deprivation therapy; • A quality assurance program was undertaken, to ensure protocol compliance within the PERYTON-trial; • An interim analysis will be performed after the inclusion of 25% (n = 135) of the total number of required participants, to identify any early signs of excessive (unexpected) acute toxicity.
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12
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Wang S, Tang W, Luo H, Jin F, Wang Y. Efficacy and Toxicity of Whole Pelvic Radiotherapy Versus Prostate-Only Radiotherapy in Localized Prostate Cancer: A Systematic Review and Meta-Analysis. Front Oncol 2022; 11:796907. [PMID: 35155197 PMCID: PMC8828576 DOI: 10.3389/fonc.2021.796907] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/31/2021] [Indexed: 01/10/2023] Open
Abstract
Background There is little level 1 evidence regarding the relative efficacy and toxicity of whole pelvic radiotherapy (WPRT) compared with prostate-only radiotherapy (PORT) for localized prostate cancer. Methods We used Cochrane, PubMed, Embase, Medline databases, and ClinicalTrials.gov to systematically search for all relevant clinical studies. The data on efficacy and toxicity were extracted for quality assessment and meta-analysis to quantify the effect of WPRT on biochemical failure-free survival (BFFS), progression-free survival (PFS), distant metastasis-free survival (DMFS), overall survival (OS), gastrointestinal (GI) toxicity, and genitourinary (GU) toxicity compared with PORT. The review is registered on PROSPERO, number: CRD42021254752. Results The results revealed that compared with PORT, WPRT significantly improved 5-year BFFS and PFS, and it was irrelevant to whether the patients had undergone radical prostatectomy (RP). In addition, for the patients who did not receive RP, the 5-year DMFS of WPRT was better than that of PORT. However, WPRT significantly increased not only the grade 2 or worse (G2+) acute GI toxicity of non-RP studies and RP studies, but also the G2+ late GI toxicity of non-RP studies. Subgroup analysis of non-RP studies found that, when the pelvic radiation dose was >49 Gy (equivalent-doses-in-2-Gy-fractions, EQD-2), WPRT was more beneficial to PFS than PORT, but significantly increased the risk of G2+ acute and late GU toxicity. Conclusions Meta-analysis demonstrates that WPRT can significantly improve BFFS and PFS for localized prostate cancer than PORT, but the increased risk of G2+ acute and late GI toxicity must be considered. Systematic Review Registration PROSPERO CRD42021254752.
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Affiliation(s)
- Shilin Wang
- Department of Radiation Oncology, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing, China
| | - Wen Tang
- Department of Rehabilitation, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Huanli Luo
- Department of Radiation Oncology, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing, China
| | - Fu Jin
- Department of Radiation Oncology, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing, China
| | - Ying Wang
- Department of Radiation Oncology, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing, China
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13
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Stone NN, Unger PD, Sheu R, Rosenstein BS, Stock RG. Factors associated with late local failure and its influence on survival in men undergoing prostate brachytherapy. Brachytherapy 2022; 21:460-467. [DOI: 10.1016/j.brachy.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 11/26/2021] [Accepted: 01/05/2022] [Indexed: 11/30/2022]
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14
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Management of patients with a persistently elevated PSA after radical prostatectomy: a narrative review. World J Urol 2022; 40:965-972. [PMID: 35024944 DOI: 10.1007/s00345-021-03923-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/28/2021] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION The management of the postoperative biological relapse of prostate cancer is most often based on salvage radiotherapy (SRT) with or without the addition of a variable duration of hormone therapy (HT). The indications for SRT +/- HT are established in the setting of a rising PSA level after a period where an undetectable PSA was achieved. However, in case of detectable PSA immediately after radical prostatectomy, the treatment options and prognosis are still unclear. MATERIALS AND METHODS We conducted a narrative review based on an analysis of the literature focusing on articles targeting the population of patients with postoperative persistently detectable PSA level. Case reports, original articles, clinical trials, and published reviews were studied for this purpose. CONCLUSION This article will describe current management of patients with detectable PSA immediately after radical prostatectomy, notably the contribution of modern imaging and new treatment options involving the combination of RT and HT.
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15
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Cailleteau A, Sargos P, Saad F, Latorzeff I, Supiot S. Drug Intensification in Future Postoperative Radiotherapy Practice in Biochemically-Relapsing Prostate Cancer Patients. Front Oncol 2021; 11:780507. [PMID: 35004302 PMCID: PMC8739777 DOI: 10.3389/fonc.2021.780507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/30/2021] [Indexed: 12/26/2022] Open
Abstract
Although salvage prostate bed radiotherapy is highly effective in biochemically-relapsing prostate cancer patients following prostatectomy, relapses remain frequent and improvements are needed. Randomized phase 3 trials have shown the benefit of adding androgen-depriving therapy to irradiation, but not all patients benefit from this combination. Preclinical studies have shown that novel agents targeting the androgen receptor, DNA repair, PI3K/AKT/mTOR pathways, or the hypoxic microenvironment may help increase the response to prostate bed irradiation while minimizing potential side effects. This perspective review focuses on the most relevant molecules that may have an impact when combined with salvage radiotherapy, and underlines the strategies that need to be developed to increase the efficacy of salvage post-prostatectomy radiotherapy in prostate cancer patients.
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Affiliation(s)
- Axel Cailleteau
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest, Nantes Saint-Herblain, France
| | - Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Fred Saad
- Department of Urology, Université de Montréal, Montreal, QC, Canada
| | - Igor Latorzeff
- Department of Radiation Oncology, Oncorad Clinique Pasteur, Toulouse, France
| | - Stéphane Supiot
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest, Nantes Saint-Herblain, France
- University of Nantes, CRCINA (CNRS, Inserm), Nantes, France
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16
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Latorzeff I, Ploussard G, Schick U, Benziane N, Pasquier D, Sargos P. [Salvage radiotherapy after prostatectomy - what do do in case of elevated post operative PSA or macroscopic relapse?]. Cancer Radiother 2021; 25:822-829. [PMID: 34702645 DOI: 10.1016/j.canrad.2021.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 02/03/2023]
Abstract
The management of the postoperative biological relapse of prostate cancer is most often based on salvage radiotherapy (RT) and a variable duration of hormone therapy (HT) in addition. The indications for RT±HT become more consensual for the adjuvant postoperative situation or in the event of a rising PSA level after a period where an undetectable PSA level was achieved. On the other hand, in the event of detectable PSA immediately postoperatively or in the event of a biological recurrence with macroscopic relapse in the prostate bed seen on conventional imaging assessment, the treatment options are still being evaluated. This article will describe these 2 situations and their current management but also will come through assessments with the contribution of modern imaging and new treatment options in terms of RT dose and RT±HT combination.
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Affiliation(s)
- I Latorzeff
- Département de radiothérapie-oncologie, Bât Atrium, clinique Pasteur, 1, rue de la Petite-Vitesse, 31300 Toulouse, France.
| | - G Ploussard
- Département d'urologie, clinique La Croix du Sud, Quint-Fonsegrives, France
| | - U Schick
- Département de radiothérapie-oncologie, CHU de Brest, Brest, France
| | - N Benziane
- Département de radiothérapie, institut Bergonié, 229 cours de l'Argonne, 33076 Bordeaux cedex, France
| | - D Pasquier
- Département universitaire de radiothérapie, centre O.-Lambret, 3, rue F.-Combemale, 59020 Lille, France
| | - P Sargos
- Département de radiothérapie, institut Bergonié, 229 cours de l'Argonne, 33076 Bordeaux cedex, France
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17
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le Guevelou J, Achard V, Mainta I, Zaidi H, Garibotto V, Latorzeff I, Sargos P, Ménard C, Zilli T. PET/CT-Based Salvage Radiotherapy for Recurrent Prostate Cancer After Radical Prostatectomy: Impact on Treatment Management and Future Directions. Front Oncol 2021; 11:742093. [PMID: 34532294 PMCID: PMC8438304 DOI: 10.3389/fonc.2021.742093] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/09/2021] [Indexed: 12/25/2022] Open
Abstract
Biochemical recurrence is a clinical situation experienced by 20 to 40% of prostate cancer patients treated with radical prostatectomy (RP). Prostate bed (PB) radiation therapy (RT) remains the mainstay salvage treatment, although it remains non-curative for up to 30% of patients developing further recurrence. Positron emission tomography with computed tomography (PET/CT) using prostate cancer-targeting radiotracers has emerged in the last decade as a new-generation imaging technique characterized by a better restaging accuracy compared to conventional imaging. By adapting targeting of recurrence sites and modulating treatment management, implementation in clinical practice of restaging PET/CT is challenging the established therapeutic standards born from randomized controlled trials. This article reviews the potential impact of restaging PET/CT on changes in the management of recurrent prostate cancer after RP. Based on PET/CT findings, it addresses potential adaptation of RT target volumes and doses, as well as use of androgen-deprivation therapy (ADT). However, the impact of such management changes on the oncological outcomes of PET/CT-based salvage RT strategies is as yet unknown.
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Affiliation(s)
- Jennifer le Guevelou
- Division of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland.,Division of Radiation Oncology, Centre François Baclesse, Caen, France
| | - Vérane Achard
- Division of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland.,Faculty of Medicine, Geneva University, Geneva, Switzerland
| | - Ismini Mainta
- Division of Nuclear Medicine and Molecular Imaging, Diagnostic Department, Geneva University Hospital, Geneva, Switzerland
| | - Habib Zaidi
- Faculty of Medicine, Geneva University, Geneva, Switzerland.,Division of Nuclear Medicine and Molecular Imaging, Diagnostic Department, Geneva University Hospital, Geneva, Switzerland.,Geneva Neuroscience Center, Geneva University, Geneva, Switzerland.,Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Department of Nuclear Medicine, University of Southern Denmark, Odense, Denmark
| | - Valentina Garibotto
- Faculty of Medicine, Geneva University, Geneva, Switzerland.,Division of Nuclear Medicine and Molecular Imaging, Diagnostic Department, Geneva University Hospital, Geneva, Switzerland.,Geneva Neuroscience Center, Geneva University, Geneva, Switzerland
| | - Igor Latorzeff
- Department of Radiation Oncology, Groupe Oncorad-Garonne, Clinique Pasteur, Toulouse, France
| | - Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Cynthia Ménard
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada
| | - Thomas Zilli
- Division of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland.,Faculty of Medicine, Geneva University, Geneva, Switzerland
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Yun Ooi K, Pereira I, Nagar H, Simcock R, Katz MS, Parker CC, Lawton C, Saeed H. Time management: Improving the timing of post-prostatectomy radiotherapy, clinical trials, and knowledge translation. Clin Transl Radiat Oncol 2021; 31:21-27. [PMID: 34522795 PMCID: PMC8424081 DOI: 10.1016/j.ctro.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 07/26/2021] [Indexed: 11/29/2022] Open
Abstract
Background Management of prostate cancer after surgery is controversial. Past studies on adjuvant radiotherapy (aRT) for higher-risk features have had conflicting results. Through the collaborative conversations of the global radiation oncology Twitter-based journal club (#RadOnc #JC), we explored this complex topic to share recent advances, better understand what the global radiation oncology community felt was important and inspire next steps. Methods We selected the recent publication of a landmark international randomized controlled trial (RCT) comparing immediate and salvage radiotherapy for prostate cancer, RADICALS-RT, for discussion over the weekend of January 16 to 17, 2021. Coordination included open access to the article and an asynchronous portion to decrease barriers to participation, cooperation of study authors (CP, MS) who participated to share deeper insights including a live hour, and curation of related resources and tweet content through a blog post and Wakelet journal club summary. Discussion of Results Our conversations created 2,370,104 impressions over 599 tweets with 51 participants spanning 11 countries and 5 continents. A quarter of the participants were from the US (13/51) followed by 10% from the UK (5/51). Clinical or Radiation Oncologists comprised 59% of active participants (16/27) with 62% (18/29) reporting giving aRT within the last 5 years. Discussion was interdisciplinary with three urologists (11%), three trainees (11%), and two physiotherapists (7%). Four months after the journal club its article Altmetric score had increased by 7% (214 to 229). Thematic analysis of tweet content suggested participants wanted clarification on definitions of adjuvant (aRT) and salvage radiotherapy (sRT) including indications, timing, and decision-making tools including guidelines; more interdisciplinary and cross-sectoral collaboration including with patients for study design including survivorship and meaningful outcomes; more effective knowledge translation including faster clinical trials; and more data including mature results of current trials, particular high-risk features (Gleason Group 4+, pT4b+, and margin-positive disease), implications of newer technologies such as PSMA-PET and genomic classifiers, and better explanations for practice pattern variations including underutilization of radiotherapy. This was further explored in the context of relevant literature. Conclusion Together, this global collaborative review on the postoperative management of prostate cancer suggested a stronger signal for the uptake of early salvage radiation treatment with careful PSA monitoring, more sensitive PSA triggers, and expected access to radiotherapy. Questions still remain on potential exceptions and barriers to use. These require better decision-making tools for all practice settings, consideration of newer technologies, more pragmatic trials, and better use of social media for knowledge translation.
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Affiliation(s)
- Kai Yun Ooi
- Royal Marsden NHS Foundation Trust, Sutton, UK.,Kuala Lumpur Hospital, Malaysia
| | - Ian Pereira
- Queen's University, Kingston, Ontario, Canada
| | | | - Richard Simcock
- Sussex Cancer Centre, Brighton and Sussex University Hospitals NHS Trust, Sussex, UK
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Kharod SM, Mercado CE, Morris CG, Bryant CM, Mendenhall NP, Mendenhall WM, Nichols RC, Hoppe BS, Liang X, Su Z, Li Z, Henderson RH. Postoperative or Salvage Proton Radiotherapy for Prostate Cancer After Radical Prostatectomy. Int J Part Ther 2021; 7:52-64. [PMID: 33829073 PMCID: PMC8019576 DOI: 10.14338/ijpt-20-00021.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 01/08/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose Postprostatectomy radiation improves disease control, but limited data exist regarding outcomes, toxicities, and patient-reported quality of life with proton therapy. Method and Materials The first 102 patients who were enrolled on an outcome tracking protocol between 2006 and 2017 and treated with double-scattered proton therapy after prostatectomy were retrospectively reviewed. Eleven (11%) received adjuvant radiation, while 91 (89%) received salvage radiation. Seventy-four received double-scattered proton therapy to the prostate bed only. Twenty-eight received a double-scattered proton therapy prostate-bed boost after prostate-bed and pelvic-node treatment. Eleven adjuvant patients received a median dose of 66.6 GyRBE (range, 66.0-70.2). Ninety-one salvage patients received a median dose of 70.2 GyRBE (range, 66.0-78.0). Forty-five patients received androgen deprivation therapy for a median 9 months (range, 1-30). Toxicities were scored using Common Terminology Criteria for Adverse Events v4.0 criteria, and patient-reported quality-of-life data were reviewed. Results The median follow-up was 5.5 years (range, 0.8-11.4 years). Five-year biochemical relapse-free and distant metastases-free survival rates were 72% and 91% for adjuvant patients, 57% and 97% for salvage patients, and 57% and 97% overall. Acute and late grade 3 or higher genitourinary toxicity rates were 1% and 7%. No patients had grade 3 or higher gastrointestinal toxicity. Acute and late grade 2 gastrointestinal toxicities were 5% and 2%. The mean values and SDs of the International Prostate Symptom Score, International Index of Erectile Function, and Expanded Prostate Cancer Index Composite bowel function and bother were 7.5 (SD = 5.9), 10.2 (SD = 8.3), 92.8 (SD = 11.1), and 91.2 (SD = 6.4), respectively, at baseline, and 12.1 (SD = 9.1), 10.1 (SD = 6.7), 87.3 (SD = 18), and 86.7 (SD = 13.8) at the 5-year follow-up. Conclusion High-dose postprostatectomy proton therapy provides effective long-term biochemical control and freedom from metastasis, with low acute and long-term gastrointestinal and genitourinary toxicity.
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Affiliation(s)
- Shivam M Kharod
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | | | - Christopher G Morris
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Curtis M Bryant
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - R Charles Nichols
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Xiaoying Liang
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Zhong Su
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Randal H Henderson
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
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20
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Beck M, Ghadjar P, Mehrhof F, Zips D, Paulsen F, Wegener D, Burock S, Kaul D, Stromberger C, Nadobny J, Ott OJ, Fietkau R, Budach V, Wust P, Müller AC, Zschaeck S. Salvage-Radiation Therapy and Regional Hyperthermia for Biochemically Recurrent Prostate Cancer after Radical Prostatectomy (Results of the Planned Interim Analysis). Cancers (Basel) 2021; 13:cancers13051133. [PMID: 33800872 PMCID: PMC7961934 DOI: 10.3390/cancers13051133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 11/18/2022] Open
Abstract
Simple Summary Several efforts like dose-escalated salvage radiation therapy and the use of androgen deprivation therapy aimed to improve the postoperative treatment in patients with biochemical recurrence of prostate cancer after prostatectomy. However, the oncological outcome is still not satisfactory. Hyperthermia is well-known to improve the efficacy of radiation therapy, whereas only limited data for postoperative therapy in prostate cancer are available. Thus, we conducted a prospective multicenter non-randomized Phase-II-Trial (HTProstate) investigating the implementation of combined salvage radiation therapy and regional hyperthermia in case of biochemical recurrence after prostatectomy with the aim to evaluate the safety, feasibility, and oncological outcome of this approach. The results of our planned interim analysis (n = 50) met the criteria of safety (only one patient with acute grade 3 hyperthermia-specific toxicity), showed feasibility of planned radiation and hyperthermia therapy, no significant changes in quality of life and promising short-term prostate-specific antigen response. Late toxicity and robust oncological outcome data will be reported after completion of the trial. Abstract Efforts to improve the outcome of prostate cancer (PC) patients after radical prostatectomy (RP) include adjuvant or salvage radiation therapy (SRT), but still up to 50% of patients develop a disease progression after radiotherapy (RT). Regional hyperthermia (HT) is well-known to improve tumor sensitivity to RT in several entities. Here we report on a planned interim analysis of tolerability and feasibility after recruitment of the first 50 patients of a trial combining SRT and HT. We conducted a prospective multicenter non-randomized Phase-II-Trial (HTProstate-NCT04159051) investigating the implementation of combined moderate-dose escalated SRT (70 Gy in 35 fractions) and locoregional deep HT (7–10 HT sessions). The primary endpoints were the rate of acute genitourinary (GU), gastrointestinal (GI), and HT-related toxicities, completed HT sessions (≥7), and SRT applications per protocol (≥95% of patients). The two-step design included a planned interim analysis for acute GU-, GI- and HT-specific toxicities to ensure patients’ safety. Between November 2016 and December 2019, 52 patients entered into the trial. After 50 patients completed therapy and three months of follow-up, we performed the planned interim analysis. 10% of patients developed acute grade 2 GU and 4% grade 2 GI toxicities. No grade ≥3 GU or GI toxicities occurred. HT-specific symptoms grade 2 and 3 were observed in 4% and 2% of all patients. Thus, the pre-specified criteria for safety and continuation of recruitment were met. Moreover, ≥7 HT treatments were applicable, indicating the combination of SRT + HT to be feasible. Evaluation of early QoL showed no significant changes. With its observed low rate of GU and GI toxicities, moderate and manageable rates of HT-specific symptoms, and good feasibility, the combined SRT + HT seems to be a promising treatment approach for biochemical recurrence after RP in PC patients.
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Affiliation(s)
- Marcus Beck
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
- Correspondence: ; Tel.: +49-30-450-627-343; Fax: +49-30-450-7527343
| | - Pirus Ghadjar
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
| | - Felix Mehrhof
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital Eberhard-Karls-University Tübingen, 72076 Tübingen, Germany; (D.Z.); (F.P.); (D.W.); (A.-C.M.)
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital Eberhard-Karls-University Tübingen, 72076 Tübingen, Germany; (D.Z.); (F.P.); (D.W.); (A.-C.M.)
| | - Daniel Wegener
- Department of Radiation Oncology, University Hospital Eberhard-Karls-University Tübingen, 72076 Tübingen, Germany; (D.Z.); (F.P.); (D.W.); (A.-C.M.)
| | - Susen Burock
- Charité Comprehensive Cancer Center, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - David Kaul
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
| | - Carmen Stromberger
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
| | - Jacek Nadobny
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
| | - Oliver J. Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany; (O.J.O.); (R.F.)
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany; (O.J.O.); (R.F.)
| | - Volker Budach
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
| | - Peter Wust
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
| | - Arndt-Christian Müller
- Department of Radiation Oncology, University Hospital Eberhard-Karls-University Tübingen, 72076 Tübingen, Germany; (D.Z.); (F.P.); (D.W.); (A.-C.M.)
| | - Sebastian Zschaeck
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (P.G.); (F.M.); (D.K.); (C.S.); (J.N.); (V.B.); (P.W.); (S.Z.)
- Berlin Institute of Health, 10117 Berlin, Germany
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Sanmamed N, Glicksman RM, Herrera-Caceres J, Lehrer EJ, Heaton J, Hansen AR, Chung P, Fleshner NE, Den RB, Zaorsky NG, Berlin A. Use of combined androgen deprivation therapy with postoperative radiation treatment for prostate cancer: Impact of randomized trials on clinical practice. Urol Oncol 2020; 38:848.e1-848.e7. [PMID: 32553790 DOI: 10.1016/j.urolonc.2020.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/01/2020] [Accepted: 04/18/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE To assess the impact of RTOG-9601 and GETUG-AFU-16 on the routine use of combination androgen deprivation therapy (ADT) with postoperative radiotherapy (PORT) for prostate cancer (CaP). MATERIAL AND METHODS Patients with localized CaP treated with radical prostatectomy (RP) and PORT with or without ADT at a comprehensive cancer center from January 2006 to June 2007 (Period 1 = P1), July 2011 to December 2012 (Period 2 = P2), and January 2017 to June 2018 (Period 3 = P3) were included. Clinicopathologic features and treatment characteristics were analyzed and compared. Multivariable logistic regression was used to assess prognostic factors and association with ADT use. Statistical tests were two-sided and a P value <0.05 was considered significant. To validate the findings, United States National Cancer Database (NCDB) and Surveillance, Epidemiology, and End Results (SEER) data were collected to assess rates of combined ADT and PORT from 2004 to 2015. RESULTS Five hundred and two patients were included: 152 (P1), 185 (P2), and 165 (P3). PORT was most commonly delivered as early SRT (delivered >1 year post-RP with undetectable PSA or PSA >0.05 and ≤0.5 ng/ml) in all periods. The use of combination PORT and ADT increased over time: 14.5% (P1), 32% (P2), and 41% (P3) (P < 0.001). The proportion of patients that met eligibility criteria for either GETUG-AFU-16 or RTOG-9601 decreased from 47% (P1) to 35% (P3) (P = 0.04). International Society of Urological Pathology grade ≥4 (P < 0.002) and pre-PORT PSA >0.5 ng/ml (P < 0.001) were associated with use of ADT. Positive surgical margin status had a negative association (RR 0.5, P < 0.002). The NCDB demonstrated similar trends for use of combined ADT with PORT, increasing from 37% to 49% from 2004 to 2015. CONCLUSION The use of combined ADT with PORT increased over time. However, only a third of contemporary patients undergoing PORT are represented in the major trials supporting the evidence for combination treatment, highlighting the need to characterize the modern impact of this intensification strategy.
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Affiliation(s)
- Noelia Sanmamed
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada; Department of Radiation Oncology, Hospital Clinico San Carlos, Madrid, Spain.
| | - Rachel M Glicksman
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jaime Herrera-Caceres
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, Mount Sinai, NY
| | - Jaqueline Heaton
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Aaron R Hansen
- Division of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Peter Chung
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Neil E Fleshner
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Canada
| | - Robert B Den
- Department of Radiation Oncology, Sidney Kimmel Medical College and Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, and the Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Canada; Techna Institute, University Health Network, Canada.
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Abstract
OBJECTIVE. In this article, we discuss the evolving roles of imaging modalities in patients presenting with biochemical recurrence after prostatectomy. CONCLUSION. Multiple imaging modalities are currently available to evaluate patients with prostate cancer presenting with biochemical recurrence after prostatectomy. Multiparametric MRI (mpMRI) focuses on the postsurgical bed as well as regional lymph nodes and bones. PET/CT studies using 18F-fluciclovine, 11C-choline, and prostate-specific membrane antigen (PSMA) ligands are useful in detecting locoregional and distant metastasis. Multiparametric MRI is preferred for patients with low risk of metastasis for localizing recurrence in prostate bed as well as pelvic lymph node and bone recurrence. Moreover, mpMRI aids in guiding biopsy and additional salvage treatments. For patients with high risk of metastatic disease, both mpMRI and whole-body PET/CT may be performed. PET/MRI using 68Ga-PSMA has potential to enable a one-stop shop for local recurrence and metastatic disease evaluation, and clinical trials of PET/MRI are ongoing.
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Gore JL, du Plessis M, Zhang J, Dai D, Thompson DJ, Karsh L, Lane B, Franks M, Chen DY, Bianco FJ, Brown G, Clark W, Kibel AS, Kim H, Lowrance W, Manoharan M, Maroni P, Perrapato S, Sieber P, Trabulsi EJ, Waterhouse R, Spratt DE, Davicioni E, Lotan Y, Lin DW. Clinical Utility of a Genomic Classifier in Men Undergoing Radical Prostatectomy: The PRO-IMPACT Trial. Pract Radiat Oncol 2020; 10:e82-e90. [DOI: 10.1016/j.prro.2019.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/18/2019] [Accepted: 09/24/2019] [Indexed: 11/30/2022]
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Coppola A, Platania G, Ticca C, De Mattia C, Bortolato B, Palazzi MF, Vanzulli A. Sensitivity of CE-MRI in detecting local recurrence after radical prostatectomy. Radiol Med 2020; 125:683-690. [PMID: 32078119 DOI: 10.1007/s11547-020-01149-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 02/06/2020] [Indexed: 02/07/2023]
Abstract
AIM The aim of our study was to evaluate the sensitivity of contrast-enhanced magnetic resonance (CE-MR) with phased array coil in the diagnosis of local recurrence in patients with prostate cancer after radical prostatectomy and referred for salvage radiotherapy (SRT). MATERIALS AND METHODS This retrospective study included 73 patients treated with SRT after radical prostatectomy in the period between September 2006 and November 2017. All patients performed a CE-MRI with phased array coil before the start of SRT. A total of 213 patients treated at the ASST Grande Ospedale Metropolitano Niguarda in the period between September 2006 and November 2017 with SRT after radical prostatectomy were reviewed. Seventy-three patients with a CE-MRI with phased array coil of the pelvis before the start of SRT were included in the present study. RESULTS At imaging review, recurrence local recurrent disease was diagnosed in 48 of 73 patients. By considering as reference standard the decrease in prostate-specific antigen (PSA) value after radiotherapy, we defined: 41 true positive (patients with MRI evidence of local recurrence and PSA value decreasing after SRT), 7 false positive (patients with MRI evidence of local recurrence without biochemical response after SRT), 3 true negative (patients without MRI evidence of local recurrence and stable or increased PSA value after SRT) and 22 false negative (patients without MRI evidence of local recurrence and PSA value decreasing after SRT) cases. The sensitivity values were calculated in relation to the PSA value before the start of treatment, obtaining a value of 74% for PSA above 0.2 ng/mL. CONCLUSION The sensitivity of CE-MRI in local recurrence detection after radical prostatectomy increases with increasing PSA values. CE-MRI with phased array coil can detect local recurrences after radical prostatectomy with a good sensitivity in patients with pre-RT PSA value above 0.2 ng/mL.
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Affiliation(s)
| | | | - Cristiana Ticca
- Department of Radiology, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Barbara Bortolato
- Unit of Radiotherapy, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Mauro F Palazzi
- Unit of Radiotherapy, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Angelo Vanzulli
- Department of Oncology and Hemato-Oncology, Grande Ospedale Metropolitano Niguarda, University of Milan, Milan, Italy
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Jeong JU, Nam TK, Song JY, Yoon MS, Ahn SJ, Chung WK, Cho IJ, Kim YH, Cho SH, Jung SI, Kwon DD. Prognostic significance of lymphovascular invasion in patients with prostate cancer treated with postoperative radiotherapy. Radiat Oncol J 2019; 37:215-223. [PMID: 31591870 PMCID: PMC6790794 DOI: 10.3857/roj.2019.00332] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/14/2019] [Indexed: 11/18/2022] Open
Abstract
Purpose To determine prognostic significance of lymphovascular invasion (LVI) in prostate cancer patients who underwent adjuvant or salvage postoperative radiotherapy (PORT) after radical prostatectomy (RP) Materials and Methods A total of 168 patients with prostate cancer received PORT after RP, with a follow-up of ≥12 months. Biochemical failure after PORT was defined as prostate-specific antigen (PSA) ≥0.2 ng/mL after PORT or initiation of androgen deprivation therapy (ADT) for increasing PSA levels regardless of the value. We analyzed the clinical outcomes including survivals, failure patterns, and prognostic factors affecting the outcomes. Results In total, 120 patients (71.4%) received salvage PORT after PSA levels were >0.2 ng/mL or owing to clinical failure. The 5-year biochemical failure-free survival (BCFFS), clinical failure-free survival (CFFS), distant metastasis-free survival (DMFS), overall survival, and cause-specific survival rates were 78.3%, 94.3%, 95.0%, 95.8%, and 97.3%, respectively, during a follow-up range of 12–157 months (median: 64 months) after PORT. On multivariate analysis, PSA level of ≤1.0 ng/mL at the time of receiving PORT predicted favorable BCFFS, CFFS, and DMFS. LVI predicted worse CFFS (p = 0.004) and DMFS (p = 0.015). Concurrent and/or adjuvant ADT resulted in favorable prognosis for BCFFS (p < 0.001) and CFFS (p = 0.017). Conclusion For patients with adverse pathologic findings, PORT should be initiated as early as possible after continence recovery after RP. Even after administering PORT, LVI was an unfavorable predictive factor, and further intensive adjuvant therapy should be considered for these patients.
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Affiliation(s)
- Jae-Uk Jeong
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Taek-Keun Nam
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Ju-Young Song
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Mee Sun Yoon
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Sung-Ja Ahn
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Woong-Ki Chung
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Ick Joon Cho
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Yong-Hyub Kim
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Shin Haeng Cho
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Seung Il Jung
- Department of Urology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Dong Deuk Kwon
- Department of Urology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
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Buwenge M, Perrone M, Siepe G, Capocaccia I, Woldemariam AA, Wondemagegnhu T, Uddin KAFM, Sumon MA, Galofaro E, Macchia G, Deodato F, Cilla S, Morganti AG. Definition of fields margins for the optimized 2D radiotherapy of prostate carcinoma. Mol Clin Oncol 2019; 11:37-42. [PMID: 31289675 PMCID: PMC6535634 DOI: 10.3892/mco.2019.1855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/15/2019] [Indexed: 12/03/2022] Open
Abstract
Prostate cancer (PCa) is one of the most common malignancies in men both in western and developing countries. Radiotherapy (RT) is an important therapeutic option. New technologies (including 3D, intensity modulated RT, image-guided RT and, volumetric modulated arc therapy) have been introduced in the last few decades with progressive improvement of clinical outcomes. However, in many developing countries, the only treatment option is the traditional two-dimensional (2D) technique based on standard simulation. The guidelines for 2D field definition are still based on expert's opinions. The aim of the present study was to propose new practical guidelines for 2D fields definition based on 3D simulation in PCa. A total of 20 patients were enrolled. Computed tomography-simulation and pelvic magnetic resonance images were merged to define the prostate volumes. Clinical Target Volume (CTV) was defined using the European Organisation for Research and Treatment of Cancer guidelines in consideration of the four risk categories: Low, intermediate, and high risk with or without seminal vesicles involvement, respectively. Planning Target Volume (PTV) was defined by adding 10 mm to the CTV. For each category, two treatment plans were calculated using a cobalt source or 10 MV photons. Progressive optimization was achieved by evaluating 3D dose distribution. Finally, the optimal distances between field margins and radiological landmarks (bones and rectum with contrast medium) were defined. The results were reported in tabular form. Both field margins (PTV D98% >95%) needed to adequately irradiate all patients and to achieve a similar result in 95% of the enrolled patients are reported. Using a group of patients with PCa and based on a 3D planning analysis, we propose new practical guidelines for PCa 2D-RT based on current criteria for risk category and CTV, and PTV definition.
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Affiliation(s)
- Milly Buwenge
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy
| | - Mariangela Perrone
- Radiotherapy Unit, Fondazione di Ricerca e Cura 'Giovanni Paolo II', Catholic University of Sacred Heart, I-86100 Campobasso, Italy
| | - Giambattista Siepe
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy
| | - Ilaria Capocaccia
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy
| | | | | | - Kamal A F M Uddin
- Radiation Oncology Department, United Hospital Limited, Gulshan, Dhaka 1212, Bangladesh
| | - Mostafa A Sumon
- Radiation Oncology Department, United Hospital Limited, Gulshan, Dhaka 1212, Bangladesh
| | - Elena Galofaro
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy
| | - Gabriella Macchia
- Radiotherapy Unit, Fondazione di Ricerca e Cura 'Giovanni Paolo II', Catholic University of Sacred Heart, I-86100 Campobasso, Italy
| | - Francesco Deodato
- Radiotherapy Unit, Fondazione di Ricerca e Cura 'Giovanni Paolo II', Catholic University of Sacred Heart, I-86100 Campobasso, Italy
| | - Savino Cilla
- Medical Physic Unit, Fondazione di Ricerca e Cura 'Giovanni Paolo II', Catholic University of Sacred Heart, I-86100 Campobasso, Italy
| | - Alessio G Morganti
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy
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Location of Recurrence by Gallium-68 PSMA-11 PET Scan in Prostate Cancer Patients Eligible for Salvage Radiotherapy. Urology 2019; 129:165-171. [PMID: 30928607 DOI: 10.1016/j.urology.2018.12.055] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify locations of recurrence after radical prostatectomy (RP) with prostate-specific antigen (PSA) <2 by Gallium-68 prostate-specific membrane antigen (PSMA)-11 Positron Emission Tomography (PET) imaging, and to determine whether standard nodal radiation fields would cover the location of prostate cancer recurrence. MATERIALS AND METHODS We performed a retrospective review of patients with PSMA-PET imaging for biochemical recurrence following RP with PSA ≤2.0 ng/mL and assessed if the recurrent disease was within standard radiation target volumes. We compared patient and clinical variables between men with recurrences covered by standard salvage radiation fields and those with recurrences outside of standard fields. RESULTS We identified 125 patients for study inclusion. The median PSA at imaging was 0.40 ng/mL (interquartile range 0.28-0.63). PSMA-avid disease was found in 66 patients (53%). Of these, 25 patients (38%) had PSMA-avid lesions found outside of the pelvis, 33 (50%) had lesions confined to the pelvic lymph nodes and prostate bed, and 8 (12%) men had PSMA-avid recurrence only in the prostate bed. Salvage radiation including standard Intensity Modulated Radiation Therapy (IMRT) pelvic nodal volumes would not cover PSMA-avid nodal disease in 38 men (30%). PSA at the time of imaging was statistically associated with having PSMA-avid disease outside of standard nodal fields (P <.01). CONCLUSION The 68Ga-PSMA-11 PET detects disease in a majority of patients with PSA ≤2.0 following RP. Nearly one-third of men had PSMA-avid disease that would be missed by standard radiation fields. This imaging modality may dramatically impact the design and use of post-RP salvage radiotherapy.
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Shelan M, Odermatt S, Bojaxhiu B, Nguyen DP, Thalmann GN, Aebersold DM, Dal Pra A. Disease Control With Delayed Salvage Radiotherapy for Macroscopic Local Recurrence Following Radical Prostatectomy. Front Oncol 2019; 9:12. [PMID: 30873377 PMCID: PMC6403145 DOI: 10.3389/fonc.2019.00012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 01/03/2019] [Indexed: 12/20/2022] Open
Abstract
Purpose: To retrospectively assess clinical outcomes and toxicity profile of prostate cancer patients treated with delayed dose-escalated image-guided salvage radiotherapy (SRT) for macroscopic local recurrence after radical prostatectomy (RP). Material and Methods: We report on a cohort of 69 consecutive patients with local recurrence after RP and no evidence of regional or distant metastasis who were referred for salvage radiotherapy between 2007 and 2016. SRT consisted of 64-66 Gy (2 Gy/fraction) to the prostatic bed followed by dose escalation to 72-74 Gy (2Gy/fraction) to the macroscopic disease. All patients received concurrent short-term androgen deprivation therapy (ADT). Biochemical recurrence-free survival (bRFS) and clinical progression-free-survival (cPFS) were depicted using Kaplan-Meier method. Multivariable Cox proportional hazards regression assessed predictors of survival outcomes. Baseline, acute, and late urinary and gastrointestinal (GI) toxicity rates were reported using CTCAE v4.03. Results: Median time from RP to SRT was 66 months (IQR: 32-124). Median pre-SRT prostate-specific antigen (PSA) was 2.7 ng/ml (IQR: 0.9-6.5). Median follow-up after SRT was 38 months (IQR: 24-66). The 3- and 5-year bRFS were 58 and 44%, respectively. The 3- and 5-year cPFS were 91 and 76%, respectively. Median time from SRT to clinical disease progression was 102 months (IQR 77.5-165). At baseline, 3 patients (4%) had grade 3 urinary symptoms. Six patients (9%) developed acute and six patients (9%) developed late grade 3 urinary toxicity. Five patients (7%) had acute grade 2 GI toxicity. No acute grade 3 GI toxicity was reported. Late grade 3 GI toxicity was reported in one patient (1.5%). Conclusions: Delayed dose-escalated SRT combined with short-course ADT for macroscopic LR after RP was associated with 44% bRFS and 76% cPFS at 5 years. Albeit improved patient stratification is warranted, these data suggest that delayed SRT provides inferior tumor control compared to early intervention.
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Affiliation(s)
- Mohamed Shelan
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Seline Odermatt
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Bojaxhiu
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel P. Nguyen
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - George N. Thalmann
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel M. Aebersold
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alan Dal Pra
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, United States
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Alexidis P, Guo W, Bekelman JE, Vapiwala N, Gabriel PE, Christodouleas JP. Use of high and very high dose radiotherapy after radical prostatectomy for prostate cancer in the United States. Prostate Cancer Prostatic Dis 2018; 21:584-593. [PMID: 30087427 PMCID: PMC6283850 DOI: 10.1038/s41391-018-0066-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 03/20/2018] [Accepted: 03/27/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND The cost-benefit tradeoff of radiation dose-intensification for prostate cancer in the post-prostatectomy setting is difficult to predict and is ideally studied in randomized trials. The purpose of this study was to assess the use of dose-escalated post-operative radiation (PORT) for prostate cancer in the United States, during a period in which there were no published level 1 studies on dose-escalation. METHODS We performed analyses on pT2-3, N0, M0 prostate cancer patients who received PORT after an R0-1 resection within the National Cancer Data Base (NCDB), 2003-2012. We classified patients according to the use of high dose (>66.60 cGy) and very high dose (>70.20 cGy) radiation. We used regression analysis to assess the association of year of treatment with use of high and very high dose PORT. To demonstrate the potential of a registry-based network like the NCDB to prospectively monitor changes in radiation dosing patterns, we determined the year in which a significant change in dose could have been first detected had dose been actively monitored. RESULTS Between 2003 and 2012, the use of high dose PORT increased from 29.9% CI (26.7-33.1) to 63.5% CI (60.6-66.5) and very high dose PORT from 4.5% CI (3.1-5.9) to 10.8% CI (8.9-12.6) (adjusted p < 0.01, for both trends). Patients diagnosed at community centers were less likely to be treated with high dose PORT compared to those at academic or comprehensive centers (p < 0.01 for both comparisons). Had the NCDB network been prospectively monitoring PORT dose, significant increases in dose would have been detected as early as 2004 and after every year of the study period. CONCLUSIONS The use of both high dose and very high dose PORT increased two-fold from 2003 to 2012 in the absence of randomized studies. This change in practice may be exposing patients to excess toxicity without cancer control benefits. Monitoring dosing patterns using cancer registries is feasible.
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Affiliation(s)
- P Alexidis
- Interbalkan Center, Thessaloniki, Greece
| | - W Guo
- Department of Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - J E Bekelman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - N Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - P E Gabriel
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - J P Christodouleas
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA.
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Battaglia A, De Meerleer G, Tosco L, Moris L, Van den Broeck T, Devos G, Everaerts W, Joniau S. Novel Insights into the Management of Oligometastatic Prostate Cancer: A Comprehensive Review. Eur Urol Oncol 2018; 2:174-188. [PMID: 31017094 DOI: 10.1016/j.euo.2018.09.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 09/04/2018] [Accepted: 09/12/2018] [Indexed: 02/01/2023]
Abstract
CONTEXT The current standard of care for metastatic prostate cancer (PCa) is androgen deprivation therapy (ADT) plus either docetaxel or abiraterone. Growing evidence suggests that metastasis-directed therapy (MDT) and/or local therapy targeted to the primary tumour (ie, prostate) may be of benefit in the setting of oligometastatic disease. Several prospective studies are underway; however, until robust evidence is available to guide treatment decisions, physicians are challenged with how best to manage patients with oligometastases. OBJECTIVE This comprehensive review aims to collate the available evidence to date for a role of MDT and/or prostate-targeted therapy in the setting of oligometastatic PCa, as well as discuss ongoing trials in this setting. EVIDENCE ACQUISITION We searched PubMed for the combination of "prostate cancer" and "oligometastatic", "oligometastases", "oligometastasis", "solitary metastases", "stereotactic body radiotherapy", "SBRT", "stereotactic ablative radiotherapy", "SABR", "salvage lymphadenectomy", or "metastasectomy" in publications over the last 20yr. We also searched ClinicalTrials.gov to identify relevant ongoing trials. EVIDENCE SYNTHESIS The studies were divided according to the timing of metastasis into synchronous (ie, detected at the time of primary PCa diagnosis) and metachronous (ie, detected after treatment of the primary tumour), and according to treatment modality into MDT (including salvage lymph node dissection [sLND]) and prostate-targeted treatment. For MDT of synchronous/metachronous metastases, we included 16 completed studies and 11 ongoing prospective studies. In the case of sLND for nodal-only recurrence after primary treatment with curative intent, we included 11 completed studies. Finally, for prostate-targeted treatment of synchronous metastatic PCa, we included 25 completed studies and 11 ongoing prospective studies. In selected patients with oligorecurrent disease, early detection and aggressive treatment of metastatic lesions (surgery or radiotherapy) appears to be a feasible strategy and may delay the use of systemic therapies. MDT is a promising option in oligometastatic PCa patients, but more robust data are needed. In the setting of synchronous oligometastatic disease, aggressive cytoreductive treatment needs further data to confirm the benefits. CONCLUSIONS In this review, we provide a comprehensive overview of the current literature on the treatment of patients with oligometastatic PCa. The data suggest that although ADT plus either docetaxel or abiraterone remains the mainstay of treatment for mPCa, in oligometastatic PCa, improved outcomes may be achieved with metastasis- and prostate-targeted therapies. The studies included in this review are mainly retrospective in nature, limiting the strength of the evidence they provide. Prospective studies are ongoing, and their results are eagerly awaited. PATIENT SUMMARY We reviewed the treatment of patients with prostate cancer that has spread to five sites or fewer. We conclude that while androgen deprivation plus either docetaxel or abiraterone should remain the standard of care, there is evidence that treatment targeted at the metastases and the primary tumour may improve the outcome for the patient and potentially delay the use of systemic treatment.
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Affiliation(s)
- Antonino Battaglia
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Gert De Meerleer
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Lorenzo Tosco
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Lisa Moris
- Department of Cellular and Molecular Medicine, Laboratory of Molecular Endocrinology, KU Leuven, Leuven, Belgium
| | - Thomas Van den Broeck
- Department of Cellular and Molecular Medicine, Laboratory of Molecular Endocrinology, KU Leuven, Leuven, Belgium
| | - Gaëtan Devos
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Wouter Everaerts
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Steven Joniau
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Urology, University Hospitals Leuven, Leuven, Belgium.
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Jackson WC, Suresh K, Tumati V, Dess RT, Soni PD, Zhao SG, Zumsteg ZS, Hannan R, Hollenbeck BK, George A, Kaffenberger SD, Salami SS, Hearn JW, Morgan TM, Mehra R, Schipper M, Feng FY, Desai NB, Spratt DE. Impact of Biochemical Failure After Salvage Radiation Therapy on Prostate Cancer–specific Mortality: Competition Between Age and Time to Biochemical Failure. Eur Urol Oncol 2018; 1:276-282. [DOI: 10.1016/j.euo.2018.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/30/2018] [Accepted: 04/20/2018] [Indexed: 10/28/2022]
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Adjuvant Radiotherapy Versus Wait-and-See Strategy for Pathologic T3 or Margin-Positive Prostate Cancer. Am J Clin Oncol 2018; 41:730-738. [DOI: 10.1097/coc.0000000000000358] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Dal Pra A, Abramowitz MC, Stoyanova R, Pollack A. Contemporary role of postoperative radiotherapy for prostate cancer. Transl Androl Urol 2018; 7:399-413. [PMID: 30050800 PMCID: PMC6043752 DOI: 10.21037/tau.2018.06.01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
While radical prostatectomy (RP) has provided long-term disease control for the majority of patients with localized prostate cancer (CaP), nearly 30% of all surgical patients have disease progression. For high-risk patients, more than half of men experience disease recurrence within 10 years. Postoperative radiotherapy is the only known potentially curative treatment for a large number of patients following prostatectomy. Lately, there have been several advances with the potential to improve outcomes for patients undergoing postoperative radiotherapy. This article will give an overview of the existing literature and current controversies on: (I) timing of postoperative radiation; (II) use of concomitant androgen deprivation therapy; (III) optimal dose to the prostate bed; (IV) use of hypofractionation; (V) elective treatment of the pelvic lymph nodes; (VI) novel imaging modalities, and (VII) genomic biomarkers.
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Affiliation(s)
- Alan Dal Pra
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Matthew C Abramowitz
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Radka Stoyanova
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Alan Pollack
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
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Abstract
Over the past few decades there is growing appreciation for the role of chemotherapy in treatment of prostate cancer. Initial successful phase III randomized trials in castration resistant prostate cancer (CRPC) have led to additional successful trials in earlier presentations of disease. Given the established role of radiation in management of locally advanced disease and demonstrated efficacy of taxanes in treatment of prostate cancer, optimal combination of radiation and chemotherapy in this patient population has garnered increased attention. Successful phase III trials in this space have given additional stimulus to further exploring combination therapy with radiation. New directions include assessment of additional chemotherapeutic agents including cabazitaxel and PARP inhibitors as well as personalization of therapy with use of genomic testing and other emerging markers to guide therapeutic decisions.
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Affiliation(s)
- Mark David Hurwitz
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, USA
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35
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Dess RT, Morgan TM, Nguyen PL, Mehra R, Sandler HM, Feng FY, Spratt DE. Adjuvant Versus Early Salvage Radiation Therapy Following Radical Prostatectomy for Men with Localized Prostate Cancer. Curr Urol Rep 2018; 18:55. [PMID: 28589403 DOI: 10.1007/s11934-017-0700-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Radical prostatectomy (RP) is now the most common definitive treatment for high-risk prostate cancer. Unfortunately, many men will have residual microscopic disease after surgery alone. Despite level 1 evidence supporting the use of adjuvant radiation therapy (ART), <10% of men with adverse pathology (positive margins or T3 disease) receive ART in the USA. Early salvage radiation therapy (eSRT) at the time of biochemical recurrence has been proposed as an alternative strategy despite the lack of published randomized trials to support this approach. Multiple randomized trials are ongoing or recently completed to compare ART to eSRT, but given the long natural history of prostate cancer, long-term oncologic outcomes from these trials will not be reported for several years. In this review, we discuss the shifting trends in the diagnosis of high-risk prostate cancer given a decline in PSA screening, use of RP for high-risk disease, and compare and contrast the retrospective and randomized evidence regarding ART and SRT.
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Affiliation(s)
- Robert T Dess
- Department of Radiation Oncology, University of Michigan School of Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rohit Mehra
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars Sinai, Los Angeles, CA, USA
| | - Felix Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan School of Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
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Abstract
PURPOSE OF REVIEW Androgen deprivation therapy (ADT) is an important adjunctive therapy to external beam radiation therapy (RT) for the definitive management of prostate cancer. The role of ADT is well-established for locally advanced or high-risk disease in conjunction with standard doses of RT, but less defined for intermediate-risk disease or with dose-escalated RT. The goal of this review is to summarize evidence evaluating the combination of ADT/RT, focusing on recent trials and current controversies as they pertain to the practicing clinician. RECENT FINDINGS The benefit of ADT on biochemical control is maintained with dose-escalated RT according to recently reported phase III studies. Furthermore, there is now prospective, randomized evidence to support the addition of ADT to RT in the post-prostatectomy setting. ADT continues to play an important role for prostate cancer patients receiving dose-escalated RT. Future research is needed to identify subgroups most likely to benefit from this combination.
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Alongi F, Cozzarini C, Di Muzio N, Scorsetti M. Postoperative Radiotherapy in Prostate Cancer: Acquired Certainties and Still Open Issues. A Review of Recent Literature. TUMORI JOURNAL 2018; 97:1-8. [DOI: 10.1177/030089161109700101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
It is recognized that radiation therapy can eradicate microscopic tumor disease, even in postoperative prostate cancer patients, when extracapsular extension, positive surgical margins or increased prostate-specific antigen is found in surgical specimens. This review of recent literature analyzes and discusses acquired certainties and still open questions regarding type, timing, doses, techniques, toxicities, and associated hormonal therapies of radiotherapy prescribed after radical prostatectomy. Free full text available at www.tumorionline.it
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Affiliation(s)
- Filippo Alongi
- Radiotherapy and Radiosurgery, IRCCS Istituto Clinico Humanitas, Rozzano (Milano)
| | - Cesare Cozzarini
- Radiotherapy, IRCCS Istituto Scientifico San Raffaele, Milano, Italy
| | - Nadia Di Muzio
- Radiotherapy, IRCCS Istituto Scientifico San Raffaele, Milano, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery, IRCCS Istituto Clinico Humanitas, Rozzano (Milano)
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Buergy D, Sertdemir M, Weidner A, Shelan M, Lohr F, Wenz F, Schoenberg SO, Attenberger UI. Detection of Local Recurrence with 3-Tesla MRI After Radical Prostatectomy: A Useful Method for Radiation Treatment Planning? In Vivo 2018; 32:125-131. [PMID: 29275309 PMCID: PMC5892648 DOI: 10.21873/invivo.11214] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 11/07/2017] [Accepted: 11/10/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND/AIM Salvage radiotherapy improves biochemical control in patients with recurrence of prostate cancer after prostatectomy. Radiotherapy target volumes of the prostatic fossa are based on empirical data and differ between different guidelines. Localization of recurrence with multiparametric magnetic resonance imaging (MRI) might be a feasible approach to localize recurrent lesions. PATIENTS AND METHODS Twenty-one patients with biochemical recurrence after radical prostatectomy were included (median prostate-specific antigen (PSA) =0.17 ng/ml). Multi-parametric MRI was performed using a 3-T MR system. RESULTS Lesions were detected in seven patients with a median PSA of 0.86 ng/ml (minimum= 0.31 ng/ml). Patients without detectable recurrence had a median PSA of 0.12 ng/ml. All patients with detectable lesions responded to radiotherapy. Eleven out of 14 patients without detectable recurrence also responded. Plasma flow in suspicious lesions was correlated with PSA level. CONCLUSION Detection of recurrence at the prostatic fossa with our approach was possible in a minority of patients with a low PSA level. Clinical relevance of plasma flow in suspicious lesions should be further investigated.
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Affiliation(s)
- Daniel Buergy
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Metin Sertdemir
- Medical Care Center Radiology Karlsruhe West, Karlsruhe, Germany
| | - Anja Weidner
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Mohamed Shelan
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Frank Lohr
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Stefan O Schoenberg
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Ulrike I Attenberger
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
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Adjuvant Radiation Therapy for High-Risk Post-prostatectomy Patients. Prostate Cancer 2018. [DOI: 10.1007/978-3-319-78646-9_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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Choi KH, Lee SR, Hong YK, Park DS. Intermittent, low-dose, antiandrogen monotherapy as an alternative therapeutic option for patients with positive surgical margins after radical prostatectomy. Asian J Androl 2017; 20:270-275. [PMID: 29271399 PMCID: PMC5952482 DOI: 10.4103/aja.aja_56_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The aim of the present study was to determine whether oncologic outcomes and adverse events associated with active on/off intermittent antiandrogen monotherapy (daily bicalutamide, 50 mg per day) are comparable with those of standard external beam radiation therapy (EBRT) or combined androgen blockade (CAB) therapy in prostate cancers with positive surgical margins after radical prostatectomy. Two hundred twenty-three patients with positive surgical margins post-radical prostatectomy who underwent active surveillance (AS, n = 32), EBRT without hormone therapy (n = 55), intermittent antiandrogen monotherapy without EBRT (IAAM, n = 50), or CAB without EBRT (n = 86), between 2007 and 2014, were reviewed retrospectively. Pathologic outcomes, biochemical recurrence rates, radiological disease progression, and adverse events were collected from medical records. Biochemical recurrence rates, biochemical recurrence-free survival rates, and radiological recurrence were not different between the groups (P = 0.225, 0.896, and 0.284, respectively). Adverse event rates and severities were lower for IAAM compared with EBRT or CAB (both P < 0.05), but were comparable to those for AS (P = 0.591 and 0.990, respectively). Grade ≥3 adverse events were not reported in the IAAM or AS groups. Erectile dysfunction and loss of libido rates were lower in the IAAM group compared with the EBRT and CAB groups (P = 0.032). Gastrointestinal complications were more frequently reported in the EBRT group (P = 0.008). Active on/off IAAM treatment might be an appropriate treatment option for patients with positive surgical margins after radical prostatectomy. Furthermore, regarding oncologic outcomes, IAAM was comparable to standard EBRT but had a milder adverse event profile.
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Affiliation(s)
- Kyung Hwa Choi
- Department Urology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Seung Ryeol Lee
- Department Urology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Young Kwon Hong
- Department Urology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Dong Soo Park
- Department Urology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Zumsteg ZS, Daskivich TJ, Sandler HM. Salvage Radiotherapy for Biochemically Recurrent Prostate Cancer After Prostatectomy. J Clin Oncol 2017; 34:3829-3833. [PMID: 27573664 DOI: 10.1200/jco.2016.69.2509] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 67-year-old man had presented to his primary physician for routine health maintenance. A digital rectal examination was performed and revealed a suspicious nodule in the right lobe of the prostate without any extraprostatic extension. A serum prostate-specific antigen (PSA) test was 12.4 ng/mL. He had no previous PSA tests. Transrectal ultrasound-guided prostate biopsy showed Gleason 3 + 4 prostate adenocarcinoma in seven of 12 cores. Bone scan and computed tomography scan of the pelvis showed no evidence of metastatic disease, and the patient underwent a robotic-assisted radical prostatectomy with bilateral pelvic lymphadenectomy. Pathology revealed Gleason 3 + 4 adenocarcinoma bilaterally, with extracapsular extension, no seminal vesicle invasion, a 2-mm positive margin at the right mid gland, and 0 of 15 lymph nodes containing adenocarcinoma. Two months after surgery, he had mild stress urinary incontinence and PSA of < 0.1 ng/mL. Adjuvant radiotherapy was discussed, but he elected to have careful follow-up. His PSA was monitored every 6 months and gradually increased from < 0.1 ng/mL to 0.4 ng/mL over the next 3 years. He was asymptomatic. He was referred to discuss the role of salvage radiotherapy.
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Lee E, Park W, Ahn SH, Cho JH, Kim JH, Cho KH, Choi YM, Kim JS, Kim JH, Jang HS, Kim YS, Nam TK. Interobserver variation in target volume for salvage radiotherapy in recurrent prostate cancer patients after radical prostatectomy using CT versus combined CT and MRI: a multicenter study (KROG 13-11). Radiat Oncol J 2017; 36:11-16. [PMID: 29207866 PMCID: PMC5903365 DOI: 10.3857/roj.2017.00080] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/12/2017] [Accepted: 06/26/2017] [Indexed: 11/29/2022] Open
Abstract
Purpose To investigate interobserver variation in target volume delineations for prostate cancer salvage radiotherapy using planning computed tomography (CT) versus combined planning CT and magnetic resonance imaging (MRI). Materials and Methods Ten radiation oncologists independently delineated a target volume on the planning CT scans of five cases with different pathological status after radical prostatectomy. Two weeks later, this was repeated with the addition of planning MRI. The volumes obtained with CT only and combined CT and MRI were compared, and the effect of the addition of planning MRI on interobserver variability was assessed. Results There were large differences in clinical target volume (CTV) delineated by each observer, regardless of the addition of planning MRI (9.44–139.27 cm3 in CT only and 7.77–122.83 cm3 in CT plus MRI) and no significant differences in the mean and standard deviation of CTV. However, there were decreases in mean volume and standard deviation as a result of using the planning MRI. Conclusion This study showed substantial interobserver variation in target volume delineation for salvage radiotherapy. The combination of planning MRI with CT tended to decrease the target volume and the variation.
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Affiliation(s)
- Eonju Lee
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Hwan Ahn
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Ho Cho
- Department of Radiation Oncology, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Kwan Ho Cho
- Proton Therapy Center, National Cancer Center, Goyang, Korea
| | - Young Min Choi
- Department of Radiation Oncology, Dong-A University College of Medicine, Busan, Korea
| | - Jae-Sung Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Hong-Seok Jang
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young-Seok Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Taek-Keun Nam
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Korea
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Sandgren K, Westerlinck P, Jonsson JH, Blomqvist L, Thellenberg Karlsson C, Nyholm T, Dirix P. Imaging for the Detection of Locoregional Recurrences in Biochemical Progression After Radical Prostatectomy-A Systematic Review. Eur Urol Focus 2017; 5:550-560. [PMID: 29133278 DOI: 10.1016/j.euf.2017.11.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/13/2017] [Accepted: 11/02/2017] [Indexed: 01/23/2023]
Abstract
CONTEXT Local and regional recurrence after radical prostatectomy (RP) can be treated using salvage radiotherapy (SRT). If the recurrence can be delineated on diagnostic imaging, this could allow for increasingly individualized SRT. OBJECTIVE This systematic review aimed at evaluating the evidence regarding the usefulness of positron emission tomography (PET) and magnetic resonance imaging (MRI) in identifying local and regional recurrences, with the aim to further individualize the SRT treatment. EVIDENCE ACQUISITION A systematic PubMed/Medline search was conducted in December 2015. Studies included were imaging studies of post-RP patients focusing on local and/or regional recurrence where sensitivity and specificity of MRI or PET were the primary end points. Only studies using biopsy, other histological analysis, and/or treatment follow-up as reference standard were included. Quality Assessment of Diagnostic Accuracy Studies-2 was used to score the study quality. Twenty-five articles were deemed of sufficient quality and included in the review. EVIDENCE SYNTHESIS [11C]Acetate had the highest pooled sensitivity (92%), while [11C]choline and [18F]choline had pooled sensitivities of 71% and 84%, respectively. The PET tracer with highest pooled specificity was [11C]choline (86%). Regarding MRI, MR spectroscopy combined with dynamic contrast enhanced (DCE) MRI showed the highest pooled sensitivity (89%). High pooled sensitivities were also seen using multiparametric MRI (84%), diffusion-weighted MRI combined with T2-weigthed (T2w) imaging (82%), and DCE MRI combined with T2w imaging (82%). These also showed high pooled specificities (85%, 89%, and 92%, respectively). CONCLUSIONS Both MRI and PET have adequate sensitivity and specificity for the detection of prostate cancer recurrences post-RP. Multiparametric MRI, using diffusion-weighted and/or DCE imaging, and the choline-labeled tracers showed high pooled sensitivity and specificity, although their ranges were broad. PATIENT SUMMARY After reviewing imaging studies of recurrent prostate cancer after prostatectomy, we concluded that choline positron emission tomography and diffusion-weighted magnetic resonance imaging can be proposed as the current standard, with high sensitivity and specificity.
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Affiliation(s)
| | - Philippe Westerlinck
- Department of Radiation Oncology, Iridium Cancer Network, Wilrijk (Antwerp), Belgium
| | | | - Lennart Blomqvist
- Department of Radiation Sciences, Umeå University, Umeå, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | | - Tufve Nyholm
- Department of Radiation Sciences, Umeå University, Umeå, Sweden; Department of Immunology, Genetics, and Pathology, Medical Radiation Science, Uppsala University, Uppsala, Sweden
| | - Piet Dirix
- Department of Radiation Oncology, Iridium Cancer Network, Wilrijk (Antwerp), Belgium; Department of Molecular Imaging, Pathology, Radiotherapy & Oncology (MIPRO), Center for Oncological Research (CORE), Edegem (Antwerp), Belgium
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44
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Sachdeva A, Veeratterapillay R, Voysey A, Kelly K, Johnson MI, Aning J, Soomro NA. Positive surgical margins and biochemical recurrence following minimally-invasive radical prostatectomy - An analysis of outcomes from a UK tertiary referral centre. BMC Urol 2017; 17:91. [PMID: 28969608 PMCID: PMC5625596 DOI: 10.1186/s12894-017-0262-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/24/2017] [Indexed: 12/05/2022] Open
Abstract
Background Positive surgical margins are a strong prognostic marker of disease outcome following radical prostatectomy, though prior evidence is largely from a PSA-screened population. We therefore aim to evaluate the biochemical recurrence in men with positive surgical margins (PSM) after minimally-invasive radical prostatectomy (MIRP) in a UK tertiary centre. Methods Retrospective study of men undergoing laparoscopic or robotic-assisted radical prostatectomy between 2002 and 2014. Men with positive surgical margins (PSM) were identified and their biochemical recurrence (BCR) rate compared with men without PSM. The primary outcome measures were BCR rates and time to BCR. Cox regression was used to estimate adjusted hazard ratios for biochemical recurrence rate (BCR), accounting for potential confounders. Results Five hundred ninety-two men were included for analysis. Pre-operative D’Amico risk stratification showed 37.5%, 53.3% and 9.3% of patients in the low, intermediate and high-risk groups, respectively. On final pathological analysis, the proportion of patients with local staging pT2, pT3a and pT3b was 68.8%, 25.2% and 6.1% respectively. Overall positive margin rate was 30.6%. On multivariate analysis, the only pre-operative factor associated with PSM was age >65years. Patients with PSM were more likely to have higher tumour volume and more advanced pathological local stage. The BCR rate was 10.7% in margin-positive patients and 5.1% in margin-negative patients, at median 4.4-year follow-up. Upon multivariate analysis, high pre-operative PSA and high Gleason group were the only significant predictors of BCR (P<0.05). Conclusions In comparison to patients with negative surgical margins, those with PSM do not translate into worse medium-term oncological outcomes in the majority of cases amongst our cohort. We found that high pre-operative PSA and high Gleason group were the only significant predictors of BCR. Electronic supplementary material The online version of this article (10.1186/s12894-017-0262-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ashwin Sachdeva
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK.,Northern Institute for Cancer Research, Newcastle University, Newcastle-upon-Tyne, UK
| | - Rajan Veeratterapillay
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Antonia Voysey
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Katherine Kelly
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Mark I Johnson
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Jonathan Aning
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Naeem A Soomro
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK. .,Northern Institute for Cancer Research, Newcastle University, Newcastle-upon-Tyne, UK.
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Isharwal S, Stephenson AJ. Post-prostatectomy radiation therapy for locally recurrent prostate cancer. Expert Rev Anticancer Ther 2017; 17:1003-1012. [PMID: 28922958 DOI: 10.1080/14737140.2017.1378575] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Approximately 15-30% of men with localized prostate cancer will experience biochemical recurrence (BCR) after radical prostatectomy. Postoperative radiation therapy is used in men with adverse pathological features to reduce the risk of BCR or with curative intent in men with known BCR. In this study, we review the evidence for the adjuvant and salvage radiation therapy after radical prostatectomy. Areas covered: A literature review of the Medline and Embase databases was performed. The search strategy included the following terms: prostate cancer, adjuvant radiotherapy, salvage radiotherapy, radical prostatectomy, biochemical recurrence, and prostate cancer recurrence. Prospective randomized trials for the adjuvant radiotherapy and observational studies supporting salvage radiotherapy were included for discussion. Expert commentary: As postoperative radiotherapy is associated with non-trivial risks of acute and long-term toxicity and given the absence of compelling data supporting adjuvant over early salvage radiotherapy, the authors advocate, with rare exceptions, close observation and timely (early) salvage radiotherapy for patients with BCR and long life expectancy. Adjuvant radiotherapy may be considered in patients at high-risk for recurrence. Observation is appropriate in patients with limited life expectancy and/or absence of adverse features.
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Affiliation(s)
- Sudhir Isharwal
- a Department of Urology , Glickman Urology and Kidney Institute, Cleveland Clinic , Cleveland , OH , USA
| | - Andrew J Stephenson
- a Department of Urology , Glickman Urology and Kidney Institute, Cleveland Clinic , Cleveland , OH , USA
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Nyarangi-Dix JN, Steimer J, Bruckner T, Jakobi H, Koerber SA, Hadaschik B, Debus J, Hohenfellner M. Post-prostatectomy radiotherapy adversely affects urinary continence irrespective of radiotherapy regime. World J Urol 2017; 35:1841-1847. [PMID: 28861691 DOI: 10.1007/s00345-017-2081-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/10/2017] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To investigate the influence of different postoperative radiotherapy (RT) regimes on post-prostatectomy continence and QoL. METHODS Men after prostatectomy (RP) and RT were assigned in adjuvant (ART), early salvage (ESRT) and salvage radiotherapy (SRT) groups depending on time of initiation, indication and pre-RT-PSA (≤/>0.5 ng/ml). Continence and QoL outcomes were evaluated by validated questionnaire. Statistical analysis included students t test, Chi square, Fisher's test, ROC- and McNemar-Bowker-Analyses. RESULTS The mean follow-up was 5.1 years. 33.5, 38.2 and 28.3% received ART, ESRT and SRT, respectively. Mean time to RT was 0.3 (±0.4), 1.8 (±2.5) and 3.3 (±3.6) years respectively. Differences in age at RP (p = 0.54) and RT (p = 0.47) between groups were not significant. Mean-RT-dose was similar (p = 0.70). Differences in continence distribution between groups before (p = 0.56) and after RT (p = 0.38) were not significant. No significant differences were observed for frequency (p = 0.58) or amount (p = 0.88) of urine loss, impact on QoL (p = 0.13) and ICIQ-SF scores (p = 0.69) between groups. Even though no significant difference in post-RT-continence (p = 0.89) was observed in the direct comparison between groups, a significant worsening of long-term continence was observed in all groups (p < 0.001). We found no cutoff and no time-point after RP at which this negative effect of RT on continence became insignificant (AUC = 0.474). A subgroup with apparent local recurrence showed no differences for ICIQ-SF-score (p = 0.155), QoL (0.077), incontinence grade (p = 0.387), frequency (p = 0.182) and amount (p = 0.415) of urine loss. Proportionally more men in this subgroup remembered deterioration of continence after RT (p = 0.029). CONCLUSION Postoperative RT adversely affects long-term continence; this negative effect is irrespective of time of initiation or indication for RT. These results suggest a need for innovative strategies of prostate cancer therapy with lasting oncological, functional and QoL outcomes.
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Affiliation(s)
- J N Nyarangi-Dix
- Department of Urology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| | - J Steimer
- Ruprecht-Karls University of Heidelberg, Medical Faculty, Heidelberg, Germany
| | - T Bruckner
- Institute of Medical Biometry & Informatics, University of Heidelberg, Heidelberg, Germany
| | - H Jakobi
- Department of Urology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - S A Koerber
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany
| | - B Hadaschik
- Department of Urology, University Hospital Essen, Essen, Germany
| | - J Debus
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany
| | - M Hohenfellner
- Department of Urology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
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Nicholls L, Winter A, Harwood A, Plank A, Bagga P, Wong W, Khoo E. Outcomes of post-prostatectomy radiotherapy at a Regional Cancer Centre. J Med Radiat Sci 2017; 64:259-265. [PMID: 28805047 PMCID: PMC5715341 DOI: 10.1002/jmrs.240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 07/01/2017] [Accepted: 07/08/2017] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION To investigate the efficacy and toxicity of radiation therapy (RT) after radical prostatectomy (RP) for prostate cancer at Radiation Oncology Centres, Toowoomba. METHODS The electronic medical records of 130 consecutive patients with histologically proven prostate adenocarcinoma who underwent post-prostatectomy RT between January 2008 and December 2014 were analysed. Primary endpoint was Biochemical Recurrence (BCR) after RT. BCR was defined by PSA > 0.2 ng/mL and BCR endpoints were analysed using Kaplan-Meier methods. The impact of RT technique and the rates of acute and late toxicities are also reported. Toxicities were graded according to Radiation Therapy Oncology Group (RTOG) criteria. RESULTS Median follow-up time after RT (regardless of technique) was 28 months. BCR occurred in 32 of the 126 patients (25%) whose prostate specific antigen (PSA) levels have been monitored post-RT. At 24 and 36 months, 85% and 75% of patients were BCR-free, respectively. Patients with a pre-RT PSA above 0.2 ng/mL had a higher probability of recurrence than patients with values below 0.2 ng/mL (P = 0.03). RT technique, pelvic nodal irradiation, androgen deprivation therapy, T staging or surgical margin did not significantly impact BCR results. No patient experienced acute toxicities greater than grade 2. Grade 1 or 2 late gastrointestinal (GI) toxicity occurred in 11% and 1 patient experienced a grade 3 event. 12% of patients developed grade 1 or 2 late genitourinary (GU) toxicity, with evidence of grade 3 severity in only 1 patient. Evidence of a trend in reduction in late GI toxicity with the use of intensity modulated radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT) was apparent but not with late GU toxicity. CONCLUSION At our regional centre, early RT (PSA < 0.2 ng/mL) was associated with significant improvement in BCR-free survival. Rates of toxicity mirror those of landmark trials which suggest no detriment for our regional prostate cancer patients. The use of IMRT/VMAT techniques was associated with a trend towards reduced rates of GI toxicity.
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Affiliation(s)
- Luke Nicholls
- Radiation Oncology Centres, St Andrews Cancer Care, Toowoomba, Queensland, Australia.,School of Medicine, University of Queensland, St Lucia, Brisbane, Queensland, Australia
| | - Amber Winter
- Radiation Oncology Centres, St Andrews Cancer Care, Toowoomba, Queensland, Australia
| | - Ashley Harwood
- Radiation Oncology Centres, St Andrews Cancer Care, Toowoomba, Queensland, Australia
| | - Ashley Plank
- Oncology Research Australia, St Andrews Cancer Care, Toowoomba, Queensland, Australia
| | - Preeti Bagga
- Radiation Oncology Centres, St Andrews Cancer Care, Toowoomba, Queensland, Australia
| | - Winnie Wong
- Radiation Oncology Centres, St Andrews Cancer Care, Toowoomba, Queensland, Australia
| | - Eric Khoo
- Radiation Oncology Centres, St Andrews Cancer Care, Toowoomba, Queensland, Australia.,School of Medicine, University of Queensland, St Lucia, Brisbane, Queensland, Australia
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Lipman D, Pieters BR, De Reijke TM. Improving postoperative radiotherapy following radical prostatectomy. Expert Rev Anticancer Ther 2017; 17:925-937. [PMID: 28787182 DOI: 10.1080/14737140.2017.1364994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Prostate cancer has one of the highest incidences in the world, with good curative treatment options like radiotherapy and radical prostatectomy. Unfortunately, about 30% of the patients initially treated with curative intent will develop a recurrence and need adjuvant treatment. Five randomized trials covered the role of postoperative radiotherapy after radical prostatectomy, but there is still a lot of debate about which patients should receive postoperative radiotherapy. Areas covered: This review will give an overview on the available literature concerning post-operative radiotherapy following radical prostatectomy with an emphasis on the five randomized trials. Also, new imaging techniques like prostate-specific membrane antigen positron emission tomography (PSMA-PET) and multiparametric magnetic resonance imaging (mp-MRI) and the development of biomarkers like genomic classifiers will be discussed in the search for an improved selection of patients who will benefit from postoperative radiotherapy following radical prostatectomy. With new treatment techniques like Intensity Modulated Radiotherapy, toxicity profiles will be kept low. Expert commentary: Patients with biochemical recurrence following radical prostatectomy with an early rise in prostate-specific antigen (PSA) will benefit most from postoperative radiotherapy. In this way, patients with only high risk pathological features can avoid unnecessary treatment and toxicity, and early intervention in progressing patients would not compromise the outcome.
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Affiliation(s)
- D Lipman
- a Department of Radiation Oncology , Academic Medical Center/University of Amsterdam , Amsterdam , The Netherlands
| | - B R Pieters
- a Department of Radiation Oncology , Academic Medical Center/University of Amsterdam , Amsterdam , The Netherlands
| | - Theo M De Reijke
- b Department of Urology , Academic Medical Center/University of Amsterdam , Amsterdam , The Netherlands
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Evaluation of the preimplantation worksheet in determining Calypso eligibility for men prescribed postprostatectomy radiotherapy with electromagnetic transponder guidance. Med Dosim 2017. [PMID: 28648818 DOI: 10.1016/j.meddos.2017.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This study aimed to assess the design and performance of the preimplant suitability worksheet in determining Calypso eligibility for prostate cancer patients prescribed postprostatectomy radiotherapy with electromagnetic transponder guidance. The medical records and radiotherapy planning datasets of 75 patients prospectively recruited between June 2015 and September 2016 to a Phase 2 trial evaluating electromagnetic transponder-guided postprostatectomy radiotherapy were retrospectively examined. Correlation and differences between computed tomography (CT)-defined greater trochanter and prostatic fossa landmarks were evaluated. Receiver operating characteristic curves were also generated to assess the expected and observed accuracy of the worksheet in determining Calypso eligibility. Strong correlation was demonstrated between anterior surface to planning CT-defined greater trochanter and prostate bed center distances (r = 0.95, p <0.001), with a mean difference between measurements of 1.1 cm (95% confidence interval [CI]: 0.9 to 1.3). A similar correlation coefficient was found for surface to greater trochanter location and posterior beacon location (r = 0.92, p <0.001) but with a reduced mean difference of 0.4 cm (95% CI: 0.1 to 0.6). Performance of the worksheet as assessed by planning CT data demonstrated excellent accuracy as a test to determine eligibility (area under the curve: 0.97; 95% CI: 0.92 to 1.00); however, this was not replicated using the same data captured clinically (area under the curve 0.83; 95% CI: 0.68 to 0.98). Although the greater trochanter is a good surrogate for the prostate bed center, it is better associated with the posterior beacon location. As a result, the worksheet will underestimate the truly eligible population if performed accurately and according to manufacturer guidelines. Theoretically, the worksheet could be improved if a cut off of 20 cm is used and the greater trochanter is accurately identified; however, the latter appears to be difficult to achieve in practice.
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50
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Salvage radiotherapy for macroscopic local recurrences after radical prostatectomy. Strahlenther Onkol 2017; 194:9-16. [DOI: 10.1007/s00066-017-1172-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 06/13/2017] [Indexed: 10/19/2022]
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