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Sorce G, Flammia RS, Hoeh B, Chierigo F, Hohenhorst L, Panunzio A, Stabile A, Gandaglia G, Tian Z, Tilki D, Terrone C, Gallucci M, Chun FKH, Antonelli A, Saad F, Shariat SF, Montorsi F, Briganti A, Karakiewicz PI. Grade and stage misclassification in intermediate unfavorable-risk prostate cancer radiotherapy candidates. Prostate 2022; 82:1040-1050. [PMID: 35365851 PMCID: PMC9325037 DOI: 10.1002/pros.24349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/20/2022] [Accepted: 03/22/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND We tested for upgrading (Gleason grade group [GGG] ≥ 4) and/or upstaging to non-organ-confined stage ([NOC] ≥ pT3/pN1) in intermediate unfavorable-risk (IU) prostate cancer (PCa) patients treated with radical prostatectomy, since both change the considerations for dose and/or type of radiotherapy (RT) and duration of androgen deprivation therapy (ADT). METHODS We relied on Surveillance, Epidemiology, and End Results (2010-2015). Proportions of (a) upgrading, (b) upstaging, or (c) upgrading and/or upstaging were tabulated and tested in multivariable logistic regression models. RESULTS We identified 7269 IU PCa patients. Upgrading was recorded in 479 (6.6%) and upstaging in 2398 (33.0%), for a total of 2616 (36.0%) upgraded and/or upstaged patients, who no longer fulfilled the IU grade and stage definition. Prostate-specific antigen, clinical stage, biopsy GGG, and percentage of positive cores, neither individually nor in multivariable logistic regression models, discriminated between upgraded and/or upstaged patients versus others. CONCLUSIONS IU PCa patients showed very high (36%) upgrading and/or upstaging proportion. Interestingly, the overwhelming majority of those were upstaged to NOC. Conversely, very few were upgraded to GGG ≥ 4. In consequence, more than one-third of IU PCa patients treated with RT may be exposed to suboptimal dose and/or type of RT and to insufficient duration of ADT, since their true grade and stage corresponded to high-risk PCa definition, instead of IU PCa. Data about magnetic resonance imaging were not available but may potentially help with better stage discrimination.
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Affiliation(s)
- Gabriele Sorce
- Department of Urology, Division of Experimental OncologyURI, Urological Research Institute, IRCCS San Raffaele Scientific InstituteMilanItaly
- Division of Urology, Cancer Prognostics and Health Outcomes UnitUniversity of Montréal Health CenterMontréalQuébecCanada
| | - Rocco Simone Flammia
- Division of Urology, Cancer Prognostics and Health Outcomes UnitUniversity of Montréal Health CenterMontréalQuébecCanada
- Department of Maternal‐Child and Urological Sciences, Policlinico Umberto I HospitalSapienza University of RomeRomeItaly
| | - Benedikt Hoeh
- Division of Urology, Cancer Prognostics and Health Outcomes UnitUniversity of Montréal Health CenterMontréalQuébecCanada
- Department of UrologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Francesco Chierigo
- Division of Urology, Cancer Prognostics and Health Outcomes UnitUniversity of Montréal Health CenterMontréalQuébecCanada
- Department of Surgical and Diagnostic Integrated Sciences (DISC)University of GenovaGenovaItaly
| | - Lukas Hohenhorst
- Division of Urology, Cancer Prognostics and Health Outcomes UnitUniversity of Montréal Health CenterMontréalQuébecCanada
- Department of UrologyMartini‐Klinik Prostate Cancer Center, University Hospital Hamburg‐EppendorfHamburgGermany
| | - Andrea Panunzio
- Division of Urology, Cancer Prognostics and Health Outcomes UnitUniversity of Montréal Health CenterMontréalQuébecCanada
- Department of UrologyUniversity of Verona, Azienda Ospedaliera Universitaria Integrata di VeronaVeronaItaly
| | - Armando Stabile
- Department of Urology, Division of Experimental OncologyURI, Urological Research Institute, IRCCS San Raffaele Scientific InstituteMilanItaly
| | - Giorgio Gandaglia
- Department of Urology, Division of Experimental OncologyURI, Urological Research Institute, IRCCS San Raffaele Scientific InstituteMilanItaly
| | - Zhe Tian
- Division of Urology, Cancer Prognostics and Health Outcomes UnitUniversity of Montréal Health CenterMontréalQuébecCanada
| | - Derya Tilki
- Department of UrologyMartini‐Klinik Prostate Cancer Center, University Hospital Hamburg‐EppendorfHamburgGermany
- Department of UrologyUniversity Hospital Hamburg‐EppendorfHamburgGermany
- Department of UrologyKoc University HospitalInstanbulTurkey
| | - Carlo Terrone
- Department of Surgical and Diagnostic Integrated Sciences (DISC)University of GenovaGenovaItaly
| | - Michele Gallucci
- Department of Maternal‐Child and Urological Sciences, Policlinico Umberto I HospitalSapienza University of RomeRomeItaly
| | - Felix K. H. Chun
- Department of UrologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Alessandro Antonelli
- Department of UrologyUniversity of Verona, Azienda Ospedaliera Universitaria Integrata di VeronaVeronaItaly
| | - Fred Saad
- Division of Urology, Cancer Prognostics and Health Outcomes UnitUniversity of Montréal Health CenterMontréalQuébecCanada
| | - Shahrokh F. Shariat
- Departments of UrologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
- Department of UrologyUniversity of Texas SouthwesternDallasTexasUSA
- Department of Urology, Second Faculty of MedicineCharles UniversityPragaCzech Republic
- Department of Urology, Institute for Urology and Reproductive HealthI.M. Sechenov First Moscow State Medical UniversityMoscowRussia
- Division of Urology, Hourani Center for Applied Scientific ResearchAl‐Ahliyya Amman UniversityAmmanJordan
- Department of Urology, Comprehensive Cancer CenterMedical University of ViennaViennaAustria
| | - Francesco Montorsi
- Department of Urology, Division of Experimental OncologyURI, Urological Research Institute, IRCCS San Raffaele Scientific InstituteMilanItaly
| | - Alberto Briganti
- Department of Urology, Division of Experimental OncologyURI, Urological Research Institute, IRCCS San Raffaele Scientific InstituteMilanItaly
| | - Pierre I. Karakiewicz
- Division of Urology, Cancer Prognostics and Health Outcomes UnitUniversity of Montréal Health CenterMontréalQuébecCanada
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Shakespeare TP, Eggert E, Wood M, Westhuyzen J, Turnbull K, Rutherford N, Aherne N. PSMA-PET guided dose-escalated volumetric arc therapy (VMAT) for newly diagnosed lymph node positive prostate cancer: Efficacy and toxicity outcomes at two years. Radiother Oncol 2019; 141:188-191. [PMID: 31668514 DOI: 10.1016/j.radonc.2019.09.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/26/2019] [Accepted: 09/29/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE/OBJECTIVES There are no published reports of prostate specific membrane antigen (PSMA) positron emission tomography (PET) guided dose-escalated intensity-modulated radiation therapy (DE-IMRT) in newly diagnosed lymph node (LN) positive prostate cancer. We report early toxicity and efficacy outcomes with this approach. MATERIALS/METHODS Patients with newly diagnosed high-risk prostate cancer were staged using PSMA PET, computed tomography (CT) and bone scans. Patients with LN positive-only metastases were offered curative therapy using 3 months androgen deprivation therapy (ADT) followed by DE-IMRT (using volumetric arc therapy), and 3 years adjuvant ADT. All patients had fiducial marker insertion, with privately insured patients having spacer hydrogel insertion. PET and prostate magnetic resonance imaging were fused with the planning CT. We aimed to deliver 81 Gy in 45 fractions (Fx) to the prostate and PET-positive LNs, and 60 Gy in 45Fx to bilateral elective pelvic LNs. RESULTS In all, 46 patients were treated, with 83% Gleason 8-10, 67% T3/T4, median number of LNs 2 (range 1-6), and median PET-positive LN volume 1.14 cc (range 0.15-4.14). LNs were outside of standard contouring guidelines in 37% of patients. The mean PET-positive LN clinical target volume dose ranged from 73.3 to 85.9 Gy (median 83.6 Gy). With 24 months median follow-up, two year failure-free survival was 100%, and 2 year overall survival 95.7%. Acute grade 1 and 2 GI toxicity occurred in 48 and 11% of patients, and GU toxicity in 72 and 24%. Late grade 1, 2 and 3 GI toxicity occurred in 13, 2 and 0%, and GU toxicity 28, 13 and 4%. No toxicity was attributable to the high dose LN boost. CONCLUSIONS PSMA PET-guided DE-IMRT up to 81 Gy to the prostate and involved LNs, and long term ADT, is a promising approach for newly diagnosed LN positive prostate cancer. LN contouring guidelines require re-evaluation in the era of PSMA PET imaging.
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Affiliation(s)
| | - Elizabeth Eggert
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Port Macquarie, Australia
| | - Maree Wood
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, Australia
| | - Justin Westhuyzen
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, Australia
| | - Kirsty Turnbull
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, Australia
| | - Natalie Rutherford
- Nuclear Medicine and PET Department, John Hunter Hospital, Newcastle, Australia
| | - Noel Aherne
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, Australia; Faculty of Medicine, University of New South Wales, Australia
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de Leon JF, Kneebone A, Gebski V, Cross S, Do V, Hayden A, Ngo D, Sidhom M, Turner S. Long-term outcomes in 1121 Australian prostate cancer patients treated with definitive radiotherapy. J Med Imaging Radiat Oncol 2018; 63:116-123. [PMID: 30188601 DOI: 10.1111/1754-9485.12797] [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] [Received: 02/28/2018] [Accepted: 08/07/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Optimal definitive treatment of prostate cancer is controversial, especially in high-risk patients. We report the largest prospective cohort of Australian patients treated with radiotherapy for localised prostate cancer. METHODS One thousand, one hundred and twenty-one patients with prostate cancer were prospectively registered and treated to a dose of 70-74 Gy. Patients were classified as low, intermediate or high risk based on PSA, clinical staging and Gleason score. Intermediate-risk patients were treated with 0-6 months of hormonal therapy (ADT) and high-risk patients were offered neoadjuvant and adjuvant ADT. Overall survival (OS) and biochemical relapse-free survival (bNED) were calculated using the Kaplan-Meier method. RESULTS Median follow-up was 92 months. Eight-year OS and bNED were 78.4% and 68.1% respectively in the entire cohort. OS for the low, intermediate and high-risk groups was 84.5%, 78.4% and 68% respectively. For these risk groups, bNED was 80.3%, 65.7% and 53.7% respectively. In the intermediate and high-risk group, OS and bNED decreased with increasing number of risk factors. CONCLUSION Definitive radiotherapy is an effective treatment for prostate cancer, including in high-risk cases.
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Affiliation(s)
- Jeremiah F de Leon
- Department of Radiation Oncology, Illawarra Cancer Care Centre, Wollongong, New South Wales, Australia
| | - Andrew Kneebone
- Northern Sydney Cancer Centre, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Val Gebski
- University of Sydney, Sydney, New South Wales, Australia.,NHMRC Clinical Trials Centre, Sydney, New South Wales, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Shamira Cross
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Nepean Cancer Centre, Sydney, New South Wales, Australia
| | - Viet Do
- Nepean Cancer Centre, Sydney, New South Wales, Australia.,Liverpool and Macarthur Cancer Therapy Centre, Sydney, New South Wales, Australia.,University of New South Wales, New South Wales, Australia
| | - Amy Hayden
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Nepean Cancer Centre, Sydney, New South Wales, Australia
| | - Diana Ngo
- Liverpool and Macarthur Cancer Therapy Centre, Sydney, New South Wales, Australia
| | - Mark Sidhom
- Liverpool and Macarthur Cancer Therapy Centre, Sydney, New South Wales, Australia.,University of New South Wales, New South Wales, Australia
| | - Sandra Turner
- University of Sydney, Sydney, New South Wales, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
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Tomita N, Soga N, Ogura Y, Furusawa J, Shimizu H, Adachi S, Tanaka H, Kato D, Koide Y, Makita C, Tachibana H, Kodaira T. Effects of dose-escalated radiotherapy in combination with long-term androgen deprivation on prostate cancer. Br J Radiol 2017; 91:20170431. [PMID: 29166142 DOI: 10.1259/bjr.20170431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE We aimed to examine the effects of a dose escalation for prostate cancer patients receiving long-term androgen deprivation therapy (ADT). METHODS A retrospective analysis of 605 patients treated with radiotherapy (RT) and long-term ADT (National Comprehensive Cancer Network criteria-defined intermediate-risk, minimum 10 months; high-risk and very-high-risk, minimum 20 months) was performed. The median ADT time was 31 months. Cox's proportional hazards models were used to compare biochemical disease-free survival (bDFS), clinical relapse-free survival (cRFS) and overall survival (OS) between the ≥70, <78 Gy group and 78 Gy group in a univariate analysis and to assess the effects of the dose escalation on bDFS in a multivariate analysis. RESULTS After a median follow-up of 70 months, 5-year bDFS was significantly better in the 78 Gy group than in the ≥70, <78 Gy group [96 vs 83%; hazard ratio 3.6 (95% confidence interval 2.2-6.1); p < 0.001]. 5-year cRFS and OS were similar between the two groups. The multivariate analysis showed that RT dose was still an independent prognostic factor of bDFS (p = 0.005). CONCLUSION The results of the present study suggest that dose escalations result in significant improvements in bDFS, even when used in combination with long-term ADT. A longer follow-up is needed to clarify the effects of dose escalations on cRFS and OS. Advances in knowledge: It remains unclear whether high-dose RT is necessary for improving the outcomes of patients receiving long-term ADT. The results suggest that dose escalations result in significant improvements in biochemical control.
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Affiliation(s)
- Natsuo Tomita
- 1 Department of Radiation Oncology , Aichi Cancer Center Hospital , Nagoya , Japan
| | - Norihito Soga
- 2 Department of Urology,Aichi Cancer Center Hospital , Aichi Cancer Center Hospital , Nagoya , Japan
| | - Yuji Ogura
- 2 Department of Urology,Aichi Cancer Center Hospital , Aichi Cancer Center Hospital , Nagoya , Japan
| | - Jun Furusawa
- 2 Department of Urology,Aichi Cancer Center Hospital , Aichi Cancer Center Hospital , Nagoya , Japan
| | - Hidetoshi Shimizu
- 1 Department of Radiation Oncology , Aichi Cancer Center Hospital , Nagoya , Japan
| | - Sou Adachi
- 1 Department of Radiation Oncology , Aichi Cancer Center Hospital , Nagoya , Japan
| | - Hiroshi Tanaka
- 1 Department of Radiation Oncology , Aichi Cancer Center Hospital , Nagoya , Japan
| | - Daiki Kato
- 1 Department of Radiation Oncology , Aichi Cancer Center Hospital , Nagoya , Japan
| | - Yutaro Koide
- 1 Department of Radiation Oncology , Aichi Cancer Center Hospital , Nagoya , Japan
| | - Chiyoko Makita
- 1 Department of Radiation Oncology , Aichi Cancer Center Hospital , Nagoya , Japan
| | - Hiroyuki Tachibana
- 1 Department of Radiation Oncology , Aichi Cancer Center Hospital , Nagoya , Japan
| | - Takeshi Kodaira
- 1 Department of Radiation Oncology , Aichi Cancer Center Hospital , Nagoya , Japan
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Daoud MA, Aboelnaga EM, Alashry MS, Fathy S, Aletreby MA. Clinical outcome and toxicity evaluation of simultaneous integrated boost pelvic IMRT/VMAT at different dose levels combined with androgen deprivation therapy in prostate cancer patients. Onco Targets Ther 2017; 10:4981-4988. [PMID: 29066917 PMCID: PMC5644603 DOI: 10.2147/ott.s141224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The role of dose escalation in patients receiving long-term androgen deprivation therapy (ADT) is still a controversial issue. The aim of the current study was to evaluate whether dose escalation for ≥76–80 Gy had any advantage in terms of biochemical disease-free survival (BDFS), distant metastasis-free survival (DMFS), or overall survival outcomes over the dose levels from 70 to <76 Gy. Patients and methods The study included a cohort of 24 patients classified with high- and intermediate-risk localized prostate cancer. All patients received ADT, starting at 4–6 months before radiation therapy and continued for a total period of 12–24 months in high-risk patients. The treatment plan was given in two phases. In the first phase, the nodal planning target volume (PTV) and the prostate PTV received 48.6 and 54 Gy, respectively, over 27 fractions. The treatment was applied through intensity-modulated radiation therapy or volumetric modulated arc therapy with a simultaneous integrated boost technique. Results More than half of the patients were in T3–T4 stage, 79.1% of the patients were in the high-risk category, and all patients received ADT. The rate of acute grade II gastrointestinal and genitourinary toxicities in all patients were 41.7% and 62.5%, respectively. The rate of freedom from grade II rectal toxicity at 2 years was 89% and 83% for patients treated with dose levels <76 and ≥76 Gy, respectively. The rate of BDFS at 2 years was 90% and 85% for doses <76 and ≥76 Gy, respectively. The DMFS at 2 years was 100% and 76% for dose levels <76 and ≥76 Gy, respectively. Conclusion In the current study, there were no significant differences in the BDFS and DMFS between patients treated with a dose of <76 and ≥76 Gy, including elective pelvic lymph nodes irradiation combined with ADT.
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Affiliation(s)
- Mohamed A Daoud
- Department of Clinical Oncology and Nuclear Medicine, Mansoura Faculty of Medicine, Mansoura University, Mansoura.,Department of Oncology, Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Engy M Aboelnaga
- Department of Clinical Oncology and Nuclear Medicine, Mansoura Faculty of Medicine, Mansoura University, Mansoura
| | - Mohamed S Alashry
- Department of Clinical Oncology and Nuclear Medicine, Mansoura Faculty of Medicine, Mansoura University, Mansoura
| | - Salwa Fathy
- Department of Radiation, Oncology and Nuclear Medicine, South Egypt Cancer Institute, Assiut University, Assiut
| | - Mostafa A Aletreby
- Department of Oncology, Fakeeh Hospital, Jeddah, Saudi Arabia.,Department of Medical Physics, Kasr Alainy Faculty of Medicine, Al Manial, Egypt
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