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Xu D, Descovich M, Liu H, Lao Y, Gottschalk AR, Sheng K. Deep match: A zero-shot framework for improved fiducial-free respiratory motion tracking. Radiother Oncol 2024; 194:110179. [PMID: 38403025 DOI: 10.1016/j.radonc.2024.110179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/24/2024] [Accepted: 02/16/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND AND PURPOSE Motion management is essential to reduce normal tissue exposure and maintain adequate tumor dose in lung stereotactic body radiation therapy (SBRT). Lung SBRT using an articulated robotic arm allows dynamic tracking during radiation dose delivery. Two stereoscopic X-ray tracking modes are available - fiducial-based and fiducial-free tracking. Although X-ray detection of implanted fiducials is robust, the implantation procedure is invasive and inapplicable to some patients and tumor locations. Fiducial-free tracking relies on tumor contrast, which challenges the existing tracking algorithms for small (e.g., <15 mm) and/or tumors obscured by overlapping anatomies. To markedly improve the performance of fiducial-free tracking, we proposed a deep learning-based template matching algorithm - Deep Match. METHOD Deep Match consists of four self-definable stages - training-free feature extractor, similarity measurements for location proposal, local refinements, and uncertainty level prediction for constructing a more trustworthy and versatile pipeline. Deep Match was validated on a 10 (38 fractions; 2661 images) patient cohort whose lung tumor was trackable on one X-ray view, while the second view did not offer sufficient conspicuity for tumor tracking using existing methods. The patient cohort was stratified into subgroups based on tumor sizes (<10 mm, 10-15 mm, and >15 mm) and tumor locations (with/without thoracic anatomy overlapping). RESULTS On X-ray views that conventional methods failed to track the lung tumor, Deep Match achieved robust performance as evidenced by >80 % 3 mm-Hit (detection within 3 mm superior/inferior margin from ground truth) for 70 % of patients and <3 mm superior/inferior distance (SID) ∼1 mm standard deviation for all the patients. CONCLUSION Deep Match is a zero-shot learning network that explores the intrinsic neural network benefits without training on patient data. With Deep Match, fiducial-free tracking can be extended to more patients with small tumors and with tumors obscured by overlapping anatomy.
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Affiliation(s)
- Di Xu
- Radiation Oncology, University of California, San Francisco, United States
| | - Martina Descovich
- Radiation Oncology, University of California, San Francisco, United States
| | - Hengjie Liu
- Radiation Oncology, University of California, Los Angeles, United States
| | - Yi Lao
- Radiation Oncology, University of California, Los Angeles, United States
| | | | - Ke Sheng
- Radiation Oncology, University of California, San Francisco, United States.
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Shee K, de la Calle CM, Chang AJ, Wong AC, Feng FY, Gottschalk AR, Carroll PR, Nguyen HG. Addition of Enzalutamide to Leuprolide and Definitive Radiotherapy is Tolerable and Effective in High-Risk Localized or Regional Non-Metastatic Prostate Cancer: Results from a Phase II Trial. Adv Radiat Oncol 2022; 7:100941. [PMID: 35847550 PMCID: PMC9280039 DOI: 10.1016/j.adro.2022.100941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/07/2022] [Indexed: 11/05/2022] Open
Abstract
Background Enzalutamide is an antiandrogen used to treat both metastatic and nonmetastatic prostate cancer. Here we present results from a phase 2 trial designed to determine the safety, tolerability, and efficacy of adding enzalutamide to standard androgen deprivation therapy with radiation therapy in high-risk localized or regional, nonmetastatic patients with prostate cancer. Methods and Materials Enrollment criteria included at least 2 of the following: stage cT3a/b, prostate specific antigen (PSA) ≥20 ng/mL, Gleason grade 8 to 10, ≥33% core involvement on biopsy, or pelvic lymph node involvement on computed tomography or magnetic resonance imaging. Patients with metastatic disease were excluded. All patients received 24 months of leuprolide and enzalutamide, and 5 weeks of intensity modulated radiation therapy followed by a brachytherapy boost. Adverse events (AE), PSA, testosterone, and basic laboratory tests were then followed for up to 36 months. Primary outcomes were safety and tolerability and PSA complete response rate (PSA-CR, defined as PSA ≤0.3). Secondary outcomes included time to biochemical recurrence (BCR; nadir + 2 ng/mL). Results Sixteen patients were enrolled; 2 were ineligible and 3 withdrew before starting treatment. Median age at enrollment was 69.0 years (interquartile range [IQR] 11.5). Median treatment duration was 24.0 months (IQR 11.9). Median follow-up time was 35.5 months (IQR 11.2), and 9 of 11 (81.8%) patients completed the 36 months of follow-up. One of 11 (9%) patients had grade 4 AE (seizure), and no grade 5 AE were reported. Four of 11 (36.4%) patients had grade 3 AE, such as erectile dysfunction and hot flashes. All patients achieved PSA-CR, and median time to PSA-CR was 4.2 months (IQR 1.4). At 24 months follow-up, 0 of 11 (0%) patients had a biochemical recurrence. At 36 months, 1 of 9 (11.1%) patient had a biochemical recurrence. Of note, this patient did not complete the full 24 months of enzalutamide and leuprolide due to AEs. Conclusions Enzalutamide in combination with standard androgen deprivation therapy and radiation therapy was well-tolerated and effective warranting further study in a randomized controlled trial.
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Wu SY, Lazar AA, Gubens MA, Blakely CM, Gottschalk AR, Jablons DM, Jahan TM, Wang VEH, Dunbar TL, Wong ML, Chan JW, Guthrie W, Belkora J, Yom SS. Evaluation of a National Comprehensive Cancer Network Guidelines-Based Decision Support Tool in Patients With Non-Small Cell Lung Cancer: A Nonrandomized Clinical Trial. JAMA Netw Open 2020; 3:e209750. [PMID: 32997124 PMCID: PMC7527870 DOI: 10.1001/jamanetworkopen.2020.9750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
IMPORTANCE The association of guideline-based decision support with the quality of care in patients with non-small cell lung cancer (NSCLC) is not known. OBJECTIVE To evaluate the association of exposure to the National Comprehensive Cancer Center (NCCN) guidelines with guideline-concordant care and patients' decisional conflict. DESIGN, SETTING, AND PARTICIPANTS A nonrandomized clinical trial, conducted at a tertiary care academic institution, enrolled patients from February 23, 2015, to September 28, 2017. Data analysis was conducted from July 19, 2019, to April 22, 2020. A cohort of 76 patients with NSCLC seen at diagnosis or disease progression and a retrospective cohort of 157 patients treated before the trial were included. Adherence to 6 NCCN recommendations were evaluated: (1) smoking cessation counseling, (2) adjuvant chemotherapy for patients with stage IB to IIB NSCLC after surgery, (3) pathologic mediastinal staging in patients with stage III NSCLC before surgery, (4) pathologic mediastinal staging in patients with stage III NSCLC before nonsurgical treatment, (5) definitive chemoradiotherapy for patients with stage III NSCLC not having surgery, and (6) molecular testing for epidermal growth factor receptor and anaplastic lymphoma kinase alterations for patients with stage IV NSCLC. Subgroup analysis was conducted to compare the rates of guideline concordance between the prospective and retrospective cohorts. Secondary end points included decisional conflict and satisfaction. INTERVENTIONS An online tool customizing the NCCN guidelines to patients' clinical and pathologic features was used during consultation, facilitated by a trained coordinator. MAIN OUTCOMES AND MEASURES Concordance of practice with 6 NCCN treatment recommendations on NSCLC and patients' decisional conflict. RESULTS Of the 76 patients with NSCLC, 44 were men (57.9%), median age at diagnosis was 68 years (interquartile range [IQR], 41-87 years), and 59 patients (77.6%) had adenocarcinoma. In the retrospective cohort, 91 of 157 patients (58.0%) were men, median age at diagnosis was 66 years (IQR, 61-65 years), and 105 patients (66.9%) had adenocarcinoma. After the intervention, patients received more smoking cessation counseling (4 of 5 [80.0%] vs 1 of 24 [4.2%], P < .001) and less adjuvant chemotherapy (0 of 7 vs 7 of 11 [63.6%]; P = .012). There was no significant change in mutation testing of non-squamous cell stage IV disease (20 of 20 [100%] vs 48 of 57 [84.2%]; P = .10). There was no significant change in pathologic mediastinal staging or initial chemoradiotherapy for patients with stage III disease. After consultation with the tool, decisional conflict scores improved by a median of 20 points (IQR, 3-34; P < .001). CONCLUSIONS AND RELEVANCE The findings of this study suggest that exposure to the NCCN guidelines is associated with increased guideline-concordant care for 2 of 6 preselected recommendations and improvement in decisional conflict. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03982459.
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Affiliation(s)
- Susan Y. Wu
- Department of Radiation Oncology, University of California, San Francisco
| | - Ann A. Lazar
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Matthew A. Gubens
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco
| | - Collin M. Blakely
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco
| | | | | | - Thierry M. Jahan
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco
| | - Victoria E. H. Wang
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco
| | - Taylor L. Dunbar
- Department of Radiation Oncology, University of California, San Francisco
| | - Melisa L. Wong
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco
| | - Jason W. Chan
- Department of Radiation Oncology, University of California, San Francisco
| | | | - Jeff Belkora
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Sue S. Yom
- Department of Radiation Oncology, University of California, San Francisco
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de la Calle CM, Chang A, Rashid G, Wong AC, Choi A, Feng FY, Gottschalk AR, Menzel PL, Carroll P, Nguyen HG. Phase II trial of definitive radiotherapy with leuprolide and enzalutamide in high-risk prostate cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
323 Background: Adding enzalutamide to standard LHRH agonist and primary radiation therapy may improve the outcomes in patients with high-risk prostate cancer. Methods: All patients met at least 2 of the following criteria: stage cT3a/b, PSA≥20 ng/mL, Gleason Grade 8-10, ≥33% core involvement on biopsy; or had pelvic lymph node involvement ≥1cm on CT or MRI. All patients were started on 24 months of leuprolide and enzalutamide and then underwent 5 weeks of IMRT (whole pelvis, 45Gy total) followed by a brachytherapy boost. PSA, Testosterone (T) and basic labs were followed during and after treatment. Primary outcome was to assess the safety, tolerability, and feasibility of the protocol and PSA complete response (PSA-CR, defined as PSA nadir ≤0.3). Secondary outcomes included: time to biochemical recurrence (BCR) and progression free survival (PFS). Results: 16 patients were enrolled, 2 were not eligible and 3 withdrew before starting treatment. Mean age at enrollment was 68.6 years (SD 9.4). Median follow up time was 28.27 months (IQR 27.3 – 29.1 months). Median time to PSA-CR was 4.20 months (IQR 3.47 – 4.87 months). Currently all patients still have PSA-CR (Table), and none have BCR per ASTRO Phoenix criteria. All-cause, any grade adverse events (AE) were reported in all 11 (100%) patients with 4 (36.4%) experiencing grade 3 AE. One (9.09%) treatment related serious AE (seizure) occurred. There were no grade 5 AE (death related to AE). 4 subjects stopped treatment early due to: seizure, myalgias, hematuria and social reasons. Most patients however were able to complete the 24 months of leuprolide and enzalutamide: median treatment duration was 24.0 months (IQR 12.1 – 24.0 months). Conclusions: Most patients were able to tolerate and complete the entire 24 months of treatment as originally planned. Currently no patients have met criteria for PSA recurrence. Will plan to follow up patients until month 36 to help determine true BCR rates and PFS. Clinical trial information: NCT02508636. [Table: see text]
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Affiliation(s)
| | - Albert Chang
- University of California, San Francisco, San Francisco, CA
| | - Ghezal Rashid
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Anthony C. Wong
- Dept. of Radiation Oncology, University of California, San Francisco, San Francisco, CA
| | - Alice Choi
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Felix Y Feng
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | | | | | - Peter Carroll
- University of California-San Francisco, San Francisco, CA
| | - Hao Gia Nguyen
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
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Chapman CH, McGuinness C, Gottschalk AR, Yom SS, Garsa AA, Anwar M, Braunstein SE, Sudhyadhom A, Keall P, Descovich M. Influence of respiratory motion management technique on radiation pneumonitis risk with robotic stereotactic body radiation therapy. J Appl Clin Med Phys 2018; 19:48-57. [PMID: 29700954 PMCID: PMC6036380 DOI: 10.1002/acm2.12338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 01/19/2018] [Accepted: 03/20/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE/OBJECTIVES For lung stereotactic body radiation therapy (SBRT), real-time tumor tracking (RTT) allows for less radiation to normal lung compared to the internal target volume (ITV) method of respiratory motion management. To quantify the advantage of RTT, we examined the difference in radiation pneumonitis risk between these two techniques using a normal tissue complication probability (NTCP) model. MATERIALS/METHOD 20 lung SBRT treatment plans using RTT were replanned with the ITV method using respiratory motion information from a 4D-CT image acquired at the original simulation. Risk of symptomatic radiation pneumonitis was calculated for both plans using a previously derived NTCP model. Features available before treatment planning that identified significant increase in NTCP with ITV versus RTT plans were identified. RESULTS Prescription dose to the planning target volume (PTV) ranged from 22 to 60 Gy in 1-5 fractions. The median tumor diameter was 3.5 cm (range 2.1-5.5 cm) with a median volume of 14.5 mL (range 3.6-59.9 mL). The median increase in PTV volume from RTT to ITV plans was 17.1 mL (range 3.5-72.4 mL), and the median increase in PTV/lung volume ratio was 0.46% (range 0.13-1.98%). Mean lung dose and percentage dose-volumes were significantly higher in ITV plans at all levels tested. The median NTCP was 5.1% for RTT plans and 8.9% for ITV plans, with a median difference of 1.9% (range 0.4-25.5%, pairwise P < 0.001). Increases in NTCP between plans were best predicted by increases in PTV volume and PTV/lung volume ratio. CONCLUSIONS The use of RTT decreased the risk of radiation pneumonitis in all plans. However, for most patients the risk reduction was minimal. Differences in plan PTV volume and PTV/lung volume ratio may identify patients who would benefit from RTT technique before completing treatment planning.
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Affiliation(s)
| | | | | | - Sue S Yom
- Department of Radiation Oncology, University of California San, Francisco, CA, USA
| | - Adam A Garsa
- Department of Radiation Oncology, University of California San, Francisco, CA, USA
| | - Mekhail Anwar
- Department of Radiation Oncology, University of California San, Francisco, CA, USA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San, Francisco, CA, USA
| | - Atchar Sudhyadhom
- Department of Radiation Oncology, University of California San, Francisco, CA, USA
| | - Paul Keall
- Sydney Medical School, University of Sydney, Camperdown, Australia
| | - Martina Descovich
- Department of Radiation Oncology, University of California San, Francisco, CA, USA
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Paulsson AK, Yom SS, Anwar M, Pinnaduwage D, Sudhyadhom A, Gottschalk AR, Chang AJ, Descovich M. Respiration-Induced Intraorgan Deformation of the Liver: Implications for Treatment Planning in Patients Treated With Fiducial Tracking. Technol Cancer Res Treat 2017; 16:776-782. [PMID: 28071340 PMCID: PMC5762032 DOI: 10.1177/1533034616687193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/06/2016] [Accepted: 11/30/2016] [Indexed: 11/15/2022] Open
Abstract
Stereotactic body radiation therapy is a well-tolerated modality for the treatment of primary and metastatic liver lesions, and fiducials are often used as surrogates for tumor tracking during treatment. We evaluated respiratory-induced liver deformation by measuring the rigidity of the fiducial configuration during the breathing cycle. Seventeen patients, with 18 distinct treatment courses, were treated with stereotactic body radiosurgery using multiple fiducials. Liver deformation was empirically quantified by measuring the intrafiducial distances at different phases of respiration. Data points were collected at the 0%, 50%, and 100% inspiration points, and the distance between each pair of fiducials was measured at the 3 phases. The rigid body error was calculated as the maximum difference in the intrafiducial distances. Liver disease was calculated with Child-Pugh score using laboratory values within 3 months of initiation of treatment. A peripheral fiducial was defined as within 1.5 cm of the liver edge, and all other fiducials were classified as central. For 5 patients with only peripheral fiducials, the fiducial configuration had more deformation (average maximum rigid body error 7.11 mm, range: 1.89-11.35 mm) when compared to patients with both central and peripheral and central fiducials only (average maximum rigid body error 3.36 mm, range: 0.5-9.09 mm, P = .037). The largest rigid body errors (11.3 and 10.6 mm) were in 2 patients with Child-Pugh class A liver disease and multiple peripheral fiducials. The liver experiences internal deformation, and the fiducial configuration should not be assumed to act as a static structure. We observed greater deformation at the periphery than at the center of the liver. In our small data set, we were not able to identify cirrhosis, which is associated with greater rigidity of the liver, as predictive for deformation. Treatment planning based only on fiducial localization must take potential intraorgan deformation into account.
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Affiliation(s)
- Anna K. Paulsson
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Sue S. Yom
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Mekhail Anwar
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Dilini Pinnaduwage
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Atchar Sudhyadhom
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Alexander R. Gottschalk
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Albert J. Chang
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Martina Descovich
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
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Zaorsky NG, Showalter TN, Ezzell GA, Nguyen PL, Assimos DG, D'Amico AV, Gottschalk AR, Gustafson GS, Keole SR, Liauw SL, Lloyd S, McLaughlin PW, Movsas B, Prestidge BR, Taira AV, Vapiwala N, Davis BJ. ACR Appropriateness Criteria for external beam radiation therapy treatment planning for clinically localized prostate cancer, part II of II. Adv Radiat Oncol 2017; 2:437-454. [PMID: 29114613 PMCID: PMC5605284 DOI: 10.1016/j.adro.2017.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 03/10/2017] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To present the most updated American College of Radiology (ACR) Appropriateness Criteria formed by an expert panel on the appropriate delivery of external beam radiation to manage stage T1 and T2 prostate cancer (in the definitive setting and post-prostatectomy) and to provide clinical variants with expert recommendations based on accompanying Appropriateness Criteria for target volumes and treatment planning. METHODS AND MATERIALS The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a panel of multidisciplinary experts. The guideline development and revision process includes an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In instances in which evidence is lacking or equivocal, expert opinion may supplement available evidence to recommend imaging or treatment. RESULTS The panel summarizes the most recent and relevant literature on the topic, including organ motion and localization methods, image guidance, and delivery techniques (eg, 3-dimensional conformal intensity modulation). The panel presents 7 clinical variants, including (1) a standard case and cases with (2) a distended rectum, (3) a large-volume prostate, (4) bilateral hip implants, (5) inflammatory bowel disease, (6) prior prostatectomy, and (7) a pannus extending into the radiation field. Each case outlines the appropriate techniques for simulation, treatment planning, image guidance, dose, and fractionation. Numerical rating and commentary is given for each treatment approach in each variant. CONCLUSIONS External beam radiation is a key component of the curative management of T1 and T2 prostate cancer. By combining the most recent medical literature, these Appropriateness Criteria can aid clinicians in determining the appropriate treatment delivery and personalized approaches for individual patients.
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Affiliation(s)
| | | | - Gary A. Ezzell
- Mayo Clinic, Phoenix, Arizona (research author [contributing])
| | - Paul L. Nguyen
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts (panel vice-chair)
| | - Dean G. Assimos
- University of Alabama School of Medicine, Birmingham, Alabama (American Urological Association)
| | - Anthony V. D'Amico
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts (American Society of Clinical Oncology)
| | | | | | | | | | - Shane Lloyd
- Huntsman Cancer Hospital, Salt Lake City, Utah
| | | | | | | | - Al V. Taira
- Mills Peninsula Hospital, San Mateo, California
| | - Neha Vapiwala
- University of Pennsylvania, Philadelphia, Pennsylvania
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8
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Davis BJ, Taira AV, Nguyen PL, Assimos DG, D'Amico AV, Gottschalk AR, Gustafson GS, Keole SR, Liauw SL, Lloyd S, McLaughlin PW, Movsas B, Prestidge BR, Showalter TN, Vapiwala N. ACR appropriateness criteria: Permanent source brachytherapy for prostate cancer. Brachytherapy 2016; 16:266-276. [PMID: 27964905 DOI: 10.1016/j.brachy.2016.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 10/10/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE To provide updated American College of Radiology (ACR) appropriateness criteria for transrectal ultrasound-guided transperineal interstitial permanent source brachytherapy. METHODS AND MATERIALS The ACR appropriateness criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. RESULTS Permanent prostate brachytherapy (PPB) is a treatment option for appropriately selected patients with localized prostate cancer with low to very high risk disease. PPB monotherapy remains an appropriate and effective curative treatment for low-risk prostate cancer patients demonstrating excellent long-term cancer control and acceptable morbidity. PPB monotherapy can be considered for select intermediate-risk patients with multiparametric MRI useful in evaluation of such patients. High-risk patients treated with PPB should receive supplemental external beam radiotherapy (EBRT) along with androgen deprivation. Similarly, patients with involved pelvic lymph nodes may also be considered for such combined treatment but reported long-term outcomes are limited. Computed tomography-based postimplant dosimetry completed within 60 days of PPB is essential for quality assurance. PPB may be considered for treatment of local recurrence after EBRT but is associated with an increased risk of toxicity. CONCLUSIONS Updated appropriateness criteria for patient evaluation, selection, treatment, and postimplant dosimetry are given. These criteria are intended to be advisory only with the final responsibility for patient care residing with the treating clinicians.
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Affiliation(s)
- Brian J Davis
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN.
| | - Al V Taira
- Dorothy Schneider Cancer Center, San Mateo, CA
| | - Paul L Nguyen
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Dean G Assimos
- Department of Urology, University of Alabama School of Medicine, Birmingham, AL; American Urological Association, Linthicum, MD
| | - Anthony V D'Amico
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA; American Society of Clinical Oncology, Alexandria, VA
| | - Alexander R Gottschalk
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | | | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic Scottsdale, Phoenix, AZ
| | - Stanley L Liauw
- Department of Radiation and Cellular Oncology, The University of Chicago Medical Center, Chicago, IL
| | - Shane Lloyd
- Department of Radiation Oncology, Huntsman Cancer Hospital, Salt Lake City, UT
| | | | - Benjamin Movsas
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI
| | | | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
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9
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Zaorsky NG, Showalter TN, Ezzell GA, Nguyen PL, Assimos DG, D'Amico AV, Gottschalk AR, Gustafson GS, Keole SR, Liauw SL, Lloyd S, McLaughlin PW, Movsas B, Prestidge BR, Taira AV, Vapiwala N, Davis BJ. ACR Appropriateness Criteria ® external beam radiation therapy treatment planning for clinically localized prostate cancer, part I of II. Adv Radiat Oncol 2016; 2:62-84. [PMID: 28740916 PMCID: PMC5514238 DOI: 10.1016/j.adro.2016.10.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/12/2016] [Indexed: 12/24/2022] Open
Affiliation(s)
| | | | | | - Gary A Ezzell
- Mayo Clinic, Phoenix, Arizona (research author, contributing)
| | - Paul L Nguyen
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts (panel vice-chair)
| | - Dean G Assimos
- University of Alabama School of Medicine, Birmingham, Alabama (American Urological Association)
| | - Anthony V D'Amico
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts (American Society of Clinical Oncology)
| | | | | | | | | | - Shane Lloyd
- Huntsman Cancer Hospital, Salt Lake City, Utah
| | | | | | | | - Al V Taira
- Mills Peninsula Hospital, San Mateo, California
| | - Neha Vapiwala
- University of Pennsylvania, Philadelphia, Pennsylvania
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Garcia MM, Gottschalk AR, Brajtbord J, Konety BR, Meng MV, Roach M, Carroll PR. Correction: Endoscopic Gold Fiducial Marker Placement into the Bladder Wall to Optimize Radiotherapy Targeting for Bladder-Preserving Management of Muscle-Invasive Bladder Cancer: Feasibility and Initial Outcomes. PLoS One 2016; 11:e0164558. [PMID: 27711167 PMCID: PMC5053526 DOI: 10.1371/journal.pone.0164558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pone.0089754.].
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Woodard GA, Crockard JC, Clary-Macy C, Zoon-Besselink CT, Jones K, Korn WM, Ko AH, Gottschalk AR, Rogers SJ, Jablons DM. Hybrid minimally invasive Ivor Lewis esophagectomy after neoadjuvant chemoradiation yields excellent long-term survival outcomes with minimal morbidity. J Surg Oncol 2016; 114:838-847. [PMID: 27569043 DOI: 10.1002/jso.24409] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 07/31/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND There is a clear survival benefit to neoadjuvant chemoradiation prior to esophagectomy for patients with stages II-III esophageal cancer. A minimally invasive esophagectomy approach may decrease morbidity but is more challenging in a previously radiated field and therefore patients who undergo neoadjuvant chemoradiation may experience more postoperative complications. METHODS A prospective database of all esophageal cancer patients who underwent attempted hybrid minimally invasive Ivor Lewis esophagectomy was maintained between 2006 and 2015. The clinical characteristics, neoadjuvant treatments, perioperative complications, and survival outcomes were reviewed. RESULTS Overall 30- and 90-day mortality rates were 0.8% (1/131) and 2.3% (3/131), respectively. The majority of patients 58% (76/131) underwent induction treatment without significant adverse impact on mortality, major complications, or hospital stay. Overall survival at 1, 3, and 5 years was 85.9%, 65.3%, and 53.9%. Five-year survival by pathologic stage was stage I 68.9%, stage II 54.0%, and stage III 29.6%. CONCLUSIONS The hybrid minimally invasive Ivor Lewis esophagectomy approach results in low perioperative morbidity and mortality and is well tolerated after neoadjuvant chemoradiation. Good long-term overall survival rates likely resulted from combined concurrent neoadjuvant chemoradiation in the majority of patients, which did not impact the ability to safely perform the operation or postoperative complications rates. J. Surg. Oncol. 2016;114:838-847. © 2016 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Gavitt A Woodard
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Jane C Crockard
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Carolyn Clary-Macy
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Clara T Zoon-Besselink
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Kirk Jones
- Department of Pathology, University of California San Francisco, San Francisco, California
| | - Wolfgang Michael Korn
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, California
| | - Andrew H Ko
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, California
| | - Alexander R Gottschalk
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Stanley J Rogers
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - David M Jablons
- Department of Surgery, University of California San Francisco, San Francisco, California.
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12
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Zhang L, Johnson J, Gottschalk AR, Chang AJ, Hsu IC, Roach M, Seymour ZA. Receiver operating curves and dose-volume analysis of late toxicity with stereotactic body radiation therapy for prostate cancer. Pract Radiat Oncol 2016; 7:e109-e116. [PMID: 28274401 DOI: 10.1016/j.prro.2016.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 07/05/2016] [Accepted: 07/11/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this study was to evaluate a receiver operating characteristic (ROC) curve method to determine dose thresholds with late genitourinary (GU) toxicity after stereotactic body radiation therapy for prostate cancer. METHODS AND MATERIALS Seventy-eight patients diagnosed with low- to intermediate-risk prostate cancer and treated with stereotactic body radiation therapy alone were reviewed retrospectively. All patients received a total dose of 38 Gy in 4 fractions with a planning target volume expansion of 2 mm. GU toxicity was documented according to the Common Terminology Criteria for Adverse Events, version 4. ROC analysis applied on a logistic regression model was used to determine optimal dosimetric parameters for GU toxicity. RESULTS The median age at treatment was 69 years with a median prostate volume of 46.2 mL. The median prescription isodose line was 67% (interquartile range, 65, 70). The median clinical follow-up was 35.49 months. Late grade 1, 2, and 3 GU toxicity occurred in 21.8%, 19.2%, and 2.6% of cases, respectively. Late grade 2+ GU toxicity was associated with prescription to isodose line (P = .009) and normalized volumes for heterogeneity ≥46 Gy. The ROC method successfully produced thresholds for dose-volume recommendations for both prostate and urethra, including normalized prostate volumes from 46 to 50 Gy, such as volume of target tissue receiving 46% of the prescribed dose (V46) Gy of 36.7% (sensitivity, 71%; specificity, 61%; area under the curve, 0.67) with an associated probability of late GU grade 2+ toxicity of 21%. CONCLUSIONS Intraprostatic heterogeneity should be controlled with potential thresholds at V46 Gy <36.7%, V48 Gy <21%, and V50 Gy <9.5% of the normalized prostate volume to keep late grade 2+ GU toxicity ≤20% with 4-fraction schemes. This may be facilitated with a higher prescription isodose line (>69%).
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Affiliation(s)
- Li Zhang
- Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, California; Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, California
| | - Julian Johnson
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California
| | - Alexander R Gottschalk
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California
| | - Albert J Chang
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California
| | - I-Chow Hsu
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California
| | - Mack Roach
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California; Department of Urology, University of California at San Francisco, San Francisco, California
| | - Zachary A Seymour
- Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, Beaumont Health System, Royal Oak, Michigan.
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Kannarunimit D, Descovich M, Garcia A, Chen J, Weinberg V, Mcguinness C, Pinnaduwage D, Murnane J, Gottschalk AR, Yom SS. Analysis of Dose Distribution and Risk of Pneumonitis in Stereotactic Body Radiation Therapy for Centrally Located Lung Tumors. Technol Cancer Res Treat 2016; 14:49-60. [DOI: 10.7785/tcrt.2012.500394] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Stereotactic body radiation therapy (SBRT) to central lung tumors is associated with normal -tissue toxicity. Highly conformal technologies may reduce the risk of complications. This study compares physical dose characteristics and anticipated risks of radiation pneumonitis (RP) among three SBRT modalities: robotic radiosurgery (RR), helical tomotherapy (HT) and volumetric modulated arc therapy (VMAT). Nine patients with central lung tumors ≤5 cm were compared. RR, HT and VMAT plans were developed per RTOG 0831. Dosimetric comparisons included target coverage, conformity index, heterogeneity index, gradient index, maximal dose at 2 cm from target (D2 cm), and dose-volume parameters for organs at risk (OARs). Efficiency endpoints included total beam-on time and monitor units. RP risk was derived from Lyman-Kutcher-Burman modeling on in-house software. The average GTV and PTV were 11.6 ± 7.86 cm3 and 36.8 ± 18.1 cm3. All techniques resulted in similar target coverage (p = 0.64) and dose conformity (p = 0.88). While RR had sharper fall-off gradient (p = 0.002) and lower D2 cm (p = 0.02), HT and VMAT produced greater homogeneity ( p < 0.001) and delivery efficiency (p = 0.001). RP risk predicted from whole or contralateral lung volumes was less than 10%, but was 2-3 times higher using ipsilateral volumes. Using whole (p = 0.04, p = 0.02) or ipsilateral (p = 0.004, p = 0.0008) volumes, RR and VMAT had a lower risk of RP than HT. Using contralateral volumes, RR had the lowest RP risk (p = 0.0002, p = 0.0003 versus HT, VMAT). RR, HT and VMAT were able to provide clinically acceptable plans following the guidelines provided by RTOG 0813. All techniques provided similar coverage and conformity. RR seemed to produce a lower RP risk for a scenario of small PTV-OAR overlap and small PTV. VMAT and HT produced greater homogeneity, potentially desirable for a large PTV-OAR overlap. VMAT probably yields the lowest RP risk for a large PTV. Understanding subtle differences among these technologies may assist in situations where multiple choices of modality are available.
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Affiliation(s)
- Danita Kannarunimit
- Department of Radiation Oncology, King Chulalongkorn University Hospital, Bangkok
| | - Martina Descovich
- Department of Radiation Oncology, University of California, San Francisco
| | - Aaron Garcia
- Department of Radiation Oncology, University of California, San Francisco
| | - Josephine Chen
- Department of Radiation Oncology, University of California, San Francisco
| | - Vivian Weinberg
- Department of Radiation Oncology, University of California, San Francisco
| | | | - Dilini Pinnaduwage
- Department of Radiation Oncology, University of California, San Francisco
| | - John Murnane
- Department of Radiation Oncology, University of California, San Francisco
| | | | - Sue S. Yom
- Department of Radiation Oncology, University of California, San Francisco
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Pinnaduwage DS, Descovich M, Lometti MW, Varad B, Roach M, Gottschalk AR. An Evaluation of Robotic and Conventional IMRT for Prostate Cancer: Potential for Dose Escalation. Technol Cancer Res Treat 2016; 16:267-275. [PMID: 27037301 DOI: 10.1177/1533034616639729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study compares conventional and robotic intensity modulated radiation therapy (IMRT) plans for prostate boost treatments and provides clinical insight into the strengths and weaknesses of each. The potential for dose escalation with robotic IMRT is further investigated using the "critical volume tolerance" method proposed by Roach et al. Three clinically acceptable treatment plans were generated for 10 prostate boost patients: (1) a robotic IMRT plan using fixed cones, (2) a robotic IMRT plan using the Iris variable aperture collimator, and (3) a conventional linac based IMRT (c-IMRT) plan. Target coverage, critical structure doses, homogeneity, conformity, dose fall-off, and treatment time, were compared across plans. The average bladder and rectum V75 was 17.1%, 20.0%, and 21.4%, and 8.5%, 11.9%, and 14.1% for the Iris, fixed, and c-IMRT plans, respectively. On average the conformity index (nCI) was 1.20, 1.30, and 1.46 for the Iris, fixed, and c-IMRT plans. Differences between the Iris and the c-IMRT plans were statistically significant for the bladder V75 (P= .016), rectum V75 (P= .0013), and average nCI (P =.002). Dose to normal tissue in terms of R50 was 4.30, 5.87, and 8.37 for the Iris, fixed and c-IMRT plans, respectively, with statistically significant differences between the Iris and c-IMRT (P = .0013) and the fixed and c-IMRT (P = .001) plans. In general, the robotic IMRT plans generated using the Iris were significantly better compared to c-IMRT plans, and showed average dose gains of up to 34% for a critical rectal volume of 5%.
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Affiliation(s)
- Dilini S Pinnaduwage
- 1 Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Martina Descovich
- 1 Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Michael W Lometti
- 1 Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Badri Varad
- 1 Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Mack Roach
- 1 Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Alexander R Gottschalk
- 1 Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
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15
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Raleigh DR, Chang AJ, Tomlin B, Cunha JA, Braunstein SE, Shinohara K, Gottschalk AR, Roach M, Hsu IC. Patient- and treatment-specific predictors of genitourinary function after high-dose-rate monotherapy for favorable prostate cancer. Brachytherapy 2015. [DOI: 10.1016/j.brachy.2015.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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16
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McGuinness CM, Gottschalk AR, Lessard E, Nakamura JL, Pinnaduwage D, Pouliot J, Sims C, Descovich M. Investigating the clinical advantages of a robotic linac equipped with a multileaf collimator in the treatment of brain and prostate cancer patients. J Appl Clin Med Phys 2015; 16:284–295. [PMID: 26699309 PMCID: PMC5690182 DOI: 10.1120/jacmp.v16i5.5502] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Revised: 04/17/2015] [Accepted: 04/09/2015] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study was to evaluate the performance of a commercially avail-able CyberKnife system with a multileaf collimator (CK-MLC) for stereotactic body radiotherapy (SBRT) and standard fractionated intensity-modulated radiotherapy (IMRT) applications. Ten prostate and ten intracranial cases were planned for the CK-MLC. Half of these cases were compared with clinically approved SBRT plans generated for the CyberKnife with circular collimators, and the other half were compared with clinically approved standard fractionated IMRT plans generated for conventional linacs. The plans were compared on target coverage, conformity, homogeneity, dose to organs at risk (OAR), low dose to the surrounding tissue, total monitor units (MU), and treatment time. CK-MLC plans generated for the SBRT cases achieved more homogeneous dose to the target than the CK plans with the circular collimators, for equivalent coverage, conformity, and dose to OARs. Total monitor units were reduced by 40% to 70% and treatment time was reduced by half. The CK-MLC plans generated for the standard fractionated cases achieved prescription isodose lines between 86% and 93%, which was 2%-3% below the plans generated for conventional linacs. Compared to standard IMRT plans, the total MU were up to three times greater for the prostate (whole pelvis) plans and up to 1.4 times greater for the intracranial plans. Average treatment time was 25min for the whole pelvis plans and 19 min for the intracranial cases. The CK-MLC system provides significant improvements in treatment time and target homogeneity compared to the CK system with circular collimators, while main-taining high conformity and dose sparing to critical organs. Standard fractionated plans for large target volumes (> 100 cm3) were generated that achieved high prescription isodose levels. The CK-MLC system provides more efficient SRS and SBRT treatments and, in select clinical cases, might be a potential alternative for standard fractionated treatments.
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17
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Seymour ZA, Chang AJ, Zhang L, Kirby N, Descovich M, Roach M, Hsu IC, Gottschalk AR. Dose-volume analysis and the temporal nature of toxicity with stereotactic body radiation therapy for prostate cancer. Pract Radiat Oncol 2015; 5:e465-e472. [DOI: 10.1016/j.prro.2015.02.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 12/24/2014] [Accepted: 02/01/2015] [Indexed: 10/23/2022]
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18
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Tinkle CL, Shiao SL, Weinberg VK, Lin AM, Gottschalk AR. Comparison of stereotactic body radiotherapy and conventional external beam radiotherapy in renal cell carcinoma. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.7_suppl.434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
434 Background: Renal cell carcinoma (RCC) is considered a radiation-resistant histology, often with poor response to conventionally fractionated external beam radiotherapy (EBRT). We compared outcomes for patients treated with EBRT versus stereotactic body radiotherapy (SBRT) for RCC. Methods: From 2004 and 2012, a total of 89 patients were treated with either EBRT or SBRT and retrospectively reviewed. Patients with locally recurrent RCC, bone or soft tissue RCC metastases, or primary RCC in a solitary kidney were included. 51 patients received EBRT, while 38 patients received SBRT. The median biologically effective dose (BED), assuming an α/β ratio of 10, was 32.6 Gy10 for the EBRT group and 48.0 Gy10 for the SBRT group. Local failure (LC) was defined pathologically or by imaging according to RECIST 1.1 and toxicity reported according to CTCAE v4.0 guidelines. Univariable and multivariable analyses using Cox’s regression model was performed to determine predictors of local control. Results: Median follow up from RT was 9.8 mo (range: <1-73 mo) with EBRT and 19.7 mo (range: <1-61 mo) with SBRT (p=0.26). EBRT patients were younger (p=0.02) and more were M1 (p=0.04), yet other baseline features did not differ significantly. Total RT dose, dose/fraction, and BED10 were significantly higher in the SBRT group (p≤0.002 for each), while number of fractions was significantly fewer (p<0.001). The 1-year LC estimate was 88% (95% CI, 72-96%) with SBRT and 50% (95% CI, 32-65%) with EBRT (p=0.001), with no significant difference in rate of distant recurrences (p=0.37). The 1-year progression free survival (PFS) and overall survival (OS) between the EBRT and SBRT groups were 17% (95% CI, 8-29%) vs. 39% (95% CI, 24-54%) (p=0.06) and 39% (95% CI, 25-52%) vs. 82% (95% CI, 65-91%) (p=0.002), respectively. The use of SBRT was the most important independent factor significantly predictive of local control on multivariable analysis (p=0.001, LLR test; HR=0.29, 95% CI, 0.13-0.61), while neither age nor metastasis at diagnosis was predictive. No drade 3-4 toxicity was observed in either RT group. Conclusions: The data support that SBRT improves local control over standard fractionation schemes. Higher dose per fraction, with a BED in the range of 48 Gy10, is a safe and effective local treatment modality for RCC.
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Affiliation(s)
| | | | | | - Amy M. Lin
- University of California, San Francisco, San Francisco, CA
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Descovich M, McGuinness C, Kannarunimit D, Chen J, Pinnaduwage D, Pouliot J, Kased N, Gottschalk AR, Yom SS. Comparison between target margins derived from 4DCT scans and real-time tumor motion tracking: Insights from lung tumor patients treated with robotic radiosurgery. Med Phys 2015; 42:1280-7. [DOI: 10.1118/1.4907956] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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20
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Gustafson GS, Nguyen PL, Assimos DG, D'Amico AV, Gottschalk AR, Hsu ICJ, Lloyd S, Mclaughlin PW, Merrick GS, Showalter TN, Taira AV, Vapiwala N, Yamada Y, Davis BJ. ACR appropriateness Criteria® Postradical prostatectomy irradiation in prostate cancer. Oncology (Williston Park) 2014; 28:1125-1136. [PMID: 25510812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The purpose of this article is to present an updated set of American College of Radiology consensus guidelines formed from an expert panel on the appropriate use of radiation therapy in postprostatectomy prostate cancer. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Recent and relevant literature reviewed by the panel led to establishment of criteria for appropriate use of radiation therapy in postprostatectomy prostate cancer. The discussion includes treatment technique, appropriate dose, field design, and the role of prostate-specific antigen (PSA). Ratings and commentary of the panel on multiple treatment parameters were used to reach consensus. Patients with high-risk pathologic features benefit from postprostatectomy radiation therapy.
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Hsu ICJ, Yamada Y, Assimos DG, D'Amico AV, Davis BJ, Frank SJ, Gottschalk AR, Gustafson GS, McLaughlin PW, Nguyen PL, Rosenthal SA, Taira AV, Vapiwala N, Merrick G. Response to Drs Rogers, Hayes, and Demanes. Brachytherapy 2014; 13:523-5. [PMID: 24880587 DOI: 10.1016/j.brachy.2014.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- I-Chow Joe Hsu
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Dean G Assimos
- Department of Urology, University of Alabama at Birmingham School of Medicine, American Urological Association, Birmingham, AL
| | - Anthony V D'Amico
- Department of Radiation Oncology, Joint Center for Radiation Therapy; American Society of Clinical Oncology, Boston, MA
| | - Brian J Davis
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Steven J Frank
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Alexander R Gottschalk
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Gary S Gustafson
- Department of Radiation Oncology, William Beaumont Hospital, Troy, MI
| | | | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Seth A Rosenthal
- Department of Radiation Oncology, Radiologic Associates of Sacramento, Sacramento, CA
| | - Al V Taira
- Department of Radiation Oncology, Western Radiation Oncology, Mountain View Oncology, Mountain View, CA
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Gregory Merrick
- Department of Radiation Oncology, Schiffler Cancer Center and Wheeling Jesuit University, Wheeling, WV
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Garcia MM, Gottschalk AR, Brajtbord J, Konety BR, Meng MV, Roach M, Carroll PR. Endoscopic gold fiducial marker placement into the bladder wall to optimize radiotherapy targeting for bladder-preserving management of muscle-invasive bladder cancer: feasibility and initial outcomes. PLoS One 2014; 9:e89754. [PMID: 24594774 PMCID: PMC3940667 DOI: 10.1371/journal.pone.0089754] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 01/23/2014] [Indexed: 12/04/2022] Open
Abstract
Background and Purpose Bladder radiotherapy is a management option for carefully selected patients with muscle-invasive bladder cancer. However, the inability to visualize the tumor site during treatment and normal bladder movement limits targeting accuracy and increases collateral radiation. A means to accurately and reliably target the bladder during radiotherapy is needed. Materials and Methods Eighteen consecutive patients with muscle-invasive bladder cancer (T1–T4) elected bladder-preserving treatment with maximal transurethral resection (TUR), radiation and concurrent chemotherapy. All underwent endoscopic placement of 24-K gold fiducial markers modified with micro-tines (70 [2.9×0.9 mm.]; 19 [2.1×0.7 mm.) into healthy submucosa 5-10 mm. from the resection margin, using custom-made coaxial needles. Marker migration was assessed for with intra-op bladder-filling cystogram and measurement of distance between markers. Set-up error and marker retention through completion of radiotherapy was confirmed by on-table portal imaging. Results Between 1/2007 and 7/2012, a total of 89 markers (3–5 per tumor site) were placed into 18 patients of mean age 73.6 years. Two patients elected cystectomy before starting treatment; 16/18 completed chemo-radiotherapy. All (100%) markers were visible with all on-table (portal, cone-beam CT), fluoroscopy, plain-film, and CT-scan imaging. In two patients, 1 of 4 markers placed at the tumor site fell-out (voided) during the second half of radiotherapy. All other markers (80/82, 98%) were present through the end of radio-therapy. No intraoperative (e.g. uncontrolled bleeding, collateral injury) or post-operative complications (e.g. stone formation, urinary tract infection, post-TUR hematuria >48 hours) occurred. Use of micro-tined fiducial tumor-site markers afforded a 2 to 6-fold reduction in bladder-area targeted with high-dose radiation. Discussion Placement of the micro-tined fiducial markers into the bladder was feasible and associated with excellent retention-rate and no complications. All markers were well-visualized during radiotherapy with all imaging modalities. Bladder fiducial markers improve targeting accuracy, and may increase treatment efficacy and reduce morbidity from collateral radiation.
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Affiliation(s)
- Maurice M. Garcia
- Department of Urology, University of California San Francisco, San Francisco, California, United States of America
- University of California San Francisco – Helen Diller Family Comprehensive Cancer Center, San Francisco, California, United States of America
- * E-mail:
| | - Alexander R. Gottschalk
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, United States of America
- University of California San Francisco – Helen Diller Family Comprehensive Cancer Center, San Francisco, California, United States of America
| | - Jonathan Brajtbord
- Department of Urology, University of California San Francisco, San Francisco, California, United States of America
| | - Badrinath R. Konety
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Maxwell V. Meng
- Department of Urology, University of California San Francisco, San Francisco, California, United States of America
- University of California San Francisco – Helen Diller Family Comprehensive Cancer Center, San Francisco, California, United States of America
| | - Mack Roach
- Department of Urology, University of California San Francisco, San Francisco, California, United States of America
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, United States of America
- University of California San Francisco – Helen Diller Family Comprehensive Cancer Center, San Francisco, California, United States of America
| | - Peter R. Carroll
- Department of Urology, University of California San Francisco, San Francisco, California, United States of America
- University of California San Francisco – Helen Diller Family Comprehensive Cancer Center, San Francisco, California, United States of America
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Braunstein SE, Dionisio SA, Lometti MW, Pinnaduwage DS, Chuang CF, Yom SS, Gottschalk AR, Descovich M. Evaluation of ray tracing and Monte Carlo algorithms in dose calculation and clinical outcomes for robotic stereotactic body radiotherapy of lung cancers. J Radiosurg SBRT 2014; 3:67-79. [PMID: 29296387 PMCID: PMC5725332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 01/20/2013] [Indexed: 06/07/2023]
Abstract
PURPOSE/OBJECTIVE Dose calculation in treatment planning must account for tissue heterogeneity, especially for tumors within low-density lung tissues. While Monte Carlo (MC) calculation methods are the most accurate, Ray Tracing (RT) methods are also commonly employed. We evaluated dose calculation differences between the RT and MC algorithms in central and peripheral lung tumors treated with CyberKnife SBRT to determine which planning parameters may predict dose differences. We also examined clinical outcomes of local-regional control (LRC) and long-term treatment-related toxicity as a function of calculation method. MATERIALS/METHODS A retrospective series of 70 patient plans (19 central and 51 peripheral lung lesions) treated between 2009 and 2011 were analyzed. Among those, 33 were primary lung cancer and 37 were metastatic lesions. Thirty-three treatment plans were developed with the RT method, and 37 plans used MC. Groups were recalculated with the reciprocal method for dose comparison. Parameters examined to quantify dose differences between the two algorithms included: dose delivered to 95% (D95) of the planning target volume (PTV), dose heterogeneity, and dose to organs at risk (OAR). Dose differences were analyzed as a function of target volume, distance to soft tissue, and fraction of target overlap with soft tissue. For the subset of primary lung tumors, LRC was assessed radiographically at a median follow-up of 19 months (mo) (range, 2 to 41 mo). RESULTS Compared to MC, the RT algorithm largely overestimated the dose delivered to the PTV. The dose difference between RT and MC plans correlated to the volume of PTV overlapping with soft tissue; the smaller the overlap volume, the larger the dose differences between RT and MC. Compared to MC, the RT algorithm overestimated the dose delivered to 10% of the ipsilateral lung (D10%). Evidence of local progression was noted in only one of the 31 patients treated for primary lung malignancy. DFS and OS were not significantly different between RT and MC plans. CONCLUSION There is a significant range of discordance between MC and RT dose calculations for SBRT treated peripheral lung tumors. While variation is correlated to target size and proximity to soft tissue, no single parameter can reliably predict dose differences. Ultimately, local control and long-term toxicity appear independent of the dose calculation method.
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Affiliation(s)
- Steve E Braunstein
- University of California, San Francisco, Department of Radiation Oncology, 1600 Divisadero St., Suite H1031, San Francisco, CA 94143, USA
| | - Sebastian A Dionisio
- University of California, San Francisco, Department of Radiation Oncology, 1600 Divisadero St., Suite H1031, San Francisco, CA 94143, USA
| | - Michael W Lometti
- University of California, San Francisco, Department of Radiation Oncology, 1600 Divisadero St., Suite H1031, San Francisco, CA 94143, USA
| | - Dilini S Pinnaduwage
- University of California, San Francisco, Department of Radiation Oncology, 1600 Divisadero St., Suite H1031, San Francisco, CA 94143, USA
| | - Cynthia F Chuang
- University of California, San Francisco, Department of Radiation Oncology, 1600 Divisadero St., Suite H1031, San Francisco, CA 94143, USA
| | - Sue S Yom
- University of California, San Francisco, Department of Radiation Oncology, 1600 Divisadero St., Suite H1031, San Francisco, CA 94143, USA
| | - Alexander R Gottschalk
- University of California, San Francisco, Department of Radiation Oncology, 1600 Divisadero St., Suite H1031, San Francisco, CA 94143, USA
| | - Martina Descovich
- University of California, San Francisco, Department of Radiation Oncology, 1600 Divisadero St., Suite H1031, San Francisco, CA 94143, USA
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Hsu ICJ, Yamada Y, Assimos DG, D'Amico AV, Davis BJ, Frank SJ, Gottschalk AR, Gustafson GS, McLaughlin PW, Nguyen PL, Rosenthal SA, Taira AV, Vapiwala N, Merrick G. ACR Appropriateness Criteria high-dose-rate brachytherapy for prostate cancer. Brachytherapy 2014; 13:27-31. [DOI: 10.1016/j.brachy.2013.11.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 11/04/2013] [Accepted: 11/25/2013] [Indexed: 10/25/2022]
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25
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Crehange G, Krishnamurthy D, Cunha JA, Pickett B, Kurhanewicz J, Hsu IC, Gottschalk AR, Shinohara K, Roach M, Pouliot J. Cold spot mapping inferred from MRI at time of failure predicts biopsy-proven local failure after permanent seed brachytherapy in prostate cancer patients: implications for focal salvage brachytherapy. Radiother Oncol 2013; 109:246-50. [PMID: 24231238 DOI: 10.1016/j.radonc.2013.10.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/22/2013] [Accepted: 10/14/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE (1) To establish a method to evaluate dosimetry at the time of primary prostate permanent implant (pPPI) using MRI of the shrunken prostate at the time of failure (tf). (2) To compare cold spot mapping with sextant-biopsy mapping at tf. MATERIAL AND METHODS Twenty-four patients were referred for biopsy-proven local failure (LF) after pPPI. Multiparametric MRI and combined-sextant biopsy with a central review of the pathology at tf were systematically performed. A model of the shrinking pattern was defined as a Volumetric Change Factor (VCF) as a function of time from time of pPPI (t0). An isotropic expansion to both prostate volume (PV) and seed position (SP) coordinates determined at tf was performed using a validated algorithm using the VCF. RESULTS pPPI CT-based evaluation (at 4weeks) vs. MR-based evaluation: Mean D90% was 145.23±19.16Gy [100.0-167.5] vs. 85.28±27.36Gy [39-139] (p=0.001), respectively. Mean V100% was 91.6±7.9% [70-100%] vs. 73.1±13.8% [55-98%] (p=0.0006), respectively. Seventy-seven per cent of the pathologically positive sextants were classified as cold. CONCLUSIONS Patients with biopsy-proven LF had poorer implantation quality when evaluated by MRI several years after implantation. There is a strong relationship between microscopic involvement at tf and cold spots.
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Affiliation(s)
- Gilles Crehange
- Department of Radiation Oncology, Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, USA; Department of Radiation Oncology, Dijon University Hospital, France.
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Descovich M, Carrara M, Morlino S, Pinnaduwage DS, Saltiel D, Pouliot J, Nash MB, Pignoli E, Valdagni R, Roach M, Gottschalk AR. Improving plan quality and consistency by standardization of dose constraints in prostate cancer patients treated with CyberKnife. J Appl Clin Med Phys 2013; 14:162-72. [PMID: 24036869 PMCID: PMC5714582 DOI: 10.1120/jacmp.v14i5.4333] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 04/24/2013] [Accepted: 04/23/2013] [Indexed: 11/23/2022] Open
Abstract
Treatment plans for prostate cancer patients undergoing stereotactic body radiation therapy (SBRT) are often challenging due to the proximity of organs at risk. Today, there are no objective criteria to determine whether an optimal treatment plan has been achieved, and physicians rely on their personal experience to evaluate the plan's quality. In this study, we propose a method for determining rectal and bladder dose constraints achievable for a given patient's anatomy. We expect that this method will improve the overall plan quality and consistency, and facilitate comparison of clinical outcomes across different institutions. The 3D proximity of the organs at risk to the target is quantified by means of the expansion-intersection volume (EIV), which is defined as the intersection volume between the target and the organ at risk expanded by 5 mm. We determine a relationship between EIV and relevant dosimetric parameters, such as the volume of bladder and rectum receiving 75% of the prescription dose (V75%). This relationship can be used to establish institution-specific criteria to guide the treatment planning and evaluation process. A database of 25 prostate patients treated with CyberKnife SBRT is used to validate this approach. There is a linear correlation between EIV and V75% of bladder and rectum, confirming that the dose delivered to rectum and bladder increases with increasing extension and proximity of these organs to the target. This information can be used during the planning stage to facilitate the plan optimization process, and to standardize plan quality and consistency. We have developed a method for determining customized dose constraints for prostate patients treated with robotic SBRT. Although the results are technology specific and based on the experience of a single institution, we expect that the application of this method by other institutions will result in improved standardization of clinical practice.
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Eberhardt SC, Carter S, Casalino DD, Merrick G, Frank SJ, Gottschalk AR, Leyendecker JR, Nguyen PL, Oto A, Porter C, Remer EM, Rosenthal SA. ACR Appropriateness Criteria prostate cancer--pretreatment detection, staging, and surveillance. J Am Coll Radiol 2013; 10:83-92. [PMID: 23374687 DOI: 10.1016/j.jacr.2012.10.021] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 10/31/2012] [Indexed: 01/01/2023]
Abstract
Prostate cancer is the most common noncutaneous male malignancy in the United States. The use of serum prostate-specific antigen as a screening tool is complicated by a significant fraction of nonlethal cancers diagnosed by biopsy. Ultrasound is used predominately as a biopsy guidance tool. Combined rectal examination, prostate-specific antigen testing, and histology from ultrasound-guided biopsy provide risk stratification for locally advanced and metastatic disease. Imaging in low-risk patients is unlikely to guide management for patients electing up-front treatment. MRI, CT, and bone scans are appropriate in intermediate-risk to high-risk patients to better assess the extent of disease, guide therapy decisions, and predict outcomes. MRI (particularly with an endorectal coil and multiparametric functional imaging) provides the best imaging for cancer detection and staging. There may be a role for prostate MRI in the context of active surveillance for low-risk patients and in cancer detection for undiagnosed clinically suspected cancer after negative biopsy results. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Shiao SL, Sahgal A, Hu W, Jabbari S, Chuang C, Descovich M, Hsu IC, Gottschalk AR, Roach M, Ma L. Temporal compartmental dosing effects for robotic prostate stereotactic body radiotherapy. Phys Med Biol 2011; 56:7767-75. [PMID: 22107791 DOI: 10.1088/0031-9155/56/24/006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The rate of dose accumulation within a given area of a target volume tends to vary significantly for non-isocentric delivery systems such as Cyberknife stereotactic body radiotherapy. In this study, we investigated whether intra-target temporal dose distributions produce significant variations in the biological equivalent dose. For the study, time courses of ten patients were reconstructed and calculation of a biologically equivalent uniform dose (EUD) was performed using a formula derived from the linear quadratic model (α/β = 3 for prostate cancer cells). The calculated EUD values obtained for the actual patient treatments were then compared with theoretical EUD values for delivering the same physical dose distribution except that the whole target being irradiated continuously (e.g. large-field 'dose-bathing' type of delivery). For all the case, the EUDs for the actual treatment delivery were found to correlate strongly with the EUDs for the large-field delivery: a linear correlation coefficient of R² = 0.98 was obtained and the average EUD for the actual Cyberknife delivery was somewhat higher (5.0 ± 4.7%) than that for the large-field delivery. However, no statistical significance was detected between the two types of delivery (p = 0.21). We concluded that non-isocentric small-field Cyberknife delivery produced consistent biological dosing that tracked well with the constant-dose-rate, large-field-type delivery for prostate stereotactic body radiotherapy.
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Affiliation(s)
- Stephen L Shiao
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
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29
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Tran QNH, Kim AC, Gottschalk AR, Wara WM, Phillips TL, O'donnell RJ, Weinberg V, Haas-Kogan DA. Clinical outcomes of intraoperative radiation therapy for extremity sarcomas. Sarcoma 2011; 2006:91671. [PMID: 17040093 PMCID: PMC1557794 DOI: 10.1155/srcm/2006/91671] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Purpose. Radiation of extremity lesions, a key component of limb-sparing therapy, presents particular challenges, with
significant risks of toxicities. We sought to explore the
efficacy of intraoperative radiation therapy (IORT) in the
treatment of soft tissue sarcomas of the extremities.
Patients. Between 1995 and 2001, 17 patients received
IORT for soft tissue sarcomas of the extremities. Indications for
IORT included recurrent tumors in a previously radiated field or
tumors adjacent to critical structures. Results. Gross
total resections were achieved in all 17 patients. Two patients
experienced locoregional relapses, six patients recurred at
metastatic sites, and one patient died without recurrence.
Thirty-six month estimates for locoregional control, disease free
survival, and overall survival were 86%, 50%, and 78%,
respectively. IORT was extremely well tolerated, with no
toxicities referable to IORT. Conclusions. For patients
with soft tissue sarcomas of the extremities, IORT used as a boost
to EBRT provides excellent local control, with limited acute
toxicities.
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Jabbari S, Weinberg VK, Kaprealian T, Hsu IC, Ma L, Chuang C, Descovich M, Shiao S, Shinohara K, Roach M, Gottschalk AR. Stereotactic body radiotherapy as monotherapy or post-external beam radiotherapy boost for prostate cancer: technique, early toxicity, and PSA response. Int J Radiat Oncol Biol Phys 2010; 82:228-34. [PMID: 21183287 DOI: 10.1016/j.ijrobp.2010.10.026] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 10/21/2010] [Accepted: 10/22/2010] [Indexed: 11/15/2022]
Abstract
PURPOSE High dose rate (HDR) brachytherapy has been established as an excellent monotherapy or after external-beam radiotherapy (EBRT) boost treatment for prostate cancer (PCa). Recently, dosimetric studies have demonstrated the potential for achieving similar dosimetry with stereotactic body radiotherapy (SBRT) compared with HDR brachytherapy. Here, we report our technique, PSA nadir, and acute and late toxicity with SBRT as monotherapy and post-EBRT boost for PCa using HDR brachytherapy fractionation. PATIENTS AND METHODS To date, 38 patients have been treated with SBRT at the University of California-San Francisco with a minimum follow-up of 12 months. Twenty of 38 patients were treated with SBRT monotherapy (9.5 Gy × 4 fractions), and 18 were treated with SBRT boost (9.5 Gy × 2 fractions) post-EBRT and androgen deprivation therapy. PSA nadir to date for 44 HDR brachytherapy boost patients with disease characteristics similar to the SBRT boost cohort was also analyzed as a descriptive comparison. RESULTS SBRT was well tolerated. With a median follow-up of 18.3 months (range, 12.6-43.5), 42% and 11% of patients had acute Grade 2 gastrourinary and gastrointestinal toxicity, respectively, with no Grade 3 or higher acute toxicity to date. Two patients experienced late Grade 3 GU toxicity. All patients are without evidence of biochemical or clinical progression to date, and favorably low PSA nadirs have been observed with a current median PSA nadir of 0.35 ng/mL (range, <0.01-2.1) for all patients (0.47 ng/mL, range, 0.2-2.1 for the monotherapy cohort; 0.10 ng/mL, range, 0.01-0.5 for the boost cohort). With a median follow-up of 48.6 months (range, 16.4-87.8), the comparable HDR brachytherapy boost cohort has achieved a median PSA nadir of 0.09 ng/mL (range, 0.0-3.3). CONCLUSIONS Early results with SBRT monotherapy and post-EBRT boost for PCa demonstrate acceptable PSA response and minimal toxicity. PSA nadir with SBRT boost appears comparable to those achieved with HDR brachytherapy boost.
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Affiliation(s)
- Siavash Jabbari
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
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31
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Kaprealian T, Weinberg V, Speight JL, Gottschalk AR, Roach M, Shinohara K, Hsu IC. High-dose-rate brachytherapy boost for prostate cancer: comparison of two different fractionation schemes. Int J Radiat Oncol Biol Phys 2010; 82:222-7. [PMID: 21163586 DOI: 10.1016/j.ijrobp.2010.09.021] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 09/17/2010] [Accepted: 09/24/2010] [Indexed: 11/26/2022]
Abstract
PURPOSE This is a retrospective study comparing our experience with high-dose-rate (HDR) brachytherapy boost for prostate cancer, using two different fractionation schemes, 600 cGy × 3 fractions (patient group 1) and 950 cGy × 2 fractions (patient group 2). METHODS AND MATERIALS A total of 165 patients were treated for prostate cancer using external beam radiation therapy up to a dose of 45 Gy, followed by an HDR brachytherapy prostate radiation boost. Between July 1997 and Nov 1999, 64 patients were treated with an HDR boost of 600 cGy × 3 fractions; and between June 2000 and Nov 2005, 101 patients were treated with an HDR boost of 950 cGy × 2 fractions. All but 9 patients had at least one of the following risk features: pretreatment prostate-specific antigen (PSA) level >10, a Gleason score ≥7, and/or clinical stage T3 disease. RESULTS Median follow-up was 105 months for group 1 and 43 months for group 2. Patients in group 2 had a greater number of high-risk features than group 1 (p = 0.02). Adjusted for comparable follow-up, there was no difference in biochemical no-evidence-of-disease (bNED) rate between the two fractionation scheme approaches, with 5-year Kaplan-Meier estimates of 93.5% in group 1 and 87.3% in group 2 (p = 0.19). The 5-year estimates of progression-free survival were 86% for group 1 and 83% for group 2 (p = 0.53). Among high-risk patients, there were no differences in bNED or PFS rate due to fractionation. CONCLUSIONS Results were excellent for both groups. Adjusted for comparable follow-up, no differences were found between groups.
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Affiliation(s)
- Tania Kaprealian
- Department of Radiation Oncology, University of California, San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco, California 94115, USA
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Burk TF, Horvai AE, Gottschalk AR, Leong SPL, Kashani-Sabet M, Goldsby RE, Law J, O'Donnell RJ. Patellar metastatic melanoma in a 13-year-old boy. Am J Orthop (Belle Mead NJ) 2010; 39:582-586. [PMID: 21720575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The incidence of melanoma in US adults is approximately 1.5 per million, with 2% to 5% of patients developing metastatic disease. In children, melanoma is distinctly uncommon, and metastatic disease occurs even more seldom. This case report, the first of a patellar lesion as the initial presentation of metastatic melanoma in a pediatric patient, highlights use of patellectomy and intraoperative radiation therapy in obtaining palliative local control while avoiding periarticular functional morbidity.
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Affiliation(s)
- Thomas F Burk
- Department of Orthopaedic Surgery, University of California, San Francisco, USA.
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33
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Faddegon BA, Aubin M, Bani-Hashemi A, Gangadharan B, Gottschalk AR, Morin O, Sawkey D, Wu V, Yom SS. Comparison of patient megavoltage cone beam CT images acquired with an unflattened beam from a carbon target and a flattened treatment beama). Med Phys 2010; 37:1737-41. [DOI: 10.1118/1.3359822] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Hossain S, Xia P, Huang K, Descovich M, Chuang C, Gottschalk AR, Roach M, Ma L. Dose gradient near target-normal structure interface for nonisocentric CyberKnife and isocentric intensity-modulated body radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys 2010; 78:58-63. [PMID: 20133073 DOI: 10.1016/j.ijrobp.2009.07.1752] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Revised: 07/08/2009] [Accepted: 07/21/2009] [Indexed: 11/16/2022]
Abstract
PURPOSE The treatment planning quality between nonisocentric CyberKnife (CK) and isocentric intensity modulation treatment was studied for hypofractionated prostate body radiotherapy. In particular, the dose gradient across the target and the critical structures such as the rectum and bladder was characterized. METHODS AND MATERIALS In the present study, patients treated with CK underwent repeat planning for nine fixed-field intensity-modulated radiotherapy (IMRT) using identical contour sets and dose-volume constraints. To calculate the dose falloff, the clinical target volume contours were expanded 30 mm anteriorly and posteriorly and 50 mm uniformly in other directions for all patients in the CK and IMRT plans. RESULTS We found that all the plans satisfied the dose-volume constraints, with the CK plans showing significantly better conformity than the IMRT plans at a relative greater dose inhomogeneity. The rectal and bladder volumes receiving a low dose were also lower for CK than for IMRT. The average conformity index, the ratio of the prescription isodose volume and clinical target volume, was 1.18 +/- 0.08 for the CK plans vs. 1.44 +/- 0.11 for the IMRT plans. The average homogeneity index, the ratio of the maximal dose and the prescribed dose to the clinical target volume, was 1.45 +/- 0.12 for the CK plans vs. 1.28 +/- 0.06 for the IMRT plans. The average percentage of dose falloff was 2.9% +/- 0.8%/mm for CK and 3.1% +/- 1.0%/mm for IMRT in the anterior direction, 3.8% +/- 1.6%/mm for CK and 3.2% +/- 1.9%/mm for IMRT in the posterior direction, and 3.6% +/- 0.4% for CK and 3.6% +/- 0.4% for IMRT in all directions. CONCLUSION Nonisocentric CK was as capable of producing equivalent fast dose falloff as high-number fixed-field IMRT delivery.
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Affiliation(s)
- Sabbir Hossain
- Department of Radiation Oncology, University of California, San Francisco, School of Medicine, San Francisco, CA 94143-1708, USA.
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Jabbari S, Weinberg VK, Shinohara K, Speight JL, Gottschalk AR, Hsu IC, Pickett B, McLaughlin PW, Sandler HM, Roach M. Equivalent Biochemical Control and Improved Prostate-Specific Antigen Nadir After Permanent Prostate Seed Implant Brachytherapy Versus High-Dose Three-Dimensional Conformal Radiotherapy and High-Dose Conformal Proton Beam Radiotherapy Boost. Int J Radiat Oncol Biol Phys 2010; 76:36-42. [DOI: 10.1016/j.ijrobp.2009.01.029] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Revised: 01/10/2009] [Accepted: 01/14/2009] [Indexed: 11/27/2022]
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Gottschalk AR. Commentary on Long-term follow-up of patients with prostate cancer and nodal metastases treated by pelvic lymphadenectomy and radical prostatectomy: The positive impact of adjuvant radiotherapy. Urol Oncol 2009. [DOI: 10.1016/j.urolonc.2009.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Gottschalk AR. Commentary on Prospective assessment of gastrointestinal and genitourinary toxicity of salvage radiotherapy for patients with prostate-specific antigen relapse or local recurrence after radical prostatectomy. Urol Oncol 2009. [DOI: 10.1016/j.urolonc.2009.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Gottschalk AR. Commentary on Endocrine treatment, with or without radiotherapy, in locally advanced prostate cancer (SPCG-7/SFUO-3): An open randomized phase III trial. Urol Oncol 2009. [DOI: 10.1016/j.urolonc.2009.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gottschalk AR. Commentary on The results of concurrent chemo-radiotherapy for recurrence after treatment with bacillus Calmette Guerin for non-muscle-invasive bladder cancer: Is immediate cystectomy always necessary? Urol Oncol 2009. [DOI: 10.1016/j.urolonc.2009.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cheung J, Aubry JF, Yom SS, Gottschalk AR, Celi JC, Pouliot J. Dose Recalculation and the Dose-Guided Radiation Therapy (DGRT) Process Using Megavoltage Cone-Beam CT. Int J Radiat Oncol Biol Phys 2009; 74:583-92. [DOI: 10.1016/j.ijrobp.2008.12.034] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Revised: 11/26/2008] [Accepted: 12/19/2008] [Indexed: 10/20/2022]
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Hossain S, Xia P, Chuang C, Verhey L, Gottschalk AR, Mu G, Ma L. Simulated real time image guided intrafraction tracking-delivery for hypofractionated prostate IMRT. Med Phys 2008; 35:4041-8. [DOI: 10.1118/1.2968333] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Yamasaki I, Hsu IC, Speight J, Gottschalk AR, Roach M, Shinohara K. LONGITUDINAL CHANGES OF ERECTILE FUNCTION AFTER LOW-DOSE-RATE (LDR) BRACHYTHERAPY MONOTHERAPY FOR LOCALIZED PROSTATE CANCER. J Urol 2008. [DOI: 10.1016/s0022-5347(08)61171-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Morin O, Gillis A, Descovich M, Chen J, Aubin M, Aubry JF, Chen H, Gottschalk AR, Xia P, Pouliot J. Patient dose considerations for routine megavoltage cone-beam CT imaging. Med Phys 2007; 34:1819-27. [PMID: 17555263 DOI: 10.1118/1.2722470] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Megavoltage cone-beam CT (MVCBCT), the recent addition to the family of in-room CT imaging systems for image-guided radiation therapy (IGRT), uses a conventional treatment unit equipped with a flat panel detector to obtain a three-dimensional representation of the patient in treatment position. MVCBCT has been used for more than two years in our clinic for anatomy verification and to improve patient alignment prior to dose delivery. The objective of this research is to evaluate the image acquisition dose delivered to patients for MVCBCT and to develop a simple method to reduce the additional dose resulting from routine MVCBCT imaging. Conventional CT scans of phantoms and patients were imported into a commercial treatment planning system (TPS: Phillips, Pinnacle) and an arc treatment mimicking the MVCBCT acquisition process was generated to compute the delivered acquisition dose. To validate the dose obtained from the TPS, a simple water-equivalent cylindrical phantom with spaces for MOSFETs and an ion chamber was used to measure the MVCBCT image acquisition dose. Absolute dose distributions were obtained by simulating MVCBCTs of 9 and 5 monitor units (MU) on pelvis and head and neck patients, respectively. A compensation factor was introduced to generate composite plans of treatment and MVCBCT imaging dose. The article provides a simple equation to compute the compensation factor. The developed imaging compensation method was tested on routinely used clinical plans for prostate and head and neck patients. The quantitative comparison between the calculated dose by the TPS and measurement points on the cylindrical phantom were all within 3%. The dose percentage difference for the ion chamber placed in the center of the phantom was only 0.2%. For a typical MVCBCT, the dose delivered to patients forms a small anterior-posterior gradient ranging from 0.6 to 1.2 cGy per MVCBCT MU. MVCBCT acquisitions in the pelvis and head and neck areas deliver slightly more dose than current portal imaging but render soft tissue information for positioning. Overall, the additional dose from daily 9 MU MVCBCTs of prostate patients is small compared to the treatment dose (<4%). Dose-volume histograms of compensated plans for pelvis and head and neck patients imaged daily with MVCBCT showed no additional dose to the target and small increases at low doses. The results indicate that the dose delivered for MVCBCT imaging can be precisely calculated in the TPS and therefore included in the treatment plan. This allows simple plan compensations, such as slightly reducing the treatment dose, to minimize the total dose received by critical structures from daily positioning with MVCBCT. The proposed compensation factor reduces the number of MU per treatment beam per fraction. Both the number of fractions and the beam arrangement are kept unchanged. Reducing the imaging volume in the cranio-caudal direction can further reduce the dose delivered for MVCBCT. This is a useful feature to eliminate the imaging dose to the eyes or to focus on a specific region of interest for alignment.
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Affiliation(s)
- Olivier Morin
- Comprehensive Cancer Center Department of Radiation Oncology, University of California San Francisco, San Francisco, California 94143, USA.
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Lee B, Shinohara K, Weinberg V, Gottschalk AR, Pouliot J, Roach M, Hsu IC. Feasibility of high-dose-rate brachytherapy salvage for local prostate cancer recurrence after radiotherapy: The University of California–San Francisco experience. Int J Radiat Oncol Biol Phys 2007; 67:1106-12. [PMID: 17197119 DOI: 10.1016/j.ijrobp.2006.10.012] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Revised: 10/11/2006] [Accepted: 10/17/2006] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of this study was to evaluate the feasibility and safety of salvage high-dose-rate (HDR) brachytherapy for locally recurrent prostate cancer after external beam radiotherapy (EBRT). METHODS AND MATERIALS We retrospectively analyzed 21 consecutively accrued patients undergoing salvage HDR brachytherapy for locally recurrent prostate cancer after EBRT between November 1998 and December 2005. After pathologic confirmation of locally recurrent disease, all patients were treated with 36 Gy in six fractions using two transrectal ultrasound-guided HDR prostate implants, separated by 1 week. Eleven patients received neoadjuvant hormonal therapy immediately presalvage, whereas none received adjuvant hormonal therapy postsalvage. Median follow-up time from recurrence was 18.7 months (range, 6-84 months). Determination of subsequent biochemical failure after brachytherapy was based on the definition by the American Society for Therapeutic Radiology and Oncology. RESULTS Based on the Common Terminology Criteria for Adverse Events (CTCAE version 3), 18 patients reported Grade 1 to 2 genitourinary symptoms by 3 months postsalvage. Three patients developed Grade 3 genitourinary toxicity. Maximum observed gastrointestinal toxicity was Grade 2; all cases spontaneously resolved. The 2-year Kaplan-Meier estimate of biochemical control after recurrence was 89%. Thirteen patients have achieved a PSA nadir < or =0.1 ng/ml, but at the time of writing this endpoint has not yet been reached for all patients. All patients are alive; however 2 have experienced biochemical failure, both with PSA nadirs > or =1, and have subsequently been found to have distant metastases. CONCLUSIONS Salvage HDR prostate brachytherapy appears to be feasible and effective.
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Affiliation(s)
- Brian Lee
- Department of Radiation Oncology, University of California-San Francisco, San Francisco, CA 94115, USA
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Schiffner DC, Gottschalk AR, Lometti M, Aubin M, Pouliot J, Speight J, Hsu IC, Shinohara K, Roach M. Daily electronic portal imaging of implanted gold seed fiducials in patients undergoing radiotherapy after radical prostatectomy. Int J Radiat Oncol Biol Phys 2007; 67:610-9. [PMID: 17236978 DOI: 10.1016/j.ijrobp.2006.09.042] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2006] [Revised: 09/20/2006] [Accepted: 09/28/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this study was to measure interfraction prostate bed motion, setup error, and total positioning error in 10 consecutive patients undergoing postprostatectomy radiotherapy. METHODS AND MATERIALS Daily image-guided target localization and alignment using electronic portal imaging of gold seed fiducials implanted into the prostate bed under transrectal ultrasound guidance was used in 10 patients undergoing adjuvant or salvage radiotherapy after prostatectomy. Prostate bed motion, setup error, and total positioning error were measured by analysis of gold seed fiducial location on the daily electronic portal images compared with the digitally reconstructed radiographs from the treatment-planning CT. RESULTS Mean (+/- standard deviation) prostate bed motion was 0.3 +/- 0.9 mm, 0.4 +/- 2.4 mm, and -1.1 +/- 2.1 mm in the left-right (LR), superior-inferior (SI), and anterior-posterior (AP) axes, respectively. Mean set-up error was 0.1 +/- 4.5 mm, 1.1 +/- 3.9 mm, and -0.2 +/- 5.1 mm in the LR, SI, and AP axes, respectively. Mean total positioning error was 0.2 +/- 4.5 mm, 1.2 +/- 5.1 mm, and -0.3 +/- 4.5 mm in the LR, SI, and AP axes, respectively. Total positioning errors >5 mm occurred in 14.1%, 38.7%, and 28.2% of all fractions in the LR, SI, and AP axes, respectively. There was no significant migration of the gold marker seeds. CONCLUSIONS This study validates the use of daily image-guided target localization and alignment using electronic portal imaging of implanted gold seed fiducials as a valuable method to correct for interfraction target motion and to improve precision in the delivery of postprostatectomy radiotherapy.
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Affiliation(s)
- Daniel C Schiffner
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA 94143-1708, USA
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Gottschalk AR, Doan A, Nakamura JL, Stokoe D, Haas-Kogan DA. Inhibition of phosphatidylinositol-3-kinase causes increased sensitivity to radiation through a PKB-dependent mechanism. Int J Radiat Oncol Biol Phys 2005; 63:1221-7. [PMID: 16253776 DOI: 10.1016/j.ijrobp.2005.08.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2005] [Revised: 08/09/2005] [Accepted: 08/11/2005] [Indexed: 11/26/2022]
Abstract
PURPOSE To identify whether inhibition of phosphatidylinositol-3-kinase (PI3K) causes increased radiosensitivity through inhibition of protein kinase B (PKB), implicating PKB as an important therapeutic target in prostate cancer. METHODS AND MATERIALS The prostate cancer cell line LNCaP was treated with the PI3K inhibitor LY294002, radiation, and combinations of the two therapies. Apoptosis and survival were measured by cell cycle analysis, Western blot analysis for cleaved poly (ADP-ribose) polymerase, and clonogenic survival. To test the hypothesis that inhibition of PKB is responsible for LY294002-induced radiosensitivity, LNCaP cells expressing a constitutively active form of PKB were used. RESULTS The combination of PI3K inhibition and radiation caused an increase in apoptosis and a decrease in clonogenic survival when compared to either modality alone. The expression of constitutively activated PKB blocked apoptosis induced by combination of PI3K inhibition and radiation and prevented radiosensitization by LY294002. CONCLUSION These data indicate that PI3K inhibition increases sensitivity of prostate cancer cell lines to ionizing radiation through inactivation of PKB. Therefore, PTEN mutations, which lead to PKB activation, may play an important role in the resistance of prostate cancer to radiation therapy. Targeted therapy against PKB could be beneficial in the management of prostate cancer patients.
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Affiliation(s)
- Alexander R Gottschalk
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA 94143-1708, USA.
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Abstract
PURPOSE Local recurrence of renal cell carcinoma in the renal fossa without distant metastatic disease is an infrequent occurrence. Management of this lesion can be challenging, with relatively few series in the literature. We describe our use of surgical extirpation with adjuvant intraoperative radiation. MATERIALS AND METHODS The University of California, San Francisco Urologic Oncology database and the University of California, San Francisco Radiation Oncology database were queried for all patients with locally recurrent renal fossa recurrence. Only patients with recurrence of renal cell carcinoma in the renal fossa were included. Survival, complications and the use of adjuvant therapy in the form of intraoperative radiation therapy were noted. RESULTS A total of 14 patients were treated for this lesion between 1990 and 2003. Mean time to recurrence was 40 months (range 5 to 180). Only 1 patient was symptomatic preoperatively, while in 13 disease had been detected on routine computerized tomography followup. Mean size of the recurrent tumor was 6.35 cm (range 2 to 17). 9 patients died of progressive, metastatic disease after a mean of 17 months (range 1 to 56) and 5 are alive with a mean survival of 66 months (range 14 to 86). The time to recurrence after nephrectomy approached statistical significance (p =0.06) when comparing the patients who were alive vs those who died of disease. Additionally, there was no statistical difference in size of mass recurrence between these 2 groups. There was no difference in survival due to adjuvant intraoperative radiation therapy. Local fossa re-recurrence developed in 2 patients. Survival was 40% at 2 years and 30% at 5 years from surgery. Complications, including minor complications, occurred in 42% of patients and there was no perioperative mortality. CONCLUSIONS Selected patients with isolated local recurrence in the renal fossa may have favorable and durable outcomes following surgical resection and possibly adjuvant intraoperative radiation therapy for isolated renal fossa recurrence following radical nephrectomy. Development of novel and effective systemic therapy is needed in high risk patients with renal cancer.
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Affiliation(s)
- Viraj A Master
- Department of Urology, Department of Radiation Oncology, University of California, San Francisco, CA 94143, USA
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Nakamura JL, Karlsson A, Arvold ND, Gottschalk AR, Pieper RO, Stokoe D, Haas-Kogan DA. PKB/Akt mediates radiosensitization by the signaling inhibitor LY294002 in human malignant gliomas. J Neurooncol 2005; 71:215-22. [PMID: 15735908 DOI: 10.1007/s11060-004-1718-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The phosphoinositide 3-kinase (PI3-kinase) signaling pathway is frequently aberrantly activated in glioblastoma multiforme (GM) by mutation or loss of the 3' phospholipid phosphatase PTEN. PTEN abnormalities result in inappropriate signaling to downstream molecules including protein kinase B (PKB/Akt), and mammalian target of rapamycin (mTOR). PI3-kinase activation increases resistance to radiation-induced cell death; conversely, PI3-kinase inhibition enhances the sensitivity of tumors to radiation. The effects of LY294002, a biochemical inhibitor of PI3-kinase, on the response to radiation were examined in the PTEN mutant glioma cell line U251 MG. Low doses of LY294002 sensitized U251 MG to clinically relevant doses of radiation. In contrast to LY294002, rapamycin, an inhibitor of mTOR, did not result in radiosensitization. We demonstrate that among multiple known targets of LY294002, PI3-kinase is the most likely molecule responsible for LY294002-induced radiosensitization. Furthermore, using a myristoylated PKB/Akt construct, we identified PKB/Akt as the downstream molecule that mediates the synergistic cytotoxicity between LY294002 and radiation. Thus PI3-kinase dysregulation may contribute to the notable radioresistance of GM tumors and inhibition of PKB/Akt offers an excellent target to enhance radiosensitivity.
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Affiliation(s)
- Jean L Nakamura
- Department of Radiation Oncology, The University of California, San Francisco, CA 94143, USA
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Gottschalk AR, Doan A, Nakamura JL, Haas-Kogan DA, Stokoe D. Inhibition of phosphatidylinositol-3-kinase causes cell death through a protein kinase B (PKB)-dependent mechanism and growth arrest through a PKB-independent mechanism. Int J Radiat Oncol Biol Phys 2005; 61:1183-8. [PMID: 15752900 DOI: 10.1016/j.ijrobp.2004.12.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2003] [Accepted: 12/03/2004] [Indexed: 01/26/2023]
Abstract
PURPOSE To identify whether inhibition of phosphatidylinositol-3-kinase (PI3K) causes apoptosis through inhibition of protein kinase B (PKB), implicating PKB as an important therapeutic target in prostate cancer. METHODS AND MATERIALS After treatment with the PI3K inhibitor, LY294002, proliferation and apoptosis of the prostate cancer cell line, LNCaP, were measured by cell cycle analysis and cleavage of poly (ADP-ribose) polymerase. To test the hypothesis that inhibition of PKB is responsible for the LY294002-induced apoptosis, LNCaP cells expressing a constitutively active form of PKB were generated. RESULTS Treatment of LNCaP cells with the PI3K inhibitor, LY294002, caused inactivation of PKB, growth arrest, and apoptosis. LY294002-induced apoptosis was increased in the absence of serum. The G1 growth arrest was associated with an increase in p27(kip1) expression. Cells expressing constitutively active PKB were protected from apoptosis induced by LY294002, but not from the G1 growth arrest induced by PI3K inhibition. CONCLUSION These data suggest that PKB activity regulates apoptosis, but not G1 arrest, and identify PKB as a potential critical target for cancer therapy. Targeted therapy against kinases might complement more conventional therapies, including androgen suppression for prostate cancer.
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Affiliation(s)
- Alexander R Gottschalk
- Radiation Oncology, University of California, 1600 Divisadero St., San Francisco, CA 94143, USA.
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Hsu ICJ, Cabrera AR, Weinberg V, Speight J, Gottschalk AR, Roach M, Shinohara K. Combined modality treatment with high-dose-rate brachytherapy boost for locally advanced prostate cancer. Brachytherapy 2005; 4:202-6. [PMID: 16182220 DOI: 10.1016/j.brachy.2005.03.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2004] [Revised: 03/03/2005] [Accepted: 03/08/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE This is a retrospective review of our experience using high-dose-rate (HDR) brachytherapy boost for prostate cancer. METHODS AND MATERIALS During the study period, we recommended external beam radiotherapy (45 Gy) and HDR boost (18 Gy in three fractions) combined with hormonal therapy (HT) for 2 months before and during radiotherapy to patients with at least one of the following risk features: pretreatment prostate-specific antigen>10, Gleason score (GS)>or=7, and clinical T3 disease. Additional HT for 2 years after radiotherapy was recommended for patients with GS>7. To patients whose risk of positive nodes exceeded 15%, we recommended whole pelvic radiotherapy. We administered HDR via single implant, and all fractions were given within 24h. RESULTS This report is based on our initial 64 patients treated with HDR boost. The median follow-up was 50 months (range 25-68 months). The 4-year estimates of overall and disease-free survival were 98% and 92%, respectively. One patient experienced late grade 4 gastrointestinal toxicity. CONCLUSIONS HDR brachytherapy is an effective means of delivering conformal prostate radiotherapy, and may be used with whole pelvic radiotherapy and HT.
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Affiliation(s)
- I-Chow J Hsu
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA 94143-1708, USA.
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