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Buyyounouski MK, Pugh SL, Chen RC, Mann MJ, Kudchadker RJ, Konski AA, Mian OY, Michalski JM, Vigneault E, Valicenti RK, Barkati M, Lawton CAF, Potters L, Monitto DC, Kittel JA, Schroeder TM, Hannan R, Duncan CE, Rodgers JP, Feng F, Sandler HM. Noninferiority of Hypofractionated vs Conventional Postprostatectomy Radiotherapy for Genitourinary and Gastrointestinal Symptoms: The NRG-GU003 Phase 3 Randomized Clinical Trial. JAMA Oncol 2024:2816344. [PMID: 38483412 PMCID: PMC10941019 DOI: 10.1001/jamaoncol.2023.7291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/24/2023] [Indexed: 03/17/2024]
Abstract
Importance No prior trial has compared hypofractionated postprostatectomy radiotherapy (HYPORT) to conventionally fractionated postprostatectomy (COPORT) in patients primarily treated with prostatectomy. Objective To determine if HYPORT is noninferior to COPORT for patient-reported genitourinary (GU) and gastrointestinal (GI) symptoms at 2 years. Design, Setting, and Participants In this phase 3 randomized clinical trial, patients with a detectable prostate-specific antigen (PSA; ≥0.1 ng/mL) postprostatectomy with pT2/3pNX/0 disease or an undetectable PSA (<0.1 ng/mL) with either pT3 disease or pT2 disease with a positive surgical margin were recruited from 93 academic, community-based, and tertiary medical sites in the US and Canada. Between June 2017 and July 2018, a total of 296 patients were randomized. Data were analyzed in December 2020, with additional analyses occurring after as needed. Intervention Patients were randomized to receive 62.5 Gy in 25 fractions (HYPORT) or 66.6 Gy in 37 fractions (COPORT). Main Outcomes and Measures The coprimary end points were the 2-year change in score from baseline for the bowel and urinary domains of the Expanded Prostate Cancer Composite Index questionnaire. Secondary objectives were to compare between arms freedom from biochemical failure, time to progression, local failure, regional failure, salvage therapy, distant metastasis, prostate cancer-specific survival, overall survival, and adverse events. Results Of the 296 patients randomized (median [range] age, 65 [44-81] years; 100% male), 144 received HYPORT and 152 received COPORT. At the end of RT, the mean GU change scores among those in the HYPORT and COPORT arms were neither clinically significant nor different in statistical significance and remained so at 6 and 12 months. The mean (SD) GI change scores for HYPORT and COPORT were both clinically significant and different in statistical significance at the end of RT (-15.52 [18.43] and -7.06 [12.78], respectively; P < .001). However, the clinically and statistically significant differences in HYPORT and COPORT mean GI change scores were resolved at 6 and 12 months. The 24-month differences in mean GU and GI change scores for HYPORT were noninferior to COPORT using noninferiority margins of -5 and -6, respectively, rejecting the null hypothesis of inferiority (mean [SD] GU score: HYPORT, -5.01 [15.10] and COPORT, -4.07 [14.67]; P = .005; mean [SD] GI score: HYPORT, -4.17 [10.97] and COPORT, -1.41 [8.32]; P = .02). With a median follow-up for censored patients of 2.1 years, there was no difference between HYPORT vs COPORT for biochemical failure, defined as a PSA of 0.4 ng/mL or higher and rising (2-year rate, 12% vs 8%; P = .28). Conclusions and Relevance In this randomized clinical trial, HYPORT was associated with greater patient-reported GI toxic effects compared with COPORT at the completion of RT, but both groups recovered to baseline levels within 6 months. At 2 years, HYPORT was noninferior to COPORT in terms of patient-reported GU or GI toxic effects. HYPORT is a new acceptable practice standard for patients receiving postprostatectomy radiotherapy. Trial Registration ClinicalTrials.gov Identifier: NCT03274687.
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Affiliation(s)
- Mark K. Buyyounouski
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Stephanie L. Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | - Mark J. Mann
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | | | | | - Jeff M. Michalski
- Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Eric Vigneault
- Radiation Oncology, CHU de Québec-Hôpital Enfant Jésus de Quebec, Quebec City, Quebec, Canada
| | | | - Maroie Barkati
- Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | | | | | - Drew C. Monitto
- Upstate Carolina Consortium Community Oncology Research Program, Spartanburg, South Carolina
| | - Jeffrey A. Kittel
- Aurora National Cancer Institute Community Oncology Research Program, Milwaukee, Wisconsin
| | | | - Raquibul Hannan
- Harold C. Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas
| | | | - Joseph P. Rodgers
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Felix Feng
- University of San Francisco, San Francisco, California
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2
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Francolini G, Gaetano Allegra A, Detti B, Di Cataldo V, Caini S, Bruni A, Ingrosso G, D'Angelillo RM, Alitto AR, Augugliaro M, Triggiani L, Parisi S, Facchini G, Banini M, Simontacchi G, Desideri I, Meattini I, Valicenti RK, Livi L. Stereotactic Body Radiation Therapy and Abiraterone Acetate for Patients Affected by Oligometastatic Castrate-Resistant Prostate Cancer: A Randomized Phase II Trial (ARTO). J Clin Oncol 2023; 41:5561-5568. [PMID: 37733977 DOI: 10.1200/jco.23.00985] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 05/05/2023] [Revised: 07/12/2023] [Accepted: 08/08/2023] [Indexed: 09/23/2023] Open
Abstract
PURPOSE ARTO (ClinicalTrials.gov identifier: NCT03449719) is a multicenter, phase II randomized clinical trial testing the benefit of adding stereotactic body radiation therapy (SBRT) to abiraterone acetate and prednisone (AAP) in patients with oligometastatic castrate-resistant prostate cancer (CRPC). MATERIALS AND METHODS All patients were affected by oligometastatic CRPC as defined as three or less nonvisceral metastatic lesions. Patients were randomly assigned 1:1 to receive either AAP alone (control arm) or AAP with concomitant SBRT to all the sites of disease (experimental arm). Primary end point was the rate of biochemical response (BR), defined as a prostate-specific antigen (PSA) decrease ≥50% from baseline measured at 6 months from treatment start. Complete BR (CBR), defined as PSA < 0.2 ng/mL at 6 months from treatment, and progression-free survival (PFS) were secondary end points. RESULTS One hundred and fifty-seven patients were enrolled between January 2019 and September 2022. BR was detected in 79.6% of patients (92% v 68.3% in the experimental v control arm, respectively), with an odds ratio (OR) of 5.34 (95% CI, 2.05 to 13.88; P = .001) in favor of the experimental arm. CBR was detected in 38.8% of patients (56% v 23.2% in the experimental v control arm, respectively), with an OR of 4.22 (95% CI, 2.12 to 8.38; P < .001). SBRT yielded a significant PFS improvement, with a hazard ratio for progression of 0.35 (95% CI, 0.21 to 0.57; P < .001) in the experimental versus control arm. CONCLUSION The trial reached its primary end point of biochemical control and PFS, suggesting a clinical advantage for SBRT in addition to first-line AAP treatment in patients with metastatic castration-resistant prostate cancer.
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Affiliation(s)
- Giulio Francolini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | - Andrea Gaetano Allegra
- Department of Biomedical, Experimental and Clinical Sciences "M. Serio", University of Florence, Florence, Italy
| | - Beatrice Detti
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | - Vanessa Di Cataldo
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | - Saverio Caini
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network (ISPO), Florence, Italy
| | - Alessio Bruni
- Radiation Oncology Unit, Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
| | - Gianluca Ingrosso
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Rolando Maria D'Angelillo
- Radiation Oncology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Anna Rita Alitto
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Matteo Augugliaro
- Unit of Radiotherapy, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Luca Triggiani
- Università degli Studi di Brescia, Department of Radiation Oncology, Brescia University, Brescia, Italy
| | - Silvana Parisi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Gaetano Facchini
- Medical Oncology Unit, SM delle Grazie Hospital, Pozzuoli, Italy
| | - Marco Banini
- Department of Biomedical, Experimental and Clinical Sciences "M. Serio", University of Florence, Florence, Italy
| | - Gabriele Simontacchi
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | - Isacco Desideri
- Department of Biomedical, Experimental and Clinical Sciences "M. Serio", University of Florence, Florence, Italy
| | - Icro Meattini
- Department of Biomedical, Experimental and Clinical Sciences "M. Serio", University of Florence, Florence, Italy
| | | | - Lorenzo Livi
- Department of Biomedical, Experimental and Clinical Sciences "M. Serio", University of Florence, Florence, Italy
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Francolini G, Banini M, Di Cataldo V, Detti B, Caini S, Loi M, Simontacchi G, Desideri I, Greto D, Valzano M, Roghi M, Serni S, Vaggelli L, Salvestrini V, Visani L, Becherini C, Olmetto E, Franzese C, Baldaccini D, Scorsetti M, Sollini M, Chiti A, Meattini I, Valicenti RK, Livi L. PSMA guided approach for bIoCHEmical relapse after prostatectomy- (PSICHE) trial (NCT05022914). Detection rate and treatment decision after 68Ga-PSMA PET/CT within a prospective study. Prostate 2023; 83:1201-1206. [PMID: 37290915 DOI: 10.1002/pros.24579] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/23/2023] [Accepted: 05/07/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Ultrasensitive imaging has been demonstrated to influence biochemical relapse treatment. PSICHE is a multicentric prospective study, aimed at exploring detection rate with 68Ga-PSMA-11 positron emission tomography/computed tomography (PET/CT) and outcomes with a predefined treatment algorithm tailored to the imaging. METHODS Patients affected by biochemical recurrence after surgery (prostate specific antigen [PSA] > 0.2 < 1 ng/mL) underwent staging with 68Ga-PSMA PET/CT. Management followed this treatment algorithm accordingly with PSMA results: prostate bed salvage radiotherapy (SRT) if negative or positive within prostate bed, stereotactic body radiotherapy (SBRT) if pelvic nodal recurrences or oligometastatic disease, androgen deprivation therapy (ADT) if nonoligometastatic disease. Chi-square test was used to evaluate the relationship between baseline features and rate of positive PSMA PET/CT. RESULTS One hundred patients were enrolled. PSMA results were negative/positive in the prostate bed in 72 patients, pelvic nodal or extrapelvic metastatic disease were detected in 23 and 5 patients. Twenty-one patients underwent observation because of prior postoperative radiotherapy (RT)/treatment refusal. Fifty patients were treated with prostate bed SRT, 23 patients underwent SBRT to pelvic nodal disease, five patients were treated with SBRT to oligometastatic disease. One patient underwent ADT. NCCN high-risk features, stage > pT3 and ISUP score >3 reported a significantly higher rate of positive PSMA PET/CT after restaging (p = 0.01, p = 0.02, and p = 0.002). By quartiles of PSA, rate of positive PSMA PET/CT was 26.9% (>0.2; <0.29 ng/mL), 24% (>0.3; <0.37 ng/mL), 26.9% (>0.38; <0.51 ng/mL), and 34.7% (>0. 52; <0.98 ng/mL). CONCLUSIONS PSICHE trial constitute a useful platform to collect data within a clinical framework where modern imaging and metastasis-directed therapy are integrated.
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Affiliation(s)
- Giulio Francolini
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Marco Banini
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Vanessa Di Cataldo
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Beatrice Detti
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Saverio Caini
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy
| | - Mauro Loi
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gabriele Simontacchi
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Isacco Desideri
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Daniela Greto
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Marianna Valzano
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Manuele Roghi
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Sergio Serni
- Unit of Urological Robotic Surgery and Renal Transplantation and Department of Experimental and Clinical Medicine, University of Florence, Careggi Hospital, Florence, Italy
| | - Luca Vaggelli
- Nuclear Medicine Division, Careggi University Hospital, Florence, Italy
| | - Viola Salvestrini
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Luca Visani
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Carlotta Becherini
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Emanuela Olmetto
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Ciro Franzese
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Davide Baldaccini
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Martina Sollini
- Department of Biomedical Sciences and Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Arturo Chiti
- Nuclear Medicine Department, IRCCS San Raffaele, Milan, Italy
| | - Icro Meattini
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | | | - Lorenzo Livi
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
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4
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Francolini G, Ganovelli M, Di Cataldo V, Detti B, Caini S, Loi M, Simontacchi G, Desideri I, Greto D, Valzano M, Serni S, Vaggelli L, Salvestrini V, Visani L, Becherini C, Olmetto E, Franzese C, Baldaccini D, Scorsetti M, Sollini M, Chiti A, Meattini I, Valicenti RK, Livi L. Early biochemical outcomes following PSMA guided approach for bIoCHEmical relapse after prostatectomy-PSICHE trial (NCT05022914): preliminary results. Clin Exp Metastasis 2023; 40:197-201. [PMID: 37012498 PMCID: PMC10113311 DOI: 10.1007/s10585-023-10204-y] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/10/2023] [Indexed: 04/05/2023]
Abstract
PSICHE (NCT05022914) is a prospective trial to test a [68Ga]Ga- PSMA-11 PET/CT imaging tailored strategy. All evaluable patients had biochemical relapse after surgery and underwent centralized [68Ga]Ga-PSMA-11 PET/CT imaging. The treatment was performed according pre-defined criteria. Observation and re-staging at further PSA progression were proposed to patients with negative PSMA and previous postoperative RT. Prostate bed SRT was proposed to all patients with a negative staging or positive imaging within prostate bed. Stereotactic body radiotherapy (SBRT) to all sites of disease was used for all patients with pelvic nodal recurrence (nodal disease < 2 cm under aortic bifurcation) or oligometastatic disease. At 3 months after treatment, 54.7% of patients had a complete biochemical response Only 2 patients experienced G2 Genitourinary toxicity. No G2 Gastrointestinal toxicity was recorded. A PSMA targeted treatment strategy led to encouraging results and was well tolerated.
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Affiliation(s)
- Giulio Francolini
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Michele Ganovelli
- Department of Biomedical, Experimental and Clinical Sciences, Serio" University of Florence, Florence, Italy
| | - Vanessa Di Cataldo
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Beatrice Detti
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
- Radiation Oncology Department, AOU Careggi, Viale Morgagni 85, Florence, 50134, Italy.
| | - Saverio Caini
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy
| | - Mauro Loi
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gabriele Simontacchi
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Isacco Desideri
- Department of Biomedical, Experimental and Clinical Sciences, Serio" University of Florence, Florence, Italy
| | - Daniela Greto
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Marianna Valzano
- Department of Biomedical, Experimental and Clinical Sciences, Serio" University of Florence, Florence, Italy
| | - Sergio Serni
- Unit of Urological Robotic Surgery and Renal Transplantation, University of Florence, Careggi Hospital, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Luca Vaggelli
- Nuclear Medicine Division, Careggi University Hospital, Florence, Italy
| | - Viola Salvestrini
- CyberKnife Center, Istituto Fiorentino di Cura e Assistenza (IFCA), Florence, Italy
| | - Luca Visani
- CyberKnife Center, Istituto Fiorentino di Cura e Assistenza (IFCA), Florence, Italy
| | - Carlotta Becherini
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Emanuela Olmetto
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Ciro Franzese
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Davide Baldaccini
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Marta Scorsetti
- Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Martina Sollini
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
| | - Arturo Chiti
- Nuclear Medicine Department, IRCCS San Raffaele, Milan, Italy
| | - Icro Meattini
- Department of Biomedical, Experimental and Clinical Sciences, Serio" University of Florence, Florence, Italy
| | | | - Lorenzo Livi
- Department of Biomedical, Experimental and Clinical Sciences, Serio" University of Florence, Florence, Italy
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5
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McDonald AM, DeMora L, Yang ES, Hoyle JM, Lenzie A, Williams GR, Michalski JM, Yee D, Bahary JP, Den RB, Roach M, Dess R, Mishra MV, Valicenti RK, Lau HY, Marcrom SR, Souhami L, Mendez LC, Chen Y, Doncals DE, Pugh SL, Feng FY, Sandler HM. Body composition and mortality in men receiving prostate radiotherapy: A pooled analysis of NRG/RTOG 9406 and NRG/RTOG 0126. Cancer 2023; 129:685-696. [PMID: 36579470 PMCID: PMC10231027 DOI: 10.1002/cncr.34596] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE To validate the association between body composition and mortality in men treated with radiation for localized prostate cancer (PCa). Secondarily, to integrate body composition as a factor to classify patients by risk of all-cause mortality. MATERIALS AND METHODS Participants of NRG/Radiation Therapy Oncology Group (RTOG) 9406 and NRG/RTOG 0126 with archived computed tomography were included. Muscle mass and muscle density were estimated by measuring the area and attenuation of the psoas muscles on a single slice at L4-L5. Bone density was estimated by measuring the attenuation of the vertebral body at mid-L5. Survival analyses, including Cox proportional hazards models, assessed the relationship between body composition and mortality. Recursive partitioning analysis (RPA) was used to create a classification tree to classify participants by risk of death. RESULTS Data from 2066 men were included in this study. In the final multivariable model, psoas area, comorbidity score, baseline prostate serum antigen, and age were significantly associated with survival. The RPA yielded a classification tree with four prognostic groups determined by age, comorbidity, and psoas area. Notably, the classification among older (≥70 years) men into prognostic groups was determined by psoas area. CONCLUSIONS This study strongly supports that body composition is related to mortality in men with localized PCa. The inclusion of psoas area in the RPA classification tree suggests that body composition provides additive information to age and comorbidity status for mortality prediction, particularly among older men. More research is needed to determine the clinical impact of body composition on prognostic models in men with PCa.
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Affiliation(s)
- Andrew M. McDonald
- Department of Radiation Oncology, University of Alabama at Birmingham O’Neal Comprehensive Cancer Center, Birmingham, Alabama, USA
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lyudmila DeMora
- Statistics and Data Management Department, NRG Oncology, Philadelphia, Pennsylvania, USA
- Statistical and Data Management Department, American College of Radiology, Philadelphia, Pennsylvania, USA
| | - Eddy S. Yang
- Department of Radiation Oncology, University of Alabama at Birmingham O’Neal Comprehensive Cancer Center, Birmingham, Alabama, USA
| | - John M. Hoyle
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrew Lenzie
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Grant R. Williams
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeff M. Michalski
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Don Yee
- Radiation Oncology Department of Radiation Oncology, Edmonton Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Jean-Paul Bahary
- Department of Radio Oncology, CHUM - Centre Hospitalier de l’Universite de Montreal, Montreal, Quebec, Canada
| | - Robert B. Den
- Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Mack Roach
- Department of Radiation Oncology, UCSF Medical Center-Mount Zion, San Francisco, California, USA
| | - Robert Dess
- Department of Radiation Oncology, University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan, USA
| | - Mark V. Mishra
- Department of Radiation Oncology, University of Maryland/Greenebaum Cancer Center, Baltimore, Maryland, USA
| | - Richard K. Valicenti
- Department of Radiation Oncology, University of California Davis, Sacramento, California, USA
| | - Harold Y. Lau
- Department of Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Samuel R. Marcrom
- Department of Radiation Oncology, University of Alabama at Birmingham O’Neal Comprehensive Cancer Center, Birmingham, Alabama, USA
| | - Luis Souhami
- The Research Institute, McGill University Health Centre (MUHC), Montreal, Quebec, Canada
| | - Lucas C. Mendez
- Department of Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - Yuhchyau Chen
- Department of Radiation Oncology, University of Rochester, Rochester, New York, USA
| | - Desiree E. Doncals
- Department of Radiation Oncology, Summa Health System - Akron Campus, Akron, Ohio, USA
| | - Stephanie L. Pugh
- Statistics and Data Management Department, NRG Oncology, Philadelphia, Pennsylvania, USA
- Statistical and Data Management Department, American College of Radiology, Philadelphia, Pennsylvania, USA
| | - Felix Y. Feng
- Department of Radiation Oncology, UCSF Medical Center-Mission Bay, San Francisco, California, USA
| | - Howard M. Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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6
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Rahma OE, Yothers G, Hong TS, Russell MM, You YN, Parker W, Jacobs SA, Colangelo LH, Lucas PC, Gollub MJ, Hall WA, Kachnic LA, Vijayvergia N, O'Rourke MA, Faller BA, Valicenti RK, Schefter TE, Moxley KM, Kainthla R, Stella PJ, Sigurdson E, Wolmark N, George TJ. Use of Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer: Initial Results From the Pembrolizumab Arm of a Phase 2 Randomized Clinical Trial. JAMA Oncol 2021; 7:1225-1230. [PMID: 34196693 DOI: 10.1001/jamaoncol.2021.1683] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance Total neoadjuvant therapy (TNT) is often used to downstage locally advanced rectal cancer (LARC) and decrease locoregional relapse; however, more than one-third of patients develop recurrent metastatic disease. As such, novel combinations are needed. Objective To assess whether the addition of pembrolizumab during and after neoadjuvant chemoradiotherapy can lead to an improvement in the neoadjuvant rectal (NAR) score compared with treatment with FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) and chemoradiotherapy alone. Design, Setting, and Participants In this open-label, phase 2, randomized clinical trial (NRG-GI002), patients in academic and private practice settings were enrolled. Patients with stage II/III LARC with distal location (cT3-4 ≤ 5 cm from anal verge, any N), with bulky disease (any cT4 or tumor within 3 mm of mesorectal fascia), at high risk for metastatic disease (cN2), and/or who were not candidates for sphincter-sparing surgery (SSS) were stratified based on clinical tumor and nodal stages. Trial accrual opened on August 1, 2018, and ended on May 31, 2019. This intent-to-treat analysis is based on data as of August 2020. Interventions Patients were randomized (1:1) to neoadjuvant FOLFOX for 4 months and then underwent chemoradiotherapy (capecitabine with 50.4 Gy) with or without intravenous pembrolizumab administered at a dosage of 200 mg every 3 weeks for up to 6 doses before surgery. Main Outcomes and Measures The primary end point was the NAR score. Secondary end points included pathologic complete response (pCR) rate, SSS, disease-free survival, and overall survival. This report focuses on end points available after definitive surgery (NAR score, pCR, SSS, clinical complete response rate, margin involvement, and safety). Results A total of 185 patients (126 [68.1%] male; mean [SD] age, 55.7 [11.1] years) were randomized to the control arm (CA) (n = 95) or the pembrolizumab arm (PA) (n = 90). Of these patients, 137 were evaluable for NAR score (68 CA patients and 69 PA patients). The mean (SD) NAR score was 11.53 (12.43) for the PA patients (95% CI, 8.54-14.51) vs 14.08 (13.82) for the CA patients (95% CI, 10.74-17.43) (P = .26). The pCR rate was 31.9% in the PA vs 29.4% in the CA (P = .75). The clinical complete response rate was 13.9% in the PA vs 13.6% in the CA (P = .95). The percentage of patients who underwent SSS was 59.4% in the PA vs 71.0% in the CA (P = .15). Grade 3 to 4 adverse events were slightly increased in the PA (48.2%) vs the CA (37.3%) during chemoradiotherapy. Two deaths occurred during FOLFOX: sepsis (CA) and pneumonia (PA). No differences in radiotherapy fractions, FOLFOX, or capecitabine doses were found. Conclusions and Relevance Pembrolizumab added to chemoradiotherapy as part of total neoadjuvant therapy was suggested to be safe; however, the NAR score difference does not support further study. Trial Registration ClinicalTrials.gov Identifier: NCT02921256.
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Affiliation(s)
- Osama E Rahma
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Medical Oncology, Dana-Farber Cancer Institute/Alliance, Boston, Massachusetts
| | - Greg Yothers
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Theodore S Hong
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Radiation Oncology, Massachusetts General Hospital, Boston
| | - Marcia M Russell
- NRG Oncology, Philadelphia, Pennsylvania.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Y Nancy You
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - William Parker
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Medical Physics, McGill University Health Centre, Montréal, Quebec, Canada
| | | | - Linda H Colangelo
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter C Lucas
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Pathology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - William A Hall
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee
| | - Lisa A Kachnic
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Radiation Oncology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, New York.,SWOG Cancer Research Network, San Antonio, Texas
| | - Namrata Vijayvergia
- NRG Oncology, Philadelphia, Pennsylvania.,Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Mark A O'Rourke
- NRG Oncology, Philadelphia, Pennsylvania.,National Cancer Institute Community Oncology Research Program, Prisma Health Cancer Institute, Greenville, South Carolina
| | - Bryan A Faller
- Missouri Baptist Medical Center, Heartland Cancer Research, National Cancer Institute Community Oncology Research Program, St Louis
| | | | - Tracey E Schefter
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Radiation Oncology, University of Colorado Cancer Center, Aurora
| | - Katherine M Moxley
- NRG Oncology, Philadelphia, Pennsylvania.,Section of Gynecologic Oncology, University of Oklahoma Stephenson Cancer Center, Oklahoma City
| | - Radhika Kainthla
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Philip J Stella
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Medical Oncology, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Elin Sigurdson
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Norman Wolmark
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Thomas J George
- NRG Oncology, Philadelphia, Pennsylvania.,Department of Medicine, University of Florida Health Cancer Center, Gainesville
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7
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Azghadi S, Moran A, Palo BM, San D, Valicenti RK, Leiserowitz GS, Zhao X. Analysis of outcomes and cost effectiveness of inpatient vs. outpatient based interstitial vaginal brachytherapy. Gynecol Oncol 2020. [DOI: 10.1016/j.ygyno.2020.07.095] [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: 12/01/2022]
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8
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Buwenge M, Deodato F, Macchia G, Siepe G, Zhao X, Valicenti RK, Cilla S, Alitto AR, Ntreta M, Bisello S, Mantini G, Valentini V, Morganti AG, Cammelli S. Radiotherapy Plus GnRH Analogue Versus High Dose Bicalutamide: A Case Control Study. Anticancer Res 2019; 39:6373-6378. [PMID: 31704870 DOI: 10.21873/anticanres.13850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 09/20/2019] [Revised: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Radiotherapy (RT) with adjuvant hormone therapy (HT) improves prognosis in prostate cancer (PC) patients. Gonadotrophin-releasing hormone agonist (GnRHa) with luteinizing hormone-releasing hormone (LH-RH) analogues is the standard HT. High-dose antiandrogen therapy also improves survival in patients with locally advanced PC. The aim of this study was to compare the results of patients treated with RT plus GnRHa and patients treated with RT plus bicalutamide. PATIENTS AND METHODS Our institutional PC database was used to identify patients treated with definitive or postoperative RT +/- HT which were included in this study. RESULTS Three hundred and eighteen patients were retrospectively reviewed (median follow-up=56 months). Five-year biochemical relapse-free survival was 85.5% and 88.3% in patients treated with GnRHa and bicalutamide, respectively (p=0.712). CONCLUSION Bicalutamide may be offered as an adjuvant treatment to RT in patients who refuse GnRHa because of related side effects. Furthermore, our study justifies randomized trials comparing RT plus GnRHa and RT plus bicalutamide.
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Affiliation(s)
- Milly Buwenge
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine - DIMES, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Francesco Deodato
- Radiotherapy Unit, Giovanni Paolo II Foundation, Catholic University of Sacred Heart, Campobasso, Italy
| | - Gabriella Macchia
- Radiotherapy Unit, Giovanni Paolo II Foundation, Catholic University of Sacred Heart, Campobasso, Italy
| | - Giambattista Siepe
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine - DIMES, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Xiao Zhao
- Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA, U.S.A
| | - Richard K Valicenti
- Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA, U.S.A
| | - Savino Cilla
- Medical Physics Unit, Giovanni Paolo II Foundation, Catholic University of Sacred Heart, Campobasso, Italy
| | - Anna Rita Alitto
- Institute of Radiology, Catholic University of Sacred Heart, Rome, Italy
| | - Maria Ntreta
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine - DIMES, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Silvia Bisello
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine - DIMES, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giovanna Mantini
- Institute of Radiology, Catholic University of Sacred Heart, Rome, Italy
| | - Vincenzo Valentini
- Institute of Radiology, Catholic University of Sacred Heart, Rome, Italy.,Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Alessio G Morganti
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine - DIMES, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Silvia Cammelli
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine - DIMES, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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9
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Dyer BA, Yuan Z, Qiu J, Benedict SH, Valicenti RK, Mayadev JS, Rong Y. Factors associated with deformation accuracy and modes of failure for MRI-optimized cervical brachytherapy using deformable image registration. Brachytherapy 2019; 18:378-386. [DOI: 10.1016/j.brachy.2019.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 12/21/2018] [Accepted: 01/03/2019] [Indexed: 10/27/2022]
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10
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Pisansky TM, Thompson IM, Valicenti RK, D'Amico AV, Selvarajah S. Adjuvant and Salvage Radiation Therapy After Prostatectomy: ASTRO/AUA Guideline Amendment, Executive Summary 2018. Pract Radiat Oncol 2019; 9:208-213. [PMID: 31051281 DOI: 10.1016/j.prro.2019.04.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 04/19/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this amendment is to incorporate newly published literature into the original American Society for Radiation Oncology/American Urological Association Adjuvant and Salvage Radiotherapy After Prostatectomy Guideline and provide an updated clinical framework for clinicians. METHODS AND MATERIALS The original systematic review yielded 294 studies published between January 1990 and December 2012. In April 2018, the guideline underwent an amendment and incorporated 155 references that were published between January 1990 and December 2017. Two new key questions were added: one on the use of genomic classifiers and the other on the treatment of oligo-metastases with radiation after radical prostatectomy. RESULTS A new statement on the use of hormone therapy with salvage radiation therapy (RT) after radical prostatectomy was added, and long-term data were used to update an existing statement on adjuvant RT. The balance of the guideline statements were reaffirmed, and references added to the existing literature base. A discussion on the use of genomic classifiers as a risk stratification tool was added to the future research discussion. No relevant data on oligo-metastases were found. CONCLUSIONS Hormone therapy should be offered to patients who have had radical prostatectomy and who are candidates for salvage RT. Clinicians should discuss possible short- and long-term side effects with patients in addition to the potential benefits of preventing recurrence. The decision to use hormone therapy should be made by the patient and a multidisciplinary team of providers with full consideration of the patient's history, values, preferences, quality of life, and functional status.
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Affiliation(s)
| | - Ian M Thompson
- Department of Urology, CHRISTUS Santa Rosa Medical Center Hospital, San Antonio, Texas.
| | - Richard K Valicenti
- Department of Radiation Oncology, University of California, Davis School of Medicine, Sacramento, California
| | - Anthony V D'Amico
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts
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11
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Dyer BA, Mayadev JS, Ready J, Dieterich S, Rong Y, Benedict S, Valicenti RK. Clinical and Design Considerations for a Dedicated Image-Guided Brachytherapy Suite. Brachytherapy 2018. [DOI: 10.1016/j.brachy.2018.04.262] [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: 11/28/2022]
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12
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Yuan Z, Nair CK, Benedict SH, Valicenti RK, Rao S, Fragoso RC, Wright C, Qiu J, Rong Y. Converting Treatment Plans From Helical Tomotherapy to L-Shape Linac: Clinical Workflow and Dosimetric Evaluation. Technol Cancer Res Treat 2018; 17:1533033818785279. [PMID: 29986638 PMCID: PMC6048611 DOI: 10.1177/1533033818785279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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] [Indexed: 11/17/2022] Open
Abstract
This work evaluated a commercial fallback planning workflow designed to provide cross-platform treatment planning and delivery. A total of 27 helical tomotherapy intensity-modulated radiotherapy plans covering 4 anatomical sites were selected, including 7 brain, 5 unilateral head and neck, 5 bilateral head and neck, 5 pelvis, and 5 prostate cases. All helical tomotherapy plans were converted to 7-field/9-field intensity-modulated radiotherapy and volumetric-modulated radiotherapy plans through fallback dose-mimicking algorithm using a 6-MV beam model. The planning target volume (PTV) coverage ( D1, D99, and homogeneity index) and organs at risk dose constraints were evaluated and compared. Overall, all 3 techniques resulted in relatively inferior target dose coverage compared to helical tomotherapy plans, with higher homogeneity index and maximum dose. The organs at risk dose ratio of fallback to helical tomotherapy plans covered a wide spectrum, from 0.87 to 1.11 on average for all sites, with fallback plans being superior for brain, pelvis, and prostate sites. The quality of fallback plans depends on the delivery technique, field numbers, and angles, as well as user selection of structures for organs at risk. In actual clinical scenario, fallback plans would typically be needed for 1 to 5 fractions of a treatment course in the event of machine breakdown. Our results suggested that <1% dose variance can be introduced in target coverage and/or organs at risk from fallback plans. The presented clinical workflow showed that the fallback plan generation typically takes 10 to 20 minutes per case. Fallback planning provides an expeditious and effective strategy for transferring patients cross platforms, and minimizing the untold risk of a patient missing treatment(s).
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Affiliation(s)
- Zilong Yuan
- 1 Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA USA.,2 Department of Radiology, Hubei Cancer Hospital, Hubei Key Laboratory of Medical Information Analysis & Tumor Diagnosis and Treatment, Wuhan, China
| | - Chithra Kumaran Nair
- 1 Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA USA
| | - Stanley H Benedict
- 1 Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA USA
| | - Richard K Valicenti
- 1 Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA USA
| | - Shyam Rao
- 1 Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA USA
| | - Ruben C Fragoso
- 1 Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA USA
| | - Cari Wright
- 1 Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA USA
| | - Jianfeng Qiu
- 3 Department of Radiology, Taishan Medical University, Tai'an, China
| | - Yi Rong
- 1 Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA USA
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13
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Dyer BA, Benedict S, Rong Y, Dieterich S, Valicenti RK, Hunt JP, Montemayor EE, Mayadev JS. Sustainable Gynecological Brachytherapy in an Increasingly Cost-Aware Healthcare System: Conversion of Labor-Intense Interstitial Brachytherapy to Hybrid Intracavitary Brachytherapy for Locally Advanced Cervical Cancer. Brachytherapy 2017. [DOI: 10.1016/j.brachy.2017.04.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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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14
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Tait L, Dieterich S, Lim J, Hunt JP, Valicenti RK, Mayadev J. Image-Guided Brachtherapy for Locally Advanced Cervical Cancer: Can Deformable Image Registration Replace MRI Simulation? Brachytherapy 2014. [DOI: 10.1016/j.brachy.2014.02.243] [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: 10/25/2022]
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15
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Greene DE, Dieterich S, Valicenti RK. Intraoperative Prostate Volume Change During Permanent Low-Dose-Rate I-125 Prostate Brachytherapy: Implications for Final Implant Dosimetry. Brachytherapy 2014. [DOI: 10.1016/j.brachy.2014.02.422] [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: 10/25/2022]
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16
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Hoffman KE, Pugh SL, James JL, Scarantino C, Movsas B, Valicenti RK, Fortin A, Pollock J, Kim H, Brachman DG, Berk LB, Bruner DW, Kachnic LA. The impact of concurrent granulocyte-macrophage colony-stimulating factor on quality of life in head and neck cancer patients: results of the randomized, placebo-controlled Radiation Therapy Oncology Group 9901 trial. Qual Life Res 2014; 23:1841-58. [PMID: 24492945 DOI: 10.1007/s11136-014-0628-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The Radiation Therapy Oncology Group (RTOG) conducted a randomized, placebo-controlled trial evaluating the efficacy of GM-CSF in reducing mucosal injury and symptom burden from curative radiotherapy for head and neck (H&N) cancer. METHODS Eligible patients with H&N cancer receiving radiation encompassing ≥50 % of the oral cavity or oropharynx received subcutaneous GM-CSF or placebo. Quality of life (QoL) was assessed using the RTOG-modified University of Washington H&N Symptom Questionnaire at baseline 4, 13, 26, and 48 weeks from radiation initiation. RESULTS Of 125 eligible patients, 114 were evaluable for QoL (58 GM-CSF, 56 placebo). Patient demographics, clinical characteristics, and baseline symptom scores were well balanced between the treatment arms. At the end of the acute period (13 weeks), patients in both arms reported negative change in total symptom score indicating increase in symptom burden relative to baseline (mean -18.4 GM-CSF, -20.8 placebo). There was no difference in change in total symptom score (p > 0.05) or change in mucous, pain, eating, or activity domain scores (p > 0.01) between patients in the GM-CSF and placebo arms. Analysis limited to patients treated per protocol or with an acceptable protocol deviation also found no difference in change in total symptom score (p > 0.05) or change in domain scores (p > 0.01) between treatment arms. Provider assessment of acute mucositis during treatment did not correlate with patient-reported mucous domain and total symptom scores (p > 0.05). CONCLUSION GM-CSF administered concurrently during head and neck radiation does not appear to significantly improve patient-reported QoL symptom burden.
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Affiliation(s)
- Karen E Hoffman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1202, Houston, TX, 77030, USA,
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17
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Valicenti RK, Thompson I, Albertsen P, Davis BJ, Goldenberg SL, Wolf JS, Sartor O, Klein E, Hahn C, Michalski J, Roach M, Faraday MM. Adjuvant and salvage radiation therapy after prostatectomy: American Society for Radiation Oncology/American Urological Association guidelines. Int J Radiat Oncol Biol Phys 2013; 86:822-8. [PMID: 23845839 DOI: 10.1016/j.ijrobp.2013.05.029] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 05/15/2013] [Accepted: 05/15/2013] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of this guideline was to provide a clinical framework for the use of radiation therapy after radical prostatectomy as adjuvant or salvage therapy. METHODS AND MATERIALS A systematic literature review using PubMed, Embase, and Cochrane database was conducted to identify peer-reviewed publications relevant to the use of radiation therapy after prostatectomy. The review yielded 294 articles; these publications were used to create the evidence-based guideline statements. Additional guidance is provided as Clinical Principles when insufficient evidence existed. RESULTS Guideline statements are provided for patient counseling, use of radiation therapy in the adjuvant and salvage contexts, defining biochemical recurrence, and conducting a restaging evaluation. CONCLUSIONS Physicians should offer adjuvant radiation therapy to patients with adverse pathologic findings at prostatectomy (ie, seminal vesicle invastion, positive surgical margins, extraprostatic extension) and salvage radiation therapy to patients with prostate-specific antigen (PSA) or local recurrence after prostatectomy in whom there is no evidence of distant metastatic disease. The offer of radiation therapy should be made in the context of a thoughtful discussion of possible short- and long-term side effects of radiation therapy as well as the potential benefits of preventing recurrence. The decision to administer radiation therapy should be made by the patient and the multidisciplinary treatment team with full consideration of the patient's history, values, preferences, quality of life, and functional status. The American Society for Radiation Oncology and American Urological Association websites show this guideline in its entirety, including the full literature review.
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Affiliation(s)
- Richard K Valicenti
- Department of Radiation Oncology, University of California, Davis School of Medicine, Davis, California, USA.
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18
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Thompson IM, Valicenti RK, Albertsen P, Davis BJ, Goldenberg SL, Hahn C, Klein E, Michalski J, Roach M, Sartor O, Wolf JS, Faraday MM. Adjuvant and salvage radiotherapy after prostatectomy: AUA/ASTRO Guideline. J Urol 2013; 190:441-9. [PMID: 23707439 DOI: 10.1016/j.juro.2013.05.032] [Citation(s) in RCA: 285] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2013] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of this guideline is to provide a clinical framework for the use of radiotherapy after radical prostatectomy as adjuvant or salvage therapy. MATERIALS AND METHODS A systematic literature review using the PubMed®, Embase, and Cochrane databases was conducted to identify peer-reviewed publications relevant to the use of radiotherapy after prostatectomy. The review yielded 294 articles; these publications were used to create the evidence-based guideline statements. Additional guidance is provided as Clinical Principles when insufficient evidence existed. RESULTS Guideline statements are provided for patient counseling, the use of radiotherapy in the adjuvant and salvage contexts, defining biochemical recurrence, and conducting a re-staging evaluation. CONCLUSIONS Physicians should offer adjuvant radiotherapy to patients with adverse pathologic findings at prostatectomy (i.e., seminal vesicle invasion, positive surgical margins, extraprostatic extension) and should offer salvage radiotherapy to patients with prostatic specific antigen or local recurrence after prostatectomy in whom there is no evidence of distant metastatic disease. The offer of radiotherapy should be made in the context of a thoughtful discussion of possible short- and long-term side effects of radiotherapy as well as the potential benefits of preventing recurrence. The decision to administer radiotherapy should be made by the patient and the multi-disciplinary treatment team with full consideration of the patient's history, values, preferences, quality of life, and functional status. Please visit the ASTRO and AUA websites (http://www.redjournal.org/webfiles/images/journals/rob/RAP%20Guideline.pdf and http://www.auanet.org/education/guidelines/radiation-after-prostatectomy.cfm) to view this guideline in its entirety, including the full literature review.
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Affiliation(s)
- Ian M Thompson
- American Urological Association Education and Research, Inc., Linthicum, Maryland, USA
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19
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Abstract
Around 70% of men presenting with prostate cancer will have organ-confined disease, with the majority presenting with low- or intermediate-risk prostate cancer. This article reviews the evidence supporting the current standard of care in radiation oncology for the evaluation and management of men with intermediate-risk prostate cancer. Dose escalation, hormonal therapy, combined modality therapy, and modern techniques for the delivery of radiation therapy are reviewed.
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Affiliation(s)
- David E Greene
- Lieutenant Commander, 4501 X st, Radiation Oncology, Sacramento, CA 95817, USA
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20
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Michalski J, Winter K, Roach M, Markoe A, Sandler HM, Ryu J, Parliament M, Purdy JA, Valicenti RK, Cox JD. Clinical outcome of patients treated with 3D conformal radiation therapy (3D-CRT) for prostate cancer on RTOG 9406. Int J Radiat Oncol Biol Phys 2012; 83:e363-70. [PMID: 22633552 DOI: 10.1016/j.ijrobp.2011.12.070] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Revised: 12/18/2011] [Accepted: 12/20/2011] [Indexed: 10/26/2022]
Abstract
PURPOSE Report of clinical cancer control outcomes on Radiation Therapy Oncology Group (RTOG) 9406, a three-dimensional conformal radiation therapy (3D-CRT) dose escalation trial for localized adenocarcinoma of the prostate. METHODS AND MATERIALS RTOG 9406 is a Phase I/II multi-institutional dose escalation study of 3D-CRT for men with localized prostate cancer. Patients were registered on five sequential dose levels: 68.4 Gy, 73.8 Gy, 79.2 Gy, 74 Gy, and 78 Gy with 1.8 Gy/day (levels I-III) or 2.0 Gy/day (levels IV and V). Neoadjuvant hormone therapy (NHT) from 2 to 6 months was allowed. Protocol-specific, American Society for Therapeutic Radiation Oncology (ASTRO), and Phoenix biochemical failure definitions are reported. RESULTS Thirty-four institutions enrolled 1,084 patients and 1,051 patients are analyzable. Median follow-up for levels I, II, III, IV, and V was 11.7, 10.4, 11.8, 10.4, and 9.2 years, respectively. Thirty-six percent of patients received NHT. The 5-year overall survival was 90%, 87%, 88%, 89%, and 88% for dose levels I-V, respectively. The 5-year clinical disease-free survival (excluding protocol prostate-specific antigen definition) for levels I-V is 84%, 78%, 81%, 82%, and 82%, respectively. By ASTRO definition, the 5-year disease-free survivals were 57%, 59%, 52%, 64% and 75% (low risk); 46%, 52%, 54%, 56%, and 63% (intermediate risk); and 50%, 34%, 46%, 34%, and 61% (high risk) for levels I-V, respectively. By the Phoenix definition, the 5-year disease-free survivals were 68%, 73%, 67%, 84%, and 80% (low risk); 70%, 62%, 70%, 74%, and 69% (intermediate risk); and 42%, 62%, 68%, 54%, and 67% (high risk) for levels I-V, respectively. CONCLUSION Dose-escalated 3D-CRT yields favorable outcomes for localized prostate cancer. This multi-institutional experience allows comparison to other experiences with modern radiation therapy.
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Affiliation(s)
- Jeff Michalski
- Department of Radiation Oncology, Washington University Medical School, St. Louis, MO 63110, USA.
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Stanic S, Mathai M, Cui J, Purdy JA, Valicenti RK. Relationship Between Pelvic Organ-at-Risk Dose and Clinical Target Volume in Postprostatectomy Patients Receiving Intensity-Modulated Radiotherapy. Int J Radiat Oncol Biol Phys 2012; 82:1897-902. [DOI: 10.1016/j.ijrobp.2010.10.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2010] [Revised: 09/10/2010] [Accepted: 10/12/2010] [Indexed: 10/18/2022]
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Perks JR, Stanic S, Stern RL, Henk B, Nelson MS, Harse RD, Mathai M, Purdy JA, Valicenti RK, Siefkin AD, Chen AM. Failure mode and effect analysis for delivery of lung stereotactic body radiation therapy. Int J Radiat Oncol Biol Phys 2011; 83:1324-9. [PMID: 22197236 DOI: 10.1016/j.ijrobp.2011.09.019] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 08/29/2011] [Accepted: 09/12/2011] [Indexed: 12/31/2022]
Abstract
PURPOSE To improve the quality and safety of our practice of stereotactic body radiation therapy (SBRT), we analyzed the process following the failure mode and effects analysis (FMEA) method. METHODS The FMEA was performed by a multidisciplinary team. For each step in the SBRT delivery process, a potential failure occurrence was derived and three factors were assessed: the probability of each occurrence, the severity if the event occurs, and the probability of detection by the treatment team. A rank of 1 to 10 was assigned to each factor, and then the multiplied ranks yielded the relative risks (risk priority numbers). The failure modes with the highest risk priority numbers were then considered to implement process improvement measures. RESULTS A total of 28 occurrences were derived, of which nine events scored with significantly high risk priority numbers. The risk priority numbers of the highest ranked events ranged from 20 to 80. These included transcription errors of the stereotactic coordinates and machine failures. CONCLUSION Several areas of our SBRT delivery were reconsidered in terms of process improvement, and safety measures, including treatment checklists and a surgical time-out, were added for our practice of gantry-based image-guided SBRT. This study serves as a guide for other users of SBRT to perform FMEA of their own practice.
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Affiliation(s)
- Julian R Perks
- University of California Davis Medical Center, Sacramento, CA, USA.
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Gomella LG, Lin J, Hoffman-Censits J, Dugan P, Guiles F, Lallas CD, Singh J, McCue P, Showalter T, Valicenti RK, Dicker A, Trabulsi EJ. Enhancing prostate cancer care through the multidisciplinary clinic approach: a 15-year experience. J Oncol Pract 2011; 6:e5-e10. [PMID: 21358951 DOI: 10.1200/jop.2010.000071] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2010] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To report on the 15-year prostate cancer experience of our multidisciplinary genitourinary cancer clinic established in 1996 at the National Cancer Institute (NCI) -designated Jefferson Kimmel Cancer Center. Patients with genitourinary cancers were evaluated weekly by multiple specialists at a single site, and we focus on the 83% of patients with prostate cancer. To our knowledge, our multidisciplinary genitourinary cancer clinic is the longest continuously operating center of its kind at an NCI Cancer Center in the United States. METHODS Data from Jefferson's Oncology Data Services were compared to SEER prostate cancer outcomes. Data on treatment changes in localized disease, patient satisfaction, and related parameters were also assessed. RESULTS Ten-year survival data approach 100% in stage I and II prostate cancer. Ten-year data for stage III (T3 N0M0) and stage IV (T4 N0M0) disease show that our institutional survival rate exceeds SEER. There is a shift toward robotically assisted laparoscopic radical prostatectomy and a slight decrease in brachytherapy relative to external beam radiation therapy in localized disease. Patient satisfaction is high as measured by survey instruments. CONCLUSION Our long-term experience suggests a benefit of the multidisciplinary clinic approach to prostate cancer, most pronounced for high-risk, locally advanced disease. A high level of satisfaction with this patient-centered model is seen. The multidisciplinary clinic approach to prostate cancer may enhance outcomes and possibly reduce treatment regret through a coordinated presentation of all therapeutic options. This clinic model serves as an interdisciplinary educational tool for patients, their families, and our trainees and supports clinical trial participation.
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Linden RA, Weiner PR, Gomella LG, Trabulsi EJ, Dicker AP, Suh DB, Valicenti RK. Reply by the Authors. Urology 2010. [DOI: 10.1016/j.urology.2008.12.030] [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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Michalski JM, Bae K, Roach M, Markoe AM, Sandler HM, Ryu J, Parliament MB, Straube W, Valicenti RK, Cox JD. Long-term toxicity following 3D conformal radiation therapy for prostate cancer from the RTOG 9406 phase I/II dose escalation study. Int J Radiat Oncol Biol Phys 2010; 76:14-22. [PMID: 19577865 DOI: 10.1016/j.ijrobp.2009.01.062] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Revised: 01/06/2009] [Accepted: 01/26/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE To update the incidence of late toxicity of RTOG 9406, a three-dimensional conformal radiation therapy (3DCRT) dose escalation trial for prostate cancer. METHODS AND MATERIALS A total of 1,084 men were registered to this Phase I/II trial of 3DCRT (eligible patients, 1,055). The dose for level I was 68.4 Gy; 73.8 Gy for level II; 79.2 Gy for level III; 74 Gy for level IV; and 78 Gy for level V. Patients in levels I to III received 1.8 Gy/fraction, and those in levels IV to V received 2.0 Gy/fraction. Disease group I patients were treated at the prostate only, group 2 patients were treated at the prostate and at the seminal vesicles with a prostate boost, and group 3 patients were treated at the prostate and seminal vesicles. The median follow-up period for surviving patients was 6.1 y (level V) to 12.1 y (level I). RESULTS The incidence rates of RTOG grade 3 or less gastrointestinal or genitourinary toxicity were 3%, 4%, 6%, 7%, and 9% in group 1 and 6%, 2%, 6%, 9%, and 12% in group 2 at dose levels of I, II, III, IV, and V, respectively. In group 1, level V patients had a higher probability of grade 2 late or greater gastrointestinal or genitourinary toxicity than those in levels I, II, and III (hazard ratio [HR] = 1.93, p = 0.0101; HR = 2.29, p = 0.0007; HR = 2.52, p = 0.0002, respectively). In group 2, dose level V patients had a higher probability of grade 2 or greater late gastrointestinal or genitourinary toxicity than those in dose levels II, III, and IV (HR = 2.61, p = 0.0002; HR = 2.22, p = 0.0051; HR = 1.60, p = 0.0276, respectively). CONCLUSIONS Tolerance to high-dose 3DCRT remains excellent. There is significantly more grade 2 or greater toxicity with a dose of 78 Gy at 2 Gy/fraction than with 68.4 Gy to 79.2 Gy at 1.8 Gy/fraction and with 74 Gy at 2 Gy/fraction.
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Affiliation(s)
- Jeff M Michalski
- Radiation Oncology, Washington University Medical School, St. Louis, MO 63110, USA.
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Siglin J, Kubicek GJ, Leiby B, Valicenti RK. Time of decline in sexual function after external beam radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys 2010; 76:31-5. [PMID: 19395191 DOI: 10.1016/j.ijrobp.2009.01.070] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2008] [Revised: 01/18/2009] [Accepted: 01/20/2009] [Indexed: 11/18/2022]
Abstract
PURPOSE Erectile dysfunction is one of the most concerning toxicities for patients in the treatment of prostate cancer. The inconsistent evaluation of sexual function (SF) and limited follow-up data have necessitated additional study to clarify the rate and timing of erectile dysfunction after external beam radiotherapy (EBRT) for prostate cancer. METHODS AND MATERIALS A total of 143 men completed baseline data on SF before treatment and at the subsequent follow-up visits. A total of 1187 validated SF inventories were analyzed from the study participants. Multiple domains of SF (sex drive, erectile function, ejaculatory function, and overall satisfaction) were analyzed for < or =8 years of follow-up. RESULTS The median follow-up was 4.03 years. The strongest predictor of SF after EBRT was SF before treatment. For all domains of SF, the only statistically significant decrease in function occurred in the first 24 months after EBRT. SF stabilized 2 years after treatment completion, with no statistically significant change in any area of SF >2 years after the end of EBRT. CONCLUSION These data suggest that SF does not have a continuous decline after EBRT. Instead, SF decreases maximally within the first 24 months after EBRT, with no significant changes thereafter.
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Affiliation(s)
- Joshua Siglin
- Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, USA
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Pe ML, Trabulsi EJ, Kedika R, Pequignot E, Dicker AP, Gomella LG, Valicenti RK. Effect of Percentage of Positive Prostate Biopsy Cores on Biochemical Outcome in Low-risk PCa Treated With Brachytherapy or 3D-CRT. Urology 2009; 73:1328-34. [DOI: 10.1016/j.urology.2008.09.078] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2008] [Revised: 08/12/2008] [Accepted: 09/06/2008] [Indexed: 10/20/2022]
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Michalski JM, Lawton C, El Naqa I, Ritter M, O'Meara E, Seider MJ, Lee WR, Rosenthal SA, Pisansky T, Catton C, Valicenti RK, Zietman AL, Bosch WR, Sandler H, Buyyounouski MK, Ménard C. Development of RTOG consensus guidelines for the definition of the clinical target volume for postoperative conformal radiation therapy for prostate cancer. Int J Radiat Oncol Biol Phys 2009; 76:361-8. [PMID: 19394158 DOI: 10.1016/j.ijrobp.2009.02.006] [Citation(s) in RCA: 278] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 01/29/2009] [Accepted: 02/03/2009] [Indexed: 12/21/2022]
Abstract
PURPOSE To define a prostate fossa clinical target volume (PF-CTV) for Radiation Therapy Oncology Group (RTOG) trials using postoperative radiotherapy for prostate cancer. METHODS AND MATERIALS An RTOG-sponsored meeting was held to define an appropriate PF-CTV after radical prostatectomy. Data were presented describing radiographic failure patterns after surgery. Target volumes used in previous trials were reviewed. Using contours independently submitted by 13 radiation oncologists, a statistical imputation method derived a preliminary "consensus" PF-CTV. RESULTS Starting from the model-derived CTV, consensus was reached for a CT image-based PF-CTV. The PF-CTV should extend superiorly from the level of the caudal vas deferens remnant to >8-12 mm inferior to vesicourethral anastomosis (VUA). Below the superior border of the pubic symphysis, the anterior border extends to the posterior aspect of the pubis and posteriorly to the rectum, where it may be concave at the level of the VUA. At this level, the lateral border extends to the levator ani. Above the pubic symphysis, the anterior border should encompass the posterior 1-2 cm of the bladder wall; posteriorly, it is bounded by the mesorectal fascia. At this level, the lateral border is the sacrorectogenitopubic fascia. Seminal vesicle remnants, if present, should be included in the CTV if there is pathologic evidence of their involvement. CONCLUSIONS Consensus on postoperative PF-CTV for RT after prostatectomy was reached and is available as a CT image atlas on the RTOG website. This will allow uniformity in defining PF-CTV for clinical trials that include postprostatectomy RT.
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Affiliation(s)
- Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Linden RA, Weiner PR, Gomella LG, Dicker AP, Suh DB, Trabulsi EJ, Valicenti RK. Technique of Outpatient Placement of Intraprostatic Fiducial Markers Before External Beam Radiotherapy. Urology 2009; 73:881-6. [DOI: 10.1016/j.urology.2008.10.071] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 10/07/2008] [Accepted: 10/11/2008] [Indexed: 10/21/2022]
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Trabulsi EJ, Valicenti RK, Hanlon AL, Pisansky TM, Sandler HM, Kuban DA, Catton CN, Michalski JM, Zelefsky MJ, Kupelian PA, Lin DW, Anscher MS, Slawin KM, Roehrborn CG, Forman JD, Liauw SL, Kestin LL, DeWeese TL, Scardino PT, Stephenson AJ, Pollack A. A multi-institutional matched-control analysis of adjuvant and salvage postoperative radiation therapy for pT3-4N0 prostate cancer. Urology 2008; 72:1298-302; discussion 1302-4. [PMID: 18672274 PMCID: PMC4020432 DOI: 10.1016/j.urology.2008.05.057] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [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] [Received: 01/16/2008] [Revised: 04/30/2008] [Accepted: 05/13/2008] [Indexed: 01/01/2023]
Abstract
OBJECTIVES It is unclear whether postoperative salvage radiation therapy (SRT) and early adjuvant radiotherapy (ART) after radical prostatectomy lead to equivalent long-term tumor control. We studied a group of patients undergoing ART by comparing them with a matched control group undergoing SRT after biochemical failure. METHODS Using a multi-institutional database of 2299 patients, 449 patients with pT3-4N0 disease were eligible for inclusion, including 211 patients receiving ART and 238 patients receiving SRT. Patients were matched in a 1:1 ratio according to preoperative prostate-specific antigen Gleason score, seminal vesicle invasion, surgical margin status, and follow-up from date of surgery. RESULTS A total of 192 patients were matched (96:96). The median follow-up was 94 months from surgery and 73 months from RT completion. There was a significant reduction in biochemical failure with ART compared with SRT. The 5-year freedom from biochemical failure (FFBF) from surgery was 75% after ART, compared with 66% for SRT (hazard ratio [HR] = 1.6, P = .049). The 5-year FFBF from the end of RT was 73% after ART, compared with 50% after SRT (HR = 2.3, log rank [LR] P = .0007). From the end of RT, SRT and Gleason score >or=8 were independent predictors of diminished FFBF. From the date of surgery, Gleason score >or=8 was a significant predictor of FFBF. CONCLUSIONS Early ART for pT3-4N0 prostate cancer significantly reduces the risk of long-term biochemical progression after radical prostatectomy compared with SRT. Gleason score >or=8 was the only factor on multivariate analysis associated with metastasic progression.
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Affiliation(s)
- Edouard J Trabulsi
- Department of Urology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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Affiliation(s)
- Robert B. Den
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Richard K. Valicenti
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
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Showalter TN, Nawaz AO, Xiao Y, Galvin JM, Valicenti RK. A Cone Beam CT-Based Study for Clinical Target Definition Using Pelvic Anatomy During Postprostatectomy Radiotherapy. Int J Radiat Oncol Biol Phys 2008; 70:431-6. [PMID: 17869021 DOI: 10.1016/j.ijrobp.2007.06.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [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: 03/08/2007] [Revised: 06/14/2007] [Accepted: 06/15/2007] [Indexed: 11/21/2022]
Abstract
PURPOSE There are no accepted guidelines for target volume definition for online image-guided radiation therapy (IGRT) after radical prostatectomy (RP). This study used cone beam CT (CBCT) imaging to generate information for use in post-RP IGRT. METHODS AND MATERIALS The pelvic anatomy of 10 prostate cancer patients undergoing post-RP radiation therapy (RT) to 68.4 Gy was studied using CBCT images obtained immediately before treatment. Contoured bladder and rectal volumes on CBCT images were compared with planning CT (CT(ref)) volumes from seminal vesicle stump (SVS) to bladder-urethral junction. This region was chosen to approximate the prostatic fossa (PF) during a course of post-RP RT. Anterior and posterior planning target volume margins were calculated using ICRU report 71 guidelines, accounting for systematic and random error based on bladder and rectal motion, respectively. RESULTS A total of 176 CBCT study sets obtained 2 to 5 times weekly were analyzed. The rectal and bladder borders were reliably identified in 166 of 176 (94%) of CBCT images. Relative to CT(ref), mean posterior bladder wall position was anterior by 0.1 to 1.5 mm, and mean anterior rectum wall position was posterior by 1.6 to 2.7 mm. Calculated anterior margin as derived from bladder motion ranged from 5.9 to 7.1 mm. Calculated posterior margin as derived from rectal motion ranged from 8.6 to 10.2 mm. CONCLUSIONS Normal tissue anatomy was definable by CBCT imaging throughout the course of post-RP RT, and the interfraction anteroposterior motion of the bladder and rectum was studied. This information should be considered in devising post-RP RT techniques using image guidance.
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Affiliation(s)
- Timothy N Showalter
- Department of Radiation Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
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Gomella LG, Valicenti RK. Concluding Remarks. Prostate Cancer 2008. [DOI: 10.1007/978-1-60327-079-3_20] [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: 10/22/2022] Open
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Stephenson AJ, Scardino PT, Kattan MW, Pisansky TM, Slawin KM, Klein EA, Anscher MS, Michalski JM, Sandler HM, Lin DW, Forman JD, Zelefsky MJ, Kestin LL, Roehrborn CG, Catton CN, DeWeese TL, Liauw SL, Valicenti RK, Kuban DA, Pollack A. Predicting the outcome of salvage radiation therapy for recurrent prostate cancer after radical prostatectomy. J Clin Oncol 2007; 25:2035-41. [PMID: 17513807 PMCID: PMC2670394 DOI: 10.1200/jco.2006.08.9607] [Citation(s) in RCA: 669] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE An increasing serum prostate-specific antigen (PSA) level is the initial sign of recurrent prostate cancer among patients treated with radical prostatectomy. Salvage radiation therapy (SRT) may eradicate locally recurrent cancer, but studies to distinguish local from systemic recurrence lack adequate sensitivity and specificity. We developed a nomogram to predict the probability of cancer control at 6 years after SRT for PSA-defined recurrence. PATIENTS AND METHODS Using multivariable Cox regression analysis, we constructed a model to predict the probability of disease progression after SRT in a multi-institutional cohort of 1,540 patients. RESULTS The 6-year progression-free probability was 32% (95% CI, 28% to 35%) overall. Forty-eight percent (95% CI, 40% to 56%) of patients treated with SRT alone at PSA levels of 0.50 ng/mL or lower were disease free at 6 years, including 41% (95% CI, 31% to 51%) who also had a PSA doubling time of 10 months or less or poorly differentiated (Gleason grade 8 to 10) cancer. Significant variables in the model were PSA level before SRT (P < .001), prostatectomy Gleason grade (P < .001), PSA doubling time (P < .001), surgical margins (P < .001), androgen-deprivation therapy before or during SRT (P < .001), and lymph node metastasis (P = .019). The resultant nomogram was internally validated and had a concordance index of 0.69. CONCLUSION Nearly half of patients with recurrent prostate cancer after radical prostatectomy have a long-term PSA response to SRT when treatment is administered at the earliest sign of recurrence. The nomogram we developed predicts the outcome of SRT and should prove valuable for medical decision making for patients with a rising PSA level.
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Affiliation(s)
- Andrew J Stephenson
- Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195-0001, USA.
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Feng M, Hanlon AL, Pisansky TM, Kuban D, Catton CN, Michalski JM, Zelefsky MJ, Kupelian PA, Pollack A, Kestin LL, Valicenti RK, DeWeese TL, Sandler HM. Predictive factors for late genitourinary and gastrointestinal toxicity in patients with prostate cancer treated with adjuvant or salvage radiotherapy. Int J Radiat Oncol Biol Phys 2007; 68:1417-23. [PMID: 17418972 DOI: 10.1016/j.ijrobp.2007.01.049] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2006] [Revised: 01/12/2007] [Accepted: 01/22/2007] [Indexed: 11/17/2022]
Abstract
PURPOSE To determine the rate and magnitude of late genitourinary (GU) and gastrointestinal (GI) toxicities after salvage or adjuvant radiotherapy (RT) for prostate cancer, and to determine predictive factors for these toxicities. METHODS AND MATERIALS A large multi-institutional database that included 959 men who received postoperative RT after radical prostatectomy (RP) was analyzed: 19% received adjuvant RT, 81% received salvage RT, 78% were treated to the prostate bed only, and 22% received radiation to the pelvis. RESULTS The median follow-up time was 55 months. At 5 years, 10% of patients had Grade 2 late GU toxicity and 1% had Grade 3 late GU toxicity, while 4% of patients had Grade 2 late GI toxicity and 0.4% had Grade 3 late GI toxicity. Multivariate analysis demonstrated that adjuvant RT (p = 0.03), androgen deprivation (p < 0.0001), and prostate bed-only RT (p = 0.007) predicted for Grade 2 or higher late GU toxicity. For GI toxicity, although adjuvant RT was significant in the univariate analysis, no significant factors were found in the multivariate analysis. CONCLUSIONS Overall, the number of high-grade toxicities for postoperative RT was low. Therefore, adjuvant and salvage RT can safely be used in the appropriate settings.
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Affiliation(s)
- Mary Feng
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109-0010, USA
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Michalski J, Bae K, Roach M, Markoe AM, Sandler HM, Ryu J, Parliament MB, Straube W, Valicenti RK, Cox JD. 1764: Long-term Toxicity following 3D Conformal Radiation Therapy for Prostate Cancer on RTOG 9406, a Phase I/II dose Escalation Study. J Urol 2007. [DOI: 10.1016/s0022-5347(18)31952-9] [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: 11/28/2022]
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Valicenti RK, DeSilvio M, Hanks GE, Porter A, Brereton H, Rosenthal SA, Shipley WU, Sandler HM. Posttreatment prostatic-specific antigen doubling time as a surrogate endpoint for prostate cancer-specific survival: An analysis of Radiation Therapy Oncology Group Protocol 92–02. Int J Radiat Oncol Biol Phys 2006; 66:1064-71. [PMID: 16979837 DOI: 10.1016/j.ijrobp.2006.06.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [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] [Received: 05/02/2006] [Accepted: 06/12/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE We evaluated whether posttreatment prostatic-specific antigen doubling time (PSADT) was predictive of prostate cancer mortality by testing the Prentice requirements for a surrogate endpoint. METHODS AND MATERIALS We analyzed posttreatment PSA measurements in a cohort of 1,514 men with localized prostate cancer (T2c-4 and PSA level <150 ng/mL), treated and monitored prospectively on Radiation Therapy Oncology Group Protocol 92-02. From June 1992 to April 1995, men were randomized to neoadjuvant androgen deprivation and 65-70 Gy of radiation therapy (n = 761), or in combination with 24 months of adjuvant androgen deprivation (n = 753). Using an adjusted Cox proportional hazards model, we tested if PSADT was prognostic and independent of randomized treatment in this cohort. The endpoints were time to PSADT (assuming first-order kinetics for a minimum of 3 rising PSA measurements) and cancer-specific survival (CSS). RESULTS After a median follow-up time of 5.9 years, randomized treatment was a significant predictor for CSS (p(Cox) = 0.002), PSADT <6 months (p(Cox) < 0.001), PSADT <9 months (p(Cox) < 0.001), and PSADT <12 months (p(Cox) < 0.001) but not for PSADT <3 (p(Cox) = 0.4). The significant posttreatment PSADTs were also significant predictors of CSS (p(Cox)< 0.001). After adjusting for T stage, Gleason score and PSA, all of Prentice's requirements were not met, indicating that the effect of PSADT on CSS was not independent of the randomized treatment. CONCLUSIONS Prostatic specific antigen doubling time is significantly associated with CSS, but did not meet all of Prentice's requirements for a surrogate endpoint of CSS. Thus, the risk of dying of prostate cancer is not fully explained by PSADT.
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Affiliation(s)
- Richard K Valicenti
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, USA.
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Trabulsi EJ, Valicenti RK. Dose escalation with proton-beam boost for low-risk prostate cancer. ACTA ACUST UNITED AC 2006; 3:256-7. [PMID: 16691237 DOI: 10.1038/ncpuro0477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2005] [Accepted: 02/23/2006] [Indexed: 11/09/2022]
Affiliation(s)
- Edouard J Trabulsi
- EJ Trabulsi is an Assistant Professor in the Department of Urology and the Director of Minimally Invasive Urologic Oncology, at Thomas Jefferson University, Philadelphia, PA, USA
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Stephenson AJ, Pollack A, Scardino PT, Kattan MW, Pisansky TM, Slawin KM, Klein EA, Kupelian PA, Anscher MS, Michalski JM, Sandler HM, Zelefsky MJ, Forman JD, Lin DW, Kestin LL, Pistenmaa DA, Cation CN, Deweese TL, Valicenti RK, Kuban DA, Bianco FJ, Fearn PA. 1192: A Nomogram to Predict the Outcome of Salvage Radiotherapy (RT) for Biochemical Recurrence (BCR) Following Radical Prostatectomy (RP). J Urol 2006. [DOI: 10.1016/s0022-5347(18)33417-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Febles C, Valicenti RK. Combining external beam radiotherapy with prostate brachytherapy: issues and rationale. Urology 2005; 64:855-61. [PMID: 15533463 DOI: 10.1016/j.urology.2004.06.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2004] [Accepted: 06/21/2004] [Indexed: 11/16/2022]
Affiliation(s)
- Clarissa Febles
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Pollack A, Hanlon AL, Pisansky TM, Sandler HM, Kuban DA, Catton C, Michalski JM, Zelefsky MJ, Kupelian PA, Kestin LL, Valicenti RK, DeWeese TL. 1136: Which Definition of Biochemical Failure after Post-Operative Radiotherapy Predicts Best for Clinical Failure? A Multi-Institutional Analysis. J Urol 2005. [DOI: 10.1016/s0022-5347(18)35292-3] [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: 10/17/2022]
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Abstract
The results of optimization of inverse treatment plans depend on a choice of the objective function. Even when the optimal solution for a given cost function can be obtained, a better solution may exist for a given clinical scenario and it could be obtained with a revised objective function. In the approach presented in this work mixed integer programming was used to introduce a new volume-based objective function, which allowed for minimization of the number of under- or overdosed voxels in selected structures. By selecting and prioritizing components of this function the user could drive the computations towards the desired solution. This optimization approach was tested using cases of patients treated for prostate and oropharyngeal cancer. Initial solutions were obtained based on minimization/maximization of the dose to critical structures and targets. Subsequently, the volume-based objective functions were used to locate solutions, which satisfied better clinical objectives particular to each of the cases. For prostate cases, these additional solutions offered further improvements in sparing of the rectum or the bladder. For oropharyngeal cases, families of solutions were obtained satisfying an intensity modulated radiation therapy protocol for this disease site, while offering significant improvement in the sparing of selected critical structures, e.g., parotid glands. An additional advantage of the present approach was in providing a convenient mechanism to test the feasibility of the dose-volume histogram constraints.
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Affiliation(s)
- Greg Bednarz
- Department of Radiation Oncology, Kimmel Cancer Center of the Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Lee HM, Solan MJ, Lupinacci P, Gomella LG, Valicenti RK. Long-term outcome of patients with prostate cancer and pathologic seminal vesicle invasion (pT3b): effect of adjuvant radiotherapy. Urology 2004; 64:84-9. [PMID: 15245941 DOI: 10.1016/j.urology.2004.02.004] [Citation(s) in RCA: 32] [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: 09/22/2003] [Accepted: 02/10/2004] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the long-term outcome of patients with prostate cancer who have pathologic seminal vesicle invasion without lymph node metastasis (pT3bN0M0) and compare management strategies. METHODS From October 1987 to August of 1997, 43 men underwent radical prostatectomy at Thomas Jefferson University Hospital, had pT3bN0M0 disease, complete preoperative and postoperative prostate-specific antigen (PSA) data, and a minimum of 2 years of follow-up. Eighteen patients with undetectable postoperative PSA levels received adjuvant radiotherapy (RT) within 6 months of surgery. Twelve patients with undetectable PSA levels postoperatively were considered for salvage treatment at biochemical progression. Thirteen patients with persistently elevated PSA levels postoperatively underwent immediate salvage RT. We evaluated the prognostic factors for freedom from biochemical failure (bNED), distant metastasis (DM), disease-specific survival, and overall survival. RESULTS The median follow-up time was 5.9 years (range 2 to 10). Patients who received adjuvant RT had significantly greater 5-year bNED survival than patients who did not (80% versus 8%, P <0.001) and increased freedom from DM that was of borderline significance (P = 0.05). The 5-year survival estimates for DM were 0% for the adjuvant RT versus 17% for the observed patient group. In patients with undetectable postoperative PSA levels, the preoperative PSA level was an independent prognostic factor for later disease progression. Patients with a preoperative PSA level of less than 20 ng/mL showed significantly greater 5-year bNED survival than those with a preoperative PSA level of 20 ng/mL or greater (56% versus 32%, P <0.05). The survival curves for risk of DM and death from prostate cancer for those two patient groups were not significantly different statistically. CONCLUSIONS Although pathologic seminal vesicle invasion has been associated with poor prognosis and high DM risk, adjuvant RT may result in improved bNED survival in patients with undetectable PSA levels after radical prostatectomy. The effect on clinical outcome awaits additional follow-up.
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Affiliation(s)
- Heather M Lee
- Department of Radiation Oncology and Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Gomella LG, Zeltser I, Valicenti RK. Use of neoadjuvant and adjuvant therapy to prevent or delay recurrence of prostate cancer in patients undergoing surgical treatment for prostate cancer. Urology 2004; 62 Suppl 1:46-54. [PMID: 14747041 DOI: 10.1016/j.urology.2003.10.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [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: 10/26/2022]
Abstract
There have been improvements in the outcome of patients with clinically localized prostate cancer treated by radical prostatectomy. However, some patients treated with radical prostatectomy will have clinical or biochemical progression. These men are at increased risk of dying of their disease. Identification of patients with adverse features at the time of radical prostatectomy may permit the use of additional multimodality therapies to improve outcomes. Whether this additional multimodality therapy should be administered in the neoadjuvant or adjuvant setting remains controversial. Further, whether a patient at increased risk for progression after radical prostatectomy requires additional therapy before the development of documented progression remains controversial. This article reviews the potential multimodality approaches to prevent or delay recurrence of prostate cancer in patients undergoing surgical treatment for prostate cancer.
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Affiliation(s)
- Leonard G Gomella
- Department of Urology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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Michalski JM, Winter K, Purdy JA, Perez CA, Ryu JK, Parliament MB, Valicenti RK, Roach M, Sandler HM, Markoe AM, Cox JD. Toxicity after three-dimensional radiotherapy for prostate cancer with RTOG 9406 dose level IV. Int J Radiat Oncol Biol Phys 2004; 58:735-42. [PMID: 14967428 DOI: 10.1016/s0360-3016(03)01578-5] [Citation(s) in RCA: 54] [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] [Received: 03/19/2003] [Revised: 07/07/2003] [Accepted: 07/18/2003] [Indexed: 11/17/2022]
Abstract
PURPOSE This is the first report of the toxicity outcomes using dose level IV (74 Gy) on Radiation Therapy Oncology Group (RTOG) study 9406 for Stage T1-T2 prostate adenocarcinoma. METHODS AND MATERIALS A total of 262 patients were entered in this cooperative group, Phase I-II, dose-escalation trial of three-dimensional conformal radiotherapy for localized prostate carcinoma treated to a dose of 74 Gy (Level IV); 256 patients were analyzable for toxicity. A minimal dose of 2 Gy/fraction was prescribed to the planning target volume (PTV). Patients were stratified according to the risk of seminal vesicle invasion on the basis of the Gleason score and presenting prostate-specific antigen level. Group 1 patients had clinical Stage T1-T2 tumors with a seminal vesicle invasion risk of <15%. Group 2 patients had clinical Stage T1-T2 tumors with a seminal vesicle invasion risk of >/=15%. Patients in Group 1 were prescribed 74 Gy to a prostate PTV. Patients in Group 2 were prescribed 54 Gy to the prostate and seminal vesicles (PTV1) followed by a boost to the prostate only (PTV2) to 74 Gy. PTV margins between 5 and 10 mm were required. Elective pelvic radiotherapy was not used. The frequency of late effects of Grade 3 or greater was compared with that for a similar group of patients treated in RTOG studies 7506 and 7706, with length of follow-up adjustments made for the interval from therapy completion. A second comparison was made with 206 patients treated to dose level II (73.8 Gy in 1.8-Gy fractions) to see whether the fraction size affected toxicity. RESULTS The average months at risk for late Grade 3+ toxicity after therapy completion were 28.9 and 23.9 months for Group 1 and 2, respectively. Acute toxicity at dose level IV (74 Gy) was remarkably low, with Grade 3 acute effects reported in only 1% of Group 1 and 3% of Group 2 patients. No Grade 4 or 5 acute toxicities were reported. Late toxicity continued to be low compared with RTOG historical controls. One patient in Group 1 and 4 patients in Group 2 experienced Grade 3 bladder toxicity. Two patients in Group 2 experienced Grade 3 bowel toxicity. No Grade 4 or 5 late effects were reported. The rate of late Grade 2 toxicity (any type) was 23% and 16% in Group 1 and 2, respectively. The observed rate of Grade 3 or greater late effects for Group 1 (1 case) was significantly lower (p <0.0001) than the 18.5 cases that would have been expected from the historical control data. The observed rate for Group 2 (6 cases) was also significantly lower (p = 0.0009) than the 21.3 cases expected. No statistically significant difference was noted in the rate of acute or late toxicity in patients who were treated to 73.8 Gy at 1.8 Gy/fraction or 74 Gy at 2.0 Gy/fraction. Patients treated with the larger 2.0-Gy fractions tended to have more Grade 3 or greater toxicity than patients treated with 1.8-Gy fractions (2% vs. 1%, p = 0.09). The results after the longer follow-up with dose level II suggest these differences may increase with additional follow-up. CONCLUSION Tolerance to three-dimensional conformal radiotherapy with 74 Gy in 2-Gy fractions remains better than expected compared with historical controls. The magnitude of any effect from fraction size requires additional follow-up.
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Affiliation(s)
- Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA.
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Valicenti RK, Chervoneva I, Gomella LG. Importance of margin extent as a predictor of outcome after adjuvant radiotherapy for Gleason score 7 pT3N0 prostate cancer. Int J Radiat Oncol Biol Phys 2004; 58:1093-7. [PMID: 15001249 DOI: 10.1016/j.ijrobp.2003.07.006] [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: 04/14/2003] [Revised: 07/28/2003] [Accepted: 07/29/2003] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate, in Gleason score 7, pT3N0 prostate cancer patients with positive surgical margins, the predictors of progression-free survival and to identify a patient subgroup that would benefit from immediate adjuvant postoperative radiotherapy (ART). METHODS AND MATERIALS Between November 1989 and August 1998, 76 men underwent radical prostatectomy and were found to have capsular penetration (pT3N0), surgical Gleason score 7, tumor present at the resection margin, and an undetectable postoperative prostate-specific antigen (PSA) level. All surgical specimens underwent whole-mount serial sectioning to determine the degree of margin positivity (focal vs. extensive). Of the 76 men, 45 underwent early ART (within 6 months with a median dose of 64.8 Gy), and 31 had no immediate treatment. We defined freedom from PSA failure (bNED) as the absence of two consecutive PSA rises >0.2 ng/mL. RESULTS The median follow-up time was 5.1 years (range, 2-10 years). The ART and non-ART patients were similar with respect to preoperative PSA level, Gleason score (4 + 3 vs. 3 + 4), presence of seminal vesicle invasion, and margin extent. On univariate analysis, margin extent was predictive for improved bNED (5-year bNED rate of 92% vs. 58%, p = 0.010, for men with focal and extensive margins, respectively). Gleason score (4 + 3 vs. 3 + 4), seminal vesicle invasion, and ART were not statistically significant predictors. On multivariate analysis, the preoperative PSA level, margin extent, and ART were independent significant factors. In the group with extensive surgical margins, men receiving ART had a significantly greater 5-year bNED survival rate compared with the non-ART patients (73% vs. 31%, p = 0.004). CONCLUSION These data suggest that the amount of microscopic residual tumor significantly affects bNED after radical prostatectomy for Gleason score 7, pT3N0 prostate cancer. In addition, men with pathologic evidence of microscopic local disease appear to benefit from early ART compared with untreated controls.
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Affiliation(s)
- Richard K Valicenti
- Department of Radiation Oncology, Jefferson Medical College and Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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