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Laughlin BS, Yu NY, Lo S, Duan J, Welchel Z, Tinnon K, Beckett M, Schild SE, Wong WW, Keole SR, Rwigema JCM, Vargas CE, Rong Y. Clinical Practice Evolvement for Post-Operative Prostate Cancer Radiotherapy-Part 2: Feasibility of Margin Reduction for Fractionated Radiation Treatment with Advanced Image Guidance. Cancers (Basel) 2022; 15:cancers15010040. [PMID: 36612040 PMCID: PMC9817842 DOI: 10.3390/cancers15010040] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/08/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose: Planning target volume (PTV) expansion for post-prostatectomy radiotherapy is typically ≥5 mm. Recent clinical trials have proved the feasibility of a reduced margin of 2−3 mm for treatments on MRI-linac. We aim to study the minimum PTV margin needed using iterative cone-beam CT (iCBCT) as image guidance on conventional linacs. Materials/Methods: Fourteen patients who received post-prostatectomy irradiation (8 with an endorectal balloon and 6 without a balloon) were included in this study. Treatment was delivered with volumetric modulated radiation therapy (VMAT). Fractional dose delivery was evaluated in 165 treatment fractions. The bladder, rectal wall, femoral heads, and prostate bed clinical tumor volume (CTV) were contoured and verified on daily iCBCT. PTV margins (0 mm, 2 mm, and 4 mm) were evaluated on daily iCBCT. CTV coverage and OAR dose parameters were assessed with each PTV margin. Results: CTV D100% was underdosed with a 0 mm margin in 32% of fractions in comparison with 2 mm (6%) and 4 mm (6%) PTV margin (p ≤ 0.001). CTV D95% > 95% was met in 93−94% fractions for all PTV expansions. CTV D95% > 95% was achieved in more patients with an endorectal balloon than those without: 0 mm—90/91 (99%) vs. 63/74 (85%); 2 mm—90/91 (99%) vs. 65/75 (87%); 4 mm—90/90 (100%) vs. 63/73 (86%). There was no difference in absolute median change in CTV D95% (0.32%) for 0-, 2-, and 4 mm margins. The maximum dose remained under 108% for 100% (0 mm), 97% (2 mm), and 98% (4 mm) of images. Rectal wall maximum dose remained under 108% for 100% (0 mm), 100% (2 mm), and 98% (4 mm) of images. Conclusions: With high-quality iCBCT image guidance, PTV margin accounting for inter-fractional uncertainties can be safely reduced for post-prostatectomy radiotherapy. For fractionated radiotherapy, an isotropic expansion of 2 mm and 4 mm may be considered for margin expansion with and without the endorectal balloon. Future application for margin reduction needs to be further evaluated and considered with the advent of shorter post-prostatectomy radiation courses.
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Affiliation(s)
- Brady S. Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Nathan Y. Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Stephanie Lo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Jingwei Duan
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Department of Radiation Oncology, University of Kentucky, Lexington, KY 40506, USA
| | - Zachary Welchel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Department of Nuclear and Radiological Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Katie Tinnon
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Mason Beckett
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Steven E. Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Sameer R. Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | | | - Carlos E. Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Correspondence: (C.E.V.); (Y.R.)
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Correspondence: (C.E.V.); (Y.R.)
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Laughlin BS, Lo S, Vargas CE, DeWees TA, Van der Walt C, Tinnon K, Beckett M, Hobbis D, Schild SE, Wong WW, Keole SR, Rwigema JCM, Yu NY, Clouser E, Rong Y. Clinical Practice Evolvement for Post-Operative Prostate Cancer Radiotherapy-Part 1: Consistent Organs at Risk Management with Advanced Image Guidance. Cancers (Basel) 2022; 15:cancers15010016. [PMID: 36612013 PMCID: PMC9817677 DOI: 10.3390/cancers15010016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/07/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose: Post-operative prostate cancer patients are treated with full bladder instruction and the use of an endorectal balloon (ERB). We reassessed the efficacy of this practice based on daily image guidance and dose delivery using high-quality iterative reconstructed cone-beam CT (iCBCT). Methods: Fractional dose delivery was calculated on daily iCBCT for 314 fractions from 14 post-operative prostate patients (8 with and 6 without ERB) treated with volumetric modulated radiotherapy (VMAT). All patients were positioned using novel iCBCT during image guidance. The bladder, rectal wall, femoral heads, and prostate bed clinical tumor volume (CTV) were contoured and verified on daily iCBCT. The dose-volume parameters of the contoured organs at risk (OAR) and CTV coverage were assessed for the clinical impact of daily bladder volume variations and the use of ERB. Minimum bladder volume was studied, and a straightforward bladder instruction was explored for easy clinical adoption. Results: A “minimum bladder” contour, the overlap between the original bladder contour and a 15 mm anterior and superior expansion from prostate bed PTV, was confirmed to be effective in identifying cases that might fail a bladder constraint of V65% <60%. The average difference between the maximum and minimum bladder volumes for each patient was 277.1 mL. The daily bladder volumes varied from 62.4 to 590.7 mL and ranged from 29 to 286% of the corresponding planning bladder volume. The bladder constraint of V65% <60% was met in almost all fractions (98%). CTVs (D90%, D95%, and D98%) remained well-covered regardless of the absolute bladder volume daily variation or the presence of the endorectal balloon. Patients with an endorectal balloon showed smaller variation but a higher average maximum rectal wall dose (D0.03mL: 104.3% of the prescription) compared to patients without (103.3%). Conclusions: A “minimum bladder” contour was determined that can be easily generated and followed to ensure sufficient bladder sparing. Further analysis and validation are needed to confirm the utility of the minimal bladder contour. Accurate dose delivery can be achieved for prostate bed target coverage and OAR sparing with or without the use of ERB.
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Affiliation(s)
- Brady S. Laughlin
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Stephanie Lo
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Carlos E. Vargas
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Todd A. DeWees
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
| | - Charles Van der Walt
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
| | - Katie Tinnon
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Mason Beckett
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Dean Hobbis
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Steven E. Schild
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Sameer R. Keole
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Jean-Claude M. Rwigema
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Nathan Y. Yu
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Edward Clouser
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
- Correspondence:
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Kneebone A, Hruby G, Harris G, Rasiah K, Vass J, Whalley D, McCloud P, Louw S, Guo L, Eade T. Contemporary salvage post prostatectomy radiotherapy: Early implementation improves biochemical control. J Med Imaging Radiat Oncol 2017; 62:240-247. [PMID: 29080287 DOI: 10.1111/1754-9485.12684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 09/20/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The optimal time to commence salvage radiotherapy (SRT) for a rising PSA post radical prostatectomy is not known. We wished to assess the impact of index PSA (iPSA) level prior to SRT on rates of biochemical failure (BCF) post treatment. METHODS Patients referred to our institution for SRT for a rising PSA post surgery were accrued onto a prospective database. Baseline demographic data, tumour and treatment factors were collected including pathologic T and N stage, margin status, Gleason score (GS), lymphovascular space invasion (LVSI), use of androgen deprivation therapy (ADT) and time from surgery to salvage radiotherapy. Our endpoint was time to BCF. RESULTS Between January 2008 and December 2013, 189 patients received SRT to a mean dose of 69.8 Gy in 34 fractions using Intensity Modulated Radiotherapy (IMRT). Median follow-up was 50 months. For patients with an iPSA of <0.2 ng/mL (n = 92), iPSA ≥ 0.2 to <1.0 ng/mL (n = 75) and ≥ 1.0 ng/mL (n = 22), rates of BCF at 5 years were 28.3%, 44.3% and 73.7% respectively. Compared to the iPSA <0.2 ng/mL group, the hazard ratios for time to BCF for an iPSA ≥ 0.2 to <1.0 ng/mL was 1.73 (P = 0.05) and >1.0 ng/mL was 3.1 (P = 0.002). Factors predicting time to BCF on univariate analysis included iPSA, GS, T stage, PSA nadir post surgery and LVSI. On multivariate analysis, GS, iPSA, use of ADT, T stage, PSA post surgery nadir and margin status remained significant. CONCLUSION Rising iPSA levels are associated with an increasing risk of biochemical failure after adjusting for known prognostic factors and early salvage post prostatectomy radiotherapy is recommended.
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Affiliation(s)
- Andrew Kneebone
- Northern Sydney Cancer Centre, Radiation Oncology Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia
| | - George Hruby
- Northern Sydney Cancer Centre, Radiation Oncology Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia
| | - Georgia Harris
- Northern Sydney Cancer Centre, Radiation Oncology Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia
| | - Kris Rasiah
- Division of Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Justin Vass
- Division of Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Deborah Whalley
- Northern Sydney Cancer Centre, Radiation Oncology Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia
| | - Philip McCloud
- McCloud Consulting Group, Sydney, New South Wales, Australia
| | - Sandra Louw
- McCloud Consulting Group, Sydney, New South Wales, Australia
| | - Linxin Guo
- Northern Sydney Cancer Centre, Radiation Oncology Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Thomas Eade
- Northern Sydney Cancer Centre, Radiation Oncology Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia
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