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Hsueh JY, Gallagher L, Koh MJ, Eden S, Shah S, Wells M, Danner M, Zwart A, Ayoob M, Kumar D, Leger P, Dawson NA, Suy S, Rubin R, Collins SP. Impact of neoadjuvant relugolix on patient-reported sexual function and bother. Front Oncol 2024; 14:1377103. [PMID: 38665954 PMCID: PMC11043501 DOI: 10.3389/fonc.2024.1377103] [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: 01/26/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
Introduction Sexual function following local treatment for prostate cancer is an important quality of life concern. Relugolix is a novel oral GnRH receptor antagonist used in combination with radiation therapy in the treatment of unfavorable prostate cancer. It has been shown to achieve rapid and profound testosterone suppression. As a result, these very low testosterone levels may impact both sexual functioning and perceptions. This prospective study sought to assess neoadjuvant relugolix-induced sexual dysfunction prior to stereotactic body radiation therapy (SBRT). Methods Between March 2021 and September 2023, 87 patients with localized prostate cancer were treated with neoadjuvant relugolix followed by SBRT per an institutional protocol. Sexual function and bother were assessed via the sexual domain of the validated Expanded Prostate Index Composite (EPIC-26) survey. Responses were collected for each patient at pre-treatment baseline and after several months of relugolix. A Utilization of Sexual Medications/Devices questionnaire was administered at the same time points to assess erectile aid usage. Results The median age was 72 years and 43% of patients were non-white. The median baseline Sexual Health Inventory for Men (SHIM) score was 13 and 41.7% of patients utilized sexual aids prior to relugolix. Patients initiated relugolix at a median of 4.5 months (2-14 months) prior to SBRT. 95% and 87% of patients achieved effective castration (≤ 50 ng/dL) and profound castration (< 20 ng/dl) at SBRT initiation, respectively. Ability to have an erection, ability to reach orgasm, quality of erections, frequency of erections, and overall sexual function significantly declined following relugolix. There was a non- significant increase in sexual bother. Discussion In concordance with known side effects of androgen deprivation therapy (ADT), neoadjuvant relugolix was associated with a significant decline in self-reported sexual function. However, patients indicated only a minimal and non-significant increase in bother. Future investigations should compare outcomes while on relugolix directly to GnRH agonist-induced sexual dysfunction.
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Affiliation(s)
- Jessica Y. Hsueh
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Lindsey Gallagher
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Min Ji Koh
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Shaine Eden
- Systems Medicine Program, Department of Biochemistry and Molecular & Cellular Biology, Georgetown University Medical Center, Washington, DC, United States
| | - Sarthak Shah
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Markus Wells
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Alan Zwart
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Deepak Kumar
- Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Paul Leger
- Department of Oncology, Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Nancy A. Dawson
- Department of Oncology, Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Rachel Rubin
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sean P. Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
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Repka MC, Sholklapper T, Zwart AL, Danner M, Ayoob M, Yung T, Lei S, Collins BT, Kumar D, Suy S, Hankins RA, Kishan AU, Collins SP. Prognostic utility of biopsy-based PTEN and ERG status on biochemical progression and overall survival after SBRT for localized prostate cancer. Front Oncol 2024; 14:1381134. [PMID: 38585005 PMCID: PMC10995255 DOI: 10.3389/fonc.2024.1381134] [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: 02/02/2024] [Accepted: 03/12/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction/background Phosphatase and tensin homolog (PTEN) genomic deletions and transmembrane protease, serine 2/v-ets avian erthyroblastosis virus E26 oncogene homolog (ERG) rearrangements are two of the most common genetic abnormalities associated with prostate cancer. Prior studies have demonstrated these alterations portend worse clinical outcomes. Our objective is to evaluate the impact of biopsy-determined PTEN losses and TMPRSS2-ERG fusion on biochemical progression-free survival (bPFS) and overall survival (OS) in patients who receive SBRT for localized prostate cancer. Methods/materials Patients received SBRT for localized prostate cancer on a prospective quality-of-life (QoL) and cancer outcomes study. For each patient, the single biopsy core with the highest grade/volume of cancer was evaluated for PTEN and ERG abnormalities. Differences in baseline patient and disease characteristics between groups were analyzed using ANOVA for age and χ2 for categorical groupings. bPFS and OS were calculated using the Kaplan Meier (KM) method with Log-Rank test comparison between groups. Predictors of bPFS and OS were identified using the Cox proportional hazards method. For all analyses, p <0.05 was considered statistically significant. Results Ninety-nine consecutive patients were included in the analysis with a median follow-up of 72 months. A statistically significant improvement in bPFS (p = 0.018) was observed for wild type ERG patients with an estimated 5-year bPFS of 94.1% vs. 72.4%. Regarding PTEN mutational status, significant improvements in were observed in both bPFS (p = 0.006) and OS (p < 0.001), with estimated 5-year bPFS rates of 91.0% vs. 67.9% and 5-year OS rates of 96.4% vs. 79.4%. When including both ERG and PTEN mutational status in the analysis, there were statistically significant differences in both bPFS (p = 0.011) and OS (p < 0.001). The estimated 5-year bPFS rates were 100%, 76.6%, 72.9%, and 63.8% for patients with ERG+/PTEN+, ERG-/PTEN+, ERG+/PTEN-, and ERG-/PTEN- phenotypes respectively. The estimated 5-year OS rates were 93.9%, 100%, 80.0%, and 78.7% for patients with ERG+/PTEN+, ERG-/PTEN+, ERG+/PTEN-, and ERG-/PTEN- phenotypes respectively. Conclusion ERG rearrangements and PTEN deletions detected on biopsy samples are associated with poorer oncologic outcomes in prostate cancer patients treated with SBRT and merit further study in a dedicated prospective trial.
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Affiliation(s)
- Michael C. Repka
- Department of Radiation Oncology, University of North Carolina (UNC) School of Medicine, Chapel Hill, NC, United States
| | - Tamir Sholklapper
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Alan L. Zwart
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Brian T. Collins
- Department of Radiation Oncology, Tampa General Hospital, Tampa, FL, United States
| | - Deepak Kumar
- Julius L Chambers Research Institute, North Carolina Central University, Durham, NC, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Ryan A. Hankins
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles (UCLA) Health, Los Angeles, CA, United States
| | - Sean P. Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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Gallagher L, Xiao J, Hsueh J, Shah S, Danner M, Zwart A, Ayoob M, Yung T, Simpson T, Fallick M, Kumar D, Leger P, Dawson NA, Suy S, Collins SP. Early biochemical outcomes following neoadjuvant/adjuvant relugolix with stereotactic body radiation therapy for intermediate to high risk prostate cancer. Front Oncol 2023; 13:1289249. [PMID: 37916156 PMCID: PMC10616590 DOI: 10.3389/fonc.2023.1289249] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction Injectable GnRH receptor agonists have been shown to improve cancer control when combined with radiotherapy. Prostate SBRT offers an abbreviated treatment course with comparable efficacy to conventionally fractionated radiotherapy. Relugolix is a new oral GnRH receptor antagonist which achieves rapid, sustained testosterone suppression. This prospective study sought to evaluate early testosterone suppression and PSA response following relugolix and SBRT for intermediate to high prostate cancer. Methods Relugolix was initiated at least 2 months prior to SBRT. Interventions to improve adherence were not utilized. PSA and total testosterone levels were obtained prior to and 1-4 months post SBRT. Profound castration was defined as serum testosterone ≤ 20 ng/dL. Early PSA nadir was defined as the lowest PSA value within 4 months of completion of SBRT. Per prior trials, we examined the percentage of patients who achieved PSA level of ≤ 0.5 ng/mL and ≤ 0.2 ng/mL during the first 4 months post SBRT. Results Between July 2021 and January 2023, 52 men were treated at Georgetown with relugolix (4-6 months) and SBRT (36.25-40 Gy in 5 fractions) per an institutional protocol (IRB 12-1775). Median age was 71 years. 26.9% of patients were African American and 28.8% were obese (BMI ≥30 kg/m2). The median pretreatment PSA was 9.1 ng/ml. 67% of patients were ≥ Grade Group 3. 44 patients were intermediate- and 8 were high-risk. Patients initiated relugolix at a median of 3.6 months prior to SBRT with a median duration of 6.2 total months. 92.3% of patients achieved profound castration during relugolix treatment. Poor drug adherence was observed in 2 patients. A third patient chose to discontinue relugolix due to side effects. By post-SBRT month 4, 87.2% and 74.4% of patients achieved PSA levels ≤ 0.5 ng/ml and ≤ 0.2 ng/ml, respectively. Discussion Relugolix combined with SBRT allows for high rates of profound castration with low early PSA nadirs. We observed a 96% testosterone suppresion rate without the utilization of scheduled cues/reminders. This finding supports the notion that patients with localized prostate cancer can consistently and successfully follow an oral ADT protocol without daily reminders. Given relugolix's potential benefits over injectable GnRH receptor agonists, its usage may be preferred in specific patient populations (fear of needles, prior cardiovascular events). Future studies should focus on boundaries to adherence in specific underserved populations.
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Affiliation(s)
- Lindsey Gallagher
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Jerry Xiao
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Jessica Hsueh
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sarthak Shah
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Alan Zwart
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Tiffany Simpson
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Mark Fallick
- Medical Science Department, Myovant Sciences, Inc, United States
| | - Deepak Kumar
- Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Paul Leger
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Nancy A. Dawson
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sean P. Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
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Shah S, Jatar SS, Hsueh J, Gallagher L, Pepin A, Danner M, Zwart A, Ayoob MJ, Yung T, Kumar D, Aghdam N, Leger P, Dawson N, Suy S, Collins SP. Bothersome Hot Flashes Following Neoadjuvant Androgen Deprivation Therapy and Stereotactic Body Radiotherapy for Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e258-e259. [PMID: 37784992 DOI: 10.1016/j.ijrobp.2023.06.1210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Androgen deprivation therapy (ADT) may improve cancer control in unfavorable localized prostate cancer treated with stereotactic body radiotherapy (SBRT). ADT is known to cause hormonally related symptoms that resolve with testosterone recovery. Hot flashes are particularly burdensome. This study sought to evaluate the timeline of hot flashes following short-course ADT and SBRT as well as its relationship with testosterone recovery. MATERIALS/METHODS Institutional IRB approval was obtained for this retrospective review of prospectively collected data (IRB#: 2009-510). ADT was initiated three months prior to the start of SBRT. Hot flashes were self-reported via question 13a a healthcare software prior to ADT initiation, the first day of robotic SBRT, and at each follow-up (1, 3, 6, 9, 12, 18, 24 and 36 months). The responses were grouped into three relevant categories (no problem, very small-small problem and moderate-big problem). Scores were transformed to a 0-100 scale with higher scores reflecting less bother. Testosterone levels were measured at each follow-up. RESULTS From 2007 to 2010, 122 localized prostate cancer patients (9 low-, 64 intermediate-, and 49 high-risk according to the D'Amico classification) at a median age of 72 years (range 54.5-88.3) were treated with short course ADT (3-6 months) and SBRT (35-36.25 Gy) at Georgetown University Hospital. Thirty-two percent were black and 27% were obese. 77% of patient received three months of ADT. At baseline, 2% of men experienced hot flashes that were a "moderate to big problem" and that proportion peaked at the start of SBRT (45%) before returning to baseline 9 months post-SBRT with a cumulative incidence of 52.4%. The median baseline healthcare software hot flash score of 94 declined to 50 at the start of SBRT but this returned to baseline by six months post SBRT. These changes were both statistically and clinically significant (MID = 9.5083). Testosterone recovery (> 230 ng/dL) occurred in approximately 70% of patients by 12 months post SBRT. Resolution of hot flashes correlated with testosterone recovery. CONCLUSION Bothersome hot flashes occur in greater than 50% of men treated with neoadjuvant ADT. Resolution of hot flashes occurs in the majority of patients within one year after treatment. Reassurance of the temporary nature of hot flashes may assist in reducing patient anxiety. Measuring testosterone levels at follow-up visits may allow for anticipatory counseling that may limit the associated bother.
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Affiliation(s)
- S Shah
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - S S Jatar
- Georgetown School Of Medicine, Washington, DC
| | - J Hsueh
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - L Gallagher
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - A Pepin
- Department of Radiation Oncology, Abramson Cancer Center, Hospital of University of Pennsylvania, Philadelphia, PA
| | - M Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - A Zwart
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - M J Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - T Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - D Kumar
- Biotechnology Research Institute, North Carolina Central University, Durham, NC
| | - N Aghdam
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Washington, DC
| | - P Leger
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - N Dawson
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - S Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - S P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
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Jatar SS, Shah S, Hsueh J, Gallagher L, Danner M, Zwart A, Ayoob MJ, Yung T, Kumar D, Leger P, Aghdam N, Dawson N, Suy S, Collins SP. Bothersome Gynecomastia Following Neoadjuvant GnRH Agonists and Stereotactic Body Radiotherapy for Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e238-e239. [PMID: 37784943 DOI: 10.1016/j.ijrobp.2023.06.1163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Androgen deprivation therapy (ADT) is increasingly utilized in combination with stereotactic body radiotherapy (SBRT) for unfavorable prostate cancer. ADT such as gonadotropin releasing hormone (GnRH) agonists are known to cause hormonal-related side effects such as gynecomastia. The incidence of bothersome breast tenderness and/or enlargement following short course GnRH agonists and SBRT is unknown. This study sought to evaluate the timeline of gynecomastia as well as its relationship with testosterone recovery. MATERIALS/METHODS Gynecomastia was self-reported via question 13b of a healthcare software prior to ADT initiation, the first day of robotic SBRT, and at each follow-up (1, 3, 6, 9, 12, 18, 24 and 36 months). The responses were grouped into three relevant categories (no problem, very small-small problem, and moderate-big problem). Scores were transformed to a 0-100 scale with higher scores reflecting less bother. Testosterone levels were measured at each follow-up. RESULTS From 2007 to 2010, 122 localized prostate cancer patients (9 low-, 64 intermediate-, and 49 high-risk according to the D'Amico classification) at a median age of 72 years (range 54.5-88.3) were treated with short course ADT (3-6 months) and SBRT (35-36.25 Gy) at Georgetown University Hospital. Of the participants, 48% percent were non-white and 48% were overweight. 77% of patients received three months of ADT. At baseline, 2% of men experienced gynecomastia that was a "moderate to big problem" and that proportion peaked at 3 and 12 months post-SBRT (7%) before returning to less than baseline (0%) 24 months post-SBRT with a cumulative incidence of 14.75%. The median baseline healthcare software hot flash score of 98 declined to 90 at 3 months post-SBRT but this returned to baseline by 24 months post SBRT. These changes were both statistically and clinically significant (MID = 6.5). Testosterone recovery (> 230 ng/dL) occurred in approximately 70% of patients by 12 months post SBRT. The development and resolution of gynecomastia fluctuated at various timepoints and did not directly correlate with testosterone recovery. CONCLUSION Bothersome gynecomastia occurs in less than 15% of men treated with neoadjuvant ADT. Resolution of gynecomastia occurs in most patients within two years after treatment. Reassurance of the temporary nature of gynecomastia may assist in reducing patient anxiety. Institutional IRB (IRB#: 2009-510) approval was obtained for retrospective review of prospectively collected data.
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Affiliation(s)
- S S Jatar
- Georgetown School Of Medicine, Washington, DC
| | - S Shah
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - J Hsueh
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - L Gallagher
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - M Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - A Zwart
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - M J Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - T Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - D Kumar
- Biotechnology Research Institute, North Carolina Central University, Durham, NC
| | - P Leger
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - N Aghdam
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Washington, DC
| | - N Dawson
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - S Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - S P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
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Bhatnagar A, Collins B, Collins SP, Jean W, Aulisi E, Harris B, Nayar V, Anaizi A, Watson J, Carrasquilla M, Suy S, Conroy D. Marginless 5-Fraction Robotic Radiosurgery for Unfavorable Nonfunctioning Pituitary Macroadenoma: 5-year Outcomes from a Single Institution Protocol. Int J Radiat Oncol Biol Phys 2023; 117:e165. [PMID: 37784765 DOI: 10.1016/j.ijrobp.2023.06.1000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Nonfunctioning macroadenoma is a commonly diagnosed pituitary tumor. Resection is the favored treatment, with radiosurgery often utilized for residual or progressing disease. Long-term outcomes are established for single-session radiosurgery, but mature outcomes are lacking for multisession radiosurgery. We report our institution's 5-year efficacy and safety results for unfavorable nonfunctioning pituitary macroadenoma patients treated with marginless 5-fraction robotic radiosurgery. MATERIALS/METHODS Between 2010-2020, patients who completed marginless 5-fraction radiosurgery for the treatment of unfavorable nonfunctioning pituitary macroadenomas were included. A tumor was considered unfavorable if the gross tumor volume (GTV) was larger than 5 cc or if it closely approached a critical structure (optic apparatus, brainstem or pituitary gland). Local control was calculated using the Kaplan-Meier Method. RESULTS Twenty predominately female patients (60%), age from 21-77 (median: 53 years) were included in this study. All underwent primary resection. Indications for radiosurgery included unresectable recurrence (85%) and residual disease progression (70%). Median tumor volume was 3.4 cm3 (range: 0.3-20.8 cm3) and 40% of the tumors were suprasellar. A mean dose of 28.8 Gy (range: 25 Gy-30 Gy), was delivered to a median isodose line of 80% (range: 75%-89%). The median optic chiasm maximum point dose was 21.8 Gy (range: 12.0-25.9 Gy). Toxicity was minimal with 12 patients (40%) developing acute short-lived headaches and 1 patient (5%) developing a brief ipsilateral 6th nerve palsy. There was no radiation induced optic or pituitary dysfunction identified in this cohort. At a median follow up of 5 years local control was 95%. There was 1 in-field failure pathologically confirmed following surgery for pituitary tumor hemorrhage and 2 radiographically confirmed out-of-field failures in patients with large tumors (>20 cc). CONCLUSION The treatment of unfavorable nonfunctioning pituitary macroadenoma with marginless 5-fraction robotic radiosurgery provides excellent local control to date, with minimal toxicity. However, tumors with GTV's greater than 20 cc may require conventionally fractionated treatment with a margin to optimize local control.
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Affiliation(s)
- A Bhatnagar
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | | | - S P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - W Jean
- Lehigh Valley Health Network, Leigh County, PA
| | - E Aulisi
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - B Harris
- Department of Pathology, Medstar Georgetown University Hospital, Washington, DC
| | - V Nayar
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - A Anaizi
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - J Watson
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - M Carrasquilla
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - S Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - D Conroy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
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Khan I, Lee Z, Zwart A, Rechter T, Tettey J, Danner M, Ayoob MJ, Yung T, Kumar D, Li H, Suy S, Collins SP. Low Incidence of Late Lymphopenia Following Stereotactic Body Radiotherapy for Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e400. [PMID: 37785339 DOI: 10.1016/j.ijrobp.2023.06.1532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Stereotactic body radiotherapy (SBRT) is increasing in use for the treatment of localized prostate cancer. The utilization of highly conformal photon therapy such as SBRT may increase the whole-body integral dose. Lymphocytes are very radiation sensitive. This dose increase could lead to unintended consequences such as lymphopenia. Prior studies have shown that lymphopenia following radiation therapy may negatively impact long-term outcomes. This study sought to evaluate the incidence and timeline of chronic lymphopenia following prostate SBRT. MATERIALS/METHODS Institutional IRB (IRB#: 2012-1175) approval was obtained. The absolute lymphocyte count was measured 1-2 hours prior to robotic SBRT (35-36.25 Gy in 5 fractions) and at each follow-up (3, 6, 12, 18 and 24 months). Lymphopenia was graded using the CTCAEv.4: Grade 1 (1.0-0.8 k/μl), Grade 2 (0.8-0.5 k/μl), Grade 3 (0.5-0.2 k/μl) and Grade 4 (<0.2 k/μl). Late lymphopenia was defined as lymphopenia occurring 3 or more months post-SBRT. RESULTS From 2019 to 2022, 198 localized prostate cancer patients (23 low-, 148 intermediate-, and 27 high-risk according to the D'Amico classification) at a median age of 73.5 years were treated with SBRT (35-36.25 Gy) at Georgetown University Hospital on a prospective clinical trial. Baseline lymphopenia was uncommon: Grade 1 (3.5%), Grade 2 (1.5%) and Grade 3 (0%). The baseline ALC of 1.9 k/μl decreased to 1.5 k/μl at 3 months post-SBRT and then remained stable for the remainder of the two-year follow-up. Overall, 14.6% of men experienced lymphopenia in the two years following SBRT: Grade 1 (7.6%), Grade 2 (6.6%) and Grade 3 (0.5%). No patient experienced Grade 4 lymphopenia. CONCLUSION Prostate SBRT leads to a low rate of late lymphopenia with the vast majority of toxicities being low grade. The peak incidence occurred at 3 months post-SBRT. Resolution of lymphopenia occurs in most patients within two years after SBRT. Future studies should explore the possible impact on quality of life and cancer control outcomes.
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Affiliation(s)
- I Khan
- Georgetown University School of Medicine, Washington, DC
| | - Z Lee
- Georgetown University Hospital, Washington, DC
| | - A Zwart
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - T Rechter
- Georgetown University Hospital Department of Radiation Medicine, Washington, DC
| | - J Tettey
- University of Maryland College Park School of Public Health, College Park, MD
| | - M Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - M J Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - T Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - D Kumar
- Biotechnology Research Institute, North Carolina Central University, Durham, NC
| | - H Li
- Georgetown University Department of Oncology, Washington, DC
| | - S Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - S P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
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Repka MC, Carrasquilla M, Paydar I, Wu B, Lei S, Suy S, Collins SP, Kole TP. Dosimetric predictors of acute bowel toxicity after Stereotactic Body Radiotherapy (SBRT) in the definitive treatment of localized prostate cancer. Acta Oncol 2023; 62:174-179. [PMID: 36826994 DOI: 10.1080/0284186x.2023.2180661] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
INTRODUCTION SBRT is an increasingly popular treatment for localized prostate cancer, though considerable variation in technical approach is common and optimal dose constraints are uncertain. In this study, we sought to identify dosimetric and patient-related predictors of acute rectal toxicity. METHODS Patients included in this study were treated with prostate SBRT on a prospective institutional protocol. Physician-graded toxicity and patient-reported outcomes were captured at one week, one month, and three months following SBRT. DVH data were extracted and converted into relative volume differential DVHs for NTCP modeling. Patient- and disease-related covariates along with NTCP model predictions were independently tested for significant association with physician-graded toxicity or a decline in bowel-related QoL. A multivariate model was constructed using forward selection, and significant parameter cutoff values were obtained with Fischer's exact test to group patients by risk of developing physician-graded toxicity or detriments in patient-reported QoL. RESULTS One hundred and three patients treated for localized prostate cancer with SBRT were included in our analysis. 52% of patients experienced a clinically significant decline in bowel-related QOL within 1 week of completion of treatment, while only 27.5% of patients developed grade 2+ physician-graded rectal toxicity. Sequential feature selection multivariate logistic regression identified rectal V22.5 Gy (p = 0.001) and D19% (p = 0.001) as independent predictors of clinically significant toxicity, while rectal V20Gy (p = 0.004) and D25.3% (p = 0.007) were independently correlated with physician-graded toxicity. Global multivariate step-wise logistic regression identified only D19% (p = 0.001) and V20Gy (p = 0.004) as independent predictors of acute bowel bother or physician-graded rectal toxicity respectively. CONCLUSIONS Moderate doses to large rectal volumes, D19% and V20Gy, were associated with an increased incidence of a clinically significant decrease in patient-reported bowel QOL and physician-scored grade 2+ rectal toxicity, respectively. These dosimetric parameters may help practitioners mitigate acute toxicity in patients treated with prostate SBRT.
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Affiliation(s)
- Michael C Repka
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Michael Carrasquilla
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Binbin Wu
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Siyuan Lei
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Simeng Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Sean P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Thomas P Kole
- Department of Radiation Oncology, Valley Mount Sinai Comprehensive Cancer Care, Paramus, NJ, USA
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9
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Simhal RK, Sholklapper TN, Simhal AK, Zwart AL, Danner MT, Kumar D, Aghdam N, Suy S, Hankins RA, Kowalczyk KJ, Collins SP. Association of baseline self-reported fatigue with overall survival after stereotactic body radiation therapy for localized prostate cancer. Front Oncol 2022; 12:1015264. [PMID: 36620537 PMCID: PMC9816795 DOI: 10.3389/fonc.2022.1015264] [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: 08/09/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Stereotactic Body Radiation Therapy (SBRT) has emerged as a definitive therapy for localized prostate cancer (PCa). However, more data is needed to predict patient prognosis to help guide which patients will benefit most from treatment. The FACIT-Fatigue (FACIT-F) is a well validated, widely used survey for assessing fatigue. However, the role of fatigue in predicting PCa survival has yet to be studied. Herein, we investigate the role of FACIT-F as a baseline predictor for overall survival (OS) in patients undergoing SBRT for localized PCa. Methods A retrospective review was conducted of 1358 patients who received SBRT monotherapy between January 2008 to April 2021 at an academic, tertiary referral center. FACIT-F scores (range 0 to 52) were summed for patients who answered all 13-items on the survey. FACIT-F total scores of ≥35 represented severe fatigue. Patients receiving androgen deprivation therapy were excluded. Differences in fatigue groups were evaluated using chi-squared tests. OS rates were determined using the Kaplan-Meier method and predictors of OS were evaluated using Cox proportional hazard method. Results Baseline full FACIT-F scores and survival data was available for 891 patients. 5-year OS was 87.6% and 95.2%, respectively, for the severely fatigued and non-fatigued groups. Chi-squared analysis of fatigue groups showed no significant difference in the following categories: D'Amico risk group, age, ethnicity, grade group, T-stage, or PSA density. Severe fatigue was associated with a significant decrease in OS (hazard ratio 2.76; 95%CI 1.55 - 4.89). The Cox proportional hazard model revealed that age and FACIT-F were both statistically significant (p <0.05). Conclusion Baseline FACIT-F scores are significantly associated with OS. Higher FACIT-F scores, representing less fatigued patients, are associated with an overall survival benefit. These results indicate that the FACIT-F survey could serve as an additional metric for clinicians in determining prognostic factors for patients undergoing SBRT.
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Affiliation(s)
- Rishabh K. Simhal
- School of Medicine, Georgetown University, Washington, DC, United States,*Correspondence: Rishabh K. Simhal,
| | | | - Anish K. Simhal
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Alan L. Zwart
- Department of Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Malika T. Danner
- Department of Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Deepak Kumar
- Julius L. Chambers Research Institute, North Carolina Central University, Durham, NC, United States
| | - Nima Aghdam
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Simeng Suy
- Department of Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Ryan A. Hankins
- School of Medicine, Georgetown University, Washington, DC, United States,Department of Urology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Keith J. Kowalczyk
- School of Medicine, Georgetown University, Washington, DC, United States,Department of Urology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sean P. Collins
- School of Medicine, Georgetown University, Washington, DC, United States,Department of Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, United States
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Cantalino J, Pernia M, Obayomi-Davies O, Aghdam N, Danner M, Suy S, Conroy D, Collins S, Salvatore M, Makariou E, Rudra S, Lischalk J, Collins B. Adjuvant Stereotactic Body Radiation Therapy (ASBRT) for Early-Stage Breast Cancer: Symptomatic Fat Necrosis is Associated with Consecutive Daily Treatments. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.734] [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: 10/31/2022]
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11
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Conroy D, Sholklapper T, Lawlor M, Cantalino J, Zwart A, Ayoob M, Danner M, Yung T, Collins B, Lei S, Rashid A, Kumar D, Suy S, Aghdam N, Collins S. Correlation between Obesity and Treatment Failure Following Stereotactic Body Radiation Therapy (SBRT) for Clinically Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1159] [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: 11/16/2022]
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12
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Repka M, Sholklapper T, Zwart A, Danner M, Ayoob M, Yung T, Lei S, Collins B, Kumar D, Suy S, Hankins R, Kishan A, Collins S. Prognostic Utility of Biopsy-Based PTEN and ERG Status on Biochemical Progression and Overall Survival after SBRT for Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.2130] [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: 10/31/2022]
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13
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Rios-Colon L, Chijioke J, Niture S, Afzal Z, Qi Q, Srivastava A, Ramalinga M, Kedir H, Cagle P, Arthur E, Sharma M, Moore J, Deep G, Suy S, Collins SP, Kumar D. Leptin modulated microRNA-628-5p targets Jagged-1 and inhibits prostate cancer hallmarks. Sci Rep 2022; 12:10073. [PMID: 35710817 PMCID: PMC9203512 DOI: 10.1038/s41598-022-13279-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 05/23/2022] [Indexed: 02/07/2023] Open
Abstract
MicroRNAs (miRNAs) are single-stranded non-coding RNA molecules that play a regulatory role in gene expression and cancer cell signaling. We previously identified miR-628-5p (miR-628) as a potential biomarker in serum samples from men with prostate cancer (PCa) (Srivastava et al. in Tumour Biol 35:4867–4873, 10.1007/s13277-014-1638-1, 2014). This study examined the detailed cellular phenotypes and pathways regulated by miR-628 in PCa cells. Since obesity is a significant risk factor for PCa, and there is a correlation between levels of the obesity-associated hormone leptin and PCa development, here we investigated the functional relationship between leptin and miR-628 regulation in PCa. We demonstrated that exposure to leptin downregulated the expression of miR-628 and increased cell proliferation/migration in PCa cells. We next studied the effects on cancer-related phenotypes in PCa cells after altering miR-628 expression levels. Enforced expression of miR-628 in PCa cells inhibited cell proliferation, reduced PCa cell survival/migration/invasion/spheroid formation, and decreased markers of cell stemness. Mechanistically, miR-628 binds with the JAG1-3′UTR and inhibits the expression of Jagged-1 (JAG1). JAG1 inhibition by miR-628 downregulated Notch signaling, decreased the expression of Snail/Slug, and modulated epithelial-mesenchymal transition and invasiveness in PC3 cells. Furthermore, expression of miR-628 in PCa cells increased sensitivity towards the drugs enzalutamide and docetaxel by induction of cell apoptosis. Collectively our data suggest that miR-628 is a key regulator of PCa carcinogenesis and is modulated by leptin, offering a novel therapeutic opportunity to inhibit the growth of advanced PCa.
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Affiliation(s)
- Leslimar Rios-Colon
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA.,Department of Cancer Biology, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA
| | - Juliet Chijioke
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Suryakant Niture
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Zainab Afzal
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Qi Qi
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Anvesha Srivastava
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Malathi Ramalinga
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Habib Kedir
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Patrice Cagle
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Elena Arthur
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Mitu Sharma
- Department of Cancer Biology, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA
| | - John Moore
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Gagan Deep
- Department of Cancer Biology, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA.,Wake Forest Baptist Comprehensive Cancer Center, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA
| | - Simeng Suy
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, 20057, USA
| | - Sean P Collins
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, 20057, USA
| | - Deepak Kumar
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA.
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Colon LR, Chijioke J, Niture S, Afzal Z, Qi Q, Srivastava A, Ramalinga M, Kedir H, Cagle P, Arthur E, Deep G, Suy S, Collins S, Kumar D. Abstract 5822: Leptin modulated microRNA-628-5p targets Jagged1 and inhibits prostate cancer hallmarks. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-5822] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Prostate cancer (PCa) is the most commonly diagnosed non-cutaneous cancer and the second leading cause of cancer deaths in men. Obesity is a major risk factor for prostate cancer. Leptin is an obesity hormone that controls body weight by regulating energy intake and expenditure, and clinical studies have demonstrated a correlation between blood leptin levels and PCa development. MicroRNAs (miRs) are master regulators of cancer cell signaling, including in advanced PCa. We previously identified miR-628-5p as a potential biomarker in PCa patients that was downregulated in serum samples of men with PCa (Tumor Biol., 2014, 35: 4867). In this study, we investigated the link between the obesity hormone leptin and the functional role of miR-628-5p in PCa cell lines. We demonstrate that leptin downregulates the expression of miR-628-5p and increases cell proliferation and migration in PCa cells. Enforced expression of miR-628-5p inhibited cell proliferation in PCa cells. Further, miR-628-5p reduced PCa cell survival/migration/invasion/spheroids formation and cell stemness. Mechanistically, miR-628-5p binds with JAG1-3’UTR and inhibits the expression of Jagged-1 (JAG1). JAG1 inhibition by miR-628-5p also downregulated Notch signaling, decreased the expression of snail/slug, and modulated epithelial-mesenchymal transition and invasiveness in PC3 cells. Furthermore, miR-628-5p increased sensitivity towards enzalutamide and docetaxel by inducing cell apoptosis. Collectively our data suggested that miR-628-5p is a key regulator of PCa carcinogenesis modulated by adipokine leptin and offers a novel therapeutic opportunity to inhibit the growth of advanced PCa.
Citation Format: Leslimar Rios Colon, Juliet Chijioke, Suryakant Niture, Zainab Afzal, Qi Qi, Anvesha Srivastava, Malathi Ramalinga, Habib Kedir, Patrice Cagle, Elena Arthur, Gagan Deep, Simeng Suy, Sean Collins, Deepak Kumar. Leptin modulated microRNA-628-5p targets Jagged1 and inhibits prostate cancer hallmarks [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5822.
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Affiliation(s)
| | | | | | | | - Qi Qi
- 1North Carolina Central University, Durham, NC
| | | | | | - Habib Kedir
- 1North Carolina Central University, Durham, NC
| | | | | | - Gagan Deep
- 2Wake Forest Baptist Medical Center, Winston-Salem, NC
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15
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Sholklapper T, Creswell M, Cantalino J, Markel M, Zwart A, Danner M, Ayoob M, Yung T, Collins B, Kumar D, Aghdam N, Rubin RS, Hankins R, Suy S, Collins S. Ejaculatory Function Following Stereotactic Body Radiation Therapy for Prostate Cancer. J Sex Med 2022; 19:771-780. [PMID: 35305936 DOI: 10.1016/j.jsxm.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 02/13/2022] [Accepted: 02/15/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ejaculatory dysfunction is an important male quality of life issue which has not yet been studied in the setting of prostate stereotactic body radiation therapy (SBRT). AIM The purpose of this study is to evaluate ejaculatory function following SBRT for prostate cancer. METHODS Two hundred and thirty-one patients on a prospective quality of life study with baseline ejaculatory capacity treated with prostate SBRT from 2013 to 2019 were included in this analysis. Ejaculation was assessed via the Ejaculation Scale (ES-8) from the Male Sexual Health Questionnaire. Patients completed the questionnaire at 1, 3, 6, 9, 12, 18, and 24 months post-SBRT. Elderly patients (Age > 70) and those who received hormonal therapy were excluded from analysis. Patients were treated to 35-36.25 Gy in 5 fractions delivered with the CyberKnife Radiosurgical System (Accuray). OUTCOMES Ejaculatory function was assessed by ES-8 scores (range 4-40) with lower values representing increased interference or annoyance. RESULTS Median age at the time of treatment was 65 years. Median follow up was 24 months (IQR 19-24.5 months). 64.5% of patients had ED at baseline (SHIM < 22). The 2-year anejaculation rate was 15%. Mean composite ES-8 scores showed a decline in the first month following treatment then stabilized: 30.4 (start of treatment); 26.5 (1 month); 27.6 (3 month); 27.0 (6 month); 26.2 (9 month); 25.4 (12 month); 25.0 (18 month) and 25.4 (24 month). White race, higher pre-treatment SHIM (≥22), and higher ES-8 (≥31) at treatment start were significantly associated with a decreased probability of a clinically significant decline. Patient-reported ejaculate volume was significantly reduced at all time points post-SBRT. Ejaculatory discomfort peaked at 1 month and 9 months post-SBRT. Prior to treatment, 8.0% of men reported that they were very to extremely bothered by their ejaculatory dysfunction. The number of patients reporting this concern increased to 14.4% at one year and dropped to 11% at 24-months post-SBRT. CLINICAL TRANSLATION Patients undergoing prostate SBRT may experience meaningful changes in ejaculatory function and should be counseled on the trajectory of these side effects. STRENGTHS & LIMITATIONS This was a retrospective analysis of a prospectively maintained database. Subjective questionnaire responses captured limited aspects of ejaculatory function in this cohort. CONCLUSION The high incidence of moderate to extreme bother in ejaculatory function before and after SBRT suggests a need for novel approaches to improving ejaculation. Sholklapper T, Creswell M, Cantalino J, et al. Ejaculatory Function Following Stereotactic Body Radiation Therapy for Prostate Cancer. J Sex Med 2022;19:771-780.
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Affiliation(s)
- Tamir Sholklapper
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Michael Creswell
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Jonathan Cantalino
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Michael Markel
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Alan Zwart
- Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, USA
| | - Malika Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Marilyn Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Thomas Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Brian Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Deepak Kumar
- Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, USA
| | - Nima Aghdam
- Department of Radiation Medicine, Beth Israel Deaconess, Boston, MA, USA
| | - Rachel S Rubin
- Department of Urology, Georgetown University Hospital, Washington, DC, USA
| | - Ryan Hankins
- Department of Urology, Georgetown University Hospital, Washington, DC, USA
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Sean Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA.
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16
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Repka MC, Creswell M, Lischalk JW, Carrasquilla M, Forsthoefel M, Lee J, Lei S, Aghdam N, Kataria S, Obayomi-Davies O, Collins BT, Suy S, Hankins RA, Collins SP. Rationale for Utilization of Hydrogel Rectal Spacers in Dose Escalated SBRT for the Treatment of Unfavorable Risk Prostate Cancer. Front Oncol 2022; 12:860848. [PMID: 35433457 PMCID: PMC9008358 DOI: 10.3389/fonc.2022.860848] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
In this review we outline the current evidence for the use of hydrogel rectal spacers in the treatment paradigm for prostate cancer with external beam radiation therapy. We review their development, summarize clinical evidence, risk of adverse events, best practices for placement, treatment planning considerations and finally we outline a framework and rationale for the utilization of rectal spacers when treating unfavorable risk prostate cancer with dose escalated Stereotactic Body Radiation Therapy (SBRT).
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Affiliation(s)
- Michael C Repka
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Michael Creswell
- Georgetown University School of Medicine, Washington, DC, United States
| | - Jonathan W Lischalk
- Department of Radiation Oncology at New York University (NYU) Long Island School of Medicine, Perlmutter Cancer Center at NYCyberKnife, New York, NY, United States
| | - Michael Carrasquilla
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Matthew Forsthoefel
- Department of Radiation Oncology, Radiotherapy Centers of Kentuckiana, Louisville, KY, United States
| | - Jacqueline Lee
- Georgetown University School of Medicine, Washington, DC, United States
| | - Siyuan Lei
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Nima Aghdam
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Shaan Kataria
- Department of Radiation Oncology, Arlington & Reston Radiation Oncology, Arlington, VA, United States
| | - Olusola Obayomi-Davies
- Department of Radiation Oncology, Wellstar Kennestone Hospital, Marietta, GA, United States
| | - Brian T Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Ryan A Hankins
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
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Sholklapper TN, Creswell ML, Payne AT, Markel M, Pepin A, Carrasquilla M, Zwart A, Danner M, Ayoob M, Yung T, Collins B, Kumar D, Aghdam N, Suy S, Hankins RA, Kowalczyk K, Collins SP. Patient-Reported Financial Burden Following Stereotactic Body Radiation Therapy for Localized Prostate Cancer. Front Oncol 2022; 12:852844. [PMID: 35402242 PMCID: PMC8990911 DOI: 10.3389/fonc.2022.852844] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/28/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction and Objectives In patients with localized prostate cancer, 5-fraction, stereotactic body radiation therapy (SBRT) has been found to offer comparable oncologic outcomes and potential for improved treatment compliance compared to conventional, 40-plus fraction radiation therapy (RT). Recent studies of oncologic patient experiences have highlighted both the impact of therapy-associated financial toxicity (FT) on treatment adherence and health-related quality of life (HRQOL). Methods A cross-sectional assessment of FT after SBRT was performed using the 12-item COST questionnaire. The total questionnaire score (range 0–44) was used to evaluate the FT grade (0–3), with a higher COST value representing lower grade. The patient zip code was used to approximate the distance from the index hospital. Univariate and multivariate analyses of the average COST score (0–4) are performed. Results The response rate was 57.5% (332 of 575 consented patients) with 90.7%, 8.2%, and 1.1% experiencing grade 0, 1, and 2 FT, respectively, with no grade 3. Unemployment or disability, non-white race, low income, and concurrent hormonal therapy were associated with a statistically significant worse FT (lower COST value) on univariate and multivariate analyses (p < 0.05). Education level and insurance status significant were evaluated on univariate analysis only. There was a non-statistically significant difference in age, marital status, time since treatment, and distance from the index hospital. Conclusions SBRT was associated with low FT. However, statistically significant socioeconomic disparities in FT remain despite ultra-hypofractionated treatment.
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Affiliation(s)
| | | | - Alexandra T Payne
- Georgetown University School of Medicine, Washington, DC, United States
| | - Michael Markel
- Georgetown University School of Medicine, Washington, DC, United States
| | - Abigail Pepin
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Michael Carrasquilla
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Alan Zwart
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Brian Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Deepak Kumar
- Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Nima Aghdam
- Department of Radiation Medicine, Beth Israel Deaconess, Boston, MA, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Ryan A Hankins
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Keith Kowalczyk
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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18
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Pepin AN, Zwart A, Danner M, Ayoob M, Yung T, Collins BT, Kumar D, Suy S, Aghdam N, Collins SP. Treatment Interruptions During Stereotactic Body Radiotherapy for Prostate Cancer. Front Oncol 2022; 11:796496. [PMID: 35127506 PMCID: PMC8807506 DOI: 10.3389/fonc.2021.796496] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 12/14/2021] [Indexed: 11/20/2022] Open
Abstract
Background During the course of radiation treatment for prostate cancer, patients may have unintentional interruptions in their treatment course due to a wide variety of factors. Stereotactic body radiation therapy (SBRT) decreases the number of treatments compared to conventionally fractionated radiation; hence, it has the potential to decrease treatment delays and non-completion. This study sought to determine the incidence of treatment delay and characterize the etiology and length in a large cohort of men treated with SBRT for their prostate cancer. Methods One thousand three hundred and thirty-six patients treated with SBRT from 2008 to 2021 at the Georgetown University Hospital for prostate cancer were included in this retrospective study. A treatment delay was defined as a patient requiring longer than 14 days to complete 5 fractions of SBRT. Non-completion was defined as patients treated with less than 5 fractions. In the patients who experienced delays, chart review was performed to characterize the length and etiology of each delay. Multivariate analysis was performed via binary logistic regression modeling on PSPP. Results All individuals in the cohort eventually completed the planned 5-fraction regimen. Thirty-three patients experienced a treatment delay. Median length of time to complete treatment was 11 days (range 5–155 days). In patients who experienced a delay, nearly half (45.5%) experienced only a one-day delay. The most common reason for a delay was a technical issue (48.5%), including the machine maintenance, fiducial misalignment, or inadequate pretreatment bowel preparation. Other reasons included unplanned breaks due to acute side effects (21.2%), logistical issues (18.2%), non-treatment related health issues (9.1%), and inclement weather (3.0%). There were no significant sociodemographic, oncologic, or treatment variables that predicted treatment interruption on multivariate analysis. Conclusions The incidence of treatment interruptions in patients undergoing SBRT for their prostate cancer was low. Most treatment delays were short.
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Affiliation(s)
- Abigail N. Pepin
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Alan Zwart
- Department of Radiation Medicine, School of Medicine, Georgetown University, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, School of Medicine, Georgetown University, Washington, DC, United States
| | - Marylin Ayoob
- Department of Radiation Medicine, School of Medicine, Georgetown University, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, School of Medicine, Georgetown University, Washington, DC, United States
| | - Brian T. Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Deepak Kumar
- The Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Simeng Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Nima Aghdam
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Sean P. Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
- *Correspondence: Sean P. Collins,
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Aghdam N, Lischalk JW, Marin MP, Hall C, O'Connor T, Campbell L, Suy S, Collins SP, Margolis M, Krochmal R, Anderson E, Collins BT. Lobar Gross Endobronchial Disease Predicts for Overall Survival and Grade 5 Pulmonary Toxicity in Medically Inoperable Early Stage Non-Small Cell Lung Cancer Patients Treated With Stereotactic Body Radiation Therapy. Front Oncol 2021; 11:728519. [PMID: 34912703 PMCID: PMC8667471 DOI: 10.3389/fonc.2021.728519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/18/2021] [Indexed: 12/31/2022] Open
Abstract
Purpose Stereotactic body radiation therapy (SBRT) is considered standard of care for medically inoperable early stage non-small cell lung cancer (ES-NSCLC). Central tumor location is a known risk factor for severe SBRT related toxicity. Bronchoscopy allows for visualization of the central airways prior to treatment. Five fraction SBRT approaches have been advocated to mitigate treatment induced toxicity. In this report, we examine the mature clinical outcomes of a diverse cohort of ES-NSCLC patients with both peripheral and central tumors treated with a conservative 5 fraction SBRT approach and evaluate the role of lobar gross endobronchial disease (LGED) in predicting overall survival and treatment-related death. Methods Medically inoperable biopsy-proven, lymph node-negative ES-NSCLC patients were treated with SBRT. Bronchoscopy was completed prior to treatment in all centrally located cases. The Kaplan-Meier method was used to estimate overall survival (OS), local control (LC), regional control (RC), distant metastasis free survival (DMFS) and disease-free survival (DFS). Overall survival was stratified based on clinical stage, histology, tumor location and LGED. Toxicities were scored according to the National Cancer Institute Common Terminology Criteria for Adverse Events, Version 5.0. Results From December 2010 to December 2015, 50 consecutive patients were treated uniformly with a 50 Gy in 5 fraction SBRT approach (tumor BED10 ≥ 100 Gy) and followed for a minimum of 5 years or until death. At a median follow up of 42 months for all patients, 3-year OS was 50%. Three-year OS did not statistically differ between stage I and stage II disease (51% vs. 47%; p=0.86), adenocarcinoma and squamous cell carcinoma (50% vs. 45%; p=0.68), or peripheral and central tumors (56% vs. 45%; p=0.46). Five central tumors were found to have LGED, and 3-year OS for this cohort was quite poor at 20%. Cox regression analysis identified LGED as a predictor of OS while controlling for age, stage and location (OR:4.536, p-value=0.038). Despite the relatively low dose delivered, treatment likely contributed to the death of 4 patients with central tumors. Lobar gross endobronchial disease was an independent predictor for grade 5 pulmonary toxicity (n=4, p=0.007). Specifically, 3 of the 5 patients with LGED developed fatal radiation-induced bronchial stricture. Three-year LC, RC, DMFS and DFS results for the group were similar to contemporary studies at 90%, 90%, 82% and 65%. Conclusions Central location of ES-NSCLC is a well-established predictor for severe SBRT-related toxicity. Here we identify LGED as a significant predictor of poor overall survival and grade 5 pulmonary toxicity. The relatively high rates of severe treatment-related toxicity seen in patients with central ES-NSCLC may be due in part to LGED. Underlying LGED may cause irreparable damage to the lobar airway, unmitigated by SBRT treatment thus increasing the risk of severe treatment-related toxicity. These findings should be verified in larger data sets. Future prospective central ES-NSCLC clinical trials should require staging bronchoscopy to identify LGED and further assess its clinical significance.
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Affiliation(s)
- Nima Aghdam
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Jonathan W Lischalk
- Department of Radiation Oncology, Perlmutter Cancer Center New York University at Langone Hospital - Long Island, New York, NY, United States
| | - Monica Pernia Marin
- Geriatrics and Palliative Medicine Division, George Washington University Hospital, Washington, DC, United States
| | - Clare Hall
- College of Arts and Sciences, Cornell University, Ithaca, NY, United States
| | - Timothy O'Connor
- Georgetown University School of Medicine, Washington, DC, United States
| | - Lloyd Campbell
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Marc Margolis
- Division of Thoracic Surgery, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Rebecca Krochmal
- Division of Pulmonary and Critical Care Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Eric Anderson
- Division of Pulmonary and Critical Care Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Brian T Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
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Shah S, Sholklapper T, Creswell M, Pepin A, Cantalino J, Hankins RA, Suy S, Collins SP. Bothersome Hematospermia Following Stereotactic Body Radiation Therapy for Prostate Cancer. Front Oncol 2021; 11:765171. [PMID: 34900713 PMCID: PMC8654776 DOI: 10.3389/fonc.2021.765171] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/05/2021] [Indexed: 12/03/2022] Open
Abstract
Background Hematospermia following prostate radiation therapy is a benign and often self-limiting side effect. However, it may be bothersome to some men and their partners with a negative impact on sexual quality of life (QOL). This study sought to evaluate the incidence, duration, and resolution of hematospermia in patients following stereotactic body radiation therapy (SBRT) for prostate cancer. Methods 227 patients treated with SBRT from 2013 to 2019 at Georgetown University Hospital for localized prostate carcinoma with a minimum follow up of two years were included in this retrospective review of data that was prospectively collected. Patients who were greater than 70 years old and/or received hormonal therapy were excluded. Hematospermia was defined as bright red blood in the ejaculate. Time points for data collection included initial consultation, pre-treatment, 1-, 3-, 6-, 9-, 12-, 18-, 24-month. All patients were treated with the CyberKnife Radiosurgical System (Accuray). Data on hematospermia including duration, resolution and recurrence was collected. Utilization of 5-alpha reductase inhibitors was documented at each visit. Results 227 patients (45 low-, 177 intermediate-, and 5 high-risk according to the D’Amico classification) at a median age of 65 years (range 47-70) received SBRT for their localized prostate cancer. The 2-year cumulative incidence of hematospermia was 5.6%(14 patients). For these patients, all but one patient (93%) saw resolution of their hematospermia by two years post-SBRT. The median time for hematospermia was 9 months post-treatment. Of the 14 patients who reported hematospermia, 70% were managed with 5-alpha reductase inhibitors. Hematospermia was transient in most patients with 70% of the men reporting resolution by the next follow-up visit. Conclusion The incidence of bothersome hematospermia following SBRT was low. Hematospermia, as noted by other studies, often self-resolves. 5-alpha reductase inhibitors may lead to quicker resolution of bothersome hematospermia.
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Affiliation(s)
- Sarthak Shah
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Tamir Sholklapper
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Michael Creswell
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Abigail Pepin
- Department of Radiation Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Jonathan Cantalino
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Ryan Andrew Hankins
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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21
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Ma TM, Roy S, Wu X, Mantz C, Fuller D, Miszczyk L, Napieralska A, Namysł-Kaletka A, Bagshaw HP, Buyyounouski MK, Glicksman R, Loblaw DA, Katz A, Upadhyaya SK, Nickols N, Steinberg ML, Philipson R, Aghdam N, Suy S, Pepin A, Collins SP, Boutros P, Rettig MB, Calais J, Wang M, Zaorsky N, Kishan AU. Refining the definition of biochemical failure in the era of stereotactic body radiation therapy for prostate cancer: The Phoenix definition and beyond. Radiother Oncol 2021; 166:1-7. [PMID: 34774650 DOI: 10.1016/j.radonc.2021.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE The Phoenix definition for biochemical failure (BCF) after radiotherapy uses nadir PSA (nPSA) + 2 ng/mL to classify a BCF and was derived from conventionally fractionated radiotherapy, which produces significantly higher nPSAs than stereotactic body radiotherapy (SBRT). We investigated whether an alternative nPSA-based threshold could be used to define post-SBRT BCFs. MATERIALS AND METHODS PSA kinetics data on 2038 patients from 9 institutions were retrospectively analyzed for low- and intermediate-risk PCa patients treated with SBRT without ADT. We evaluated the performance of various nPSA-based definitions. We also investigated the relationship of relative PSA decline (rPSA, PSA18month/PSA6month) and timing of reaching nPSA + 2 with BCF. RESULTS Median follow-up was 71.9 months. BCF occurred in 6.9% of patients. Median nPSA was 0.16 ng/mL. False positivity of nPSA + 2 was 30.2%, compared to 40.9%, 57.8%, and 71.0% for nPSA + 1.5, nPSA + 1.0, and nPSA + 0.5, respectively. Among patients with BCF, the median lead time gained from an earlier nPSA + threshold definition over the Phoenix definition was minimal. Patients with BCF had significantly lower rates of early PSA decline (mean rPSA 1.19 vs. 0.39, p < 0.0001) and were significantly more likely to reach nPSA + 2 ≥ 18 months (83.3% vs. 21.1%, p < 0.0001). The proposed criterion (rPSA ≥ 2.6 or nPSA + 2 ≥ 18 months) had a sensitivity and specificity of 92.4% and 81.5%, respectively, for predicting BCF in patients meeting the Phoenix definition and decreased its false positivity to 6.4%. CONCLUSION The Phoenix definition remains an excellent definition for BCF post-SBRT. Its high false positivity can be mitigated by applying additional criteria (rPSA ≥ 2.6 or time to nPSA + 2 ≥ 18 months).
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Affiliation(s)
- Ting Martin Ma
- Department of Radiation Oncology, University of California Los Angeles, USA
| | - Soumyajit Roy
- Department of Radiation Oncology, Rush University Medical Center, Chicago, USA
| | - Xue Wu
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State College of Medicine, Hershey, USA
| | | | - Donald Fuller
- Division of Genesis Healthcare Partners Inc, CyberKnife Centers of San Diego Inc, USA
| | - Leszek Miszczyk
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Alexandra Napieralska
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Agnieska Namysł-Kaletka
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Hilary P Bagshaw
- Department of Radiation Oncology, Stanford University School of Medicine, USA
| | - Mark K Buyyounouski
- Department of Radiation Oncology, Stanford University School of Medicine, USA
| | | | - D Andrew Loblaw
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Canada
| | | | - Shrinivasa K Upadhyaya
- Department of Biological and Agricultural Engineering, University of California, Davis, USA
| | - Nicholas Nickols
- Department of Radiation Oncology, University of California Los Angeles, USA
| | | | | | - Nima Aghdam
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, USA
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington D.C., USA
| | - Abigail Pepin
- University of Pennsylvania Health System, Philadelphia, USA
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington D.C., USA
| | - Paul Boutros
- University of Pennsylvania Health System, Philadelphia, USA
| | | | - Jeremie Calais
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, University of California Los Angeles, USA
| | - Ming Wang
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State College of Medicine, Hershey, USA
| | - Nicholas Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, USA.
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22
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Ma T, Roy S, Mantz C, Fuller D, Miszczyk L, Napieralska A, Namysł-Kaletka A, Bagshaw H, Buyyounouski M, Glicksman R, Loblaw D, Katz A, Nickols N, Steinberg M, Philipson R, Aghdam N, Suy S, Pepin A, Collins S, Kishan A. Working Towards a New Definition of Biochemical Failure in the Era of Stereotactic Body Radiation Therapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Pepin A, Shah S, Pernia M, Lei S, Ayoob M, Danner M, Yung T, Collins BT, Suy S, Aghdam N, Collins SP. Bleeding Risk Following Stereotactic Body Radiation Therapy for Localized Prostate Cancer in Men on Baseline Anticoagulant or Antiplatelet Therapy. Front Oncol 2021; 11:722852. [PMID: 34604059 PMCID: PMC8485025 DOI: 10.3389/fonc.2021.722852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/09/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose Patients on anticoagulant/antiplatelet medications are at a high risk of bleeding following external beam radiation therapy for localized prostate cancer. SBRT may reduce the bleeding risk by decreasing the volume of bladder/rectum receiving high doses. This retrospective study sought to evaluate the rates of hematuria and hematochezia following SBRT in these patients. Methods Localized prostate cancer patients treated with SBRT from 2007 to 2017 on at least one anticoagulant/antiplatelet at baseline were included. The minimum follow-up was 3 years with a median follow-up of 72 months. Patients who had a rectal spacer placed prior to SBRT were excluded. Radiotherapy was delivered in 5 fractions to a dose of 35 Gy or 36.25 Gy utilizing the CyberKnife system. Hematuria and hematochezia were prospectively assessed before and after treatment using the Expanded Prostate Cancer Index Composite (EPIC-26). Toxicities were scored using the CTCAE v4. Cystoscopy and colonoscopy findings were retrospectively reviewed. Results Forty-four men with a median age of 72 years with a history of taking at least one anticoagulant and/or antiplatelet medication received SBRT. Warfarin (46%), clopidogrel (34%) and rivaroxaban (9%) were the most common medications. Overall, 18.2% experienced hematuria with a median time of 10.5 months post-SBRT. Altogether, 38.6% experienced hematochezia with a median time of 6 months post-SBRT. ≥ Grade 2 hematuria and hematochezia occurred in 4.6% and 2.5%, respectively. One patient required bladder neck fulguration and one patient underwent rectal cauterization for multiple non-confluent telangiectasia. There were no grade 4 or 5 toxicities. Cystoscopy revealed bladder cancer (40%) and benign prostatic bleeding (40%) as the most common hematuria etiology. Colonoscopy demonstrated hemorrhoids (54.5%) and radiation proctitis (9.1%) as the main causes of hematochezia. There was no significant change from the mean baseline EPIC-26 hematuria and hematochezia scores at any point during follow up. Conclusion In patients with baseline anticoagulant usage, moderate dose prostate SBRT was well tolerated without rectal spacing. High grade bleeding toxicities were uncommon and resolved with time. Baseline anticoagulation usage should not be considered a contraindication to prostate SBRT.
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Affiliation(s)
- Abigail Pepin
- George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Sarthak Shah
- George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Monica Pernia
- George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Brian T Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Nima Aghdam
- Department of Radiation Medicine, Harvard, Boston, MA, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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24
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Juarez JE, Romero T, Mantz CA, Pepin A, Aghdam N, Suy S, Steinberg ML, Levin-Epstein RG, Nickols NG, Kaplan ID, Meier RM, Pham HT, Linson PW, Hong RL, Buyyounouski MK, Bagshaw HP, Fuller DB, Katz AJ, Loblaw A, Collins SP, Kishan AU. Toxicity After Stereotactic Body Radiation Therapy for Prostate Cancer in Patients With Inflammatory Bowel Disease: A Multi-institutional Matched Case-Control Series. Adv Radiat Oncol 2021; 6:100759. [PMID: 34585025 PMCID: PMC8453194 DOI: 10.1016/j.adro.2021.100759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/29/2021] [Accepted: 07/07/2021] [Indexed: 02/07/2023] Open
Abstract
Purpose To evaluate the safety of stereotactic body radiation therapy (SBRT) for prostate cancer in men with inflammatory bowel disease (IBD). Methods and Materials We queried a consortium database for patients with IBD receiving SBRT for prostate cancer between 2006 and 2012. Identified patients were matched with patients without a history of IBD in a 3:1 fashion based on dose, fractionation, use of androgen deprivation therapy, and age distribution. Logistic regression was used to evaluate the association between having IBD and experiencing acute and late gastrointestinal (GI) and genitourinary (GU) toxicities as scored on the Common Terminology Criteria for Adverse Events scale. Time to late toxicity was evaluated using proportional hazard Cox models. Our study was limited by absence of data on prostate size, baseline International Prostate Symptom Score, and rectal dose-volume histogram parameters. Results Thirty-nine patients with flare-free IBD at time of treatment (median follow-up 83.9 months) and 117 matched controls (median follow-up 88.7 months) were identified. A diagnosis of IBD was associated with increased odds of developing any late grade GI toxicity (odds ratio [OR] 6.11, P <.001) and GU toxicity (odds ratio 6.14, P < .001), but not odds of developing late grade ≥2 GI (P = .08) or GU toxicity (P = .069). Acute GI and GU toxicity, both overall and for grade ≥2 toxicities, were more frequent in men with IBD (P < .05). Time to late GI and GU toxicity of any grade was significantly shorter in patients with IBD (P < .001). Time to late grade ≥2 GU, but not grade ≥2 GI toxicity, was also shorter in patients with IBD (P = .044 for GU and P = .144 for GI). Conclusions Patients with IBD who received SBRT for PCa had a higher likelihood of developing acute GI and GU toxicity, in addition to experiencing lower grade late toxicities that occurred earlier. However, patients with IBD did not have a higher likelihood for late grade ≥2 GI or GU toxicity after SBRT compared with the control cohort. Interpretation of this data are limited by the small sample size. Thus, men with IBD in remission should be properly counseled about these risks when considering SBRT.
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Affiliation(s)
- Jesus E Juarez
- Department of Radiation Oncology, UCLA Medical Center, Los Angeles, California
| | - Tahmineh Romero
- Department of Medicine Statistics Core, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Abigail Pepin
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC.,Department of Radiation Oncology, George Washington School of Medicine and Health Sciences, Washington, DC
| | - Nima Aghdam
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - Michael L Steinberg
- Department of Radiation Oncology, UCLA Medical Center, Los Angeles, California
| | | | - Nicholas G Nickols
- Department of Radiation Oncology, UCLA Medical Center, Los Angeles, California.,Department of Radiation Oncology, West Los Angeles Veterans Health Administration, Los Angeles, California
| | - Irving D Kaplan
- Department of Radiation Oncology, Beth Israel Deaconess, Boston, Massachusetts
| | | | - Huong T Pham
- Section of Radiation Oncology, Virginia Mason Medical Center, Seattle, Washington
| | - Patrick W Linson
- Department of Radiation Oncology, Scripps MD Anderson Cancer Center, San Diego, California
| | - Robert L Hong
- Department of Radiation Oncology, Virginia Hospital Center, Arlington, Virginia
| | | | - Hilary P Bagshaw
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Donald B Fuller
- Division of Genesis Health care Partners Inc, CyberKnife Centers of San Diego Inc, San Diego, California
| | - Alan J Katz
- Flushing Radiation Oncology Services, New York
| | - Andrew Loblaw
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - Amar U Kishan
- Department of Radiation Oncology, UCLA Medical Center, Los Angeles, California.,Department of Urology, University of California, Los Angeles, California
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25
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Pepin A, Shah S, Pernia M, Lei S, Ayoob M, Danner M, Yung T, Collins B, Suy S, Aghdam N, Collins S. PO-1364 Bleeding Risk after Prostate SBRT in Men on Baseline Anticoagulant/Antiplatelet Therapy. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)07815-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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26
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Cheema AK, Grindrod S, Li Y, Bansal S, Suy S, Collins S, Dritschilo A. Abstract PO-060: Blood based metabolomic biomarker assay to predict radiation late effects in prostate cancer patients. Clin Cancer Res 2021. [DOI: 10.1158/1557-3265.radsci21-po-060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction and Objective: Radiation therapy (RT) is an effective modality as a primary treatment of cancers, or as an adjuvant to surgery or chemotherapy. However, about 10 % of treated patients experience radiation treatment related late effects that adversely affect quality of life. Availability of a blood test that can be used to predict or monitor adverse symptoms would help stratify sensitive sub-populations of patients receiving radiation therapy. We have developed a kit based assay for the measurement of a small molecule based biomarker panel that is predictive of radiation treatment related toxicities in prostate cancer patients. Methods: We performed multiple reaction monitoring based targeted metabolomic/lipidomic analyses using baseline (samples obtained before radiation therapy) from the plasma of a cohort of 100 prostate cancer patients. Pre-processed data along with clinical annotations were used for the analyses. An optimized classifier algorithm was developed, using baseline plasma samples collected prior to the initiation of radiation therapy. We compared groups of sub-sets of patients who developed adverse symptoms to those who did not (control group), over the course of a two-year follow-up interval. Feature selection for building classifiers was performed using LASSO Logistic regression to avoid over-fitting of the model through iterative selection, and cross validation of candidate markers, in compliance with FDA biomarker development guidelines. Results: We have used a combination of metabolomics and clinical data for developing a kit based assay for identification of prostate cancer patients Metabolite signatures predictive of adverse responses to radiation therapy were developed in the patient cohort treated with stereotactic body radiation therapy (SBRT) for prostate cancer. We were able to develop high accuracy, predictive algorithms for recurrence, urinary symptoms and rectal proctitis episodes in this cohort. A plasma metabolite index was developed for the evaluation of susceptibility to adverse outcomes of radiation therapy. Furthermore, a visualization software was developed to integrate clinical and biomarker data for easier clinical translation. Conclusions: We developed candidate predictive biomarker panels that can be used for identifying patients who are at increased risk for developing adverse symptoms following radiation therapy. Following analytical validation, this kit based assay is a candidate for a clinical validation study to determine clinical utility.
Citation Format: Amrita K. Cheema, Scott Grindrod, Yaoxiang Li, Shivani Bansal, Simeng Suy, Sean Collins, Anatoly Dritschilo. Blood based metabolomic biomarker assay to predict radiation late effects in prostate cancer patients [abstract]. In: Proceedings of the AACR Virtual Special Conference on Radiation Science and Medicine; 2021 Mar 2-3. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(8_Suppl):Abstract nr PO-060.
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Affiliation(s)
| | | | | | | | | | - Sean Collins
- 4MedStar Georgetown University Hospital, Washington, DC
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Aghdam N, Carrasquilla M, Wang E, Pepin AN, Danner M, Ayoob M, Yung T, Collins BT, Kumar D, Suy S, Collins SP, Lischalk JW. Ten-Year Single Institutional Analysis of Geographic and Demographic Characteristics of Patients Treated With Stereotactic Body Radiation Therapy for Localized Prostate Cancer. Front Oncol 2021; 10:616286. [PMID: 33718117 PMCID: PMC7947279 DOI: 10.3389/fonc.2020.616286] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 12/23/2020] [Indexed: 11/28/2022] Open
Abstract
Objectives Stereotactic Body Radiation Therapy (SBRT) offers definitive treatment for localized prostate cancer with comparable efficacy and toxicity to conventionally fractionated radiotherapy. Decreasing the number of treatment visits from over 40 to five may ease treatment burden and increase accessibility for logistically challenged patients. Travel distance is one factor that affects a patient’s access to treatment and is often related to geographic location and socioeconomic status. In this study, we review the demographic and geographic factors of patients treated with SBRT for prostate cancer for a single institution with over a decade of experience. Methods Patient zip codes from one thousand and thirty-five patients were derived from a large, prospectively maintained quality of life database for patients treated for prostate cancer with SBRT from 2008 to 2017. The geospatial distance between the centroid of each zip code to our institution was calculated using the R package Geosphere. Characteristics for seven hundred and twenty-one patients were evaluated at the time of analysis including: race, age, and insurance status. To assess the geographic reach of our institution, we evaluated the demographic features of each zip code using US Census data. Statistical comparisons for these features and their relation to distance traveled for treatment was performed using the Mann-Whitney U test. Finally, an unsupervised learning algorithm was performed to identify distinct clusters of patients with respect to median income, racial makeup, educational level, and rural residency. Results Patients traveled from 246 distinct zip codes at a median distance of 11.35 miles. Forty percent of patients were African American, 6.9% resided in a rural region, and 22% were over the age of 75. Using K-means cluster analysis, four distinct patient zip-code groups were identified based on the aforementioned demographic features: Suburban/high-income (45%), Urban (30%), Suburban/low-income (17%), and Rural (8%). For each of the clusters, the average travel distance for SBRT was significantly different at 11.17, 9.26, 11.75, and 40.2 miles, respectively (p-value: <0.001). Conclusions Distinct demographic features are related to travel distance for prostate SBRT. In our large cohort, travel distance did not prevent uptake of prostate SBRT in African American, elderly or rural patient populations. Prostate SBRT offers a diverse population modern treatment for their localized prostate cancer and particularly for those who live significant distances from a treatment center.
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Affiliation(s)
- Nima Aghdam
- Department of Radiation Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Michael Carrasquilla
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Edina Wang
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Abigail N Pepin
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States.,George Washington University School of Medicine, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Brian T Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Deepak Kumar
- The Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Simeng Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Jonathan W Lischalk
- Perlmutter Cancer Center, Langone Medical Center, New York University, New York, NY, United States
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Parzen JS, Quinn TJ, Thompson AB, Chang P, Collins SP, Suy S, Michalski JM, Mantz CA, Seymour Z, Hamstra DA. Evaluating the correlation between early and late quality-of-life declines using the Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP) after definitive stereotactic body radiotherapy, intensity-modulated radiotherapy, or brachytherapy for prostate cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
214 Background: Multiple authorities including an NCI Taskforce have recommended routine evaluation of patient reported outcomes (PRO) in cancer care. The Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP) is a single-page quality-of-life (QOL) tool which is easily integrated into routine clinical practice. The EPIC-CP has 5 domains (each scored 0-12). The present study evaluated whether early clinically significant changes in EPIC-CP were correlated with later changes in patients undergoing definitive radiotherapy (RT) for prostate cancer. Methods: A cohort of 979 patients including the PROSTQA study and 3 other institutions with prospective QOL data pooled for analysis were evaluated for patient-reported outcomes. Patients were treated with definitive low-dose rate brachytherapy (n=284), intensity-modulated RT (n=251), or stereotactic body RT (n=444). EPIC-CP scores were derived based upon responses to the EPIC-26. Data were evaluated using minimal clinically important difference (MCID) thresholds to compare QOL at 1-2 months and 24 months from baseline. Univariate analysis was used to assess the correlation between early and late MCID changes. Results: On univariate analysis, early ≥1 MCID change from baseline was strongly associated with a late ≥1 MCID across all 5 domains (urinary incontinence, urinary irritation/obstruction, bowel, sexual, and vitality/hormonal) within EPIC-CP and for the overall EPIC-CP score (Table). When MCID was instead defined as 1 or 3, early toxicity remained predictive of late toxicity for all domains and the overall EPIC-CP score. Conclusions: The EPIC-CP is an easy-to-use QOL assessment with clinically relevant outcomes. Early QOL decline was strongly associated with late QOL decline in patients undergoing definitive RT for prostate cancer across all EPIC-CP domains. Patients with early QOL decline may be candidates for early QOL-based interventions to alleviate their late toxicity burden from treatment. [Table: see text]
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Affiliation(s)
- Jacob Samuel Parzen
- Beaumont Health, Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Thomas J Quinn
- Beaumont Health, Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Andrew B Thompson
- Beaumont Health, Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Peter Chang
- Beth Israel Deaconess Medical Center, Boston, MA
| | - Sean P. Collins
- Department of Radiation Medicine, Georgetown University, Washington, DC
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University, Washington, DC
| | - Jeff M. Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | | | - Zachary Seymour
- Beaumont Health, Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, Dearborn, MI
| | - Daniel A. Hamstra
- Beaumont Health, Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, Dearborn, MI
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van Dams R, Jiang NY, Fuller DB, Loblaw A, Jiang T, Katz AJ, Collins SP, Aghdam N, Suy S, Stephans KL, Yuan Y, Nickols NG, Murthy V, Telkhade TP, Kupelian PA, Steinberg ML, Romero T, Kishan AU. Stereotactic Body Radiotherapy for High-Risk Localized Carcinoma of the Prostate (SHARP) Consortium: Analysis of 344 Prospectively Treated Patients. Int J Radiat Oncol Biol Phys 2021; 110:731-737. [PMID: 33493615 DOI: 10.1016/j.ijrobp.2021.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/06/2021] [Accepted: 01/10/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To explore the efficacy and toxicity of stereotactic body radiation therapy (SBRT) in high-risk prostate cancer (HRPCa) in a consortium of 7 institutional phase 2 trials and prospective registries. METHODS AND MATERIALS Individual patient data were pooled for 344 patients with a minimum follow-up of 24 months. Biochemical recurrence-free survival (BCRFS) and distant metastasis-free survival (DMFS) were estimated using a Kaplan-Meier framework. Fine and Gray competing risk and Cox proportional hazards regression models were developed to assess the association between time to BCR and time to distant metastasis and prespecified variables of interest. Logistic regression models were developed to evaluate associations between acute and late grade ≥2 genitourinary and gastrointestinal and the following a priori-specified variables: age, dose per fraction, ADT use, and nodal radiation therapy. RESULTS Median follow-up was 49.5 months. Seventy-two percent of patients received ADT, with a median duration of 9 months, and 19% received elective nodal radiation therapy. Estimated 4-year BCRFS and DMFS rates were 81.7% (95% CI, 77.2%-86.5%) and 89.1% (95% CI, 85.3%-93.1%). The crude incidences of late grade ≥3 genitourinary and gastrointestinal toxicity were 2.3% and 0.9%. CONCLUSIONS These data support a favorable toxicity and efficacy profile for SBRT for HRPCa. Further prospective studies are needed to evaluate the optimal dose and target volume in the context of SBRT for HRPCa.
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Affiliation(s)
- Ritchell van Dams
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Naomi Y Jiang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | | | - Andrew Loblaw
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Tommy Jiang
- University of California, Los Angeles, Los Angeles, California
| | - Alan J Katz
- FROS Radiation Oncology and CyberKnife Center, Flushing, New York
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - Nima Aghdam
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - Kevin L Stephans
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ye Yuan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | | | - Patrick A Kupelian
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Tahmineh Romero
- University of California, Los Angeles, Los Angeles, California
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California.
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Carrasquilla M, Creswell ML, Pepin AN, Wang E, Forsthoefel M, McGunigal M, Bullock E, Lei S, Collins BT, Lischalk JW, Esposito G, Aghdam N, Kumar D, Suy S, Leger P, Hankins RA, Dawson NA, Collins SP. Rationale for Involved Field Stereotactic Body Radiation Therapy-Enhanced Intermittent Androgen Deprivation Therapy in Hormone-Sensitive Nodal Oligo-Recurrent Prostate Cancer Following Prostate Stereotactic Body Radiation Therapy. Front Oncol 2021; 10:606260. [PMID: 33537236 PMCID: PMC7848164 DOI: 10.3389/fonc.2020.606260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/25/2020] [Indexed: 12/31/2022] Open
Abstract
Lymph node recurrent prostate cancer is a common clinical scenario that is likely to increase significantly with the widespread adoption of novel positron emission tomography (PET) agents. Despite increasing evidence that localized therapy is disease modifying, most men with lymph node recurrent prostate cancer receive only systemic therapy with androgen deprivation therapy (ADT). For men who receive localized therapy the intent is often to delay receipt of systemic therapy. Little evidence exists on the optimal combination of local and systemic therapy in this patient population. In this hypothesis generating review, we will outline the rationale and propose a framework for combining involved field SBRT with risk adapted intermittent ADT for hormone sensitive nodal recurrent prostate cancer. In patients with a limited number of nodal metastases, involved field stereotactic body radiation therapy (SBRT) may have a role in eliminating castrate-resistant clones and possibly prolonging the response to intermittent ADT. We hypothesize that in a small percentage of patients, such a treatment approach may lead to long term remission or cure.
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Affiliation(s)
- Michael Carrasquilla
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | | | - Abigail N. Pepin
- George Washington University School of Medicine, Washington, DC, United States
| | - Edina Wang
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Matthew Forsthoefel
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Mary McGunigal
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Elizabeth Bullock
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Brian T. Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Jonathan W. Lischalk
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Giuseppe Esposito
- Department of Nuclear Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Nima Aghdam
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Deepak Kumar
- Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Paul Leger
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Ryan A. Hankins
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Nancy A. Dawson
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Sean P. Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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Conroy D, Becht K, Forsthoefel M, Pepin AN, Lei S, Rashid A, Collins BT, Lischalk JW, Suy S, Aghdam N, Hankins RA, Collins SP. Utilization of Iodinated SpaceOAR Vue™ During Robotic Prostate Stereotactic Body Radiation Therapy (SBRT) to Identify the Rectal-Prostate Interface and Spare the Rectum: A Case Report. Front Oncol 2021; 10:607698. [PMID: 33489918 PMCID: PMC7817609 DOI: 10.3389/fonc.2020.607698] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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] [Received: 10/05/2020] [Accepted: 11/23/2020] [Indexed: 11/28/2022] Open
Abstract
We describe the utilization of SpaceOAR Vue™, a new iodinated rectal spacer, during Robotic Stereotactic Body Radiation Therapy (SBRT) for a Prostate Cancer Patient with a contraindication to Magnetic Resonance Imaging. A 69-year-old Caucasian male presented with unfavorable intermediate risk prostate cancer and elected to undergo SBRT. His medical history was significant for atrial fibrillation on Rivaroxaban with a pacemaker. He was felt to be at increased risk of radiation proctitis following SBRT due to the inability to accurately contour the anterior rectal wall at the prostate apex without a treatment planning MRI and an increased risk of late rectal bleeding due to prescribed anticoagulants. In this case report, we discuss the technical aspects of appropriate placement and treatment planning for utilizing SpaceOAR Vue™ with Robotic SBRT.
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Affiliation(s)
- Dylan Conroy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Kelly Becht
- Georgetown University School of Medicine, Washington, DC, United States
| | - Matthew Forsthoefel
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Abigail N Pepin
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Abdul Rashid
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Brian Timothy Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Jonathan W Lischalk
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Nima Aghdam
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Ryan Andrew Hankins
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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Aghdam N, Repka MC, McGunigal M, Pepin A, Paydar I, Rudra S, Paudel N, Pernia Marin M, Suy S, Collins SP, Barnes W, Collins BT. Stereotactic Body Radiation Therapy: A Versatile, Well-Tolerated, and Effective Treatment Option for Extracranial Metastases From Primary Ovarian and Uterine Cancer. Front Oncol 2020; 10:572564. [PMID: 33425723 PMCID: PMC7793788 DOI: 10.3389/fonc.2020.572564] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 09/23/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Single extracranial metastases from ovarian and uterine malignancies have historically been treated with surgery or conventional radiation. We report mature local control (LC), overall survival (OS), progression free survival (PFS), and toxicity for patients who completed 5-fraction stereotactic body radiation therapy (SBRT). Methods Patients with biopsy-proven, single extracranial metastases from primary ovarian and uterine malignancies treated with 5-fraction SBRT were included. Patients were stratified based on tumor volume (small < 50 cc or large ≥ 50 cc) and dose (low dose < 35 Gy or high ≥ 35 Gy). Kaplan–Meier method was used to estimate LC, OS, and PFS. Results Between July 2007 and July 2012, 20 patients underwent SBRT to a single extracranial metastasis. Primary site was divided evenly between ovarian and uterine (n = 10 each). Metastases involved the liver (30%), abdominal lymph nodes (25%), lung (20%), pelvic lymph nodes (10%), spine (10%), and extremity (5%). The median gross tumor volume (GTV) was 42.5 cc (range, 5–273 cc) and the median dose to the GTV was 35 Gy (range, 30–50 Gy). At a median follow-up of 56 months, the 5-year LC and OS estimates were 73 and 46%. When stratified by tumor volume, the 5-year LC and OS for small tumors were significantly better at 100% (p < 0.01) and 65% (p < 0.02). When stratified by dose, the 5-year LC was 87.5% with high dose and 53.6% with low dose (p = 0.035). The 5-year PFS for the entire cohort was 20%. Four patients with small metastases who had complete response remained disease free at study completion and were considered cured (median PFS > 10 years). Treatment was generally well tolerated, and only one patient experienced a late grade III musculoskeletal SBRT related toxicity. Conclusions SBRT is a versatile, well-tolerated, and effective treatment option for single extracranial metastases from ovarian and uterine primary tumors. 35 Gy in five fractions appears to be a practical minimum effective dose. Four patients with small metastases were disease free at the study completion and considered cured. However, patients with larger metastases (≥50 cc) may require higher SBRT dosing or alternative treatments.
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Affiliation(s)
- Nima Aghdam
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States.,Department of Radiation Oncology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Michael C Repka
- Department of Radiation Oncology, New York University Winthrop Hospital, Mineola, NY, United States
| | - Mary McGunigal
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Abby Pepin
- School of Medicine and Health Sciences, George Washington University, Washington, DC, United States
| | - Ima Paydar
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, United States
| | - Sonali Rudra
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Nitika Paudel
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Monica Pernia Marin
- Geriatric and Palliative Medicine Division, George Washington University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Willard Barnes
- Division of Gynecologic Oncology, Georgetown University Hospital, Washington, DC, United States
| | - Brian T Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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Seymour Z, Hamstra D, Daignault-Newton S, Thompson A, Sanda M, Michalski J, Zietman A, Kuban D, Ciezki J, Kaplan I, Collins S, Suy S, Mantz C, Chang P, Chen R, Fuller D. External Validation of Early Quality of Life (QOL) Declines Correlated with Late QOL after Intensity Modulated, Low Dose Rate Brachytherapy, or Stereotactic Radiation for Prostate Cancer within a Prospective Trial. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.2208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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van Dams R, Jiang N, King C, Fuller D, Loblaw D, Jiang T, Romero T, Katz A, Collins S, Aghdam N, Suy S, Stephans K, Kaplan I, Yuan Y, Nickols N, Murthy V, Telkhade T, Kupelian P, Steinberg M, Kishan A. Stereotactic Body Radiotherapy for High-Risk Localized Carcinoma of the Prostate (SHARP) Consortium: Analysis of 323 Prospectively Treated Patients. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Aghdam N, Pepin AN, Creswell M, Hsieh K, Smith C, Drescher N, Danner M, Ayoob M, Yung T, Lei S, Kumar D, Collins BT, Lischalk JW, Krishnan P, Suy S, Lynch J, Bandi G, Hankins RA, Collins SP. Management of Isolated Local Failures Following Stereotactic Body Radiation Therapy for Low to Intermediate Risk Prostate Cancer. Front Oncol 2020; 10:551491. [PMID: 33251131 PMCID: PMC7673419 DOI: 10.3389/fonc.2020.551491] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/31/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Stereotactic body radiation therapy (SBRT) is a safe and effective treatment option for patients with low to intermediate risk prostate cancer (1). SBRT results in very low PSA nadirs secondary to the delivery of high biologically effective doses. Studies reporting on the diagnosis, confirmation, and management of salvageable isolated local failures (ILF) are limited. This study aims to determine the incidence and management approach of ILF after SBRT in a large single institution cohort. Method: All patients with low or intermediate risk localized prostate cancer treated with SBRT at Georgetown University Hospital were eligible for this study. Treatment was delivered using robotic SBRT with doses of 35-36.25 Gy in five fractions. ILF were diagnosed using multiparametric MRI and/or biopsy prompted by rising PSA levels after achieving long-term nadir. Patient's characteristics were extracted from a prospective institutional quality of life trial (IRB 2009-510). Type of salvage therapy and post-salvage PSA were determined on subsequent follow-up and chart review. Results: Between December 2008 to August 2018, 998 men with low to intermediate risk prostate cancer were eligible for inclusion in this analysis. Twenty-four patients (low risk, n = 5; intermediate risk, n = 19) were found to have ILF within the prostate on either MRI (n = 19) and/or biopsy (n = 20). Median pre-treatment PSA was 7.55 ng/ml. Median time to diagnosis of ILF was 72 months (24-110 months) with median PSA at the time of ILF of 2.8 ng/ml (0.7-33 ng/ml). Median PSA doubling time was 17 months (5-47 months). Thirteen patients with biopsy proven ILF proceeded with salvage therapy (cryotherapy n = 12, HIFU n = 1). Of 12 patients who underwent cryotherapy, 7 had a post-treatment PSA of <0.1 ng/ml. One patient experienced a urethral-cutaneous fistula (grade 3 toxicity). Conclusion: The incidence of isolated local recurrence is rare in our cohort. Diagnosis and management of isolated local failures post-SBRT continues to evolve. Our report highlights the importance of early utilization of MRI and confirmatory biopsy at relatively low PSA levels and long PSA doubling time (1). Additionally, undetectable PSA levels after salvage therapy supports the role of early treatment in ILF (1). Further research is needed to determine appropriate patient selection and salvage modality in this population.
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Affiliation(s)
- Nima Aghdam
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Abigail N. Pepin
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
- George Washington School of Medicine and Health Sciences, Washington, DC, United States
| | - Michael Creswell
- Georgetown University School of Medicine, Washington, DC, United States
| | - Kristin Hsieh
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
- Columbia University Valegos College of Physicians and Surgeons, New York, NY, United States
| | - Clayton Smith
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Nicolette Drescher
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
- Geisinger Commonwealth School of Medicine, Scranton, PA, United States
| | - Malika Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Deepak Kumar
- Julius L. Chambers Biomedical/Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Brian Timothy Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Jonathan W. Lischalk
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Pranay Krishnan
- Department of Radiology, Georgetown University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - John Lynch
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Guarav Bandi
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Ryan Andrew Hankins
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Sean P. Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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Levin-Epstein RG, Jiang NY, Wang X, Upadhyaya SK, Collins SP, Suy S, Aghdam N, Mantz C, Katz AJ, Miszczyk L, Napieralska A, Namysl-Kaletka A, Prionas N, Bagshaw H, Buyyounouski MK, Cao M, Agazaryan N, Dang A, Yuan Y, Kupelian PA, Zaorsky NG, Spratt DE, Mohamad O, Feng FY, Mahal BA, Boutros PC, Kishan AU, Juarez J, Shabsovich D, Jiang T, Kahlon S, Patel A, Patel J, Nickols NG, Steinberg ML, Fuller DB, Kishan AU. Dose-response with stereotactic body radiotherapy for prostate cancer: A multi-institutional analysis of prostate-specific antigen kinetics and biochemical control. Radiother Oncol 2020; 154:207-213. [PMID: 33035622 DOI: 10.1016/j.radonc.2020.09.053] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/22/2020] [Accepted: 09/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE The optimal dose for prostate stereotactic body radiotherapy (SBRT) is still unknown. This study evaluated the dose-response relationships for prostate-specific antigen (PSA) decay and biochemical recurrence (BCR) among 4 SBRT dose regimens. MATERIALS AND METHODS In 1908 men with low-risk (50.0%), favorable intermediate-risk (30.9%), and unfavorable intermediate-risk (19.1%) prostate cancer treated with prostate SBRT across 8 institutions from 2003 to 2018, we examined 4 regimens (35 Gy/5 fractions [35/5, n = 265, 13.4%], 36.25 Gy/5 fractions [36.25/5, n = 711, 37.3%], 40 Gy/5 fractions [40/5, n = 684, 35.8%], and 38 Gy/4 fractions [38/4, n = 257, 13.5%]). Between dose groups, we compared PSA decay slope, nadir PSA (nPSA), achievement of nPSA ≤0.2 and ≤0.5 ng/mL, and BCR-free survival (BCRFS). RESULTS Median follow-up was 72.3 months. Median nPSA was 0.01 ng/mL for 38/4, and 0.17-0.20 ng/mL for 5-fraction regimens (p < 0.0001). The 38/4 cohort demonstrated the steepest PSA decay slope and greater odds of nPSA ≤0.2 ng/mL (both p < 0.0001 vs. all other regimens). BCR occurred in 6.25%, 6.75%, 3.95%, and 8.95% of men treated with 35/5, 36.25/5, 40/5, and 38/4, respectively (p = 0.12), with the highest BCRFS after 40/5 (vs. 35/5 hazard ratio [HR] 0.49, p = 0.026; vs. 36.25/5 HR 0.42, p = 0.0005; vs. 38/4 HR 0.55, p = 0.037) including the entirety of follow-up, but not for 5-year BCRFS (≥93% for all regimens, p ≥ 0.21). CONCLUSION Dose-escalation was associated with greater prostate ablation and PSA decay. Dose-escalation to 40/5, but not beyond, was associated with improved BCRFS. Biochemical control remains excellent, and prospective studies will provide clarity on the benefit of dose-escalation.
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Affiliation(s)
| | - Naomi Y Jiang
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Xiaoyan Wang
- UCLA Division of General Internal Medicine and Health Services Research, USA
| | - Shrinivasa K Upadhyaya
- Department of Biological and Agricultural Engineering, University of California, Davis, USA
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, USA
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, USA
| | - Nima Aghdam
- Department of Radiation Medicine, Georgetown University Hospital, USA
| | | | - Alan J Katz
- FROS Radiation Oncology and CyberKnife Center, Flushing, USA
| | - Leszek Miszczyk
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Poland
| | - Aleksandra Napieralska
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Poland
| | | | - Nicholas Prionas
- Department of Radiation Oncology, Stanford University Medical Center, USA
| | - Hilary Bagshaw
- Department of Radiation Oncology, Stanford University Medical Center, USA
| | | | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Nzhde Agazaryan
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Audrey Dang
- Department of Radiation Oncology, Tulane Medical Center, New Orleans, USA
| | - Ye Yuan
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Patrick A Kupelian
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, USA
| | - Osama Mohamad
- Department of Radiation Oncology, University of California San Francisco, USA
| | - Felix Y Feng
- Department of Radiation Oncology, University of California San Francisco, USA
| | | | - Paul C Boutros
- Department of Human Genetics, University of California, Los Angeles, USA; Department of Urology, University of California, Los Angeles, USA
| | - Arun U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Jesus Juarez
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - David Shabsovich
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Tommy Jiang
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Sartajdeep Kahlon
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Ankur Patel
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Jay Patel
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California, Los Angeles, USA; Department of Radiation Oncology, West Los Angeles Veterans Health Administration, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, USA
| | | | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, USA; Department of Urology, University of California, Los Angeles, USA.
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Levin-Epstein R, Cook RR, Wong JK, Stock RG, Jeffrey Demanes D, Collins SP, Aghdam N, Suy S, Mantz C, Katz AJ, Nickols NG, Miszczyk L, Napieralska A, Namysl-Kaletka A, Prionas ND, Bagshaw H, Buyyounouski MK, Cao M, Mahal BA, Shabsovich D, Dang A, Yuan Y, Rettig MB, Chang AJ, Jackson WC, Spratt DE, Lehrer EJ, Zaorsky NG, Kupelian PA, Steinberg ML, Horwitz EM, Jiang NY, Kishan AU. Prostate-specific antigen kinetics and biochemical control following stereotactic body radiation therapy, high dose rate brachytherapy, and low dose rate brachytherapy: A multi-institutional analysis of 3502 patients. Radiother Oncol 2020; 151:26-32. [PMID: 32663537 DOI: 10.1016/j.radonc.2020.07.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/02/2020] [Accepted: 07/06/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE Stereotactic body radiation therapy (SBRT), low dose rate brachytherapy (LDR-BT) and high dose rate brachytherapy (HDR-BT) are ablative-intent radiotherapy options for prostate cancer (PCa). These vary considerably in dose delivery, which may impact post-treatment prostate-specific antigen (PSA) patterns and biochemical control. We compared PSA kinetics between SBRT, HDR-BT, and LDR-BT, and assessed their relationships to biochemical recurrence-free survival (BCRFS). METHODS AND MATERIALS Retrospective PSA data were analyzed for 3502 men with low-risk (n = 2223; 63.5%), favorable intermediate-risk (n = 869; 24.8%), and unfavorable intermediate-risk (n = 410; 11.7%) PCa treated with SBRT (n = 1716; 49.0%), HDR-BT (n = 512; 14.6%), or LDR-BT (n = 1274; 36.4%) without upfront androgen deprivation therapy at 10 institutions from 1990 to 2017. We compared nadir PSA (nPSA), time to nPSA, achievement of nPSA <0.2 ng/mL and <0.5 ng/mL, rates of nPSA <0.4 ng/mL at 4 years, and BCRFS. RESULTS Median follow-up was 72 months. Median nPSA and nPSA <0.2 ng/mL were stratified by risk group (interaction p ≤ 0.001). Median nPSA and time to nPSA were 0.2 ng/mL at 44 months after SBRT, 0.1-0.2 ng/mL at 37 months after HDR-BT, and 0.01-0.2 ng/mL at 51 months after LDR-BT (mean log nPSA p ≤ 0.009 for LDR-BT vs. SBRT or HDR-BT for low/favorable intermediate-risk). There were no differences in nPSA <0.4 ng/mL at 4 years (p ≥ 0.51). BCRFS was similar for all three modalities (p ≥ 0.27). Continued PSA decay beyond 4 years was predictive of durable biochemical control. CONCLUSION LDR-BT led to lower nPSAs with longer continued decay compared to SBRT and HDR-BT, but no differences in BCRFS.
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Affiliation(s)
- Rebecca Levin-Epstein
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Ryan R Cook
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - J Karen Wong
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, United States
| | - Richard G Stock
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, United States
| | - D Jeffrey Demanes
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States; California Endocurietherapy Cancer Center, Oakland, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, United States
| | - Nima Aghdam
- Department of Radiation Medicine, Georgetown University Hospital, Washington, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, United States
| | | | - Alan J Katz
- FROS Radiation Oncology and Cyberknife Center, Flushing, United States
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States; Department of Radiation Oncology, West Los Angeles Veterans Health Administration, Los Angeles, United States
| | - Leszek Miszczyk
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Aleksandra Napieralska
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Agnieszka Namysl-Kaletka
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Nicholas D Prionas
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, United States
| | - Hilary Bagshaw
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, United States
| | - Mark K Buyyounouski
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, United States
| | - Minsong Cao
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Brandon A Mahal
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, United States
| | - David Shabsovich
- David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Audrey Dang
- Department of Radiation Oncology, Tulane Medical Center, New Orleans, United States
| | - Ye Yuan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Matthew B Rettig
- Department of Medical Oncology, University of California Los Angeles, Los Angeles, United States; Department of Medical Oncology, West Los Angeles Veterans Health Administration, Los Angeles, United States
| | - Albert J Chang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, United States
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, United States
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, United States
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, United States
| | - Patrick A Kupelian
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, United States
| | - Naomi Y Jiang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, United States.
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Aghdam N, Pepin A, Buchberger D, Hirshberg J, Lei S, Ayoob M, Danner M, Yung T, Kumar D, Collins BT, Lynch J, Kataria S, Suy S, Collins SP. Stereotactic Body Radiation Therapy (SBRT) for Prostate Cancer in Men With a High Baseline International Prostate Symptom Score (IPSS ≥ 15). Front Oncol 2020; 10:1060. [PMID: 32719744 PMCID: PMC7350884 DOI: 10.3389/fonc.2020.01060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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] [Received: 02/16/2020] [Accepted: 05/28/2020] [Indexed: 01/25/2023] Open
Abstract
Background: Patients with a high pretreatment IPSS may have higher rates of late urinary morbidity after radiation therapy for prostate cancer (1). Stereotactic body radiation therapy (SBRT) delivers fewer high-dose fractions of radiation, which may be radiobiologically favorable to the conventional low-dose external beam fractions. The urinary toxicity associated with SBRT, however, remains unclear in patients with a high IPSS (1). We report our experience using SBRT for localized prostate cancer in patients with pretreatment IPSS ≥ 15. Methods: Localized prostate cancer patients with a pre-treatment IPSS ≥ 15 treated with SBRT at Georgetown University Hospital from 2009 to 2016 were included in this retrospective review of prospectively collected data. These patients were treated to 35–36.25 Gy in five fractions delivered via CyberKnife (Accuray Inc., Sunnyvale, CA). Urinary toxicity was assessed using the Common Terminology Criteria for Adverse Events version 4.0 (CTCAE v4). Urinary quality of life was assessed using validated questionnaires (IPSS and EPIC-26). Results: 53 patients at a median age of 71 years (range 57–89 years) received SBRT with a minimum follow up of 3 years. The median prostate size was 37 cm3 (range 12–100 cm3) and 30.2% patients received ADT. The 3-years incidence rate of Grade 3 urinary toxicity was 7.5% with median time to toxicity of 2.9 years. There were no Grade 4 or 5 toxicities. A mean baseline IPSS score of 19.8 significantly decreased to 12.9 at 3 months post-SBRT (p = 0.002) and remained stable at 36 months (13.7). A mean baseline EPIC-26 obstructive/irritative score of 64.1 significantly improved to 80.2 at 3 months (p = 0.002). This improvement was maintained to 36 months. There was no significant change from the mean baseline EPIC-26 urinary incontinence score at any point during follow up. Conclusions: SBRT for clinically localized prostate cancer was well-tolerated in men with baseline IPSS ≥ 15 (1). Grade 3 toxicities occurred but resolved with time. Our data suggest that poor baseline urinary function does not worsen following SBRT and may even improve. High baseline IPSS score should not be considered a contraindication to SBRT.
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Affiliation(s)
- Nima Aghdam
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Abigail Pepin
- George Washington University, School of Medicine and Health Sciences, Washington, DC, United States
| | - David Buchberger
- University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Jason Hirshberg
- Arizona College of Osteopathic Medicine, Glendale, AZ, United States
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Deepak Kumar
- Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Brian T Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - John Lynch
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Shaan Kataria
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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39
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Pepin A, Aghdam N, Shah S, Kataria S, Tsou H, Datta S, Danner M, Ayoob M, Yung T, Lei S, Gurka M, Collins BT, Krishnan P, Suy S, Hankins R, Lynch JH, Collins SP. Urinary Morbidity in Men Treated With Stereotactic Body Radiation Therapy (SBRT) for Localized Prostate Cancer Following Transurethral Resection of the Prostate (TURP). Front Oncol 2020; 10:555. [PMID: 32432033 PMCID: PMC7214538 DOI: 10.3389/fonc.2020.00555] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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] [Received: 01/30/2020] [Accepted: 03/27/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Clinical data suggest that stereotactic body radiation therapy (SBRT) provides similar clinical outcomes as other radiation modalities for prostate cancer. However, data reporting on the safety of SBRT after TURP is limited. Herein, we report our experience using SBRT to deliver hypofractionated radiotherapy in patients with a history of TURP including physician-reported toxicities and patient-reported quality of life. Methods: Forty-seven patients treated with SBRT from 2007 to 2016 at Georgetown University Hospital for localized prostate carcinoma with a history of prior TURP were included in this retrospective analysis. Treatment was delivered using the CyberKnife® (Accuray Incorporated, Sunnyvale, CA) with doses of 35 Gy or 36.25 Gy in 5 fractions without prostatic urethral sparing. Toxicities were recorded and scored using the CTCAE v.4. Cystoscopy findings were retrospectively reviewed. Urinary quality of life data was assessed using the International Prostate Symptom Scoring (IPSS) and Expanded Prostate Cancer Index Composite 26 (EPIC-26). A Wilcoxon signed-rank sum test was used to determine if there was a statistically significant increase or decrease in IPSS or EPIC scores between timepoints. Minimally important differences were calculated by obtaining half the standard deviation at time of start of treatment. Results: Forty-seven patients at a median age of 72 years (range 63–84) received SBRT. The mean follow-up was 4.7 years (range 2–10 years). Late Grade 2 and grade 3 urinary toxicity occurred in 23 (48.9%) and 3 (6.4%) men, respectively. There were no Grade 4 or 5 toxicities. Approximately 51% of patients experienced hematuria following treatment. Mean time to hematuria was 10.5 months. Twenty-five cystoscopies were performed during follow-up and the most common finding was hyperemia, varices of the bladder neck/TURP defect, and/or necrotic tissue in the TURP defect. Baseline urinary QOL composite scores were low, but they did not clinically significantly decline in the first 2 years following treatment. Conclusions: In patients with prior TURP, prostate SBRT was well-tolerated. GU toxicity rates were comparable to similar patients treated with conventionally fractionated radiation therapy. Urinary quality of life was poor at baseline, but did not worsen clinically over time. Stricter dosimetric criteria could potentially improve the rate of high-grade late toxicity, but may increase the risk of peri-urethral recurrence.
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Affiliation(s)
- Abigail Pepin
- School of Medicine and Health Sciences, George Washington University, Washington, DC, United States
| | - Nima Aghdam
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Sarthak Shah
- Columbian College of Arts and Sciences, George Washington University, Washington, DC, United States
| | - Shaan Kataria
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Harry Tsou
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Subhradeep Datta
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Marie Gurka
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Brian T Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Pranay Krishnan
- Department of Radiology, Georgetown University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Ryan Hankins
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - John H Lynch
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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40
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Nalbantoglu S, Abu-Asab M, Suy S, Collins S, Amri H. Metabolomics-Based Biosignatures of Prostate Cancer in Patients Following Radiotherapy. OMICS 2020; 23:214-223. [PMID: 31009330 DOI: 10.1089/omi.2019.0006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Metabolomics offers new promise for research on prostate cancer (PCa) and its personalized treatment. Metabolomic profiling of radiation-treated PCa patients is particularly important to reveal their new metabolomic status, and evaluate the radiation effects. In addition, bioinformatics-integrated metabolomics-based approaches for disease profiling and assessment of therapy could help develop precision biomarkers in a context of PCa. We report mass spectrometry-based untargeted (global) serum metabolomics findings from patients with PCa (n = 55) before and after treatment with stereotactic body radiation therapy (SBRT), and intensity-modulated radiation therapy (IMRT) with SBRT, and using parsimony phylogenetic analysis. Importantly, the radiation-treated serum metabolome of patients represented a unique robust cluster on a cladogram that was distinct from the pre-RT metabolome. The altered radiation responsive serum metabolome was defined by predominant aberrations in the metabolic pathways of nitrogen, pyrimidine, purine, porphyrin, alanine, aspartate, glutamate, and glycerophospholipid. Our findings collectively suggest that global metabolomics integrated with parsimony phylogenetics offer a unique and robust systems biology analytical platform for powerful unbiased determination of radiotherapy (RT)-associated biosignatures in patients with PCa. These new observations call for future translational research for evaluation of metabolomic biomarkers in PCa prognosis specifically, and response to radiation treatment broadly. Radiation metabolomics is an emerging specialty of systems sciences and clinical medicine that warrants further research and educational initiatives.
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Affiliation(s)
- Sinem Nalbantoglu
- 1 Department of Biochemistry, Cellular and Molecular Biology, School of Medicine, Georgetown University, Washington, District of Columbia.,2 TUBITAK Marmara Research Center, Institute of Gene Engineering and Biotechnology, Molecular Oncology Laboratory, Gebze, Kocaeli, Turkey
| | - Mones Abu-Asab
- 3 Section of Ultrastructural Biology, NEI/NIH, Bethesda, Maryland
| | - Simeng Suy
- 4 Department of Radiation Oncology, School of Medicine, Georgetown University, Washington, District of Columbia
| | - Sean Collins
- 4 Department of Radiation Oncology, School of Medicine, Georgetown University, Washington, District of Columbia
| | - Hakima Amri
- 1 Department of Biochemistry, Cellular and Molecular Biology, School of Medicine, Georgetown University, Washington, District of Columbia
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41
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Aghdam N, Pepin A, Carrasquilla M, Johnson C, Danner M, Ayoob M, Yung T, Lei S, Collins BT, Kumar D, Suy S, Lynch J, Collins SP. Self-Reported Burden in Elderly Patients With Localized Prostate Cancer Treated With Stereotactic Body Radiation Therapy (SBRT). Front Oncol 2020; 9:1528. [PMID: 32039015 PMCID: PMC6987387 DOI: 10.3389/fonc.2019.01528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/18/2019] [Indexed: 11/25/2022] Open
Abstract
Purpose: Retaining quality of life in patients treated with SBRT for prostate cancer remains paramount. As such, balancing the benefits of treatment against the effects of therapy on elderly patients is essential. The EORTC QLQ-ELD14 (ELD-14) is a validated questionnaire with a domain dedicated to burden of illness and treatment in the elderly. The Expanded Prostate Cancer Index Composite (EPIC)-26 is a validated questionnaire which measures urinary, bowel, sexual, and hormonal symptoms. This study reports trends in self-reported burden in patients with prostate cancer treated with SBRT and reveals convergence of self-reported burden with treatment related side effects obtained from the EPIC-26 questionnaire. Methods: All patients ≥70 years old, with localized prostate cancer treated with SBRT ± ADT at Medstar Georgetown University Hospital from 2013 to 2018 and had completed the ELD-14 were eligible for inclusion in this cross-sectional cohort study. Percentage of responses to questions related to disease and treatment burden were counted for each category (“not at all” and “a little” vs. “quite a bit” and “very much”). Additional demographic features were derived from available medical records. A total of 111 patients (median age of 74) responded to the ELD-14 questionnaire at onset of treatment and at the 2-year mark. Responses to EPIC questionnaires at matched follow-ups were scored and correlated with the self-reported burden domain of the ELD-14 using the Spearman correlation coefficient. Results: Number of patients reporting “quite a bit” or “very much” burden from prostate cancer was 6.3% prior to treatment. This was highest at 1-month (10.8%) and decreased to 9.0% at 24 months post-SBRT (X2 = 3.836, p = 0.6986). By comparison, 3.6 and 5.4% reported “quite a bit” or “very much” burden from treatment at start of treatment and 24 months, respectively (X2 = 1.046, p = 0.9838). Patient reported treatment burden was found to converge well with individual domains of EPIC-26. Patients undergoing ADT experienced more burden than their non-ADT counterparts. Conclusions: This cross-sectional study suggests a minority of patients reported high burden from their clinically localized prostate cancer or from their SBRT treatment. Self-reported burden converged well with lower EPIC scores in multiple domains.
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Affiliation(s)
- Nima Aghdam
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Abigail Pepin
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States.,George Washington School of Medicine and Health Sciences, Washington, DC, United States
| | - Michael Carrasquilla
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Colin Johnson
- Department of Surgery, University of Southampton, Southampton, United Kingdom
| | - Malika Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Brian T Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Deepak Kumar
- Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - John Lynch
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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Wang E, Aziz A, Danner M, Yung T, Ayoob M, Lei S, Rashid A, Dritschilo A, Lischalk J, Collins B, Lynch J, Suy S, Aghdam N, Collins S. Patterns of Recurrence Following Stereotactic Body Radiation Therapy for Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1782] [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: 10/26/2022]
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Forsthoefel M, Burlile J, Lane S, Tsou H, Kataria S, Danner M, Yung T, Ayoob M, Lischalk J, Collins B, Suy S, Aghdam N, Collins S. Testosterone Recovery Following Short Course Androgen Deprivation Therapy and Stereotactic Body Radiotherapy Correlates Closely with Improvements in Patient-Reported Hormonal and Sexual Domain Scores. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1194] [Citation(s) in RCA: 1] [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] [Indexed: 11/26/2022]
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Cousins M, Aghdam N, Dess R, Suy S, Desai N, Spratt D, Collins S, Jackson W. Transient Declines in Serum Testosterone Levels Following Prostate SBRT Do Not Drive Post-treatment Declines in Health-Related Sexual Quality of Life. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1891] [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: 10/26/2022]
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Cagle P, Niture S, Srivastava A, Ramalinga M, Aqeel R, Rios-Colon L, Chimeh U, Suy S, Collins SP, Dahiya R, Kumar D. MicroRNA-214 targets PTK6 to inhibit tumorigenic potential and increase drug sensitivity of prostate cancer cells. Sci Rep 2019; 9:9776. [PMID: 31278310 PMCID: PMC6611815 DOI: 10.1038/s41598-019-46170-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 06/14/2019] [Indexed: 01/06/2023] Open
Abstract
Prostate cancer is the most commonly diagnosed cancer in men with African American men disproportionally suffering from the burden of this disease. Biomarkers that could discriminate indolent from aggressive and drug resistance disease are lacking. MicroRNAs are small non-coding RNAs that affect numerous physiological and pathological processes, including cancer development and have been suggested as biomarkers and therapeutic targets. In the present study, we investigated the role of miR-214 on prostate cancer cell survival/migration/invasion, cell cycle regulation, and apoptosis. miR-214 was differentially expressed between Caucasian and African American prostate cancer cells. Importantly, miR-214 overexpression in prostate cancer cells induced apoptosis, inhibiting cell proliferation and colony forming ability. miR-214 expression in prostate cancer cells also inhibited cell migration and 3D spheroid invasion. Mechanistically, miR-214 inhibited prostate cancer cell proliferation by targeting protein tyrosine kinase 6 (PTK6). Restoration of PTK6 expression attenuated the inhibitory effect of miR-214 on cell proliferation. Moreover, simultaneous inhibition of PTK6 by ibrutinib and miR-214 significantly reduced cell proliferation/survival. Our data indicates that miR-214 could act as a tumor suppressor in prostate cancer and could potentially be utilized as a biomarker and therapeutic target.
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Affiliation(s)
- Patrice Cagle
- Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, 27707, United States
| | - Suryakant Niture
- Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, 27707, United States
| | - Anvesha Srivastava
- Cancer Research Laboratory, Division of Science and Mathematics, University of the District of Columbia, Washington, DC, 20008, United States
| | - Malathi Ramalinga
- Cancer Research Laboratory, Division of Science and Mathematics, University of the District of Columbia, Washington, DC, 20008, United States
| | - Rasha Aqeel
- Cancer Research Laboratory, Division of Science and Mathematics, University of the District of Columbia, Washington, DC, 20008, United States
| | - Leslimar Rios-Colon
- Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, 27707, United States
| | - Uchechukwu Chimeh
- Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, 27707, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University, Washington, DC, 20057, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University, Washington, DC, 20057, United States
| | - Rajvir Dahiya
- VA Medical Center and University of California San Francisco, San Francisco, CA, 94121, United States
| | - Deepak Kumar
- Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, 27707, United States. .,Cancer Research Laboratory, Division of Science and Mathematics, University of the District of Columbia, Washington, DC, 20008, United States. .,Department of Pharmaceutical Sciences, North Carolina Central University, Durham, NC, 27707, United States.
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Jiang NY, Dang AT, Yuan Y, Chu FI, Shabsovich D, King CR, Collins SP, Aghdam N, Suy S, Mantz CA, Miszczyk L, Napieralska A, Namysl-Kaletka A, Bagshaw H, Prionas N, Buyyounouski MK, Jackson WC, Spratt DE, Nickols NG, Steinberg ML, Kupelian PA, Kishan AU. Multi-Institutional Analysis of Prostate-Specific Antigen Kinetics After Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2019; 105:628-636. [PMID: 31276777 DOI: 10.1016/j.ijrobp.2019.06.2539] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/17/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Understanding prostate-specific antigen (PSA) kinetics after radiation therapy plays a large role in the management of patients with prostate cancer (PCa). This is particularly true in establishing expectations regarding PSA nadir (nPSA) and PSA bounces, which can be disconcerting. As increasingly more patients are being treated with stereotactic body radiation therapy (SBRT) for low- and intermediate-risk PCa, it is imperative to understand the PSA response to SBRT. METHODS AND MATERIALS PSA data from 5 institutions were retrospectively analyzed for patients with localized PCa treated definitively with SBRT alone from 2004 to 2016. Patients received 35 to 40 Gy in 5 fractions, per institutional standards. Patients who had less than 12 months of PSA data or received androgen deprivation therapy were excluded from this study. Linear and logistic multivariable analysis were performed to identify predictors of nPSA, bounce, and biochemical recurrence, and joint latent class models were developed to identify significant predictors of time to biochemical failure. RESULTS A total of 1062 patients were included in this study. Median follow-up was 66 months (interquartile range [IQR], 36.4-89.9 months). Biochemical failure per the Phoenix criteria occurred in 4% of patients. Median nPSA was 0.2 ng/mL, median time to nPSA was 40 months, 84% of patients had an nPSA ≤0.5 ng/mL, and 54% of patients had an nPSA ≤0.2 ng/mL. On multivariable analysis, nPSA was a significant predictor of biochemical failure. Benign PSA bounce was noted in 26% of patients. The median magnitude of PSA bounce was 0.52 ng/mL (IQR, 0.3-1.0 ng/mL). Median time to PSA bounce was 18.1 months (IQR, 12.0-31.1 months). On multivariable analysis, age and radiation dose were significantly associated with a lower incidence of bounce. Joint latent class models modeling found that nPSA and radiation dose were significantly associated with longer time to biochemical failure. CONCLUSIONS In this multi-institutional cohort of patients with long-term follow-up, we found that SBRT led to low nPSAs. In turn, lower nPSAs are associated with reduced incidence of, and longer time to, biochemical failure. Benign PSA bounces occurred in a quarter of patients, as late as several years after treatment. Further studies are needed to directly compare the PSA response of patients who receive SBRT versus other treatment modalities.
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Affiliation(s)
- Naomi Y Jiang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Audrey T Dang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Ye Yuan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Fang-I Chu
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - David Shabsovich
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Christopher R King
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - Nima Aghdam
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | | | - Leszek Miszczyk
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Aleksandra Napieralska
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Agnieszka Namysl-Kaletka
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Hilary Bagshaw
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Nicolas Prionas
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Mark K Buyyounouski
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Patrick A Kupelian
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California.
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Aghdam N, Kataria S, Pernia M, Hall C, O’Connor T, Campbell L, Suy S, Collins S, Krochmal R, Anderson E, Lischalk J, Collins B. PV-0206 Gross endobronchial disease: predictor of clinical outcomes for early stage NSCLC treated with SBRT. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)30626-7] [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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Aghdam N, Katarian S, Danner M, Ayoob M, Yung T, Lei S, Kumar D, Collins B, Lischalk J, Dritschilo A, Suy S, Lynch J, Collins S. PO-0852 Stereotactic Body Radiation Therapy for Unfavorable Prostate Cancer: Large institutional experience. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)31272-1] [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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49
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Drescher N, Aghdam N, Danner M, Ayoob M, Yung TM, Lei S, Collins BT, Lischalk J, Dritschilo A, Suy S, Kumar D, Lynch JJ, Collins SP. Management of isolated local failures following stereotactic body radiation therapy for low to intermediate risk prostate cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.66] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
66 Background: SBRT is a safe and effective treatment option for patients with low to intermediate risk prostate cancer (PCa). SBRT delivers high biologically effective doses resulting in very low PSA nadirs. Strategies to diagnose and confirm salvageable isolated local failures (ILF) are needed. This study aims to examine the incidence and approach to management of ILF after SBRT in a large single institution cohort. Methods: All patients with low or intermediate risk PCa treated with SBRT at our institution were eligible for this study. Treatment was delivered using the robotic SBRT with doses of 35-36.25 Gy in five fractions. ILF were diagnosed using mpMRI and/or biopsy prompted by PSA rise after achieving long-term nadir. Choice of salvage therapy and post-salvage PSA were ascertained on follow up. Results: Between December, 2008 to August, 2018, 998 men with low to intermediate risk prostate cancer were eligible for analysis. Twenty patients (low risk, n = 4; intermediate risk, n = 16) were found to have ILF on either MRI (n = 15) and/or biopsy (n = 17). Three patients with MRI-identified ILF elected active surveillance in lieu of biopsy. Median pre-treatment PSA was 7.5 ng/ml. Median time to diagnosis of ILF was 72 months (37-96 months) with median PSA at the time of ILF of 2.3 ng/ml (1.1-10 ng/ml). Median PSA doubling time was 17 months (5-22 months). Thirteen patients with biopsy proven ILF proceeded with salvage therapy (cryotherapy n = 12, HIFU n = 1). Of 12 patients who underwent cryotherapy, 8 had a post-treatment PSA of < 0.1ng/ml, two patient’s results were unavailable, one patient had a PSA nadir of 0.7 ng/ml and one patient had yet to undergo post-salvage PSA test at the time of this report. Conclusions: The incidence of ILF is rare in our series. Diagnosis and management of ILF post-SBRT continues to evolve in the era of successful salvage therapy. Our report suggests an important role for early utilization of MRI and confirmatory biopsy at relatively low PSA levels and long PSA doubling time. Additionally, undetectable PSA post-salvage therapy supports early treatment after identifying ILF. Larger trials are needed for refinement of patient selection and most appropriate salvage modality.
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Affiliation(s)
| | - Nima Aghdam
- Georgetown University Hospital, Washington, DC
| | | | | | | | - Siyuan Lei
- Georgetown University Hospital, Washington, DC
| | | | | | | | - Simeng Suy
- Georgetown University Hospital, Washington, DC
| | - Deepak Kumar
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI) North Carolina Central University, Durham, NC
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Jiang NY, King CR, Katz AJ, Collins SP, Aghdam N, Suy S, Stephans KL, Reddy CA, Kaplan ID, Appelbaum L, Dang A, Yuan Y, Nickols NG, Steinberg ML, Kupelian P, Kishan AU. Multi-institutional analysis of high-risk prostate cancer patients treated with stereotactic body radiotherapy. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
51 Background: Stereotactic Body Radiotherapy (SBRT) delivers ablative doses of radiation (RT) over a course of five treatments and has been increasingly used as a definitive RT option for low- and intermediate-risk prostate cancer (PCa). Ongoing prospective trials are evaluating the efficacy of SBRT for high-risk PCa, but clinical outcomes reports are limited. Methods: Patients treated for high-risk PCa between 2006-2017 at any of five institutions were included. SBRT doses ranged from 35-40 Gy in 5 fractions per institutional standards, with one institution using an integrated boost approach. The Phoenix definition was used to define biochemical failure (BCR). Physician-reported genitourinary (GU) and gastrointestinal (GI) toxicity outcomes were scored using the Radiation Therapy Oncology Group or Common Terminology Criteria for Adverse Events systems. Results: In total, 182 patients were included in this study with a median follow-up time of 38.4 months (mos). The median age was 72. Most patients (72%) had Gleason 8-10 disease. Sixty-eight percent of patients received androgen deprivation therapy (ADT) for a median of 9 mos (interquartile range 6-9 mos). The rate of distant metastases was 3.8%. There were no acute Grade 3 (G3) or higher GU or GI toxicities. Three patients (1.6%) experienced a late G3 GU toxicity and one patient (0.5%) experienced a late G3 GI toxicity. The incidence of BCR was significantly higher in patients who did not receive ADT (30% vs. 15%, p = 0.02 by Chi-square). Conclusions: In this multi-institutional study, SBRT demonstrated an acceptable safety profile for the treatment of high-risk PCa. Longer term follow-up is necessary to evaluate the oncologic efficacy of this approach, but given the potentially higher incidence of BCR without ADT, ADT likely has an important oncologic role even with SBRT regimens.
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Affiliation(s)
- Naomi Y Jiang
- University of California Los Angeles, Los Angeles, CA
| | | | | | | | - Nima Aghdam
- Georgetown University Hospital, Washington, DC
| | - Simeng Suy
- Georgetown University Hospital, Washington, DC
| | | | | | | | | | - Audrey Dang
- University of California Los Angeles, Los Angeles, CA
| | - Ye Yuan
- UCLA School of Medicine, Los Angeles, CA
| | | | | | - Patrick Kupelian
- University of California Los Angeles Health Syst, Los Angeles, CA
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