Rectal retractor application during image-guided dose-escalated prostate radiotherapy

Rectal retractor in prostate radiotherapy: pros and cons

Dose escalation in prostate radiotherapy (RT) have led to improved biochemical controls and reduced the risk of distant metastases. Over the past three decades, despite technological advancements in RT planning and delivery, the rectum is a dose-limiting structure in prostate RT owing to the close anatomical proximity of the anterior rectal wall (ARW) to the prostate gland. RT-induced rectal toxicities remain a clinical challenge, limiting the prescribed dose during prostate RT. To address the spatial proximity challenge by physically increasing the distance between the posterior aspect of the prostate and the ARW, several physical devices such as endorectal balloons (ERBs), rectal hydrogel spacers, and rectal retractor (RR) have been developed. Previously, various aspects of ERBs and rectal hydrogel spacers have extensively been discussed. Over recent years, given the interest in the application of RR in prostate external beam radiotherapy (EBRT), this editorial will discuss opportunities and challenges of using RR during prostate EBRT and provide information regarding which aspects of this device need attention.

Clinical effects of rectal retractor application in prostate cancer radiotherapy

Background: Radiation-induced rectal toxicities remain as a major risk during prostate radiotherapy. One approach to the reduction of rectal radiation dose is to physically increase the distance between the rectal wall and prostate. Therefore, the aim of this study was to evaluate whether the application of the rectal retractor (RR) can reduce rectal dose and toxicity in prostate cancer 3-dimensional conformal radiotherapy (3D-CRT).

Methods: Overall, 36 patients with localized prostate cancer were randomized into the 2 groups, 18 patients with RR in-place and 18 without RR. All patients underwent planning computed tomography (CT). Patients were treated with 70 Gy in 35 fractions of 3D-CRT. In the RR group, RR was used during cone-down 20 treatment fractions. Acute and late gastrointestinal (GI) toxicities were assessed using EORTC/RTOG scoring system weekly during radiotherapy, 3, and 12 months after treatment. Device-related events were recorded according to CTCAE version 4.0. Patient characteristics, cancer differences, and dosimetric data for the RR and non-RR groups were compared using a Man-Whitney U test for continuous variables, and Fisher exact test for categorical data. The EORTC/RTOG scores for the 2 groups were compared using Fisher exact test. A P value <0.05 was considered statistically significant.

Results: A RR significantly reduced mean dose (Dmean) to the rectum as well as rectal volume receiving 50% to 95% (V50-95%) of prescribed dose. The absolute reduction of rectal Dmean was 10.3 Gy. There was no statistically significant difference in acute GI toxicity between groups during treatment or at 3 months. At 12 months, 2 patients in the RR group and 9 in the control group experienced late grade ≥ 1 GI toxicity (p=0.027). No patients in the RR group reported late grade ≥ 2 GI toxicity, whereas 3 patients in the control group experienced late grade 2 GI toxicity. In the RR group, 6 patients reported grade 1 rectal discomfort and pain according to CTCAE version 4.0.

Conclusion: The application of the RR showed a significant rectum sparing effect, resulting in substantially reducing late GI toxicity.

A Ten-year-long Update on Radiation Proctitis Among Prostate Cancer Patients Treated With Curative External Beam Radiotherapy

This comprehensive synopsis summarizes the most relevant information obtained from a systematic analysis of studies of the last decade on radiation proctitis, one of the most feared radioinduced side effects among prostate cancer patients treated with curative external beam radiotherapy. The present review provides a useful support to radiation oncologists for limiting the onset or improving the treatment of radiation proctitis. This work shows that the past decade was a harbinger of significant new evidence in technological advances and technical tricks to avoid radiation proctitis, in addition to dosimetric perspectives and goals, understanding of pathogenesis, diagnostic work-up and treatment. We believe that a well-rounded knowledge of such an issue is fundamental for its appropriate management.

Treatment of low-risk prostate cancer: a retrospective study with 477 patients comparing external beam radiotherapy and I-125 seeds brachytherapy in terms of biochemical control and late side effects

PURPOSE

The goal of our study was comparison of external beam radiotherapy (EBRT) and I‑125 seeds brachytherapy in terms of biochemical control and development of late gastrointestinal and genitourinary side effects.

PATIENTS AND METHODS

477 low-risk prostate cancer patients treated between 2000 and 2019 at our department using either I‑125 seeds brachytherapy or EBRT with a dose of 74 or 78 Gy were reviewed for our analysis. 213 patients were treated with EBRT and 264 with seeds.

RESULTS

Patients were followed up yearly with a median follow-up of 70 (3-192) months. The biochemical no evidence of disease (bNED) rates after 5 years were 95% for both EBRT and seeds, and after 10 years 87% for EBRT and 94% for seeds using the Phoenix criteria, although no significant difference was observed. Concerning gastrointestinal side effects, EBRT showed significantly higher rates of RTOG grade ≥2 toxicity compared to seeds, but at no point in follow-up more than 15% of all patients. On the other hand, genitourinary side effects were significantly more prevalent in patients treated with seeds, with 40% RTOG grade ≥2 toxicity 12 months after treatment. Nevertheless, both types of side effects decreased over time.

CONCLUSION

Both EBRT and seeds provide excellent biochemical control with bNED rates after 10 years of about 90%. In terms of side effects, patients treated with seeds show higher grades of genitourinary side effects, while patients treated with EBRT show higher grades of gastrointestinal side effects.

Novel treatment setup for urethral carcinoma radiotherapy: A complete response case report

A homemade personalized penis holder can provide the reproducibility of the penis during urethra carcinoma (UC) radiotherapy.

Application of rectal retractor for postprostatectomy salvage radiotherapy of prostate cancer: A case report and literature review

Using a rectal retractor (RR) during salvage radiotherapy after radical prostatectomy is a promising approach for reducing dose to the rectum. The patient well tolerated the daily RR insertion. This area of research encourages researchers for a comprehensive evaluation of the role of the RR in postprostatectomy radiotherapy.

Optimization of prostate brachytherapy techniques with polyethylene glycol-based hydrogel spacers: A systematic review

PURPOSE

The objective of this overview was to critically evaluate the effect of polyethylene glycol (PEG)-based hydrogel spacers during prostate brachytherapy with regard to dosimetric and clinical benefits, as well as procedure-related toxicity.

METHODS AND MATERIALS

A systematic search in the PubMed database was performed.

RESULTS

A total of 12 studies, involving 615 patients with PEG hydrogel injection, were included. Overall, patients well tolerated the implantation of PEG hydrogel spacers with an excellent safety profile. However, although there were some procedure-related complications, rates of these complications were very rare. Toxicities related to the spacer were limited to Grade 1 rectal discomfort and pain (9/615 patients), Grade 2 rectal ulceration (1 in 615 patients), perineal abscess (1 in 615 patients), and bacterial prostatitis (2/615 patients) according to Common Terminology Criteria for Adverse Events v4.0 grading scheme. The application of PEG hydrogel spacers significantly reduced radiation doses to the rectum during prostate brachytherapy in the different setting. Although there was no prospective randomized clinical trial, retrospective studies showed that reducing rectal doses by the implantation of PEG hydrogel may result in an improvement in rectal toxicity.

CONCLUSIONS

The insertion of hydrogel spacers is safe, resulting in a significant decrease in rectal doses. This may lead to a reduction in rectal or gastrointestinal toxicity. Prospective randomized clinical trials are warranted to confirm the clinical impact of rectal dosimetric improvements.

Fiducial markers in prostate cancer image-guided radiotherapy

Background: Image-guided radiotherapy (IGRT) is recommended to reduce the risk of geometrical miss when modern radiotherapy technologies with high grades of conformity are used. The purpose of this study was to evaluate the efficacy of fiducial markers (FMs) for electronic portal imaging in prostate cancer radiotherapy in term of evaluating the complications associated with FMs implantation, quantifying inter-fraction prostate motion, and determination of optimal planning target volume (PTV) margins.

Methods: In this single institution, prospective, consecutive study, 27 patients underwent implantation of three-gold seed FMs into the prostate gland before prostate radiotherapy. Prior to computed tomography planning, all patients were asked to report any complication associated with FMs implantation that have experienced to date. Daily pre-treatment electronic portal images were captured, and prostate position errors were corrected if they were greater than 2 mm along three translational directions. Optimal PTV expansions were computed using van Herk formula [PTV-margin= 2.5Σ + 0.7σ].

Results: FMs implantation was successful with an acceptable toxicity profile in all patients. Without IGRT, margins of 5.4 mm, 5.8 mm and 5.5 mm, in vertical, longitudinal and lateral directions, respectively, are needed for a 95% confidence level of complete clinical target volume (CTV) coverage in each treatment session. The PTV margins of 3.0 mm, 3.3 mm and 4.0 mm in corresponding directions were calculated when FMs based electronic portal imaging was applied.

Conclusion: FMs based electronic portal imaging is an effective tool for prostate cancer IGRT.