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Hurwitz JC, Haas J, Mendez C, Sanchez A, Santos VF, Akerman M, Carpenter T, Tam M, Katz A, Corcoran A, Mahadevan A, Taneja SS, Lepor H, Lischalk JW. Stereotactic Body Radiation Therapy for the Curative Treatment of Prostate Cancer in Ultralarge (≥100 cc) Glands. Pract Radiat Oncol 2024; 14:241-251. [PMID: 37984713 DOI: 10.1016/j.prro.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/01/2023] [Accepted: 11/06/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE Historically, toxicity concerns have existed in patients with large prostate glands treated with radiation therapy, particularly brachytherapy. There are questions whether this risk extends to stereotactic body radiation therapy (SBRT). In this retrospective review, we examine clinical outcomes of patients with prostate glands ≥100 cc treated curatively with SBRT. METHODS AND MATERIALS We retrospectively analyzed a large institutional database to identify patients with histologically confirmed localized prostate cancer in glands ≥100 cc, who were treated with definitive-robotic SBRT. Prostate volume (PV) was determined by treatment planning magnetic resonance imaging. Toxicity was measured using Common Terminology Criteria for Adverse Events, version 5.0. Many patients received the Expanded Prostate Cancer Index Composite Quality of Life questionnaires. Minimum follow-up (FU) was 2 years. RESULTS Seventy-one patients were identified with PV ≥100 cc. Most had grade group (GG) 1 or 2 (41% and 37%, respectively) disease. All patients received a total dose of 3500 to 3625 cGy in 5 fractions. A minority (27%) received androgen deprivation therapy (ADT), which was used for gland size downsizing in only 10% of cases. Nearly half (45%) were taking GU medications for urinary dysfunction before RT. Median toxicity FU was 4.0 years. Two-year rates of grade 1+ genitourinary (GU), grade 1+ gastrointestinal (GI), and grade 2+ GU toxicity were 43.5%, 15.9%, and 30.4%, respectively. Total grade 3 GU toxicities were very limited (2.8%). There were no grade 3 GI toxicities. On logistic regression analysis, pretreatment use of GU medications was significantly associated with increased rate of grade 2+ GU toxicity (odds ratio, 3.19; P = .024). Furthermore, PV (analyzed as a continuous variable) did not have an effect on toxicity, quality of life, or oncologic outcomes. CONCLUSIONS With early FU, ultra large prostate glands do not portend increased risk of high-grade toxicity after SBRT but likely carry an elevated risk of low-grade GU toxicity.
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Affiliation(s)
- Joshua C Hurwitz
- Department of Radiation Oncology, New York University Long Island School of Medicine, Mineola, New York
| | - Jonathan Haas
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Christopher Mendez
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Astrid Sanchez
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Vianca F Santos
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Meredith Akerman
- Division of Health Services Research, New York University Long Island School of Medicine, New York University Langone Health, New York, New York
| | - Todd Carpenter
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Moses Tam
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Aaron Katz
- Department of Urology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Anthony Corcoran
- Department of Urology, Perlmutter Cancer Center at New York University Langone Hospital-Long Island, New York, New York
| | - Anand Mahadevan
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Grossman School of Medicine, New York, New York
| | - Samir S Taneja
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Grossman School of Medicine, New York, New York
| | - Herbert Lepor
- Department of Urology, Perlmutter Cancer Center at New York University Grossman School of Medicine, New York, New York
| | - Jonathan W Lischalk
- Department of Radiation Oncology, New York University Long Island School of Medicine, Mineola, New York.
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Remick JS, Sabouri P, Zhu M, Bentzen SM, Sun K, Kwok Y, Kaiser A. Simulation of an HDR "Boost" with Stereotactic Proton versus Photon Therapy in Prostate Cancer: A Dosimetric Feasibility Study. Int J Part Ther 2021; 7:11-23. [PMID: 33604412 PMCID: PMC7886266 DOI: 10.14338/ijpt-20-00029.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/19/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose/Objectives To compare the dose escalation potential of stereotactic body proton therapy (SBPT) versus stereotactic body photon therapy (SBXT) using high-dose rate prostate brachytherapy (HDR-B) dose-prescription metrics. Patients and Methods Twenty-five patients previously treated with radiation for prostate cancer were identified and stratified by prostate size (≤ 50cc; n = 13, > 50cc; n = 12). Initial CT simulation scans were re-planned using SBXT and SBPT modalities using a prescription dose of 19Gy in 2 fractions. Target coverage goals were designed to mimic the dose distributions of HDR-B and maximized to the upper limit constraint for the rectum and urethra. Dosimetric parameters between SBPT and SBXT were compared using the signed-rank test and again after stratification for prostate size (≤ 50cm3 and >50cm3) using the Wilcoxon rank test. Results Prostate volume receiving 100% of the dose (V100) was significantly greater for SBXT (99%) versus SBPT (96%) (P ≤ 0.01), whereas the median V125 (82% vs. 73%, P < 0.01) and V200 (12% vs. 2%, P < 0.01) was significantly greater for SBPT compared to SBXT. Median V150 was 49% for both cohorts (P = 0.92). V125 and V200 were significantly correlated with prostate size. For prostates > 50cm3, V200 was significantly greater with SBPT compared to SBXT (14.5% vs. 1%, P = 0.005), but not for prostates 50cm3 (9% vs 4%, P = 0.11). Median dose to 2cm3 of the bladder neck was significantly lower with SBPT versus SBXT (9.6 Gy vs. 14 Gy, P < 0.01). Conclusion SBPT and SBXT can be used to simulate an HDR-B boost for locally advanced prostate cancer. SBPT demonstrated greater dose escalation potential than SBXT. These results are relevant for future trial design, particularly in patients with high risk prostate cancer who are not amenable to brachytherapy.
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Affiliation(s)
- Jill S Remick
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Pouya Sabouri
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mingyao Zhu
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Søren M Bentzen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kai Sun
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Young Kwok
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Adeel Kaiser
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
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Press RH, Morgan TM, Cutrell PK, Zhang C, Chen Z, Rahnema S, Sanda M, Pattaras J, Patel P, Jani AB, Rossi PJ. Patient-reported health-related quality of life outcomes after HDR brachytherapy between small (<60 cc) and large (≥60 cc) prostate glands. Brachytherapy 2018; 18:13-21. [PMID: 30262410 DOI: 10.1016/j.brachy.2018.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/02/2018] [Accepted: 08/15/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE Patients with large prostate glands are underrepresented in clinical trials incorporating brachytherapy due to concerns for excessive toxicity. We sought to compare health-related quality of life (HRQOL) outcomes between small (<60 cc) and large (≥60 cc) prostates treated with high-dose-rate brachytherapy (HDR-B). METHODS AND MATERIALS One hundred thirty patients at Emory University were treated with HDR-B monotherapy (n = 75) or HDR-B in combination with external beam radiation therapy (n = 55). American Urologic Association Symptom Score (AUASS) and expanded prostate cancer index composite for clinical practice (EPIC-CP) scores were recorded. A linear mixed model was performed dichotomizing prostate volume (<60 and ≥ 60 cc) with AUASS, individual EPIC-CP domains (urinary incontinence, urinary irritation/obstruction [UIO], bowel function, sexual function, and vitality/hormonal function), and overall EPIC-CP HRQOL scores. RESULTS Median followup was 22.6 months (range 2.2-55.8). The median gland volume for the entire cohort (n = 130), <60 cc cohort (n = 104), and ≥60 cc cohort (n = 26) was 44 cc, 41.1 cc, and 68.0 cc, respectively. There were no baseline differences in HRQOL scores between cohorts. At 2 months, AUASS and UIO scores increased similarly between cohorts (AUASS p = 0.807; UIO p = 0.539), then decreased (longitudinal effect p < 0.001 and p = 0.005, respectively) to remain not significantly different at 12 months (AUASS p = 0.595; UIO p = 0.673). Overall, prostate volume was not significantly associated with change in AUASS (p = 0.403), urinary incontinence (p = 0.322), UIO symptoms (p = 0.779), bowel symptoms (p = 0.757), vitality/hormonal symptoms (p = 0.503), or overall HRQOL (p = 0.382). CONCLUSIONS In appropriately selected patients, HDR-B appears well tolerated in patients with ≥60 cc prostate glands without an increase in patient-reported toxicity. Volume should not be a strict contraindication in those with adequate baseline function.
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Affiliation(s)
- Robert H Press
- Deptartment of Radiation Oncology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA.
| | - Tiffany M Morgan
- Deptartment of Radiation Oncology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Patrick K Cutrell
- Deptartment of Radiation Oncology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Chao Zhang
- Deptartment of Biostatistics and Bioinformatics Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Zhengjia Chen
- Deptartment of Biostatistics and Bioinformatics Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Sara Rahnema
- Deptartment of Radiation Oncology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Martin Sanda
- Deptartment of Urology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - John Pattaras
- Deptartment of Urology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Pretesh Patel
- Deptartment of Radiation Oncology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Ashesh B Jani
- Deptartment of Radiation Oncology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
| | - Peter J Rossi
- Deptartment of Radiation Oncology Atlanta, GA; Winship Cancer Institute of Emory University, Atlanta, GA
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Zaorsky NG, Davis BJ, Nguyen PL, Showalter TN, Hoskin PJ, Yoshioka Y, Morton GC, Horwitz EM. The evolution of brachytherapy for prostate cancer. Nat Rev Urol 2017; 14:415-439. [PMID: 28664931 PMCID: PMC7542347 DOI: 10.1038/nrurol.2017.76] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Brachytherapy (BT), using low-dose-rate (LDR) permanent seed implantation or high-dose-rate (HDR) temporary source implantation, is an acceptable treatment option for select patients with prostate cancer of any risk group. The benefits of HDR-BT over LDR-BT include the ability to use the same source for other cancers, lower operator dependence, and - typically - fewer acute irritative symptoms. By contrast, the benefits of LDR-BT include more favourable scheduling logistics, lower initial capital equipment costs, no need for a shielded room, completion in a single implant, and more robust data from clinical trials. Prospective reports comparing HDR-BT and LDR-BT to each other or to other treatment options (such as external beam radiotherapy (EBRT) or surgery) suggest similar outcomes. The 5-year freedom from biochemical failure rates for patients with low-risk, intermediate-risk, and high-risk disease are >85%, 69-97%, and 63-80%, respectively. Brachytherapy with EBRT (versus brachytherapy alone) is an appropriate approach in select patients with intermediate-risk and high-risk disease. The 10-year rates of overall survival, distant metastasis, and cancer-specific mortality are >85%, <10%, and <5%, respectively. Grade 3-4 toxicities associated with HDR-BT and LDR-BT are rare, at <4% in most series, and quality of life is improved in patients who receive brachytherapy compared with those who undergo surgery.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, Pennsylvania 19111-2497, USA
| | - Brian J Davis
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Charlton Bldg/Desk R - SL, Rochester, Minnesota 5590, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital, 75 Francis St BWH. Radiation Oncology, Boston, Massachusetts 02115, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, 1240 Lee St, Charlottesville, Virginia 22908, USA
| | - Peter J Hoskin
- Mount Vernon Cancer Centre, Rickmansworth Road, Northwood, Middlesex HA6 2RN, UK
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan
| | - Gerard C Morton
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, Pennsylvania 19111-2497, USA
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Zaorsky NG, Shaikh T, Murphy CT, Hallman MA, Hayes SB, Sobczak ML, Horwitz EM. Comparison of outcomes and toxicities among radiation therapy treatment options for prostate cancer. Cancer Treat Rev 2016; 48:50-60. [PMID: 27347670 DOI: 10.1016/j.ctrv.2016.06.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 06/07/2016] [Accepted: 06/08/2016] [Indexed: 01/13/2023]
Abstract
We review radiation therapy (RT) options available for prostate cancer, including external beam (EBRT; with conventional fractionation, hypofractionation, stereotactic body RT [SBRT]) and brachytherapy (BT), with an emphasis on the outcomes, toxicities, and contraindications for therapies. PICOS/PRISMA methods were used to identify published English-language comparative studies on PubMed (from 1980 to 2015) that included men treated on prospective studies with a primary endpoint of patient outcomes, with ⩾70 patients, and ⩾5year median follow up. Twenty-six studies met inclusion criteria; of these, 16 used EBRT, and 10 used BT. Long-term freedom from biochemical failure (FFBF) rates were roughly equivalent between conventional and hypofractionated RT with intensity modulation (evidence level 1B), with 10-year FFBF rates of 45-90%, 40-60%, and 20-50% (for low-, intermediate-, and high-risk groups, respectively). SBRT had promising rates of BF, with shorter follow-up (5-year FFBF of >90% for low-risk patients). Similarly, BT (5-year FFBF for low-, intermediate-, and high-risk patients have generally been >85%, 69-97%, 63-80%, respectively) and BT+EBRT were appropriate in select patients (evidence level 1B). Differences in overall survival, distant metastasis, and cancer specific mortality (5-year rates: 82-97%, 1-14%, 0-8%, respectively) have not been detected in randomized trials of dose escalation or in studies comparing RT modalities. Studies did not use patient-reported outcomes, through Grade 3-4 toxicities were rare (<5%) among all modalities. There was limited evidence available to compare proton therapy to other modalities. The treatment decision for a man is usually based on his risk group, ability to tolerate the procedure, convenience for the patient, and the anticipated impact on quality of life. To further personalize therapy, future trials should report (1) race; (2) medical comorbidities; (3) psychiatric comorbidities; (4) insurance status; (5) education status; (6) marital status; (7) income; (8) sexual orientation; and (9) facility-related characteristics.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
| | - Talha Shaikh
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Colin T Murphy
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Mark A Hallman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Mark L Sobczak
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Outcomes for prostate glands >60 cc treated with low-dose-rate brachytherapy. Brachytherapy 2016; 15:163-8. [DOI: 10.1016/j.brachy.2015.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 12/03/2015] [Accepted: 12/08/2015] [Indexed: 11/24/2022]
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