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Bock F, Frerker B, Schubert L, Rennau H, Kurth J, Krause BJ, Hildebrandt G, Schwarzenböck SM. Impact of 68Ga-PSMA PET/CT on radiation treatment planning of prostate cancer patients. Nuklearmedizin 2024; 63:199-206. [PMID: 38580313 DOI: 10.1055/a-2284-0593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
AIM This study aimed to assess the impact of 68Ga-PSMA PET/CT on radiation treatment (RT) planning in prostate cancer patients with salvage (sRT) or definitive (dRT) radiotherapy. METHODS 38 patients (27 sRT, median PSA 0.79 ng/ml (range 0.06-12.1); 11 dRT, median PSA 4.35 ng/ml (range 1.55-55.5) underwent 68Ga-PSMA PET/CT before RT. Influence of 68Ga-PSMA PET/CT on the extent of planning target volume (PTV) and addition of PET-based boosts were assessed. Median follow up was 12 months (range 3-24). RESULTS 68Ga-PSMA PET/CT showed positive findings in 23/38 patients (8/23: local recurrence (LR), 11/23: nodal metastasis, 1/23: LR and nodal, 2/23: solitary bone metastasis, 1/23: oligometastatic nodal/ bone metastases). In sRT primary PTV was changed in 16/27 patients extending the PTV to the lymphatic drainage (10/16), PSMA-positive LR (3/16), bone metastases (2/16) and both nodal/bone metastases (1/16). PET-based increase of primary PTV was 116%. PET-based boosts were administered in 19/27 patients (8/19: local, 10/19: nodal, 1/19: both), median boost volume was 31.3 cm3 (range 17.2-80.2) (local) and 19.7 cm3 (range 3.0-109.3) (nodal). PTV was changed in 1/11 (9%) of dRT patients (extension of primary PTV to the lymphatic drainage (RT volume of 644.5 cm3), additional nodal boost (volume of 2.7 cm3, 23.1 Gy)). All patients showed biochemical response (mean PSA decrease 88.8 +/- 14.0%). Nadir PSA was reached 10 months (range 1-17) after end of RT (median 0.07 ng/ml, range 0.002-3.96). Within a median 12 months follow-up (range 3-22/8-24 in sRT/dRT), median PSA was 0.05 ng/ml (range 0.002-8.5) (sRT) and 0.26 ng/ml (range 0.02-2.68) (dRT). CONCLUSIONS 68Ga-PSMA PET/CT influenced sRT planning in almost 63% and dRT in 9% of patients by change of PTV and additional boosts.
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Affiliation(s)
- Felix Bock
- Department of Radiotherapy and Radiation Oncology, Rostock University Medical Center, Rostock, Germany
| | - Bernd Frerker
- Department of Radiotherapy and Radiation Oncology, Rostock University Medical Center, Rostock, Germany
| | - Laura Schubert
- Department of Nuclear Medicine, Rostock University Medical Center, Rostock, Germany
| | - Hannes Rennau
- Department of Radiotherapy and Radiation Oncology, Rostock University Medical Center, Rostock, Germany
| | - Jens Kurth
- Department of Nuclear Medicine, Rostock University Medical Center, Rostock, Germany
| | - Bernd J Krause
- Department of Nuclear Medicine, Rostock University Medical Center, Rostock, Germany
| | - Guido Hildebrandt
- Department of Radiotherapy and Radiation Oncology, Rostock University Medical Center, Rostock, Germany
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Ah-Thiane L, Campion L, Allouache N, Meyer E, Pommier P, Mesgouez-Nebout N, Serre AA, Créhange G, Guimas V, Rio E, Sargos P, Ladoire S, Mahier Ait Oukhatar C, Supiot S. Combination of Abiraterone Acetate, Prostate Bed Radiotherapy, and Luteinizing Hormone-releasing Hormone Agonists in Biochemically Relapsing Patients After Prostatectomy (CARLHA): A Phase 2 Clinical Trial. Eur Urol Oncol 2024:S2588-9311(24)00108-1. [PMID: 38734543 DOI: 10.1016/j.euo.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/26/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND The relevance of next-generation hormone therapies and circulating tumor cells (CTCs) are not elucidated in biochemical recurrence after prostatectomy. OBJECTIVE To evaluate the combination of abiraterone acetate plus prednisone (AAP), prostate bed radiotherapy (PBRT), and goserelin in biochemically relapsing men after prostatectomy, and to investigate the utility of CTCs. DESIGN, SETTING, AND PARTICIPANTS In this single-arm multicenter phase 2 trial, 46 biochemically relapsing men were enrolled between December 2012 and January 2019. The median follow-up was 47 mo. INTERVENTION All patients received AAP 1000 mg daily (but 750 mg during PBRT), salvage PBRT, and goserelin. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was 3-yr biochemical recurrence-free survival (bRFS) when prostate-specific antigen (PSA) levels were ≥0.2 ng/ml. The secondary outcomes included alternative bRFS (alt-bRFS) when PSA levels were ≥0.5 ng/ml and safety assessment. CTC count was assessed. RESULTS AND LIMITATIONS The 3-yr bRFS and alt-bRFS were 81.5% (95% confidence interval or CI [66.4-90.3%]) and 95.6% (95% CI [83.5-98.9%]), respectively. The most common acute radiotherapy-related adverse effect (AE; all grades was pollakiuria (41.3%). The most common late AE (all grades) was urinary incontinence (15.2%). Grade 3-4 acute or late radiotherapy-related AEs were scarce. Most frequent AEs nonrelated to radiotherapy were hot flashes (76%), hypertension (63%), and hepatic cytolysis (50%, of which 20% were of grades 3-4). Of the patients, 11% had a CTC count of ≥5, which was correlated with poorer bRFS (p = 0.042) and alt-bRFS (p = 0.008). The association between CTC count and higher rates of relapse was independent of the baseline PSA level and PSA doubling time (p = 0.42 and p = 0.09, respectively). This study was nonrandomized with a limited number of patients, and few clinical events were reported. CONCLUSIONS Adding AAP to salvage radiation therapy and goserelin resulted in high bRFS and alt-bRFS. AEs remained manageable, although a close liver surveillance is advised. CTC count appears as a promising biomarker for prognosis and predicting response to treatment. PATIENT SUMMARY Our study was a phase 2 clinical trial that exhibited the efficacy and tolerance of a novel androgen-receptor targeting agent (abiraterone acetate plus prednisone) in patients with prostate cancer who experienced rising prostate-specific antigen after radical prostatectomy, in combination with prostate bed radiotherapy. The results also indicated the feasibility and potential value of circulating tumor cell detection, which constitutes a possible advance in managing prostate cancers.
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Affiliation(s)
- Loic Ah-Thiane
- Department of Radiotherapy, ICO Rene Gauducheau, St-Herblain, France
| | - Loic Campion
- Department of Biostatistics, ICO Rene Gauducheau, St-Herblain, France
| | - Nedjla Allouache
- Department of Radiotherapy, Francois Baclesse Center, Caen, France
| | - Emmanuel Meyer
- Department of Radiotherapy, Francois Baclesse Center, Caen, France
| | - Pascal Pommier
- Department of Radiotherapy, Leon Berard Center, Lyon, France
| | | | | | - Gilles Créhange
- Department of Radiotherapy, Georges Francois Leclerc Center, Dijon, France
| | - Valentine Guimas
- Department of Radiotherapy, ICO Rene Gauducheau, St-Herblain, France
| | - Emmanuel Rio
- Department of Radiotherapy, ICO Rene Gauducheau, St-Herblain, France
| | - Paul Sargos
- Department of Radiotherapy, Bergonie Institute, Bordeaux, France
| | - Sylvain Ladoire
- Department of Radiotherapy, Georges Francois Leclerc Center, Dijon, France
| | | | - Stéphane Supiot
- Department of Radiotherapy, ICO Rene Gauducheau, St-Herblain, France; Inserm UMR1232, CNRS ERL 6001, Nantes University, Nantes, France.
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3
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Takano S, Tomita N, Takaoka T, Niwa M, Torii A, Kita N, Okazaki D, Uchiyama K, Nakanishi-Imai M, Ayakawa S, Iida M, Tsuzuki Y, Otsuka S, Manabe Y, Nomura K, Ogawa Y, Miyakawa A, Miyamoto A, Takemoto S, Yasui T, Hiwatashi A. Late genitourinary toxicity in salvage radiotherapy for prostate cancer after radical prostatectomy: impact of daily fraction doses. Br J Radiol 2024; 97:1050-1056. [PMID: 38466928 DOI: 10.1093/bjr/tqae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 08/31/2023] [Accepted: 03/07/2024] [Indexed: 03/13/2024] Open
Abstract
OBJECTIVE To evaluate the impact of daily fraction doses on late genitourinary (GU) toxicity after salvage radiotherapy (SRT) for prostate cancer. METHODS This multi-institutional retrospective study included 212 patients who underwent SRT between 2008 and 2018. All patients received image-guided intensity-modulated SRT at a median dose of 67.2 Gy in 1.8-2.3 Gy/fraction. The cumulative rates of late grade ≥2 GU and gastrointestinal (GI) toxicities were compared using Gray test, stratified by the ≤2.0 Gy/fraction (n = 137) and ≥2.1 Gy/fraction groups (n = 75), followed by multivariate analyses. The total dose was represented as an equivalent dose in 2-Gy fractions (EQD2) with α/β = 3 Gy. RESULTS After a median follow-up of 63 months, the cumulative rates of 5-year late grade ≥2 GU and GI toxicities were 14% and 2.5%, respectively. The cumulative rates of 5-year late grade ≥2 GU toxicity in the ≥2.1 Gy/fraction and ≤2.0 Gy/fraction groups were 22% and 10%, respectively (P = .020). In the multivariate analysis, ≥2.1 Gy/fraction was still associated with an increased risk of late grade ≥2 GU toxicity (hazard ratio, 2.37; 95% confidence interval, 1.12-4.99; P = .023), while the total dose was not significant. CONCLUSION The present results showed that ≥2.1 Gy/fraction resulted in a higher incidence of late grade ≥2 GU toxicity in SRT. ADVANCES IN KNOWLEDGE The impact of fraction doses on late GU toxicity after SRT remains unknown. The results suggest that higher fraction doses may increase the risk of late GU toxicity in SRT.
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Affiliation(s)
- Seiya Takano
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Natsuo Tomita
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Taiki Takaoka
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Masanari Niwa
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Akira Torii
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Nozomi Kita
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Dai Okazaki
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Kaoru Uchiyama
- Department of Radiology, Kariya Toyota General Hospital, Kariya, Aichi 448-8505, Japan
| | - Mikiko Nakanishi-Imai
- Department of Radiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi 466-8650, Japan
| | - Shiho Ayakawa
- Department of Radiology, Japan Community Health care Organization Chukyo Hospital, Nagoya, Aichi 457-8510, Japan
| | - Masato Iida
- Department of Radiation Oncology, Suzuka General Hospital, Suzuka, Mie 513-0818, Japan
| | - Yusuke Tsuzuki
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Aichi 462-8508, Japan
| | - Shinya Otsuka
- Department of Radiology, Okazaki City Hospital, Okazaki, Aichi 444-8553, Japan
| | - Yoshihiko Manabe
- Department of Radiation Oncology, Nanbu Tokushukai General Hospital, Shimajiri, Okinawa 901-0493, Japan
| | - Kento Nomura
- Department of Radiotherapy, Nagoya City West Medical Center, Nagoya, Aichi 462-8508, Japan
| | - Yasutaka Ogawa
- Department of Radiation Oncology, Kasugai Municipal Hospital, Kasugai, Aichi 486-8510, Japan
| | - Akifumi Miyakawa
- Department of Radiation Oncology, National Hospital Organization Nagoya Medical Center, Nagoya, Aichi 460-0001, Japan
| | - Akihiko Miyamoto
- Department of Radiation Oncology, Hokuto Hospital, Obihiro, Hokkaido 080-0833, Japan
| | - Shinya Takemoto
- Department of Radiation Oncology, Fujieda Heisei Memorial Hospital, Fujieda, Shizuoka 426-8662, Japan
| | - Takahiro Yasui
- Department of Urology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Akio Hiwatashi
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
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Miyazaki S, Tasaki Y, Nakatake M, Honda K, Nakamura D, Egawa A, Oki N, Mitsunari K, Nakamura Y, Imamura R, Toya R. Dose-escalated Salvage Whole-pelvic Radiotherapy for Biochemical Recurrence After Radical Prostatectomy for High-risk Prostate Cancer. CANCER DIAGNOSIS & PROGNOSIS 2024; 4:315-319. [PMID: 38707723 PMCID: PMC11062159 DOI: 10.21873/cdp.10326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/06/2024] [Indexed: 05/07/2024]
Abstract
Background/Aim To investigate the institutional experience of dose-escalated salvage whole-pelvic radiotherapy (WPRT) with the simultaneous integrated boost (SIB) technique in patients with biochemical recurrence (BCR) after radical prostatectomy for high-risk prostate cancer. Patients and Methods This retrospective study included 21 patients with BCR who received radical prostatectomy for high-risk prostate cancer and underwent salvage RT. Clinical target volume (CTV) of the whole pelvis (CTV56) included the prostate bed, common iliac, external iliac, internal iliac, and obturator lymph node regions. The boost CTV (CTV66) included the prostate bed. Planning target volumes (PTV) were generated by adding a margin of 6-8 mm to CTV (PTV56 and PTV66). Doses of 56.1 and 66 Gy in 33 fractions were delivered to PTV56 and PTV66, respectively. Results The 5-year biochemical progression-free survival, overall survival, and cause-specific survival rates were 72%, 94%, and 94%, respectively. A grade 3 late genitourinary toxicity event of gross hematuria was observed in one patient (4%). Acute and late toxicities of grade ≥3, other than gross hematuria, were not observed in any patient. Conclusion Dose-escalated salvage WPRT using the SIB technique provides appropriate tumor control without increasing the incident of significant toxicities.
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Affiliation(s)
- Shuhei Miyazaki
- Department of Radiological Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Yutaro Tasaki
- Department of Radiological Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Mika Nakatake
- Department of Radiological Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Koichi Honda
- Department of Radiological Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Daisuke Nakamura
- Department of Radiological Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Akiko Egawa
- Department of Radiological Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Nozomi Oki
- Department of Radiological Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Kensuke Mitsunari
- Department of Urology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Yuichiro Nakamura
- Department of Urology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Ryoichi Imamura
- Department of Urology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Ryo Toya
- Department of Radiological Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
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5
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Buyyounouski MK, Pugh SL, Chen RC, Mann MJ, Kudchadker RJ, Konski AA, Mian OY, Michalski JM, Vigneault E, Valicenti RK, Barkati M, Lawton CAF, Potters L, Monitto DC, Kittel JA, Schroeder TM, Hannan R, Duncan CE, Rodgers JP, Feng F, Sandler HM. Noninferiority of Hypofractionated vs Conventional Postprostatectomy Radiotherapy for Genitourinary and Gastrointestinal Symptoms: The NRG-GU003 Phase 3 Randomized Clinical Trial. JAMA Oncol 2024; 10:584-591. [PMID: 38483412 PMCID: PMC10941019 DOI: 10.1001/jamaoncol.2023.7291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/24/2023] [Indexed: 03/17/2024]
Abstract
Importance No prior trial has compared hypofractionated postprostatectomy radiotherapy (HYPORT) to conventionally fractionated postprostatectomy (COPORT) in patients primarily treated with prostatectomy. Objective To determine if HYPORT is noninferior to COPORT for patient-reported genitourinary (GU) and gastrointestinal (GI) symptoms at 2 years. Design, Setting, and Participants In this phase 3 randomized clinical trial, patients with a detectable prostate-specific antigen (PSA; ≥0.1 ng/mL) postprostatectomy with pT2/3pNX/0 disease or an undetectable PSA (<0.1 ng/mL) with either pT3 disease or pT2 disease with a positive surgical margin were recruited from 93 academic, community-based, and tertiary medical sites in the US and Canada. Between June 2017 and July 2018, a total of 296 patients were randomized. Data were analyzed in December 2020, with additional analyses occurring after as needed. Intervention Patients were randomized to receive 62.5 Gy in 25 fractions (HYPORT) or 66.6 Gy in 37 fractions (COPORT). Main Outcomes and Measures The coprimary end points were the 2-year change in score from baseline for the bowel and urinary domains of the Expanded Prostate Cancer Composite Index questionnaire. Secondary objectives were to compare between arms freedom from biochemical failure, time to progression, local failure, regional failure, salvage therapy, distant metastasis, prostate cancer-specific survival, overall survival, and adverse events. Results Of the 296 patients randomized (median [range] age, 65 [44-81] years; 100% male), 144 received HYPORT and 152 received COPORT. At the end of RT, the mean GU change scores among those in the HYPORT and COPORT arms were neither clinically significant nor different in statistical significance and remained so at 6 and 12 months. The mean (SD) GI change scores for HYPORT and COPORT were both clinically significant and different in statistical significance at the end of RT (-15.52 [18.43] and -7.06 [12.78], respectively; P < .001). However, the clinically and statistically significant differences in HYPORT and COPORT mean GI change scores were resolved at 6 and 12 months. The 24-month differences in mean GU and GI change scores for HYPORT were noninferior to COPORT using noninferiority margins of -5 and -6, respectively, rejecting the null hypothesis of inferiority (mean [SD] GU score: HYPORT, -5.01 [15.10] and COPORT, -4.07 [14.67]; P = .005; mean [SD] GI score: HYPORT, -4.17 [10.97] and COPORT, -1.41 [8.32]; P = .02). With a median follow-up for censored patients of 2.1 years, there was no difference between HYPORT vs COPORT for biochemical failure, defined as a PSA of 0.4 ng/mL or higher and rising (2-year rate, 12% vs 8%; P = .28). Conclusions and Relevance In this randomized clinical trial, HYPORT was associated with greater patient-reported GI toxic effects compared with COPORT at the completion of RT, but both groups recovered to baseline levels within 6 months. At 2 years, HYPORT was noninferior to COPORT in terms of patient-reported GU or GI toxic effects. HYPORT is a new acceptable practice standard for patients receiving postprostatectomy radiotherapy. Trial Registration ClinicalTrials.gov Identifier: NCT03274687.
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Affiliation(s)
- Mark K. Buyyounouski
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Stephanie L. Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | - Mark J. Mann
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | | | | | - Jeff M. Michalski
- Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Eric Vigneault
- Radiation Oncology, CHU de Québec-Hôpital Enfant Jésus de Quebec, Quebec City, Quebec, Canada
| | | | - Maroie Barkati
- Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | | | | | - Drew C. Monitto
- Upstate Carolina Consortium Community Oncology Research Program, Spartanburg, South Carolina
| | - Jeffrey A. Kittel
- Aurora National Cancer Institute Community Oncology Research Program, Milwaukee, Wisconsin
| | | | - Raquibul Hannan
- Harold C. Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas
| | | | - Joseph P. Rodgers
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Felix Feng
- University of San Francisco, San Francisco, California
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6
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Scharl S, Zamboglou C, Strouthos I, Farolfi A, Serani F, Koerber SA, Debus J, Peeken JC, Vogel MME, Kroeze SGC, Guckenberger M, Krafcsik M, Hruby G, Emmett L, Schmidt-Hegemann NS, Trapp C, Spohn SKB, Henkenberens C, Mayer B, Shelan M, Aebersold DM, Thamm R, Wiegel T. European association of urology risk stratification predicts outcome in patients receiving PSMA-PET-planned salvage radiotherapy for biochemical recurrence following radical prostatectomy. Radiother Oncol 2024; 194:110215. [PMID: 38458259 DOI: 10.1016/j.radonc.2024.110215] [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: 02/03/2024] [Revised: 03/01/2024] [Accepted: 03/03/2024] [Indexed: 03/10/2024]
Abstract
PURPOSE The European Association of Urology (EAU) proposed a risk stratification (high vs. low risk) for patients with biochemical recurrence (BR) following radical prostatectomy (RP). Here we investigated whether this stratification accurately predicts outcome, particularly in patients staged with PSMA-PET. METHODS For this study, we used a retrospective database including 1222 PSMA-PET-staged prostate cancer patients who were treated with salvage radiotherapy (SRT) for BR, at 11 centers in 5 countries. Patients with lymph node metastases (pN1 or cN1) or unclear EAU risk group were excluded. The remaining cohort comprised 526 patients, including 132 low-risk and 394 high-risk patients. RESULTS The median follow-up time after SRT was 31.0 months. The 3-year biochemical progression-free survival (BPFS) was 85.7 % in EAU low-risk versus 69.4 % in high-risk patients (p = 0.002). The 3-year metastasis-free survival (MFS) was 94.4 % in low-risk versus 87.6 % in high-risk patients (p = 0.005). The 3-year overall survival (OS) was 99.0 % in low-risk versus 99.6 % in high-risk patients (p = 0.925). In multivariate analysis, EAU risk group remained a statistically significant predictor of BPFS (p = 0.003, HR 2.022, 95 % CI 1.262-3.239) and MFS (p = 0.013, HR 2.986, 95 % CI 1.262-7.058). CONCLUSION Our data support the EAU risk group definition. EAU risk grouping for BCR reliably predicted outcome in patients staged lymph node-negative after RP and with PSMA-PET before SRT. To our knowledge, this is the first study validating the EAU risk grouping in patients treated with PSMA-PET-planned SRT.
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Affiliation(s)
- Sophia Scharl
- Department of Radiation Oncology, University Hospital Ulm, Germany.
| | - Constantinos Zamboglou
- Department of Radiation Oncology, Medical Center -Faculty of Medicine, University of Freiburg, Germany
| | - Iosif Strouthos
- Department of Radiation Oncology, German Oncology Center, University Hospital of the European University, Limassol, Cyprus
| | - Andrea Farolfi
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesca Serani
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Stefan A Koerber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Department of Radiation Oncology, Barmherzige Brüder Hospital Regensburg, Regensburg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan C Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Germany
| | - Marco M E Vogel
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Germany
| | | | | | - Manuel Krafcsik
- Department of Radiation Oncology, University Hospital Ulm, Germany
| | - George Hruby
- Department of Radiation Oncology, Royal North Shore Hospital - University of Sydney, Australia
| | - Louise Emmett
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Nina-Sophie Schmidt-Hegemann
- Department of Department of Radiotherapy and Oncology, University Hospital, LMU Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, 81377 Munich, Germany; Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Christian Trapp
- Department of Department of Radiotherapy and Oncology, University Hospital, LMU Munich, Germany
| | - Simon K B Spohn
- Department of Radiation Oncology, Medical Center -Faculty of Medicine, University of Freiburg, Germany
| | - Christoph Henkenberens
- Department of Radiotherapy and Special Oncology, Medical School Hannover, Hannover, Germany
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University Ulm, Ulm, Germany
| | - Mohamed Shelan
- Department of Radiation Oncology, Inselspital Bern, Bern University Hospital, University of Bern, Switzerland
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital Bern, Bern University Hospital, University of Bern, Switzerland
| | - Reinhard Thamm
- Department of Radiation Oncology, University Hospital Ulm, Germany
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Germany
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7
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Castelluccia A, Tramacere F, Colciago RR, Borgia M, Sallustio A, Proto T, Portaluri M, Arcangeli PS. 10-yr Results of Moderately Hypofractionated Postoperative Radiotherapy for Prostate Cancer Focused on Treatment Related Toxicity. Clin Genitourin Cancer 2024; 22:102102. [PMID: 38759337 DOI: 10.1016/j.clgc.2024.102102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/04/2024] [Accepted: 04/22/2024] [Indexed: 05/19/2024]
Abstract
INTRODUCTION To retrospectively report long term outcomes following postoperative hypofractionated radiotherapy (RT) for prostate cancer, emphasizing treatment related toxicity. MATERIAL AND METHODS Patients for whom adjuvant or salvage RT was indicated after prostatectomy were treated with a course of moderate hypofractionation consisting in the delivery of 62.5 Gy in 25 fractions (2.5 Gy per fraction) on the prostate bed in 5 consecutive weeks (EQD21.5 = 70 Gy) by means of 3D-CRT in most of them. Androgen deprivation therapy (ADT) was allowed at physician's discretion. Patients were evaluated for urinary and rectal complications according to the Common Terminology Criteria for Adverse Events v4 (CTCAE v.4). Overall survival (OS), biochemical recurrence free survival (bRFS), and metastasis-free survival (MFS) were estimated using the Kaplan-Meier method. RESULTS One hundred and ten patients with a median age of 67 years (range 51-78) were enrolled. The majority of them (82%) had adverse pathologic features only, while 31 (28%) had early biochemical relapse. Median PSA level before RT was 0.12 ng/mL (range 0-9 ng/mL). Median time from surgery was 4 months (range 1-136 months). Twenty-eight patients (25.4%) also received ADT. At a median follow up of 103 months (range 19-138 months), late Grade 3 and Grade 4 rectal toxicity were 0.9% (1 case of hematochezia) and 0.9% (1 case of fistula), respectively, while late Grade 3 GU side effects (urethral stenosis) occurred in 9 cases (8%). No late Grade 4 events were observed, respectively. Ten-year OS, b-RFS and MFS were 77.3% (95%CI: 82.1%-72.5%), 53.3% (95%CI: 59.9%-47.6%), and 76.7% (95%CI: 81.2%-72.2%), respectively. CONCLUSION Our study provides long term data that a shortened course of postoperative RT is as safe and effective as a long course of conventionally fractionated RT and would improve patients' convenience and significantly reduce RT department workloads.
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Affiliation(s)
| | | | | | - Marzia Borgia
- Department of Radiation Oncology, Perrino Hospital, 72100, Brindisi, Italy
| | | | - Tiziana Proto
- Department of Radiation Oncology, Perrino Hospital, 72100, Brindisi, Italy
| | - Maurizio Portaluri
- Department of Radiation Oncology, Perrino Hospital, 72100, Brindisi, Italy
| | - Prof Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy; Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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8
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Le Bao V, Haworth A, Dowling J, Walker A, Arumugam S, Jameson M, Chlap P, Wiltshire K, Keats S, Cloak K, Sidhom M, Kneebone A, Holloway L. Evaluating the relationship between contouring variability and modelled treatment outcome for prostate bed radiotherapy. Phys Med Biol 2024; 69:085008. [PMID: 38471173 DOI: 10.1088/1361-6560/ad3325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/12/2024] [Indexed: 03/14/2024]
Abstract
Objectives.Contouring similarity metrics are often used in studies of inter-observer variation and automatic segmentation but do not provide an assessment of clinical impact. This study focused on post-prostatectomy radiotherapy and aimed to (1) identify if there is a relationship between variations in commonly used contouring similarity metrics and resulting dosimetry and (2) identify the variation in clinical target volume (CTV) contouring that significantly impacts dosimetry.Approach.The study retrospectively analysed CT scans of 10 patients from the TROG 08.03 RAVES trial. The CTV, rectum, and bladder were contoured independently by three experienced observers. Using these contours reference simultaneous truth and performance level estimation (STAPLE) volumes were established. Additional CTVs were generated using an atlas algorithm based on a single benchmark case with 42 manual contours. Volumetric-modulated arc therapy (VMAT) treatment plans were generated for the observer, atlas, and reference volumes. The dosimetry was evaluated using radiobiological metrics. Correlations between contouring similarity and dosimetry metrics were calculated using Spearman coefficient (Γ). To access impact of variations in planning target volume (PTV) margin, the STAPLE PTV was uniformly contracted and expanded, with plans created for each PTV volume. STAPLE dose-volume histograms (DVHs) were exported for plans generated based on the contracted/expanded volumes, and dose-volume metrics assessed.Mainresults. The study found no strong correlations between the considered similarity metrics and modelled outcomes. Moderate correlations (0.5 <Γ< 0.7) were observed for Dice similarity coefficient, Jaccard, and mean distance to agreement metrics and rectum toxicities. The observations of this study indicate a tendency for variations in CTV contraction/expansion below 5 mm to result in minor dosimetric impacts.Significance. Contouring similarity metrics must be used with caution when interpreting them as indicators of treatment plan variation. For post-prostatectomy VMAT patients, this work showed variations in contours with an expansion/contraction of less than 5 mm did not lead to notable dosimetric differences, this should be explored in a larger dataset to assess generalisability.
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Affiliation(s)
- Viet Le Bao
- South Western Clinical School, University of New South Wales, Sydney, Australia
- Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Annette Haworth
- Institute of Medical Physics, School of Physics, University of Sydney, Australia
| | - Jason Dowling
- South Western Clinical School, University of New South Wales, Sydney, Australia
- Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Amy Walker
- South Western Clinical School, University of New South Wales, Sydney, Australia
- Ingham Institute for Applied Medical Research, Sydney, Australia
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia
| | - Sankar Arumugam
- South Western Clinical School, University of New South Wales, Sydney, Australia
- Ingham Institute for Applied Medical Research, Sydney, Australia
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
| | - Michael Jameson
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
- GenesisCare, Sydney, NSW, Australia
| | - Phillip Chlap
- South Western Clinical School, University of New South Wales, Sydney, Australia
- Ingham Institute for Applied Medical Research, Sydney, Australia
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
| | - Kirsty Wiltshire
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | - Sarah Keats
- Ingham Institute for Applied Medical Research, Sydney, Australia
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
| | - Kirrily Cloak
- South Western Clinical School, University of New South Wales, Sydney, Australia
- Ingham Institute for Applied Medical Research, Sydney, Australia
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
| | - Mark Sidhom
- South Western Clinical School, University of New South Wales, Sydney, Australia
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
| | | | - Lois Holloway
- South Western Clinical School, University of New South Wales, Sydney, Australia
- Ingham Institute for Applied Medical Research, Sydney, Australia
- Institute of Medical Physics, School of Physics, University of Sydney, Australia
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia
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9
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Gao Y, Yoon S, Ma TM, Yang Y, Sheng K, Low DA, Ballas L, Steinberg ML, Kishan AU, Cao M. Intra-fractional geometric and dose/volume metric variations of magnetic resonance imaging-guided stereotactic radiotherapy of prostate bed after radical prostatectomy. Phys Imaging Radiat Oncol 2024; 30:100573. [PMID: 38585371 PMCID: PMC10997948 DOI: 10.1016/j.phro.2024.100573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/22/2024] [Accepted: 03/22/2024] [Indexed: 04/09/2024] Open
Abstract
Background and purpose Magnetic Resonance Imaging (MRI)-guided Stereotactic body radiotherapy (SBRT) treatment to prostate bed after radical prostatectomy has garnered growing interests. The aim of this study is to evaluate intra-fractional anatomic and dose/volume metric variations for patients receiving this treatment. Materials and methods Nineteen patients who received 30-34 Gy in 5 fractions on a 0.35T MR-Linac were included. Pre- and post-treatment MRIs were acquired for each fraction (total of 75 fractions). The Clinical Target Volume (CTV), bladder, rectum, and rectal wall were contoured on all images. Volumetric changes, Hausdorff distance, Mean Distance to Agreement (MDA), and Dice similarity coefficient (DSC) for each structure were calculated. Median value and Interquartile range (IQR) were recorded. Changes in target coverage and Organ at Risk (OAR) constraints were compared and evaluated using Wilcoxon rank sum tests at a significant level of 0.05. Results Bladder had the largest volumetric changes, with a median volume increase of 48.9 % (IQR 28.9-76.8 %) and a median MDA of 5.1 mm (IQR 3.4-7.1 mm). Intra-fractional CTV volume remained stable with a median volume change of 1.2 % (0.0-4.8 %). DSC was 0.97 (IQR 0.94-0.99). For the dose/volume metrics, there were no statistically significant changes observed except for an increase in bladder hotspot and a decrease of bladder V32.5 Gy and mean dose. The CTV V95% changed from 99.9 % (IQR 98.8-100 %) to 99.6 % (IQR 93.9-100 %). Conclusion Despite intra-fractional variations of OARs, CTV coverage remained stable during MRI-guided SBRT treatments for the prostate bed.
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Affiliation(s)
- Yu Gao
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Radiation Oncology, Stanford University, Palo Alto, CA, USA
| | - Stephanie Yoon
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Radiation Oncology, City of Hope, Duarte, CA, USA
| | - Ting Martin Ma
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Yingli Yang
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Radiation Oncology, Shanghai Ruijin Hospital, China
| | - Ke Sheng
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel A. Low
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Leslie Ballas
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael L. Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
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10
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Staal FHE, Janssen J, Oprea-Lager DE, Engelen AM, van Limbergen EJ, Smeenk RJ, de Jong MAA, Budiharto TCG, Jacobs I, Haverkort DMAD, Brouwer CL, Ng Wei Siang K, Langendijk JA, Verzijlbergen JF, de Jong IJ, Noordzij W, Aluwini S. Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography-Based Clinical Target Volume Delineation Guideline for Postprostatectomy Salvage Radiation Therapy: The PERYTON Guideline. Int J Radiat Oncol Biol Phys 2024; 118:688-696. [PMID: 37729971 DOI: 10.1016/j.ijrobp.2023.09.016] [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: 06/19/2023] [Revised: 09/04/2023] [Accepted: 09/09/2023] [Indexed: 09/22/2023]
Abstract
PURPOSE Prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) scan is the standard imaging procedure for biochemical recurrent prostate cancer postprostatectomy because of its high detection rate at low serum prostate-specific antigen levels. However, existing guidelines for clinical target volume (CTV) in prostate bed salvage external beam radiation therapy (sEBRT) are primarily based on experience-based clinical consensus and have been validated using conventional imaging modalities. Therefore, this study aimed to optimize CTV definition in sEBRT by using PSMA PET/CT-detected local recurrences (LRs). METHODS AND MATERIALS Patients with suspected LR on PSMA PET/CT postprostatectomy were retrospectively enrolled in 9 Dutch centers. Anonymized scans were centrally reviewed by an expert nuclear medicine physician. Each boundary of the CTV guideline from the Groupe Francophone de Radiothérapie en Urologie (GFRU) was evaluated and adapted to improve the accuracy and coverage of the area at risk of LR (CTV) on PSMA PET/CT. The proposed CTV adaptation was discussed with the radiation oncologists of the participating centers, and final consensus was reached. To assess reproducibility, the participating centers were asked to delineate 3 new cases according to the new PERYTON-CTV, and the submitted contours were evaluated using the Dice similarity coefficient (DSC). RESULTS After central review, 93 LRs were identified on 83 PSMA PET/CTs. The proposed CTV definition improved the coverage of PSMA PET/CT-detected LRs from 67% to 96% compared with the GFRU-CTV, while reducing the GFRU-CTV by 25%. The new CTV was highly reproducible, with a mean DSC of 0.82 (range, 0.81-0.83). CONCLUSIONS This study contributes to the optimization of CTV definition in postprostatectomy sEBRT by using the pattern of LR detected on PSMA PET/CT. The PERYTON-CTV is highly reproducible across the participating centers and ensures coverage of 96% LRs while reducing the GFRU-CTV by 25%.
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Affiliation(s)
- Floor H E Staal
- Department of Radiation Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| | - Jorinde Janssen
- Department of Radiation Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Daniela E Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers - Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Evert J van Limbergen
- Department of Radiation Oncology, MAASTRO Clinic, GROW - School for Oncology and Developmental Biology, Maastricht, The Netherlands
| | - Robert Jan Smeenk
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Tom C G Budiharto
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | - Inge Jacobs
- Zuidwest Radiotherapeutisch Instituut, Vlissingen/Roosendaal, The Netherlands
| | | | - Charlotte L Brouwer
- Department of Radiation Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Kelvin Ng Wei Siang
- Department of Radiation Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J Fred Verzijlbergen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ingle Jan de Jong
- Department of Urology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Walter Noordzij
- Department of Nuclear Medicine & Molecular Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Shafak Aluwini
- Department of Radiation Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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11
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Li HZ, Qi X, Gao XS, Li XM, Qin SB, Li XY, Ma MW, Bai Y, Chen JY, Ren XY, Li XY, Wang D. Dose-Intensified Postoperative Radiation Therapy for Prostate Cancer: Long-Term Results From the PKUFH Randomized Phase 3 Trial. Int J Radiat Oncol Biol Phys 2024; 118:697-705. [PMID: 37717784 DOI: 10.1016/j.ijrobp.2023.09.011] [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: 05/24/2023] [Revised: 09/02/2023] [Accepted: 09/09/2023] [Indexed: 09/19/2023]
Abstract
PURPOSE In the randomized, single-center, PKUFH phase 3 trial, dose-intensified (72 Gy) radiation therapy was compared with conventional (66 Gy) radiation therapy. In a previous study, we found no significant difference in biochemical progression-free survival (bPFS) between the 2 cohorts at 4 years. In the current analysis, we provide 7-year outcomes. METHODS AND MATERIALS Patients with stage pT3-4, positive surgical margins, or a prostate-specific antigen increase ≥0.2 ng/mL after radical prostatectomy were randomly assigned 1:1 to receive either 72 Gy in 36 fractions or 66 Gy in 33 fractions. All the patients underwent image guided intensity modulated radiation therapy. The primary endpoint was bPFS. Secondary endpoints were distant metastasis-free survival (DMFS), cancer-specific survival (CSS), and overall survival (OS) as estimated using the Kaplan-Meier method. RESULTS Between September 2011 and November 2016, 144 patients were enrolled with 73 and 71 in the 72- and 66-Gy cohorts, respectively. At a median follow-up of 89.5 months (range, 73-97 months), there was no difference in 7-year bPFS between the 72- and 66-Gy cohorts (70.3% vs 61.2%; hazard ratio [HR], 0.73; 95% CI, 0.41-1.29; P = .274). However, in patients with a higher Gleason score (8-10), the 72-Gy cohort had statistically significant improvement in 7-year bPFS compared with the 66-Gy cohort (66.5% vs 30.2%; HR, 0.37; 95% CI, 0.17-0.82; P = .012). In addition, in patients with multiple positive surgical margins, the 72-Gy cohort had statistically significant improvement in 7-year bPFS compared with single positive surgical margin (82.5% vs 57.5%; HR, 0.36; 95% CI, 0.13-0.99; P = .037). The 7-year DMFS (88.4% vs 84.9%; HR, 0.93; 95% CI, 0.39-2.23; P = .867), CSS (94.1% vs 95.5%; HR, 1.19; 95% CI, 0.42-3.39; P = .745), and OS (92.8% vs 94.1%; HR, 1.29; 95% CI, 0.51-3.24; P = .594) had no statistical differences between the 72- and 66-Gy cohorts. CONCLUSIONS The current 7-year bPFS results confirmed our previous findings that dose escalation (72 Gy) demonstrated no improvement in 7-year bPFS, DMFS, CSS, or OS compared with the 66-Gy regimen. However, patients with a higher Gleason score (8-10) or multiple positive surgical margins might benefit from the 72-Gy regimen, but this requires further prospective research.
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Affiliation(s)
| | - Xin Qi
- Departments of Radiation Oncology and
| | | | | | | | | | | | - Yun Bai
- Departments of Radiation Oncology and
| | | | | | - Xue-Ying Li
- Medical Statistics, Peking University First Hospital, Peking University, Beijing, People's Republic of China
| | - Dian Wang
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois.
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12
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Yalman D, Köylü M, Duran Ö. Does a patient-specific bladder-filling protocol affect bladder volume and dose in postprostatectomy radiotherapy? Int Urol Nephrol 2024; 56:999-1006. [PMID: 37821762 DOI: 10.1007/s11255-023-03814-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/15/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE Our aim is to develop a patient-specific bladder-filling protocol (PSP) using an ultrasound-based bladder scanner (BS) and compare the volumetric and dosimetric parameters with those of the standard filling protocol (SP) in postprostatectomy patients. METHODS Twenty postprostatectomy patients who received salvage radiotherapy (72 Gy/36 fx) were included. For PSP, the patient was asked to drink 500 mL of water after emptying his bladder. Bladder volume was measured using BS every 10 min. Each patient's unique time to reach a 150-200 cc volume was used for simulation and treatment. For the SP, the patient was asked about the feeling of having a full bladder. Organs at risk (OAR) were contoured on cone-beam computed tomography (CBCT) scans that were transferred to the treatment planning system (TPS). Treatment plans were applied to CBCTs. Changes in bladder volume and doses for planning computed tomography (PCT) and CBCT were determined. RESULTS In the SP, there was no significant difference in mean bladder volume for PCT and CBCT (p = 0.139); however, there was a trend for significance in the mean bladder dose (p = 0.074). In PSP, there was no significant difference in the mean bladder volume or dose for PCT and CBCT (p = 0.139 and p = 0.799, respectively). There was a significant difference in terms of mean CBCT bladder volume between the two protocols (p = 0.007), whereas no significant difference was detected in terms of bladder dose (p = 0.130). CONCLUSION With PSP, optimal bladder filling was obtained and maintained throughout the whole treatment course, and it was reproducible in every fraction.
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Affiliation(s)
- Deniz Yalman
- Department of Radiation Oncology, Ege University Medical Faculty, Izmir, Turkey.
| | - Murat Köylü
- Department of Radiation Oncology, Ege University Medical Faculty, Izmir, Turkey
| | - Özge Duran
- Department of Radiation Oncology, Celal Bayar University Medical Faculty, Manisa, Turkey
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13
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Tegtmeier RC, Kutyreff CJ, Smetanick JL, Hobbis D, Laughlin BS, Toesca DAS, Clouser EL, Rong Y. Custom-Trained Deep Learning-Based Auto-Segmentation for Male Pelvic Iterative CBCT on C-Arm Linear Accelerators. Pract Radiat Oncol 2024:S1879-8500(24)00035-3. [PMID: 38325548 DOI: 10.1016/j.prro.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/21/2023] [Accepted: 01/11/2024] [Indexed: 02/09/2024]
Abstract
PURPOSE The purpose of this investigation was to evaluate the clinical applicability of a commercial artificial intelligence-driven deep learning auto-segmentation (DLAS) tool on enhanced iterative cone beam computed tomography (iCBCT) acquisitions for intact prostate and prostate bed treatments. METHODS AND MATERIALS DLAS models were trained using 116 iCBCT data sets with manually delineated organs at risk (bladder, femoral heads, and rectum) and target volumes (intact prostate and prostate bed) adhering to institution-specific contouring guidelines. An additional 25 intact prostate and prostate bed iCBCT data sets were used for model testing. Segmentation accuracy relative to a reference structure set was quantified using various geometric comparison metrics and qualitatively evaluated by trained physicists and physicians. These results were compared with those obtained for an additional DLAS-based model trained on planning computed tomography (pCT) data sets and for a deformable image registration (DIR)-based automatic contour propagation method. RESULTS In most instances, statistically significant differences in the Dice similarity coefficient (DSC), 95% directed Hausdorff distance, and mean surface distance metrics were observed between the models, as the iCBCT-trained DLAS model outperformed the pCT-trained DLAS model and DIR-based method for all organs at risk and the intact prostate target volume. Mean DSC values for the proposed method were ≥0.90 for these volumes of interest. The iCBCT-trained DLAS model demonstrated a relatively suboptimal performance for the prostate bed segmentation, as the mean DSC value was <0.75 for this target contour. Overall, 90% of bladder, 93% of femoral head, 67% of rectum, and 92% of intact prostate contours generated by the proposed method were deemed clinically acceptable based on qualitative scoring, and approximately 63% of prostate bed contours required moderate or major manual editing to adhere to institutional contouring guidelines. CONCLUSIONS The proposed method presents the potential for improved segmentation accuracy and efficiency compared with the DIR-based automatic contour propagation method as commonly applied in CBCT-based dose evaluation and calculation studies.
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Affiliation(s)
- Riley C Tegtmeier
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | | | | | - Dean Hobbis
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona; Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Brady S Laughlin
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | | | - Edward L Clouser
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona.
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14
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Staal FH, Siang KNW, Brouwer CL, Janssen J, Budiharto TC, Haverkort DM, Hollmann B, Jacobs I, De Jong MA, van de Sande MA, Vanneste BG, De Jong IJ, Verzijlbergen JF, Langendijk JA, Smeenk RJ, Aluwini S. Pretrial Quality Assurance for Hypofractionated Salvage Radiation Therapy After Prostatectomy in the Multi-Institutional PERYTON-trial. Adv Radiat Oncol 2024; 9:101379. [PMID: 38405312 PMCID: PMC10885595 DOI: 10.1016/j.adro.2023.101379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/12/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose The PERYTON trial is a multicenter randomized controlled trial that will investigate whether the treatment outcome of salvage external beam radiation therapy (sEBRT) will be improved with hypofractionated radiation therapy. A pretrial quality assurance (QA) program was undertaken to ensure protocol compliance within the PERYTON trial and to assess variation in sEBRT treatment protocols between the participating centers. Methods and Materials Completion of the QA program was mandatory for each participating center (N = 8) to start patient inclusion. The pretrial QA program included (1) a questionnaire on the center-specific sEBRT protocol, (2) a delineation exercise of the clinical target volume (CTV) and organs at risk, and (3) a treatment planning exercise. All contours were analyzed using the pairwise dice similarity coefficient (DSC) and the 50th and 95th percentile Hausdorff distance (HD50 and HD95, respectively). The submitted treatment plans were reviewed for protocol compliance. Results The results of the questionnaire showed that high-quality, state-of-the-art radiation therapy techniques were used in the participating centers and identified variations of the sEBRT protocols used concerning the position verification and preparation techniques. The submitted CTVs showed significant variation, with a range in volume of 29 cm3 to 167 cm3, a mean pairwise DSC of 0.52, and a mean HD50 and HD95 of 2.3 mm and 24.4 mm, respectively. Only in 1 center the treatment plan required adaptation before meeting all constraints of the PERYTON protocol. Conclusions The pretrial QA of the PERYTON trial demonstrated that high-quality, but variable, radiation techniques were used in the 8 participating centers. The treatment planning exercise confirmed that the dose constraints of the PERYTON protocol were feasible for all participating centers. The observed variation in CTV delineation led to agreement on a new (image-based) delineation guideline to be used by all participating centers within the PERYTON trial.
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Affiliation(s)
- Floor H.E. Staal
- Department of Radiation Oncology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Kelvin Ng Wei Siang
- Department of Radiation Oncology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Charlotte L. Brouwer
- Department of Radiation Oncology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jorinde Janssen
- Department of Radiation Oncology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Tom C.G. Budiharto
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Birgit Hollmann
- Department of Radiation Oncology, HAGA Ziekenhuis, Den Haag, The Netherlands
| | - Inge Jacobs
- Zuidwest Radiotherapy Institute Vlissingen/Roosendaal, Vlissingen, The Netherlands
| | | | | | - Ben G.L. Vanneste
- Department of Radiation Oncology, MAASTRO Clinic, GROW—School for Oncology and Developmental Biology, Maastricht, The Netherlands
| | - Igle Jan De Jong
- Department of Urology, University Medical Centre Groningen, Groningen, The Netherlands
| | - J. Fred Verzijlbergen
- Department of Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Johannes A. Langendijk
- Department of Radiation Oncology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Robert Jan Smeenk
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Shafak Aluwini
- Department of Radiation Oncology, University Medical Centre Groningen, Groningen, The Netherlands
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Sritharan K, Akhiat H, Cahill D, Choi S, Choudhury A, Chung P, Diaz J, Dysager L, Hall W, Huddart R, Kerkmeijer LGW, Lawton C, Mohajer J, Murray J, Nyborg CJ, Pos FJ, Rigo M, Schytte T, Sidhom M, Sohaib A, Tan A, van der Voort van Zyp J, Vesprini D, Zelefsky MJ, Tree AC. Development of Prostate Bed Delineation Consensus Guidelines for Magnetic Resonance Image-Guided Radiotherapy and Assessment of Its Effect on Interobserver Variability. Int J Radiat Oncol Biol Phys 2024; 118:378-389. [PMID: 37633499 DOI: 10.1016/j.ijrobp.2023.08.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023]
Abstract
PURPOSE The use of magnetic resonance imaging (MRI) in radiotherapy planning is becoming more widespread, particularly with the emergence of MRI-guided radiotherapy systems. Existing guidelines for defining the prostate bed clinical target volume (CTV) show considerable heterogeneity. This study aimed to establish baseline interobserver variability (IOV) for prostate bed CTV contouring on MRI, develop international consensus guidelines, and evaluate its effect on IOV. METHODS AND MATERIALS Participants delineated the CTV on 3 MRI scans, obtained from the Elekta Unity MR-Linac, as per their normal practice. Radiation oncologist contours were visually examined for discrepancies, and interobserver comparisons were evaluated against simultaneous truth and performance level estimation (STAPLE) contours using overlap metrics (Dice similarity coefficient and Cohen's kappa), distance metrics (mean distance to agreement and Hausdorff distance), and volume measurements. A literature review of postradical prostatectomy local recurrence patterns was performed and presented alongside IOV results to the participants. Consensus guidelines were collectively constructed, and IOV assessment was repeated using these guidelines. RESULTS Sixteen radiation oncologists' contours were included in the final analysis. Visual evaluation demonstrated significant differences in the superior, inferior, and anterior borders. Baseline IOV assessment indicated moderate agreement for the overlap metrics while volume and distance metrics demonstrated greater variability. Consensus for optimal prostate bed CTV boundaries was established during a virtual meeting. After guideline development, a decrease in IOV was observed. The maximum volume ratio decreased from 4.7 to 3.1 and volume coefficient of variation reduced from 40% to 34%. The mean Dice similarity coefficient rose from 0.72 to 0.75 and the mean distance to agreement decreased from 3.63 to 2.95 mm. CONCLUSIONS Interobserver variability in prostate bed contouring exists among international genitourinary experts, although this is lower than previously reported. Consensus guidelines for MRI-based prostate bed contouring have been developed, and this has resulted in an improvement in contouring concordance. However, IOV persists and strategies such as an education program, development of a contouring atlas, and further refinement of the guidelines may lead to additional improvements.
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Affiliation(s)
- Kobika Sritharan
- Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom.
| | | | - Declan Cahill
- Department of Urology, Royal Marsden Hospital NHS Trust, London, United Kingdom
| | - Seungtaek Choi
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Ananya Choudhury
- Christie National Health Service Foundation Trust, Manchester, United Kingdom; University of Manchester, Manchester, United Kingdom
| | - Peter Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Lars Dysager
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - William Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert Huddart
- Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom
| | - Linda G W Kerkmeijer
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Colleen Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Julia Murray
- Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom
| | | | - Floris J Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michele Rigo
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar Di Valpolicella, Italy
| | - Tine Schytte
- Department of Oncology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mark Sidhom
- Cancer Therapy Centre, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Aslam Sohaib
- Department of Radiology, Royal Marsden Hospital NHS Trust, Sutton, United Kingdom
| | - Alex Tan
- Sunshine Coast Hospital and Health Service, Queensland, Australia; James Cook University, Townsville, Queensland, Australia
| | | | - Danny Vesprini
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alison C Tree
- Royal Marsden NHS Foundation Trust, Sutton, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, Sutton, United Kingdom
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Armstrong WR, Kishan AU, Booker KM, Grogan TR, Elashoff D, Lam EC, Clark KJ, Steinberg ML, Fendler WP, Hope TA, Nickols NG, Czernin J, Calais J. Impact of Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography on Prostate Cancer Salvage Radiotherapy Management: Results from a Prospective Multicenter Randomized Phase 3 Trial (PSMA-SRT NCT03582774). Eur Urol 2024:S0302-2838(24)00013-7. [PMID: 38290964 DOI: 10.1016/j.eururo.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/12/2023] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Both imaging and several prognostic factors inform the planning of salvage radiotherapy (SRT). Prostate-specific membrane antigen positron emission tomography (PSMA-PET) can localize disease unseen by other imaging modalities. OBJECTIVE To evaluate the impact of PSMA-PET on biochemical recurrence-free survival rate after SRT. DESIGN, SETTING, AND PARTICIPANTS This prospective randomized, controlled, phase 3 clinical trial randomized 193 patients with biochemical recurrence of prostate cancer after radical prostatectomy to proceed with SRT (control arm, n = 90) or undergo a PSMA-PET/computed tomography (CT) scan prior to SRT planning (investigational arm, n = 103) from June 2018 to August 2020. Any other approved imaging modalities were allowed in both arms (including fluciclovine-PET). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS This is a secondary endpoint analysis: impact of PSMA-PET on SRT planning. Case-report forms were sent to referring radiation oncologists to collect the management plans before randomization and after completion of SRT. The relative frequency (%) of management changes within each arm were compared using chi-square and Fisher's exact tests. RESULTS AND LIMITATIONS The delivered SRT plan was available in 178/193 patients (92.2%; 76/90 control [84.4%] and 102/103 PSMA-PET [99%]). Median prostate-specific antigen levels at enrollment was 0.30 ng/ml (interquartile range [IQR] 0.19-0.91) in the control arm and 0.23 ng/ml (IQR 0.15-0.54) in the PSMA-PET arm. Fluciclovine-PET was used in 33/76 (43%) in the control arm. PSMA-PET localized recurrence(s) in 38/102 (37%): nine of 102 (9%) outside of the pelvis (M1), 16/102 (16%) in the pelvic LNs (N1, with or without local recurrence), and 13/102 (13%) in the prostate fossa only. There was a 23% difference (95% confidence interval [CI] 9-35%, p = 0.002) of frequency of major changes between the control arm (22% [17/76]) and the PSMA-PET intervention arm (45% [46/102]). Of the major changes in the intervention group, 33/46 (72%) were deemed related to PSMA-PET. There was a 17.6% difference (95% CI 5.4-28.5%, p = 0.005) of treatment escalation frequency between the control arm (nine of 76 [12%]) and the intervention arm (30/102 [29%]). Treatment de-escalation occurred in the control and intervention arms in eight of 76 (10.5%) and 12/102 (11.8%) patients, and mixed changes in zero of 76 (0%) and four of 102 (3.9%) patients, respectively. CONCLUSIONS In this prospective randomized phase 3 study, PSMA-PET findings provided information that initiated major management changes to SRT planning in 33/102 (33%) patients. The final readout of the primary endpoint planned in 2025 may provide evidence on whether these changes result in improved outcomes. PATIENT SUMMARY Prostate-specific membrane antigen positron emission tomography leads to management changes in one-third of patients receiving salvage radiotherapy for post-radical prostatectomy biochemical recurrence of prostate cancer.
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Affiliation(s)
- Wesley R Armstrong
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA; UCLA-Caltech Medical Scientist Training Program, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA; Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Kiara M Booker
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Tristan R Grogan
- Department of Medicine Statistics Core (DOMStat), David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - David Elashoff
- Department of Medicine Statistics Core (DOMStat), David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Ethan C Lam
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Kevyn J Clark
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA; Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Wolfgang P Fendler
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA; Department of Nuclear Medicine, University of Duisburg-Essen and German Cancer Consortium (DKTK) - University Hospital Essen, Essen, Germany
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Nicholas G Nickols
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA; Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, USA; Department of Radiation Oncology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Johannes Czernin
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA; Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Jeremie Calais
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA; Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, USA.
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Sayyid RK, Bernardino R, Al-Daqqaq Z, Tiwari R, Cockburn J, Vijayakanthan S, Leão R, Qaoud Y, Berjaoui MB, Metser U, Berlin A, Fleshner NE. Mesorectal nodal metastasis with seminal vesicle invasion in biochemically recurrent prostate cancer. BJU Int 2023; 132:664-670. [PMID: 37433574 DOI: 10.1111/bju.16123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
OBJECTIVES To determine the prevalence and predictors of mesorectal lymph node (MLN) metastases on prostate-specific membrane antigen (PSMA)-based positron emission tomography/computed tomography (PET/CT) in patients with biochemically recurrent prostate cancer (PCa) following radical therapy. MATERIALS AND METHODS This was a cross-sectional analysis of all PCa patients with biochemical failure following radical prostatectomy or radiotherapy who underwent an 18 F-DCFPyL-PSMA-PET/CT at the Princess Margaret Cancer Centre between December 2018 and February 2021. Lesions with PSMA scores ≥2 were considered positive for PCa involvement (PROMISE classification). Predictors of MLN metastasis were evaluated using univariable and multivariable logistic regression analyses. RESULTS Our cohort consisted of 686 patients. The primary treatment method was radical prostatectomy and radiotherapy in 528 (77.0%) and 158 patients (23.0%), respectively. The median serum PSA level was 1.15 ng/mL. Overall, 384 patients (56.0%) had a positive scan. Seventy-eight patients (11.3%) had MLN metastasis, with 48/78 (61.5%) having MLN involvement as the only site of metastasis. On multivariable analysis, presence of pT3b disease (odds ratio 4.31, 95% confidence interval 1.44-14.2; P = 0.011) was significantly associated with increased odds of MLN metastasis, whereas surgical factors (radical prostatectomy vs radiotherapy; performance/extent of pelvic nodal dissection), surgical margin positivity, and Gleason Grade were not. CONCLUSIONS In this study, 11.3% of PCa patients with biochemical failure had MLN metastasis on 18 F-DCFPyL-PET/CT. pT3b disease was associated with 4.31-fold significantly increased odds of MLN metastasis. These findings suggest alternate drainage routes for PCa cells, either via alternate lymphatic drainage from the seminal vesicles themselves or secondary to direct extension from posteriorly located tumours invading the seminal vesicles.
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Affiliation(s)
- Rashid K Sayyid
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Rui Bernardino
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Zizo Al-Daqqaq
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Raj Tiwari
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Jessica Cockburn
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | | | - Ricardo Leão
- Faculty of Medicine of the University of Coimbra, Coimbra, Portugal
- Urology, CUF Hospitals, Lisbon, Portugal
| | - Yazan Qaoud
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Mohamad Baker Berjaoui
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Ur Metser
- Joint Department of Medical Imaging, University Health Network, Toronto, ON, Canada
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Neil E Fleshner
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
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Ah-Thiane L, Sargos P, Chapet O, Jolicoeur M, Terlizzi M, Salembier C, Boustani J, Prevost C, Gaudioz S, Derashodian T, Palumbo S, De Hertogh O, Créhange G, Zilli T, Supiot S. Managing postoperative biochemical relapse in prostate cancer, from the perspective of the Francophone group of Urological radiotherapy (GFRU). Cancer Treat Rev 2023; 120:102626. [PMID: 37734178 DOI: 10.1016/j.ctrv.2023.102626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/23/2023]
Abstract
Up to 50% of patients treated with radical surgery for localized prostate cancer may experience biochemical recurrence that requires appropriate management. Definitions of biochemical relapse may vary, but, in all cases, consist of an increase in a PSA without clinical or radiological signs of disease. Molecular imaging through to positron emission tomography has taken a preponderant place in relapse diagnosis, progressively replacing bone scan and CT-scan. Prostate bed radiotherapy is currently a key treatment, the action of which should be potentiated by androgen deprivation therapy. Nowadays perspectives consist in determining the best combination therapies, particularly thanks to next-generation hormone therapies, but not exclusively. Several trials are ongoing and should address these issues. We present here a literature review aiming to discuss the current management of biochemical relapse in prostate cancer after radical surgery, in lights of recent findings, as well as future perspectives.
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Affiliation(s)
- Loic Ah-Thiane
- Department of Radiation Oncology, ICO René Gauducheau, St-Herblain, France
| | - Paul Sargos
- Department of Radiation Oncology, Bergonie Institute, Bordeaux, France
| | - Olivier Chapet
- Department of Radiation Oncology, CHU Lyon Sud, Pierre-Bénite, France
| | - Marjory Jolicoeur
- Department of Radiation Oncology, Charles Le Moyne Hospital, Montreal, Canada
| | - Mario Terlizzi
- Department of Radiation Oncology, Gustave Roussy Cancer Center, Villejuif, France
| | - Carl Salembier
- Department of Radiation Oncology, Europe Hospitals Brussels, Belgium
| | - Jihane Boustani
- Department of Radiation Oncology, CHU Besançon, Besançon, France
| | - Célia Prevost
- Department of Radiation Oncology, CHU Lyon Sud, Pierre-Bénite, France
| | - Sonya Gaudioz
- Department of Radiation Oncology, CHU Lyon Sud, Pierre-Bénite, France
| | - Talar Derashodian
- Department of Radiation Oncology, Sindi Ahluwalia Hawkins Centre, Kelowna, Canada
| | - Samuel Palumbo
- Department of Radiation Oncology, CHU UCL Namur-Sainte Elisabeth, Namur, Belgium
| | - Olivier De Hertogh
- Department of Radiation Oncology, CHR Verviers East Belgium, Verviers, Belgium
| | - Gilles Créhange
- Department of Radiation Oncology, Curie Institute, Saint-Cloud, France
| | - Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Stéphane Supiot
- Department of Radiation Oncology, ICO René Gauducheau, St-Herblain, France.
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19
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Le Guevelou J, Magne N, Counago F, Magsanoc JM, Vermeille M, De Crevoisier R, Benziane-Ouaritini N, Ost P, Niazi T, Supiot S, Sargos P. Stereotactic body radiation therapy after radical prostatectomy: current status and future directions. World J Urol 2023; 41:3333-3344. [PMID: 37725131 DOI: 10.1007/s00345-023-04605-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 08/28/2023] [Indexed: 09/21/2023] Open
Abstract
PURPOSE Around 40% of men with intermediate-risk or high-risk prostate cancer will experience a biochemical recurrence after radical prostatectomy (RP). The aim of this review is to describe both toxicity and oncological outcomes following stereotactic body radiation therapy (SBRT) delivered to the prostate bed (PB). METHOD In april 2023, we performed a systematic review of studies published in MEDLINE or ClinicalTrials.gov according to Preferred Reporting Items for Systematic Reviews, using the keywords "stereotactic radiotherapy" AND "postoperative" AND "prostate cancer". RESULTS A total of 14 studies assessing either adjuvant or salvage SBRT to the whole PB or macroscopic local recurrence (MLR) within the PB, and SBRT on radiorecurrent MLR within the PB were included. Doses delivered to either whole PB or MLR between 30 to 40 Gy are associated with a low rate of late grade ≥ 2 genitourinary (GU) toxicity, ranging from 2.2 to 15.1%. Doses above 40 Gy are associated with increased rate of late GU toxicity, raising up to 38%. Oncological outcomes should be interpreted with caution, due to both short follow-up, heterogeneous populations and androgen deprivation therapy (ADT) use. CONCLUSION PB or MLR SBRT delivered at doses up to 40 Gy appears safe with relatively low late severe GU toxicity rates. Caution is needed with dose-escalated RT schedules above 40 Gy. Further prospective trials are eagerly awaited in this disease setting.
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Affiliation(s)
| | - Nicolas Magne
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
| | - Felipe Counago
- Radiation Oncology Department, GenesisCare Madrid Clinical Director, San Francisco de Asis and La Milagrosa Hospitals, National Chair of Research and Clinical Trials, GenesisCare, Madrid, Spain
| | | | - Matthieu Vermeille
- Radiation Oncology Department, Genolier Swiss Radio-Oncology Network, Genolier, Switzerland
| | | | | | - Piet Ost
- Radiation Oncology Department, Iridium Network, Antwerp, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Tamim Niazi
- Department of Radiation Oncology, Jewish General Hospital, Montreal, QC, Canada
| | - Stéphane Supiot
- Radiation Oncology Department, Institut de Cancérologie de L'Ouest, Nantes, France
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France.
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Grierson E, Wilkinson D, Causer L, de Leon J. Evaluating the geometric and dosimetric impact of applying anisotropic CTV to PTV margins in image-guided post-prostatectomy radiation therapy. J Med Imaging Radiat Oncol 2023; 67:796-805. [PMID: 37454334 DOI: 10.1111/1754-9485.13563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Guidelines for clinical target volume (CTV) to planning target volume (PTV) margins in post-prostatectomy radiation therapy (PPRT) are varied and often not clearly defined. Assessment of appropriateness of margins is commonly measured on prevalence of geographic miss. METHODS Cone-beam CT (CBCT) images (n = 92) for 10 PPRT patients were incorporated to provide on-treatment information on the appropriateness of six different CTV expansion margins in terms of geographic miss and change in dose-volume statistics for CTV, rectum and bladder. Uniform margins included 10 mm, 5 mm, 10 mm + 5 mm posteriorly and 5 mm + 3 mm posteriorly. In addition, two anisotropic margins were evaluated by separating the superior and inferior portions of the CTV before expansion. Treatment plans were created for each PTV retrospectively. RESULTS The frequency of geographic miss was the smallest for the large uniform expansions but resulted in the highest organ-at-risk (OAR) doses. Geographic miss in the smaller uniform and anisotropic PTVs was more prevalent but commonly to a small volume < 1% of CTV. When averaged over all CBCT fractions, V95% dose for all CTV margins remained > 99%. The anisotropic expansions generated smaller irradiated target volumes and consequently saw up to 7.3% reduction in bladder dose when compared with similar uniform expansion margins. CONCLUSION Supplementing the incidence of geographic miss with dosimetric information on target coverage and OAR doses provides more informed assessment of the appropriateness of different CTV expansion margins. Our study extends the evaluation of anisotropic margins for PPRT.
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Affiliation(s)
- Emma Grierson
- Illawarra Cancer Care Centre, Wollongong, New South Wales, Australia
| | - Dean Wilkinson
- Illawarra Cancer Care Centre, Wollongong, New South Wales, Australia
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia
| | - Lauren Causer
- Illawarra Cancer Care Centre, Wollongong, New South Wales, Australia
| | - Jeremiah de Leon
- Illawarra Cancer Care Centre, Wollongong, New South Wales, Australia
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21
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Huang HF, Gao XX, Li Q, Ma XY, Du LN, Sun PF, Li S. Dosimetric comparison between stereotactic body radiotherapy and carbon-ion radiation therapy for prostate cancer. Quant Imaging Med Surg 2023; 13:6965-6978. [PMID: 37869307 PMCID: PMC10585578 DOI: 10.21037/qims-23-340] [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: 03/17/2023] [Accepted: 08/25/2023] [Indexed: 10/24/2023]
Abstract
Background Prostate cancer rates have been steadily increasing in recent years. As high-precision radiation therapy methods, stereotactic body radiation therapy (SBRT) and carbon-ion radiation therapy (CIRT) have unique advantages. Analyzing the dosimetric differences between SBRT and CIRT in the treatment of localized prostate cancer can help provide patients with more accurate, individualized treatment plans. Methods We selected computed tomography positioning images and the contours of target volumes of 16 patients with localized prostate cancer who received radiotherapy. We delineated the organs at risk (OARs) on the CyberKnife (CK) treatment planning system (TPS) MultiPlan4.0, which were imported into the CIRT uniform scanning TPS HIMM-1 ci-Plan. Two treatment plans, SBRT and CIRT, were designed for the same patient, and we used SPSS 22.0 for the statistical analysis of data. Results Both SBRT and CIRT plans met the prescribed dose requirements. In terms of target volume exposure dose, D2 (P<0.001), D5 (P<0.001), D50 (P<0.001), D90 (P=0.029), D95 (P<0.001), D98 (P<0.001), and Dmean (P<0.001) under SBRT were significantly higher than those under CIRT; the conformity index (CI) under SBRT was significantly better than that under CIRT (P<0.001); the target volume coverage rate (V95%) and dose homogeneity index (HI) under CIRT were significantly better than those under SBRT (P<0.001). In terms of OAR exposure dosage, the Dmax of the bladder and rectum under SBRT was significantly lower than that under CIRT (P<0.001), but Dmean was in the other direction; the exposure dose of the intestinal tract under CIRT was significantly lower than that under SBRT (P<0.05); Dmax of the femoral head under CIRT was significantly lower than that under SBRT (P<0.05), and there was no statistical difference between them at other doses. Conclusions In this study, we found that when CIRT was used for treating localized prostate cancer, the dose distribution in target volume was more homogeneous and the coverage rate was higher; the average dose of OARs was lower. SBRT had a better CI and higher dose in target volume; the dose hotspot was lower in OARs. It is important to comprehensively consider the dose relationship between local tumor and surrounding tissues when selecting treatment plans.
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Affiliation(s)
- He-Fa Huang
- Department of Irradiation Oncology, the 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army, Lanzhou, China
- School of Nuclear Science and Technology, Lanzhou University, Lanzhou, China
| | - Xing-Xin Gao
- Department of Irradiation Oncology, the 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army, Lanzhou, China
| | - Qiang Li
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
| | - Xiao-Yun Ma
- Heavy Ion Center, Wuwei Cancer Hospital, Wuwei, China
| | - Lan-Ning Du
- Department of Radiotherapy, The First Hospital of Lanzhou University, Lanzhou, China
| | - Peng-Fei Sun
- Department of Radiotherapy, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Sha Li
- Department of Irradiation Oncology, the 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army, Lanzhou, China
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22
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Shakespeare TP, Yap SZL, Hsieh M, Tahir ARM, Armstrong S. Prostate-specific membrane antigen positron emission tomography detected local failure after post-prostatectomy radiation therapy: Low rates of out-of-field recurrence validates current Australian prostate bed contouring guidelines. J Med Imaging Radiat Oncol 2023; 67:662-667. [PMID: 37401187 DOI: 10.1111/1754-9485.13556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 06/26/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION The Australian Faculty of Radiation Oncology Genitourinary Group (FROGG) developed prostate bed clinical target volume (CTV) contouring guidelines which were subsequently used to develop the National EviQ guidelines for adjuvant and salvage post-prostatectomy radiotherapy (PPRT). These guidelines were based mainly upon consensus agreement. With the advent of prostate-specific membrane antigen (PSMA) positron emission tomography (PET), sites of recurrence can now be detected with low prostate-specific antigen (PSA) levels following radical prostatectomy. We evaluated sites of recurrence in patients treated with FROGG/EviQ CTVs to inform upcoming modifications of these guidelines. METHODS At our institution, we use the FROGG/EviQ guidelines for PPRT. From 2015, patients with PSA failure following PPRT have been re-staged using PSMA PET imaging. We identified patients with PET-avid local, nodal, and distant recurrences, fusing them with original treatment plans to determine whether recurrences were within or outside the prostate bed CTV. Regional nodal failures were reviewed to determine if they were within current elective node contouring guidelines. RESULTS Ninety-four patients had positive PSMA PET following PPRT. Nine (9.6%) recurrences were local, seven being local-only. One local recurrence (1.1%) was just superior to the contoured prostate bed CTV, located within the vas deferens. Seventy-three (77.7%) patients had a component of node failure, with 56 (59.6%) having node-only failure. Sites of nodal relapses were covered by standard contouring guidelines 60.3% of the time. CONCLUSION The low recurrence rate outside of current prostate bed CTV contouring guidelines is consistent with other studies using contemporary contouring, and validates the efficacy of the current FROGG/EviQ prostate bed CTV definition.
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Affiliation(s)
- Thomas Philip Shakespeare
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Shaun Zheng Liang Yap
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Michael Hsieh
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Abdul Rahim Mohd Tahir
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Shreya Armstrong
- Department of Radiation Oncology, North Coast Cancer Institute, Lismore Base Hospital, Lismore, New South Wales, Australia
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Marciscano AE, Wolfe S, Zhou XK, Barbieri CE, Formenti SC, Hu JC, Molina AM, Nanus DM, Nauseef JT, Scherr DS, Sternberg CN, Tagawa ST, Nagar H. Randomized phase II trial of MRI-guided salvage radiotherapy for prostate cancer in 4 weeks versus 2 weeks (SHORTER). BMC Cancer 2023; 23:781. [PMID: 37608258 PMCID: PMC10463903 DOI: 10.1186/s12885-023-11278-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Ultra-hypofractionated image-guided stereotactic body radiotherapy (SBRT) is increasingly used for definitive treatment of localized prostate cancer. Magnetic resonance imaging-guided radiotherapy (MRgRT) facilitates improved visualization, real-time tracking of targets and/or organs-at-risk (OAR), and capacity for adaptive planning which may translate to improved targeting and reduced toxicity to surrounding tissues. Given promising results from NRG-GU003 comparing conventional and moderate hypofractionation in the post-operative setting, there is growing interest in exploring ultra-hypofractionated post-operative regimens. It remains unclear whether this can be done safely and whether MRgRT may help mitigate potential toxicity. SHORTER (NCT04422132) is a phase II randomized trial prospectively evaluating whether salvage MRgRT delivered in 5 fractions versus 20 fractions is non-inferior with respect to gastrointestinal (GI) and genitourinary (GU) toxicities at 2-years post-treatment. METHODS A total of 136 patients will be randomized in a 1:1 ratio to salvage MRgRT in 5 fractions or 20 fractions using permuted block randomization. Patients will be stratified according to baseline Expanded Prostate Cancer Index Composite (EPIC) bowel and urinary domain scores as well as nodal treatment and androgen deprivation therapy (ADT). Patients undergoing 5 fractions will receive a total of 32.5 Gy over 2 weeks and patients undergoing 20 fractions will receive a total of 55 Gy over 4 weeks, with or without nodal coverage (25.5 Gy over 2 weeks and 42 Gy over 4 weeks) and ADT as per the investigator's discretion. The co-primary endpoints are change scores in the bowel and the urinary domains of the EPIC. The change scores will reflect the 2-year score minus the pre-treatment (baseline) score. The secondary endpoints include safety endpoints, including change in GI and GU symptoms at 3, 6, 12 and 60 months from completion of treatment, and efficacy endpoints, including time to progression, prostate cancer specific survival and overall survival. DISCUSSION The SHORTER trial is the first randomized phase II trial comparing toxicity of ultra-hypofractionated and hypofractionated MRgRT in the salvage setting. The primary hypothesis is that salvage MRgRT delivered in 5 fractions will not significantly increase GI and GU toxicities when compared to salvage MRgRT delivered in 20 fractions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04422132. Date of registration: June 9, 2020.
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Affiliation(s)
- Ariel E Marciscano
- Department of Radiation Oncology, Weill Cornell Medicine/NewYork-Presbyterian, 525 East 68th Street, Box 169, New York, NY, N-046, USA.
| | - Sydney Wolfe
- Department of Radiation Oncology, Weill Cornell Medicine/NewYork-Presbyterian, 525 East 68th Street, Box 169, New York, NY, N-046, USA
| | - Xi Kathy Zhou
- Department of Population Health Sciences, Division of Biostatistics, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
| | - Christopher E Barbieri
- Department of Urology, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
- Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
- Englander Institute for Precision Medicine, Weill Cornell Medicine/New York-Presbyterian, New York, NY, USA
| | - Silvia C Formenti
- Department of Radiation Oncology, Weill Cornell Medicine/NewYork-Presbyterian, 525 East 68th Street, Box 169, New York, NY, N-046, USA
- Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
| | - Jim C Hu
- Department of Urology, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
| | - Ana M Molina
- Englander Institute for Precision Medicine, Weill Cornell Medicine/New York-Presbyterian, New York, NY, USA
- Division of Hematology/Oncology, Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
| | - David M Nanus
- Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
- Division of Hematology/Oncology, Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
| | - Jones T Nauseef
- Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
- Englander Institute for Precision Medicine, Weill Cornell Medicine/New York-Presbyterian, New York, NY, USA
- Division of Hematology/Oncology, Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
| | - Douglas S Scherr
- Department of Urology, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
| | - Cora N Sternberg
- Englander Institute for Precision Medicine, Weill Cornell Medicine/New York-Presbyterian, New York, NY, USA
- Division of Hematology/Oncology, Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
| | - Scott T Tagawa
- Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
- Englander Institute for Precision Medicine, Weill Cornell Medicine/New York-Presbyterian, New York, NY, USA
- Division of Hematology/Oncology, Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian, New York, NY, USA
| | - Himanshu Nagar
- Department of Radiation Oncology, Weill Cornell Medicine/NewYork-Presbyterian, 525 East 68th Street, Box 169, New York, NY, N-046, USA
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Dubinsky P, Vojtek V, Belanova K, Janickova N, Balazova N, Tomkova Z. Hypofractionated Post-Prostatectomy Radiotherapy in 16 Fractions: A Single-Institution Outcome. Life (Basel) 2023; 13:1610. [PMID: 37511985 PMCID: PMC10381816 DOI: 10.3390/life13071610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The optimal hypofractionated schedule of post-prostatectomy radiotherapy remains to be established. We evaluated treatment outcomes and toxicity of moderately hypofractionated post-prostatectomy radiotherapy in 16 daily fractions delivered with intensity-modulated radiotherapy. The treatment schedule selection was motivated by limited technology resources and was radiobiologically dose-escalated. METHODS One hundred consecutive M0 patients with post-prostatectomy radiotherapy were evaluated. Radiotherapy indication was adjuvant (ART) in 19%, early-salvage (eSRT) in 46% and salvage (SRT) in 35%. The dose prescription for prostate bed planning target volume was 52.8 Gy in 16 fractions of 3.3 Gy. The Common Terminology Criteria v. 4 for Adverse Events scale was used for toxicity grading. RESULTS The median follow-up was 61 months. Five-year biochemical recurrence-free survival (bRFS) was 78.6%, distant metastases-free survival (DMFS) was 95.7% and overall survival was 98.8%. Treatment indication (ART or eSRT vs. SRT) was the only significant factor for bRFS (HR 0.15, 95% CI 0.05-0.47, p = 0.001) and DMFS (HR 0.16, 95% CI 0.03-0.90; p = 0.038). Acute gastrointestinal (GI) toxicity grade 2 was recorded in 24%, grade 3 in 2%, acute genitourinary (GU) toxicity grade 2 in 10% of patients, and no grade 3. A cumulative rate of late GI toxicity grade ≥ 2 was observed in 9% and late GU toxicity grade ≥ 2 in 16% of patients. CONCLUSIONS The observed results confirmed efficacy and showed a higher than anticipated rate of early GI, late GI, and GU toxicity of post-prostatectomy radiobiologically dose-escalated hypofractionated radiotherapy in 16 daily fractions.
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Affiliation(s)
- Pavol Dubinsky
- Department of Radiation Oncology, East Slovakia Institute of Oncology, 041 91 Kosice, Slovakia
- Faculty of Health, Catholic University in Ruzomberok, 034 01 Ruzomberok, Slovakia
| | - Vladimir Vojtek
- Department of Radiation Oncology, East Slovakia Institute of Oncology, 041 91 Kosice, Slovakia
| | - Katarina Belanova
- Department of Radiation Oncology, East Slovakia Institute of Oncology, 041 91 Kosice, Slovakia
| | - Natalia Janickova
- Department of Radiation Oncology, East Slovakia Institute of Oncology, 041 91 Kosice, Slovakia
| | - Noemi Balazova
- Department of Radiation Oncology, East Slovakia Institute of Oncology, 041 91 Kosice, Slovakia
| | - Zuzana Tomkova
- Department of Radiation Oncology, East Slovakia Institute of Oncology, 041 91 Kosice, Slovakia
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Hjelle LV, Sælen M, Aarsæther E, Knutsen T, Andersen S, Bentzen AG, Richardsen E, Wilsgaard T, Fosså SD, Haugnes HS. The Longitudinal Course of Prospectively Recorded Patient-reported Outcomes in Prostate Cancer Patients Treated with Surgery and Salvage Radiotherapy. EUR UROL SUPPL 2023; 53:6-15. [PMID: 37441342 PMCID: PMC10334245 DOI: 10.1016/j.euros.2023.04.005] [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] [Accepted: 04/05/2023] [Indexed: 07/15/2023] Open
Abstract
Background Patient-reported outcome measures (PROMs) after prostate cancer (PC) treatment, including both radical prostatectomy (RP) and salvage radiation therapy (SRT), are under-reported. Objective To investigate PROMs longitudinally from before SRT until 18 mo after SRT for men treated with contemporary treatment modalities. Design setting and participants This prospective, longitudinal cohort study included 120 men (whole cohort) treated with SRT administered with volumetric modulated arc radiotherapy from 2016 to 2021 at the University Hospital of North Norway. The whole cohort was followed from before SRT until 18 mo after SRT. A subcohort of 48 men was followed from before RP until 18 mo after SRT. Outcome measurements and statistical analysis PROMs were collected with the Expanded Prostate Cancer Index-26 (EPIC-26), covering symptoms of urinary incontinence, urinary irritative, bowel, sexual, and hormonal domains. The domain scores were inquired before RP, 3 mo after RP, before SRT, at SRT termination, and 3 and 18 mo after SRT. We used linear mixed models with repeated measurements design to assess changes in PROMs throughout the treatment period. Results and limitations The median age before SRT was 63 yr. For the whole cohort, all five domains worsened at 3 and 18 mo after SRT compared with those before SRT. The estimated mean changes from before SRT to 18 mo after SRT are as follows: urinary incontinence -13.1, urinary irritative function -10.4, bowel -16.8, sexual function -9.1, and hormonal function -20.2 (at clinically important levels for all domains but sexual). For the subcohort, the mean urinary incontinence, bowel, sexual, and hormonal functions were significantly worsened 3 and 18 mo after SRT compared with those before RP at clinically important levels. Conclusions Men treated for PC report particular increased severity of urinary, bowel, sexual, and hormonal symptoms after SRT compared with baseline status. Patient summary For men with prostate cancer, the treatment combination of surgery and salvage radiotherapy worsens urinary incontinence and bowel, sexual, and hormonal functions.
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Affiliation(s)
- Line V. Hjelle
- Department of Oncology, University Hospital of North Norway, Tromsø, Norway
| | - Marie Sælen
- Department of Oncology, University Hospital of North Norway, Tromsø, Norway
| | - Erling Aarsæther
- Department of Urology, University Hospital of North Norway, Tromsø, Norway
| | - Tore Knutsen
- Department of Urology, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UIT The Artic University, Tromsø, Norway
| | - Sigve Andersen
- Department of Oncology, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UIT The Artic University, Tromsø, Norway
| | - Anne G. Bentzen
- Department of Oncology, University Hospital of North Norway, Tromsø, Norway
| | - Elin Richardsen
- Department of Pathology, University Hospital of North Norway, Tromsø, Norway
| | - Tom Wilsgaard
- Institute of Community Medicine, UIT-The Artic University, Tromsø, Norway
| | - Sophie D. Fosså
- Division of Cancer Medicine and Radiotherapy, Oslo University Hospital, Oslo, Norway
| | - Hege S. Haugnes
- Department of Oncology, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UIT The Artic University, Tromsø, Norway
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Dal Pra A, Dirix P, Khoo V, Carrie C, Cozzarini C, Fonteyne V, Ghadjar P, Gomez-Iturriaga A, Panebianco V, Zapatero A, Bossi A, Wiegel T. ESTRO ACROP guideline on prostate bed delineation for postoperative radiotherapy in prostate cancer. Clin Transl Radiat Oncol 2023; 41:100638. [PMID: 37251620 PMCID: PMC10209331 DOI: 10.1016/j.ctro.2023.100638] [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: 05/03/2023] [Accepted: 05/06/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose/Objective Radiotherapy to the prostate bed is a potentially curative salvage option after radical prostatectomy. Although prostate bed contouring guidelines are available in the literature, important variabilities exist. The objective of this work is to provide a contemporary consensus guideline for prostate bed delineation for postoperative radiotherapy. Methods An ESTRO-ACROP contouring consensus panel consisting of 11 radiation oncologists and one radiologist, all with known subspecialty expertise in prostate cancer, was established. Participants were asked to delineate the prostate bed clinical target volumes (CTVs) in 3 separate clinically relevant scenarios: adjuvant radiation, salvage radiation with PSA progression, and salvage radiation with persistently elevated PSA. These cases focused on the presence of positive surgical margin, extracapsular extension, and seminal vesicles involvement. None of the cases had radiographic evidence of local recurrence on imaging. A single computed tomography (CT) dataset was shared via FALCON platform and contours were performed using EduCaseTM software. Contours were analyzed qualitatively using heatmaps which provided a visual assessment of controversial regions and quantitatively analyzed using Sorensen-Dice similarity coefficients. Participants also answered case-specific questionnaires addressing detailed recommendations on target delineation. Discussions via electronic mails and videoconferences for final editing and consensus were performed. Results The mean CTV for the adjuvant case was 76 cc (SD = 26.6), salvage radiation with PSA progression was 51.80 cc (SD = 22.7), and salvage radiation with persistently elevated PSA 57.63 cc (SD = 25.2). Compared to the median, the mean Sorensen-Dice similarity coefficient for the adjuvant case was 0.60 (SD 0.10), salvage radiation with PSA progression was 0.58 (SD = 0.12), and salvage radiation with persistently elevated PSA 0.60 (SD = 0.11). A heatmap for each clinical scenario was generated. The group agreed to proceed with a uniform recommendation for all cases, independent of the radiotherapy timing. Several controversial areas of the prostate bed CTV were identified based on both heatmaps and questionnaires. This formed the basis for discussions via videoconferences where the panel achieved consensus on the prostate bed CTV to be used as a novel guideline for postoperative prostate cancer radiotherapy. Conclusion Variability was observed in a group formed by experienced genitourinary radiation oncologists and a radiologist. A single contemporary ESTRO-ACROP consensus guideline was developed to address areas of dissonance and improve consistency in prostate bed delineation, independent of the indication.There is important variability in existing contouring guidelines for postoperative prostate bed (PB) radiotherapy (RT) after radical prostatectomy. This work aimed at providing a contemporary consensus guideline for PB delineation. An ESTRO ACROP consensus panel including radiation oncologists and a radiologist, all with known subspecialty expertise in prostate cancer, delineated the PB CTV in 3 scenarios: adjuvant RT, salvage RT with PSA progression, and salvage RT with persistently elevated PSA. None of the cases had evidence of local recurrence. Contours were analysed qualitatively using heatmaps for visual assessment of controversial regions and quantitatively using Sorensen-Dice coefficient. Case-specific questionnaires were also discussed via e-mails and videoconferences for consensus. Several controversial areas of the PB CTV were identified based on both heatmaps and questionnaires. This formed the basis for discussions via videoconferences. Finally, a contemporary ESTRO-ACROP consensus guideline was developed to address areas of dissonance and improve consistency in PB delineation, independent of the indication.
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Affiliation(s)
- Alan Dal Pra
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, USA
- University of Bern, Bern University Hospital, Bern, Switzerland
| | - Piet Dirix
- Department of Radiation Oncology, Iridium Network, Antwerp, Belgium
| | - Vincent Khoo
- Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | | | - Cesare Cozzarini
- Department of Radiotherapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valérie Fonteyne
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium
| | - Pirus Ghadjar
- Department of Radiation Oncology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | - Alfonso Gomez-Iturriaga
- Radiation Oncology, Biocruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | - Valeria Panebianco
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Almudena Zapatero
- Department of Radiation Oncology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria IP, Madrid, Spain
| | - Alberto Bossi
- Radiation Oncology, Centre Charlebourg, La Garenne Colombe, France
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
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27
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Sonni I, Dal Pra A, O'Connell DP, Ells Z, Benz M, Nguyen K, Yoon SM, Deng J, Smith C, Grogan T, Nickols NG, Cao M, Kishan AU, Calais J. 68Ga-PSMA PET/CT-Based Atlas for Prostate Bed Recurrence After Radical Prostatectomy: Clinical Implications for Salvage Radiation Therapy Contouring Guidelines. J Nucl Med 2023; 64:902-909. [PMID: 36759200 PMCID: PMC10241009 DOI: 10.2967/jnumed.122.265025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/26/2023] [Accepted: 01/26/2023] [Indexed: 02/11/2023] Open
Abstract
The aim of this study was to analyze the patterns of prostate bed (PB) recurrence in prostate cancer patients experiencing prostate-specific antigen (PSA) persistence (BCP) or biochemical recurrence (BCR) after radical prostatectomy using 68Ga-PSMA-11 PET/CT (68Ga-PSMA PET) in relation to the Radiation Therapy Oncology Group (RTOG) clinical target volumes (CTVs). Methods: This single-center, retrospective analysis included patients with BCP or BCR after radical prostatectomy and PB recurrence on 68Ga-PSMA PET. The PB recurrences were delineated by nuclear medicine physicians, the CTVs by radiation oncologists contouring guidelines on the 68Ga-PSMA PET, respectively, masked from each other. The coverage of the 68Ga-PSMA PET recurrence was categorized as PSMA recurrence completely covered, partially covered, or not covered by the RTOG-based CTV. Further, we evaluated the differences in PSMA recurrence patterns among patients with different 68Ga-PSMA PET staging (miTNM). Mann-Whitney U tests, the chi-square test, and Spearman (ρ) correlation analysis were used to investigate associations between CTV coverage and 68Ga-PSMA PET-based tumor volume, serum PSA levels, miTNM, and rectal/bladder involvement. Results: A total of 226 patients were included in the analysis; 127 patients had PSMA recurrence limited to the PB (miTrN0M0), 30 had pelvic nodal disease (miTrN1M0), 32 had extrapelvic disease (miTrN0M1), and 37 had both pelvic nodal disease and extrapelvic disease (miTrN1M1). In the miTrN0M0 cohort, the recurrence involved the rectal and bladder walls in 12 of 127 (9%) and 4 of 127 (3%), respectively. The PSMA-positive PB recurrences were completely covered by the CTV in 68 of 127 patients (53%), partially covered in 43 of 127 (34%), and not covered in 16 of 127 (13%). Full coverage was associated with a smaller tumor volume (P = 0.043), a lack of rectal/bladder wall involvement (P = 0.03), and lower miTNM staging (P = 0.035) but not with lower serum PSA levels (P = 0.979). Conclusion: Our study suggests that 68Ga-PSMA PET can be a valuable tool for guiding salvage radiation therapy (SRT) planning directed to the PB in the setting of postoperative BCR or BCP. These data should be incorporated into the redefinition of PB contouring guidelines.
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Affiliation(s)
- Ida Sonni
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California;
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
- Nuclear Medicine Unit, Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Alan Dal Pra
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Dylan P O'Connell
- Department of Radiation Oncology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Zachary Ells
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Matthias Benz
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
- Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Kathleen Nguyen
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Stephanie M Yoon
- Department of Radiation Oncology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Jie Deng
- Department of Radiation Oncology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Clayton Smith
- Department of Radiation Oncology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Tristan Grogan
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; and
| | - Nickolas G Nickols
- Department of Radiation Oncology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
- Department of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Minsong Cao
- Department of Radiation Oncology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Amar U Kishan
- Department of Radiation Oncology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Jeremie Calais
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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Scharl S, Zamboglou C, Strouthos I, Farolfi A, Serani F, Lanzafame H, Giuseppe Morganti A, Trapp C, Koerber SA, Debus J, Peeken JC, Vogel MME, Vrachimis A, K B Spohn S, Ruf J, Grosu AL, Ceci F, Fendler WP, Bartenstein P, Kroeze SGC, Guckenberger M, Krafcsik M, Klopscheck C, Fanti S, Hruby G, Emmett L, Belka C, Stief C, Schmidt-Hegemann NS, Henkenberens C, Mayer B, Miksch J, Shelan M, Aebersold DM, Thamm R, Wiegel T. Salvage radiotherapy is effective in patients with PSMA-PET-negative biochemical recurrence- results of a retrospective study. Radiother Oncol 2023; 184:109678. [PMID: 37146766 DOI: 10.1016/j.radonc.2023.109678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND /Purpose: The present study aimed to assess whether SRT to the prostatic fossa should be initiated in a timely manner after detecting biochemical recurrence (BR) in patients with prostate cancer, when no correlate was identified with prostate-specific membrane antigen positron emission tomography (PSMA-PET). MATERIALS AND METHODS This retrospective, multicenter analysis included 1222 patients referred for PSMA-PET after a radical prostatectomy due to BR. Exclusion criteria were: pathological lymph node metastases, prostate-specific antigen (PSA) persistence, distant or lymph node metastases, nodal irradiation, and androgen deprivation therapy (ADT). This led to a cohort of 341 patients. Biochemical progression-free survival (BPFS) was the primary study endpoint. RESULTS The median follow-up was 28.0 months. The 3-year BPFS was 71.6% in PET-negative cases and 80.8% in locally PET-positive cases. This difference was significant in univariate (p=0.019), but not multivariate analyses (p=0.366, HR: 1.46, 95%CI: 0.64-3.32). The 3-year BPFS in PET-negative cases was significantly influenced by age (p=0.005), initial pT3/4 (p<0.001), pathology scores (ISUP) ≥3 (p=0.026), and doses to fossa >70 Gy (p=0.027) in univariate analyses. In multivariate analyses, only age (HR: 1.096, 95%CI: 1.023-1.175, p=0.009) and PSA-doubling time (HR: 0.339, 95%CI: 0.139-0.826, p=0.017) remained significant. CONCLUSION To our best knowledge, this study provided the largest SRT analysis in patients without ADT that were lymph node-negative on PSMA-PET. A multivariate analysis showed no significant difference in BPFS between locally PET-positive and PET-negative cases. These results supported the current EAU recommendation to initiate SRT in a timely manner after detecting BR in PET negative patients.
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Affiliation(s)
- Sophia Scharl
- Department of Radiation Oncology, University Hospital Ulm, Germany.
| | - Constantinos Zamboglou
- Department of Radiation Oncology, Medical Center -Faculty of Medicine, University of Freiburg, Germany; German Cancer Consortium (DKTK), Partner Site Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany; German Oncology Center, University Hospital of the European University, Limassol, Cyprus
| | - Iosif Strouthos
- Department of Radiation Oncology, German Oncology Center, University Hospital of the European University, Limassol, Cyprus
| | - Andrea Farolfi
- Division of Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesca Serani
- Division of Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Helena Lanzafame
- Division of Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Radiation Oncology, Royal North Shore Hospital - University of Sydney, Australia
| | | | - Christian Trapp
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Stefan A Koerber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Jan C Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Germany; Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum, München, Germany; Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Germany
| | - Marco M E Vogel
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Germany; Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum, München, Germany; Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Germany
| | - Alexis Vrachimis
- Department of Nuclear Medicine, German Oncology Center, University Hospital of the European University, Limassol, Cyprus; C.A.R.I.C. Cancer Research & Innovation Center, Limassol, Cyprus
| | - Simon K B Spohn
- Department of Radiation Oncology, Medical Center -Faculty of Medicine, University of Freiburg, Germany; German Cancer Consortium (DKTK), Partner Site Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany
| | - Juri Ruf
- German Cancer Consortium (DKTK), Partner Site Freiburg, Germany; Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, Medical Center -Faculty of Medicine, University of Freiburg, Germany; German Cancer Consortium (DKTK), Partner Site Freiburg, Germany
| | - Francesco Ceci
- Division of Nuclear Medicine, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Wolfgang P Fendler
- Department of Nuclear Medicine, University Hospital, LMU Munich, Germany; Department of Nuclear Medicine, University Hospital Essen, Essen, Germany
| | - Peter Bartenstein
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Switzerland
| | - Stephanie G C Kroeze
- Department of Radiation Oncology, University Hospital Ulm, Germany; Radiation Oncology Center KSA-KSB, Canton Hospital of Aarau, Aarau, Switzerland
| | | | - Manuel Krafcsik
- Department of Radiation Oncology, University Hospital Ulm, Germany
| | | | - Stefano Fanti
- Division of Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - George Hruby
- Department of Radiation Oncology, Royal North Shore Hospital - University of Sydney, Australia
| | - Louise Emmett
- Department of Theranostics and Nuclear medicine, St Vincent's Hospital Sydney Australia; St Vincent's Clinical School, University of New South Wales, Sydney Australia
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Christian Stief
- Department of Urology, University Hospital, LMU Munich, Germany
| | | | - Christoph Henkenberens
- Department of Radiotherapy and Special Oncology, Medical School Hannover, Hannover, Germany
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University Ulm, Ulm, Germany
| | - Jonathan Miksch
- Department of Nuclear Medicine, University Hospital Ulm, University Ulm, Ulm, Germany
| | - Mohamed Shelan
- Department of Radiation Oncology, Inselspital Bern, University of Bern, Switzerland
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital Bern, University of Bern, Switzerland
| | - Reinhard Thamm
- Department of Radiation Oncology, University Hospital Ulm, Germany
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Germany
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Wang F, Xu X, Yang D, Chen RC, Royce TJ, Wang A, Lian J, Lian C. Dynamic Cross-Task Representation Adaptation for Clinical Targets Co-Segmentation in CT Image-Guided Post-Prostatectomy Radiotherapy. IEEE TRANSACTIONS ON MEDICAL IMAGING 2023; 42:1046-1055. [PMID: 36399586 PMCID: PMC10209913 DOI: 10.1109/tmi.2022.3223405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Adjuvant and salvage radiotherapy after radical prostatectomy requires precise delineations of prostate bed (PB), i.e., the clinical target volume, and surrounding organs at risk (OARs) to optimize radiotherapy planning. Segmenting PB is particularly challenging even for clinicians, e.g., from the planning computed tomography (CT) images, as it is an invisible/virtual target after the operative removal of the cancerous prostate gland. Very recently, a few deep learning-based methods have been proposed to automatically contour non-contrast PB by leveraging its spatial reliance on adjacent OARs (i.e., the bladder and rectum) with much more clear boundaries, mimicking the clinical workflow of experienced clinicians. Although achieving state-of-the-art results from both the clinical and technical aspects, these existing methods improperly ignore the gap between the hierarchical feature representations needed for segmenting those fundamentally different clinical targets (i.e., PB and OARs), which in turn limits their delineation accuracy. This paper proposes an asymmetric multi-task network integrating dynamic cross-task representation adaptation (i.e., DyAdapt) for accurate and efficient co-segmentation of PB and OARs in one-pass from CT images. In the learning-to-learn framework, the DyAdapt modules adaptively transfer the hierarchical feature representations from the source task of OARs segmentation to match up with the target (and more challenging) task of PB segmentation, conditioned on the dynamic inter-task associations learned from the learning states of the feed-forward path. On a real-patient dataset, our method led to state-of-the-art results of PB and OARs co-segmentation. Code is available at https://github.com/ladderlab-xjtu/DyAdapt.
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The Role of Adaptive Planning in Margin-Reduced, MRI-Guided Stereotactic Body Radiotherapy to the Prostate Bed Following Radical Prostatectomy: Post-hoc Analysis of a Phase II Clinical Trial. Radiother Oncol 2023; 183:109631. [PMID: 36934894 DOI: 10.1016/j.radonc.2023.109631] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/02/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND AND PURPOSE We examined the interfractional variations of clinical target volumes (CTVs), planning target volumes (PTVs), and organs-at-risk (OARs) in patients receiving MRI-guided stereotactic body radiotherapy (SBRT) to the prostate bed and evaluated the potential role of adaptive planning. MATERIALS AND METHODS 31 patients received 30-34 Gy in five fractions to the prostate bed on a phase II clinical trial. OARs, CTVs, and PTVs were retrospectively contoured on daily pretreatment MRIs (n=155). Geometric comparisons were made between initial planning contours and daily pretreatment contours. Predicted treatment plans for each fraction were evaluated using the following constraints: CTV V95%>93%, PTV V95%>90%, bladder Dmax<36.7Gy, bladder V32.5Gy<35%, rectum Dmax<36.7Gy, rectum V27.5Gy<45%, rectum 32.5Gy<30%, and rectal wall V24Gy<50%. Adaptive planning was simulated for all fractions that failed to meet these criteria. Plans were then re-evaluated. RESULTS Median change in volume was 0.48% for CTV, -24.5% for bladder, and 6.95% for rectum. Median DSC was 0.89 for CTV, 0.79 for bladder, and 0.76 for rectum. 145/155 fractions (93.5%) met CTV V95%>93%. 75/155 fractions (48.4%) failed at least one OAR dose constraint. Overall, 83/155 fractions (53.5%) met criteria for adapting planning. This affected 24/31 patients (77.4%). Following adaptive planning, all fractions met CTV V95%>93% and PTV V95%>90% and 120/155 fractions (77.4%) met all OAR constraints. CONCLUSION Due to significant interfractional variations in anatomy, a majority of fractions failed to meet both target volume and OAR constraints. However, adaptive planning was effective in overcoming these anatomic changes. Adaptive planning should be routinely considered in prostate bed SBRT. This was a post-hoc analysis of the following registered clinical trial: NCT03541850.
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Padayachee J, Chaudhary S, Shim B, So J, Lim R, Raman S. Utilizing clinical, pathological and radiological information to guide postoperative radiotherapy in prostate cancer. Expert Rev Anticancer Ther 2023; 23:293-305. [PMID: 36795862 DOI: 10.1080/14737140.2023.2181795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
INTRODUCTION A detectable and rising PSA following radical prostatectomy is indicative of recurrent prostate cancer. Salvage radiotherapy (SRT) with/without androgen deprivation therapy represents the main treatment option for these patients and has been historically associated with a biochemical control rate of ~70%. To determine the optimal timing, diagnostic workup, radiotherapy dosefractionation, treatment volume, and use of systemic therapy, several informative studies have been conducted in the last decade. AREAS COVERED This review examines the recent evidence to guide radiotherapy decision making in the SRT setting. Key topics include adjuvant vs salvage RT, utilization of molecular imaging and genomic classifiers, length of androgen deprivation therapy, inclusion of elective pelvic volume, and emerging role for hypofractionation. EXPERT OPINION Recently reported trials, conducted in an era prior to the routine use of molecular imaging and genomic classifiers, have been pivotal in establishing the current standard of care for SRT in prostate cancer. However, decisions about radiation treatment and systemic therapy may be tailored based on available prognostic and predictive biomarkers. Data from contemporary clinical trials are awaited to define and establish individualized, biomarker-driven approaches for SRT.
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Affiliation(s)
- Jerusha Padayachee
- Department of Radiation Oncology, Auckland City Hospital, Auckland, New Zealand
| | - Simone Chaudhary
- Princess Margaret Hospital Cancer Centre, Radiation Medicine Program, Toronto, ON, Canada
| | - Brian Shim
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jonathan So
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Remy Lim
- Mercy PET/CT Epsom, Auckland, New Zealand.,Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Srinivas Raman
- Princess Margaret Hospital Cancer Centre, Radiation Medicine Program, Toronto, ON, Canada
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Kishan AU, Marco N, Ma TM, Steinberg ML, Sachdeva A, Cao M, Ballas LK, Rietdorf E, Telesca D, Weidhaas JB. Application of a genetic signature of late GU toxicity in SCIMITAR, a Post-op SBRT trial. Clin Transl Radiat Oncol 2023; 39:100594. [PMID: 36880064 PMCID: PMC9984404 DOI: 10.1016/j.ctro.2023.100594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/02/2023] [Accepted: 02/05/2023] [Indexed: 02/10/2023] Open
Abstract
Predictors of genitourinary toxicity after post-prostatectomy radiotherapy remain elusive. A previously defined germline DNA signature (PROSTOX) has shown predictive ability for late grade ≥ 2 GU toxicity after intact prostate stereotactic body radiotherapy. We explore whether PROSTOX would predict toxicity among patients receiving post-prostatectomy SBRT on a phase II clinical trial.
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Affiliation(s)
- Amar U. Kishan
- University of California, Department of Radiation Oncology, Los Angeles, CA 90025, USA
| | - Nicholas Marco
- University of California, Department of Statistics, Los Angeles, CA 90025, USA
| | - Ting Martin Ma
- University of California, Department of Radiation Oncology, Los Angeles, CA 90025, USA
| | - Michael L. Steinberg
- University of California, Department of Radiation Oncology, Los Angeles, CA 90025, USA
| | - Ankush Sachdeva
- University of California, Institute of Urologic Oncology, Los Angeles, CA 90025, USA
| | - Minsong Cao
- University of California, Department of Radiation Oncology, Los Angeles, CA 90025, USA
| | - Leslie K. Ballas
- Cedars Sinai, Department of Radiation Oncology, Los Angeles, CA 90048, USA
| | - Emily Rietdorf
- University of California, Department of Radiation Oncology, Los Angeles, CA 90025, USA
| | - Donatello Telesca
- University of California, Department of Statistics, Los Angeles, CA 90025, USA
| | - Joanne B. Weidhaas
- University of California, Department of Radiation Oncology, Los Angeles, CA 90025, USA
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Latorzeff I, Le Guevelou J, Sargos P. Radiation therapy post radical prostatectomy: who, when and why? Curr Opin Support Palliat Care 2023; 17:47-54. [PMID: 36367534 DOI: 10.1097/spc.0000000000000627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE OF REVIEW During decades, adjuvant radiotherapy (ART) has been the standard of care after surgery, based on four randomized clinical trials (RCTs). As early salvage radiotherapy (SRT) recently challenged the ART paradigm, the optimal timing to initiate radiotherapy remains a matter of debate. RECENT FINDINGS Three RCTs evaluated ART or SRT for postprostatectomy patients, with pathological risk factors (Gleason score > 8, pT3, positive margins). The ARTISTIC meta-analysis demonstrated similar 5-year biochemical recurrence-free survival for ART and SRT (89 vs. 88%). Lower rates of late genitourinary toxicity were demonstrated within the SRT arm, favouring early SRT in clinical practice.The addition of pelvic lymph node radiotherapy recently demonstrated an improvement in freedom from progression within the randomized RTOG 0534 trial, especially for patients with pretreatment prostate serum antigen (PSA) levels more than 0.35 ng/ml. The most appropriate androgen deprivation therapy duration remains a point of controversy. SUMMARY The SRT approach can be favoured for the vast majority of patients, provided close monitoring of PSA and early treatment in the event of biochemical recurrence. Radiotherapy dose and volumes and ADT use might be correlated to SRT timing (early vs. late). Results from trials including genomic tests and metabolic imaging will probably help to refine these criteria.
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Affiliation(s)
- Igor Latorzeff
- Department of Radiation Oncology, Clinique Pasteur, Toulouse, France
| | - Jennifer Le Guevelou
- Department of Radiation Oncology, Geneva University Hospital, and Faculty of Medicine, Geneva, Switzerland
| | - Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
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Mask R-CNN assisted 2.5D object detection pipeline of 68Ga-PSMA-11 PET/CT-positive metastatic pelvic lymph node after radical prostatectomy from solely CT imaging. Sci Rep 2023; 13:1696. [PMID: 36717727 PMCID: PMC9886937 DOI: 10.1038/s41598-023-28669-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 01/23/2023] [Indexed: 02/01/2023] Open
Abstract
Prostate-specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) is a molecular and functional imaging modality with better restaging accuracy over conventional imaging for detecting prostate cancer in men suspected of lymph node (LN) progression after definitive therapy. However, the availability of PSMA PET/CT is limited in both low-resource settings and for repeating imaging surveillance. In contrast, CT is widely available, cost-effective, and routinely performed as part of patient follow-up or radiotherapy workflow. Compared with the molecular activities, the morphological and texture changes of subclinical LNs in CT are subtle, making manual detection of positive LNs infeasible. Instead, we harness the power of artificial intelligence for automated LN detection on CT. We examined 68Ga-PSMA-11 PET/CT images from 88 patients (including 739 PSMA PET/CT-positive pelvic LNs) who experienced a biochemical recurrence after radical prostatectomy and presented for salvage radiotherapy with prostate-specific antigen < 1 ng/mL. Scans were divided into a training set (nPatient = 52, nNode = 400), a validation set (nPatient = 18, nNode = 143), and a test set (nPatient = 18, nNodes = 196). Using PSMA PET/CT as the ground truth and consensus pelvic LN clinical target volumes as search regions, a 2.5-dimensional (2.5D) Mask R-CNN based object detection framework was trained. The entire framework contained whole slice imaging pretraining, masked-out region fine-tuning, prediction post-processing, and "window bagging". Following an additional preprocessing step-pelvic LN clinical target volume extraction, our pipeline located positive pelvic LNs solely based on CT scans. Our pipeline could achieve a sensitivity of 83.351%, specificity of 58.621% out of 196 positive pelvic LNs from 18 patients in the test set, of which most of the false positives can be post-removable by radiologists. Our tool may aid CT-based detection of pelvic LN metastasis and triage patients most unlikely to benefit from the PSMA PET/CT scan.
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Ozyigit G, Onal C, Beduk Esen CS, Tilki B, Hurmuz P. Treatment outcomes of postoperative ultra-hypofractionated stereotactic body radiotherapy in prostate cancer. Urol Oncol 2023; 41:252.e1-252.e8. [PMID: 36631368 DOI: 10.1016/j.urolonc.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/29/2022] [Accepted: 12/03/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND This study aimed to evaluate the safety and efficacy of ultra-hypofractionated stereotactic body radiation therapy (SBRT) to prostate bed. METHODS Sixty-six prostate cancer patients treated with postoperative ultra-hypofractionated SBRT between 2018 and 2020 were retrospectively reviewed. All patients received a total dose of 35 Gy to prostate bed in 5 fractions. Biochemical complete response (BCR), biochemical failure (BF), acute and late toxicities were assessed. RESULTS After a median follow-up of 24.2 months (range, 6.4-37.2), seven patients (10.6%) developed BF, and the 2-year freedom from BF (FFBF) rate was 88.4%. BCR was observed in 57 patients (86.4%). The 2-year FFBF in patients with pre-SBRT PSA value of <0.2 ng/mL was higher than those with pre-SBRT PSA of ≥0.2 ng/mL (100% vs. 81.4%; P = 0.04). The 2-year FFBF in patients with BCR was significantly higher than in those without BCR (94.5% vs. 58.3%; P < 0.001). In multivariate analysis, pre-SBRT PSA and post-SBRT PSA values were prognostic factors for FFBF (P = 0.009 and P = 0.01, respectively). Nine patients (13.6 %) developed acute and late grade 2 genitourinary (GU) toxicities. There was no acute or late grade ≥3 GU toxicity. Acute and late grade ≥2 gastrointestinal (GI) toxicity was observed in 9 (13.6%) and 2 (3%) patients, respectively. CONCLUSION Postoperative ultra-fractionated SBRT showed no severe acute toxicity and late toxicity rates of about 15%, in addition to excellent biochemical control rates. Pre- and post-SBRT PSA levels may be a predictor of BCR in patients receiving post-operative ultra-fractionated SBRT.
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Affiliation(s)
- Gokhan Ozyigit
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
| | - Cem Onal
- Department of Radiation Oncology, Adana Dr. Turgut Noyan Research and Treatment Center, Baskent University Faculty of Medicine, Adana, Turkey; Department of Radiation Oncology, Baskent University Faculty of Medicine, Ankara, Turkey
| | | | - Burak Tilki
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Pervin Hurmuz
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Horsley PJ, Koo CM, Eade T, Hsiao E, Emmett L, Brown C, Kneebone A, Hruby G. Mapping of Local Recurrences After Radical Prostatectomy Using 68-Gallium-Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography: Implications for Postprostatectomy Radiation Therapy Clinical Target Volumes. Int J Radiat Oncol Biol Phys 2023; 115:106-117. [PMID: 35716849 DOI: 10.1016/j.ijrobp.2022.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/23/2022] [Accepted: 05/28/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Our objective is to describe the distribution of local recurrences after radical prostatectomy (RP) as delineated using 68-Gallium-prostate-specific membrane antigen positron emission tomography/computed tomography (68Ga-PSMA PET/CT) to identify areas where current consensus guideline clinical target volumes (CTVs) are insufficient or excessive and to identify predictors of recurrence location within the fossa. METHODS AND MATERIALS Retrospective review of databases from 2 tertiary referral centers was performed to identify patients who underwent 68Ga-PSMA PET/CT for biochemical recurrence after RP. Those with a component of local recurrence were included for further analysis. The epicenter of each recurrence was defined relative to reference points in 3 axes, categorized into 1 of 7 levels in the superior/inferior axis relative to the vesicourethral anastomosis, and recorded as within or outside the Faculty of Radiation Oncology Genito-urinary Group (FROGG) and Radiation Therapy Oncology Group consensus CTVs. Univariate and multivariate analysis was performed to identify predictors of recurrence location based on clinical and histopathologic variables. RESULTS One thousand forty-nine 68Ga-PSMA PET/CT scans were reviewed. One hundred forty sites of local recurrence were identified on 132 scans. Relative to the vesicourethral anastomosis, 13 (9%), 31 (22%), 17 (12%), 24 (17%), 27 (19%), 20 (14%), and 8 (6%) recurrences occurred >5 mm inferior; within 5 mm above or below; and 6 to 15 mm, 16 to 25 mm, 26 to 35 mm, 36 to 45 mm, and >45 mm superiorly, respectively. Thirteen (9%) and 2 (1.4%) recurrences occurred beyond the FROGG and Radiation Therapy Oncology Group consensus CTVs, respectively, with all below the inferior CTV margin. CONCLUSIONS In the largest study to date mapping local recurrences after RP in 3-dimensions, we provide several insights to inform future contouring guidelines; in particular, 9% of recurrences occurred inferior to the FROGG CTV.
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Affiliation(s)
- Patrick J Horsley
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
| | - Chung Mo Koo
- Department of Nuclear Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Thomas Eade
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, New South Wales, Australia; GenesisCare, Sydney, New South Wales, Australia; University of Sydney, Camperdown, New South Wales, Australia
| | - Edward Hsiao
- Department of Nuclear Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Louise Emmett
- Department of Nuclear Medicine and Theranostics, St. Vincent's Hospital, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia
| | - Chris Brown
- NHMRC Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Andrew Kneebone
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, New South Wales, Australia; GenesisCare, Sydney, New South Wales, Australia; University of Sydney, Camperdown, New South Wales, Australia
| | - George Hruby
- Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, New South Wales, Australia; GenesisCare, Sydney, New South Wales, Australia; University of Sydney, Camperdown, New South Wales, Australia
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Confirming and Refining Our Existing Postoperative Treatment Strategies Through the Use of Novel Prostate-Specific Positron Emission Tomography (PET) Imaging. Int J Radiat Oncol Biol Phys 2023; 115:118-119. [PMID: 36526378 DOI: 10.1016/j.ijrobp.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 12/15/2022]
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Quality-of-Life Outcomes and Toxicity Profile Among Patients With Localized Prostate Cancer After Radical Prostatectomy Treated With Stereotactic Body Radiation: The SCIMITAR Multicenter Phase 2 Trial. Int J Radiat Oncol Biol Phys 2023; 115:142-152. [PMID: 36007724 DOI: 10.1016/j.ijrobp.2022.08.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/26/2022] [Accepted: 08/16/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE Postoperative radiation therapy (RT) is an underused standard-of-care intervention for patients with prostate cancer and recurrence/adverse pathologic features after radical prostatectomy. Although stereotactic body RT (SBRT) is a well-studied and convenient option for definitive treatment, data on the postprostatectomy setting are extremely limited. The purpose of this study was to evaluate short-term physician-scored genitourinary (GU) and gastrointestinal (GI) toxicities and patient-reported outcomes after postprostatectomy SBRT. METHODS AND MATERIALS The SCIMITAR trial was a phase 2, dual-center, open-label, single-arm trial that enrolled patients with postoperative prostate-specific antigen >0.03 ng/mL or adverse pathologic features. Coprimary endpoints were 4-year biochemical recurrence-free survival, physician-scored acute and late GU and GI toxicities by the Common Terminology Criteria for Adverse Events (version 4.03) scale, and patient-reported quality-of-life (QOL) outcomes, as represented by the Expanded Prostate Cancer Index-26 and the International Prostate Symptom Score. Patients received SBRT 30 to 34 Gy/5 fractions to the prostate bed ± bed boost ± pelvic nodes with computed tomography (CTgRT) or magnetic resonance imaging guidance (MRgRT) in a nonrandomized fashion. Physician-scored toxicities and patient-reported QOL outcomes were collected at baseline and at 1, 3, and 6 months of follow-up. Univariable and multivariable analyses were performed to evaluate predictors of toxicities and QOL outcomes. RESULTS One hundred participants were enrolled (CTgRT, n = 69; MRgRT, n = 31). The median follow-up was 29.5 months (CTgRT: 33.3 months, MRgRT: 22.6 months). The median (range) prostate bed dose was 32 (30-34) Gy. Acute and late grade 2 GU toxicities were both 9% while acute and late grade 2 GI toxicities were 5% and 0%, respectively. Three patients had grade 3 toxicity (n = 1 GU, n = 2 GI). No patient receiving MRgRT had grade 3 GU or grade ≥2 GI toxicity. Compared with CTgRT, MRgRT was associated with a 30.5% (95% confidence interval, 11.6%-49.5%) reduction in any-grade acute GI toxicity (P = .006). MRgRT was independently associated with improved any-grade GI toxicity and improved bowel QOL. CONCLUSIONS Postprostatectomy SBRT was well tolerated at short-term follow-up. MRgRT may decrease GI toxicity. Longer toxicity and/or efficacy follow-up and randomized studies are needed.
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Poon DMC, Yang B, Geng H, Wong OL, Chiu ST, Cheung KY, Yu SK, Chiu G, Yuan J. Analysis of online plan adaptation for 1.5T magnetic resonance-guided stereotactic body radiotherapy (MRgSBRT) of prostate cancer. J Cancer Res Clin Oncol 2023; 149:841-850. [PMID: 35199189 PMCID: PMC8866042 DOI: 10.1007/s00432-022-03950-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/06/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE To analyze and characterize the online plan adaptation of 1.5T magnetic resonance-guided stereotactic body radiotherapy (MRgSBRT) of prostate cancer (PC). METHODS PC patients (n = 107) who received adaptive 1.5 Tesla MRgSBRT were included. Online plan adaptation was implemented by either the adapt-to-position (ATP) or adapt-to-shape (ATS) methods. Patients were assigned to the ATS group if they underwent ≥ 1 ATS fraction (n = 51); the remainder were assigned to the ATP group (n = 56). The online plan adaptation records of 535 (107 × 5) fractions were retrospectively reviewed. Rationales for ATS decision-making were determined and analyzed using predefined criteria. Statistics of ATS fractions were summarized. Associations of patient characteristics and clinical factors with ATS utilization were investigated. RESULTS There were 87 (16.3%) ATS fractions and 448 ATP fractions (83.7%). The numbers of ATS adoptions in fractions 1-5 were 29 (29/107, 27.1%), 18 (16.8%), 15 (14.0%), 16 (15.0%), and 9 (8.4%), respectively, with significant differences in adoption frequency between fractions (p = 0.007). Other baseline patient characteristics and clinical factors were not significantly associated with ATS classification (all p > 0.05). Underlying criteria for the determination of ATS implementation comprised anatomical changes (77 fractions in 50 patients) and discrete multiple targets (15 fractions in 3 patients). No ATS utilization was determined using dosimetric or online quality assurance criteria. CONCLUSIONS This study contributes to facilitating the establishment of a standardized protocol for online MR-guided adaptive radiotherapy in PC.
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Affiliation(s)
- Darren M. C. Poon
- grid.414329.90000 0004 1764 7097Comprehensive Oncology Centre, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Bin Yang
- grid.414329.90000 0004 1764 7097Medical Physics Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Hui Geng
- grid.414329.90000 0004 1764 7097Medical Physics Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Oi Lei Wong
- grid.414329.90000 0004 1764 7097Research Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Sin Ting Chiu
- grid.414329.90000 0004 1764 7097Department of Radiotherapy, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Kin Yin Cheung
- grid.414329.90000 0004 1764 7097Medical Physics Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Siu Ki Yu
- grid.414329.90000 0004 1764 7097Medical Physics Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - George Chiu
- grid.414329.90000 0004 1764 7097Department of Radiotherapy, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
| | - Jing Yuan
- grid.414329.90000 0004 1764 7097Research Department, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, Hong Kong SAR China
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Nabian N, Ghalehtaki R, Couñago F. Necessity of Pelvic Lymph Node Irradiation in Patients with Recurrent Prostate Cancer after Radical Prostatectomy in the PSMA PET/CT Era: A Narrative Review. Biomedicines 2022; 11:biomedicines11010038. [PMID: 36672547 PMCID: PMC9855373 DOI: 10.3390/biomedicines11010038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/16/2022] [Accepted: 11/23/2022] [Indexed: 12/28/2022] Open
Abstract
The main prostate cancer (PCa) treatments include surgery or radiotherapy (with or without ADT). However, none of the suggested treatments eliminates the risk of lymph node metastases. Conventional imaging methods, including MRI and CT scanning, are not sensitive enough for the diagnosis of lymph node metastases; however, the novel imaging method, PSMA PET/CT scanning, has provided valuable information about the pelvic LN involvement in patients with recurrent PCa (RPCa) after radical prostatectomy. The high sensitivity and negative predictive value enable accurate N staging in PCa patients. In this narrative review, we summarize the evidence on the treatment and extent of radiation in prostate-only or whole-pelvis radiation in patients with positive and negative LN involvement on PSMA PET/CT scans.
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Affiliation(s)
- Naeim Nabian
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran P.O. Box 1419733141, Iran
- Department of Radiation Oncology, Cancer Institute, Tehran University of Medical Sciences, Tehran P.O. Box 1419733141, Iran
| | - Reza Ghalehtaki
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran P.O. Box 1419733141, Iran
- Department of Radiation Oncology, Cancer Institute, Tehran University of Medical Sciences, Tehran P.O. Box 1419733141, Iran
- Correspondence:
| | - Felipe Couñago
- Department of Radiation Oncology, San Francisco de Asís and La Milagrosa Hospitals, GenesisCare, 28010 Madrid, Spain
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Laughlin BS, Yu NY, Lo S, Duan J, Welchel Z, Tinnon K, Beckett M, Schild SE, Wong WW, Keole SR, Rwigema JCM, Vargas CE, Rong Y. Clinical Practice Evolvement for Post-Operative Prostate Cancer Radiotherapy-Part 2: Feasibility of Margin Reduction for Fractionated Radiation Treatment with Advanced Image Guidance. Cancers (Basel) 2022; 15:cancers15010040. [PMID: 36612040 PMCID: PMC9817842 DOI: 10.3390/cancers15010040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/08/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose: Planning target volume (PTV) expansion for post-prostatectomy radiotherapy is typically ≥5 mm. Recent clinical trials have proved the feasibility of a reduced margin of 2−3 mm for treatments on MRI-linac. We aim to study the minimum PTV margin needed using iterative cone-beam CT (iCBCT) as image guidance on conventional linacs. Materials/Methods: Fourteen patients who received post-prostatectomy irradiation (8 with an endorectal balloon and 6 without a balloon) were included in this study. Treatment was delivered with volumetric modulated radiation therapy (VMAT). Fractional dose delivery was evaluated in 165 treatment fractions. The bladder, rectal wall, femoral heads, and prostate bed clinical tumor volume (CTV) were contoured and verified on daily iCBCT. PTV margins (0 mm, 2 mm, and 4 mm) were evaluated on daily iCBCT. CTV coverage and OAR dose parameters were assessed with each PTV margin. Results: CTV D100% was underdosed with a 0 mm margin in 32% of fractions in comparison with 2 mm (6%) and 4 mm (6%) PTV margin (p ≤ 0.001). CTV D95% > 95% was met in 93−94% fractions for all PTV expansions. CTV D95% > 95% was achieved in more patients with an endorectal balloon than those without: 0 mm—90/91 (99%) vs. 63/74 (85%); 2 mm—90/91 (99%) vs. 65/75 (87%); 4 mm—90/90 (100%) vs. 63/73 (86%). There was no difference in absolute median change in CTV D95% (0.32%) for 0-, 2-, and 4 mm margins. The maximum dose remained under 108% for 100% (0 mm), 97% (2 mm), and 98% (4 mm) of images. Rectal wall maximum dose remained under 108% for 100% (0 mm), 100% (2 mm), and 98% (4 mm) of images. Conclusions: With high-quality iCBCT image guidance, PTV margin accounting for inter-fractional uncertainties can be safely reduced for post-prostatectomy radiotherapy. For fractionated radiotherapy, an isotropic expansion of 2 mm and 4 mm may be considered for margin expansion with and without the endorectal balloon. Future application for margin reduction needs to be further evaluated and considered with the advent of shorter post-prostatectomy radiation courses.
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Affiliation(s)
- Brady S. Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Nathan Y. Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Stephanie Lo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Jingwei Duan
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Department of Radiation Oncology, University of Kentucky, Lexington, KY 40506, USA
| | - Zachary Welchel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Department of Nuclear and Radiological Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Katie Tinnon
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Mason Beckett
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Steven E. Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Sameer R. Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | | | - Carlos E. Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Correspondence: (C.E.V.); (Y.R.)
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Correspondence: (C.E.V.); (Y.R.)
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Morgan HE, Wang K, Yan Y, Desai N, Hannan R, Chambers E, Cai B, Lin MH, Sher DJ, Wang J, Wang AZ, Jiang S, Timmerman R, Park CJ, Garant A. Preliminary Evaluation of PTV Margins for Online Adaptive Radiation Therapy of the Prostatic Fossa. Pract Radiat Oncol 2022:S1879-8500(22)00366-6. [PMID: 36509197 DOI: 10.1016/j.prro.2022.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE In modern trials, traditional planning target volume (PTV) margins for postoperative prostate radiation therapy have been large (7-10 mm) to account for both daily changes in patient positioning and target deformation. With daily adaptive radiation therapy, these interfractional changes could be minimized, potentially reducing the margins required for treatment and improving adjacent normal-tissue dosimetry. METHODS AND MATERIALS A single-center retrospective study was conducted from March 2021 to November 2021. Patients receiving conventionally fractionated postoperative radiation therapy (PORT) for prostate cancer with pretreatment and posttreatment cone beam computed tomography (CBCT) imaging (pre-CBCT and post-CBCT, respectively) were included (248 paired images). Pretreatment and posttreatment clinical target volumes (pre-CTVs and post-CTVs) were contoured by a single observer on all CBCTs and verified by a second observer. Motion was calculated from pre-CTV to that of the post-CTV, and predicted margins were calculated with van Herk's formula. Adequate coverage of the proposed planning target volume (PTV) margin expansions (pre-PTV) were verified by determining overlap with post-CTV. In a smaller cohort (25 paired images), dosimetric changes with the proposed online adaptive margins were compared with conventional plans in the Ethos emulator environment. RESULTS The estimated margins predicted to achieve ≥95% CTV coverage for 90% of the population were 1.6 mm, 2.0 mm, and 2.2 mm (x-, y-, and z -xes, respectively), with 95% of the absolute region of interest displacement being within 1.9 mm, 2.8 mm, and 2.1 mm. After symmetrically expanding all pre-CTVs by 3 mm, the percentage of paired images achieving ≥95% CTV coverage was 97.1%. When comparing adaptive plans (3-mm margins) with scheduled plans (7-mm margins), rectum dosimetry significantly improved, with an average relative reduction in V40Gy[cc] of 59.2% and V65Gy[cc] of 79.5% (where V40Gy and V65Gy are defined as the volumes receiving 40 Gy and 65 Gy or higher dose, respectively). CONCLUSIONS Online daily adaptive radiation therapy could significantly decrease PTV margins for prostatic PORT and improve rectal dosimetry, with a symmetrical expansion of 3 mm achieving excellent coverage in this cohort. These results need to be validated in a larger prospective cohort.
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Affiliation(s)
- Howard E Morgan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Radiation Oncology, CARTI Cancer Center, Little Rock, Arkansas
| | - Kai Wang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas; Medical Artificial Intelligence and Automation (MAIA) Laboratory, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yulong Yan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Neil Desai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Raquibul Hannan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eric Chambers
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bin Cai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mu-Han Lin
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David J Sher
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jing Wang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas; Medical Artificial Intelligence and Automation (MAIA) Laboratory, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Andrew Z Wang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Steve Jiang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas; Medical Artificial Intelligence and Automation (MAIA) Laboratory, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Robert Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chunjoo Justin Park
- Department of Radiation Oncology, Mayo Clinic-Jacksonville, Jacksonville, Florida.
| | - Aurelie Garant
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Vogel MME, Düsberg M, Stöhrer L, Dewes S, Sage EK, Borm KJ, Gschwend JE, Eiber M, Combs SE, Schiller K. Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography-based Lymph Node Atlas for Salvage Radiotherapy in Patients with Recurrent Prostate Cancer: A Validation of the New NRG Oncology 2020 guideline. Eur Urol Oncol 2022; 5:668-676. [PMID: 36280446 DOI: 10.1016/j.euo.2022.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 09/07/2022] [Accepted: 09/30/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Approximately 20-40% of patients with prostate cancer (PC) who undergo radical prostatectomy (RP) experience relapse, with the majority of these cases developing pelvic lymph node (LN) metastases. Taking new data from the prostate-specific membrane antigen (PSMA) positron emission tomography (PET) era into account, the Radiation Therapy Oncology Group (RTOG) 2009 contouring guideline for the pelvic LNs from 2009 was updated by the NRG Oncology group in 2020 (NRG 2020). OBJECTIVE To evaluate and validate the updated NRG 2020 guideline with our established LN atlas. DESIGN, SETTING, AND PARTICIPANTS We screened 1653 PSMA PET/computed tomography (CT) data sets for patients with biochemical relapse who underwent a PET scan between November 2012 and November 2017. After screening, we developed an LN atlas using data from 233 patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We evaluated LN overlap (OL) with the RTOG 2009 and NRG 2020 contouring guidelines. OL was defined as within (>90%), partly within (10-90%), or outside (<10%). RESULTS AND LIMITATIONS In comparison to the RTOG 2009 guideline, 403 (52%), 134 (17%), and 241 (31%) of the LNs were not, were partly, or were fully covered within the overall group, respectively. By contrast, using the NRG 2020 guideline, 302 (39%), 190 (24%), and 286 (37%) of the LNs were not, were partly, or were fully covered, respectively (p < 0.001). Limitations include the retrospective design with missing data and no histopathological confirmation of the PET results. CONCLUSIONS The updated NRG 2020 contouring guideline improves coverage of the pelvic LNs in patients undergoing salvage radiation therapy. However, PET/CT should be considered whenever possible to ensure coverage of untypical LN spread. PATIENT SUMMARY We compared the 2009 and 2020 guidelines on the radiation area for the pelvis for patients with recurrent prostate cancer that has spread to lymph nodes. The newer guideline provides better coverage of pelvic lymph nodes than the older one and is useful in planning radiation therapy. However, a scan of the pelvis using the newest technique should be considered for individual patients to ensure coverage of untypical lymph nodes.
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Affiliation(s)
- Marco M E Vogel
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany.
| | - Mathias Düsberg
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Lucia Stöhrer
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Sabrina Dewes
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Eva K Sage
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Kai J Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Jürgen E Gschwend
- Department of Urology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Matthias Eiber
- Department of Nuclear Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany; Institute for Radiation Medicine, Department of Radiation Sciences, Helmholtz Zentrum München, Neuherberg, Germany; Deutsches Konsortium für Translationale Krebsforschung, Munich Partner Site, Munich, Germany
| | - Kilian Schiller
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
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Ng M, Guerrieri M, Wong LM, Taubman K, Sutherland T, Benson A, Byrne G, Koschel S, Yap K, Starmans M, Ong G, Macleod C, Foo M, Chao M. Changes in Management After 18F-DCFPyL PSMA PET in Patients Undergoing Postprostatectomy Radiotherapy, with Early Biochemical Response Outcomes. J Nucl Med 2022; 63:1343-1348. [PMID: 35058320 PMCID: PMC9454460 DOI: 10.2967/jnumed.121.263521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/12/2022] [Indexed: 01/26/2023] Open
Abstract
Prostate-specific membrane antigen (PSMA) tracers have increased sensitivity in the detection of prostate cancer, compared with conventional imaging. We assessed the management impact of 18F-DCFPyL PSMA PET/CT in patients with prostate-specific antigen (PSA) recurrence after radical prostatectomy (RP) and report early biochemical response in patients who underwent radiation treatment. Methods: One hundred patients were enrolled into a prospective study, with a prior RP for prostate cancer, a PSA of 0.2-2.0 ng/mL, and no prior treatment. All patients underwent diagnostic CT and PSMA PET/CT, and management intent was completed at 3 time points (original, post-CT, and post-PSMA) and compared. Patients who underwent radiotherapy with 6-mo PSA response data are presented. Results: Ninety-eight patients are reported, with a median PSA of 0.32 ng/mL (95% CI, 0.28-0.36), pT3a/b disease in 71.4%, and an International Society of Urological Pathology grade group of at least 3 in 59.2%. PSMA PET/CT detected disease in 46.9% of patients, compared with 15.5% using diagnostic CT (PSMA PET, 29.2% local recurrence and 29.6% pelvic nodal disease). A major change in management intent was higher after PSMA than after CT (12.5% vs. 3.2%, P = 0.010), as was a moderate change in intent (31.3% vs. 13.7%, P = 0.001). The most common change was an increase in the recommendation for elective pelvic radiation (from 15.6% to 33.3%), nodal boost (from 0% to 22.9%), and use of concurrent androgen deprivation therapy (ADT) (from 22.9% to 41.7%) from original to post-PSMA intent because of detection of nodal disease. Eighty-six patients underwent 18F-DCFPyL-guided radiotherapy. Fifty-five of 86 patients either did not receive ADT or recovered after ADT, with an 18-mo PSA response from 0.32 to 0.02 ng/mL; 94.5% of patients had a PSA of no more than 0.20 ng/mL, and 74.5% had a PSA of no more than 0.03 ng/mL. Conclusion: 18F-DCFPyL PET/CT has a significant impact on management intent in patients being considered for salvage radiotherapy after RP with PSA recurrence. Increased detection of disease, particularly in the pelvic lymph nodes, resulted in increased pelvic irradiation and concurrent ADT use. Early results in patients who are staged with 18F-DCFPyL PET/CT show a favorable PSA response.
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Affiliation(s)
- Michael Ng
- GenesisCare St. Vincent's Hospital, Melbourne, Victoria, Australia;
| | | | - Lih Ming Wong
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia;,Department of Surgery, St. Vincent’s Hospital, Melbourne, Victoria, Australia
| | - Kim Taubman
- Department of Nuclear Medicine, St. Vincent’s Hospital, Melbourne, Victoria, Australia
| | - Tom Sutherland
- Department of Medical Imaging, St. Vincent’s Hospital, Melbourne, Victoria, Australia;,Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Angela Benson
- GenesisCare CancerCare Research, Melbourne, Victoria, Australia
| | - Graeme Byrne
- La Trobe University Statistics Consultancy Platform, Melbourne, Victoria, Australia
| | - Sam Koschel
- GenesisCare CancerCare Research, Melbourne, Victoria, Australia
| | - Kelvin Yap
- Department of Medical Imaging, St. Vincent’s Hospital, Melbourne, Victoria, Australia
| | | | - Grace Ong
- GenesisCare, Shepparton, Victoria, Australia
| | | | - Marcus Foo
- GenesisCare, Berwick, Victoria, Australia; and
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Faiella E, Santucci D, Vertulli D, Esperto F, Messina L, Castiello G, Papalia R, Flammia G, Scarpa RM, Fiore M, Trodella LE, Ramella S, Grasso RF, Beomonte Zobel B. The role of multiparametric mri in the diagnosis of local recurrence after radical prostatectomy and before salvage radiotherapy. Actas Urol Esp 2022; 46:397-406. [PMID: 35778338 DOI: 10.1016/j.acuroe.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 12/11/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Assess multiparametric-MRI (mp-MRI) diagnostic accuracy in the detection of local recurrence of Prostate Cancer (PCa) after Radical Prostatectomy (PR) and before Radiation Therapy (RT). MATERIALS AND METHODS A total of 188 patients underwent 1.5-T mp-MRI after RP before RT. Patients were divided into two groups: with biochemical recurrence (group A) and without but with high risk of local recurrence (group B). Continuous variables were compared between two groups using T-Student; categoric variables were analyzed using Pearson chi-square. ROC analysis was performed considering PSA before RT, ISUP, pT and pN as grouping variables. RESULTS PCa recurrence (reduction of PSA levels after RT) was 89.8% in the group A and 80.3% in the group B. Comparing patients with and without PCa recurrence, there was a significant difference in PSA values before RT for group A and for PSA values before RT and after RT for group B. In group A, there was a significant correlation between PSA before RT and diameter of recurrence and between PSA before RT and time spent before recurrence. The mp-MRI diagnostic accuracy in detecting PCa local recurrence after RP is of 62.2% in group A and 38% in group B. DWI is the most specific MRI-sequence and DCE the most sensitive. For PSA = 0.5 ng/ml, the AUC decreases while sensitivity and accuracy increase for each MRI-sequence. For PSA = 0.9 ng/ml, DCE-AUC increases significantly. CONCLUSION mp-MRI should always be performed before RT when a recurrence is suspected. New scenarios can be opened considering the role of DWI for PSA ≤ 0.5 ng/ml.
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Affiliation(s)
- E Faiella
- Department of Radiology, University of Rome Campus Bio-medico, Rome, Italy.
| | - D Santucci
- Department of Radiology, University of Rome Campus Bio-medico, Rome, Italy
| | - D Vertulli
- Department of Radiology, University of Rome Campus Bio-medico, Rome, Italy
| | - F Esperto
- Department of Urology, University of Rome Campus Bio-medico, Rome, Italy
| | - L Messina
- Department of Radiology, University of Rome Campus Bio-medico, Rome, Italy
| | - G Castiello
- Department of Radiology, University of Rome Campus Bio-medico, Rome, Italy
| | - R Papalia
- Department of Urology, University of Rome Campus Bio-medico, Rome, Italy
| | - G Flammia
- Department of Urology, University of Rome Campus Bio-medico, Rome, Italy
| | - R M Scarpa
- Department of Urology, University of Rome Campus Bio-medico, Rome, Italy
| | - M Fiore
- Department of Radiotherapy, University of Rome Campus Bio-medico, Rome, Italy
| | - L Eolo Trodella
- Department of Radiotherapy, University of Rome Campus Bio-medico, Rome, Italy
| | - S Ramella
- Department of Radiotherapy, University of Rome Campus Bio-medico, Rome, Italy
| | - R F Grasso
- Department of Radiology, University of Rome Campus Bio-medico, Rome, Italy
| | - B Beomonte Zobel
- Department of Radiology, University of Rome Campus Bio-medico, Rome, Italy
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Casas-Nebra J, Blanco-Gomez B, Medina-González A, Formoso-Garcia I, Escaf-Barmadah S, Alvarez-Arenal A. Impact of a radical prostatectomy on the urodynamic results of prostate cancer patients treated with intensity modulated radiation therapy. Actas Urol Esp 2022; 46:431-441. [PMID: 35339398 DOI: 10.1016/j.acuroe.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 06/21/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION AND OBJECTIVES To evaluate the effect of radical prostatectomy and age on urodynamics before and after intensity-modulated radiation therapy administered to prostate cancer patients. MATERIALS AND METHODS The sample consisted of 40 prostate cancer patients, 22 of whom had undergone a radical prostatectomy. Urodynamic parameters before and after an average of 4.2 months of radiotherapy were measured and compared. External radiotherapy was administered via Volumetric Modulated Arc Therapy (VMAT), Intensity Modulated Radiation Therapy (IMRT) techniques. RESULTS Uroflowmetry presented no significant parameters. In the case of Cystomanometry, the data did not show an increase in secondary stress urinary incontinence, although there is 7 percent increase in urge urinary incontinence. There were statistically significant changes in reduced bladder capacity with a strong desire to void, with an urge to void and also in the detrusor pressure with a normal desire to void. Furthermore, pressure/flow analysis revealed a statistically significant reduction of residual urine volume. CONCLUSIONS The effect of prostatectomy and age varies according to the evolution of urodynamics. There was a significant reduction in terms of residual urine volume and detrusor pressure with a normal desire to void in patients without a prostatectomy and in those under 75 years old. In addition to an increase in urge incontinence, there was also a significant worsening of the bladder filling urodynamics and a decrease in the cystomanometric bladder capacity with a strong desire and an urge to void. None of these were modified by age or prostatectomy.
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Affiliation(s)
- J Casas-Nebra
- Servicio de Urología, Hospital Universitario Lucus Augusti, Lugo, Spain.
| | - B Blanco-Gomez
- Servicio de Urología, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - A Medina-González
- Servicio de Urología, Hospital Universitario Virgen de Valme, Sevilla, Spain
| | - I Formoso-Garcia
- Service de Oncología Radioterápica, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - S Escaf-Barmadah
- Servicio de Urología, Hospital Universitario Central de Asturias, Oviedo, Spain; Departamento de Cirugía y Especialidades Medicoquirúrgicas, Facultad de Medicina y Ciencias de la Salud, Universidad de Oviedo, Oviedo, Spain
| | - A Alvarez-Arenal
- Departamento de Cirugía y Especialidades Medicoquirúrgicas, Facultad de Medicina y Ciencias de la Salud, Universidad de Oviedo, Oviedo, Spain
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Dhere VR, Schuster DM, Goyal S, Schreibmann E, Hershatter BW, Rossi PJ, Shelton JW, Patel PR, Jani AB. Randomized Trial of Conventional Versus Conventional Plus Fluciclovine ( 18F) Positron Emission Tomography/Computed Tomography-Guided Postprostatectomy Radiation Therapy for Prostate Cancer: Volumetric and Patient-Reported Analyses of Toxic Effects. Int J Radiat Oncol Biol Phys 2022; 113:1003-1014. [PMID: 35417762 DOI: 10.1016/j.ijrobp.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/23/2022] [Accepted: 04/05/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE Postprostatectomy radiation therapy planning with fluciclovine (18F) positron emission tomography (PET)/computed tomography has demonstrated improved disease-free survival over conventional only (computed tomography- or magnetic resonance imaging-based) treatment planning. We hypothesized that incorporating PET would result in larger clinical target volumes (CTVs) without increasing patient-reported toxic effects. METHODS AND MATERIALS From 2012 to 2019, 165 postprostatectomy patients with detectable prostate-specific antigen were randomized (arm 1 [no PET]: 82; arm 2 [PET]: 83). Prostate bed target volumes with (CTV1: 45.0-50.4 Gy/1.8 Gy) or without (CTV2/CTV: 64.8-70.2 Gy/1.8 Gy) pelvic nodes, as well as organ-at-risk doses, were compared pre- versus post-PET (arm 2) using the paired t test and between arms using the t test. Patient-reported outcomes used International Prostate Symptom Score and Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP). Univariate and multivariable analyses were performed and linear mixed models were fitted. RESULTS Median follow-up of the whole cohort was 3.52 years. All patients had baseline patient-reported outcomes, 1 patient in arm 1 and 3 patients in arm 2 withdrew, and 4 arm 2 patients had extrapelvic uptake on PET with radiotherapy aborted, leaving 81 (arm 1) and 76 patients (arm 2) for analysis of toxic effects. Mean CTV1 (427.6 vs 452.2 mL; P = .462, arm 1 vs arm 2) and CTV2/CTV (137.18 vs 134.2 mL; P = .669) were similar before PET incorporation. CTV1 (454.57 vs 461.33 mL; P = .003) and CTV2/CTV (134.14 vs 135.61 mL; P < .001) were modestly larger after PET incorporation. Although V40 Gy (P = .402 and P = .522 for rectum and bladder, respectively) and V65 Gy (P = .157 and P = .182 for rectum and bladder, respectively) were not significantly different pre- versus post-PET, penile bulb dose significantly increased post-PET (P < .001 for both V40 Gy and V65 Gy). On univariate and multivariable analyses, arm was not significant for any EPIC-CP subdomain. International Prostate Symptom Score and EPIC-CP linear mixed models were not significantly different between arms. CONCLUSIONS Despite larger CTVs after incorporation of fluciclovine (18F) PET, we found no significant difference in patient-reported toxic effects with long-term follow-up.
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Affiliation(s)
- Vishal R Dhere
- Departments of Radiation Oncology, Winship Cancer Institute.
| | | | - Subir Goyal
- Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | | | | | - Peter J Rossi
- Departments of Radiation Oncology, Winship Cancer Institute
| | | | | | - Ashesh B Jani
- Departments of Radiation Oncology, Winship Cancer Institute
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Hervás-Morón A, Domínguez-Rullán J, Santana VD, Valero M, Vallejo C, Sancho S, Fuentes JDG, Cámara Gallego M, López-Campos F. Assessing radiation dose for postoperative radiotherapy in prostate cancer: Real world data. World J Clin Oncol 2022; 13:652-662. [PMID: 36157159 PMCID: PMC9346429 DOI: 10.5306/wjco.v13.i7.652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/04/2022] [Accepted: 07/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Approximately 30% of patients with localized prostate cancer (PCa) who undergo radical prostatectomy will develop biochemical recurrence. In these patients, the only potentially curative treatment is postoperative radiotherapy (PORT) with or without hormone therapy. However, the optimal radiotherapy dose is unknown due to the limited data available.
AIM To determine whether the postoperative radiotherapy dose influences biochemical failure-free survival (BFFS) in patients with PCa.
METHODS Retrospective analysis of patients who underwent radical prostatectomy for PCa followed by PORT-either adjuvant radiotherapy (ART) or salvage radiotherapy (SRT)-between April 2002 and July 2015. From 2002 to 2010, the prescribed radiation dose to the surgical bed was 66-70 Gy in fractions of 2 Gy; from 2010 until July 2015, the prescribed dose was 70-72 Gy. Patients were grouped into three categories according to the total dose administered: 66-68 Gy, 70 Gy, and 72 Gy. The primary endpoint was BFFS, defined as the post-radiotherapy prostate-specific antigen (PSA) nadir + 0.2 ng/mL. Secondary endpoints were overall survival (OS), cancer-specific survival (CSS), and metastasis-free survival (MFS; based on conventional imaging tests). Treatment-related genitourinary (GU) and gastrointestinal (GI) toxicity was evaluated according to Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer criteria. Finally, we aimed to identify potential prognostic factors. BFFS, OS, CSS, and MFS were calculated with the Kaplan-Meier method and the log-rank test. Univariate and multivariate Cox regression models were performed to explore between-group differences in survival outcome measures.
RESULTS A total of 301 consecutive patients were included. Of these, 93 (33.6%) received ART and 186 (66.4%) SRT; 22 patients were excluded due to residual macroscopic disease or local recurrence in the surgical bed. In this subgroup (n = 93), 43 patients (46.2%) were Gleason score (GS) ≤ 6, 44 (47.3%) GS 7, and 6 (6.5%) GS ≥ 8; clinical stage was cT1 in 51 (54.8%), cT2 in 35 (39.3%), and cT3 in one patient (1.1%); PSA was < 10 ng/mL in 58 (63%) patients, 10-20 ng/mL in 28 (30.6%), and ≥ 20 ng/mL in 6 (6.4%) patients. No differences were found in BFFS in this patient subset versus the entire cohort of patients (P = 0.66). At a median follow-up of 113 months (range, 4-233), 5- and 10-year BFFS rates were 78.8% and 73.7%, respectively, with OS rates of 93.3% and 81.4%. The 5-year BFFS rates in three groups were as follows: 69.6% (66-68 Gy), 80.5% (70 Gy) and 82.6% (72 Gy) (P = 0.12):the corresponding 10-year rates were 63.9%, 72.9%, and 82.6% (P = 0.12), respectively. No significant between-group differences were observed in MFS, CSS, or OS. On the univariate analysis, the following variables were significantly associated with BFFS: PSA at diagnosis; clinical stage (cT1 vs cT2); GS at diagnosis; treatment indication (ART vs SRT); pre-RT PSA levels; and RT dose 66 -68 Gy vs. 72 Gy (HR: 2.05; 95%CI: 1.02-4.02, P = 0.04). On the multivariate analysis, the following variables remained significant: biopsy GS (HR: 2.85; 95%CI: 1.83-4.43, P < 0.001); clinical stage (HR: 2.31; 95%CI: 1.47-4.43, P = 0.01); and treatment indication (HR: 4.11; 95%CI: 2.06-8.17, P < 0.001). Acute grade (G) 1 GU toxicity was observed in 11 (20.4%), 17 (19.8%), and 3 (8.3%) patients in each group (66-68 Gy, 70 Gy and 72 Gy), respectively (P = 0.295). Acute G2 toxicity was observed in 2 (3.7%), 4 (4.7%) and 2 (5.6%) patients, respectively (P = 0.949). Acute G1 GI toxicity was observed in 16 (29.6%), 23 (26.7%) and 2 (5.6%) patients in each group, respectively (P = 0.011). Acute G2 GI toxicity was observed in 2 (3.7%), 6 (6.9%) and 1 (2.8%) patients, respectively (P = 0.278). No cases of acute G3 GI toxicity were observed.
CONCLUSION The findings of this retrospective study suggest that postoperative radiotherapy dose intensification in PCa is not superior to conventional radiotherapy treatment.
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Affiliation(s)
- Asunción Hervás-Morón
- Department of Radiation Oncology, Hospital Universitario Ramón Y Cajal, Madrid 28034, Spain
| | - Jose Domínguez-Rullán
- Department of Radiation Oncology, Hospital Universitario Ramón Y Cajal, Madrid 28034, Spain
| | - Victor Duque Santana
- Department of Radiation Oncology, Hospital Universitario Ramón Y Cajal, Madrid 28034, Spain
| | - Mireia Valero
- Department of Radiation Oncology, Hospital Universitario Ramón Y Cajal, Madrid 28034, Spain
| | - Carmen Vallejo
- Department of Radiation Oncology, Hospital Universitario Ramón Y Cajal, Madrid 28034, Spain
| | - Sonsoles Sancho
- Department of Radiation Oncology, Hospital Universitario Ramón Y Cajal, Madrid 28034, Spain
| | | | - Miguel Cámara Gallego
- Department of Medical Physics, Hospital Universitario Ramón Y Cajal, Madrid 28034, Spain
| | - Fernando López-Campos
- Department of Radiation Oncology, Hospital Universitario Ramón Y Cajal, Madrid 28034, Spain
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Dundee P, Furrer MA, Corcoran NM, Peters J, Pan H, Ballok Z, Ryan A, Guerrieri M, Costello AJ. Defining Prostatic Vascular Pedicle Recurrence and the Anatomy of Local Recurrence of Prostate Cancer on Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography. EUR UROL SUPPL 2022; 41:116-122. [PMID: 35813255 PMCID: PMC9257633 DOI: 10.1016/j.euros.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 11/30/2022] Open
Abstract
Background The term local recurrence in prostate cancer is considered to mean persistent local disease in the prostatic bed, most commonly at the site of the vesicourethral anastomosis (VUA). Since the introduction of prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) and magnetic resonance imaging for assessment of early biochemical recurrence (BCR), we have found histologically confirmed prostate cancer in the prostatic vascular pedicle (PVP). If a significant proportion of local recurrences are distant to the VUA, it may be possible to alter adjuvant and salvage radiation fields in order to reduce the potential morbidity of radiation in selected patients. Objective To describe PVP local recurrence and to map the anatomic pattern of prostate bed recurrence on PSMA PET/CT. Design, setting, and participants This was a retrospective multicentre study of 185 patients imaged with PSMA PET/CT following radical prostatectomy (RP) between January 2016 and November 2018. All patient data and clinical outcomes were prospectively collected. Recurrences were documented according to anatomic location. For patients presenting with local recurrence, the precise location of the recurrence within the prostate bed was documented. Intervention PSMA PET/CT for BCR following RP. Results and limitations A total of 43 local recurrences in 41/185 patients (22%) were identified. Tumour recurrence at the PVP was found in 26 (63%), VUA in 15 (37%), and within a retained seminal vesicle and along the anterior rectal wall in the region of the neurovascular bundle in one (2.4%) each. Histological and surgical evidence of PVP recurrence was acquired in two patients. The study is limited by its retrospective nature with inherent selection bias. This is an observational study reporting on the anatomy of local recurrence and does not include follow-up for patient outcomes. Conclusions Our study showed that prostate cancer can recur in the PVP and is distant to the VUA more commonly than previously thought. This may have implications for RP technique and for the treatment of selected patients in the local recurrence setting. Patient summary We investigated more precise identification of the location of tumour recurrence after removal of the prostate for prostate cancer. We describe a new definition of local recurrence in an area called the prostatic vascular pedicle. This new concept may alter the treatment recommended for recurrent disease.
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Affiliation(s)
- Philip Dundee
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Grattan Street Parkville, Australia 3052
- The Australian Medical Robotics Academy, North Melbourne, Australia
- Australian Prostate Cancer Centre, North Melbourne, Australia
- Epworth Healthcare, Melbourne, Australia
- Corresponding author. Department of Urology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia. Tel. +61 3 9342 7294.
| | - Marc A. Furrer
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Grattan Street Parkville, Australia 3052
- The Australian Medical Robotics Academy, North Melbourne, Australia
- Epworth Healthcare, Melbourne, Australia
- Department of Urology, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Niall M. Corcoran
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Grattan Street Parkville, Australia 3052
- Australian Prostate Cancer Centre, North Melbourne, Australia
| | - Justin Peters
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Grattan Street Parkville, Australia 3052
- The Australian Medical Robotics Academy, North Melbourne, Australia
- Australian Prostate Cancer Centre, North Melbourne, Australia
- Epworth Healthcare, Melbourne, Australia
| | - Henry Pan
- Department of Urology, University Hospital of Bern, University of Bern, Bern, Switzerland
| | | | - Andrew Ryan
- Healthcare Imaging Services, Melbourne, Australia
| | | | - Anthony J. Costello
- Department of Urology, The University of Melbourne, Royal Melbourne Hospital, Grattan Street Parkville, Australia 3052
- The Australian Medical Robotics Academy, North Melbourne, Australia
- Australian Prostate Cancer Centre, North Melbourne, Australia
- Epworth Healthcare, Melbourne, Australia
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A Phase I Trial of Highly Conformal, Hypofractionated Post-Prostatectomy Radiotherapy. Adv Radiat Oncol 2022; 7:101024. [DOI: 10.1016/j.adro.2022.101024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 07/05/2022] [Indexed: 11/18/2022] Open
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