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Tonetto F, Magli A, Moretti E, Guerini AE, Tullio A, Reverberi C, Ceschia T, Spiazzi L, Titone F, Prisco A, Signor MA, Buglione M, De Giorgi G, Trovò M, Triggiani L. Prostate Cancer Treatment-Related Toxicity: Comparison between 3D-Conformal Radiation Therapy (3D-CRT) and Volumetric Modulated Arc Therapy (VMAT) Techniques. J Clin Med 2022; 11:6913. [PMID: 36498488 PMCID: PMC9737605 DOI: 10.3390/jcm11236913] [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: 10/17/2022] [Revised: 11/13/2022] [Accepted: 11/18/2022] [Indexed: 11/25/2022] Open
Abstract
Objective: This paper illustrates the results of a mono-institutional registry trial, aimed to test whether gastrointestinal (GI) and genitourinary (GU) toxicity rates were lower in localized prostate cancer patients treated with image-guided volumetric modulated arc therapy (IG-VMAT) compared to those treated with IG-3D conformal radiation therapy (IG-3DCRT). Materials and Methods: Histologically proven prostate cancer patients with organ-confined disease, treated between October 2008 and September 2014 with moderately hypofractionated radiotherapy, were reviewed. Fiducial markers were placed in the prostate gland by transrectal ultrasound guide. The prescribed total dose was 70 Gy in 28 fractions. The mean and median dose volume constraints for bladder and rectum as well as total volume of treatment were analyzed as potentially prognostic factors influencing toxicity. The Kaplan−Meier method was applied to calculate survival. Results: Overall, 83 consecutive patients were included. Forty-two (50.6%) patients were treated with 3D-CRT and 41 (49.4%) with the VMAT technique. The median follow-up for toxicity was 77.26 months for the whole cohort. The VMAT allowed for a dose reduction to the rectum and bladder for the large majority of the considered parameters; nonetheless, the only parameter correlated with a clinical outcome was a rectal dose limit V66 > 8.5% for late GI toxicity G ≥ 2 (p = 0.045). Rates of G ≥ 2 toxicities were low among the whole cohort of these patients treated with IGRT. The analysis for rectum dose volume histograms (DVHs) showed that a severe (grade ≥ 2) late GI toxicity was related with the rectal dose limit V66 > 8.5% (p = 0.045). Conclusions: This study shows that moderate hypofractionation is feasible and safe in patients with intermediate and high-risk prostate cancer. Daily IGRT may decrease acute and late toxicity to organs at risk and improve clinical benefit and disease control rate, cutting down the risk of PTV geographical missing. The adoption of VMAT allows for promising results in terms of OAR sparing and a reduction in toxicity that, also given the small sample, did not reach statistical significance.
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Affiliation(s)
- Fabrizio Tonetto
- Department of Radiation Oncology, University General Hospital, 33100 Udine, Italy
| | - Alessandro Magli
- Department of Radiation Oncology, University General Hospital, 33100 Udine, Italy
| | - Eugenia Moretti
- Department of Medical Physics, University General Hospital, 33100 Udine, Italy
| | - Andrea Emanuele Guerini
- Department of Radiation Oncology, ASST Spedali Civili and Brescia University, 25100 Brescia, Italy
| | - Annarita Tullio
- Hygiene and Clinical Epidemiology Unit, University General Hospital, 33100 Udine, Italy
| | - Chiara Reverberi
- Department of Radiation Oncology, University General Hospital, 33100 Udine, Italy
| | - Tino Ceschia
- Department of Radiation Oncology, University General Hospital, 33100 Udine, Italy
| | - Luigi Spiazzi
- Department of Radiation Oncology, ASST Spedali Civili and Brescia University, 25100 Brescia, Italy
| | - Francesca Titone
- Department of Radiation Oncology, University General Hospital, 33100 Udine, Italy
| | - Agnese Prisco
- Department of Radiation Oncology, University General Hospital, 33100 Udine, Italy
| | - Marco Andrea Signor
- Department of Radiation Oncology, University General Hospital, 33100 Udine, Italy
| | - Michela Buglione
- Department of Radiation Oncology, ASST Spedali Civili and Brescia University, 25100 Brescia, Italy
| | | | - Marco Trovò
- Department of Radiation Oncology, University General Hospital, 33100 Udine, Italy
| | - Luca Triggiani
- Department of Radiation Oncology, ASST Spedali Civili and Brescia University, 25100 Brescia, Italy
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Smith GA, Dunlop A, Barnes H, Herbert T, Lawes R, Mohajer J, Tree AC, McNair HA. Bladder filling in patients undergoing prostate radiotherapy on a MR-linac: The dosimetric impact. Tech Innov Patient Support Radiat Oncol 2022; 21:41-45. [PMID: 35243043 PMCID: PMC8857515 DOI: 10.1016/j.tipsro.2022.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/19/2022] [Accepted: 02/07/2022] [Indexed: 11/28/2022] Open
Abstract
The implementation of adaptive radiotherapy for prostate cancer compensates for inter-fraction motion, at the penalty of increased time in room. The subsequent increase in bladder filling may impact dosimetry, which we have investigated on ten patients treated on the MR-linac. Patients drank water before treatment, to achieve a bladder volume of 200-300 cm3. Bladder and bowel were re-outlined offline on 140 images and plans recalculated. All mandatory bladder dose constraints and 99.1% of bowel constraints were achieved at time of treatment, despite varying bladder volumes and varying adherence to original bladder filling guidance.
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Affiliation(s)
| | - Alex Dunlop
- Royal Marsden NHS Foundation Trust, United Kingdom
- Institute of Cancer Research, United Kingdom
| | - Helen Barnes
- Royal Marsden NHS Foundation Trust, United Kingdom
| | | | | | - Jonathan Mohajer
- Royal Marsden NHS Foundation Trust, United Kingdom
- Institute of Cancer Research, United Kingdom
| | - Alison C. Tree
- Royal Marsden NHS Foundation Trust, United Kingdom
- Institute of Cancer Research, United Kingdom
| | - Helen A. McNair
- Royal Marsden NHS Foundation Trust, United Kingdom
- Institute of Cancer Research, United Kingdom
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3
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Rowe LS, Mandia JJ, Salerno KE, Shankavaram UT, Das S, Escorcia FE, Ning H, Citrin DE. Bowel and bladder reproducibility in image guided radiation therapy for prostate cancer: Results of a patterns of practice survey. Adv Radiat Oncol 2022; 7:100902. [PMID: 35847548 PMCID: PMC9280021 DOI: 10.1016/j.adro.2022.100902] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/16/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose Optimal management of patients with prostate cancer (PCa) to achieve bowel and bladder reproducibility for radiation therapy (RT) and the appropriate planning target volume (PTV) expansions for use with modern image guidance is uncertain. We surveyed American Society of Radiation Oncology radiation oncologists to ascertain practice patterns for definitive PCa RT with respect to patient instructions and set up, daily image guidance, and subsequent PTV expansions. Methods and Materials A pattern of practice survey was sent to American Society of Radiation Oncology radiation oncologists who self-identified as specializing in PCa. Respondents identified the fractionation regimens routinely used, and their practices regarding diet, bowel, and bladder instructions for patients with PCa before RT simulation and throughout treatment. Questions regarding PTV margins, daily set up practices, and use of image guidance were included. Results Of 190 respondents, 158 reported using conventional fractionation (CFx), 49 moderate hypofractionation (MHFx), and 61 stereotactic body radiation therapy (SBRT). Diet modifications during RT were advised by 84% of respondents, treatment with full bladder by 96%, and bowel instructions by 78%. Prescription of bowel medication was higher for respondents using SBRT (95.1%) versus those using CFx/MHFx (55.1%; 34.7%). The most common implantable device reported was fiducial markers, with increased use in SBRT (86.0%; 68.9%) versus CFx/MHFx. Cone beam computed tomography was the most common daily imaging technique across fractionation regimens. SBRT showed correlation between PTV margin expansions, fiducial marker use, and image guidance. Conclusions Survey results indicate heterogeneity in treatment modality, dose, patient instructions, and PTV expansions used by radiation oncologists in the treatment of patients with PCa. Further investigation to define appropriate patient instructions on bowel preparation to maximize target reproducibility in PCa is needed, as is continued guidance on evidence-based approaches for image guidance and PTV margin selection.
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4
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Fiagan YA, Bossuyt E, Nevens D, Dirix P, Theys F, Gevaert T, Verellen D. In vivo dosimetry for patients with prostate cancer to assess possible impact of bladder and rectum preparation. Tech Innov Patient Support Radiat Oncol 2020; 16:65-69. [PMID: 33294646 PMCID: PMC7701258 DOI: 10.1016/j.tipsro.2020.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 11/19/2022] Open
Abstract
PURPOSE/OBJECTIVE In all treatment sites of our radiotherapy network, in vivo dosimetry (PerFRACTION™) was fully implemented in February 2018. We hypothesized that additional help with bladder and rectum preparation by home nursing would improve patients' preparation and investigated if this could be assessed using in vivo dosimetry (IVD). MATERIALS/METHODS A retrospective study was conducted with a test group who received additional help with bladder and rectum preparation by home nurses and a control group who only received information on bladder and rectum preparation according to the standard protocol. Patients were treated with a 6 MV Volumetric Modulated Arc Therapy (VMAT) technique. Electronic portal imaging device (EPID)-based integrated transit dose images were acquired on the first 3 days of treatment and weekly thereafter or more if failed fractions (FF) occurred. Results were analyzed using a global gamma analysis with a threshold of 20%, tolerance of 5% (dose difference) and 5 mm (distance to agreement), and a passing level of 95%. RESULTS Data of 462 prostate patients was analyzed: 39 and 423 in a test and control group respectively with a comparable number of measurements (on average 8.0 (σ = 4.8) and 7.1 (σ = 4.5) respectively per treatment course). Of the FF, 39% and 31% were related to variations in bladder and rectum filling for the test and control group respectively. Subgroups were created based on the number of FF, no statistically significant differences were observed. CONCLUSION Two dimensional EPID-based IVD successfully detected deviations due to variations in bladder and rectum filling, however it could not confirm the hypothesis.
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Affiliation(s)
- Yawo A.C. Fiagan
- Iridium Netwerk, Radiation Oncology Department, Universiteit Antwerpen, Antwerp, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Evy Bossuyt
- Iridium Netwerk, Radiation Oncology Department, Universiteit Antwerpen, Antwerp, Belgium
| | - Daan Nevens
- Iridium Netwerk, Radiation Oncology Department, Universiteit Antwerpen, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, Universiteit Antwerpen, Antwerp, Belgium
| | - Piet Dirix
- Iridium Netwerk, Radiation Oncology Department, Universiteit Antwerpen, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, Universiteit Antwerpen, Antwerp, Belgium
| | - Frank Theys
- Iridium Netwerk, Radiation Oncology Department, Universiteit Antwerpen, Antwerp, Belgium
| | - Thierry Gevaert
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Dirk Verellen
- Iridium Netwerk, Radiation Oncology Department, Universiteit Antwerpen, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, Universiteit Antwerpen, Antwerp, Belgium
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5
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Webster A, Appelt A, Eminowicz G. Image-Guided Radiotherapy for Pelvic Cancers: A Review of Current Evidence and Clinical Utilisation. Clin Oncol (R Coll Radiol) 2020; 32:805-816. [DOI: 10.1016/j.clon.2020.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/18/2020] [Accepted: 09/30/2020] [Indexed: 02/07/2023]
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6
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Nguyen TT, Nguyen BT, Mai NV. Robustness evaluation of Intensity Modulated Proton Therapy plans using Dose Volume Population Histogram. Phys Med 2019; 65:219-226. [DOI: 10.1016/j.ejmp.2019.09.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/26/2019] [Accepted: 09/05/2019] [Indexed: 10/26/2022] Open
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7
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Tøndel H, Solberg A, Lydersen S, Jensen CA, Kaasa S, Lund JÅ. Rectal volume variations and estimated rectal dose during 8 weeks of image-guided radical 3D conformal external beam radiotherapy for prostate cancer. Clin Transl Radiat Oncol 2019; 15:113-117. [PMID: 30834350 PMCID: PMC6384310 DOI: 10.1016/j.ctro.2019.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/24/2019] [Accepted: 02/14/2019] [Indexed: 11/30/2022] Open
Abstract
Modern IGRT has given new insight regarding organ motion in radiotherapy. Rectal volume variation may increase the risk of biochemical and local failure. Rectal volume decreased significantly during eight weeks of radiotherapy. The percentage of irradiated rectal volume did not change statistically significant. Our study shows that IGRT ensures a close to stable dose to the rectum.
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Affiliation(s)
- Hanne Tøndel
- Cancer Clinic, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology Trondheim, Norway
| | - Arne Solberg
- Cancer Clinic, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology Trondheim, Norway
| | - Stian Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Stein Kaasa
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology Trondheim, Norway.,Department of Oncology, Oslo University Hospital and University of Oslo, Oslo, Norway.,European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Jo-Åsmund Lund
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology Trondheim, Norway.,Department of Oncology, Aalesund Hospital, Aalesund, Norway
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8
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David JM, Gresham G, Jabbour SK, Deek M, Thomassian S, Robertson JM, Newman NB, Herman JM, Osipov A, Kabolizadeh P, Tuli R. Neoadjuvant PET and MRI-based intensity modulated radiotherapy leads to less toxicity and improved pathologic response rates in locally advanced rectal cancer. J Gastrointest Oncol 2018; 9:641-649. [PMID: 30151260 DOI: 10.21037/jgo.2018.03.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Neoadjuvant chemoradiation (NeoCRT) is standard of care for the treatment of locally advanced rectal cancer (LARC). Contemporary radiation techniques and pre-treatment imaging may impact toxicities and pathologic response (PR). Herein we compare intensity modulated radiotherapy (IMRT) and advanced pre-treatment imaging in the neoadjuvant treatment of LARC and resulting impact on toxicities and pathologic outcomes relative to 3 dimensional conformal radiotherapy (3DCRT). Methods LARC patients treated at 4 large academic centers in the US from 2007-2016 were reviewed. Patients received 5-FU-based NeoCRT concurrently with IMRT or 3DCRT. PR was recorded as none, partial, or complete. Common terminology for adverse events version 4 was used to grade toxicities. Toxicity rates were compared using Chi-square analysis. Multivariable models were fit adjusting for age, gender, pre-tx CT to identify independent predictors of PR and toxicity. Results A total of 128 patients were analyzed: 60.1% male and 39.8% female, median age 57.7 years (range, 31-85 years). Clinical characteristics were similar across RT groups. The outcome of partial and complete PR was similar for IMRT and 3DCRT (48.1%, 23.1% vs. 31.7%, 23.3%), respectively. After adjusting for gender, age, and pre-RT chemotherapy type, IMRT and pretreatment PET and/or MRI imaging was significantly associated with increased odds for complete and partial response (OR =2.95, 95% CI: 1.21-7.25, P=0.018; OR =14.70, 95% CI: 3.69-58.78, P<0.0001). Additionally, IMRT was associated with reduced rates of dehydration, dermatitis, rectal pain, rectal bleeding, and diverting ostomy (P<0.05). Overall rates of grade 2 and higher toxicities were significantly reduced in IMRT vs. 3DCRT after adjusting for confounders (OR =0.27, 95% CI: 0.08-0.87). Conclusions NeoCRT IMRT with pretreatment PET and/or MRI for LARC leads to reduced acute toxicities and improved PR compared to 3DCRT. Given the challenges associated with prospective validation of these data, IMRT with pretreatment PET and/or MRI should be considered standard treatment for LARC.
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Affiliation(s)
- John M David
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gillian Gresham
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Salma K Jabbour
- Department of Radiation Oncology, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Matthew Deek
- Department of Radiation Oncology, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Shant Thomassian
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John M Robertson
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI USA
| | - Neil B Newman
- Department of Radiation Oncology, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Joseph M Herman
- Department of Radiation Oncology, MD Anderson Comprehensive Cancer Center, Houston, TX, USA
| | - Arsen Osipov
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Peyman Kabolizadeh
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI USA
| | - Richard Tuli
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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A case-control study using motion-inclusive spatial dose-volume metrics to account for genito-urinary toxicity following high-precision radiotherapy for prostate cancer. Phys Imaging Radiat Oncol 2018; 7:65-69. [PMID: 33458407 PMCID: PMC7807649 DOI: 10.1016/j.phro.2018.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/19/2018] [Accepted: 09/24/2018] [Indexed: 11/21/2022] Open
Abstract
Background and purpose Material and methods Results Conclusions
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10
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Ballare A, Di Salvo M, Loi G, Ferrari G, Beldì D, Krengli M. Conformal Radiotherapy of Clinically Localized Prostate Cancer: Analysis of Rectal and Urinary Toxicity and Correlation with Dose-Volume Parameters. TUMORI JOURNAL 2018; 95:160-8. [DOI: 10.1177/030089160909500206] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background Rectal and urinary toxicities are the principal limiting factors in delivering a high target dose to patients affected by prostate cancer. The verification of such toxicity is an important step before starting a dose-escalation program. The present observational study reports on the acute and late rectal and urinary toxicity in relation with dose-volume parameters in 104 patients with localized prostate cancer treated with 3-dimensional conformal radiation therapy. Methods and study design One hundred and four patients with stage T1b-T3b prostate cancer were treated with three-dimensional conformal radiation therapy to a total dose of 74 Gy, 2 Gy per fraction. Rigid dose constraints were applied for rectum and bladder. Acute and late rectal and urinary toxicities were analyzed also in relation to dose-volume histograms. Biochemical relapse-free survival was defined according to the American Society of Therapeutic Radiation Oncology (ASTRO) criteria and to the RTOG-ASTRO Phoenix Consensus Conference Recommendations using the Kaplan-Meier method. Results No grade 3 toxicity was observed. Acute and late grade 2 toxicity rates were 5.8% and 9.0% for rectum and 12.5% and 2.0% for bladder, respectively. Rectal V70 influenced the occurrence of late grade 2 toxicity. A relationship between acute and late urinary toxicity was also found. After a median follow-up of 30 months (range, 20–50), the actuarial overall and biochemical relapse-free survival rates were 84% and 77%, respectively, with a significant difference between low-intermediate and high-risk patients. Conclusions Conformal radiotherapy to the dose of 74 Gy was administered with good compliance. The incidence of acute and late toxicity was relatively low in accord with our dose constraints. Rectal V70 proved to be a reliable prognosticator of late toxicity. Overall survival and biochemical relapse-free survival rates were more favorable for low and intermediate-risk and significantly less favorable for high-risk patients.
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Affiliation(s)
- Andrea Ballare
- Radiotherapy, University of Piemonte Orientale Amedeo Avogadro and Hospital Maggiore della Carità, Novara, Italy
| | - Maurizio Di Salvo
- Radiotherapy, University of Piemonte Orientale Amedeo Avogadro and Hospital Maggiore della Carità, Novara, Italy
| | - Gianfranco Loi
- Medical Physics, Hospital Maggiore della Carità, Novara, Italy
| | - Gianmarco Ferrari
- Radiotherapy, University of Piemonte Orientale Amedeo Avogadro and Hospital Maggiore della Carità, Novara, Italy
| | - Debora Beldì
- Radiotherapy, University of Piemonte Orientale Amedeo Avogadro and Hospital Maggiore della Carità, Novara, Italy
| | - Marco Krengli
- Radiotherapy, University of Piemonte Orientale Amedeo Avogadro and Hospital Maggiore della Carità, Novara, Italy
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11
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Impact of age at diagnosis on overall and disease-free survival in men with prostate cancer following conformal 3D radiation therapy. TUMORI JOURNAL 2018; 98:722-7. [DOI: 10.1177/030089161209800608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background The impact of age on prostate cancer outcome has been controversial. The aim of the study was to evaluate the role of age on overall survival and disease-free survival in patients affected by prostate cancer when treated with 3D conformal radiation therapy. Methods and study design From 1999 to 2005, 1002 patients with T1–T3 prostate cancer were treated with 3D conformal radiation therapy, delivering a median dose of 75.6, 66.6 and 45 Gy to the prostate, seminal vesicles and pelvic nodes (if necessary), respectively. Patients were divided into four groups (<65, 65–70, 70–75, >75 years) according to age at diagnosis. The relationship between age and both overall survival and disease-free survival was calculated with Kaplan-Meier analysis and the comparison between curves was performed by the logrank test. ROC analysis allowed assessment of the best age cutoff. Results Mean age was 71 ± 6 years (median, 72). Median and mean follow-up was 71.4 and 69 months, respectively. In multivariate analysis, there was no significant difference in the distribution of disease risk between age groups. Analysis demonstrated that older age is a strong positive predictor of survival (odds ratio for stratified patients older than 70 years was <1). In fact, at the 90 month follow-up, overall survival and disease-free survival varied with age, increasing from 85% to 95% and from 78% to 94%, respectively. ROC curve analysis yielded a cutoff age value discriminating overall survival and disease-free survival of 72 years. Conclusions Age is a strong positive predictor of overall survival and disease-free survival, playing a protective role for stratified patients up to 72 years of age.
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12
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Collery A, Forde E. Daily Rectal Dose-volume Histogram Variation in Prostate Intensity-modulated Radiation Therapy: Is It Clinically Significant in the Era of Image Guidance? J Med Imaging Radiat Sci 2017; 48:346-351. [DOI: 10.1016/j.jmir.2017.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 03/23/2017] [Accepted: 04/20/2017] [Indexed: 12/25/2022]
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13
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Maggio A, Gabriele D, Garibaldi E, Bresciani S, Delmastro E, Di Dia A, Miranti A, Poli M, Varetto T, Stasi M, Gabriele P. Impact of a rectal and bladder preparation protocol on prostate cancer outcome in patients treated with external beam radiotherapy. Strahlenther Onkol 2017. [PMID: 28620751 DOI: 10.1007/s00066-017-1163-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE AND OBJECTIVE To test the hypothesis that a rectal and bladder preparation protocol is associated with an increase in prostate cancer specific survival (PCSS), clinical disease free survival (CDFS) and biochemical disease free survival (BDFS). PATIENTS AND METHODS From 1999 to 2012, 1080 prostate cancer (PCa) patients were treated with three-dimensional conformal radiotherapy (3DCRT). Of these patients, 761 were treated with an empty rectum and comfortably full bladder (RBP) preparation protocol, while for 319 patients no rectal/bladder preparation (NRBP) protocol was adopted. RESULTS Compared with NRBP patients, patients with RBP had significantly higher BDFS (64% vs 48% at 10 years, respectively), CDFS (81% vs 70.5% at 10 years, respectively) and PCSS (95% vs 88% at 10 years, respectively) (log-rank test p < 0.001). Multivariate analysis (MVA) indicated for all treated patients and intermediate high-risk patients that the Gleason score (GS) and the rectal and bladder preparation were the most important prognostic factors for PCSS, CDFS and BDFS. With regard to high- and very high-risk patients, GS, RBP, prostate cancer staging and RT dose were predictors of PCSS, CDFS and BDFS in univariate analysis (UVA). CONCLUSION We found strong evidence that rectal and bladder preparation significantly decreases biochemical and clinical failures and the probability of death from PCa in patients treated without daily image-guided prostate localization, presumably since patients with RBP are able to maintain a reproducibly empty rectum and comfortably full bladder across the whole treatment compared with NRPB patients.
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Affiliation(s)
- A Maggio
- Medical Physic Department, Candiolo Cancer Institute - FPO,IRCCS, Candiolo (To), Italy.
| | - D Gabriele
- Radiotherapy Department, Candiolo Cancer Institute - FPO,IRCCS, Candiolo (To), Italy.,Division of Radiation Oncology, University of Sassari, Sassari, Italy
| | - E Garibaldi
- Radiotherapy Department, Candiolo Cancer Institute - FPO,IRCCS, Candiolo (To), Italy
| | - S Bresciani
- Medical Physic Department, Candiolo Cancer Institute - FPO,IRCCS, Candiolo (To), Italy
| | - E Delmastro
- Radiotherapy Department, Candiolo Cancer Institute - FPO,IRCCS, Candiolo (To), Italy
| | - A Di Dia
- Medical Physic Department, Candiolo Cancer Institute - FPO,IRCCS, Candiolo (To), Italy
| | - A Miranti
- Medical Physic Department, Candiolo Cancer Institute - FPO,IRCCS, Candiolo (To), Italy
| | - M Poli
- Medical Physic Department, Candiolo Cancer Institute - FPO,IRCCS, Candiolo (To), Italy
| | - T Varetto
- Nuclear Medicine Department, Candiolo Cancer Institute - FPO,IRCCS, Candiolo (To), Italy
| | - M Stasi
- Medical Physic Department, Candiolo Cancer Institute - FPO,IRCCS, Candiolo (To), Italy
| | - P Gabriele
- Radiotherapy Department, Candiolo Cancer Institute - FPO,IRCCS, Candiolo (To), Italy
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14
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Onal C, Dolek Y, Ozdemir Y. The impact of androgen deprivation therapy on setup errors during external beam radiation therapy for prostate cancer. Strahlenther Onkol 2017; 193:472-482. [PMID: 28409246 DOI: 10.1007/s00066-017-1131-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 03/22/2017] [Indexed: 02/03/2023]
Abstract
PURPOSE To determine whether setup errors during external beam radiation therapy (RT) for prostate cancer are influenced by the combination of androgen deprivation treatment (ADT) and RT. MATERIALS AND METHODS Data from 175 patients treated for prostate cancer were retrospectively analyzed. Treatment was as follows: concurrent ADT plus RT, 33 patients (19%); neoadjuvant and concurrent ADT plus RT, 91 patients (52%); RT only, 51 patients (29%). Required couch shifts without rotations were recorded for each megavoltage (MV) cone beam computed tomography (CBCT) scan, and corresponding alignment shifts were recorded as left-right (x), superior-inferior (y), and anterior-posterior (z). The nonparametric Mann-Whitney test was used to compare shifts by group. Pearson's correlation coefficient was used to measure the correlation of couch shifts between groups. Mean prostate shifts and standard deviations (SD) were calculated and pooled to obtain mean or group systematic error (M), SD of systematic error (Σ), and SD of random error (σ). RESULTS No significant differences were observed in prostate shifts in any direction between the groups. Shifts on CBCT were all less than setup margins. A significant positive correlation was observed between prostate volume and the z‑direction prostate shift (r = 0.19, p = 0.04), regardless of ADT group, but not between volume and x‑ or y‑direction shifts (r = 0.04, p = 0.7; r = 0.03, p = 0.7). Random and systematic errors for all patient cohorts and ADT groups were similar. CONCLUSION Hormone therapy given concurrently with RT was not found to significantly impact setup errors. Prostate volume was significantly correlated with shifts in the anterior-posterior direction only.
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Affiliation(s)
- Cem Onal
- Faculty of Medicine, Adana Dr. Turgut Noyan Research and Treatment Centre, Department of Radiation Oncology, Baskent University, 01120, Adana, Turkey.
| | - Yemliha Dolek
- Faculty of Medicine, Adana Dr. Turgut Noyan Research and Treatment Centre, Department of Radiation Oncology, Baskent University, 01120, Adana, Turkey
| | - Yurday Ozdemir
- Faculty of Medicine, Adana Dr. Turgut Noyan Research and Treatment Centre, Department of Radiation Oncology, Baskent University, 01120, Adana, Turkey
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Does body mass index or subcutaneous adipose tissue thickness affect interfraction prostate motion in patients receiving radical prostate radiotherapy? JOURNAL OF RADIOTHERAPY IN PRACTICE 2016. [DOI: 10.1017/s1460396916000364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AbstractAimIt is unclear whether body mass index (BMI) is a useful measurement for examining prostate motion. Patient’s subcutaneous adipose tissue thickness (SAT) and weight has been shown to correlate with prostate shifts in the left/right direction. We sought to analyse the relationship between BMI and interfraction prostate movement in order to determine planning target volume (PTV) margins based on patient BMI.Materials and methodsIn all, 38 prostate cancer patients with three implanted gold fiducial markers in their prostate were recruited. Height, mass and SAT were measured, and the extent of interfraction prostate movement in the left/right, superior/inferior and anterior/posterior directions was recorded during each daily fiducial marker-based image-guided radiotherapy treatment. Mean corrective shift in each direction for each patient, along with BMI values, were calculated.ResultsThe median BMI value was 28·4 kg/m2 (range 21·4–44·7). Pearson’s product-moment correlation analysis showed no significant relationship between BMI, mass or SAT and the extent of prostate movement in any direction. Linear regression analysis also showed no relationship between any of the patient variables and the extent of prostate movement in any direction (BMI: R2=0·006 (ρ=0·65), 0·002 (ρ=0·80) and 0·001 (ρ=0·86); mass: R2=0·001 (ρ=0·87), 0·010 (ρ=0·54) and 0·000 (ρ=0·99); SAT: R2=0·012 (ρ=0·51), 0·013 (ρ=0·50) and 0·047 (ρ=0·19) for shifts in the X, Y and Z axis, respectively). Patients were grouped according to BMI, as BMI<30 (n=25, 65·8%) and BMI≥30 (n=13, 34·2%). A two-tailed t-test showed no significant difference between the mean prostate shifts for the two groups in any direction (ρ=0·320, 0·839 and 0·325 for shifts in the X, Y and Z axis, respectively).FindingsBMI is not a useful parameter for determining individualised PTV margins. Gold fiducial marker insertion should be used as standard to improve treatment accuracy.
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Moulton CR, House MJ, Lye V, Tang CI, Krawiec M, Joseph DJ, Denham JW, Ebert MA. Prostate external beam radiotherapy combined with high-dose-rate brachytherapy: dose-volume parameters from deformably-registered plans correlate with late gastrointestinal complications. Radiat Oncol 2016; 11:144. [PMID: 27799048 PMCID: PMC5087115 DOI: 10.1186/s13014-016-0719-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 10/17/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Derivation of dose-volume correlated with toxicity for multi-modal treatments can be difficult due to the perceived need for voxel-by-voxel dose accumulation. With data available for a single-institution cohort with long follow-up, an investigation was undertaken into rectal dose-volume effects for gastrointestinal toxicities after deformably-registering each phase of a combined external beam radiotherapy (EBRT)/high-dose-rate (HDR) brachytherapy prostate treatment. METHODS One hundred and eighteen patients received EBRT in 23 fractions of 2 Gy and HDR (TG43 algorithm) in 3 fractions of 6.5 Gy. Results for the Late Effects of Normal Tissues - Subjective, Objective, Management and Analytic toxicity assessments were available with a median follow-up of 72 months. The HDR CT was deformably-registered to the EBRT CT. Doses were corrected for dose fractionation. Rectum dose-volume histogram (DVH) parameters were calculated in two ways. (1) Distribution-adding: parameters were calculated after the EBRT dose distribution was 3D-summed with the registered HDR dose distribution. (2) Parameter-adding: the EBRT DVH parameters were added to HDR DVH parameters. Logistic regressions and Mann-Whitney U-tests were used to correlate parameters with late peak toxicity (dichotomised at grade 1 or 2). RESULTS The 48-80, 40-63 and 49-55 Gy dose regions from distribution-adding were significantly correlated with rectal bleeding, urgency/tenesmus and stool frequency respectively. Additionally, urgency/tenesmus and anorectal pain were associated with the 25-26 Gy and 44-48 Gy dose regions from distribution-adding respectively. Parameter-adding also indicated the low-mid dose region was significantly correlated with stool frequency and proctitis. CONCLUSIONS This study confirms significant dose-histogram effects for gastrointestinal toxicities after including deformable registration to combine phases of EBRT/HDR prostate cancer treatment. The findings from distribution-adding were in most cases consistent with those from parameter-adding. The mid-high dose range and near maximum doses were important for rectal bleeding. The distribution-adding mid-high dose range was also important for stool frequency and urgency/tenesmus. We encourage additional studies in a variety of institutions using a variety of dose accumulation methods with appropriate inter-fraction motion management. TRIAL REGISTRATION NCT NCT00193856 . Retrospectively registered 12 September 2005.
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Affiliation(s)
- Calyn R. Moulton
- School of Physics (M013), University of Western Australia, 35 Stirling Highway, Crawley, WA 6009 Australia
| | - Michael J. House
- School of Physics (M013), University of Western Australia, 35 Stirling Highway, Crawley, WA 6009 Australia
| | - Victoria Lye
- Radiation Oncology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Colin I. Tang
- Radiation Oncology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Michele Krawiec
- Radiation Oncology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - David J. Joseph
- Radiation Oncology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
- School of Surgery, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009 Australia
| | - James W. Denham
- School of Medicine and Population Health, University of Newcastle, University Drive, Callaghan, NSW 2308 Australia
| | - Martin A. Ebert
- School of Physics (M013), University of Western Australia, 35 Stirling Highway, Crawley, WA 6009 Australia
- Radiation Oncology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
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Lee HS, Choi DH, Park HC, Park W, Yu JI, Chung K. Correlation between tumor regression grade and rectal volume in neoadjuvant concurrent chemoradiotherapy for rectal cancer. Radiat Oncol J 2016; 34:186-192. [PMID: 27592514 PMCID: PMC5066448 DOI: 10.3857/roj.2016.01746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 05/31/2016] [Accepted: 06/17/2016] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To determine whether large rectal volume on planning computed tomography (CT) results in lower tumor regression grade (TRG) after neoadjuvant concurrent chemoradiotherapy (CCRT) in rectal cancer patients. MATERIALS AND METHODS We reviewed medical records of 113 patients treated with surgery following neoadjuvant CCRT for rectal cancer between January and December 2012. Rectal volume was contoured on axial images in which gross tumor volume was included. Average axial rectal area (ARA) was defined as rectal volume divided by longitudinal tumor length. The impact of rectal volume and ARA on TRG was assessed. RESULTS Average rectal volume and ARA were 11.3 mL and 2.9 cm². After completion of neoadjuvant CCRT in 113 patients, pathologic results revealed total regression (TRG 4) in 28 patients (25%), good regression (TRG 3) in 25 patients (22%), moderate regression (TRG 2) in 34 patients (30%), minor regression (TRG 1) in 24 patients (21%), and no regression (TRG0) in 2 patients (2%). No difference of rectal volume and ARA was found between each TRG groups. Linear correlation existed between rectal volume and TRG (p = 0.036) but not between ARA and TRG (p = 0.058). CONCLUSION Rectal volume on planning CT has no significance on TRG in patients receiving neoadjuvant CCRT for rectal cancer. These results indicate that maintaining minimal rectal volume before each treatment may not be necessary.
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Affiliation(s)
- Hong Seok Lee
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwangzoo Chung
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Effect of constipation on dosimetry after permanent seed brachytherapy for prostate cancer. J Contemp Brachytherapy 2015; 7:247-51. [PMID: 26622226 PMCID: PMC4643726 DOI: 10.5114/jcb.2015.53491] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/14/2015] [Accepted: 07/04/2015] [Indexed: 11/17/2022] Open
Abstract
Purpose A major concern in prostate brachytherapy is rectal toxicity, which mainly depends on the dose and volume of rectum involved by radiation. We hypothesize that the rectal distension, as produced by constipation, influences the dosimetric parameters of the rectum and other pelvic organs. Material and methods An open, controlled, prospective, paired trial (pre-post test) was designed and conducted. Twenty-three patients treated with prostate brachytherapy were recruited, of which 21 were evaluated. All of them underwent two CT scans, the first one with empty rectum and the second with rectum distended by a catheter balloon. Target volumes and organs at risk were delineated, and dosimetric parameters were calculated and then compared for each patient between both CT. Results For rectum, D2cc increased 15.8% (p < 0.001) and D0.1cc 24.05% (p = 0.002) when the rectum was full. A significant difference was also found in dose distribution to prostate, when rectum is distended, a 1% decrease in V100 (p = 0.031) and a 3.25% in D90 (p = 0.033) was registered. Conclusions The status of rectal distension, as occurs in constipation, has a deleterious influence on prostate brachytherapy dosimetry. This situation increases the radiation to rectum and modifies dose distribution to prostate. We recommend prevention of constipation for at least two half lives of the radioactive seeds.
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Consistency of Organ Geometries during Prostate Radiotherapy with Two Different Bladder and Bowel Regimens. J Med Imaging Radiat Sci 2015; 46:380-387. [PMID: 31052118 DOI: 10.1016/j.jmir.2015.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/01/2015] [Accepted: 09/05/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND The majority of Ontario cancer centres incorporate bladder and bowel preparation protocols for the treatment of prostate cancer with radical radiotherapy. Differing methods are used to achieve a full bladder and empty rectum for planning and treatment. We compared the effects of two different bladder and bowel preparation regimens on bladder, rectum, and prostate +/- seminal vesicle geometries through a course of radiotherapy. An optimal preparation would achieve reliable spatial arrangements and a high therapeutic ratio. METHODS This prospective longitudinal study involved 59 prostate cancer patients treated with radical radiotherapy, of which half followed cohort 1 (laxative cohort) and the other cohort 2 (consistent timing cohort) bladder and bowel preparation regimen. Participants were asked to maintain an empty rectum for both planning and daily treatment appointments in cohort 1 through a fleet enema the morning of the planning appointment, and intake milk of magnesium during daily treatments. No specific bowel preparation was provided to cohort 2 patients. Instead, their appointment times were aligned with their natural bowel habits. This information was collected through a prescreening tool before treatment booking. All cohort 1 and 2 participants were asked to drink 250 mL of water 1 hour before planning and daily treatment appointments. Cohort 2 participants who identified no pre-existing urinary conditions were also asked to drink 2 L of water within 24 hours before the planning session and to continue this during treatment trajectory unless unable to do so because of treatment-induced bladder toxicities later in the treatment. A total of 1,335 structures (bladder, rectum +/- gas, and prostate +/- seminal vesicles) were contoured on the cone beam computerized tomography scans by three radiotherapists. A stringent quality assurance process was performed to assure quality and consistency of contours. Organ volumes were measured and evaluated for consistency over time from planning to completion of radiotherapy. Data analysis included the Fischer exact test and mixed effect modelling for total and subvolumes for bladder, rectum, rectal gas, and prostate +/- seminal vesicles. RESULTS Baseline total volumes for bladder ranged from 132 mL to 501 mL with means of 325 mL and 315 mL in cohorts 1 and 2, respectively. Bladder volume declined 3.6 mL per fraction and 2.4 mL per fraction in cohorts 1 and 2, respectively. The volume of the bladder structure inside the planning target volume (PTV) on simulation showed no difference by cohort (P = .095) but there was an effect of time (linear P < .0005). Baseline total volumes for rectum ranged from 19.2 mL to 106.3 mL with means of 52.0 mL and 54.7 mL in cohorts 1 and 2, respectively. The volume of the rectum inside the PTV on simulation showed no difference by cohort (P = .12) or time (P = .30) during the treatment course. Volume of gas in the rectum did not vary by cohort (P = .6) or time (P = .08). Baseline total volumes for the clinical prostate +/- seminal vesicles target ranged from 37.1 mL to 167.5 mL with means of 76.2 mL and 66.0 mL in cohorts 1 and 2, respectively. The clinical target decreased by 3% in total volume during the course of radiotherapy in both cohorts, with similar rates of the target falling outside the planned PTV structure. CONCLUSIONS No significant difference was found between cohorts for rectal volume, gas volume, target coverage, and rectal and bladder volumes in the PTV. Hence, patients should be offered a choice between cohort 1 and 2 bowel preparation regimens to allow for patient preference customization. Cohort 2 bladder preparation regimen was shown to be superior for consistency with slightly larger volume over time.
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Scaife JE, Barnett GC, Noble DJ, Jena R, Thomas SJ, West CML, Burnet NG. Exploiting biological and physical determinants of radiotherapy toxicity to individualize treatment. Br J Radiol 2015; 88:20150172. [PMID: 26084351 PMCID: PMC4628540 DOI: 10.1259/bjr.20150172] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/07/2015] [Accepted: 05/21/2015] [Indexed: 12/16/2022] Open
Abstract
The recent advances in radiation delivery can improve tumour control probability (TCP) and reduce treatment-related toxicity. The use of intensity-modulated radiotherapy (IMRT) in particular can reduce normal tissue toxicity, an objective in its own right, and can allow safe dose escalation in selected cases. Ideally, IMRT should be combined with image guidance to verify the position of the target, since patients, target and organs at risk can move day to day. Daily image guidance scans can be used to identify the position of normal tissue structures and potentially to compute the daily delivered dose. Fundamentally, it is still the tolerance of the normal tissues that limits radiotherapy (RT) dose and therefore tumour control. However, the dose-response relationships for both tumour and normal tissues are relatively steep, meaning that small dose differences can translate into clinically relevant improvements. Differences exist between individuals in the severity of toxicity experienced for a given dose of RT. Some of this difference may be the result of differences between the planned dose and the accumulated dose (DA). However, some may be owing to intrinsic differences in radiosensitivity of the normal tissues between individuals. This field has been developing rapidly, with the demonstration of definite associations between genetic polymorphisms and variation in toxicity recently described. It might be possible to identify more resistant patients who would be suitable for dose escalation, as well as more sensitive patients for whom toxicity could be reduced or avoided. Daily differences in delivered dose have been investigated within the VoxTox research programme, using the rectum as an example organ at risk. In patients with prostate cancer receiving curative RT, considerable daily variation in rectal position and dose can be demonstrated, although the median position matches the planning scan well. Overall, in 10 patients, the mean difference between planned and accumulated rectal equivalent uniform doses was -2.7 Gy (5%), and a dose reduction was seen in 7 of the 10 cases. If dose escalation was performed to take rectal dose back to the planned level, this should increase the mean TCP (as biochemical progression-free survival) by 5%. Combining radiogenomics with individual estimates of DA might identify almost half of patients undergoing radical RT who might benefit from either dose escalation, suggesting improved tumour cure or reduced toxicity or both.
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Affiliation(s)
- J E Scaife
- University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
| | - G C Barnett
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - D J Noble
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - R Jena
- University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
| | - S J Thomas
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
- Medical Physics Department, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - C M L West
- Institute of Cancer Sciences, University of Manchester, Manchester Academic Health Science Centre, Christie Hospital, Manchester, UK
| | - N G Burnet
- University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
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Assessment and clinical validation of margins for adaptive simultaneous integrated boost in neo-adjuvant radiochemotherapy for rectal cancer. Phys Med 2015; 31:167-72. [DOI: 10.1016/j.ejmp.2014.12.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 12/12/2014] [Accepted: 12/13/2014] [Indexed: 11/19/2022] Open
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A systematic review: Effectiveness of rectal emptying preparation in prostate cancer patients. Pract Radiat Oncol 2014; 4:437-47. [DOI: 10.1016/j.prro.2014.06.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 06/13/2014] [Accepted: 06/16/2014] [Indexed: 01/10/2023]
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Maund IF, Benson RJ, Fairfoul J, Cook J, Huddart R, Poynter A. Image-guided radiotherapy of the prostate using daily CBCT: the feasibility and likely benefit of implementing a margin reduction. Br J Radiol 2014; 87:20140459. [PMID: 25354015 DOI: 10.1259/bjr.20140459] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To investigate whether planning target volume (PTV) margins may be safely reduced in radiotherapy of localized prostate cancer incorporating daily online tube potential-cone beam CT (CBCT) image guidance and the anticipated benefit in predicted rectal toxicity. METHODS The prostate-only clinical target volume (CTV2) and rectum were delineated on 1 pre-treatment CBCT each week in 18 randomly selected patients. By transposing these contours onto the original plan, dose-volume histograms (DVHs) for CTV2 and the rectum were each calculated and combined, for each patient, to produce a single mean DVH representative of the dose delivered over the treatment course. Plans were reoptimized using reduced CTV2 to PTV2 margins and the consequent radiobiological impact modelled by the tumour control probability (TCP) and normal tissue complication probability (NTCP) of the rectum. RESULTS All CBCT images were deemed of sufficient quality to identify the CTV and rectum. No loss of TCP was observed when plans using the standard 5-mm CTV2 to PTV2 margin of the centre were reoptimized with a 4- or 3-mm margin. Margin reduction was associated with a significant decrease in rectal NTCP (5-4 mm; p < 0.05 and 5-3 mm; p < 0.01). CONCLUSION Using daily online image guidance with CBCT, a reduction in CTV2 to PTV2 margins to 3 mm is achievable without compromising tumour control. The consequent sparing of surrounding normal tissues is associated with reduced anticipated rectal toxicity. ADVANCES IN KNOWLEDGE Margin reduction is feasible and potentially beneficial. Centres with image-guided radiotherapy capability should consider assessing whether margin reduction is possible within their institutes.
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Affiliation(s)
- I F Maund
- 1 Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Scaife J, Harrison K, Romanchikova M, Parker A, Sutcliffe M, Bond S, Thomas S, Freeman S, Jena R, Bates A, Burnet N. Random variation in rectal position during radiotherapy for prostate cancer is two to three times greater than that predicted from prostate motion. Br J Radiol 2014; 87:20140343. [PMID: 25138155 PMCID: PMC4170867 DOI: 10.1259/bjr.20140343] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective: Radiotherapy for prostate cancer does not explicitly take into account daily variation in the position of the rectum. It is important to accurately assess accumulated dose (DA) to the rectum in order to understand the relationship between dose and toxicity. The primary objective of this work was to quantify systematic (Σ) and random (σ) variation in the position of the rectum during a course of prostate radiotherapy. Methods: The rectum was manually outlined on the kilo-voltage planning scan and 37 daily mega-voltage image guidance scans for 10 participants recruited to the VoxTox study. The femoral heads were used to produce a fixed point to which all rectal contours were referenced. Results: Σ [standard deviation (SD) of means] between planning and treatment was 4.2 mm in the anteroposterior (AP) direction and 1.3 mm left–right (LR). σ (root mean square of SDs) was 5.2 mm AP and 2.7 mm LR. Superior–inferior variation was less than one slice above and below the planning position. Conclusion: Our results for Σ are in line with published data for prostate motion. σ, however, was approximately twice as great as that seen for prostate motion. This suggests that DA may differ from planned dose in some patients treated with radiotherapy for prostate cancer. Advances in knowledge: This work is the first to use daily imaging to quantify Σ and σ of the rectum in prostate cancer. σ was found to be greater than published data, providing strong rationale for further investigation of individual DA.
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Affiliation(s)
- J Scaife
- 1 Department of Oncology, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Nishimura T, Yamazaki H, Iwama K, Oota Y, Aibe N, Nakamura S, Yoshida K, Okabe H, Yamada K. Potential risk of alpha-glucosidase inhibitor administration in prostate cancer external radiotherapy by exceptional rectal gas production: a case report. J Med Case Rep 2014; 8:136. [PMID: 24886457 PMCID: PMC4046525 DOI: 10.1186/1752-1947-8-136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 02/17/2014] [Indexed: 11/10/2022] Open
Abstract
Introduction Radiotherapy is a standard treatment for prostate cancer, and image-guided radiotherapy is increasingly being used to aid precision of dose delivery to targeted tissues. However, precision during radiotherapy cannot be maintained when unexpected intrafraction organ motion occurs. Case presentation We report our experience of internal organ motion caused by persistent gas production in a patient taking an alpha-glucosidase inhibitor. A 68-year-old Japanese man with prostate cancer visited our institution for treatment with helical tomotherapy. He suffered from diabetes mellitus and took an alpha-glucosidase inhibitor. Routine treatment planning computed tomography showed a large volume of rectal gas; an enema was given to void the rectum. Subsequent treatment planning computed tomography again showed a large volume of gas. After exercise (walking) to remove the intestinal gas, a third scan was performed as a test scan without tight fixation, which showed a sufficiently empty rectum for planning. However, after only a few minutes, treatment planning computed tomography again showed extreme accumulation of gas. Therefore, we postponed treatment planning computed tomography and consulted his doctor to suspend the alpha-glucosidase inhibitor, which was the expected cause of his persistent gas. Four days after the alpha-glucosidase inhibitor regimen was suspended, we took a fourth treatment planning computed tomography and made a treatment plan without gas accumulation. Thereafter, the absence of rectal gas accumulation was confirmed using daily megavolt computed tomography before treatment, and the patient received 37 fractions of intensity-modified radiotherapy at 74Gy without rectal gas complications. In this case study, the alpha-glucosidase inhibitor induced the accumulation of intestinal gas, which may have caused unexpected organ motion, untoward reactions, and insufficient doses to clinical targets. Conclusions We suggest that patients who are taking an alpha-glucosidase inhibitor for diabetes should discontinue use of that particular medicine prior to beginning radiotherapy.
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Affiliation(s)
| | - Hideya Yamazaki
- Department of Radiology, Ujitakeda Hospital, 24-1, Umonji, Uji-city, Kyoto 611-0021, Japan.
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The impact of rectal and bladder variability on target coverage during post-prostatectomy intensity modulated radiotherapy. Radiother Oncol 2014; 110:245-50. [PMID: 24560757 DOI: 10.1016/j.radonc.2013.10.042] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 10/23/2013] [Accepted: 10/28/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND PURPOSE Accuracy when delivering post-prostatectomy intensity modulated radiotherapy (IMRT) is crucial. The aims of this study were to quantify prostate bed movement and determine what amount of bladder or rectum size variation creates the potential for geographic miss. METHODS AND MATERIALS The Cone Beam CT (CBCT) images (n=377) of forty patients who received post-prostatectomy IMRT with daily on-line alignment to bony anatomy were reviewed. Prostate bed movement was estimated using the location of surgical clips in the upper and lower sections of the PTV and correlated with rectal and bladder filling (defined as changes in the cross sectional diameter at defined levels). The number of potential geographic misses caused by bladder and rectum variation was calculated assuming a uniform CTV to PTV expansion of 1cm except 0.5 cm posteriorly. RESULTS Variations in bladder filling of >2 cm larger, ±1 cm, or >2 cm smaller occurred in 3.4%, 56.2%, and 15.1% of images respectively with potential geographic misses in the upper prostate bed of 61.5%, 9.9% and 26.3% respectively. Variations in rectal filling in the upper prostate bed of >1.5 cm larger, 1.5 cm larger to 1cm smaller, and >1cm smaller occurred in 17.2%, 75.6%, and 7.2% of images respectively. These variations resulted in geographic misses in the upper prostate bed in 29.2%, 12.3%, and 63.0% of images respectively. Variations in bladder and rectal filling in the lower prostate bed region had minimal impact on geographic misses. CONCLUSIONS Bladder and rectal size changes at treatment affect prostate bed coverage, especially in the upper aspect of the prostate bed. The greatest potential for geographic miss occurred when either the bladder increased in size or when the rectum became smaller. Ensuring a full bladder and empty rectum at simulation will minimise this risk. Our data also support anisotropic PTV margins with larger margins superiorly than inferiorly.
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Yahya S, Zarkar A, Southgate E, Nightingale P, Webster G. Which bowel preparation is best? Comparison of a high-fibre diet leaflet, daily microenema and no preparation in prostate cancer patients treated with radical radiotherapy to assess the effect on planned target volume shifts due to rectal distension. Br J Radiol 2013; 86:20130457. [PMID: 23995876 PMCID: PMC3830438 DOI: 10.1259/bjr.20130457] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 08/26/2013] [Accepted: 08/28/2013] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE We evaluated and compared a high-fibre diet leaflet, daily microenema and no preparation to establish how best to achieve consistent bowel preparation in prostate cancer patients being treated with radical radiotherapy. METHODS 3 cohorts of 10 patients had different dietary interventions: no bowel preparation, high-fibre diet information leaflet and daily microenemas. The available cone beam CT (CBCT) scans of each patient were used to quantify interfractional changes in rectal distension (measured using average cross-sectional area-CSA), prostate shifts relative to bony anatomy compared with that at CT planning scan and rates of geometric miss (i.e. shifts of ≥5 mm). 85 CBCT scans were available in the pre-leaflet cohort, 89 scans in the post-leaflet, and 89 scans in the post-enema group. RESULTS Mean rectal CSA in the post-enema group was reduced compared with both pre-leaflet (p=0.010) and post-leaflet values (p=0.031). The magnitude of observed mean prostate shifts was significantly reduced in the post-enema group compared with the pre-leaflet group (p=0.014). The proportion of scans showing geometric miss (i.e. shift >5 mm) in the post-enema group (31%) was significantly lower than in the pre-leaflet (62%, p<0.001) or post-leaflet groups (56%, p<0.001). CONCLUSION This study indicates microenema to be an effective measure to achieve reduction in rectal CSA, prostate shift and reduce geometric miss of ≥5 mm. A further prospective randomised study is advocated to validate the results. ADVANCES IN KNOWLEDGE The use of microenema is effective in reducing prostate shift and rectal CSA, consequently decreasing the incidence of geographical miss.
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Affiliation(s)
- S Yahya
- Hall-Edwards Radiotherapy Research Group, The Cancer Centre, Queen Elizabeth Hospital, Birmingham, UK
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Ki Y, Kim W, Nam J, Kim D, Lee J, Park D, Jeon H, Ha H, Kim T, Kim D. Probiotics for rectal volume variation during radiation therapy for prostate cancer. Int J Radiat Oncol Biol Phys 2013; 87:646-50. [PMID: 24054874 DOI: 10.1016/j.ijrobp.2013.07.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 07/02/2013] [Accepted: 07/30/2013] [Indexed: 12/18/2022]
Abstract
PURPOSE To investigate the effect of the probiotic Lactobacillus acidophilus on the percentage volume change of the rectum (PVCR), a crucial factor of prostate movement. METHODS AND MATERIALS Prostate cancer patients managed with tomotherapy as a radical treatment were enrolled in the study to take a probiotic capsule containing 1.0×10(8) colony-forming units of L acidophilus or a placebo capsule twice daily. Radiation therapy was performed at a dose of 78 Gy in 39 fractions. The PVCR, defined as the difference in rectal volume between the planning computed tomographic (CT) and daily megavoltage CT images, was analyzed. RESULTS Forty patients were randomized into 2 groups. The L acidophilus group showed significantly lower median rectal volume and median PVCR values than the placebo group. L acidophilus showed a significant reduction effect on the PVCR (P<.001). However, the radiation therapy fraction number did not significantly influence the PVCR. CONCLUSIONS L acidophilus was useful in reducing the PVCR, which is the most important determining factor of prostate position, during radiation therapy for prostate cancer.
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Affiliation(s)
- Yongkan Ki
- Department of Radiation Oncology, Pusan National University School of Medicine, Busan, Republic of Korea
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Macias V, Gonzalez Celador R, Marti-Macia C, Cigarral C, Perez-Romasanta LA. Prognostic factors for acute toxicity in prostate cancer patients treated with high-dose hypofractionated radiotherapy. Clin Transl Oncol 2013; 15:643-51. [PMID: 23359176 DOI: 10.1007/s12094-012-0987-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 12/05/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE To prospectively study acute genitourinary (GU) and gastrointestinal (GI) toxicity during hypofractionated radiotherapy. PATIENTS AND MATERIALS One-hundred and seventy-one consecutive men with cT1-T3cN0cM0 prostate cancer were treated at 2.6 Gy/fraction to a total dose of 67.6 for low risk (EQD2 = 79 Gy) and 70.2 Gy for intermediate-high risk (EQD2 = 82 Gy) over 5.2-5.4 weeks (α/β 1.5). Acute toxicity was scored according to RTOG/EORTC toxicity extended criteria after completing a 22-item questionnaire (basal, weekly, at 6 months). RESULTS Minimum and median follow-up were 36 and 54.2 months, respectively. GU toxicity grades 0, 1, 2 and 3 were found in 30.4, 37, 32 and 0.6 % of patients, respectively. The figures for grades 0, 1, 2 and 3 GI toxicity were 66, 24, 10 and 0 %. The highest degree of acute reactions was reached at 4-5 weeks. At 6 months, 15 % of patients had GU toxicity (11 % grade 1, 4 % grade 2) and 5.8 % GI toxicity (5.3 % grade 1, 0.5 % grade 2). Multivariate analysis shows that bladder volume receiving ≥65 Gy (V 65) is associated with an increased risk of GU complications (p = 0.017, HR = 1.143, 95 % CI = 1.025-1.276), while history of TURP is linked to lower risk (p = 0.002, HR = 0.310, 95 % CI 0.004-0.370). Mean rectal dose (p = 0.013, HR = 1.089, 95 % CI 1.018-1.116) and total dose (p = 0.019, HR = 0.734, 95 % CI 0.567-0.950) are significantly related to GI toxicity. CONCLUSIONS This 5-week dose-escalation hypofractionated radiotherapy schedule that uses 3D-conformal radiotherapy without IGRT has resulted in <1 % grade 3 acute complications. Our study suggests that reducing the mean rectal dose and the bladder V 65 helps prevent acute toxicity. TURP before radiotherapy was associated with lower acute GU toxicity.
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Affiliation(s)
- V Macias
- Servicio de Oncología Radioterápica, Complejo Asistencial Universitario de Salamanca (CAUSA), Paseo de San Vicente 58-182, 37007, Salamanca, Spain.
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Gwynne S, Webster R, Adams R, Mukherjee S, Coles B, Staffurth J. Image-guided Radiotherapy for Rectal Cancer — A Systematic Review. Clin Oncol (R Coll Radiol) 2012; 24:250-60. [DOI: 10.1016/j.clon.2011.07.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 06/16/2011] [Accepted: 07/04/2011] [Indexed: 11/27/2022]
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Graf R, Boehmer D, Budach V, Wust P. Interfraction rotation of the prostate as evaluated by kilovoltage X-ray fiducial marker imaging in intensity-modulated radiotherapy of localized prostate cancer. Med Dosim 2012; 37:396-400. [PMID: 22534137 DOI: 10.1016/j.meddos.2012.02.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 02/10/2012] [Accepted: 02/22/2012] [Indexed: 10/28/2022]
Abstract
To quantify the daily rotation of the prostate during a radiotherapy course using stereoscopic kilovoltage (kV) x-ray imaging and intraprostatic fiducials for localization and positioning correction. From 2005 to 2009, radio-opaque fiducial markers were inserted into 38 patients via perineum into the prostate. The ExacTrac/Novalis Body X-ray 6-day image acquisition system (ET/NB; BrainLab AG, Feldkirchen, Germany) was used to determine and correct the target position. During the first period in 10 patients we recorded all rotation errors but used only Y (table) for correction. For the next 28 patients we used for correction all rotational coordinates, i.e., in addition Z (superior-inferior [SI] or roll) and X (left-right [LR] or tilt/pitch) according to the fiducial marker position by use of the Robotic Tilt Module and Varian Exact Couch. Rotation correction was applied above a threshold of 1° displacement. The systematic and random errors were specified. Overall, 993 software-assisted rotational corrections were performed. The interfraction rotation errors of the prostate as assessed from the radiodense surrogate markers around the three axes Y, Z, and X were on average 0.09, -0.52, and -0.01° with standard deviations of 2.01, 2.30, and 3.95°, respectively. The systematic uncertainty per patient for prostate rotation was estimated with 2.30, 1.56, and 4.13° and the mean random components with 1.81, 2.02, and 3.09°. The largest rotational errors occurred around the X-axis (pitch), but without preferring a certain orientation. Although the error around Z (roll) can be compensated on average by a transformation with 4 coordinates, a significant error around X remains and advocates the full correction with 6 coordinates. Rotational errors as assessed via daily stereoscopic online imaging are significant and dominate around X. Rotation possibly degrades the dosimetric coverage of the target volume and may require suitable strategies for correction.
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Affiliation(s)
- Reinhold Graf
- Charité Universitätsmedizin Berlin, Department of Radiation Oncology, Campus Virchow-Klinikum, Berlin, Germany
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Analysis of inter-fraction setup errors and organ motion by daily kilovoltage cone beam computed tomography in intensity modulated radiotherapy of prostate cancer. Radiat Oncol 2012; 7:56. [PMID: 22472040 PMCID: PMC3359229 DOI: 10.1186/1748-717x-7-56] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 04/02/2012] [Indexed: 12/03/2022] Open
Abstract
Background Intensity-modulated radiotherapy (IMRT) enables a better conformality to the target while sparing the surrounding normal tissues and potentially allows to increase the dose to the target, if this is precisely and accurately determined. The goal of this work is to determine inter-fraction setup errors and prostate motion in IMRT for localized prostate cancer, guided by daily kilovoltage cone beam computed tomography (kVCBCT). Methods Systematic and random components of the shifts were retrospectively evaluated by comparing two matching modalities (automatic bone and manual soft-tissue) between each of the 641 daily kVCBCTs (18 patients) and the planning kVCT. A simulated Adaptive Radiation Therapy (ART) protocol using the average of the first 5 kVCBCTs was tested by non-parametric bootstrapping procedure. Results Shifts were < 1 mm in left-right (LR) and in supero-inferior (SI) direction. In antero-posterior (AP) direction systematic prostate motion (2.7 ± 0.7 mm) gave the major contribution to the variability of results; the averages of the absolute total shifts were significantly larger in anterior (6.3 ± 0.2 mm) than in posterior (3.9 mm ± 0.2 mm) direction. The ART protocol would reduce margins in LR, SI and anterior but not in posterior direction. Conclusions The online soft-tissue correction based on daily kVCBCT during IMRT of prostate cancer is fast and efficient. The large random movements of prostate respect to bony anatomy, especially in the AP direction, where anisotropic margins are needed, suggest that daily kVCBCT is at the present time preferable for high dose and high gradients IMRT prostate treatments.
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Leborgne F, Fowler J, Leborgne JH, Mezzera J. Later Outcomes and Alpha/Beta Estimate From Hypofractionated Conformal Three-Dimensional Radiotherapy Versus Standard Fractionation for Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2012; 82:1200-7. [DOI: 10.1016/j.ijrobp.2010.12.040] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 12/15/2010] [Accepted: 12/21/2010] [Indexed: 11/26/2022]
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Maggiulli E, Fiorino C, Passoni P, Broggi S, Gianolini S, Salvetti C, Slim N, Di Muzio NG, Calandrino R. Characterisation of rectal motion during neo-adjuvant radiochemotherapy for rectal cancer with image-guided tomotherapy: implications for adaptive dose escalation strategies. Acta Oncol 2012; 51:318-24. [PMID: 22497434 DOI: 10.3109/0284186x.2012.666358] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Interest in boosting the dose to the tumour during neo-adjuvant radiochemotherapy for rectal cancer is ever increasing, especially within the frame of adaptive radiotherapy. Rectal motion remains a potentially important obstacle to the full exploitation of this approach and needs to be carefully investigated. MATERIAL AND METHODS The main purposes of this work were to: a) quantify rectal motion on all fractions of a treatment course; and b) assess margins for adaptive boosting in the second part of the treatment in order to benefit of tumour reduction during treatment. Ten consecutive patients treated with image-guided tomotherapy (41.4 Gy, 18 fractions) were selected. The cranial half of the rectum (subject to motion) was contoured by a single observer on daily MVCTs. The variations of rectal volume and of the envelope of rectum positions were investigated (169 MVCTs). The impact of applying different margins to the rectum in including all its possible positions was also investigated when considering the planning kVCT, the first fraction MVCT, the half-treatment MVCT or the median rectal contours of the whole or second half of treatment as reference volumes. RESULTS Rectal volume reduced during treatment in all patients, with a significant time-trend in 6/10 patients. The median values of the envelope volumes were 129 cm(3) and 87 cm(3) in the first and second half of the treatment, respectively. On average, 95% of the rectal envelope was included by an isotropic expansion of 12 mm and 5 mm of the median contours when considering the whole or the second half of the treatment, respectively. CONCLUSION A significant reduction of rectal volume was found in the second part of the treatment where rectal mobility was limited. As a consequence, relatively small margins may be used around the residual tumour volume when adaptive boost is delivered in the second half of the treatment.
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Chong I, Hawkins M, Hansen V, Thomas K, McNair H, O’Neill B, Aitken A, Tait D. Quantification of Organ Motion During Chemoradiotherapy of Rectal Cancer Using Cone-Beam Computed Tomography. Int J Radiat Oncol Biol Phys 2011; 81:e431-8. [DOI: 10.1016/j.ijrobp.2011.04.060] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 03/19/2011] [Accepted: 04/25/2011] [Indexed: 01/08/2023]
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Assessment of the dosimetric consequences of prostate movement through rectal distension for patients receiving 3DCRT. JOURNAL OF RADIOTHERAPY IN PRACTICE 2011. [DOI: 10.1017/s1460396910000361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPurpose: To investigate the dosimetric consequences of rectal distension at the time of the planning computed tomography (CT) scan and any resultant prostate movement on the planned dose delivery for patients receiving three-dimensional conformal radiotherapy (3DCRT) to the prostate.Methods and materials: 25 prostate cancer patients whose planning CT scan demonstrated a full rectum were rescanned after following a laxative protocol. Rectal dimensions on the two scans and 3DCRT treatment plans produced on each plan were compared. The dosimetric implications of changes in rectal size on the treatment plans and the delivered dose were determined. Statistical significance was evaluated with the Wilcoxon signed ranks test.Results: Significant differences in rectal size were found between the initial CT scan and the rescan. The corresponding median change in prostate position was 4.7 mm. The use of planning scans with a full rectum, that is unrepresentative of the rectum, during treatment causes significant reductions in planning target volume (PTV) minimum dose (median reduction 33.7%) and coverage by the 95% isodose (median reduction 3.7% of the PTV).Conclusion: Rectal distension on the initial planning scan can lead to significant PTV underdosage. Patients presenting with large initial rectal fillings must be rescanned in order to avoid a systematic underdosing of the PTV.
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Zucca S, Carau B, Solla I, Garibaldi E, Farace P, Lay G, Meleddu G, Gabriele P. Prostate image-guided radiotherapy by megavolt cone-beam CT. Strahlenther Onkol 2011; 187:473-8. [PMID: 21786110 DOI: 10.1007/s00066-011-2241-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 04/08/2011] [Indexed: 11/29/2022]
Abstract
PURPOSE To test megavolt cone-beam CT (MV-CBCT) in order to evaluate setup errors in prostate radiotherapy. PATIENTS AND METHODS The setup of 9 patients was verified weekly by electronic portal imaging (EPI) and MV-CBCT, both per-formed in the same treatment session. EPI were compared with digitally reconstructed radiographies (DRRs). MV-CBCTs were matched to simulation CTs by manual registration based on bone markers (BMR), by manual registration based on soft tissues (STR) - rectum, bladder, and seminal vesicles - and by automatic registration (AR) performed by a mutual information algorithm. Shifts were evaluated along the three main axes: anteroposterior (AP), craniocaudal (CC), and laterolateral (LL). Finally, in 4 additional patients showing intraprostatic calcifications, the calcification mismatch error was used to evaluate the three MV-CBCT matching methods. RESULTS A total of 50 pairs of orthogonal EPIs and 50 MV-CBCTs were analyzed. Assuming an overall tolerance of 2 mm, no significant differences were observed comparing EPI vs BMR in any axis. A significant difference (p < 0.001) was observed along the AP axis comparing EPI vs AR and EPI vs STR. On the calcification data set (22 measures), the calcification mismatch along the AP direction was significantly lower (p < 0.05) after STR than after BMR or AR. CONCLUSION Bone markers were not an effective surrogate of the target position and significant differences were observed comparing EPI or BMR vs STR, supporting the assessment of soft tissue position by MVCBs to verify and correct patient setup in prostate radiotherapy.
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Affiliation(s)
- Sergio Zucca
- Department of Radiooncology, Regional Oncological Hospital, Cagliari, Italy
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A Method for the Prediction of Late Organ-at-Risk Toxicity After Radiotherapy of the Prostate Using Equivalent Uniform Dose. Int J Radiat Oncol Biol Phys 2011; 80:608-13. [DOI: 10.1016/j.ijrobp.2010.07.1994] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 06/26/2010] [Accepted: 07/16/2010] [Indexed: 11/17/2022]
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Hayden AJ, Martin JM, Kneebone AB, Lehman M, Wiltshire KL, Skala M, Christie D, Vial P, McDowall R, Tai KH. Australian & New Zealand Faculty of Radiation Oncology Genito-Urinary Group: 2010 consensus guidelines for definitive external beam radiotherapy for prostate carcinoma. J Med Imaging Radiat Oncol 2010; 54:513-25. [DOI: 10.1111/j.1754-9485.2010.02214.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Variability in Bladder Volumes of Full Bladders in Definitive Radiotherapy for Cases of Localized Prostate Cancer. Strahlenther Onkol 2010; 186:637-42. [DOI: 10.1007/s00066-010-2105-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 08/03/2010] [Indexed: 10/18/2022]
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Button M, Staffurth J. Clinical Application of Image-guided Radiotherapy in Bladder and Prostate Cancer. Clin Oncol (R Coll Radiol) 2010; 22:698-706. [DOI: 10.1016/j.clon.2010.06.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 06/30/2010] [Indexed: 11/28/2022]
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de Crevoisier R, Fiorino C, Dubray B. Radiothérapie prostatique : prédiction de la toxicité tardive à partir des données dosimétriques. Cancer Radiother 2010; 14:460-8. [DOI: 10.1016/j.canrad.2010.07.225] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Accepted: 07/12/2010] [Indexed: 12/25/2022]
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Dosimetric effect of online image-guided anatomical interventions for postprostatectomy cancer patients. Int J Radiat Oncol Biol Phys 2010; 79:623-32. [PMID: 20643519 DOI: 10.1016/j.ijrobp.2010.04.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Revised: 04/04/2010] [Accepted: 04/06/2010] [Indexed: 11/22/2022]
Abstract
PURPOSE To assess daily variations in delivered doses in postprostatectomy patients, using kilovoltage cone-beam CT (CBCT) datasets acquired before and after interventions to correct for observed distortions in volume/shape of rectum and bladder. METHODS AND MATERIALS Seventeen consecutive patients treated with intensity-modulated radiotherapy to the prostate bed were studied. For patients with large anatomical variations, quantified by either a rectal wall displacement of >5 mm or bladder volume change of >50% on the CBCT compared with the planning CT, an intervention was performed to adjust the rectum and/or bladder filling. Cumulative doses over the pre- and post-intervention fractions were calculated by tracking the position of the planning CT voxels on different CBCTs using a deformable surface-mapping algorithm. Dose and displacements vectors were projected on two-dimensional maps, the minimal dose received by the highest 95% of the planing target volume (PTV D95) and the highest 10% of the rectum volume (D10) as well as the bladder volume receiving >2 Gy (V2) were evaluated. RESULTS Of 544 fractions, 96 required intervention. Median (range) number of interventions per patient was 5 (2-12). Compared with the planning values, the mean (SD) pre- vs. postintervention value for PTV D95 was -2% (2%) vs. -1% (2%) (p < 0.12), for rectum D10 was -1% (4%) vs. +1% (4%) (p < 0.24), and for bladder V2 was +6% vs. +20% (p < 0.84). CONCLUSIONS Interventions to reduce treatment volume deformations due to bladder and rectum fillings are not necessary when patients receive daily accurate CBCT localization, and the frequency of those potential interventions is low. However, for hypofractionated treatments, the relative frequency can significantly increase, and interventions can become more dosimetrically beneficial.
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Waldenström AC, Alsadius D, Pettersson N, Johansson KA, Holmberg E, Steineck G, Müller M. Variation in position and volume of organs at risk in the small pelvis. Acta Oncol 2010; 49:491-9. [PMID: 20397776 DOI: 10.3109/02841861003702536] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED In preparation for studies of dose volume of ionizing radiation and long-term side effects, we assessed both variation in position and volume of organs at risk in the small pelvis. MATERIAL AND METHODS On 10 men and seven women we delineated the sigmoid, rectum, anal sphincter, bladder, penile bulb, and cavernous bodies in two CT scans taken between five to 69 days apart. RESULTS The measured overlap of the two delineated volumes divided by the maximum possible overlap, was below 50% for the sigmoid in six of 17 patients, for the distal 4 cm of the sigmoid in five of 17 patients, for the rectum in none of 17 patients, for the anal sphincter in three of 17 patients and for the urinary bladder in none of 17 patients. The smaller volume divided by the larger volume was below 50% in three of 17 patients for the sigmoid, in six of 17 patients for the 4 distal cm of the sigmoid, in two of 17 patients for the rectum, in two of 17 patients for the anal sphincter and in seven of 17 patients for the urinary bladder. For the urinary bladder the largest deviation was found cranially, 4.0 cm (SD 2.0 cm), the caudal part being relatively fixed. For the rectum the largest deviation was found in the anterior wall, 1.8 cm (SD 0.7 cm), with maximum documented variation in cranial direction of 3.2 cm (SD 1.8 cm). CONCLUSIONS The sigmoid varies considerably in documented position with the largest deviation anteriorly, the urinary bladder change in volume with the extension mainly located cranially and for the rectum the anterior wall is the most mobile with the distension becoming more pronounced cranially. In modeling dose-volume effects one may consider our results.
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Diot Q, Olsen C, Kavanagh B, Raben D, Miften M. Impact of anatomical interventions on the localization of post-prostatectomy cancer patients. Med Phys 2010; 37:629-37. [PMID: 20229872 DOI: 10.1118/1.3284249] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Anatomical deformations of prostate-bed, rectum, and bladder can compromise the targeting accuracy in post-prostatectomy cancer patients. In this work, the impact of anatomical interventions on the localization data from post-prostatectomy patients who received image-guided IMRT was analyzed. METHODS Patients were localized daily with online kilovoltage cone-beam computed tomography (kV-CBCT). The target and the organs at risk (OARs) positional and volumetric changes were evaluated and couch shifts were applied. For patients with large target or OAR volumetric changes, quantified by either a rectal or bladder wall displacement of >5 mm on the CBCT sagittal images compared to the planning CT, repeated localization CBCT scans were performed following an interventional procedure. The procedure involves insertion of a catheter to deflate the rectum, evacuation of stools, and/or adjustment of bladder filling. The required shifts were then evaluated, and the IMRT treatment was subsequently delivered after proper patient positioning. The pre- and post-intervention shifts were compared in the lateral [left-right (LR)], longitudinal [superior-inferior (SI)], and vertical [anterior-posterior (AP)] directions. The percentage of shifts larger than 5 mm in all directions was also compared. Clinical target volume to planning target volume (CTV-to-PTV) expansion margins were estimated based on the pre- and post-intervention localization data. RESULTS Intervention was performed on all patients (n=17) treated between October 2008 and March 2009. The number of interventions ranged from 2 to 12 with a median number of 5, resulting in a total of 96 pairs of pre- and post-intervention shifts. The mean value (sigma) and standard deviation (sigma) of the shifts from pre- versus post-intervention data were LR, 0.0 +/- 3.0 mm vs. 0.5 +/- 2.8 mm; SI, 0.2 +/- 3.1 mm vs. -1.0 +/- 2.1 mm; and AP, -2.6 +/- 5.8 mm vs. 1.7 +/- 3.9 mm. The mean 3D shift distance was 7.0 +/- 3.1 mm vs. 5.0 +/- 2.6 mm. The percentage of pre-intervention shifts larger than 5 mm were 7%, 7%, and 45% in the LR, SI, and AP directions, respectively, compared to 8%, 4%, and 21% for post-intervention. Localization data from pre- and post-intervention procedures suggest that treatments that do not include intervention to correct for rectum/bladder anatomical variations require an additional 3.3 mm CTV-to-PTV margin. CONCLUSIONS Anatomical interventions reduced the localization errors arising from large volume and shape changes in the rectum and/or bladder compared to treatments without interventions.
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Affiliation(s)
- Quentin Diot
- Department of Radiation Oncology, University of Colorado Denver, Aurora, Colorado 80045, USA
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Darud M, Giddings A, Keyes M, McGahan C, Tyldesely S. Evaluation of a Protocol to Reduce Rectal Volume and Prostate Motion for External Beam Radiation Therapy of the Prostate. J Med Imaging Radiat Sci 2010; 41:12-19. [DOI: 10.1016/j.jmir.2009.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Revised: 06/30/2009] [Accepted: 07/16/2009] [Indexed: 11/25/2022]
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Arbea L, Ramos LI, Martínez-Monge R, Moreno M, Aristu J. Intensity-modulated radiation therapy (IMRT) vs. 3D conformal radiotherapy (3DCRT) in locally advanced rectal cancer (LARC): dosimetric comparison and clinical implications. Radiat Oncol 2010; 5:17. [PMID: 20187944 PMCID: PMC2845593 DOI: 10.1186/1748-717x-5-17] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 02/26/2010] [Indexed: 02/07/2023] Open
Abstract
Purpose To compare target dose distribution, comformality, normal tissue avoidance, and irradiated body volume (IBV) in 3DCRT using classic anatomical landmarks (c3DCRT), 3DCRT fitting the PTV (f3DCRT), and intensity-modulated radiation therapy (IMRT) in patients with locally advanced rectal cancer (LARC). Materials and methods Fifteen patients with LARC underwent c3DCRT, f3DCRT, and IMRT planning. Target definition followed the recommendations of the ICRU reports No. 50 and 62. OAR (SB and bladder) constraints were D5 ≤ 50 Gy and Dmax < 55 Gy. PTV dose prescription was defined as PTV95 ≥ 45 Gy and PTVmin ≥ 35 Gy. Target coverage was evaluated with the D95, Dmin, and Dmax. Target dose distribution and comformality was evaluated with the homogeneity indices (HI) and Conformity Index (CI). Normal tissue avoidance of OAR was evaluated with the D5 and V40. IBV at 5 Gy (V5), 10 Gy (V10), and 20 Gy (V20) were calculated. Results The mean GTV95, CTV95, and PTV95 doses were significantly lower for IMRT plans. Target dose distribution was more inhomogeneous after IMRT planning and 3DCRTplans had significantly lower CI. The V40 and D5 values for OAR were significantly reduced in the IMRT plans .V5 was greater for IMRT than for f3DCRT planning (p < 0.05) and V20 was smaller for IMRT plans(p < 0.05). Conclusions IMRT planning improves target conformity and decreases irradiation of the OAR at the expense of increased target heterogeneity. IMRT planning increases the IBV at 5 Gy or less but decreases the IBV at 20 Gy or more.
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Affiliation(s)
- Leire Arbea
- Department of Oncology, Clínica Universidad de Navarra, Pamplona, Spain.
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Fiorino C, Valdagni R, Rancati T, Sanguineti G. Dose–volume effects for normal tissues in external radiotherapy: Pelvis. Radiother Oncol 2009; 93:153-67. [DOI: 10.1016/j.radonc.2009.08.004] [Citation(s) in RCA: 225] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Revised: 08/11/2009] [Accepted: 08/11/2009] [Indexed: 02/07/2023]
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Stillie AL, Kron T, Fox C, Herschtal A, Haworth A, Thompson A, Owen R, Tai KH, Duchesne G, Foroudi F. Rectal filling at planning does not predict stability of the prostate gland during a course of radical radiotherapy if patients with large rectal filling are re-imaged. Clin Oncol (R Coll Radiol) 2009; 21:760-7. [PMID: 19804961 DOI: 10.1016/j.clon.2009.09.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Revised: 08/24/2009] [Accepted: 08/25/2009] [Indexed: 10/20/2022]
Abstract
AIMS It has been suggested that large rectal filling is associated with an increased risk of prostate motion in radiotherapy. The aim of the present study was to determine if there is a correlation between rectal distension on planning computed tomography and the intrafraction and interfraction stability of the prostate gland during a course of radical radiotherapy for prostate cancer if a protocol was used to rescan patients with excessive rectal diameter during planning. MATERIALS AND METHODS The computed tomography planning scans of 89 patients with adenocarcinoma of the prostate treated with conformal radiotherapy were reviewed. All patients had three gold seed fiducial markers implanted into the prostate before planning computed tomography. About one in five patients had repeat computed tomography because their rectum was judged to be too large at the time of the first planning computed tomography. Rectal distension was assessed on planning computed tomography using outlines following European Organization for Research and Treatment of Cancer guidelines by measuring the rectal volume, the average cross-sectional area and the mean anterior-posterior diameter of the rectum. Daily kV images were obtained before and after treatment delivery to determine positional matching of the fiducial markers in the superior-inferior, anterior-posterior and right-left dimensions. RESULTS In total, 2860 pre- and post-treatment daily kV image pairs were obtained of 89 patients (average 32.1 image pairs per patient). The median rectal cross-sectional area was 7.3cm(2) (range 2.8-17.1), the median rectal volume was 54.8cm(3) (range 20.9-128.2), and the median anterior-posterior rectal diameter was 3.03cm (range 1.58-8.30). Unifactor linear regression models showed no statistically significant relationship between intra- and interfraction prostate stability and rectal volume on planning computed tomography. CONCLUSIONS No statistically significant relationship between rectal distension on planning computed tomography and the intra- and interfraction stability of the prostate gland was identified if patients with a large rectal volume were rescanned for planning.
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Affiliation(s)
- A L Stillie
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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