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Kass-Iliyya A, Jovic G, Murphy C, Fisher C, Syndikus I, Jose C, Scrase CD, Graham JD, Nicol D, Sydes MR, Dearnaley D. Two-years Postradiotherapy Biopsies: Lessons from MRC RT01 Trial. Eur Urol 2018; 73:968-976. [PMID: 29307509 PMCID: PMC5954168 DOI: 10.1016/j.eururo.2017.12.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 12/14/2017] [Indexed: 11/13/2022]
Abstract
BACKGROUND The importance of 2-yr postradiotherapy prostate biopsy status remains uncertain. OBJECTIVE To assess the value of 2 year post treatment biopsies in a randomised trial of radiotherapy dose escalation. DESIGN, SETTING, AND PARTICIPANTS Between 1998 and 2001, 843 men with localised prostate cancer were randomised to receive either control-64Gy or escalated-74Gy conformal radiotherapy (CFRT) in the MRC RT01 trial in combination with 3-6-mo neoadjuvant androgen deprivation therapy. Prostate biopsies were planned at 2 yr from start of CFRT in suitable men. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Prostate biopsy results and prostate-specific antigen (PSA) levels performed at 2 yr post-CFRT were evaluated with long-term biochemical progression free survival (bPFS) and overall survival. Outcome measures were timed from the 2-yr biopsy using a landmark approach. RESULTS AND LIMITATIONS A 2-yr biopsy was performed in 312/843 patients. One hundred and seventy-seven patients were included in the per-protocol group with median follow-up of 7.8 yr from biopsy. Median PSA at biopsy was 0.5ng/ml. Sixty-four bPFS events were reported: 46/145 (32%) in patients with negative, 6/18 (33%) suspicious, and 12/14 (86%) positive biopsies. A positive biopsy was prognostic of worse bPFS, going forward, compared with negative and suspicious biopsies, hazard ratio (HR)=4.81 (95% confidence interval [CI]: 2.50-9.26, p<0.001). The estimate for survival was HR=1.58 (95% CI: 0.52-4.78, p=0.42). PSA values at 2 yr between 1.01ng/ml and 2.09ng/ml were also associated with subsequent PSA failures (HR=2.71, 95% CI: 1.98-3.71), bPFS events (HR=2.45, 95% CI: 1.81-3.32), and prostate cancer-specific survival (HR=2.87, 95% CI: 1.08-7.64) compared with PSA ≤1.0ng/ml. CONCLUSIONS Two-year postradiotherapy prostate biopsies have limited value in patients with PSA control but both positive biopsy and higher PSA status are strongly associated with future bPFS events. A policy of selected biopsy may provide an opportunity for early salvage interventions. PATIENT SUMMARY Routine 2-yr postradiotherapy biopsy is not recommended but can be considered in selected patients with unfavourable post-treatment prostate-specific antigen levels who are suitable for early salvage treatments.
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Affiliation(s)
- Antoine Kass-Iliyya
- MRC Clinical Trials Unit at UCL, London, UK; North Bristol Trust, Bristol, UK
| | | | | | | | | | - Chakiath Jose
- Department of Radiation Oncology, Auckland City Hospital, Auckland, New Zealand
| | | | - John D Graham
- Taunton & Somerset National Health Service Foundation Trust, Musgrove Park Hospital, Taunton, UK
| | | | | | - David Dearnaley
- Institute of Cancer Research and Royal Marsden Hospitals, Sutton and London, UK.
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Nishimura S, Ohashi T, Momma T, Sakayori M, Eriguchi T, Tanaka T, Yamashita S, Kosaka T, Oya M, Shigematsu N. Prostate-specific antigen nadir within 12 months as an early surrogate marker of biochemical failure and distant metastasis after low-dose-rate brachytherapy or external beam radiotherapy for localized prostate cancer. Cancer Med 2018; 7:1794-1801. [PMID: 29577651 PMCID: PMC5943430 DOI: 10.1002/cam4.1443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 02/01/2018] [Accepted: 02/19/2018] [Indexed: 11/09/2022] Open
Abstract
Prostate-specific antigen nadir (nPSA) after radiotherapy for localized prostate cancer has been investigated as a predictor. However, nPSA usually requires several years, limiting its clinical utility. We investigated the significance of nPSA within 12 months (nPSA12) after low-dose-rate prostate brachytherapy (LDR-PB) or external beam radiotherapy (EBRT) on treatment outcomes. Between 2006 and 2014, 663 patients with prostate cancer were treated with LDR-PB or EBRT at two institutions. Four hundred and seventy-four men received LDR-PB and 189 men received EBRT, without androgen deprivation therapy. The Kaplan-Meier method was used for biochemical failure (BF)-free survival (BFFS) and distant metastasis (DM)-free survival (DMFS) analyses, and multivariable Cox regression analysis was performed. The median follow-up was 61.3 months. The median nPSA12 in the LDR-PB and EBRT cohorts was 0.7 and 1.0 ng/mL, respectively. The 7-year BFFS and DMFS rates in LDR-PB patients with nPSA12 ≤ 0.7 ng/mL were 99.1% and 99.5%, respectively; when nPSA12 was >0.7 ng/mL, they were 90.2% and 94.8%, respectively. In EBRT patients with nPSA12 ≤ 1.0 ng/mL, BFFS and DMFS rates were 85.4% and 98.5%, respectively; when nPSA12 was >1.0 ng/mL, they were 67.1% and 87.2%, respectively. nPSA12 was an independent predictor of BF and DM in both cohorts (LDR-PB, P = 0.004 and 0.020, respectively; EBRT, P = 0.005 and 0.041, respectively). The nPSA12 after LDR-PB or EBRT is significantly associated with treatment outcomes of prostate cancer. Higher nPSA12 may identify patients at high risk of relapse who might benefit from salvage treatment.
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Affiliation(s)
- Shuichi Nishimura
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Toshio Ohashi
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Tetsuo Momma
- Department of Urology, National Hospital Organization Saitama Hospital, Saitama, Japan
| | - Masanori Sakayori
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Takahisa Eriguchi
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Tomoki Tanaka
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Shoji Yamashita
- Department of Radiology, National Hospital Organization Saitama Hospital, Saitama, Japan
| | - Takeo Kosaka
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Naoyuki Shigematsu
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
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Biomarkers of Outcome in Patients With Localized Prostate Cancer Treated With Radiotherapy. Semin Radiat Oncol 2017; 27:11-20. [DOI: 10.1016/j.semradonc.2016.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Franca CADS, Vieira SL, Carvalho ACP, Bernabe AJS, Penna ABRC. Relationship between two year PSA nadir and biochemical recurrence in prostate cancer patients treated with iodine-125 brachytherap. Radiol Bras 2015; 47:89-93. [PMID: 25741055 PMCID: PMC4337165 DOI: 10.1590/s0100-39842014000200010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 10/22/2013] [Indexed: 11/22/2022] Open
Abstract
Objective To evaluate the relationship between two year PSA nadir (PSAn) after brachytherapy
and biochemical recurrence rates in prostate cancer patients. Materials and Methods In the period from January 1998 to August 2007, 120 patients were treated with
iodine-125 brachytherapy alone. The results analysis was based on the definition
of biochemical recurrence according to the Phoenix Consensus. Results Biochemical control was observed in 86 patients (71.7%), and biochemical
recurrence, in 34 (28.3%). Mean PSAn was 0.53 ng/ml. The mean follow-up was 98
months. The patients were divided into two groups: group 1, with two year PSAn
< 0.5 ng/ml after brachytherapy (74 patients; 61.7%), and group 2, with two
year PSAn ≥ 0.5 ng/ml after brachytherapy (46 patients; 38.3%). Group 1
presented biochemical recurrence in 15 patients (20.3%), and group 2, in 19
patients (43.2%) (p < 0.02). The analysis of biochemical
disease-free survival at seven years, stratified by the two groups, showed values
of 80% and 64% (p < 0.02), respectively. Conclusion Levels of two year PSAn ≥ 0.5 ng/ml after brachytherapy are strongly
correlated with a poor prognosis. This fact may help to identify patients at risk
for disease recurrence.
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Affiliation(s)
- Carlos Antônio da Silva Franca
- Master, MD, Radiation Oncology at Instituto Brasileiro de Oncologia (IBO), Radioterapia Botafogo, Universidade Federal do Rio de Janeiro (UFRJ) and Pontifícia Universidade Católica do Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Sérgio Lannes Vieira
- Full Professor, MD, Radiation Oncology at Instituto Brasileiro de Oncologia (IBO), Radioterapia Botafogo and Pontifícia Universidade Católica do Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | | | | | - Antonio Belmiro Rodrigues Campbell Penna
- PhD, MD, Radiation Oncology at Instituto Brasileiro de Oncologia (IBO), Radioterapia Botafogo and Pontifícia Universidade Católica do Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
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5
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Morris LM, Izard MA, Wan WY. Does prostate-specific antigen nadir predict longer-term outcomes of prostate cancer after neoadjuvant and adjuvant androgen deprivation therapy in conjunction with brachytherapy? Brachytherapy 2014; 14:322-8. [PMID: 25487524 DOI: 10.1016/j.brachy.2014.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 11/01/2014] [Accepted: 11/05/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate whether nadir prostate-specific antigen (nPSA), time to nPSA (TnPSA), and nPSA 3-years post-treatment are prognostic for prostate cancer (PC) in patients treated with temporary brachytherapy plus external beam radiation therapy (EBRT) and hormonal manipulation. METHODS AND MATERIALS We retrospectively analyzed our database of 253 patients with Stage T1-T3 N0M0 PC who underwent brachytherapy with temporary brachytherapy plus EBRT. All patients received neoadjuvant androgen deprivation for a median of 6 months. Treatment consisted of three pulses of pseudo pulsed-dose-rate brachytherapy to a median dose of 18Gy with 50.4Gy in 28 fractions of EBRT. Treatment took place between December 1999 and March 2006. RESULTS At a median of 6-years followup, nPSA value was a predictor of biochemical control. Rising nPSA categories of <0.01, 0.01-<0.05, 0.05-≤0.1, 0.1-≤ 1.0, or >1.0 ng/mL correlated with a deteriorating 5-year biochemical control (nBED) by the Phoenix definition of 100%, 90.0%, 82.5%, 64.3%, and 10%, respectively. A highly statistically significant relationship between nPSA value and subsequent clinical failure is also demonstrated. The relationship between TnPSA and nBED was strongly significant (p<0.0001), with a significantly longer nPSA for patients who had Phoenix nBED. A PSA of <1.5 ng/mL achieved 3-year post radiation therapy was prognostic for biochemical and clinical disease control (p<0.0001). CONCLUSION The nPSA, TnPSA, and reaching a PSA cutoff level of <1.5 ng/mL at 3 years post-treatment can provide useful prognostic information on long-term biochemical and clinical control of PC in patients treated with pseudo PDR, EBRT, and hormone manipulation.
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Affiliation(s)
- Lucinda May Morris
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, Australia.
| | - Michael Anthony Izard
- Department of Radiotherapy, Mater Hospital, North Sydney, New South Wales, Australia
| | - Wai-Yin Wan
- Department of Biostatistics, University of Sydney, New South Wales, Australia
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Wallace T, Torre T, Grob M, Yu J, Avital I, Brücher BLDM, Stojadinovic A, Man Y. Current approaches, challenges and future directions for monitoring treatment response in prostate cancer. J Cancer 2014; 5:3-24. [PMID: 24396494 PMCID: PMC3881217 DOI: 10.7150/jca.7709] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 11/01/2013] [Indexed: 01/23/2023] Open
Abstract
Prostate cancer is the most commonly diagnosed non-cutaneous neoplasm in men in the United States and the second leading cause of cancer mortality. One in 7 men will be diagnosed with prostate cancer during their lifetime. As a result, monitoring treatment response is of vital importance. The cornerstone of current approaches in monitoring treatment response remains the prostate-specific antigen (PSA). However, with the limitations of PSA come challenges in our ability to monitor treatment success. Defining PSA response is different depending on the individual treatment rendered potentially making it difficult for those not trained in urologic oncology to understand. Furthermore, standard treatment response criteria do not apply to prostate cancer further complicating the issue of treatment response. Historically, prostate cancer has been difficult to image and no single modality has been consistently relied upon to measure treatment response. However, with newer imaging modalities and advances in our understanding and utilization of specific biomarkers, the future for monitoring treatment response in prostate cancer looks bright.
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Affiliation(s)
- T.J. Wallace
- 1. Bon Secours Cancer Institute, Bon Secours Health Care System, Richmond VA, USA
- 2. Division of Radiation Oncology, Bon Secours Health Care System, Richmond VA, USA
- 3. Virginia Urology, Richmond VA, USA
| | - T. Torre
- 1. Bon Secours Cancer Institute, Bon Secours Health Care System, Richmond VA, USA
- 2. Division of Radiation Oncology, Bon Secours Health Care System, Richmond VA, USA
- 3. Virginia Urology, Richmond VA, USA
| | - M. Grob
- 4. Department of Urology, Virginia Commonwealth University Health System, Richmond VA, USA
| | - J. Yu
- 5. Department of Radiology, Virginia Commonwealth University Health System, Richmond VA, USA
| | - I. Avital
- 1. Bon Secours Cancer Institute, Bon Secours Health Care System, Richmond VA, USA
- 6. Division of Surgical Oncology, Bon Secours Health Care System, Richmond VA, USA
| | - BLDM Brücher
- 1. Bon Secours Cancer Institute, Bon Secours Health Care System, Richmond VA, USA
- 6. Division of Surgical Oncology, Bon Secours Health Care System, Richmond VA, USA
- 7. INCORE, International Consortium of Research Excellence of the Theodor-Billroth-Adademy
| | - A. Stojadinovic
- 1. Bon Secours Cancer Institute, Bon Secours Health Care System, Richmond VA, USA
- 6. Division of Surgical Oncology, Bon Secours Health Care System, Richmond VA, USA
- 7. INCORE, International Consortium of Research Excellence of the Theodor-Billroth-Adademy
| | - Y.G. Man
- 1. Bon Secours Cancer Institute, Bon Secours Health Care System, Richmond VA, USA
- 6. Division of Surgical Oncology, Bon Secours Health Care System, Richmond VA, USA
- 8. South Hospital of Nanjing, Nanjing, China
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7
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Kapadia NS, Olson K, Sandler HM, Feng FY, Hamstra DA. Interval to biochemical failure as a biomarker for cause-specific and overall survival after dose-escalated external beam radiation therapy for prostate cancer. Cancer 2011; 118:2059-68. [DOI: 10.1002/cncr.26498] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 06/29/2011] [Accepted: 07/18/2011] [Indexed: 11/10/2022]
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8
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Zelefsky MJ, Shi W, Yamada Y, Kollmeier MA, Cox B, Park J, Seshan VE. Postradiotherapy 2-year prostate-specific antigen nadir as a predictor of long-term prostate cancer mortality. Int J Radiat Oncol Biol Phys 2009; 75:1350-6. [PMID: 19515504 DOI: 10.1016/j.ijrobp.2008.12.067] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Revised: 12/05/2008] [Accepted: 12/29/2008] [Indexed: 11/26/2022]
Abstract
PURPOSE To report the influence of posttreatment prostate-specific antigen (PSA) nadir response at 2 years after external beam radiotherapy (RT) on distant metastases (DM) and cause-specific mortality (CSM). METHODS AND MATERIALS Eight hundred forty-four patients with localized prostate cancer were treated with conformal RT. The median duration of follow-up was 9.1 years. A fixed landmark time point at 2 years was used to assess the influence of nadir PSA value as a time-dependent variable on long-term outcomes. RESULTS Multivariate analysis demonstrated that nadir PSA <or=1.5 ng/mL at the landmark was an independent predictor of progression-free survival after adjusting for T stage, Gleason score, pre-RT PSA value, and RT dose (p = 0.03). The 5- and 10-year cumulative incidences of DM were 2.4% and 7.9%, respectively, in those with nadir PSA levels <or=1.5 ng/mL at the 2-year landmark, and were 10.3% and 17.5%, respectively, in patients with higher nadir values. Multivariate analysis showed that the higher nadir PSA value at the 2-year landmark (p = 0.002), higher Gleason scores (p < 0.001), and increasing T stage (p = 0.03) were predictors of DM after adjusting for pre-RT PSA values and RT dose. Multivariate analysis also showed that higher Gleason scores (p = 0.002), and higher nadir PSA values at the 2-year landmark (p = 0.03) were risk factors associated with CSM after adjusting for T stage and pre-RT PSA value. CONCLUSIONS Nadir PSA values of <or=1.5 ng/mL at 2 years after RT for prostate cancer predict for long-term DM and CSM outcomes. Patients with higher absolute nadir levels at 2 years after treatment should be evaluated for the presence of nonresponding disease, and earlier salvage treatment interventions should be considered.
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Affiliation(s)
- Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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9
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Bellera CA, Hanley JA, Joseph L, Albertsen PC. Hierarchical changepoint models for biochemical markers illustrated by tracking postradiotherapy prostate-specific antigen series in men with prostate cancer. Ann Epidemiol 2008; 18:270-82. [PMID: 18374279 DOI: 10.1016/j.annepidem.2007.10.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2007] [Revised: 09/25/2007] [Accepted: 10/05/2007] [Indexed: 11/26/2022]
Abstract
PURPOSE Biomarkers provide valuable information when detecting disease onset or monitoring disease progression; examples include bone mineral density (for osteoporosis), cholesterol (for coronary artery diseases), or prostate-specific antigens (PSA, for prostate cancer). Characteristics of markers series can then be used as prognostic factors of disease progression, such as the postradiotherapy PSA doubling time in men treated for prostate cancer. The statistical analysis of such data has to incorporate the within and between-series variabilities, the complex patterns of the series over time, the unbalanced format of the data, and the possibly nonconstant precision of the measurements. METHODS We base our analysis on a population-based cohort of 470 men treated with radiotherapy for prostate cancer; after treatment, the log(2)PSA concentrations follow a piecewise-linear pattern. We illustrate the flexibility of Bayesian hierarchical changepoint models by estimating the individual and population postradiotherapy log(2)PSA profiles; parameters such as the PSA nadir and the PSA doubling time were estimated, and their associations with baseline patient characteristics were investigated. The residual PSA variability was modeled as a function of the PSA concentration. For comparison purposes, two alternative models were briefly considered. RESULTS Precise estimates of all parameters of the PSA trajectory are provided at both the individual and population levels. Estimates suggest greater PSA variability at lower PSA concentrations, as well as an association between shorter PSAdts and greater baseline PSA levels, higher Gleason scores, and older age. CONCLUSIONS The use of Bayesian hierarchical changepoint models accommodates multiple complex features of longitudinal data, permits realistic modeling of the variability as a function of the marker concentration, and provides precise estimates of all clinically important parameters. This type of model should be applicable to the study of marker series in other diseases.
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Affiliation(s)
- Carine A Bellera
- Department of Clinical Epidemiology and Clinical Research, Institut Bergonié, Regional Comprehensive Cancer Center, Bordeaux, France.
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10
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Buyyounouski MK, Hanlon AL, Horwitz EM, Pollack A. Interval to Biochemical Failure Highly Prognostic for Distant Metastasis and Prostate Cancer-Specific Mortality After Radiotherapy. Int J Radiat Oncol Biol Phys 2008; 70:59-66. [DOI: 10.1016/j.ijrobp.2007.05.047] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Revised: 05/25/2007] [Accepted: 05/31/2007] [Indexed: 10/22/2022]
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Zapotoczna A, Sasso G, Simpson J, Roach M. Current role and future perspectives of magnetic resonance spectroscopy in radiation oncology for prostate cancer. Neoplasia 2007; 9:455-63. [PMID: 17603627 PMCID: PMC1899254 DOI: 10.1593/neo.07277] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2007] [Revised: 04/24/2007] [Accepted: 04/24/2007] [Indexed: 01/27/2023] Open
Abstract
Prostatic neoplasms are not uniformly distributed within the prostate volume. With recent developments in three-dimensional intensity-modulated and image-guided radiation therapy, it is possible to treat different volumes within the prostate to different thresholds of doses. This approach has the potential to adapt the dose to the biologic aggressiveness of various clusters of tumor cells within the gland. The definition of tumor burden volume in prostate cancer can be facilitated by the use of magnetic resonance spectroscopy (MRS). The increasing sensitivity and specificity of MRS to the prostate is causing new interest in its potential role in the definition of target subvolumes at higher risk of failure following radical radiotherapy. Prostate MRS might also play a role as a noninvasive predictive factor for tumor response and treatment outcome. We review the use of MRS in radiation therapy for prostate cancer by evaluating its accuracy in the classification of aggressive cancer regions and target definition; its current role in the radiotherapy planning process, with special interest in technical issues behind the successful inclusion of MRS in clinical use; and available early experiences as a prognostic tool.
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Affiliation(s)
- Aleksandra Zapotoczna
- Department of Radiation Oncology, Townsville Teaching Hospital, Queensland, Australia
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12
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Ray ME, Levy LB, Horwitz EM, Kupelian PA, Martinez AA, Michalski JM, Pisansky TM, Zelefsky MJ, Zietman AL, Kuban DA. Nadir prostate-specific antigen within 12 months after radiotherapy predicts biochemical and distant failure. Urology 2006; 68:1257-62. [PMID: 17141830 DOI: 10.1016/j.urology.2006.08.1056] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 05/19/2006] [Accepted: 08/11/2006] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine whether nadir prostate-specific antigen (PSA) levels within 12 months (nadir PSA12) after completion of radiotherapy (RT) can be used as an early marker of recurrence risk. METHODS A total of 4839 patients were treated with RT and without hormonal therapy from 1986 to 1995 for Stage T1-T2 prostate cancer at nine institutions. Of these 4839 patients, 4833, with a median follow-up of 6.3 years, met the criteria for analysis. The study endpoints included freedom from PSA failure, initiation of androgen deprivation, or documented local or distant failure (PSA-DFS); freedom from clinically apparent distant metastasis (DMFS); and overall survival (OS). RESULTS Patients with a nadir PSA12 of 2.0 ng/mL or less had an 8-year PSA-DFS, DMFS, and OS rate of 55%, 95%, and 73%, respectively, compared with 40%, 88%, and 69%, respectively, for patients with a nadir PSA12 of more than 2.0 ng/mL. Multivariate analysis confirmed that a nadir PSA12 of greater than 2 ng/mL was an independent predictor of PSA-DFS, DMFS, and OS. Classification and regression tree analysis identified the nadir PSA12 levels after RT associated with PSA-DFS, DMFS, and OS. Nadir PSA12, combined with the pretreatment PSA level, identified patients at particularly high risk of distant metastasis. CONCLUSIONS The results of this large, multi-institutional study have demonstrated that nadir PSA12 is predictive of clinical outcomes for patients with localized prostate cancer after RT. A high pretreatment PSA level and high nadir PSA12 will identify patients at particularly high risk who might benefit from early adjuvant therapy.
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Affiliation(s)
- Michael E Ray
- Department of Radiation Oncology, University of Michigan Medical Center, Ann Arbor, Michigan 48109-0010, USA.
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13
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Pickett B, Kurhanewicz J, Pouliot J, Weinberg V, Shinohara K, Coakley F, Roach M. Three-dimensional conformal external beam radiotherapy compared with permanent prostate implantation in low-risk prostate cancer based on endorectal magnetic resonance spectroscopy imaging and prostate-specific antigen level. Int J Radiat Oncol Biol Phys 2006; 65:65-72. [PMID: 16517094 DOI: 10.1016/j.ijrobp.2005.11.037] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2005] [Revised: 11/21/2005] [Accepted: 11/23/2005] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the metabolic response by comparing the time to resolution of spectroscopic abnormalities (TRSA) and the time to prostate-specific antigen level in low-risk prostate cancer patients after treatment with three-dimensional conformal external beam radiotherapy (3D-CRT) compared with permanent prostate implantation (PPI). Recent studies have suggested that the treatment of low-risk prostate cancer yields similar results for patients treated with 3D-CRT or PPI. METHODS AND MATERIALS A total of 50 patients, 25 in each group, who had been treated with 3D-CRT or PPI, had undergone endorectal magnetic resonance spectroscopy imaging before and/or at varying times after therapy. The 3D-CRT patients had received radiation doses of > or =72 Gy compared with 144 Gy for the PPI patients. The spectra from all usable voxels were examined for detectable levels of metabolic signal, and the percentages of atrophic and cancerous voxels were tabulated. RESULTS The median time to resolution of the spectroscopic abnormalities was 32.2 and 24.8 months and the time to the nadir prostate-specific antigen level was 52.4 and 38.0 months for the 3D-CRT and PPI patients, respectively. Of the 3D-CRT patients, 92% achieved negative endorectal magnetic resonance spectroscopy imaging findings, with 40% having complete metabolic atrophy. All 25 PPI patients had negative endorectal magnetic resonance spectroscopy imaging findings, with 60% achieving complete metabolic atrophy. CONCLUSION The results of this study suggest that metabolic and biochemical responses of the prostate are more pronounced after PPI. Our results have not proved PPI is more effective at curing prostate cancer, but they have demonstrated that it may be more effective at destroying prostate metabolism.
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Affiliation(s)
- Barby Pickett
- Department of Radiation Oncology, University of California, San Francisco, School of Medicine, San Francisco, CA 94143, USA.
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14
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Ray ME, Thames HD, Levy LB, Horwitz EM, Kupelian PA, Martinez AA, Michalski JM, Pisansky TM, Shipley WU, Zelefsky MJ, Zietman AL, Kuban DA. PSA nadir predicts biochemical and distant failures after external beam radiotherapy for prostate cancer: a multi-institutional analysis. Int J Radiat Oncol Biol Phys 2005; 64:1140-50. [PMID: 16198506 DOI: 10.1016/j.ijrobp.2005.07.006] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2005] [Revised: 07/04/2005] [Accepted: 07/05/2005] [Indexed: 11/28/2022]
Abstract
PURPOSE To determine the significance of prostate-specific antigen (PSA) nadir (nPSA) and the time to nPSA (T(nPSA)) in predicting biochemical or clinical disease-free survival (PSA-DFS) and distant metastasis-free survival (DMFS) in patients treated with definitive external beam radiotherapy (RT) for clinical Stage T1b-T2 prostate cancer. METHODS AND MATERIALS Nine participating institutions submitted data on 4839 patients treated between 1986 and 1995 for Stage T1b-T2cN0-NxM0 prostate cancer. All patients were treated definitively with RT alone to doses > or =60 Gy, without neoadjuvant or planned adjuvant androgen suppression. A total of 4833 patients with a median follow-up of 6.3 years met the criteria for analysis. Two endpoints were considered: (1) PSA-DFS, defined as freedom from PSA failure (American Society for Therapeutic Radiology and Oncology definition), initiation of androgen suppression after completion of RT, or documented local or distant failure; and (2) DMFS, defined as freedom from clinically apparent distant failure. In patients with failure, nPSA was defined as the lowest PSA measurement before any failure. In patients without failure, nPSA was the lowest PSA measurement during the entire follow-up period. T(nPSA) was calculated from the completion of RT to the nPSA date. RESULTS A greater nPSA level and shorter T(nPSA) were associated with decreased PSA-DFS and DMFS in all patients and in all risk categories (low [Stage T1b, T1c, or T2a, Gleason score < or =6, and PSA level < or =10 ng/mL], intermediate [Stage T1b, T1c, or T2a, Gleason score < or =6, and PSA level >10 but < or =20 ng/mL, or Stage T2b or T2c, Gleason score < or =6, and PSA level < or =20 ng/mL, or Gleason score 7 and PSA level < or =20 ng/mL], and high [Gleason score 8-10 or PSA level >20 ng/mL]), regardless of RT dose. The 8-year PSA-DFS and DMFS rate for patients with nPSA <0.5 ng/mL was 75% and 97%; nPSA > or =0.5 but <1.0 ng/mL, 52% and 96%; nPSA > or =1.0 but <2.0 ng/mL, 40% and 91%; and nPSA > or =2.0 ng/mL, 17% and 73%, respectively. The 8-year PSA-DFS and DMFS rate for patients with T(nPSA) <6 months was 27% and 66%; T(nPSA) > or =6 but <12 months, 31% and 85%; T(nPSA) > or =12 but <24 months, 42% and 94%; and T(nPSA) > or =24 months, 75% and 99%, respectively. A shorter T(nPSA) was associated with decreased PSA-DFS and DMFS, regardless of the nPSA. Both nPSA and T(nPSA) were significant predictors of PSA-DFS and DMFS in multivariate models incorporating clinical stage, Gleason score, initial PSA level, and RT dose. The significance of nPSA and T(nPSA) was supported by landmark analysis, as well as by analysis of nPSA and T(nPSA) as time-dependent covariates. A dose > or =70 Gy was associated with a lower nPSA level and longer T(nPSA) in all risk categories, and a greater dose was significantly associated with greater PSA-DFS and DMFS in multivariate analysis. Regression analysis confirmed that higher clinical stage, Gleason score, and initial PSA were associated with a greater nPSA level. CONCLUSION The results of this large, multi-institutional analysis of 4833 patients have provided important evidence that nPSA and T(nPSA) after definitive external beam RT are not only predictive of a predominantly PSA endpoint (PSA-DFS), but are also predictive of distant metastasis in all clinical risk categories. Greater RT doses were associated with lower nPSA, longer T(nPSA), and improved PSA-DFS and DMFS.
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Affiliation(s)
- Michael E Ray
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109-0010, USA.
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Unger HA, Kane RD, Fox KM, Gandhi S, Alzola C, Lamerato L, Newling D, Kumar S. Relative importance of PSA in prostate cancer treatment. Urol Oncol 2005; 23:238-45. [PMID: 16018938 DOI: 10.1016/j.urolonc.2005.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2004] [Revised: 02/21/2005] [Accepted: 03/03/2005] [Indexed: 01/02/2023]
Abstract
METHODS AND MATERIALS A retrospective study was conducted to (1) determine the relationship between baseline prostate-specific antigen (PSA) levels and initial treatment decisions for prostate cancer (surgery, hormone therapy, radiation, or watchful waiting) and (2) estimate the impact of PSA progression (doubling or three consecutive rises) on subsequent treatment decisions. Patient records (n=1116) from three community urology practices and a large academic health system were reviewed. Multivariate models were fitted to assess the relationship between initial treatment and baseline PSA, Gleason score, race, number of comorbid conditions and age and between PSA progression and time to subsequent therapy (adjusted for other factors). RESULTS Baseline PSA was a significant predictor of initial treatment among men with localized disease with the likelihood of hormone therapy increasing with higher PSA levels and the likelihood of surgery decreasing steadily with higher PSA levels. PSA was the strongest predictor of hormone therapy as first choice followed by age. Age followed by PSA was the strongest predictor of surgery as first treatment as well as radiation therapy. Initial PSA levels did not predict the choice of watchful waiting. Patients with PSA progression were eight times (95% CI: 5.3-12.1) more likely to initiate a subsequent therapy than patients who did not have PSA progression when controlling for other predictors. CONCLUSIONS In clinical practice, PSA significantly impacts the urologist's primary therapy choice and determines when they introduce subsequent treatments.
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Wiltshire K, Bristow RG, Warde P, Gospodarowicz M. Re: Vikram, B., The PSA conundrum. Radiother Oncol, 2004. 71(1): p. 1–2. Radiother Oncol 2004; 73:252-4; author reply 254-5. [PMID: 15542174 DOI: 10.1016/j.radonc.2004.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2004] [Indexed: 11/22/2022]
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Pickett B, Kurhanewicz J, Coakley F, Shinohara K, Fein B, Roach M. Use of MRI and spectroscopy in evaluation of external beam radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys 2004; 60:1047-55. [PMID: 15519774 DOI: 10.1016/j.ijrobp.2004.05.015] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2004] [Revised: 04/29/2004] [Accepted: 05/10/2004] [Indexed: 10/26/2022]
Abstract
PURPOSE To characterize the metabolic response in the prostate, the time to resolution of disease, and the correlation between magnetic resonance imaging (MRI) with spectroscopy (MRSI) results, biopsy findings, and serum prostate-specific antigen (PSA) level after external beam radiotherapy. METHODS AND MATERIALS A total of 55 patients underwent MRSI before and/or at varying times after external beam radiotherapy. The percentage of the cancerous, healthy, and atrophic voxels was calculated, and the time to resolution of disease was determined and compared with the PSA nadir. RESULTS Of the 55 patients, 70% had negative MRSI and 30% had positive MRSI findings. A strong correlation was found between negative MRSI and negative biopsy findings (n = 11) and between positive MRSI and positive biopsy findings (n = 7). A weak correlation was observed between the PSA level and the MRSI and biopsy findings. The mean time to disease resolution was 40.3 months and the mean time to PSA nadir was 50 months. With time, an increase in atrophy and a decline in cancerous metabolism was found. CONCLUSION When used in conjunction with PSA measurement and biopsy, the results of this study suggest that MRSI contributes to a greater level of confidence in determining the outcome and may be a useful adjunct for assessing local control before PSA failure when striving to distinguish the benign "blip" from local recurrence.
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Affiliation(s)
- Barby Pickett
- Department of Radiation Oncology, University of California, San Francisco, School of Medicine, San Francisco, CA, USA.
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Abstract
PURPOSE OF REVIEW This paper will review the current staging system for prostate adenocarcinoma patients, and will also review new information that can be combined with clinical and pathological staging in order to assess a patient's risk of success or failure of treatment. RECENT FINDINGS There has been significant stage migration of prostate cancer patients in the past 15 years, such that patients are currently being diagnosed younger, with lower clinical stages and serum prostate-specific antigen levels, and a lower risk of metastatic disease than previously. The incorporation of the results of extended prostate biopsy schemes, with stage, grade and serum prostate-specific antigen levels, improves the risk assessment of newly diagnosed prostate cancer patients. New imaging techniques, such as transrectal ultrasound Doppler flow and magnetic resonance spectroscopy hold promise for improving risk assessment. Molecular biomarkers may improve risk assessment in the future, although none are currently approved by the US Food and Drug Administration for this indication. Gene chip arrays may further refine risk assessment and assist with the identification of therapeutic targets. SUMMARY There has been significant stage migration of prostate cancer patients in the prostate-specific antigen era. Incorporating biopsy information into nomograms and risk assessment equations improves upon clinical staging and risk assessment. New imaging techniques, molecular markers and gene chip arrays hold promise for future risk assessment.
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Affiliation(s)
- Adam B Hittelman
- Department of Urology, University of California San Francisco, 94143, USA
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