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Mattes MD. Overview of Radiation Therapy in the Management of Localized and Metastatic Prostate Cancer. Curr Urol Rep 2024:10.1007/s11934-024-01217-5. [PMID: 38861238 DOI: 10.1007/s11934-024-01217-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2024] [Indexed: 06/12/2024]
Abstract
PURPOSE OF REVIEW The goal is to describe the evolution of radiation therapy (RT) utilization in the management of localized and metastatic prostate cancer. RECENT FINDINGS Long term data for a variety of hypofractionated definitive RT dose-fractionation schemes has matured, allowing patients and providers many standard-of-care options to choose from. Post-prostatectomy, adjuvant RT has largely been replaced by an early salvage approach. Multiparametric MRI and PSMA PET have enabled increasingly targeted RT delivery to the prostate and oligometastatic tumors. Areas of active investigation include determining the value of proton beam therapy and perirectal spacers, and optimally incorporate genomic tumor profiling and next generation hormonal therapies with RT in the curative setting. The use of radiation therapy to treat prostate cancer is rapidly evolving. In the coming years, there will be continued improvements in a variety of areas to enhance the value of RT in multidisciplinary prostate cancer management.
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Affiliation(s)
- Malcolm D Mattes
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ, 08901, USA.
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Nachbar M, Lo Russo M, Gani C, Boeke S, Wegener D, Paulsen F, Zips D, Roque T, Paragios N, Thorwarth D. Automatic AI-based contouring of prostate MRI for online adaptive radiotherapy. Z Med Phys 2024; 34:197-207. [PMID: 37263911 PMCID: PMC11156783 DOI: 10.1016/j.zemedi.2023.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/03/2023] [Accepted: 05/02/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND PURPOSE MR-guided radiotherapy (MRgRT) online plan adaptation accounts for tumor volume changes, interfraction motion and thus allows daily sparing of relevant organs at risk. Due to the high interfraction variability of bladder and rectum, patients with tumors in the pelvic region may strongly benefit from adaptive MRgRT. Currently, fast automatic annotation of anatomical structures is not available within the online MRgRT workflow. Therefore, the aim of this study was to train and validate a fast, accurate deep learning model for automatic MRI segmentation at the MR-Linac for future implementation in a clinical MRgRT workflow. MATERIALS AND METHODS For a total of 47 patients, T2w MRI data were acquired on a 1.5 T MR-Linac (Unity, Elekta) on five different days. Prostate, seminal vesicles, rectum, anal canal, bladder, penile bulb, body and bony structures were manually annotated. These training data consisting of 232 data sets in total was used for the generation of a deep learning based autocontouring model and validated on 20 unseen T2w-MRIs. For quantitative evaluation the validation set was contoured by a radiation oncologist as gold standard contours (GSC) and compared in MATLAB to the automatic contours (AIC). For the evaluation, dice similarity coefficients (DSC), and 95% Hausdorff distances (95% HD), added path length (APL) and surface DSC (sDSC) were calculated in a caudal-cranial window of ± 4 cm with respect to the prostate ends. For qualitative evaluation, five radiation oncologists scored the AIC on the possible usage within an online adaptive workflow as follows: (1) no modifications needed, (2) minor adjustments needed, (3) major adjustments/ multiple minor adjustments needed, (4) not usable. RESULTS The quantitative evaluation revealed a maximum median 95% HD of 6.9 mm for the rectum and minimum median 95% HD of 2.7 mm for the bladder. Maximal and minimal median DSC were detected for bladder with 0.97 and for penile bulb with 0.73, respectively. Using a tolerance level of 3 mm, the highest and lowest sDSC were determined for rectum (0.94) and anal canal (0.68), respectively. Qualitative evaluation resulted in a mean score of 1.2 for AICs over all organs and patients across all expert ratings. For the different autocontoured structures, the highest mean score of 1.0 was observed for anal canal, sacrum, femur left and right, and pelvis left, whereas for prostate the lowest mean score of 2.0 was detected. In total, 80% of the contours were rated be clinically acceptable, 16% to require minor and 4% major adjustments for online adaptive MRgRT. CONCLUSION In this study, an AI-based autocontouring was successfully trained for online adaptive MR-guided radiotherapy on the 1.5 T MR-Linac system. The developed model can automatically generate contours accepted by physicians (80%) or only with the need of minor corrections (16%) for the irradiation of primary prostate on the clinically employed sequences.
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Affiliation(s)
- Marcel Nachbar
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Monica Lo Russo
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Simon Boeke
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Daniel Wegener
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany; German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiation Oncology, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | | | - Nikos Paragios
- TheraPanacea, Paris, France; CentraleSupelec, University of Paris-Saclay, Gif-sur-Yvette, France
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University of Tübingen, Tübingen, Germany; German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Moll M, Goldner G. Assessing the toxicity after moderately hypofractionated prostate and whole pelvis radiotherapy compared to conventional fractionation. Strahlenther Onkol 2024; 200:188-194. [PMID: 37341774 PMCID: PMC10876811 DOI: 10.1007/s00066-023-02104-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/19/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVE To evaluate acute and late gastrointestinal (GI) and genitourinary (GU) toxicities after moderately hypofractionated (HF) or conventionally fractionated (CF) primary whole-pelvis radiotherapy (WPRT). METHODS Primary prostate-cancer patients treated between 2009 and 2021 with either 60 Gy at 3 Gy/fraction to the prostate and 46 Gy at 2.3 Gy/fraction to the whole pelvis (HF), or 78 Gy at 2 Gy/fraction to the prostate and 50/50.4 Gy at 1.8-2 Gy/fraction to the whole pelvis (CF). Acute and late GI and GU toxicities were retrospectively assessed. RESULTS 106 patients received HF and 157 received CF, with a median follow-up of 12 and 57 months. Acute GI toxicity rates in the HF and CF groups were, respectively, grade 2: 46.7% vs. 37.6%, and grade 3: 0% vs. 1.3%, with no significant difference (p = 0.71). Acute GU toxicity rates were, respectively, grade 2: 20.0% vs. 31.8%, and grade 3: 2.9% vs. 0%, (p = 0.04). We compared prevalence of late GI and GU toxicities between groups after 3, 12, and 24 months and did not find any significant differences (respectively, p = 0.59, 0.22, and 0.71 for GI toxicity; p = 0.39, 0.58, and 0.90 for GU toxicity). CONCLUSION Moderate HF WPRT was well tolerated during the first 2 years. Randomized trials are needed to confirm these findings.
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Affiliation(s)
- Matthias Moll
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria.
| | - Gregor Goldner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
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Niazi T, Nabid A, Malagon T, Bettahar R, Vincent L, Martin AG, Jolicoeur M, Yassa M, Barkati M, Igidbashian L, Bahoric B, Archambault R, Villeneuve H, Tsui JMG, Mohiuddin M. Hypofractionated, Dose Escalation Radiation Therapy for High-Risk Prostate Cancer: The Safety Analysis of the Prostate Cancer Study-5, a Groupe de Radio-Oncologie Génito-Urinaire de Quebec Led Phase 3 Trial. Int J Radiat Oncol Biol Phys 2024; 118:52-62. [PMID: 37224928 DOI: 10.1016/j.ijrobp.2023.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 04/27/2023] [Accepted: 05/08/2023] [Indexed: 05/26/2023]
Abstract
PURPOSE The low α\β ratio of 1.2 to 2 for prostate cancer (PCa) suggests high radiation-fraction sensitivity and predicts a therapeutic advantage of hypofractionated (HF) radiation therapy (RT). To date, no phase 3 randomized clinical trial has compared moderately HF RT with standard fractionation (SF) exclusively in high-risk PCa patients. We are reporting the safety of moderate HF RT in high-risk PCa in an initially noninferiority-designed phase 3 clinical trial. METHODS AND MATERIALS From February 2012 to March 2015, 329 high-risk PCa patients were randomized to receive either SF or HF RT. All patients received neoadjuvant, concurrent, and long-term adjuvant androgen deprivation therapy. Standard fractionation RT consisted of 76 Gy in 2 Gy per fraction to the prostate, where 46 Gy was delivered to the pelvic lymph nodes. Hypofractionated RT included concomitant dose escalation of 68 Gy in 2.72 Gy per fraction to the prostate and 45 Gy in 1.8 Gy per fraction to the pelvic lymph nodes. The coprimary endpoints were acute and delayed toxicity at 6 and 24 months, respectively. The trial was originally designed as a noninferiority with a 5% absolute margin. Given the lower-than-expected toxicities in both arms, the noninferiority analysis was completely dropped. RESULTS Of the 329 patients, 164 were randomized to the HF and 165 to the SF arms. In total, there were more grade 1 or worse acute gastrointestinal (GI) events in the HF arm, 102 versus 83 events in the HF and SF arm, respectively (P = .016). This did not remain significant at 8 weeks of follow-up. There were no differences in grade 1 or worse acute GU events in the 2 arms, 105 versus 99 events in the HF and SF arm, respectively (P = .3). At 24 months, 12 patients in the SF arm and 15 patients in the HF arm had grade 2 or worse delayed GI-related adverse events (hazard ratio, 1.32; 95% CI, 0.62-2.83; P = .482). There were 11 patients in the SF arm and 3 patients in the HF arm with grade 2 or higher delayed genitourinary (GU) toxicities (hazard ratio, 0.26; 95% CI, 0.07-0.94; P = .037). There were 3 grade 3 GI and one grade 3 GU delayed toxicities in the HF arm and 3 grade 3 GU and no grade 3 GI toxicities in the SF arm. No grade 4-toxicities were reported. CONCLUSIONS This is the first study of moderate HF dose-escalated RT in exclusively high-risk patients with prostate cancer treated with long-term androgen deprivation therapy and pelvic RT. Although our data were not analyzed as a noninferiority, our results demonstrate that moderately HF RT is well-tolerated, similar to SF RT at 2 years, and could be considered an alternative to SF RT.
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Affiliation(s)
- Tamim Niazi
- Department of Oncology, Division of Radiation Onclogy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada.
| | - Abdenour Nabid
- Department of Oncology, Division of Radiation Onclogy, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Talia Malagon
- Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Redouane Bettahar
- Division of Radiation Onclogy, Centre Hospitalier Régional de Rimouski-Centre de Cancer, Rimouski, Quebec, Canada
| | - Linda Vincent
- Division of Radiation Onclogy, Pavillon Ste-Marie Centre Hospitalier Régional de Trois-Rivières, Trois-Rivières, Quebec, Canada
| | - Andre-Guy Martin
- Department of Oncology, Division of Radiation Onclogy, Centre Hospitalier Universitaire de Québec-L'Hôtel-Dieu de Québec, Quebec City, Quebec, Canada
| | - Marjory Jolicoeur
- Department of Oncology, Division of Radiation Onclogy, Hôpital Charles LeMoyne, Greenfield Park, Quebec, Canada
| | - Michael Yassa
- Department of Oncology, Division of Radiation Onclogy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Maroie Barkati
- Department of Oncology, Division of Radiation Onclogy, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Levon Igidbashian
- Division of Radiation Onclogy, Hôpital Cité-de-la-Santé, Laval, Quebec, Canada
| | - Boris Bahoric
- Department of Oncology, Division of Radiation Onclogy, Jewish General Hospital, McGill University, Quebec, Canada
| | - Robert Archambault
- Department of Oncology, Division of Radiation Onclogy, Hôpital Gatineau, Gatineau, Quebec, Canada
| | - Hugo Villeneuve
- Department of Oncology, Division of Radiation Onclogy, Hôpital de Chicoutimi, Chicoutimi, Quebec, Canada
| | - James Man Git Tsui
- Department of Oncology, Division of Radiation Onclogy, McGill University Health Centre, Montreal, Quebec, Canada
| | - Mohammed Mohiuddin
- Department of Oncology, Division of Radiation Onclogy, Saint John Regional Hospital (MM), Saint John, New Brunswick, Canada
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ESTRO-ACROP recommendations for evidence-based use of androgen deprivation therapy in combination with external-beam radiotherapy in prostate cancer. Radiother Oncol 2023; 183:109544. [PMID: 36813168 DOI: 10.1016/j.radonc.2023.109544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND AND PURPOSE There is no consensus concerning the appropriate use of androgen deprivation therapy (ADT) during primary and postoperative external-beam radiotherapy (EBRT) in the management of prostate cancer (PCa). Thus, the European Society for Radiotherapy and Oncology (ESTRO) Advisory Committee for Radiation Oncology Practice (ACROP) guidelines seeks to present current recommendations for the clinical use of ADT in the various indications of EBRT. MATERIAL AND METHODS A literature search was conducted in MEDLINE PubMed that evaluated EBRT and ADT in prostate cancer. The search focused on randomized, Phase II and III trials published in English from January 2000 to May 2022. In case topics were addressed in the absence of Phase II or III trials, recommendations were labelled accordingly based on the limited body of evidence. Localized PCa was classified according to D'Amico et al. classification in low-, intermediate and high risk PCa. The ACROP clinical committee identified 13 European experts who discussed and analyzed the body of evidence concerning the use of ADT with EBRT for prostate cancer. RESULTS Key issues were identified and are discussed: It was concluded that no additional ADT is recommended for low-risk prostate cancer patients, whereas for intermediate- and high-risk patients four to six months and two to three years of ADT are recommended. Likewise, patients with locally advanced prostate cancer are recommended to receive ADT for two to three years and when ≥ 2 high-risk factors (cT3-4, ISUP grade ≥ 4 or PSA ≥ 40 ng/ml) or cN1 is present ADT for three years plus additional Abiraterone for two years is recommended. For postoperative patients no ADT is recommended for adjuvant EBRT in pN0 patients whereas for pN1 patients adjuvant EBRT with long-term ADT is performed for at least 24 to 36 months. In the setting of salvage EBRT ADT is performed in biochemically persistent PCa patients with no evidence of metastatic disease. Long-term ADT (24 months) is recommended in pN0 patients with high risk of further progression (PSA ≥ 0.7 ng/ml and ISUP grade group ≥ 4) and a life expectancy of over ten years, whereas short-term ADT (6 months) is recommended in pN0 patients with lower risk profile (PSA < 0.7 ng/ml and ISUP grade group 4). Patients considered for ultra-hypofractionated EBRT as well as patients with image based local recurrence within the prostatic fossa or lymph node recurrence should participate in appropriate clinical trials evaluating the role of additional ADT. CONCLUSION These ESTRO-ACROP recommendations are evidence-based and relevant to the use of ADT in combination with EBRT in PCa for the most common clinical settings.
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Imlach F, Dunn A, Costello S, Gurney J, Sarfati D. Driving quality improvement through better data: The story of New Zealand's radiation oncology collection. J Med Imaging Radiat Oncol 2023; 67:119-127. [PMID: 36305425 DOI: 10.1111/1754-9485.13488] [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: 03/08/2022] [Accepted: 10/14/2022] [Indexed: 11/29/2022]
Abstract
Aotearoa/New Zealand is one of the first nations in the world to develop a comprehensive, high-quality collection of radiation therapy data (the Radiation Oncology Collection, ROC) that is able to report on treatment delivery by health region, patient demographics and service provider. This has been guided by radiation therapy leaders, who have been instrumental in overseeing the establishment of clear and robust data definitions, a centralised database and outputs delivered via an online tool. In this paper, we detail the development of the ROC, provide examples of variation in practice identified from the ROC and how these changed over time, then consider the ramifications of the ROC in the wider context of cancer care quality improvement. In addition to a review of relevant literature, primary data were sourced from the ROC on radiation therapy provided nationally in New Zealand between 2017 and 2020. The total intervention rate, number of fractions and doses are reported for select cancers by way of examples of national variation in practice. Results from the ROC have highlighted areas of treatment variation and have prompted increased uptake of hypofractionation for curative prostate and breast cancer treatment and for palliation of bone metastases. Future development of the ROC will increase its use for quality improvement and ultimately link to a real time cancer services database.
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Affiliation(s)
- Fiona Imlach
- Te Aho o Te Kahu/Cancer Control Agency, Wellington, New Zealand
| | - Alexander Dunn
- Te Aho o Te Kahu/Cancer Control Agency, Wellington, New Zealand
| | | | - Jason Gurney
- Te Aho o Te Kahu/Cancer Control Agency, Wellington, New Zealand.,Cancer and Chronic Conditions (C3) Research Group, Department of Public Health, University of Otago, Wellington, New Zealand
| | - Diana Sarfati
- Te Aho o Te Kahu/Cancer Control Agency, Wellington, New Zealand
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Patel S, Olatunji E, Mallum A, Benjika BB, Joseph AO, Joseph S, Lasebikan N, Mahuna H, Ngoma M, Ngoma TA, Nnko G, Onwualu C, Vorster M, Ngwa W. Expanding radiotherapy access in Sub-Saharan Africa: an analysis of travel burdens and patient-related benefits of hypofractionation. Front Oncol 2023; 13:1136357. [PMID: 37143940 PMCID: PMC10151787 DOI: 10.3389/fonc.2023.1136357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/20/2023] [Indexed: 05/06/2023] Open
Abstract
Purpose The purpose of this project was to examine the travel burdens for radiotherapy patients in Nigeria, Tanzania, and South Africa, and to assess the patient-related benefits of hypofractionated radiotherapy (HFRT) for breast and prostate cancer patients in these countries. The outcomes can inform the implementation of the recent Lancet Oncology Commission recommendations on increasing the adoption of HFRT in Sub-Saharan Africa (SSA) to enhance radiotherapy access in the region. Methods Data were extracted from electronic patient records at the NSIA-LUTH Cancer Center (NLCC) in Lagos, Nigeria and the Inkosi Albert Luthuli Central Hospital (IALCH) in Durban, South Africa, from written records at the University of Nigeria Teaching Hospital (UNTH) Oncology Center in Enugu, Nigeria, and from phone interviews at Ocean Road Cancer Institute (ORCI) in Dar Es Salaam, Tanzania. Google Maps was used to calculate the shortest driving distance between a patient's home address and their respective radiotherapy center. QGIS was used to map the straight-line distances to each center. Descriptive statistics were used to compare transportation costs, time expenditures, and lost wages when using HFRT versus conventionally fractionated radiotherapy (CFRT) for breast and prostate cancer. Results Patients in Nigeria (n=390) traveled a median distance of 23.1 km to NLCC and 86.7 km to UNTH, patients in Tanzania (n=23) traveled a median distance of 537.0 km to ORCI, and patients in South Africa (n=412) traveled a median distance of 18.0 km to IALCH. Estimated transportation cost savings for breast cancer patients in Lagos and Enugu were 12,895 Naira and 7,369 Naira, respectively and for prostate cancer patients were 25,329 and 14,276 Naira, respectively. Prostate cancer patients in Tanzania saved a median of 137,765 Shillings in transportation costs and 80.0 hours (includes travel, treatment, and wait times). Mean transportation cost savings for patients in South Africa were 4,777 Rand for breast cancer and 9,486 Rand for prostate cancer. Conclusion Cancer patients in SSA travel considerable distances to access radiotherapy services. HFRT decreases patient-related costs and time expenditures, which may increase radiotherapy access and alleviate the growing burden of cancer in the region.
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Affiliation(s)
- Saloni Patel
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Saloni Patel,
| | - Elizabeth Olatunji
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Abba Mallum
- Department of Radiotherapy and Oncology, University of KwaZulu-Natal, Durban, South Africa
- Department of Oncology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | | | - Adedayo O. Joseph
- NSIA-LUTH Cancer Center, Lagos University Teaching Hospital, Lagos, Nigeria
| | | | - Nwamaka Lasebikan
- Oncology Center, University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu, Nigeria
| | - Habiba Mahuna
- Ocean Road Cancer Institute, Dar Es Salaam, Tanzania
| | - Mamsau Ngoma
- Ocean Road Cancer Institute, Dar Es Salaam, Tanzania
| | - Twalib Athumani Ngoma
- Ocean Road Cancer Institute, Dar Es Salaam, Tanzania
- Department of Clinical Oncology, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Godwin Nnko
- Ocean Road Cancer Institute, Dar Es Salaam, Tanzania
| | - Chinelo Onwualu
- Oncology Center, University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu, Nigeria
| | - Mariza Vorster
- College of Health Science, University of KwaZulu-Natal, Durban, South Africa
| | - Wilfred Ngwa
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
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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:jcm11236913. [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
- Correspondence: ; Tel.: +39-03-0399-5272
| | - 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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Baré M, Poeta S, Fernandes P, Jourani Y, Otte FX, Van Brussel S, Van Gestel D, Van den Begin R. Lymphocyte-sparing pelvic radiotherapy for prostate cancer: An in-silico study. Phys Imaging Radiat Oncol 2022; 23:127-133. [PMID: 35941862 PMCID: PMC9356260 DOI: 10.1016/j.phro.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/25/2022] [Accepted: 07/27/2022] [Indexed: 12/04/2022] Open
Abstract
Lymphocyte-sparing planning was developed for prostate cancer pelvic radiotherapy. A significant dose reduction to the bone marrow was successfully demonstrated. An Effective Dose to Immune Cells (EDIC) model was proposed for pelvic irradiation.
Background and Purpose Evidence regarding radiation-induced lymphopenia and its negative impact on oncological outcome is incrementing. Therefore, the aim of this study is to evaluate the feasibility of lymphocyte-rich organs at risk (LOAR) sparing in pelvic irradiation for localized prostate cancer and to estimate its impact on the effective dose to circulating immune cells (EDIC). Materials and Methods Twenty patients with pelvic nodal and prostate or prostate bed irradiation were included. The following bone marrow (BM) structures were delineated as LOARs using semi-automatic segmentation: lumbosacral spine (Ls-BM), ilium (Il-BM), lower pelvis (Lp-BM), and the combined whole-pelvis (Wp-BM). Twenty new lymphocyte sparing treatment plans (LS plans) were calculated, optimizing doses to LOARs while maintaining strict coverage of the targets and respecting standard OARs dose constraints. Finally, we elaborated an EDIC calculation model for pelvic irradiation. Results LS plans showed a statistically significant dose decrease for LOAR compared to standard of care plans without compromising target coverage nor classic OAR dose constraints: in prostate plans, the V40Gy for Ls-BM, Il-BM, and Lp-BM was decreased by 23 %, 36 %, 52 % respectively. For prostate bed plans, the V40Gy for Ls-BM, Il-BM, and Lp-BM was decreased by 25 %, 59 %, 56 %, respectively. For Wp-BM, the V10Gy, V20Gy, and Dmean have been decreased by 3 %, 14 %, 15 %, and by 5 %, 15 %, 17 %, respectively for prostate and prostate bed plans. A statistically significant decrease in EDIC was seen for LS plans in both groups. Conclusions We successfully demonstrated the feasability of lympocyte-sparing treatment planning in pelvic irradiation, also proposing a model for EDIC calculation.
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Affiliation(s)
- Mathilde Baré
- Radiation Oncology Department, Institut Jules Bordet Université Libre de Bruxelles, Brussels, Belgium
- Radiation Oncology Department, EpiCURA, Baudour, Belgium
- Corresponding author.
| | - Sara Poeta
- Medical Physics Department, Institut Jules Bordet Université Libre de Bruxelles, Brussels, Belgium
| | - Patricia Fernandes
- Medical Physics Department, Institut Jules Bordet Université Libre de Bruxelles, Brussels, Belgium
| | - Younes Jourani
- Medical Physics Department, Institut Jules Bordet Université Libre de Bruxelles, Brussels, Belgium
| | - François-Xavier Otte
- Radiation Oncology Department, Institut Jules Bordet Université Libre de Bruxelles, Brussels, Belgium
| | | | - Dirk Van Gestel
- Radiation Oncology Department, Institut Jules Bordet Université Libre de Bruxelles, Brussels, Belgium
| | - Robbe Van den Begin
- Radiation Oncology Department, Institut Jules Bordet Université Libre de Bruxelles, Brussels, Belgium
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10
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Donlon NE, Davern M, O’Connell F, Sheppard A, Heeran A, Bhardwaj A, Butler C, Narayanasamy R, Donohoe C, Phelan JJ, Lynam-Lennon N, Dunne MR, Maher S, O’Sullivan J, Reynolds JV, Lysaght J. Impact of radiotherapy on the immune landscape in oesophageal adenocarcinoma. World J Gastroenterol 2022; 28:2302-2319. [PMID: 35800186 PMCID: PMC9185220 DOI: 10.3748/wjg.v28.i21.2302] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/19/2022] [Accepted: 04/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In the contemporary era of cancer immunotherapy, an abundance of clinical and translational studies have reported radiotherapy (RT) and immunotherapies as a viable option for immunomodulation of many cancer subtypes, with many related clinical trials ongoing. In locally advanced disease, chemotherapy or chemoradiotherapy followed by surgical excision of the tumour remain the principal treatment strategy in oesophageal adenocarcinoma (OAC), however, the use of the host immune system to improve anti-tumour immunity is rapidly garnering increased support in the curative setting.
AIM To immunophenotype OAC patients’ immune checkpoint (IC) expression with and without radiation and evaluate the effects of checkpoint blockade on cell viability.
METHODS In the contemporary era of cancer immunotherapy, an abundance of studies have demonstrated that combination RT and IC inhibitors (ICIs) are effective in the immunomodulation of many cancer subtypes, with many related clinical trials ongoing. Although surgical excision and elimination of tumour cells by chemotherapy or chemoradiotherapy remains the gold standard approach in OAC, the propagation of anti-tumour immune responses is rapidly garnering increased support in the curative setting. The aim of this body of work was to immunophenotype OAC patients’ IC expression with and without radiation and to establish the impact of checkpoint blockade on cell viability. This study was a hybrid combination of in vitro and ex vivo models. Quantification of serum immune proteins was performed by enzyme-linked immunosorbent assay. Flow cytometry staining was performed to evaluate IC expression for in vitro OAC cell lines and ex vivo OAC biopsies. Cell viability in the presence of radiation with and without IC blockade was assessed by a cell counting kit-8 assay.
RESULTS We identified that conventional dosing and hypofractionated approaches resulted in increased IC expression (PD-1, PD-L1, TIM3, TIGIT) in vitro and ex vivo in OAC. There were two distinct subcohorts with one demonstrating significant upregulation of ICs and the contrary in the other cohort. Increasing IC expression post RT was associated with a more aggressive tumour phenotype and adverse features of tumour biology. The use of anti-PD-1 and anti-PD-L1 immunotherapies in combination with radiation resulted in a significant and synergistic reduction in viability of both radiosensitive and radioresistant OAC cells in vitro. Interleukin-21 (IL-21) and IL-31 significantly increased, with a concomitant reduction in IL-23 as a consequence of 4 Gray radiation. Similarly, radiation induced an anti-angiogenic tumour milieu with reduced expression of vascular endothelial growth factor-A, basic fibroblast growth factor, Flt-1 and placental growth factor.
CONCLUSION The findings of the current study demonstrate synergistic potential for the use of ICIs and ionising radiation to potentiate established anti-tumour responses in the neoadjuvant setting and is of particular interest in those with advanced disease, adverse features of tumour biology and poor treatment responses to conventional therapies.
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Affiliation(s)
- Noel E Donlon
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Maria Davern
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Fiona O’Connell
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Andrew Sheppard
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Aisling Heeran
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Anshul Bhardwaj
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Christine Butler
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Ravi Narayanasamy
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Claire Donohoe
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - James J Phelan
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Niamh Lynam-Lennon
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Margaret R Dunne
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Stephen Maher
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Jacintha O’Sullivan
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - John V Reynolds
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
| | - Joanne Lysaght
- Department of Surgery, Trinity Translational Medicine Institute, St James Hospital, Dublin D08, Ireland
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11
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Kissel M, Créhange G, Graff P. Stereotactic Radiation Therapy versus Brachytherapy: Relative Strengths of Two Highly Efficient Options for the Treatment of Localized Prostate Cancer. Cancers (Basel) 2022; 14:2226. [PMID: 35565355 PMCID: PMC9105931 DOI: 10.3390/cancers14092226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
Stereotactic body radiation therapy (SBRT) has become a valid option for the treatment of low- and intermediate-risk prostate cancer. In randomized trials, it was found not inferior to conventionally fractionated external beam radiation therapy (EBRT). It also compares favorably to brachytherapy (BT) even if level 1 evidence is lacking. However, BT remains a strong competitor, especially for young patients, as series with 10-15 years of median follow-up have proven its efficacy over time. SBRT will thus have to confirm its effectiveness over the long-term as well. SBRT has the advantage over BT of less acute urinary toxicity and, more hypothetically, less sexual impairment. Data are limited regarding SBRT for high-risk disease while BT, as a boost after EBRT, has demonstrated superiority against EBRT alone in randomized trials. However, patients should be informed of significant urinary toxicity. SBRT is under investigation in strategies of treatment intensification such as combination of EBRT plus SBRT boost or focal dose escalation to the tumor site within the prostate. Our goal was to examine respective levels of evidence of SBRT and BT for the treatment of localized prostate cancer in terms of oncologic outcomes, toxicity and quality of life, and to discuss strategies of treatment intensification.
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Affiliation(s)
| | | | - Pierre Graff
- Department of Radiation Oncology, Institut Curie, 26 Rue d’Ulm, 75005 Paris, France; (M.K.); (G.C.)
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12
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Bedford JL, Hanson IM. A recurrent neural network for rapid detection of delivery errors during real-time portal dosimetry. Phys Imaging Radiat Oncol 2022; 22:36-43. [PMID: 35493850 PMCID: PMC9048084 DOI: 10.1016/j.phro.2022.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/04/2022] [Accepted: 03/28/2022] [Indexed: 11/18/2022] Open
Abstract
Background and purpose Real-time portal dosimetry compares measured images with predicted images to detect delivery errors as the radiotherapy treatment proceeds. This work aimed to investigate the performance of a recurrent neural network for processing image metrics so as to detect delivery errors as early as possible in the treatment. Materials and methods Volumetric modulated arc therapy (VMAT) plans of six prostate patients were used to generate sequences of predicted portal images. Errors were introduced into the treatment plans and the modified plans were delivered to a water-equivalent phantom. Four different metrics were used to detect errors. These metrics were applied to a threshold-based method to detect the errors as soon as possible during the delivery, and also to a recurrent neural network consisting of four layers. A leave-two-out approach was used to set thresholds and train the neural network then test the resulting systems. Results When using a combination of metrics in conjunction with optimal thresholds, the median segment index at which the errors were detected was 107 out of 180. When using the neural network, the median segment index for error detection was 66 out of 180, with no false positives. The neural network reduced the rate of false negative results from 0.36 to 0.24. Conclusions The recurrent neural network allowed the detection of errors around 30% earlier than when using conventional threshold techniques. By appropriate training of the network, false positive alerts could be prevented, thereby avoiding unnecessary disruption to the patient workflow.
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Affiliation(s)
- James L. Bedford
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London SM2 5PT, UK
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13
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Faustino FDLC, Altei WF, Canton HP, Morato L, de Paula LLRJ, Salvador GB, Fonseca DDSL, Gonçalves TK, Kupelian PA, Zaparolli JC, Ercolin L, Marconi DG. RAdiotherapy for Prostate cancer using HYpofractionation Directed by UltraSound (RAPHYDUS): a Brazilian public health care system study. Pract Radiat Oncol 2022; 12:e286-e295. [DOI: 10.1016/j.prro.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 10/18/2022]
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14
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Staffurth JN, Haviland JS, Wilkins A, Syndikus I, Khoo V, Bloomfield D, Parker C, Logue J, Scrase C, Birtle A, Malik Z, Panades M, Eswar C, Graham J, Russell M, Ferguson C, O'Sullivan JM, Cruickshank CA, Dearnaley D, Hall E. Impact of Hypofractionated Radiotherapy on Patient-reported Outcomes in Prostate Cancer: Results up to 5 yr in the CHHiP trial (CRUK/06/016). Eur Urol Oncol 2021; 4:980-992. [PMID: 34489210 PMCID: PMC8674146 DOI: 10.1016/j.euo.2021.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/13/2021] [Accepted: 07/21/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Moderate hypofractionation is the recommended standard of care for localised prostate cancer following the results of trials including Conventional or Hypofractionated High Dose Intensity Modulated Radiotherapy in Prostate Cancer (CHHiP). Evaluation of long-term patient-reported outcomes (PROs) is important to confirm safety and enhance patient information. OBJECTIVE To determine whether 5-yr PROs from the CHHiP quality of life (QoL) substudy confirm 2-yr findings and assess patterns over follow-up. DESIGN, SETTING, AND PARTICIPANTS A phase III randomised controlled trial recruited from 2002 to 2011. The QoL substudy completed accrual in 2009; participants were followed up to 5 yr after radiotherapy. Analyses used data snapshot taken on August 26, 2016. A total of 71 radiotherapy centres were included in the study (UK, Republic of Ireland, Switzerland, and New Zealand); all 57 UK centres participated in the QoL substudy. CHHiP recruited 3216 men with localised prostate cancer (cT1b-T3aN0M0). INTERVENTION Conventional (74 Gy/37 fractions/7.4 wk) or hypofractionated radiotherapy (60 Gy/20 fractions/4 wk or 57 Gy/19 fractions/3.8 wk) was delivered with intensity-modulated techniques. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS University of California Los Angeles Prostate Cancer Index, Short Form 36 and Functional Assessment of Cancer Therapy-Prostate, or Expanded Prostate Cancer Index Composite and Short Form 12 questionnaires were administered at baseline, before radiotherapy, at 10 wk, and at 6, 12, 18, 24, 36, 48, and 60 mo after radiotherapy. The QoL primary endpoint was overall bowel bother. RESULTS AND LIMITATIONS The QoL substudy recruited 2100 patients; 1141 5-yr forms were available from 1957 patients still alive (58%). There were no statistically significant differences in 5-yr prevalence of overall "moderate or big" bowel bother: 19/349 (5.4%), 29/381 (7.6%), and 21/393 (5.3%) for 74, 60, and 57 Gy, respectively; overall urinary or sexual bother at 5 yr was similar between schedules. Bowel and urinary symptoms remained stable from 2 to 5 yr for all schedules. Some evidence of worsening overall sexual bother from baseline to 5 yr was less likely in the hypofractionated schedules compared with 74 Gy (odds ratios for increase in bother score vs 74 Gy: 0.55 [0.30-0.99], p = 0.009 for 60 Gy, and 0.52 [0.29-0.94], p = 0.004 for 57 Gy). General QoL scores were similar between schedules at 5 yr. CONCLUSIONS Longer follow-up confirms earlier findings, with similar patient-reported bowel, urinary, and sexual problems between schedules overall. The continued low incidence of moderate or high bother confirms that moderate hypofractionation should be the standard of care for intermediate-risk localised prostate cancer. PATIENT SUMMARY We looked at patient-reported outcomes up to 5 yr after treatment in a trial of different radiotherapy schedules for prostate cancer. The findings confirmed that shorter radiotherapy schedules were as safe as standard radiotherapy in terms of bowel, urinary, and sexual problems. TAKE HOME MESSAGE: Bowel, urinary, and sexual symptoms were similar between schedules up to 5 yr. The continued low incidence of moderate/high bother confirms that moderate hypofractionated radiotherapy should be considered the standard of care for men with intermediate-risk prostate cancer.
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Affiliation(s)
| | | | | | | | - Vincent Khoo
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK
| | | | - Chris Parker
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK
| | | | | | - Alison Birtle
- Rosemere Cancer Centre, Royal Preston Hospital, Preston, UK
| | | | | | | | - John Graham
- Beacon Centre, Musgrove Park Hospital, Taunton, UK
| | | | | | | | | | - David Dearnaley
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK
| | - Emma Hall
- The Institute of Cancer Research, London, UK
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15
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Kim JO, McDonald MO, Ong A, Koul R, Dubey A, Hunter W, Ahmed S, Quon H, Yee D, Parliament M, Sivananthan G, Danielson B, Rowe L, Ghosh S, Usmani N. Gastrointestinal and genitourinary toxicity profiles of metformin versus placebo in men with prostate cancer receiving prostate radiotherapy: interim toxicity results of a double-blinded, multicenter, phase II randomized controlled trial. Radiat Oncol 2021; 16:212. [PMID: 34736499 PMCID: PMC8567697 DOI: 10.1186/s13014-021-01935-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 10/20/2021] [Indexed: 11/13/2022] Open
Abstract
Androgen deprivation therapy (ADT) used for prostate cancer (PCa) management is associated with metabolic and anthropometric toxicity. Metformin given concurrent to ADT is hypothesized to counteract these changes. This planned interim analysis reports the gastrointestinal and genitourinary toxicity profiles of PCa patients receiving ADT and prostate/pelvic radiotherapy plus metformin versus placebo as part of a phase 2 randomized controlled trial. Men with intermediate or high-risk PCa were randomized 1:1 to metformin versus placebo. Both groups were given ADT for 18–36 months with minimum 2-month neoadjuvant phase prior to radiotherapy. Acute gastrointestinal and genitourinary toxicities were quantified using CTCAE v4.0. Differences in ≥ grade 2 toxicities by treatment were assessed by chi-squared test. 83 patients were enrolled with 44 patients randomized to placebo and 39 randomized to metformin. There were no significant differences at any time point in ≥ grade 2 gastrointestinal toxicities or overall gastrointestinal toxicity. Overall ≥ grade 2 gastrointestinal toxicity was low prior to radiotherapy (7.9% (placebo) vs. 3.1% (metformin), p = 0.39) and at the end of radiotherapy (2.8% (placebo) vs 3.1% (metformin), p = 0.64). There were no differences in overall ≥ grade 2 genitourinary toxicity between treatment arms (19.0% (placebo) vs. 9.4% (metformin), p = 0.30). Metformin added to radiotherapy and ADT did not increase rates of ≥ grade 2 gastrointestinal or genitourinary toxicity and is generally safe and well-tolerated.
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Affiliation(s)
- Julian O Kim
- Radiation Oncology, Department of Radiology, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada. .,CancerCare Manitoba Research Institute, CancerCare Manitoba, 675 McDermot Ave, Winnipeg, Manitoba, R3E 0V9, Canada.
| | - Megan O McDonald
- Postgraduate Medical Education, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Aldrich Ong
- Radiation Oncology, Department of Radiology, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rashmi Koul
- Radiation Oncology, Department of Radiology, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Arbind Dubey
- Radiation Oncology, Department of Radiology, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - William Hunter
- Radiation Oncology, Department of Radiology, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Western Manitoba Cancer Center, Brandon, Manitoba, Canada
| | - Shahida Ahmed
- Radiation Oncology, Department of Radiology, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Harvey Quon
- Division of Radiation Oncology, Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Don Yee
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew Parliament
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Gokulan Sivananthan
- Radiation Oncology, Department of Radiology, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Western Manitoba Cancer Center, Brandon, Manitoba, Canada
| | - Brita Danielson
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Lindsay Rowe
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Sunita Ghosh
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Nawaid Usmani
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
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16
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Bennie LA, Feng J, Emmerson C, Hyland WB, Matchett KB, McCarthy HO, Coulter JA. Formulating RALA/Au nanocomplexes to enhance nanoparticle internalisation efficiency, sensitising prostate tumour models to radiation treatment. J Nanobiotechnology 2021; 19:279. [PMID: 34538237 PMCID: PMC8451112 DOI: 10.1186/s12951-021-01019-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/30/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Gold nanoparticles (AuNP) are effective radiosensitisers, however, successful clinical translation has been impeded by short systemic circulation times and poor internalisation efficiency. This work examines the potential of RALA, a short amphipathic peptide, to enhance the uptake efficiency of negatively charged AuNPs in tumour cells, detailing the subsequent impact of AuNP internalisation on tumour cell radiation sensitivity. RESULTS RALA/Au nanoparticles were formed by optimising the ratio of RALA to citrate capped AuNPs, with assembly occurring through electrostatic interactions. Physical nanoparticle characteristics were determined by UV-vis spectroscopy and dynamic light scattering. Nano-complexes successfully formed at w:w ratios > 20:1 (20 µg RALA:1 µg AuNP) yielding positively charged nanoparticles, sized < 110 nm with PDI values < 0.52. ICP-MS demonstrated that RALA enhanced AuNP internalisation by more than threefold in both PC-3 and DU145 prostate cancer cell models, without causing significant toxicity. Importantly, all RALA-AuNP formulations significantly increased prostate cancer cell radiosensitivity. This effect was greatest using the 25:1 RALA-AuNP formulation, producing a dose enhancement effect (DEF) of 1.54 in PC3 cells. Using clinical radiation energies (6 MV) RALA-AuNP also significantly augmented radiation sensitivity. Mechanistic studies support RALA-AuNP nuclear accumulation resulting in increased DNA damage yields. CONCLUSIONS This is the first study to demonstrate meaningful radiosensitisation using low microgram AuNP treatment concentrations. This effect was achieved using RALA, providing functional evidence to support our previous imaging study indicating RALA-AuNP nuclear accumulation.
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Affiliation(s)
- Lindsey A Bennie
- School of Pharmacy, Queen's University Belfast, Belfast, BT9 7BL, Northern Ireland, UK
| | - Jie Feng
- School of Pharmacy, Queen's University Belfast, Belfast, BT9 7BL, Northern Ireland, UK
| | - Christopher Emmerson
- School of Pharmacy, Queen's University Belfast, Belfast, BT9 7BL, Northern Ireland, UK
| | - Wendy B Hyland
- Western Health & Social Care Trust, North West Cancer Centre, Altnagelvin Hospital, Derry/Londonderry, BT47 6SB, Northern Ireland, UK
| | - Kyle B Matchett
- Northern Ireland Centre for Stratified Medicine, C-TRIC, Altnagelvin Hospital Campus, Derry/Londonderry, BT47 6SB, Northern Ireland, UK
| | - Helen O McCarthy
- School of Pharmacy, Queen's University Belfast, Belfast, BT9 7BL, Northern Ireland, UK
- School of Chemical Sciences, Dublin City University, Dublin 9, Ireland
| | - Jonathan A Coulter
- School of Pharmacy, Queen's University Belfast, Belfast, BT9 7BL, Northern Ireland, UK.
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17
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Maulik S, Arunsingh M, Arun B, Prasath S, Mallick I. Moderately Hypofractionated Radiotherapy and Androgen Deprivation Therapy for High-risk Localised Prostate Cancer: Predictors of Long-term Biochemical Control and Toxicity. Clin Oncol (R Coll Radiol) 2021; 34:e52-e60. [PMID: 34456107 DOI: 10.1016/j.clon.2021.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/26/2021] [Accepted: 08/16/2021] [Indexed: 11/15/2022]
Abstract
AIMS There is a paucity of long-term data on outcomes of high-risk prostatic adenocarcinoma after moderately hypofractionated radiotherapy with elective nodal treatment and long-term androgen deprivation therapy (ADT). We report long-term control and toxicity outcomes and analyse the predictors of failure and toxicity. MATERIALS AND METHODS The records of 120 consecutive high-risk prostate cancer patients treated in a single institution between February 2012 and December 2016 were retrospectively analysed. A moderately hypofractionted radiotherapy (HypoRT) regimen of 60 Gy in 20 fractions over 4 weeks with simultaneous elective pelvic irradiation to 44 Gy in 20 fractions with intensity-modulated radiotherapy was used, together with long-term ADT with either orchiectomy or medical castration for a total duration of 2-3 years. We analysed biochemical control, metastasis-free survival and late toxicities and their predictive factors using survival analysis. RESULTS Patients had locally advanced cancers (cT3 77.5%, median pretreatment prostate-specific antigen 30 ng/ml, Gleason score 8-10 in 45.8%). The median follow-up time was 70 months. The 3- and 5-year probability of freedom from biochemical progression was 93% and 80%, respectively. The 5-year probability of freedom from local relapse/intra-pelvic nodal relapse/distant metastases as the site of first failure was 96%/97%/86%, respectively. Gleason score 8-10 and medical ADT for 2-3 years (as opposed to orchidectomy) were independent risk factors for distant metastases. A total of 18 grade 2 and above late gastrointestinal toxicity events and a total of 23 grade 2 and above late genitourinary toxicity events were documented. Patients who underwent a transurethral resection of prostate prior to radiotherapy had worse urological toxicity. CONCLUSIONS HypoRT with elective nodal treatment results in excellent pelvic control. Distant metastases are the primary mode of failure. Risk of metastases is associated with Gleason score and the duration of ADT. Late urinary toxicities are more common in those with prior transurethral resection of prostate.
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Affiliation(s)
- S Maulik
- Department of Radiation Oncology, Tata Medical Center, Newtown, Kolkata, West Bengal, India
| | - M Arunsingh
- Department of Radiation Oncology, Tata Medical Center, Newtown, Kolkata, West Bengal, India
| | - B Arun
- Department of Radiation Oncology, Tata Medical Center, Newtown, Kolkata, West Bengal, India
| | - S Prasath
- Department of Radiation Oncology, Tata Medical Center, Newtown, Kolkata, West Bengal, India
| | - I Mallick
- Department of Radiation Oncology, Tata Medical Center, Newtown, Kolkata, West Bengal, India.
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18
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Francolini G, Detti B, Becherini C, Caini S, Ingrosso G, Di Cataldo V, Stocchi G, Salvestrini V, Lancia A, Scartoni D, Giacomelli I, Sardaro A, Carbonara R, Borghesi S, Aristei C, Livi L. Toxicity after moderately hypofractionated versus conventionally fractionated prostate radiotherapy: A systematic review and meta-analysis of the current literature. Crit Rev Oncol Hematol 2021; 165:103432. [PMID: 34352361 DOI: 10.1016/j.critrevonc.2021.103432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 07/06/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Moderately hypofractionated radiotherapy (RT) currently represents the standard RT approach for all prostate cancer (PCa) risk categories. We performed a systematic review and meta-analysis of available literature, focusing on acute and late genitourinary (GU) and gastrointestinal (GI) adverse events (AEs) of moderate hypofractionation for localized PCa. MATERIALS AND METHODS Literature search was performed and two independent reviewers selected the records according to the following Population (P) Intervention (I) Comparator (C) and Outcomes (O) (PICO) question: "In patients affected by localized PCa (P), moderately hypofractionated RT (defined as a treatment schedule providing a single dose per fraction of 3-4.5 Gy) (I) can be considered equivalent to conventionally fractionated RT (C) in terms of G > 2 GI and GU acute and late adverse events (O)?". Bias assessment was performed using Cochrane Cochrane Collaboration's Tool for Assessing Risk of Bias. RESULTS Thirteen records were identified and a meta-analysis was performed. Risk of acute GI and GU > 2 adverse events in the moderately hypofractionated arm was increased by 9.8 % (95 %CI 4.8 %-14.7 %; I2 = 57 %) and 1.5 % (95 % CI -1.5 %-4.4 %; I2 = 0%), respectively. DISCUSSION Overall, majority of trials included in our meta-analysis suggested that moderately hypofractionated RT is equivalent, in terms of GI and GU adverse events, to conventional fractionation. Pooled analysis showed a trend to increased GI toxicity after hypofractionated treatment, but this might be related to dose escalation rather than hypofractionation.
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Affiliation(s)
- G Francolini
- Radiation Oncology Unit, University of Florence, Florence, Italy
| | - B Detti
- Radiation Oncology Unit, University of Florence, Florence, Italy.
| | - C Becherini
- Radiation Oncology Unit, University of Florence, Florence, Italy
| | - S Caini
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy
| | - G Ingrosso
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia, Italy
| | | | - G Stocchi
- Radiation Oncology Unit, University of Florence, Florence, Italy
| | - V Salvestrini
- Radiation Oncology Unit, University of Florence, Florence, Italy
| | - A Lancia
- Department of Medical Sciences and Infectious Disease, Radiation Oncology Unit, Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
| | - D Scartoni
- Proton Treatment Center, Azienda Provinciale Per i Servizi Sanitari, Trento, Italy
| | - I Giacomelli
- Proton Treatment Center, Azienda Provinciale Per i Servizi Sanitari, Trento, Italy
| | - A Sardaro
- Section of Radiology and Radiation Oncology, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - R Carbonara
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle Fonti, BA, Italy
| | - S Borghesi
- Radiotherapy Department, Azienda USL Toscana Sud Est, San Donato Hospital, Arezzo, Italy
| | - C Aristei
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia, Italy
| | - L Livi
- Radiation Oncology Unit, University of Florence, Florence, Italy
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19
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Fagundes M, Rodrigues MA, Olszewski S, Khan F, McKenzie C, Gutierrez A, Chuong M, Mehta M. Expanding the Utilization of Rectal Spacer Hydrogel for Larger Prostate Glands (>80 cc): Feasibility and Dosimetric Outcomes. Adv Radiat Oncol 2021; 6:100651. [PMID: 34195489 PMCID: PMC8233470 DOI: 10.1016/j.adro.2021.100651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/26/2020] [Accepted: 01/05/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose The Hydrogel Spacer Prospective Randomized Pivotal Trial achieved mean rectoprostatic spacing of 12.6 mm resulting in lowering of rectal V70 from 12.4% (without spacer) to 3.3% (with spacer) in patients with glands up to 80 cm3. The value of this approach in patients with larger glands is inadequately established. This study assesses the feasibility and dosimetric outcomes of perirectal spacing in patients with prostate cancer with larger glands (>80 cm3). Methods and Materials Between January 2017 and December 2019, 33 patients with prostate glands >80 cm3 (mean 108.1 cm3; range, 81.1-186.6 cm3) were treated, 15 with glands >80 to 100 cm3 and 18 >100 cm3. Median follow-up was 10 months (range, 3-26). The median international prostate symptom score was 9 (range, 1-18). Hydrogel was placed under local anesthesia in all cases. Treatment modality included intensity modulated radiation therapy in 15 and proton therapy (PT) in 18 patients. Treatment targeted the prostate plus seminal vesicles in 21 patients and 12 also had elective nodal irradiation. Conventional fractionation (CF) to 78 Gy in 39 fractions was used in 16 and moderate hypofractionation (HF) to 70 Gy in 28 fractions in 17 patients. Results In the CF group, mean rectum (r) V75, 70, 60, 50 was 0.87%, 2.25%, 5.61%, and 10.5%, respectively. For glands >80 to 100 cm3 and >100 cm3, rV70 was 2.55% and 2%, respectively. In HF patients, mean rV65, 63, 60, and 50 was 1.67%, 2.3%, 3.4%, and 8.6%. For glands >80 to 100 cm3 and >100 cm3, rV63 was 2% and 2.56%, respectively. Overall, the mean midgland rectoprostatic hydrogel separation was 9.3 mm (range, 4.7-19.4 mm). All patients tolerated treatment well; no acute grade 2 or higher adverse gastrointestinal events were observed. Conclusions Hydrogel placement is feasible in prostate glands larger than 80 cm3 with favorable dosimetric outcomes.
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Affiliation(s)
- Marcio Fagundes
- Radiation Oncology Department, Miami Cancer Institute, Miami, Florida
| | | | - Steve Olszewski
- Radiation Oncology Department, Miami Cancer Institute, Miami, Florida
| | - Fazal Khan
- Radiation Oncology Department, Miami Cancer Institute, Miami, Florida
| | - Craig McKenzie
- Radiation Oncology Department, Miami Cancer Institute, Miami, Florida
| | - Alonso Gutierrez
- Radiation Oncology Department, Miami Cancer Institute, Miami, Florida
| | - Michael Chuong
- Radiation Oncology Department, Miami Cancer Institute, Miami, Florida
| | - Minesh Mehta
- Radiation Oncology Department, Miami Cancer Institute, Miami, Florida
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20
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Brand DH, Brüningk SC, Wilkins A, Fernandez K, Naismith O, Gao A, Syndikus I, Dearnaley DP, Tree AC, van As N, Hall E, Gulliford S. Estimates of Alpha/Beta (α/β) Ratios for Individual Late Rectal Toxicity Endpoints: An Analysis of the CHHiP Trial. Int J Radiat Oncol Biol Phys 2021; 110:596-608. [PMID: 33412260 PMCID: PMC8129972 DOI: 10.1016/j.ijrobp.2020.12.041] [Citation(s) in RCA: 12] [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: 10/06/2020] [Revised: 12/10/2020] [Accepted: 12/24/2020] [Indexed: 12/04/2022]
Abstract
PURPOSE Changes in fraction size of external beam radiation therapy exert nonlinear effects on subsequent toxicity. Commonly described by the linear-quadratic model, fraction size sensitivity of normal tissues is expressed by the α/β ratio. We sought to study individual α/β ratios for different late rectal effects after prostate external beam radiation therapy. METHODS AND MATERIALS The CHHiP trial (ISRCTN97182923) randomized men with nonmetastatic prostate cancer 1:1:1 to 74 Gy/37 fractions (Fr), 60 Gy/20 Fr, or 57 Gy/19 Fr. Patients in the study had full dosimetric data and zero baseline toxicity. Toxicity scales were amalgamated to 6 bowel endpoints: bleeding, diarrhea, pain, proctitis, sphincter control, and stricture. Lyman-Kutcher-Burman models with or without equivalent dose in 2 Gy/Fr correction were log-likelihood fitted by endpoint, estimating α/β ratios. The α/β ratio estimate sensitivity was assessed using sequential inclusion of dose modifying factors (DMFs): age, diabetes, hypertension, inflammatory bowel or diverticular disease (IBD/diverticular), and hemorrhoids. 95% confidence intervals (CIs) were bootstrapped. Likelihood ratio testing of 632 estimator log-likelihoods compared the models. RESULTS Late rectal α/β ratio estimates (without DMF) ranged from bleeding (G1 + α/β = 1.6 Gy; 95% CI, 0.9-2.5 Gy) to sphincter control (G1 + α/β = 3.1 Gy; 95% CI, 1.4-9.1 Gy). Bowel pain modelled poorly (α/β, 3.6 Gy; 95% CI, 0.0-840 Gy). Inclusion of IBD/diverticular disease as a DMF significantly improved fits for stool frequency G2+ (P = .00041) and proctitis G1+ (P = .00046). However, the α/β ratios were similar in these no-DMF versus DMF models for both stool frequency G2+ (α/β 2.7 Gy vs 2.5 Gy) and proctitis G1+ (α/β 2.7 Gy vs 2.6 Gy). Frequency-weighted averaging of endpoint α/β ratios produced: G1 + α/β ratio = 2.4 Gy; G2 + α/β ratio = 2.3 Gy. CONCLUSIONS We estimated α/β ratios for several common late adverse effects of rectal radiation therapy. When comparing dose-fractionation schedules, we suggest using late a rectal α/β ratio ≤ 3 Gy.
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Affiliation(s)
- Douglas H Brand
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom.
| | - Sarah C Brüningk
- Department of Biosystems Science and Engineering, ETH Zurich, Basel, Switzerland
| | - Anna Wilkins
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom; Tumour Cell Biology Laboratory, The Francis Crick Institute, London, United Kingdom
| | - Katie Fernandez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Olivia Naismith
- Radiotherapy Trials QA Group, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Annie Gao
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Isabel Syndikus
- Radiotherapy Department, Clatterbridge Cancer Centre, United Kingdom
| | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Nicholas van As
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Sarah Gulliford
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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21
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Acute toxicity of 4-week versus 5-week hypofractionated radiotherapy in localised prostate cancer. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021. [DOI: 10.1017/s146039692100025x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Aim:
To compare the acute radiation-induced bowel and bladder toxicities of two hypofractionated radiotherapy (HFRT) regimens in localised prostate cancer (PCa).
Materials and methods:
This trial consists of patients with histologically confirmed stage T1-T3aN0M0 PCa, a prostate-specific antigen concentration of 40 ng/mL or lower, and Eastern Cooperative Oncology Group performance status of 0–2. Participants were randomly assigned (1:1) to 56 Gy in 16 fractions over 4 weeks (arm A) or 70·2 Gy in 26 fractions over 5 weeks (arm B). Acute bowel and bladder toxicities were assessed using Radiation Therapy Oncology Group criteria.
Results:
Between June 2018 and December 2019, 40 patients were randomly assigned to treatment with 4-week (n = 20) and 5-week HFRT (n = 20). In the third month after completion of radiotherapy, the cumulative incidence of acute bowel and bladder toxicities of arms A and B was 20 versus 5% and 70 versus 85%, respectively. The cumulative incidence of grade 2 or worse bowel and bladder toxicities of the 5-week regimen was non-inferior to 4-week HFRT [bowel toxicity: 5% (arm A) versus 5% (arm B), bladder toxicity: 50% (arm A) versus 60% (arm B), p = 0·52).
Findings:
The 5-week regimen of HFRT is non-inferior to 4-week HFRT in terms of acute bowel and bladder toxicities.
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22
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Bedford JL, Hanson IM. Optimisation of a composite difference metric for prompt error detection in real-time portal dosimetry of simulated volumetric modulated arc therapy. Br J Radiol 2021; 94:20201014. [PMID: 33733813 PMCID: PMC8010558 DOI: 10.1259/bjr.20201014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/15/2020] [Accepted: 10/28/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES In real-time portal dosimetry, thresholds are set for several measures of difference between predicted and measured images, and signals larger than those thresholds signify an error. The aim of this work is to investigate the use of an additional composite difference metric (CDM) for earlier detection of errors. METHODS Portal images were predicted for the volumetric modulated arc therapy plans of six prostate patients. Errors in monitor units, aperture opening, aperture position and path length were deliberately introduced into all 180 segments of the treatment plans, and these plans were delivered to a water-equivalent phantom. Four different metrics, consisting of central axis signal, mean image value and two image difference measures, were used to identify errors, and a CDM was added, consisting of a weighted power sum of the individual metrics. To optimise the weights of the CDM and to evaluate the resulting timeliness of error detection, a leave-pair-out strategy was used. For each combination of four patients, the weights of the CDM were determined by an exhaustive search, and the result was evaluated on the remaining two patients. RESULTS The median segment index at which the errors were identified was 87 (range 40-130) when using all of the individual metrics separately. Using a CDM as well as multiple separate metrics reduced this to 73 (35-95). The median weighting factors of the four metrics constituting the composite were (0.15, 0.10, 0.15, 0.00). Due to selection of suitable threshold levels, there was only one false positive result in the six patients. CONCLUSION This study shows that, in conjunction with appropriate error thresholds, use of a CDM is able to identify increased image differences around 20% earlier than the separate measures. ADVANCES IN KNOWLEDGE This study shows the value of combining difference metrics to allow earlier detection of errors during real-time portal dosimetry for volumetric modulated arc therapy treatment.
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Affiliation(s)
- James L Bedford
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Ian M Hanson
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
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23
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Wang MH, Vos LJ, Yee D, Patel S, Pervez N, Parliament M, Usmani N, Danielson B, Amanie J, Pearcey R, Ghosh S, Field C, Fallone BG, Murtha AD. Clinical Outcomes of the CHIRP Trial: A Phase II Prospective Randomized Trial of Conventionally Fractionated Versus Moderately Hypofractionated Prostate and Pelvic Nodal Radiation Therapy in Patients With High-Risk Prostate Cancer. Pract Radiat Oncol 2021; 11:384-393. [PMID: 33705985 DOI: 10.1016/j.prro.2021.02.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 01/23/2023]
Abstract
PURPOSE Hypofractionated radiation therapy (HFRT) may offer treatment advantages for patients with prostate cancer. However, HFRT may also increase the risk of gastrointestinal (GI) or genitourinary (GU) toxicity compared with conventionally fractionated radiation therapy (CFRT). Several large trials have found that HFRT is well tolerated in mixed risk population studies. Here, we report on a phase II, randomized controlled study conducted to evaluate these endpoints in exclusively high-risk patients with prostate cancer treated with prostate and pelvic nodal radiation. METHODS AND MATERIALS After giving informed consent, patients with high-risk prostate cancer were randomly assigned to prostate plus pelvic nodal radiation therapy with either HFRT (68 Gy in 25 fractions) or CFRT (78 Gy in 39 fractions) and 18 months of androgen suppression therapy. Toxicity was scored using the Common Terminology Criteria for Adverse Events (version 4.0). Biochemical failure was determined by the Phoenix definition. Patients were analyzed on an intention-to-treat basis. RESULTS From 2012 to 2018, 111 patients with high-risk prostate cancer were enrolled and 109 patients were treated. The cumulative incidence of grade 2 or higher acute GI toxicity was not significantly different between the arms (HFRT 18.9% vs CFRT 21.8%; P = .812). Similarly, acute GU (HFRT 30.2% vs CFRT 30.9%; P = 1.00), late GI (HFRT 16.0% vs CFRT 10.0%; P = .554), and late GU (HFRT 16.0% vs CFRT 6.0%; P = .200) were not significantly different between the arms. Median follow-up was 38.0 months (4.8-77.8 months). The 3-year biochemical recurrence-free survival was not significantly different between the 2 arms (97.3% for HFRT vs 91.0% for CFRT; P = .606). The 3-year overall survival was 94.8% in the HFRT arm and 100.0% in the CFRT arm (P = .116). CONCLUSIONS HFRT and CFRT using intensity modulated radiation therapy were both well tolerated for patients with high-risk prostate cancer and resulted in similar 3-year biochemical recurrence-free survival and overall survival.
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Affiliation(s)
- Michael H Wang
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Larissa J Vos
- Clinical Trials Unit, Cross Cancer Institute, Edmonton, AB, Canada
| | - Don Yee
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Samir Patel
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Nadeem Pervez
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Matthew Parliament
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Nawaid Usmani
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Brita Danielson
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - John Amanie
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Robert Pearcey
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Sunita Ghosh
- Department of Oncology, University of Alberta, Edmonton, AB, Canada; Division of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Colin Field
- Department of Oncology, University of Alberta, Edmonton, AB, Canada; Division of Medical Physics, Cross Cancer Institute, Edmonton, AB, Canada
| | - B Gino Fallone
- Department of Oncology, University of Alberta, Edmonton, AB, Canada; Division of Medical Physics, Cross Cancer Institute, Edmonton, AB, Canada
| | - Albert D Murtha
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, University of Alberta, Edmonton, AB, Canada.
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24
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Hafeez S, Webster A, Hansen VN, McNair HA, Warren-Oseni K, Patel E, Choudhury A, Creswell J, Foroudi F, Henry A, Kron T, McLaren DB, Mitra AV, Mostafid H, Saunders D, Miles E, Griffin C, Lewis R, Hall E, Huddart R. Protocol for tumour-focused dose-escalated adaptive radiotherapy for the radical treatment of bladder cancer in a multicentre phase II randomised controlled trial (RAIDER): radiotherapy planning and delivery guidance. BMJ Open 2020; 10:e041005. [PMID: 33384390 PMCID: PMC7780718 DOI: 10.1136/bmjopen-2020-041005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 11/03/2020] [Accepted: 11/12/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Daily radiotherapy delivered with radiosensitisation offers patients with muscle invasive bladder cancer (MIBC) comparable outcomes to cystectomy with functional organ preservation. Most recurrences following radiotherapy occur within the bladder. Increasing the delivered radiotherapy dose to the tumour may further improve local control. Developments in image-guided radiotherapy have allowed bladder tumour-focused 'plan of the day' radiotherapy delivery. We aim to test within a randomised multicentre phase II trial whether this technique will enable dose escalation with acceptable rates of toxicity. METHODS AND ANALYSIS Patients with T2-T4aN0M0 unifocal MIBC will be randomised (1:1:2) between standard/control whole bladder single plan radiotherapy, standard dose adaptive tumour-focused radiotherapy or dose-escalated adaptive tumour-focused radiotherapy (DART). Adaptive tumour-focused radiotherapy will use a library of three plans (small, medium and large) for treatment. A cone beam CT taken prior to each treatment will be used to visualise the anatomy and inform selection of the most appropriate plan for treatment.Two radiotherapy fractionation schedules (32f and 20f) are permitted. A minimum of 120 participants will be randomised in each fractionation cohort (to ensure 57 evaluable DART patients per cohort).A comprehensive radiotherapy quality assurance programme including pretrial and on-trial components is instituted to ensure standardisation of radiotherapy planning and delivery.The trial has a two-stage non-comparative design. The primary end point of stage I is the proportion of patients meeting predefined normal tissue constraints in the DART group. The primary end point of stage II is late Common Terminology Criteria for Adverse Events grade 3 or worse toxicity aiming to exclude a rate of >20% (80% power and 5% alpha, one sided) in each DART fractionation cohort. Secondary end points include locoregional MIBC control, progression-free survival overall survival and patient-reported outcomes. ETHICS AND DISSEMINATION This clinical trial is approved by the London-Surrey Borders Research Ethics Committee (15/LO/0539). The results when available will be disseminated via peer-reviewed scientific journals, conference presentations and submission to regulatory authorities. TRIAL REGISTRATION NUMBER NCT02447549; Pre-results.
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Affiliation(s)
- Shaista Hafeez
- Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- Radiotherapy Department, The Royal Marsden NHS Foundation Trust, London, UK
| | - Amanda Webster
- National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Hospital, Northwood, UK
| | - Vibeke N Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Helen A McNair
- Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- Radiotherapy Department, The Royal Marsden NHS Foundation Trust, London, UK
| | - Karole Warren-Oseni
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Emma Patel
- National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Hospital, Northwood, UK
| | - Ananya Choudhury
- Division of Cancer Studies, The University of Manchester, Manchester, UK
- Department of Clinical Oncology, Christie NHS Foundation Trust, Manchester, UK
| | - Joanne Creswell
- Department of Urology, James Cook University Hospital, Middlesbrough, UK
| | - Farshad Foroudi
- Department of Radiation Oncology, Austin Health, Heidelberg, Victoria, Australia
| | - Ann Henry
- Leeds Institute of Medical Research, University of Leeds, Leeds, West Yorkshire, UK
- Department of Clinical Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Tomas Kron
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Duncan B McLaren
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - Anita V Mitra
- Cancer Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Hugh Mostafid
- The Stokes Centre for Urology, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Daniel Saunders
- Department of Clinical Oncology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Elizabeth Miles
- National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Hospital, Northwood, UK
| | - Clare Griffin
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Rebecca Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Robert Huddart
- Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
- Radiotherapy Department, The Royal Marsden NHS Foundation Trust, London, UK
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25
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Moderately Hypofractionated Radiotherapy with Simultaneous Integrated Boost in Prostate Cancer: A Comparative Study with Conventionally Fractionated Radiation. JOURNAL OF ONCOLOGY 2020; 2020:3170396. [PMID: 33312201 PMCID: PMC7719538 DOI: 10.1155/2020/3170396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 11/07/2020] [Accepted: 11/21/2020] [Indexed: 11/17/2022]
Abstract
Background To report 5-year clinical outcomes and toxicity in organ-confined prostate cancer (PCa) for low- and intermediate-risk patients treated with a moderately hypofractionated schedule of radiotherapy (RT) delivered with simultaneous integrated boost (SIB) compared to a conventionally fractionated RT regimen. Methods Data of 384 patients with PCa treated between August 2006 and June 2017 were retrospectively reviewed. The treatment schedule consisted of hypofractionated RT (HYPO FR) with SIB up to 70 Gy to the prostate gland and 63 Gy to seminal vesicles delivered in 28 fractions or in conventionally fractionated RT (CONV FR) up to a total dose of 80 Gy in 40 fractions. Patient allocation to treatment was based on the time period considered. For intermediate-risk patients, androgen deprivation was given for a median duration of 6 months. The 5-year biochemical relapse-free survival (bRFS), cancer-specific survival (CSS), and overall survival (OS) were assessed. Furthermore, we evaluated gastrointestinal (GI) and genitourinary (GU) toxicities. Uni- and multivariate Cox regression analyses were used to test the impact of clinical variables on both outcome and toxicity. Results A total of 198 patients was treated with hypofractionated RT and 186 with the conventional schedule. At a median follow-up of 5 years, no significant differences were observed in terms of GI toxicity and outcome between the two groups. Early GU toxicity was significantly increased in HYPO FR, while late GU toxicity was significantly higher in CONV FR. In HYPO FR, a biochemical relapse occurred in 12 patients (6.1%), and 9 patients (4.5%) reported a clinical relapse (4 local, 2 locoregional, and 3 systemic recurrence). In CONV FR, 15 patients (8.1%) experienced a biochemical relapse and 11 patients (5.9%) showed a clinical relapse (5 local, 4 locoregional, and 3 systemic recurrences). Early grades 1-2 GU and GI toxicities were observed in 60 (30.3%) and 37 (18.7%) patients, respectively, in the hypofractionated group and in 33 (17.7%) and 27 (14.5%) patients, respectively, in the conventionally fractionated RT group. Late GU and GI toxicities occurred in 1 (0.51%) and 8 (4.1%) patients, respectively, in HYPO FR. In CONV FR, 5 (2.7%) and 6 (3.2%) patients experienced late GU and GI toxicities, respectively. The 5-year OS, bRFS, and CSS were 98.9%, 94.1%, and 99.5%, respectively, in HYPO FR, and 94.5%, 92.1%, and 99.0%, respectively, in CONV FR. Conclusions Results obtained in this study showed that moderately hypofractionated RT employing SIB can be an effective approach providing valuable clinical outcomes with an acceptable toxicity profile.
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Marcello M, Denham JW, Kennedy A, Haworth A, Steigler A, Greer PB, Holloway LC, Dowling JA, Jameson MG, Roach D, Joseph DJ, Gulliford SL, Dearnaley DP, Sydes MR, Hall E, Ebert MA. Reduced Dose Posterior to Prostate Correlates With Increased PSA Progression in Voxel-Based Analysis of 3 Randomized Phase 3 Trials. Int J Radiat Oncol Biol Phys 2020; 108:1304-1318. [PMID: 32739320 DOI: 10.1016/j.ijrobp.2020.07.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 07/13/2020] [Accepted: 07/20/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Reducing margins during treatment planning to decrease dose to healthy organs surrounding the prostate can risk inadequate treatment of subclinical disease. This study aimed to investigate whether lack of dose to subclinical disease is associated with increased disease progression by using high-quality prostate radiation therapy clinical trial data to identify anatomically localized regions where dose variation is associated with prostate-specific antigen progression (PSAP). METHODS AND MATERIALS Planned dose distributions for 683 patients of the Trans-Tasman Radiation Oncology Group 03.04 Randomized Androgen Deprivation and Radiotherapy (RADAR) trial were deformably registered onto a single exemplar computed tomography data set. These were divided into high-risk and intermediate-risk subgroups for analysis. Three independent voxel-based statistical tests, using permutation testing, Cox regression modeling, and least absolute shrinkage selection operator feature selection, were applied to identify regions where dose variation was associated with PSAP. Results from the intermediate-risk RADAR subgroup were externally validated by registering dose distributions from the RT01 (n = 388) and Conventional or Hypofractionated High Dose Intensity Modulated Radiotherapy for Prostate Cancer Trial (CHHiP) (n = 253) trials onto the same exemplar and repeating the tests on each of these data sets. RESULTS Voxel-based Cox regression revealed regions where reduced dose was correlated with increased prostate-specific androgen progression. Reduced dose in regions associated with coverage at the posterior prostate, in the immediate periphery of the posterior prostate, and in regions corresponding to the posterior oblique beams or posterior lateral beam boundary, was associated with increased PSAP for RADAR and RT01 patients, but not for CHHiP patients. Reduced dose to the seminal vesicle region was also associated with increased PSAP for RADAR intermediate-risk patients. CONCLUSIONS Ensuring adequate dose coverage at the posterior prostate and immediately surrounding posterior region (including the seminal vesicles), where aggressive cancer spread may be occurring, may improve tumor control. It is recommended that particular care be taken when defining margins at the prostate posterior, acknowledging the trade-off between quality of life due to rectal dose and the preferences of clinicians and patients.
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Affiliation(s)
- Marco Marcello
- Department of Physics, University of Western Australia, Perth, Western Australia, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Annette Haworth
- School of Physics, University of Sydney, Sydney, New South Wales, Australia
| | - Allison Steigler
- Prostate Cancer Trials Group, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Peter B Greer
- School of Mathematical and Physical Sciences, University of Newcastle, Newcastle, New South Wales, Australia; Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Lois C Holloway
- Department of Medical Physics, Liverpool Cancer Centre, Sydney, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia
| | - Jason A Dowling
- School of Mathematical and Physical Sciences, University of Newcastle, Newcastle, New South Wales, Australia; CSIRO, Brisbane, Queensland, Australia
| | - Michael G Jameson
- Department of Medical Physics, Liverpool Cancer Centre, Sydney, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia; Cancer Research Team, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Dale Roach
- Department of Medical Physics, Liverpool Cancer Centre, Sydney, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Cancer Research Team, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - David J Joseph
- School of Surgery, University of Western Australia, Perth, Western Australia, Australia; 5D Clinics, Claremont, Perth, Western Australia, Australia; GenesisCare WA, Perth, Western Australia, Australia
| | - Sarah L Gulliford
- Radiotherapy Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - David P Dearnaley
- Academic UroOncology Unit, The Institute of Cancer Research and the Royal Marsden NHS Trust, London, United Kingdom
| | - Matthew R Sydes
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Martin A Ebert
- Department of Physics, University of Western Australia, Perth, Western Australia, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; 5D Clinics, Claremont, Perth, Western Australia, Australia
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Miyahira AK, Pienta KJ, Babich JW, Bander NH, Calais J, Choyke P, Hofman MS, Larson SM, Lin FI, Morris MJ, Pomper MG, Sandhu S, Scher HI, Tagawa ST, Williams S, Soule HR. Meeting report from the Prostate Cancer Foundation PSMA theranostics state of the science meeting. Prostate 2020; 80:1273-1296. [PMID: 32865839 PMCID: PMC8442561 DOI: 10.1002/pros.24056] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The Prostate Cancer Foundation (PCF) convened a PCF prostate-specific membrane antigen (PSMA) Theranostics State of the Science Meeting on 18 November 2019, at Weill Cornell Medicine, New York, NY. METHODS The meeting was attended by 22 basic, translational, and clinical researchers from around the globe, with expertise in PSMA biology, development and use of PSMA theranostics agents, and clinical trials. The goal of this meeting was to discuss the current state of knowledge, the most important biological and clinical questions, and critical next steps for the clinical development of PSMA positron emission tomography (PET) imaging agents and PSMA-targeted radionuclide agents for patients with prostate cancer. RESULTS Several major topic areas were discussed including the biology of PSMA, the role of PSMA-targeted PET imaging in prostate cancer, the physics and performance of different PSMA-targeted PET imaging agents, the current state of clinical development of PSMA-targeted radionuclide therapy (RNT) agents, the role of dosimetry in PSMA RNT treatment planning, barriers and challenges in PSMA RNT clinical development, optimization of patient selection for PSMA RNT trials, and promising combination treatment approaches with PSMA RNT. DISCUSSION This article summarizes the presentations from the meeting for the purpose of globally disseminating this knowledge to advance the use of PSMA-targeted theranostic agents for imaging and treatment of patients with prostate cancer.
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Affiliation(s)
- Andrea K. Miyahira
- Science Department, Prostate Cancer Foundation, Santa Monica, California
| | - Kenneth J. Pienta
- Department of Urology, The Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John W. Babich
- Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Neil H. Bander
- Laboratory of Urologic Oncology, Department of Urology and Meyer Cancer Center, Weill Cornell Medicine, New York, New York
| | - Jeremie Calais
- Ahmanson Translational Theranostics Division, Department of Molecular & Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Peter Choyke
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Michael S. Hofman
- Prostate Cancer Theranostics and Imaging Centre of Excellence (ProsTIC), Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
- Department of Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
| | - Steven M. Larson
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Frank I. Lin
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Michael J. Morris
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Martin G. Pomper
- Department of Urology, The Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shahneen Sandhu
- Prostate Cancer Theranostics and Imaging Centre of Excellence (ProsTIC), Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
| | - Howard I. Scher
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Scott T. Tagawa
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Scott Williams
- Prostate Cancer Theranostics and Imaging Centre of Excellence (ProsTIC), Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
| | - Howard R. Soule
- Science Department, Prostate Cancer Foundation, Santa Monica, California
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Schad MD, Patel AK, Ling DC, Smith RP, Beriwal S. Hypofractionated Prostate Radiation Therapy: Adoption and Dosimetric Adherence Through Clinical Pathways in an Integrated Oncology Network. JCO Oncol Pract 2020; 17:e537-e547. [PMID: 33095692 DOI: 10.1200/op.20.00508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Updates to consensus guidelines in October 2018 recommending moderately hypofractionated external beam radiotherapy (mHF-EBRT) in prostate cancer lagged several years after publication of evidence supporting its efficacy. In January 2018, we amended our prostate cancer clinical pathway (CP) to facilitate adoption of mHF-EBRT. Herein, we analyze patterns of care and changes in mHF-EBRT use after the CP modification. METHODS Our prostate CP was amended in January 2018 to make mHF-EBRT the recommended treatment for patients with low- and intermediate-risk prostate cancer pursuing curative EBRT monotherapy. Normal-tissue dose constraints accompanied the CP modification to guide planning. Use of mHF-EBRT from 2015 to 2017 was compared with use in 2018 after the CP modification, using the Cochran-Armitage test for trend. Predictors of mHF-EBRT use and adherence to dose constraints were analyzed with binary logistic regression. RESULTS In 560 patients treated with EBRT monotherapy, mHF-EBRT use increased from 3.7% in 2015-2017 to 85.6% in 2018 (P < .001), whereas conventionally fractionated EBRT (CF-EBRT) use decreased from 96.3% to 14.4% (P < .001). Consultation year of 2018 (odds ratio [OR], 214.6; 95% CI, 94.5 to 484.6; P < .001), treatment at an academic facility (OR, 4.5; 95% CI, 1.8 to 11.3; P = 0.001), and having a smaller prostate (OR, 0.99; 95% CI, 0.97 to 1.00; P = .028) predicted for mHF-EBRT use. At least five of six recommended bladder and rectal dose constraints were met in 89.4% of patients. CONCLUSION Modification of our prostate cancer CP, in concert with institutional policies to monitor and audit CP compliance, facilitated rapid adoption of mHF-EBRT in our large, integrated cancer center with good adherence to dosimetric constraints.
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Affiliation(s)
| | - Ankur K Patel
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Diane C Ling
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ryan P Smith
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Marcello M, Denham JW, Kennedy A, Haworth A, Steigler A, Greer PB, Holloway LC, Dowling JA, Jameson MG, Roach D, Joseph DJ, Gulliford SL, Dearnaley DP, Sydes MR, Hall E, Ebert MA. Relationships between rectal and perirectal doses and rectal bleeding or tenesmus in pooled voxel-based analysis of 3 randomised phase III trials. Radiother Oncol 2020; 150:281-292. [PMID: 32745667 DOI: 10.1016/j.radonc.2020.07.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 07/25/2020] [Accepted: 07/28/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE This study aimed to identify anatomically-localised regions where planned radiotherapy dose is associated with gastrointestinal toxicities in healthy tissues throughout the pelvic anatomy. MATERIALS AND METHODS Planned dose distributions for up to 657 patients of the Trans Tasman Radiation Oncology Group 03.04 RADAR trial were deformably registered onto a single exemplar computed tomography dataset. Voxel-based multiple comparison permutation dose difference testing, Cox regression modelling and LASSO feature selection were used to identify regions where dose-increase was associated with grade ≥2 rectal bleeding (RB) or tenesmus, according to the LENT/SOMA scale. This was externally validated by registering dose distributions from the RT01 (n = 388) and CHHiP (n = 241) trials onto the same exemplar and repeating the tests on each of these data sets, and on all three datasets combined. RESULTS Voxel-based Cox regression and permutation dose difference testing revealed regions where increased dose was correlated with gastrointestinal toxicity. Grade ≥2 RB was associated with posteriorly extended lateral beams that manifested high doses (>55 Gy) in a small rectal volume adjacent to the clinical target volume. A correlation was found between grade ≥2 tenesmus and increased low-intermediate dose (∼25 Gy) at the posterior beam region, including the posterior rectum and perirectal fat space (PRFS). CONCLUSIONS The serial response of the rectum with respect to RB has been demonstrated in patients with posteriorly extended lateral beams. Similarly, the parallel response of the PRFS with respect to tenesmus has been demonstrated in patients treated with the posterior beam.
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Affiliation(s)
- Marco Marcello
- Department of Physics, University of Western Australia, Crawley, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia.
| | - James W Denham
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Annette Haworth
- School of Physics, University of Sydney, Camperdown, Australia
| | - Allison Steigler
- Prostate Cancer Trials Group, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Peter B Greer
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, Australia; Department of Radiation Oncology, Calvary Mater Newcastle, Waratah, Australia
| | - Lois C Holloway
- Department of Medical Physics, Liverpool Cancer Centre, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Centre for Medical Radiation Physics, University of Wollongong, Australia
| | - Jason A Dowling
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, Australia; CSIRO, Herston, Australia
| | - Michael G Jameson
- Department of Medical Physics, Liverpool Cancer Centre, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Centre for Medical Radiation Physics, University of Wollongong, Australia; Cancer Research Team, Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Dale Roach
- Department of Medical Physics, Liverpool Cancer Centre, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Cancer Research Team, Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - David J Joseph
- School of Surgery, University of Western Australia, Crawley, Australia; 5D Clinics, Claremont, Australia; GenesisCare WA, Wembley, Australia
| | - Sarah L Gulliford
- Radiotherapy Department, University College London Hospitals NHS Foundation Trust, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, United Kingdom
| | - David P Dearnaley
- Academic UroOncology Unit, The Institute of Cancer Research and the Royal Marsden NHS Trust, London, Australia
| | - Mathew R Sydes
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, Sutton, United Kingdom
| | - Martin A Ebert
- Department of Physics, University of Western Australia, Crawley, Australia; Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia; 5D Clinics, Claremont, Australia
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Parker C, Castro E, Fizazi K, Heidenreich A, Ost P, Procopio G, Tombal B, Gillessen S. Prostate cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2020; 31:1119-1134. [PMID: 32593798 DOI: 10.1016/j.annonc.2020.06.011] [Citation(s) in RCA: 446] [Impact Index Per Article: 111.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 02/07/2023] Open
Affiliation(s)
- C Parker
- Royal Marsden Hospital, Sutton, UK
| | - E Castro
- Department of Medical Oncology, Virgen de la Victoria University Hospital, Institute of Biomedical Research in Málaga, Malaga, Spain
| | - K Fizazi
- Department of Cancer Medicine, Institut Gustave Roussy, University of Paris Saclay, Villejuif, France
| | - A Heidenreich
- Department of Urology, Uro-Oncology, Robot-Assisted and Specialized Urologic Surgery, University Hospital of Cologne, Cologne, Germany
| | - P Ost
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - G Procopio
- Department of Medical Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - B Tombal
- Institut de Recherche Clinique, Université catholique de Louvain, Brussels, Belgium
| | - S Gillessen
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Faculty of Biomedical Sciences, USI, Lugano, Switzerland; Division of Cancer Medicine, University of Manchester, Manchester, UK
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31
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Marcello M, Denham JW, Kennedy A, Haworth A, Steigler A, Greer PB, Holloway LC, Dowling JA, Jameson MG, Roach D, Joseph DJ, Gulliford SL, Dearnaley DP, Sydes MR, Hall E, Ebert MA. Increased Dose to Organs in Urinary Tract Associates With Measures of Genitourinary Toxicity in Pooled Voxel-Based Analysis of 3 Randomized Phase III Trials. Front Oncol 2020; 10:1174. [PMID: 32793485 PMCID: PMC7387667 DOI: 10.3389/fonc.2020.01174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 06/09/2020] [Indexed: 12/21/2022] Open
Abstract
Purpose: Dose information from organ sub-regions has been shown to be more predictive of genitourinary toxicity than whole organ dose volume histogram information. This study aimed to identify anatomically-localized regions where 3D dose is associated with genitourinary toxicities in healthy tissues throughout the pelvic anatomy. Methods and Materials: Dose distributions for up to 656 patients of the Trans-Tasman Radiation Oncology Group 03.04 RADAR trial were deformably registered onto a single exemplar CT dataset. Voxel- based multiple comparison permutation dose difference testing, Cox regression modeling and LASSO feature selection were used to identify regions where 3D dose-increase was associated with late grade ≥ 2 genitourinary dysuria, incontinence and frequency, and late grade ≥ 1 haematuria. This was externally validated by registering dose distributions from the RT01 (up to n = 388) and CHHiP (up to n = 247) trials onto the same exemplar and repeating the voxel-based tests on each of these data sets. All three datasets were then combined, and the tests repeated. Results: Voxel-based Cox regression and multiple comparison permutation dose difference testing revealed regions where increased dose was correlated with genitourinary toxicity. Increased dose in the vicinity of the membranous and spongy urethra was associated with dysuria for all datasets. Haematuria was similarly correlated with increased dose at the membranous and spongy urethra, for the RADAR, CHHiP, and combined datasets. Some evidence was found for the association between incontinence and increased dose at the internal and external urethral sphincter for RADAR and the internal sphincter alone for the combined dataset. Incontinence was also strongly correlated with dose from posterior oblique beams. Patients with fields extending inferiorly and posteriorly to the CTV, adjacent to the membranous and spongy urethra, were found to experience increased frequency. Conclusions: Anatomically-localized dose-toxicity relationships were determined for late genitourinary symptoms in the urethra and urinary sphincters. Low-intermediate doses to the extraprostatic urethra were associated with risk of late dysuria and haematuria, while dose to the urinary sphincters was associated with incontinence.
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Affiliation(s)
- Marco Marcello
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Department of Physics, University of Western Australia, Perth, WA, Australia
| | - James W. Denham
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Angel Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Annette Haworth
- School of Physics, University of Sydney, Sydney, NSW, Australia
| | - Allison Steigler
- Prostate Cancer Trials Group, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Peter B. Greer
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, NSW, Australia
- Department of Radiation Oncology, Calvary Mater Newcastle, Waratah, NSW, Australia
| | - Lois C. Holloway
- Department of Medical Physics, Liverpool Cancer Centre, Liverpool, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia
| | - Jason A. Dowling
- School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, NSW, Australia
- CSIRO, St Lucia, QLD, Australia
| | - Michael G. Jameson
- Department of Medical Physics, Liverpool Cancer Centre, Liverpool, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia
- Cancer Research Team, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Dale Roach
- Department of Medical Physics, Liverpool Cancer Centre, Liverpool, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia
- Cancer Research Team, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - David J. Joseph
- School of Surgery, University of Western Australia, Perth, WA, Australia
- 5D Clinics, Claremont, WA, Australia
- GenesisCare WA, Wembley, WA, Australia
| | - Sarah L. Gulliford
- Radiotherapy Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - David P. Dearnaley
- Academic UroOncology Unit, The Institute of Cancer Research and the Royal Marsden NHS Trust, London, United Kingdom
| | - Matthew R. Sydes
- MRC Clinical Trials Unit, Medical Research Council, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Martin A. Ebert
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Department of Physics, University of Western Australia, Perth, WA, Australia
- 5D Clinics, Claremont, WA, Australia
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Blake SW, Stapleton A, Brown A, Curtis S, Ash-Miles J, Dennis E, Masson S, Bowers D, Hilman S. A study of the clinical, treatment planning and dosimetric feasibility of dose painting in external beam radiotherapy of prostate cancer. Phys Imaging Radiat Oncol 2020; 15:66-71. [PMID: 33458328 PMCID: PMC7807863 DOI: 10.1016/j.phro.2020.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 07/26/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Radiotherapy dose painting is a promising technique which enables dose escalation to areas of higher tumour cell density within the prostate which are associated with radioresistance, known as dominant intraprostatic lesions (DILs). The aim of this study was to determine factors affecting the feasibility of radiotherapy dose painting in patients with high and intermediate risk prostate cancer. MATERIALS & METHODS Twenty patients were recruited into the study for imaging using a 3 T magnetic resonance imaging (MRI) scanner. Identified DILs were outlined and the scan registered with the planning computed tomography (CT) dataset. Intensity-modulated plans were produced and evaluated to determine the effect of the organ-at-risk constraints on the dose that could be delivered to the DILs. Measurements were made to verify that the distribution could be safely delivered. RESULTS MRI scans were obtained for nineteen patients. Fourteen patients had one to two DILs with ten overlapping the urethra and/or rectum. The target boost of 86 Gy was achieved in seven plans but was limited to 80 Gy for five patients whose boost volume overlapped or abutted the urethra. Dosimetric measurements gave a satisfactory gamma pass rate at 3%/3 mm. CONCLUSIONS It was feasible to produce dose-painted plans for a boost of 86 Gy for approximately half the patients with DILs. The main limiting factor was the proximity of the urethra to the boost volumes. For a small proportion of patients, rigid registration between CT and MRI images was not adequate for planning purposes.
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Affiliation(s)
- Steve W. Blake
- Medical Physics, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
| | - Alison Stapleton
- Medical Physics, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
| | - Andrew Brown
- Medical Physics, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
| | - Sian Curtis
- Bioengineering, Innovation & Research Hub, Medical Physics, St Michael's Hospital, Bristol BS2 8EG, UK
- Clinical Research and Imaging Centre (CRICBristol), Bristol BS2 8DX, UK
| | | | - Emma Dennis
- Oncology, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
| | - Susan Masson
- Oncology, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
| | - Dawn Bowers
- Oncology, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
| | - Serena Hilman
- Oncology, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
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33
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Lehrer EJ, Kishan AU, Yu JB, Trifiletti DM, Showalter TN, Ellis R, Zaorsky NG. Ultrahypofractionated versus hypofractionated and conventionally fractionated radiation therapy for localized prostate cancer: A systematic review and meta-analysis of phase III randomized trials. Radiother Oncol 2020; 148:235-242. [DOI: 10.1016/j.radonc.2020.04.037] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/02/2020] [Accepted: 04/07/2020] [Indexed: 01/01/2023]
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34
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Beckmann K, Garmo H, Nilsson P, Franck Lissbrant I, Widmark A, Stattin P. Radical radiotherapy for prostate cancer: patterns of care in Sweden 1998-2016. Acta Oncol 2020; 59:549-557. [PMID: 32122185 DOI: 10.1080/0284186x.2020.1730003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Radiotherapy is an established treatment option for prostate cancer (PCa), both as primary treatment and secondary treatment after radical prostatectomy (RP). Since 1998, detailed data on radiotherapy delivered to Swedish men with PCa (e.g. treatment modalities, absorbed doses, fractionation) have been collated within PCa data Base Sweden (PCBaSe). This study reports patterns of radical radiotherapy for PCa in Sweden over the past two decades.Materials and methods: All men with non-metastatic PCa (1998-2016) who received external beam radiotherapy (EBRT) or high or low dose-rate brachytherapy (HDR-BT/LDR-BT) were identified in PCBaSe. Analyses included: trends in radiation techniques, fractionation patterns and total doses over time; PCa-specific survival comparing treatment in 2007-2017 with 1998-2006; and regional variation in type of primary radiotherapy.Results: About 20,876 men underwent primary radiotherapy. The main treatment modalities include conventionally fractionated (2.0 Gy/fraction) EBRT (51%), EBRT with HDR-BT boost (27%) and hypofractionated (>2.4 Gy/fraction) EBRT (11%). EBRT with photon or proton boost and HDR-BT and LDR-BT monotherapies were each used minimally. Use of dose-escalated EBRT (>74 Gy) and moderate hypofractionation increased over time, while use of HDR-BT declined. Considerable regional variation in treatment modalities was apparent. Risk of PCa death following primary radiotherapy had declined for intermediate-risk (HR: 0.60; 95%CI 0.47-0.87) and high-risk PCa (HR: 0.72; 95%CI 0.61-0.86).Discussion: Increased use of dose escalation and hypofractionated EBRT has occurred in Sweden over the past two decades, reflecting current evidence and practice guidelines. Disease-specific outcomes have also improved. Data collected in PCBaSe provide an excellent resource for further research into RT use in PCa management.
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Affiliation(s)
- Kerri Beckmann
- Translational Oncology and Urology Research (TOUR), School of Cancer and Pharmaceutical Studies, King’s College London, London, UK
- University of South Australia Cancer Research Institute, University of South Australia, Adelaide, Australia
| | - Hans Garmo
- Regional Cancer Centre Uppsala, Uppsala University Hospital, Uppsala, Sweden
| | - Per Nilsson
- Department of Oncology and Radiation Physics, Skane University Hospital and Lund University, Lund, Sweden
| | | | - Anders Widmark
- Department of Radiation Sciences, Umea University, Umea, Sweden
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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Shelley LEA, Sutcliffe MPF, Thomas SJ, Noble DJ, Romanchikova M, Harrison K, Bates AM, Burnet NG, Jena R. Associations between voxel-level accumulated dose and rectal toxicity in prostate radiotherapy. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2020; 14:87-94. [PMID: 32582869 PMCID: PMC7301619 DOI: 10.1016/j.phro.2020.05.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 12/25/2022]
Abstract
Background and Purpose Associations between dose and rectal toxicity in prostate radiotherapy are generally poorly understood. Evaluating spatial dose distributions to the rectal wall (RW) may lead to improvements in dose-toxicity modelling by incorporating geometric information, masked by dose-volume histograms. Furthermore, predictive power may be strengthened by incorporating the effects of interfraction motion into delivered dose calculations.Here we interrogate 3D dose distributions for patients with and without toxicity to identify rectal subregions at risk (SRR), and compare the discriminatory ability of planned and delivered dose. Material and Methods Daily delivered dose to the rectum was calculated using image guidance scans, and accumulated at the voxel level using biomechanical finite element modelling. SRRs were statistically determined for rectal bleeding, proctitis, faecal incontinence and stool frequency from a training set (n = 139), and tested on a validation set (n = 47). Results SRR patterns differed per endpoint. Analysing dose to SRRs improved discriminative ability with respect to the full RW for three of four endpoints. Training set AUC and OR analysis produced stronger toxicity associations from accumulated dose than planned dose. For rectal bleeding in particular, accumulated dose to the SRR (AUC 0.76) improved upon dose-toxicity associations derived from planned dose to the RW (AUC 0.63). However, validation results could not be considered significant. Conclusions Voxel-level analysis of dose to the RW revealed SRRs associated with rectal toxicity, suggesting non-homogeneous intra-organ radiosensitivity. Incorporating spatial features of accumulated delivered dose improved dose-toxicity associations. This may be an important tool for adaptive radiotherapy in the future.
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Affiliation(s)
- Leila E A Shelley
- Cancer Research UK VoxTox Research Group, Cambridge University Hospitals NHS Foundation Trust, Department of Oncology, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom.,Edinburgh Cancer Centre, Western General Hospital, Edinburgh EH4 2XU, United Kingdom.,Department of Engineering, University of Cambridge, Trumpington St, Cambridge CB21PZ, United Kingdom
| | - Michael P F Sutcliffe
- Cancer Research UK VoxTox Research Group, Cambridge University Hospitals NHS Foundation Trust, Department of Oncology, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom.,Department of Engineering, University of Cambridge, Trumpington St, Cambridge CB21PZ, United Kingdom
| | - Simon J Thomas
- Cancer Research UK VoxTox Research Group, Cambridge University Hospitals NHS Foundation Trust, Department of Oncology, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom.,Department of Medical Physics and Clinical Engineering, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - David J Noble
- Cancer Research UK VoxTox Research Group, Cambridge University Hospitals NHS Foundation Trust, Department of Oncology, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom.,Department of Oncology, University of Cambridge, Cambridge Biomedical Campus, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, United Kingdom
| | - Marina Romanchikova
- Cancer Research UK VoxTox Research Group, Cambridge University Hospitals NHS Foundation Trust, Department of Oncology, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom.,National Physical Laboratory, Teddington TW11 0JE, United Kingdom
| | - Karl Harrison
- Cancer Research UK VoxTox Research Group, Cambridge University Hospitals NHS Foundation Trust, Department of Oncology, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom.,Cavendish Laboratory, University of Cambridge, J J Thomson Avenue, Cambridge CB3 0HE, United Kingdom
| | - Amy M Bates
- Cancer Research UK VoxTox Research Group, Cambridge University Hospitals NHS Foundation Trust, Department of Oncology, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom.,Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Neil G Burnet
- Cancer Research UK VoxTox Research Group, Cambridge University Hospitals NHS Foundation Trust, Department of Oncology, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom.,University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, United Kingdom
| | - Raj Jena
- Cancer Research UK VoxTox Research Group, Cambridge University Hospitals NHS Foundation Trust, Department of Oncology, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom.,Department of Oncology, University of Cambridge, Cambridge Biomedical Campus, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, United Kingdom
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Murray JR, Tree AC, Alexander EJ, Sohaib A, Hazell S, Thomas K, Gunapala R, Parker CC, Huddart RA, Gao A, Truelove L, McNair HA, Blasiak-Wal I, deSouza NM, Dearnaley D. Standard and Hypofractionated Dose Escalation to Intraprostatic Tumor Nodules in Localized Prostate Cancer: Efficacy and Toxicity in the DELINEATE Trial. Int J Radiat Oncol Biol Phys 2020; 106:715-724. [PMID: 31812718 DOI: 10.1016/j.ijrobp.2019.11.402] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/11/2019] [Accepted: 11/25/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE To report a planned analysis of the efficacy and toxicity of dose escalation to the intraprostatic dominant nodule identified on multiparametric magnetic resonance imaging using standard and hypofractionated external beam radiation therapy. METHODS AND MATERIALS DELINEATE is a single centre prospective phase 2 multicohort study including standard (cohort A: 74 Gy in 37 fractions) and moderately hypofractionated (cohort B: 60 Gy in 20 fractions) prostate image guided intensity modulated radiation therapy in patients with National Comprehensive Cancer Network intermediate- and high-risk disease. Patients received an integrated boost of 82 Gy (cohort A) and 67 Gy (cohort B) to lesions visible on multiparametric magnetic resonance imaging. Fifty-five patients were treated in cohort A, and 158 patients were treated in cohort B; the first 50 sequentially treated patients in cohort B were included in this planned analysis. The primary endpoint was late Radiation Therapy Oncology Group rectal toxicity at 1 year. Secondary endpoints included acute and late toxicity measured with clinician- and patient-reported outcomes at other time points and biochemical relapse-free survival for cohort A. Median follow-up was 74.5 months for cohort A and 52.0 months for cohort B. RESULTS In cohorts A and B, 27% and 40% of patients, respectively, were classified as having National Comprehensive Cancer Network high-risk disease. The cumulative 1-year incidence of Radiation Therapy Oncology Group grade 2 or worse rectal and urinary toxicity was 3.6% and 0% in cohort A and 8% and 10% in cohort B, respectively. There was no reported late grade 3 rectal toxicity in either cohort. Within cohort A, 4 of 55 (7%) patients had biochemical relapse. CONCLUSIONS Delivery of a simultaneous integrated boost to intraprostatic dominant nodules is feasible in prostate radiation therapy using standard and moderately hypofractionated regimens, with rectal and genitourinary toxicity comparable to contemporary series without an intraprostatic boost.
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Affiliation(s)
- Julia R Murray
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom.
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | | | - Aslam Sohaib
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Steve Hazell
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Karen Thomas
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Ranga Gunapala
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Chris C Parker
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Robert A Huddart
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Annie Gao
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Lesley Truelove
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Helen A McNair
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Irena Blasiak-Wal
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Nandita M deSouza
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - David Dearnaley
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
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Murthy V, Mallick I, Gavarraju A, Sinha S, Krishnatry R, Telkhade T, Moses A, Kannan S, Prakash G, Pal M, Menon S, Popat P, Rangarajan V, Agarwal A, Kulkarni S, Bakshi G. Study protocol of a randomised controlled trial of prostate radiotherapy in high-risk and node-positive disease comparing moderate and extreme hypofractionation (PRIME TRIAL). BMJ Open 2020; 10:e034623. [PMID: 32114475 PMCID: PMC7050316 DOI: 10.1136/bmjopen-2019-034623] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION There has been an interest in studying the efficacy of extreme hypofractionation in low and intermediate risk prostate cancer utilising the low alpha/beta ratio of prostate. Its role in high-risk and node-positive prostate cancer, however, is unknown. We hypothesise that a five-fraction schedule of extreme hypofractionation will be non-inferior to a moderately hypofractionated regimen over 5 weeks in efficacy and will have acceptable toxicity and quality of life while reducing the cost implications during treatment. METHODS AND ANALYSIS This is an ongoing, non-inferiority, multicentre, randomised trial (NCT03561961) of two schedules for National Cancer Control Network high-risk and/or node-positive non-metastatic carcinoma of the prostate. The standard arm will be a schedule of 68 Gy/25# over 5 weeks while the test arm will be extremely hypofractionated radiotherapy with stereotactic body radiation therapy to 36.25 Gy/5# (7 to 10 days). The block randomisation will be stratified by nodal status (N0/N+), hormonal therapy (luteinizing hormone-releasing hormone therapy/orchiectomy) and centre. All patients will receive daily image-guided radiotherapy.The primary end point is 4-year biochemical failure free survival (BFFS). The power calculations assume 4-year BFFS of 80% in the moderate hypofractionation arm. With a 5% one-sided significance and 80% power, a total of 434 patients will be randomised to both arms equally (217 in each arm). The secondary end points include overall survival, prostate cancer specific survival, acute and late toxicities, quality of life and out-of-pocket expenditure. DISCUSSION The trial aims to establish a therapeutically efficacious and cost-efficient modality for high-risk and node-positive prostate cancer with an acceptable toxicity profile. Presently, this is the only trial evaluating and answering such a question in this cohort. ETHICS AND DISSEMINATION The trial has been approved by IEC-III of Tata Memorial Centre, Mumbai. TRIAL REGISTRATION NUMBER Registered with CTRI/2018/05/014054 (http://ctri.nic.in) on 24 May 2018.
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Affiliation(s)
- Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Indranil Mallick
- Department of Radiation Oncology, Tata Medical Centre, Kolkata, India
| | | | - Shwetabh Sinha
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Rahul Krishnatry
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Tejshri Telkhade
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Arunsingh Moses
- Department of Radiation Oncology, Tata Medical Centre, Kolkata, India
| | - Sadhna Kannan
- Clinical Research Secretariat, Tata Memorial Centre, Mumbai, India
| | - Gagan Prakash
- Division of Uro-Oncology, Tata Memorial Centre, Mumbai, India
| | - Mahendra Pal
- Division of Uro-Oncology, Tata Memorial Centre, Mumbai, India
| | - Santosh Menon
- Department of Pathology, Tata Memorial Centre, Mumbai, India
| | - Palak Popat
- Department of Radiology, Tata Memorial Centre, Mumbai, India
| | - Venkatesh Rangarajan
- Department of Nuclear Imaging and Bio imaging, Tata Memorial Centre, Mumbai, India
| | - Archi Agarwal
- Department of Nuclear Imaging and Bio imaging, Tata Memorial Centre, Mumbai, India
| | - Sheetal Kulkarni
- Clinical Research Secretariat, Tata Memorial Centre, Mumbai, India
| | - Ganesh Bakshi
- Division of Uro-Oncology, Tata Memorial Centre, Mumbai, India
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Simões R, Miles E, Yang H, Le Grange F, Bhat R, Forsyth S, Seddon B. IMRiS phase II study of IMRT in limb sarcomas: Results of the pre-trial QA facility questionnaire and workshop. Radiography (Lond) 2020; 26:71-75. [PMID: 31902458 DOI: 10.1016/j.radi.2019.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/21/2019] [Accepted: 08/28/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Soft tissue sarcomas of the extremities (STSE) are rare malignancies. We report current UK practice for immobilisation of soft tissue sarcoma of STSE, as part of the initial study set-up within the IMRiS trial, a phase II study of intensity modulated radiotherapy (IMRT) in primary bone and soft tissue sarcoma. METHODS A facility questionnaire (FQ) was circulated to 29 IMRiS centres investigating the variation in immobilisation devices, planning techniques, and imaging protocols. A workshop was held to address concerns raised by centres. It focused on STSE immobilisation and patient set-up. Robustness of patient set-up at each centre was evaluated based on the following criteria: evidence of local set-up audit, calculation of margins based on set-up audit results, imaging frequency, and number of patients treated per centre per annum. RESULTS Twenty-seven (93%) questionnaires were returned. 30% (8/27) of responders routinely treated STSE with IMRT. The remaining 70% (19/27) had little or no experience with IMRT for STSE. Vacuum bags were the most frequent immobilisation device (9/27), followed by thermoplastic shells (7/27). Nine centres had audited their local set-up; however, only 4 had calculated margins in response to the results. Ten centres were classified as having high level of robustness. CONCLUSIONS Immobilisation devices and planning techniques for STSE are inconsistent across centres. Robustness of set-up is an important tool to ensure quality of results in a multicentre trial setting with such different levels of experience. The IMRiS trial Quality Assurance programme encourages centres to assess robustness of set-up through local audit and subsequent calculation of treatment margins. IMPLICATIONS FOR PRACTICE This is the first study that used robustness criteria to tailor QA support to individual centres.
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Affiliation(s)
- R Simões
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Hospital, London, UK.
| | - E Miles
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Hospital, London, UK
| | - H Yang
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Hospital, London, UK
| | - F Le Grange
- University College of London Hospital, London, UK
| | - R Bhat
- Cancer Research UK & UCL Cancer Trials Centre, London, UK
| | - S Forsyth
- Cancer Research UK & UCL Cancer Trials Centre, London, UK
| | - B Seddon
- University College of London Hospital, London, UK
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Comparison of dose statistics for bladder wall and rectum wall vs whole organs for VMAT prostate treatment. Med Dosim 2020; 45:140-148. [DOI: 10.1016/j.meddos.2019.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 08/15/2019] [Accepted: 08/18/2019] [Indexed: 11/19/2022]
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Murray J, Griffin C, Gulliford S, Syndikus I, Staffurth J, Panades M, Scrase C, Parker C, Khoo V, Dean J, Mayles H, Mayles P, Thomas S, Naismith O, Baker A, Mossop H, Cruickshank C, Hall E, Dearnaley D. A randomised assessment of image guided radiotherapy within a phase 3 trial of conventional or hypofractionated high dose intensity modulated radiotherapy for prostate cancer. Radiother Oncol 2020; 142:62-71. [PMID: 31767473 PMCID: PMC7005673 DOI: 10.1016/j.radonc.2019.10.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE Image-guided radiotherapy (IGRT) improves treatment set-up accuracy and provides the opportunity to reduce target volume margins. We introduced IGRT methods using standard (IGRT-S) or reduced (IGRT-R) margins in a randomised phase 2 substudy within CHHiP trial. We present a pre-planned analysis of the impact of IGRT on dosimetry and acute/late pelvic side effects using gastrointestinal and genitourinary clinician and patient-reported outcomes (PRO) and evaluate efficacy. MATERIALS AND METHODS CHHiP is a randomised phase 3, non-inferiority trial for men with localised prostate cancer. 3216 patients were randomly assigned to conventional (74 Gy in 2 Gy/fraction (f) daily) or moderate hypofractionation (60 or 57 Gy in 3 Gy/f daily) between October 2002 and June 2011. The IGRT substudy included a second randomisation assigning to no-IGRT, IGRT-S (standard CTV-PTV margins), or IGRT-R (reduced CTV-PTV margins). Primary substudy endpoint was late RTOG bowel and urinary toxicity at 2 years post-radiotherapy. RESULTS Between June 2010 to July 2011, 293 men were recruited from 16 centres. Median follow-up is 56.9(IQR 54.3-60.9) months. Rectal and bladder dose-volume and surface percentages were significantly lower in IGRT-R compared to IGRT-S group; (p < 0.0001). Cumulative proportion with RTOG grade ≥ 2 toxicity reported to 2 years for bowel was 8.3(95% CI 3.2-20.7)%, 8.3(4.7-14.6)% and 5.8(2.6-12.4)% and for urinary 8.4(3.2-20.8)%, 4.6(2.1-9.9)% and 3.9(1.5-9.9)% in no IGRT, IGRT-S and IGRT-R groups respectively. In an exploratory analysis, treatment efficacy appeared similar in all three groups. CONCLUSION Introduction of IGRT was feasible in a national randomised trial and IGRT-R produced dosimetric benefits. Overall side effect profiles were acceptable in all groups but lowest with IGRT and reduced margins. ISRCTN 97182923.
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Affiliation(s)
- Julia Murray
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK
| | | | - Sarah Gulliford
- The Institute of Cancer Research, London, UK; Department of Radiotherapy, University College London Hospitals NHS Foundation Trust, UK
| | | | | | | | | | - Chris Parker
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK
| | - Vincent Khoo
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK
| | - Jamie Dean
- The Institute of Cancer Research, London, UK
| | | | | | | | | | | | | | | | - Emma Hall
- The Institute of Cancer Research, London, UK
| | - David Dearnaley
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK.
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Current use of stereotactic body radiation therapy for low and intermediate risk prostate cancer: A National Cancer Database Analysis. Prostate Cancer Prostatic Dis 2019; 23:349-355. [DOI: 10.1038/s41391-019-0191-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 11/07/2019] [Accepted: 11/14/2019] [Indexed: 02/02/2023]
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Hickey BE, James ML, Daly T, Soh F, Jeffery M. Hypofractionation for clinically localized prostate cancer. Cochrane Database Syst Rev 2019; 9:CD011462. [PMID: 31476800 PMCID: PMC6718288 DOI: 10.1002/14651858.cd011462.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Using hypofractionation (fewer, larger doses of daily radiation) to treat localized prostate cancer may improve convenience and resource use. For hypofractionation to be feasible, it must be at least as effective for cancer-related outcomes and have comparable toxicity and quality of life outcomes as conventionally fractionated radiation therapy. OBJECTIVES To assess the effects of hypofractionated external beam radiation therapy compared to conventionally fractionated external beam radiation therapy for men with clinically localized prostate cancer. SEARCH METHODS We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and trials registries from 1946 to 15 March 2019 with reference checking, citation searching and contact with study authors. Searches were not limited by language or publication status. We reran all searches within three months (15th March 2019) prior to publication. SELECTION CRITERIA Randomized controlled comparisons which included men with clinically localized prostate adenocarcinoma where hypofractionated radiation therapy (external beam radiation therapy) to the prostate using hypofractionation (greater than 2 Gy per fraction) compared with conventionally fractionated radiation therapy to the prostate delivered using standard fractionation (1.8 Gy to 2 Gy per fraction). DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology. Two authors independently assessed trial quality and extracted data. We used Review Manager 5 for data analysis and meta-analysis. We used the inverse variance method and random-effects model for data synthesis of time-to-event data with hazard ratios (HR) and 95% confidence intervals (CI) reported. For dichotomous data, we used the Mantel-Haenzel method and random-effects model to present risk ratios (RR) and 95% CI. We used GRADE to assess evidence quality for each outcome. MAIN RESULTS We included 10 studies with 8278 men in our analysis comparing hypofractionation with conventional fractionation to treat prostate cancer.Primary outcomesHypofractionation may result in little or no difference in prostate cancer-specific survival [PC-SS] (HR 1.00, 95% CI 0.72 to 1.39; studies = 8, participants = 7946; median follow-up 72 months; low-certainty evidence). For men in the intermediate-risk group undergoing conventional fractionation this corresponds to 976 per 1000 men alive after 6 years and 0 more (44 fewer to 18 more) alive per 1000 men undergoing hypofractionation.We are uncertain about the effect of hypofractionation on late radiation therapy gastrointestinal (GI) toxicity (RR 1.10, 95% CI 0.68 to 1.78; studies = 4, participants = 3843; very low-certainty evidence).Hypofractionation probably results in little or no difference to late radiation therapy genitourinary (GU) toxicity (RR 1.05, 95% CI 0.93 to 1.18; studies = 4, participants = 3843; moderate-certainty evidence). This corresponds to 262 per 1000 late GU radiation therapy toxicity events with conventional fractionation and 13 more (18 fewer to 47 more) per 1000 men when undergoing hypofractionation.Secondary outcomesHypofractionation results in little or no difference in overall survival (HR 0.94, 95% CI 0.83 to 1.07; 10 studies, 8243 participants; high-certainty evidence). For men in the intermediate-risk group undergoing conventional fractionation this corresponds to 869 per 1000 men alive after 6 years and 17 fewer (54 fewer to 17 more) participants alive per 1000 men when undergoing hypofractionation.Hypofractionation may result in little to no difference in metastasis-free survival (HR 1.07, 95% CI 0.65 to 1.76; 5 studies, 4985 participants; low-certainty evidence). This corresponds to 981 men per 1000 men metastasis-free at 6 years when undergoing conventional fractionation and 5 more (58 fewer to 19 more) metastasis-free per 1000 when undergoing hypofractionation.Hypofractionation likely results in a small, possibly unimportant reduction in biochemical recurrence-free survival based on Phoenix criteria (HR 0.88, 95% CI 0.68 to 1.13; studies = 5, participants = 2889; median follow-up 90 months to 108 months; moderate-certainty evidence). In men of the intermediate-risk group, this corresponds to 804 biochemical-recurrence free men per 1000 participants at six years with conventional fractionation and 42 fewer (134 fewer to 37 more) recurrence-free men per 1000 participants with hypofractionationHypofractionation likely results in little to no difference to acute GU radiation therapy toxicity (RR 1.03, 95% CI 0.95 to 1.11; 4 studies, 4174 participants at 12 to 18 weeks' follow-up; moderate-certainty evidence). This corresponds to 360 episodes of toxicity per 1000 participants with conventional fractionation and 11 more (18 fewer to 40 more) per 1000 when undergoing hypofractionation. AUTHORS' CONCLUSIONS These findings suggest that moderate hypofractionation (up to a fraction size of 3.4 Gy) results in similar oncologic outcomes in terms of disease-specific, metastasis-free and overall survival. There appears to be little to no increase in both acute and late toxicity.
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Affiliation(s)
- Brigid E Hickey
- Princess Alexandra HospitalRadiation Oncology Mater Service31 Raymond TerraceBrisbaneQueenslandAustralia4101
- The University of QueenslandSchool of MedicineBrisbaneAustralia
| | - Melissa L James
- Christchurch HospitalCanterbury Regional Cancer and Haematology ServicePrivate Bag 4710ChristchurchNew Zealand8140
| | - Tiffany Daly
- Princess Alexandra HospitalRadiation Oncology Mater Service31 Raymond TerraceBrisbaneQueenslandAustralia4101
| | - Feng‐Yi Soh
- NHS HighlandDepartment of Clinical OncologyInvernessUK
| | - Mark Jeffery
- Christchurch HospitalCanterbury Regional Cancer and Haematology ServicePrivate Bag 4710ChristchurchNew Zealand8140
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Forward- and Inverse-Planned Intensity-Modulated Radiotherapy in the CHHiP Trial: A Comparison of Dosimetry and Normal Tissue Toxicity. Clin Oncol (R Coll Radiol) 2019; 31:600-610. [PMID: 31178346 PMCID: PMC6688097 DOI: 10.1016/j.clon.2019.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/21/2019] [Accepted: 03/27/2019] [Indexed: 02/07/2023]
Abstract
AIMS The CHHiP (Conventional or Hypofractionated High-dose Intensity Modulated Radiotherapy In Prostate Cancer; CRUK/06/016) trial investigated hypofractionated radiotherapy for localised prostate cancer. Forward- (FP) or inverse-planned (IP) intensity-modulated techniques were permitted. Dose-volume histogram and toxicity data were compared to explore the effects of planning method. MATERIALS AND METHODS In total, 337 participants with intermediate-risk disease and prospectively collected toxicity data were included. Patients were matched on prostate and rectum/bladder volumes and on radiotherapy dose for toxicity comparisons. The primary outcome was grade 2 or higher Radiation Therapy Oncology Group (RTOG) bowel or bladder toxicity at 2 years. RESULTS IP patients had smaller volumes of rectum irradiated to 50-70 Gy (P < 0.001); FP patients had smaller volumes of bladder irradiated to 74 Gy (P = 0.001). Acute grade 2 + bowel toxicity was worse with FP (27/53 [52%]; 11/53 [21%] IP; P = 0.0002); with no significant differences in acute urinary toxicity. At 2 years, RTOG grade 2 + bowel toxicity rates were FP 0/53 and IP 2/53 and RTOG grade 2 + bladder rates were FP 0/54 and IP 1/57. CONCLUSIONS Significant differences were found between dose-volume histograms from FP and IP methods. IP may result in small reductions in acute bowel toxicity but both techniques were associated with low rates of late radiotherapy side-effects.
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[Moderate or extreme hypofractionation and localized prostate cancer: The times are changing]. Cancer Radiother 2019; 23:503-509. [PMID: 31471253 DOI: 10.1016/j.canrad.2019.07.139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 02/07/2023]
Abstract
There are many treatment options for localized prostate cancers, including active surveillance, brachytherapy, external beam radiotherapy, and radical prostatectomy. Quality of life remains a primary objective in the absence of superiority of one strategy over another in terms of specific survival with similar long-term biochemical control rates. Despite a significant decrease in digestive and urinary toxicities thanks to IMRT and IGRT, external radiotherapy remains a treatment that lasts approximately 2 months or 1.5 months, when combined with a brachytherapy boost. Given the specific radiosensitivity of this tumor, several randomized studies have shown that a hypofractionated scheme is not inferior in terms of biochemical control and toxicities, allowing to divide the number of fractions by a factor 2 to 8. Given that SBRT becomes a validated therapeutic option for a selected population of patients with localized prostate cancer, extreme hypofractionation is becoming a strong challenger of conventional external radiotherapy or brachytherapy.
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Ferella L, Limoncin E, Vittorini F, Chalaszczyk A, Sorce C, Grimaldi G, Franzese P, Ruggieri V, Varrassi E, Di Staso M, Gimenez De Lorenzo R, Marampon F, Tombolini V, Masciocchi C, Gravina GL. Are we ready for a paradigm shift from high-dose conventional to moderate hypofractionated radiotherapy in intermediate-high risk prostate cancer? A systematic review of randomized controlled trials with trial sequential analysis. Crit Rev Oncol Hematol 2019; 139:75-82. [DOI: 10.1016/j.critrevonc.2019.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 03/25/2019] [Accepted: 04/13/2019] [Indexed: 10/26/2022] Open
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Martin SE, Begun EM, Samir E, Azaiza MT, Allegro S, Abdelhady M. Incidence and Morbidity of Radiation-Induced Hemorrhagic Cystitis in Prostate Cancer. Urology 2019; 131:190-195. [PMID: 31201826 DOI: 10.1016/j.urology.2019.05.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/30/2019] [Accepted: 05/30/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine if reported incidence rates of hemorrhagic cystitis after radiation therapy for prostate cancer are accurate, to investigate the effect of different radiation modalities on the development of hemorrhagic cystitis and to assess its morbidity and treatment. MATERIALS AND METHODS A retrospective chart review was completed of 709 patients at 2 Detroit Medical Center hospitals who underwent radiation therapy for prostate cancer between January 2000 and September 2015. In patients who developed hemorrhagic cystitis, we analyzed the incidence, radiation modality, morbidity, treatment, and complications. RESULTS The incidence rate of hemorrhagic cystitis after radiation for prostate cancer was 11.1%. There was no significant difference between external beam and intensity-modulated radiation therapy and the development of hemorrhagic cystitis (P = .18). Patients developed hemorrhagic cystitis an average of 79.1 months (4-230 months) after radiation. The average number of admissions was 2.5 (1-9) with an average length of stay of 7.6 days (1-42 days). Fifty-two percent of patients required blood transfusion with an average of 4.3 units transfused per patient (1-33U). The most common treatment was cystoscopy with fulguration/clot evacuation in 86% of patients. Complications included urinary tract infection, acute kidney injury, urosepsis, and even death. CONCLUSION The incidence of hemorrhagic cystitis following radiation therapy for prostate cancer is under-reported in the literature. Hemorrhagic cystitis is associated with high morbidity and complications for patients, requiring multiple hospitalizations, blood transfusions, and procedures. Advances in radiation have not significantly reduced the risk of developing hemorrhagic cystitis.
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Affiliation(s)
- Sarah E Martin
- Detroit Medical Center, Department of Urology, Detroit, MI.
| | - Evan M Begun
- Detroit Medical Center, Department of Urology, Detroit, MI
| | | | | | - Steven Allegro
- Detroit Medical Center, Department of Urology, Detroit, MI
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Patient-reported Urinary, Bowel, and Sexual Function After Hypofractionated Intensity-modulated Radiation Therapy for Prostate Cancer: Results From a Randomized Trial. Am J Clin Oncol 2019; 41:558-567. [PMID: 27635624 DOI: 10.1097/coc.0000000000000325] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Hypofractionated prostate radiotherapy may increase biologically effective dose delivered while shortening treatment duration, but information on patient-reported urinary, bowel, and sexual function after dose-escalated hypofractionated radiotherapy is limited. We report patient-reported outcomes (PROs) from a randomized trial comparing hypofractionated and conventional prostate radiotherapy. METHODS Men with localized prostate cancer were enrolled in a trial that randomized men to either conventionally fractionated intensity-modulated radiation therapy (CIMRT, 75.6 Gy in 1.8 Gy fractions) or to dose-escalated hypofractionated IMRT (HIMRT, 72 Gy in 2.4 Gy fractions). Questionnaires assessing urinary, bowel, and sexual function were completed pretreatment and at 2, 3, 4, and 5 years after treatment. RESULTS Of 203 eligible patients, 185 were evaluable for PROs. A total of 173 completed the pretreatment questionnaire (82 CIMRT, 91 HIMRT) and 102 completed the 2-year questionnaire (46 CIMRT, 56 HIMRT). Patients who completed PROs were similar to those who did not complete PROs (all P>0.05). Patient characteristics, clinical characteristics, and baseline symptoms were well balanced between the treatment arms (all P>0.05). There was no difference in patient-reported bowel (urgency, control, frequency, or blood per rectum), urinary (dysuria, hematuria, nocturia, leakage), or sexual symptoms (erections firm enough for intercourse) between treatment arms at 2, 3, 4, and 5 years after treatment (all P>0.01). Concordance between physician-assessed toxicity and PROs varied across urinary and bowel domains. DISCUSSION We did not detect an increase in patient-reported urinary, bowel, and sexual symptom burden after dose-escalated intensity-modulated prostate radiation therapy using a moderate hypofractionation regimen (72 Gy in 2.4 Gy fractions) compared with conventionally fractionated radiation.
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Villaggi E, Hernandez V, Fusella M, Moretti E, Russo S, Vaccara EML, Nardiello B, Esposito M, Saez J, Cilla S, Marino C, Stasi M, Mancosu P. Plan quality improvement by DVH sharing and planner's experience: Results of a SBRT multicentric planning study on prostate. Phys Med 2019; 62:73-82. [PMID: 31153401 DOI: 10.1016/j.ejmp.2019.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/12/2019] [Accepted: 05/02/2019] [Indexed: 01/31/2023] Open
Abstract
PURPOSE To evaluate, in a multi-institutional context, the role of Dose Volume Histogram (DVH) sharing in order to achieve higher plan quality, to harmonize prostate Stereotactic Body Radiation Therapy (SBRT) plans and to assess if the planner's experience in SBRT could lead to lower dose at organs at risk (OARs). METHODS During the first phase five patients enrolled for prostate SBRT were planned by multiple physicists according to common protocol. The prescription dose was 35 Gy in 5 fractions. Dosimetric parameters, modulation index (MIt), plan parameters, and planner experience level (EL) were statistically analyzed. During the second phase median DVHs from all centers were shared and physicists replanned one patient of the five, aiming at inter-planner harmonization and further OARs sparing. Data were summarized by Spearman-correlogram (p < 0.05) and boxplots. The Kruskal-Wallis test was used to compare the re-plans to the original plans. RESULTS Seventy-eight SBRT plans from 13 centers were evaluated. EL correlated with modulation of plan parameters and reduction of OARs doses, such as volume receiving 28 Gy of rectum (rectum-V28Gy), rectum-V32Gy, and bladder-V30Gy. The re-plans showed significant reduced variability in rectum-V28Gy and increased PTV dose homogeneity. No significant difference in plan complexity metrics and plan parameters between plans and re-plans were obtained. CONCLUSIONS Planner's experience in prostate SBRT was correlated with dosimetric parameters. Sharing median DVHs reduced variability among centers whilst keeping the same level of plan complexity. SBRT planning skills can benefit from a replanning phase after sharing DVHs from multiple centers, improving plan quality and concordance among centers.
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Affiliation(s)
- Elena Villaggi
- Medical Physics Unit, Azienda Unità Sanitaria Locale di Piacenza, Italy.
| | - Victor Hernandez
- Hospital Universitari Sant Joan de Reus, Department of Medical Physics, Tarragona, Spain
| | - Marco Fusella
- Medical Physics Department, Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
| | - Eugenia Moretti
- Department of Medical Physics, Azienda Sanitaria Universitaria Integrata di Udine, Italy
| | - Serenella Russo
- Medical Physics Unit, Azienda USL Toscana Centro, Firenze I-50012, Italy
| | | | | | - Marco Esposito
- Medical Physics Unit, Azienda USL Toscana Centro, Firenze I-50012, Italy
| | - Jordi Saez
- Hospital Clinic de Barcelona, Department of Radiation Oncology, Barcelona, Spain
| | - Savino Cilla
- Medical Physics Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Campobasso, Italy
| | | | - Michele Stasi
- Department of Medical Physics, Azienda Ospedaliera Ordine Mauriziano di Torino, Turin, Italy
| | - Pietro Mancosu
- Medical Physics Unit of Radiation Oncology Dept., Humanitas Research Hospital, Milano, Italy
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Proton versus photon-based radiation therapy for prostate cancer: emerging evidence and considerations in the era of value-based cancer care. Prostate Cancer Prostatic Dis 2019; 22:509-521. [PMID: 30967625 DOI: 10.1038/s41391-019-0140-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/30/2019] [Accepted: 02/25/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Advances in radiation technology have transformed treatment options for patients with localized prostate cancer. The evolution of three-dimensional conformal radiation therapy and intensity-modulated radiation therapy (IMRT) have allowed physicians to spare surrounding normal organs and reduce adverse effects. The introduction of proton beam technology and its physical advantage of depositing its energy in tissue at the end-of-range maximum may potentially spare critical organs such as the bladder and rectum in prostate cancer patients. Data thus far are limited to large, observational studies that have not yet demonstrated a definite benefit of protons over conventional treatment with IMRT. The cost of proton beam treatment adds to the controversy within the field. METHODS We performed an extensive literature review for all proton treatment-related prostate cancer studies. We discuss the history of proton beam technology, as well as its role in the treatment of prostate cancer, associated controversies, novel technology trends, a discussion of cost-effectiveness, and an overview of the ongoing modern large prospective studies that aim to resolve the debate between protons and photons for prostate cancer. RESULTS Present data have demonstrated that proton beam therapy is safe and effective compared with the standard treatment options for prostate cancer. While dosimetric studies suggest lower whole-body radiation dose and a theoretically higher relative biological effectiveness in prostate cancer compared with photons, no studies have demonstrated a clear benefit with protons. CONCLUSIONS Evolving trends in proton treatment delivery and proton center business models are helping to reduce costs. Introduction of existing technology into proton delivery allows further control of organ motion and addressing organs-at-risk. Finally, the much-awaited contemporary studies comparing photon with proton-based treatments, with primary endpoints of patient-reported quality-of-life, will help us understand the differences between proton and photon-based treatments for prostate cancer in the modern era.
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Murthy V, Sinha S, Kannan S, Datta D, Das R, Bakshi G, Prakash G, Krishnatry R. Safety of Prostate Stereotactic Body Radiation Therapy after Transurethral Resection of Prostate (TURP): A Propensity Score Matched Pair Analysis. Pract Radiat Oncol 2019; 9:347-353. [PMID: 30978467 DOI: 10.1016/j.prro.2019.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 02/03/2023]
Abstract
PURPOSE To determine the genitourinary (GU) toxicity outcomes in prostate cancer patients treated with stereotactic body radiation therapy (SBRT) who have undergone a prior transurethral resection of prostate (TURP) and compare it to a similar non-TURP cohort. MATERIALS AND METHODS Fifty prostate cancer patients who had undergone a single TURP, had a good baseline urinary function, and had been subsequently treated with SBRT were chosen from a prospectively maintained database. These were propensity score matched to a similar non-TURP cohort treated during the same period. Matching was done for diabetes mellitus and volume of radiation therapy. Acute GU and late GU toxicity were scored using the Radiation Therapy Oncology Group (RTOG) criteria. Stricture and incontinence were scored using Common Terminology for Common Adverse Events version 4.0. RESULTS Median follow-up for the entire cohort was 26 months (non-TURP vs TURP, 30 months vs 22 months, P = .34). The median duration between TURP and start of SBRT was 10 months. There was no significant difference between non-TURP versus TURP cohort in terms of RTOG acute GU toxicities grade ≥2 (8% vs 6%, P = .45), RTOG late GU toxicities grade ≥2 (8% vs 12%, P = .10), stricture rates (4% vs 6%, P = .64), and incontinence rates (0% vs 4%, P = .15). The median duration of time to late toxicity was 16 months vs 10 months (P = .12) in non-TURP and TURP cohort, respectively. CONCLUSIONS Although modestly increased as compared with non-TURP patients, GU toxicities remains low with SBRT in post-TURP patients. SBRT can be safely performed in carefully selected post-TURP prostate cancer patients.
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Affiliation(s)
- Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India.
| | - Shwetabh Sinha
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India
| | - Sadhana Kannan
- Department of Biostatistics, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Homi Bhabha National Institute, Kharghar, Navi Mumbai, India
| | - Debanjali Datta
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India
| | - Rabi Das
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India
| | - Ganesh Bakshi
- Division of Urology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India
| | - Gagan Prakash
- Division of Urology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India
| | - Rahul Krishnatry
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, India
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