HIGH DOSE RADIATION DELIVERED BY INTENSITY MODULATED CONFORMAL RADIOTHERAPY IMPROVES THE OUTCOME OF LOCALIZED PROSTATE CANCER
|
|
- Candace Cannon
- 5 years ago
- Views:
Transcription
1 /01/ /0 THE JOURNAL OF UROLOGY Vol. 166, , September 2001 Copyright 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC. Printed in U.S.A. HIGH DOSE RADIATION DELIVERED BY INTENSITY MODULATED CONFORMAL RADIOTHERAPY IMPROVES THE OUTCOME OF LOCALIZED PROSTATE CANCER MICHAEL J. ZELEFSKY,* ZVI FUKS, MARGIE HUNT, HENRY J. LEE, DANNA LOMBARDI, CLIFTON C. LING, VICTOR E. REUTER, E. S. VENKATRAMAN AND STEVEN A. LEIBEL From the Departments of Radiation Oncology, Medical Physics, Pathology and Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York ABSTRACT Purpose: We present the long-term outcome and tolerance of 3-dimensional (D) conformal and intensity modulated radiation therapy for localized prostate cancer. Materials and Methods: Between October 1988 and December 1998, 1,100 patients with clinical stages T1c-T3 prostate cancer were treated with 3-D conformal or intensity modulated radiation therapy. Patients were categorized into prognostic risk groups based on pretreatment prostate specific antigen (PSA), Gleason score and clinical stage. Sextant biopsies were performed 2.5 years or greater after treatment to assess local control. PSA relapse was defined according to the consensus guidelines of the American Society for Therapeutic Radiation Oncology. Late toxicity was classified according to the Radiation Therapy Oncology Group morbidity grading scale. Median followup was 60 months. Results: At 5 years the PSA relapse-free survival rate in patients at favorable, intermediate and unfavorable risk was 85% (95% confidence interval [CI] 4), 58% (95% CI 6) and 38% (95% CI 6), respectively (p 0.001). Radiation dose was the most powerful variable impacting PSA relapse-free survival in each prognostic risk group. The 5-year actuarial PSA relapse-free survival rate for patients at favorable risk who received 64.8 to 70.2 Gy. was 77% (95% CI 8) compared to 90% (95% CI 8) for those treated with 75.6 to 86.4 Gy. (p 0.05). The corresponding rates were 50% (95% CI 8) versus 70% (95% CI 6) in intermediate risk cases (p 0.001), and 21% (95% CI 8) versus 47% (95% CI 6) in unfavorable risk cases (p 0.002). Only 4 of 41 patients (10%) who received 81 Gy. had a positive biopsy 2.5 years or greater after treatment compared with 27 of 119 (23%) after 75.6, 23 of 68 (34%) after 70.2 and 13 of 24 (54%) after 64.8 Gy. The incidence of toxicity after 3-D conformal radiation therapy was dose dependent. The 5-year actuarial rate of grade 2 rectal toxicity in patients who received 75.6 Gy. or greater was 14% (95% CI 2) compared with 5% (95% CI 2) in those treated at lower dose levels (p 0.001). Treatment with intensity modulated radiation therapy significantly decreased the incidence of late grade 2 rectal toxicity since the 3-year actuarial incidence in 189 cases managed by 81 Gy. was 2% (95% CI 2) compared with 14% (95% CI 2) in 61 managed by the same dose of 3-D conformal radiation therapy (p 0.005). The 5-year actuarial rate of grade 2 urinary toxicity in patients who received 75.6 Gy. or greater 3-D conformal radiation therapy was 13% compared with 4% in those treated up to lower doses (p 0.001). Intensity modulated radiation therapy did not affect the incidence of urinary toxicity. Conclusions: Sophisticated conformal radiotherapy techniques with high dose 3-D conformal and intensity modulated radiation therapy improve the biochemical outcome in patients with favorable, intermediate and unfavorable risk prostate cancer. Intensity modulated radiation therapy is associated with minimal rectal and bladder toxicity, and, hence, represents the treatment delivery approach with the most favorable risk-to-benefit ratio. KEY WORDS: prostate; prostatic neoplasms; radiotherapy, conformal; risk; radiation dosage The frequent persistence of local residual tumor after external beam irradiation for prostate cancer has been a matter of concern. Recent studies have indicated prostate specific antigen (PSA) relapse-free survival in only 65% of patients with stages T1-T2 disease. 1 Biopsy proved local recurrence has been identified in 23% to 65% of patients in whom stages Accepted for publication April 27, Supported in part by Grant CA from the National Cancer Institute, Department of Health and Human Services, Bethesda, Maryland. * Requests for reprints: Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, New York T1-T3 disease was treated with conventional radiotherapy doses of 70 Gy. or less. 2 5 While the probability of eradicating prostate cancer increases with increasing dose, 6, 7 classic radiotherapy techniques have failed at doses exceeding 70 Gy. because of high rates of severe rectal and bladder toxicity. 8 Three-dimensional (D) conformal and intensity modulated radiation therapy were developed to address these issues. 9, 10 Three-D conformal and intensity modulated radiation therapy planning use advanced imaging for tumor and normal organ segmentation, new algorithms for dose calculations and computer aided optimization to generate treatment plans that conform the prescribed dose to the prostate, while 876
2 HIGH DOSE RADIATION IMPROVES OUTCOME OF PROSTATE CANCER 877 attempting to exclude maximally the adjacent normal organs. This planning has resulted in a significant decrease in rectal and bladder toxicity, enabling tumor dose escalation to improve local control. 11, 12 Based on these principles and techniques in October 1998 a dose escalation study in patients with localized prostate cancer was initiated at our institution. 13 In a preliminary study of 743 patients we showed the feasibility, safety and preliminary observations of the outcome of dose escalation with 3-D conformal radiation therapy to 81 Gy. 12, 14 However, it became apparent that escalation of the radiation dose to 81 Gy. or greater required enhanced conformality, such as that provided by intensity modulated radiation therapy, to decrease the risk of toxicity. We present an update on the long-term outcome in 1,100 patients treated with 3-D conformal and intensity modulated radiation therapy. To our knowledge we report for the first time preliminary toxicity findings of 86.4 Gy. The data stress the need for high radiation doses for improving the biochemical outcome in prostate cancer with radiation and indicate that intensity modulated radiation therapy represents a safe method for delivering the dose levels required to achieve the maximal rate of local tumor control. MATERIALS AND METHODS An institutional review board approved phases I and II study was initiated in October 1988 to assess the toxicity of dose escalation with 3-D conformal and intensity modulated radiation therapy in prostate cancer. The radiation dose was increased from 64.8 to 86.4 Gy. by increments of 5.4 Gy. in consecutive groups of patients. The 1,100 patients with clinically localized prostate cancer accumulated through December 1998 included 96 (9%) treated with 64.8, 269 (24%) treated with 70.2, 445 (40%) treated with 75.6, 250 (23%) treated with 81 and 40 (4%) treated with 86.4 Gy. Median patient age was 69 years (range 46 to 86). Pretreatment diagnostic evaluations were performed as previously described American Joint Commission on Cancer 1997 clinical stage 16 was T1c in 284 patients (26%), T2a in 354 (32%), T2b in 200 (18%) and T3 in 262 (24%). All patients were histologically diagnosed with prostatic adenocarcinoma classified according to the Gleason grading system. 17 Serum PSA concentration was determined by radioimmunoassay (Tosoh, Foster City, California) with a normal range of 4 ng./ml. or less and a minimal detectable level of 0.02 ng./ml. The techniques for treatment planning and delivering 3-D conformal and intensity modulated radiation therapy have been previously described in detail. 10, 11, 13 15, Three-D conformal radiation therapy was administered in 810 patients to a dose of 64.8 to 75.6 Gy. and the initial 61 received 81 Gy. The subsequent 229 patients received 81 and 86.4 Gy. intensity modulated radiation therapy. Treatment was delivered with 15 mv. x-rays in daily fractions of 1.8 Gy. The radiation dose was prescribed as a minimum tumor dose to the whole prostate and seminal vesicles with a 1 cm. margin except at the prostatorectal interface, where a 0.6 cm. margin was used. A total of 427 patients (39%) with a large volume prostate were given a 3-month course of neoadjuvant complete androgen deprivation to decrease prostate size. 21, 22 This treatment was discontinued at the completion of radiotherapy. Followup evaluations after treatment were performed at 3 to 6-month intervals for 5 years and yearly thereafter. Median followup was 60 months (range 24 to 142) and 339 patients (31%) were followed 7 years or longer. Median followup of patients treated up to 81, 75.6 and 70.2 Gy. or less was 40, 72 and 95 months, respectively. Combined median followup for the high dose group that received 75.6 Gy. or greater was 69 months. Late toxicity was scored according to the Radiation Therapy Oncology Group morbidity grading scale, including grade 1 minimal side effects not requiring medication for symptom control, grade 2 symptoms requiring medication, grade 3 complications requiring minor surgical intervention, such as transurethral resection, laser coagulation or blood transfusion, and grade 4 hospitalization and major intervention. Disease status was determined at analysis in November PSA relapse was defined as 3 successive PSA elevations after a posttreatment nadir was achieved. 24 The date of failure was considered the midpoint between the last nonincreasing and first increasing PSA value. 1 None of the patients received post-irradiation androgen deprivation or other anti-cancer therapy before documentation of a PSA relapse. To assess the local tumor response to treatment sextant prostate biopsies were performed in patients followed 2.5 years or longer (median 35 months) after the completion of 3-D conformal/intensity modulated radiation therapy. An ongoing attempt was made to biopsy all eligible cases. Of 586 surviving patients meeting the time requirement 252 (43%) underwent this procedure. The remaining patients did not undergo biopsy because of patient or physician refusal, or medical contraindications. The histological diagnosis was classified as positive prostatic adenocarcinoma without typical radiation induced changes, negative no evidence of carcinoma and severe treatment effects such as residual tumor cells showing radiation changes. Histological features of the latter category have been described previously. 25, 26 Since long-term followup has indicated that the histological pattern defined as severe treatment effects does not indicate active relapsing tumor 4, and the PSA outcome in our patients with these changes was similar to that in patients with negative biopsy specimens (data not shown), those with these features were included in the negative biopsy group. Patients were classified into prognostic risk groups according to pretreatment variables that independently affected PSA relapse-free survival. 14 Parameters used to characterize the risk groups included pretreatment PSA 10 ng./ml. or less, stages T1-2 disease and Gleason score 6 or greater (p 0.01). When all 3 indicators were present, the case was classified in a favorable prognosis group. An increase in the value of 1 and 2 or more indicators classified the case in an intermediate and an unfavorable prognosis group, respectively. The distribution of PSA relapse-free survival time was calculated according to the Kaplan-Meier product-limit method. 27 Differences in time adjusted incidence rates were evaluated using the Mantel log rank test for censored data. 28 The relative impact of covariates that affect time adjusted outcome was determined using the stepwise Cox proportional hazards regression model. 29 RESULTS Therapeutic outcome by PSA relapse-free survival. Figure 1 shows the PSA relapse-free survival rate by prognostic risk group. The 5-year actuarial PSA relapse-free survival was 85% (95% confidence interval [CI] 4) for the 279 patients at favorable, 58% (95% CI 6) for the 405 at intermediate and 38% (95% CI 6) for the 416 at unfavorable risk. In addition to pretreatment PSA, Gleason score and T stage, the radiation dose of 70.2 or less versus 75.6 Gy. or greater was a significant independent variable affecting PSA outcome after each type of radiotherapy (table 1). In favorable and intermediate risk cases a significant improvement in PSA outcome was observed after 75.6 Gy. or greater were given compared with lower doses (fig. 2). At analysis we detected no improvement in PSA relapse-free survival for patients at favorable and intermediate risk treated with 81 versus 75.6 Gy. However, in unfavorable risk cases 81 Gy. was associated with improved PSA relapse-free survival compared with 75.6 Gy. and lower doses. In the latter group the 5-year PSA relapse-free survival rate for 81 Gy. was 67% (95% CI 4)
3 878 HIGH DOSE RADIATION IMPROVES OUTCOME OF PROSTATE CANCER FIG. 1. Kaplan-Meier actuarial probability of achieving PSA relapse-free survival in favorable, intermediate and unfavorable prognostic risk subgroups. At 5 years 77, 79 and 41 patients were at risk, respectively. Values in parentheses indicate number of patients per subgroup. TABLE 1. Cox regression analysis of variables affecting PSA relapse-free survival p Value Mean Regression Coefficient ( SE) Regression Coefficient Exponent PSA 10 ng./ml. or less Stage less than T Dose 75.6 Gy. or greater Gleason score 6 or less Androgen deprivation Not significant versus 43% (95% CI 4) for 75.6 and 21% (95% CI 4) for 64.8 to 70.2 Gy. (fig. 3). Therapeutic outcome by post-irradiation biopsy findings. Because radiation was confined to the prostate only, it is reasonable to assume that improved PSA relapse-free survival according to dose may be largely attributable to improved local control. To explore further this notion sextant prostate biopsies were performed at an interval of 2.5 years or greater after radiotherapy in 252 cases. Overall only 4 of 41 patients (10%) who received 81 Gy. had positive biopsy indicating residual or relapsing disease compared with 27 of 119 (23%) after 75.6, 23 of 68 (34%) after 70.2 and 13 of 24 (54%) after 64.8 Gy. (75.6 or greater versus less than 75.6 Gy. p and 81 versus 75.6 Gy. p 0.07). Table 2 shows the relationships among biopsy findings, prognostic risk groups and dose. Within each risk group a clear trend was observed for a decreasing incidence of positive biopsy with increasing dose. In addition, in each dose bin the rate of positive biopsy increased as the prognostic group became less favorable except for 81 Gy., in which there was no apparent difference in biopsy outcome among the 3 risk groups. These data indicate that the more aggressive biological phenotypes of prostate tumor cells are more radioresistant. However, even for the more favorable phenotypes conventional radiation doses of 65 to 70 Gy. are ineffective for local tumor control. It appears that doses on the order of 81 Gy. may be necessary to achieve maximal local cure. Whether 86.4 Gy. or higher doses would further decrease the risk of local relapse requires further investigation. Late toxicity. The critical attribute of the 3-D conformal paradigm is that it delivers high radiation doses with a minimal concomitant risk of normal tissue toxicity. Table 3 lists the rate of late complications in our cohort of patients. In 12 patients (1%) grade 3 rectal bleeding required 1 or more transfusions, or 1 or more laser cauterization procedures. In a patient (0.09%) with a history of inflammatory bowel disease who was treated with 64.8 Gy. grade 4 rectal toxicity developed. Figure 4 shows the actuarial incidence of rectal toxicity for each dose level. The overall 5-year actuarial likelihood of grade 2 rectal toxicity was 11% (95% CI 2). Doses of 75.6 Gy. or greater 3-D conformal radiation therapy were associated with a 14% (95% CI 2) rate of late grade 2 rectal toxicity compared with 5% (95% CI 2) for lower dose levels (p 0.001). Perhaps the most important observation is that intensity modulated radiation therapy significantly decreased the incidence of late rectal toxicity in patients who received 81 Gy. The overall rate of late grade 2 and 3 rectal toxicity in these cases was 2% and 0.5% compared with 12% and 2%, respectively, in those managed by 3-D conformal radiation therapy (p 0.01). The 3-year actuarial incidence of late grade 2 rectal toxicity in 189 patients treated with 81 Gy. intensity modulated radiation therapy was 2% (95% CI 2) compared with 14% (95% CI 2) in 61 treated at the same dose level with 3-D conformal radiation therapy (p 0.005). Of 17 patients (1.5%) grade 3 urethral stricture required dilation in 15 and grade 3 hematuria developed in 2. The 5-year actuarial rate of grade 2 urinary toxicity was 10%, including 13% (95% CI 2) after 75.6 Gy. or greater and 4% (95% CI 2) after lower dose levels (p 0.001). The rates for 3-D conformal and intensity modulated radiation therapy did not differ significantly (p 0.32). Improved tolerance, as indicated by decreased rectal bleeding, associated with intensity modulated radiation therapy enabled the escalation of treatment dose to 86.4 Gy, representing the latest arm of the phase I dose escalation study. We have followed 40 patients treated at the 86.4 Gy. level with intensity modulated radiation therapy a median of 31 months (range 24 to 40). To date 2 patients (5%) have had late grade 2 rectal and 8 (20%) have had grade 2 urinary toxicity. No grade 3 or higher toxicity has been observed. Together these data further underscore the safety of dose escalation and improved treatment delivery of intensity modulated radiation therapy. DISCUSSION These data indicate that higher than conventional radiation doses are associated with improved local tumor control on posttreatment biopsy as well as with freedom from PSA biochemical relapse. Patients at favorable, intermediate and unfavorable risk benefited from the increased dose. In previous studies we did not show that dose escalation affected the outcome of favorable risk cases. 14 With more patients and a longer observation interval we have now shown improved PSA relapse-free survival in those at favorable risk who received 75.6 Gy. or greater with a 5-year PSA relapse-free survival rate of 90%. This outcome is consistent with that in series of similar patients treated with radical prostatectomy. 30, 31 An improved PSA outcome is also now apparent in unfavorable risk cases managed by 81 Gy. versus those managed by lower doses. Furthermore, our post-irradiation biopsy findings indicate that a dose of 81 Gy. is associated with the lowest incidence of positive posttreatment biopsy in patients in each prognostic risk group. Previous studies have also shown improved PSA outcome with escalated doses of external beam radiotherapy, although none has reached the high dose levels that we report. Hanks et al observed that increasing the radiation dose from 73 to 78 Gy. achieved 22% to 40% incremental improvement in the 5-year PSA relapse-free survival rate in various subgroups of patients. 32 However, a benefit to dose escalation was not identified in patients with favorable risk features and in those with unfavorable risk features with PSA 20 ng./ml. or greater. Pollack and Zagars observed that the 3-year PSA relapse-free survival rate after doses of 67 or less, greater than 67 to 77 and greater than 77 Gy. were 61%, 74%
4 HIGH DOSE RADIATION IMPROVES OUTCOME OF PROSTATE CANCER 879 FIG. 2. Kaplan-Meier actuarial probability of achieving PSA relapse-free survival according to dose. A, in favorable high and low dose groups at 3 to 5 years 97, 66 and 35, and 70, 58 and 43 patients were at risk, respectively. B, in intermediate high and low dose groups at 3 to 5 years 109, 64 and 33, and 79, 66 and 46 patients were at risk, respectively. Values in parentheses indicate number of patients per subgroup. TABLE 3. Incidence of late treatment related toxicity after 3-D conformational radiation therapy in 1,100 patients No. Urinary (%) No. Rectal (%) None 798 (72.5) 807 (73) Grade: (16) 174 (16) (10) 106 (10) 3 17 (1.5) 12 (1) FIG. 3. Kaplan-Meier actuarial probability of achieving PSA relapse-free survival in unfavorable prognostic risk subgroups according to 3 dose levels. At 3 to 5 years at 81 Gy. 23, 15 and 9, at 75 Gy. 86, 45 and 18, and at 64.8 to 70.2 Gy. 45, 31 and 15 patients were at risk, respectively. Values in parentheses indicate number of patients per subgroup. TABLE 2. Incidence of positive posttreatment prostate biopsy according to prognostic risk group in 252 patients Dose (Gy.) No./Total No. (%) Favorable Intermediate Unfavorable 81 0/7 3/18 (17) 1/16 (6) /18 (11) 8/44 (19) 17/57 (30) /20 (15) 5/21 (24) 15/27 (56) /3 (33) 6/13 (46) 6/8 (75) Totals 6/48 (13) 22/96 (23) 39/108 (37) FIG. 4. Kaplan-Meier actuarial probability of grade 2 or greater late rectal toxicity, that is rectal bleeding, according to dose. At 3 to 5 years at 81 Gy. conventional 3-D and intensity modulated radiation therapy (IMRT) 50, 42 and 33, and 27.3 and 0 patients were at risk, and at 75 and 64.8 to 70.2 Gy. 309, 239 and 142, and 318, 295 and 262 patients were at risk, respectively. At 81 Gy. intensity modulated radiation therapy was associated with lowest incidence of late rectal toxicity. and 96%, respectively. 7 More recently, Pollack et al presented preliminary data on a randomized trial comparing patients treated at the 70 Gy. level with a 4-field technique with those receiving an additional 8 Gy. to a total of 78 Gy. using a 6-field conformal boost. 33 To date a significant improvement in PSA relapse-free survival has been noted in patients with stages T1-T2 disease and PSA greater than 10 ng./ml. who received 78 Gy. Although our dose escalation study was nonrandomized, the data provide additional evidence that higher doses are required to achieve a maximal probability of local tumor cure regardless of the biological phenotype of the tumor. These data further support the notion that high dose radiotherapy given with conformal techniques, such as 3-D conformal and intensity modulated radiation therapy, represents a new gold standard for the optimal outcome of managing localized prostate cancer. In our patients we did not note that androgen ablation administered with either type of radiotherapy further enhanced the biochemical outcome (table 1). However, its administration in the neoadjuvant setting, as in our cases, may not be as effective as in the adjuvant setting. Combining adjuvant androgen deprivation with standard doses of radiotherapy has demonstrated a significant benefit for high grade, locally advanced disease. 35, 36 To our knowledge whether androgen ablation would obviate the need for dose escalation or androgen deprivation may be unnecessary when higher dose levels are administered remains unknown. In some cases combining the 2 approaches may further improve outcome. Clinical trials are needed to resolve these important questions.
5 880 HIGH DOSE RADIATION IMPROVES OUTCOME OF PROSTATE CANCER The success of dose escalation for prostate cancer may be directly attributed to the emergence of advanced, computer aided technologies that enable the delivery of heretofore unprecedented radiation doses with minimal toxicity. The risk of radiation induced complications to the rectum depends on the dose and on the rectal volume included in the high dose region. 37 The critical contribution of 3-D conformal and intensity modulated radiation therapy in the modern management of prostate cancer appears to be reduction of the volume of the anterior rectal wall included in the planned target volume carried to high radiation doses. 20 Based on our dose escalation studies we have recommended that the rectal dose should be limited to a maximum of 75.6 Gy. delivered to no more than 30% of the rectal wall. 21, 22 With similar dose volume restrictions others have also observed a low rate of rectal complications. 38 The advantage of intensity modulated over 3-D conformal radiation therapy is that this goal may be achieved with tumor doses of 81 Gy. or greater. In fact, the development of intensity modulated radiation therapy was required to enable safe escalation of the dose to 86.4 Gy. In conclusion, low radiation doses should no longer be considered adequate and patients should be appropriately counseled to seek treatment at centers with experience in the planning and delivery of high dose radiation, preferably by intensity modulated radiation therapy. REFERENCES 1. Shipley, W. U., Thames, H. D., Sandler, H. M. et al: Radiation therapy for clinically localized prostate cancer: a multiinstitutional pooled analysis. JAMA, 281: 1598, Scardino, P. T., Frankel, J. M., Wheeler, T. M. et al: The prognostic significance of post-irradiation biopsy results in patients with prostatic cancer. J Urol, 135: 510, Sewell, R. A., Braren, V. and Wilson, S. K.: Extended biopsy followup after full course radiation for resectable prostatic carcinoma. J Urol, 113: 371, Crook, J. M., Perry, G. A., Robertson, S. et al: Routine prostate biopsies following radiotherapy for prostate cancer: results for 226 patients. Urology, 45: 624, Laverdiere, J., Gomez, J. L., Cusan, L. et al: Beneficial effect of combination hormonal therapy administered prior and following external beam radiation therapy in localized prostate cancer. Int J Radiat Oncol Biol Phys, 37: 247, Hanks, G. E., Martz, K. L. and Diamond, J. J.: The effect of dose on local control of prostate cancer. Int J Radiat Oncol Biol Phys, 15: 1299, Pollack, A. and Zagars, G. K.: External beam radiotherapy doseresponse of prostate cancer. Int J Radiat Oncol Biol Phys, 39: 1011, Smit, W. G., Helle, P. A., van Putten, W. L. et al: Late radiation damage in prostate cancer patients treated by high dose external radiotherapy in relation to rectal dose. Int J Radiat Oncol Biol Phys, 18: 23, Leibel, S. A., Zelefsky, M. J., Kutcher, G. J. et al: The biological basis and clinical application of three-dimensional conformal external beam radiation therapy in carcinoma of the prostate. Semin Oncol, 21: 580, Zelefsky, M. J., Leibel, S. A., Kutcher, G. J. et al: Threedimensional conformal radiotherapy and dose escalation: where do we stand? Semin Radiat Oncol, 8: 107, Zelefsky, M. J., Leibel, S. A., Kutcher, G. J. et al: The feasibility of dose escalation with three-dimensional conformal radiotherapy in patients with prostatic carcinoma. Cancer J Sci Am, 1: 42, Zelefsky, M. J., Cowen, D., Fuks, Z. et al: Long term tolerance of high dose three dimensional conformal radiotherapy in patients with localized prostate cancer. Cancer, 85: 2460, Leibel, S. A., Zelefsky, M. J., Kutcher, G. J. et al: Threedimensional conformal radiation therapy in localized carcinoma of the prostate: Interim report of a phase I doseescalation study. J Urol, part 2, 152: 1792, Zelefsky, M. J., Leibel, S. A., Gaudin, P. B. et al: Dose escalation with three dimensional conformal radiation therapy affects the outcome in prostate cancer. Int J Radiat Oncol Biol Phys, 41: 491, Zelefsky, M. J., Fuks, Z., Wolfe, T. et al: Locally advanced prostatic cancer: long-term toxicity after three-dimensional conformal radiation therapy a dose-escalation study. Radiology, 209: 169, Fleming, I. D., Cooper, J. S., Henson, D. E. et al: Prostate. In: American Joint Committee on Cancer. Cancer Staging Manual, 5th ed. Philadelphia: Lippincott-Raven, p. 181, Gleason, D. F.: Histologic grading and clinical staging of prostatic carcinoma. In: Urologic Pathology: The Prostate. Edited by M. Tannenbaum. Philadelphia: Lea & Febiger, Chapt. 9, p. 171, Ling, C. C., Burman, C., Chui, C. S. et al: Conformal radiation treatment of prostate cancer using inversely planned intensity-modulated photon beams produced with dynamic multileaf collimation. Int J Radiat Oncol Biol Phys, 35: 721, Burman, C., Chui, C. S., Kutcher, G. J. et al: Planning, delivery, and quality assurance of intensity-modulated radiotherapy using dynamic multileaf collimator: a strategy for large-scale implementation for the treatment of carcinoma of the prostate. Int J Radiat Oncol Biol Phys, 39: 863, Zelefsky, M. J., Fuks, Z., Happersett, L. et al: Clinical experience with intensity modulated radiation therapy (IMRT) in prostate cancer. Radiother Oncol, 55: 241, Zelefsky, M. J., Leibel, S. A., Burman, C. M. et al: Neoadjuvant hormonal therapy improves the therapeutic ratio in patients with bulky prostatic cancer treated with three-dimensional conformal radiation therapy. Int J Radiat Oncol Biol Phys, 29: 755, Zelefsky, M. J. and Harrison, A.: Neoadjuvant androgen ablation prior to radiotherapy for prostate cancer: reducing the potential morbidity of therapy. Urology, suppl., 49: 38, Lawton, C. A., Won, M., Pilepich, M. V. et al: Long-term treatment sequelae following external beam irradiation for adenocarcinoma of the prostate: analysis of RTOG studies 7506 and Int J Radiat Oncol Biol Phys, 21: 935, Consensus statement: guidelines for PSA following radiation therapy. American Society for Therapeutic Radiology and Oncology Consensus Panel. Int J Radiat Oncol Biol Phys, 37: 1035, Crook, J. M., Bahdur, Y. A., Robertson, S. J. et al: Evaluation of radiation effect, tumor differentiation and prostate specific antigen staining in sequential prostate biopsies after external beam radiotherapy for patients with prostate carcinoma. Cancer, 79: 81, Gaudin, P. B., Zelefsky, M. J., Leibel, S. A. et al: Histopathologic effects of three dimensional conformal external beam radiation therapy on benign and malignant prostate tissues. Am J Surg Pathol, 23: 1021, Kaplan, E. L. and Meier, P.: Nonparametric estimation from incomplete observations. J Am Stat Assoc, 53: 457, Mantel, N.: Evaluation of survival data and two new rank order statistics arising in its consideration. Cancer Chemother Reports, 50: 163, Cox, D. R.: Regression models and life tables. J R Stat Soc, 34: series B, 187, Kupelian, P., Katcher, J., Levin, H. et al: External beam radiotherapy versus radical prostatectomy for clinical stage T1 2 prostate cancer: therapeutic implications of stratification by pretreatment PSA levels and biopsy Gleason scores. Cancer J Sci Am, 3: 78, D Amico, A. V., Whittington, R., Kaplan, I. et al: Equivalent biochemical failure-free survival after external beam radiation therapy or radical prostatectomy in patients with a pretreatment prostate specific antigen of 4 20 ng/ml. Int J Radiat Oncol Biol Phys, 37: 1053, Hanks, G. E., Hanlon, A. L., Pinover, W. H. et al: Dose selection for prostate cancer patients based on dose comparison and dose response studies. Int J Radiat Oncol Biol Phys, 46: 823, Pollack, A., Zagars, G. K., Smith, L. G. et al: Preliminary results of a randomized radiotherapy dose escalation study comparing 70 Gy to 78 Gy for prostate cancer. J Clin Oncol, 18: 3904, Lyons, J. A., Kupelian, P. A., Mohan, D. S. et al: Importance of high radiation doses (72 Gy or greater) in the treatment of stage T1 T3 adenocarcinoma of the prostate. Urology, 55: 85, Bolla, M., Gonzalez, D., Warde, P. et al: Improved survival in
6 HIGH DOSE RADIATION IMPROVES OUTCOME OF PROSTATE CANCER 881 patients with locally advanced prostate cancer treated with radiotherapy and goserelin. N Engl J Med, 337: 295, Pilepich, M. V., Caplan, R., Byhardt, R. W. et al: Phase III trial of androgen suppression using goserelin in unfavorable prognosis carcinoma of the prostate treated with definitive radiotherapy: report of Radiation Therapy Oncology Group Protocol J Clin Oncol, 15: 1013, Skwarchuk, M. W., Jackson, A., Zelefsky, M. J. et al: Late rectal toxicity after conformal radiotherapy of prostate cancer (I): multivariate analysis and dose-response. Int J Radiat Oncol Biol Phys, 47: 103, Storey, M. R., Pollack, A., Zagars, G. et al: Complications from radiotherapy dose escalation in prostate cancer: preliminary results of a randomized trial. Int J Radiat Oncol Biol Phys, 48: 635, 2000 EDITORIAL COMMENT Ten years ago the debate was framed by the question, radical prostatectomy or radiation? Now the debate must be extended to reflect developments in radiation oncology. Which type of radiation: brachytherapy or external? Three-D conformal or intensity modulated? Conventional dose, high dose or ultra high dose? These authors have long recommended radiation dose escalation and this study as well as others recently published appears to vindicate their approach. In the early 1990s they reacted to new data on PSA in followup and prostate re-biopsy showing that the outcome after conventional radiation therapy was far from optimal. Radiation oncologists had previously ascribed failure to bad disease and high rates of occult metastasis. However, re-biopsy data made it evident that local control was as great if not a greater issue and increasing the delivered dose to the prostate was the intuitive answer. Unfortunately radiation doses in excess of 72 Gy. cannot be given using conventional techniques without unacceptable morbidity. These authors were among the first to apply the new strategy of 3-D conformal radiation to decrease the volume of normal tissue irradiated and, thus, allow the dose to the prostate to be increased. Since then, they have been escalating the dose progressively in prospective studies and now they have data sufficiently mature to warrant close attention. The results seem to show that in all prognostic groups there is an advantage in terms of biochemical control to dose escalation beyond 75 Gy. This result is in keeping with and even goes beyond an interim report of a randomized trial comparing 70 with 78 Gy. 1 This trial shows in some subgroups a 5-year outcome advantage in the higher dose arm. The data presented are at first glance powerful but they are somewhat weakened by biases inherent in the use of American Society for Therapeutic Radiation Oncology criteria for PSA failure. These criteria mandate 3 successive increases before failure is considered, making outcome particularly sensitive to the duration of followup. 2 Such a bias is especially true in the low and intermediate prognosis subgroups, in which patients mostly experience a third increase 4 or more years after treatment, a time at which patients are often only monitored yearly. In this study median followup in the 81, 75.6 and less than 70.2 Gy. groups was 40, 72 and 95 months, respectively. While these differences are probably insufficient to erase the advantage of 75.6 Gy. over lower doses, they are of sufficient magnitude that we cannot conclude that 81 Gy. is definitely superior to 75.6 Gy. This distinction is important since doses of 75.6 Gy. are readily achieved by widely available 3-D conformal techniques. However, these authors argue that doses of 81 Gy. or higher mandate much more sophisticated technology, such as intensity modulated radiation therapy or proton beam. These technologies are currently only available at a limited number of major centers and the implication is that only these centers are of sufficient quality to treat effectively and safely. However, their data show that ultra high dose radiation may be given relatively safely via the 3-D conformal approach, although a higher rate of grade 2 rectal bleeding must be tolerated than with intensity modulated radiation therapy (14% versus 2% at 81 Gy.). No grade 3 morbidity was noted. If dose escalation to 81 Gy. proved to be essential for cancer control in a randomized trial, I believe that patients would be prepared to accept a 14% risk of mild rectal bleeding in exchange for an increased likelihood of cure if intensity modulated radiation therapy were not locally available. This study strongly affirms the trend toward higher dose in radiation therapy and redefines the acceptable standard dose somewhere above 75 Gy. It does not yet set an upper level at which the law of diminishing returns takes over. Their early results suggest that 81 to 86 Gy. may be tolerable with intensity modulated radiation therapy but they may only be considered preliminary. While the rectum and bladder are largely spared the maximum doses, the urethra and bladder neck are not. Dose limiting toxicity is likely to involve these structures and to manifest late. Therefore, high dose radiation has become acceptable but ultra high dose radiation needs mature randomized study before it may also be regarded as necessary or safe. These trials are soon to open. Anthony L. Zietman Department of Radiation Oncology Massachusetts General Hospital Harvard Medical School Boston, Massachusetts 1. Pollack, A., Zagars, G. K., Smith, L. G. et al: Preliminary results of a randomized dose-escalation study comparing 70 Gy. to 78 Gy. for the treatment of prostate cancer. Int J Radiat Oncol Biol Phys, Suppl. 45: 146, abstract 4, Vicini, F. A., Kestin, L. L., and Martinez, A. A.: The importance of adequate followup in defining treatment success after external beam irradiation for prostate cancer. Int J Radiat Oncol Biol Phys, 45: 553, 1999
Outcomes Following Negative Prostate Biopsy for Patients with Persistent Disease after Radiotherapy for Prostate Cancer
Clinical Urology Post-radiotherapy Prostate Biopsy for Recurrent Disease International Braz J Urol Vol. 36 (1): 44-48, January - February, 2010 doi: 10.1590/S1677-55382010000100007 Outcomes Following Negative
More informationProject approved by the Fondo de investigaciones Socio Sanitarias (FISS). Resolution dated June 8, Official State Gazette: June 17, 2004.
Edition No. 01 Phase III randomized and multicenter trial of adjuvant androgen deprivation combined with high-dose 3-dimensional conformal radiotherapy in intermediate- or high-risk localized prostate
More informationNew Technologies for the Radiotherapy of Prostate Cancer
Prostate Cancer Meyer JL (ed): IMRT, IGRT, SBRT Advances in the Treatment Planning and Delivery of Radiotherapy. Front Radiat Ther Oncol. Basel, Karger, 27, vol. 4, pp 315 337 New Technologies for the
More informationVol. 36, pp , 2008 T1-3N0M0 : T1-3. prostate-specific antigen PSA. 68 Gy National Institutes of Health 10
25 Vol. 36, pp. 25 32, 2008 T1-3N0M0 : 20 2 18 T1-3 N0M0 1990 2006 16 113 59.4-70 Gy 68 Gy 24 prostate-specific antigen PSA 1.2 17.2 6.5 5 91 95 5 100 93 p 0.04 T3 PSA60 ng ml 68 Gy p 0.0008 0.03 0.04
More informationThe Phoenix Definition of Biochemical Failure Predicts for Overall Survival in Patients With Prostate Cancer
55 The Phoenix Definition of Biochemical Failure Predicts for Overall Survival in Patients With Prostate Cancer Matthew C. Abramowitz, MD 1 Tiaynu Li, MA 2 Mark K. Buyyounouski, MD 1 Eric Ross, PhD 2 Robert
More informationRadiation dose has been reported to be an important determinant
538 The Relationship of Increasing Radiotherapy Dose to Reduced Distant Metastases and Mortality in Men with Prostate Cancer Rojymon Jacob, M.D. 1 Alexandra L. Hanlon, Ph.D. 2 Eric M. Horwitz, M.D. 1 Benjamin
More informationRadical Prostatectomy versus Intensity Modulated Radiation Therapy in the Management of Localized Prostate Cancer
Yale University EliScholar A Digital Platform for Scholarly Publishing at Yale Yale Medicine Thesis Digital Library School of Medicine 10-19-2009 Radical Prostatectomy versus Intensity Modulated Radiation
More informationSRO Tutorial: Prostate Cancer Clinics
SRO Tutorial: Prostate Cancer Clinics May 7th, 2010 Daniel M. Aebersold Klinik und Poliklinik für Radio-Onkologie Universität Bern, Inselspital Is cure necessary in those in whom it may be possible, and
More informationSalvage prostatectomy for post-radiation adenocarcinoma with treatment effect: Pathological and oncological outcomes
ORIGINAL RESEARCH Salvage prostatectomy for post-radiation adenocarcinoma with treatment effect: Pathological and oncological outcomes Michael J. Metcalfe, MD ; Patricia Troncoso, MD 2 ; Charles C. Guo,
More informationComparison of external radiation therapy vs radical prostatectomy in lymph node positive prostate cancer patients
Comparison of external radiation therapy vs radical prostatectomy in lymph node positive prostate cancer patients R Kuefer 1, BG Volkmer 1, M Loeffler 1, RL Shen 2, L Kempf 3, AS Merseburger 4, JE Gschwend
More informationRadiation treatment in prostate cancer : balancing between tumor control and toxicity Heemsbergen, W.D.
UvA-DARE (Digital Academic Repository) Radiation treatment in prostate cancer : balancing between tumor control and toxicity Heemsbergen, W.D. Link to publication Citation for published version (APA):
More informationdoi: /s (03) CLINICAL INVESTIGATION
doi:10.1016/s0360-3016(03)01746-2 Int. J. Radiation Oncology Biol. Phys., Vol. 58, No. 4, pp. 1048 1055, 2004 Copyright 2004 Elsevier Inc. Printed in the USA. All rights reserved 0360-3016/04/$ see front
More informationDepartment of Radiotherapy & Nuclear Medicine, National Cancer Institute, Cairo University, Cairo, Egypt.
Original article Res. Oncol. Vol. 12, No. 1, Jun. 2016:10-14 Dosimetric comparison of 3D conformal conventional radiotherapy versus intensity-modulated radiation therapy both in conventional and high dose
More informationHeterogeneity in high-risk prostate cancer treated with high-dose radiation therapy and androgen deprivation therapy
Cagney et al. BMC Urology (2017) 17:60 DOI 10.1186/s12894-017-0250-2 RESEARCH ARTICLE Heterogeneity in high-risk prostate cancer treated with high-dose radiation therapy and androgen deprivation therapy
More informationProstate Cancer in comparison to Radiotherapy alone:
Prostate Cancer in comparison to Radiotherapy alone: 1 RTOG 86-10 (2001) 456 patients with > a-goserelin 2 month before RTand during RT + Cyproterone acetate (1 month) vs b-pelvic irradiation (50 gy) +
More informationJAMA. 1998;280:
Original Contributions Biochemical Outcome After Radical Prostatectomy, Radiation Therapy, or Interstitial for Clinically Localized Prostate Cancer Anthony V. D Amico, MD, PhD; Richard Whittington, MD;
More informationThe introduction of serum prostate-specific antigen
ADULT UROLOGY CME ARTICLE COMPARING PSA OUTCOME AFTER RADICAL PROSTATECTOMY OR MAGNETIC RESONANCE IMAGING- GUIDED PARTIAL PROSTATIC IRRADIATION IN SELECT PATIENTS WITH CLINICALLY LOCALIZED ADENOCARCINOMA
More informationProstate Cancer. 3DCRT vs IMRT : Hasan Murshed
Prostate Cancer 3DCRT vs IMRT : the second debate Hasan Murshed Take home message IMRT allows dose escalation. Preliminary data shows IMRT technique improves cancer control while keeping acceptable morbidity
More informationBiochemical progression-free survival in localized prostate cancer patients treated with definitive external beam radiotherapy
Electronic Physician (ISSN: 2008-5842) http://www.ephysician.ir October 2015, Volume: 7, Issue: 6, Pages: 1330-1335, DOI: 10.14661/1330 Biochemical progression-free survival in localized prostate cancer
More informationOutcomes of Radical Prostatectomy in Thai Men with Prostate Cancer
Original Article Outcomes of Radical Prostatectomy in Thai Men with Prostate Cancer Sunai Leewansangtong, Suchai Soontrapa, Chaiyong Nualyong, Sittiporn Srinualnad, Tawatchai Taweemonkongsap and Teerapon
More informationStrategies of Radiotherapy for Intermediate- to High-Risk Prostate Cancer
Strategies of Radiotherapy for Intermediate- to High-Risk Prostate Cancer Daisaku Hirano, MD Department of Urology Higashi- matsuyama Municipal Hospital, Higashi- matsuyama- city, Saitama- prefecture,
More informationHormone Therapy for Prostate Cancer: Guidelines versus Clinical Practice
european urology supplements 5 (2006) 362 368 available at www.sciencedirect.com journal homepage: www.europeanurology.com Hormone Therapy for Prostate Cancer: Guidelines versus Clinical Practice Antonio
More informationPreoperative Gleason score, percent of positive prostate biopsies and PSA in predicting biochemical recurrence after radical prostatectomy
JBUON 2013; 18(4): 954-960 ISSN: 1107-0625, online ISSN: 2241-6293 www.jbuon.com E-mail: editorial_office@jbuon.com ORIGINAL ARTICLE Gleason score, percent of positive prostate and PSA in predicting biochemical
More informationMonotherapy with Carbon Ion Radiation for Localized Prostate Cancer
Japanese Journal of Clinical Oncology Advance Access published May 30, 2006 Monotherapy with Carbon Ion Radiation for Localized Prostate Cancer Jun Shimazaki 1, Koichiro Akakura 1, Hiroyoshi Suzuki 1,
More informationInformation Content of Five Nomograms for Outcomes in Prostate Cancer
Anatomic Pathology / NOMOGRAMS IN PROSTATE CANCER Information Content of Five Nomograms for Outcomes in Prostate Cancer Tarek A. Bismar, MD, 1 Peter Humphrey, MD, 2 and Robin T. Vollmer, MD 3 Key Words:
More informationjournal of medicine The new england Preoperative PSA Velocity and the Risk of Death from Prostate Cancer after Radical Prostatectomy abstract
The new england journal of medicine established in 1812 july 8, 4 vol. 31 no. 2 Preoperative PSA Velocity and the Risk of Death from Prostate Cancer after Radical Prostatectomy Anthony V. D Amico, M.D.,
More informationin 32%, T2c in 16% and T3 in 2% of patients.
BJUI Gleason 7 prostate cancer treated with lowdose-rate brachytherapy: lack of impact of primary Gleason pattern on biochemical failure Richard G. Stock, Joshua Berkowitz, Seth R. Blacksburg and Nelson
More informationPost Radical Prostatectomy Radiation in Intermediate and High Risk Group Prostate Cancer Patients - A Historical Series
Post Radical Prostatectomy Radiation in Intermediate and High Risk Group Prostate Cancer Patients - A Historical Series E. Z. Neulander 1, Z. Wajsman 2 1 Department of Urology, Soroka UMC, Ben Gurion University,
More informationRadiation Therapy for Prostate Cancer. Resident Dept of Urology General Surgery Grand Round November 24, 2008
Radiation Therapy for Prostate Cancer Amy Hou,, MD Resident Dept of Urology General Surgery Grand Round November 24, 2008 External Beam Radiation Advances Improving Therapy Generation of linear accelerators
More informationThe Use of Conformal Radiotherapy and the Selection of Radiation Dose in T1 or T2 Prostate Cancer
Evidence-based Series 3-11 EDUCATION AND INFORMATION 2011 The Use of Conformal Radiotherapy and the Selection of Radiation Dose in T1 or T2 Prostate Cancer Members of the Genitourinary Cancer Disease Site
More informationCONTEMPORARY UPDATE OF PROSTATE CANCER STAGING NOMOGRAMS (PARTIN TABLES) FOR THE NEW MILLENNIUM
RAPID COMMUNICATION CME ARTICLE CONTEMPORARY UPDATE OF PROSTATE CANCER STAGING NOMOGRAMS (PARTIN TABLES) FOR THE NEW MILLENNIUM ALAN W. PARTIN, LESLIE A. MANGOLD, DANA M. LAMM, PATRICK C. WALSH, JONATHAN
More informationSupported by M. D. Anderson Cancer Center physician investigator funds. We thank Gerald E. Hanks, MD, for help and guidance with this project.
1496 Biochemical and Clinical Significance of the Posttreatment Prostate-Specific Antigen Bounce for Prostate Cancer Patients Treated With External Beam Radiation Therapy Alone A Multiinstitutional Pooled
More informationPrognostic value of the Gleason score in prostate cancer
BJU International (22), 89, 538 542 Prognostic value of the Gleason score in prostate cancer L. EGEVAD, T. GRANFORS*, L. KARLBERG*, A. BERGH and P. STATTIN Department of Pathology and Cytology, Karolinska
More information3-Dimensional conformal radiotherapy versus intensity modulated radiotherapy for localized prostate cancer: Dosimetric and radiobiologic analysis
Iran. J. Radiat. Res., 2007; 5 (1): 1-8 3-Dimensional conformal radiotherapy versus intensity modulated radiotherapy for localized prostate cancer: Dosimetric and radiobiologic analysis A.K. Bhardwaj 1*,T.S.
More informationDOSE ESCALATION USING CONFORMAL HIGH-DOSE-RATE BRACHYTHERAPY IMPROVES OUTCOME IN UNFAVORABLE PROSTATE CANCER
PII S0360-3016(02)02733-5 Int. J. Radiation Oncology Biol. Phys., Vol. 53, No. 2, pp. 316 327, 2002 Copyright 2002 Elsevier Science Inc. Printed in the USA. All rights reserved 0360-3016/02/$ see front
More informationGUIDELINES ON PROSTATE CANCER
10 G. Aus (chairman), C. Abbou, M. Bolla, A. Heidenreich, H-P. Schmid, H. van Poppel, J. Wolff, F. Zattoni Eur Urol 2001;40:97-101 Introduction Cancer of the prostate is now recognized as one of the principal
More information2015 myresearch Science Internship Program: Applied Medicine. Civic Education Office of Government and Community Relations
2015 myresearch Science Internship Program: Applied Medicine Civic Education Office of Government and Community Relations Harguneet Singh Science Internship Program: Applied Medicine Comparisons of Outcomes
More informationIntensity Modulated Radiotherapy (IMRT) of the Prostate
Medical Policy Manual Medicine, Policy No. 137 Intensity Modulated Radiotherapy (IMRT) of the Prostate Next Review: August 2018 Last Review: November 2017 Effective: December 1, 2017 IMPORTANT REMINDER
More informationExternal Beam Radiation Therapy for Low/Intermediate Risk Prostate Cancer
External Beam Therapy for Low/Intermediate Risk Prostate Cancer Jeff Michalski, M.D. The Carlos A. Perez Distinguished Professor of Department of and Siteman Cancer Center Learning Objectives Understand
More informationRadiation Dose Escalation for Localized Prostate Cancer
Radiation Dose Escalation for Localized Prostate Cancer Intensity-Modulated Radiotherapy Versus Permanent Transperineal Brachytherapy William W. Wong, MD 1 ; Sujay A. Vora, MD 1 ; Steven E. Schild, MD
More informationIntroduction ORIGINAL RESEARCH
Cancer Medicine ORIGINAL RESEARCH Open Access Prostate- specific antigen nadir within 12 months as an early surrogate marker of biochemical failure and distant metastasis after low- dose- rate brachytherapy
More informationconcordance indices were calculated for the entire model and subsequently for each risk group.
; 2010 Urological Oncology ACCURACY OF KATTAN NOMOGRAM KORETS ET AL. BJUI Accuracy of the Kattan nomogram across prostate cancer risk-groups Ruslan Korets, Piruz Motamedinia, Olga Yeshchina, Manisha Desai
More informationOPTIMIZATION OF COLLIMATOR PARAMETERS TO REDUCE RECTAL DOSE IN INTENSITY-MODULATED PROSTATE TREATMENT PLANNING
Medical Dosimetry, Vol. 30, No. 4, pp. 205-212, 2005 Copyright 2005 American Association of Medical Dosimetrists Printed in the USA. All rights reserved 0958-3947/05/$ see front matter doi:10.1016/j.meddos.2005.06.002
More informationDevelopment of a treatment planning protocol for prostate treatments using intensity modulated radiotherapy
JOURNAL OF APPLIED CLINICAL MEDICAL PHYSICS, VOLUME 2, NUMBER 2, SPRING 2001 Development of a treatment planning protocol for prostate treatments using intensity modulated radiotherapy Gary A. Ezzell,*
More informationCLINICAL TRIALS Open clinical uro-oncology trials in Canada George Rodrigues, MD, Eric Winquist, MD
Open clinical uro-oncology trials in Canada George Rodrigues, MD, Eric Winquist, MD London Health Sciences Centre, London, Ontario, Canada bladder cancer AN OPEN-LABEL, MULTICENTER, RANDOMIZED PHASE II
More informationOverview of Radiotherapy for Clinically Localized Prostate Cancer
Session 16A Invited lectures: Prostate - H&N. Overview of Radiotherapy for Clinically Localized Prostate Cancer Mack Roach III, MD Department of Radiation Oncology UCSF Helen Diller Family Comprehensive
More informationAccuracy of post-radiotherapy biopsy before salvage radical prostatectomy
Accuracy of post-radiotherapy biopsy before salvage radical prostatectomy Joshua J. Meeks, Marc Walker*, Melanie Bernstein, Matthew Kent and James A. Eastham Urology Service, Department of Surgery and
More informationCyberKnife SBRT for Prostate Cancer
CyberKnife SBRT for Prostate Cancer Robert Meier, MD Swedish Radiosurgery Center Swedish Cancer Institute Seattle, WA 2017 ESTRO Meeting, Vienna Austria 5-year safety, efficacy & quality of life outcomes
More informationOpen clinical uro-oncology trials in Canada Eric Winquist, MD, George Rodrigues, MD
CLINICAL TRIALS Open clinical uro-oncology trials in Canada Eric Winquist, MD, George Rodrigues, MD London Health Sciences Centre, London, Ontario, Canada bladder cancer A PHASE II PROTOCOL FOR PATIENTS
More informationHigh-Dose Rate Temporary Prostate Brachytherapy. Original Policy Date
MP 8.01.15 High-Dose Rate Temporary Prostate Brachytherapy Medical Policy Section Therapy Issue 12/2013 Original Policy Date 12/2013 Last Review Status/Date Reviewed with literature search/12/2013 Return
More informationJure Murgic 1, Matthew H Stenmark 1, Schuyler Halverson 1, Kevin Blas 1, Felix Y Feng 1,2 and Daniel A Hamstra 1,3*
Murgic et al. Radiation Oncology 2012, 7:127 RESEARCH Open Access The role of the maximum involvement of biopsy core in predicting outcome for patients treated with dose-escalated radiation therapy for
More informationTanaka et al. BMC Cancer (2017) 17:573 DOI /s
Tanaka et al. BMC Cancer (2017) 17:573 DOI 10.1186/s12885-017-3565-1 RESEARCH ARTICLE Comparison of PSA value at last follow-up of patients who underwent low-dose rate brachytherapy and intensity-modulated
More informationSection: Therapy Effective Date: October 15, 2016 Subsection: Therapy Original Policy Date: December 7, 2011 Subject:
Last Review Status/Date: September 2016 Page: 1 of 10 Description High-dose rate (HDR) temporary prostate brachytherapy is a technique of delivering a high-intensity radiation source directly to the prostate
More informationEORTC radiation Oncology Group Intergroup collaboration with RTOG EORTC 1331-ROG; RTOG 0924
EORTC radiation Oncology Group Intergroup collaboration with RTOG EORTC 1331-ROG; RTOG 0924 Title of the Study Medical Condition Androgen deprivation therapy and high dose radiotherapy with or without
More informationHigh Risk Localized Prostate Cancer Treatment Should Start with RT
High Risk Localized Prostate Cancer Treatment Should Start with RT Jason A. Efstathiou, M.D., D.Phil. Assistant Professor of Radiation Oncology Massachusetts General Hospital Harvard Medical School 10
More informationPSA is rising: What to do? After curative intended radiotherapy: More local options?
Klinik und Poliklinik für Urologie und Kinderurologie Direktor: Prof. Dr. H. Riedmiller PSA is rising: What to do? After curative intended radiotherapy: More local options? Klinische und molekulare Charakterisierung
More informationCYBERKNIFE SBRT FOR THE TREATMENT OF PROSTATE CANCER: 5 VS. 44 FRACTIONS THE PHILADELPHIA CYBERKNIFE CENTER EXPERIENCE
CYBERKNIFE SBRT FOR THE TREATMENT OF PROSTATE CANCER: 5 VS. 44 FRACTIONS THE PHILADELPHIA CYBERKNIFE CENTER EXPERIENCE Olusola Obayomi-Davies M.D. Philadelphia CyberKnife Center September 26 th, 2017 Disclosure
More informationProstate Cancer Dashboard
Process Risk Assessment Risk assessment: family history assessment of family history of prostate cancer Best Observed: 97 %1 ; Ideal Benchmark:100% measure P8 2 Process Appropriateness of Care Pre-treatment
More informationClinical Study Oncologic Outcomes of Surgery in T3 Prostate Cancer: Experience of a Single Tertiary Center
Advances in Urology Volume 22, Article ID 64263, 8 pages doi:.55/22/64263 Clinical Study Oncologic Outcomes of Surgery in T3 Prostate Cancer: Experience of a Single Tertiary Center D. Milonas, G. Smailyte,
More informationOpen clinical uro-oncology trials in Canada
Open clinical uro-oncology trials in Canada Eric Winquist, MD, George Rodrigues, MD London Health Sciences Centre, London, Ontario, Canada bladder cancer A PHASE II PROTOCOL FOR PATIENTS WITH STAGE T1
More informationJ Clin Oncol 28: by American Society of Clinical Oncology INTRODUCTION
VOLUME 28 NUMBER 1 JANUARY 1 2010 JOURNAL OF CLINICAL ONCOLOGY O R I G I N A L R E P O R T Clinical Results of Long-Term Follow-Up of a Large, Active Surveillance Cohort With Localized Prostate Cancer
More informationRadiation with oral hormonal manipulation for non-metastatic, intermediate or high risk prostate cancer in men 70 and older or with comorbidities
Radiation with oral hormonal manipulation for non-metastatic, intermediate or high risk prostate cancer in men 70 and older or with comorbidities Prostate cancer is predominately a disease of older men,
More informationHORMONAL THERAPY COMBINED WITH RADIOTHERAPY IN LOCALLY ADVANCED PROSTATE CANCER
HORMONAL THERAPY COMBINED WITH RADIOTHERAPY IN LOCALLY ADVANCED PROSTATE CANCER Piotr Milecki 1, Zbigniew Kwias 2 1 Department of Radiotherapy, Great Poland Cancer Centre, ul. Garbary St. 15, 61-866 Poznań,
More informationCyberKnife Radiotherapy For Localized Prostate Cancer: Rationale And Technical Feasibility
Open Access Article The authors, the publisher, and the right holders grant the right to use, reproduce, and disseminate the work in digital form to all users. Technology in Cancer Research & Treatment
More informationWhen PSA fails. Urology Grand Rounds Alexandra Perks. Rising PSA after Radical Prostatectomy
When PSA fails Urology Grand Rounds Alexandra Perks Rising PSA after Radical Prostatectomy Issues Natural History Local vs Metastatic Treatment options 1 10 000 men / year in Canada 4000 RRP 15-year PSA
More informationSupplemental Information
Supplemental Information Prediction of Prostate Cancer Recurrence using Quantitative Phase Imaging Shamira Sridharan 1, Virgilia Macias 2, Krishnarao Tangella 3, André Kajdacsy-Balla 2 and Gabriel Popescu
More informationProton beam therapy for prostate cancer. 1. What is the clinical effectiveness of proton beam therapy in the treatment of prostate cancer?
QUESTION(S) TO BE ADDRESSED Proton beam therapy for prostate cancer 1. What is the clinical effectiveness of proton beam therapy in the treatment of prostate cancer? 2. What is the cost effectiveness of
More informationA comparative study of radical prostatectomy and permanent seed brachytherapy for low- and intermediate-risk prostate cancer
ORIGINAL RESEARCH A comparative study of radical prostatectomy and permanent seed brachytherapy for low- and intermediate-risk prostate cancer Daniel Taussky, MD; 1 Véronique Ouellet, MD; 2 Guila Delouya,
More informationJ Clin Oncol 26: by American Society of Clinical Oncology INTRODUCTION
VOLUME 26 NUMBER 4 FEBRUARY 1 28 JOURNAL OF CLINICAL ONCOLOGY O R I G I N A L R E P O R T Short-Term Neoadjuvant Androgen Deprivation Therapy and External-Beam Radiotherapy for Locally Advanced Prostate
More informationDescription. Section: Therapy Effective Date: October 15, 2015 Subsection: Therapy Original Policy Date: December 7, 2011 Subject:
Last Review Status/Date: September 2015 Page: 1 of 14 Description High-dose rate (HDR) temporary prostate brachytherapy is a technique of delivering a high-intensity radiation source directly to the prostate
More informationTreatment Failure After Primary and Salvage Therapy for Prostate Cancer
307 Treatment Failure After Primary and Salvage Therapy for Prostate Cancer Likelihood, Patterns of Care, and Outcomes Piyush K. Agarwal, MD 1 Natalia Sadetsky, MD, MPH 2 Badrinath R. Konety, MD, MBA 2
More informationPROSTATE-SPECIFIC ANTIGEN (PSA) is a sensitive
Prostate-Specific Antigen Doubling Times Are Similar in Patients With Recurrence After Radical Prostatectomy or Radiotherapy: A Novel Analysis By Bryan D. Leibman, Ozdal Dillioglugil, Peter T. Scardino,
More informationUnderstanding the risk of recurrence after primary treatment for prostate cancer. Aditya Bagrodia, MD
Understanding the risk of recurrence after primary treatment for prostate cancer Aditya Bagrodia, MD Aditya.bagrodia@utsouthwestern.edu 423-967-5848 Outline and objectives Prostate cancer demographics
More informationdoi: /j.ijrobp CLINICAL INVESTIGATION
CME doi:10.1016/j.ijrobp.2010.07.2004 Int. J. Radiation Oncology Biol. Phys., Vol. 81, No. 5, pp. 1293 1301, 2011 Copyright Ó 2011 Elsevier Inc. Printed in the USA. All rights reserved 0360-3016/$ - see
More informationImpact of the duration of hormonal therapy following radiotherapy for localized prostate cancer
ONCOLOGY LETTERS 10: 255-259, 2015 Impact of the duration of hormonal therapy following radiotherapy for localized prostate cancer MITSURU OKUBO, HIDETUGU NAKAYAMA, TOMOHIRO ITONAGA, YU TAJIMA, SACHIKA
More informationAn examination of existing trial data on the treatment of prostate cancer using external beam radiotherapy combined with hormone therapy.
1.0 Introduction. An examination of existing trial data on the treatment of prostate cancer using external beam radiotherapy combined with hormone therapy. Professor L.J.S.Bradbury Ph.D. For low or intermediate
More informationRadical prostatectomy as radical cure of prostate cancer in a high risk group: A single-institution experience
MOLECULAR AND CLINICAL ONCOLOGY 1: 337-342, 2013 Radical prostatectomy as radical cure of prostate cancer in a high risk group: A single-institution experience NOBUKI FURUBAYASHI 1, MOTONOBU NAKAMURA 1,
More informationClinical Commissioning Policy Proposition: Proton Beam Therapy for Cancer of the Prostate
Clinical Commissioning Policy Proposition: Proton Beam Therapy for Cancer of the Prostate Reference: NHS England B01X09 First published: March 2016 Prepared by NHS England Specialised Services Clinical
More informationNIH Public Access Author Manuscript World J Urol. Author manuscript; available in PMC 2012 February 1.
NIH Public Access Author Manuscript Published in final edited form as: World J Urol. 2011 February ; 29(1): 11 14. doi:10.1007/s00345-010-0625-4. Significance of preoperative PSA velocity in men with low
More informationEvaluation of prognostic factors after radical prostatectomy in pt3b prostate cancer patients in Japanese population
Japanese Journal of Clinical Oncology, 2015, 45(8) 780 784 doi: 10.1093/jjco/hyv077 Advance Access Publication Date: 15 May 2015 Original Article Original Article Evaluation of prognostic factors after
More informationOpen clinical uro-oncology trials in Canada Eric Winquist, MD, George Rodrigues, MD
Open clinical uro-oncology trials in Canada Eric Winquist, MD, George Rodrigues, MD London Health Sciences Centre, London, Ontario, Canada BLADDER CANCER A MULTICENTRE, RANDOMIZED PLACEBO-CONTROLLED, DOUBLE-BLIND
More information2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
Measure #104 (NQF 0390): Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer National Quality Strategy Domain: Effective Clinical Care 2016 PQRS OPTIONS FOR INDIVIDUAL
More informationRadiotherapy for Localized Hormone-refractory Prostate Cancer in Japan
Radiotherapy for Localized Hormone-refractory Prostate Cancer in Japan KATSUMASA NAKAMURA 1, TERUKI TESHIMA 2, YUTAKA TAKAHASHI 2, ATSUSHI IMAI 3, MASAHIKO KOIZUMI 4, NORIO MITSUHASHI 5, YOSHIYUKI SHIOYAMA
More informationPost Radical Prostatectomy Adjuvant Radiation in Patients with Seminal Vesicle Invasion - A Historical Series
Post Radical Prostatectomy Adjuvant Radiation in Patients with Seminal Vesicle Invasion - A Historical Series E. Z. Neulander 1, K. Rubinov 2, W. Mermershtain 2, Z. Wajsman 3 1 Department of Urology, Soroka
More informationWhen to worry, when to test?
Focus on CME at the University of Calgary Prostate Cancer: When to worry, when to test? Bryan J. Donnelly, MSc, MCh, FRCSI, FRCSC Presented at a Canadian College of Family Practitioner s conference (October
More informationThree-year outcomes of 324 prostate carcinoma patients treated with combination high-dose-rate brachytherapy and intensity modulated radiation therapy
Original Article Three-year outcomes of 324 prostate carcinoma patients treated with combination high-dose-rate brachytherapy and intensity modulated radiation therapy Jekwon Yeh, Brandon Lehrich, Albert
More informationfailure (FBF) rates were calculated using the Phoenix definition.
. JOURNAL COMPILATION 2009 BJU INTERNATIONAL Urological Oncology GLEASON SCORES 8 10 PROSTATE CANCER TREATED WITH TRIMODAL THERAPY STOCK et al. BJUI BJU INTERNATIONAL Outcomes for patients with high-grade
More informationTreatment of exceptionally large prostate cancer patients with low-energy intensity-modulated photons
JOURNAL OF APPLIED CLINICAL MEDICAL PHYSICS, VOLUME 7, NUMBER 4, FALL 2006 Treatment of exceptionally large prostate cancer patients with low-energy intensity-modulated photons Mei Sun and Lijun Ma a University
More informationMichael J. Zelefsky MD a,, W. Robert Lee MD b, Anthony Zietman MD c, Najma Khalid MS d, Cheryl Crozier RN d, Jean Owen PhD d, J.
Practical Radiation Oncology (2013) 3, 2 8 www.practicalradonc.org Original Report Evaluation of adherence to quality measures for prostate cancer radiotherapy in the United States: Results from the Quality
More informationName of Policy: High-Dose Rate Temporary Prostate Brachytherapy
Name of Policy: High-Dose Rate Temporary Prostate Brachytherapy Policy #: 024 Latest Review Date: June 2014 Category: Therapy Policy Grade: C Background/Definitions: As a general rule, benefits are payable
More informationQ&A. Overview. Collecting Cancer Data: Prostate. Collecting Cancer Data: Prostate 5/5/2011. NAACCR Webinar Series 1
Collecting Cancer Data: Prostate NAACCR 2010-2011 Webinar Series May 5, 2011 Q&A Please submit all questions concerning webinar content through the Q&A panel Overview NAACCR 2010-2011 Webinar Series 1
More informationThe use of hormonal therapy with radiotherapy for prostate cancer: analysis of prospective randomised trials
British Journal of Cancer (2004) 90, 950 954 All rights reserved 0007 0920/04 $25.00 www.bjcancer.com Minireview The use of hormonal therapy with radiotherapy for prostate cancer: analysis of prospective
More informationAn Update on Radiation Therapy for Prostate Cancer
An Update on Radiation Therapy for Prostate Cancer David C. Beyer, MD, FACR, FACRO, FASTRO Arizona Oncology Services Phoenix, Arizona Objectives Review significant new data Identify leading trends in PCa
More informationCorporate Medical Policy
Corporate Medical Policy Intensity-Modulated Radiation Therapy (IMRT) of the Prostate File Name: Origination: Last CAP Review: Next CAP Review: Last Review: intensity_modulated_radiation_therapy_imrt_of_the_prostate
More informationGene expression profiling predicts clinical outcome of prostate cancer. Gennadi V. Glinsky, Anna B. Glinskii, Andrew J. Stephenson, Robert M.
SUPPLEMENTARY DATA Gene expression profiling predicts clinical outcome of prostate cancer Gennadi V. Glinsky, Anna B. Glinskii, Andrew J. Stephenson, Robert M. Hoffman, William L. Gerald Table of Contents
More informationProstate Overview Quiz
Prostate Overview Quiz 1. The path report reads: Gleason 3 + 4 = 7. The Gleason s score is a. 3 b. 4 c. 7 d. None of the above 2. The path report reads: Moderately differentiated adenocarcinoma of the
More informationMichelle S Ludwig 1*, Deborah A Kuban 2, Xianglin L Du 4, David S Lopez 4, Jose-Miguel Yamal 5 and Sara S Strom 3
Ludwig et al. BMC Cancer (2015) 15:190 DOI 10.1186/s12885-015-1180-6 RESEARCH ARTICLE Open Access The role of androgen deprivation therapy on biochemical failure and distant metastasis in intermediate-risk
More informationBIOCHEMICAL RECURRENCE POST RADICAL PROSTATECTOMY
BIOCHEMICAL RECURRENCE POST RADICAL PROSTATECTOMY AZHAN BIN YUSOFF AZHAN BIN YUSOFF 2013 SCENARIO A 66 year old man underwent Robotic Radical Prostatectomy for a T1c Gleason 4+4, PSA 15 ng/ml prostate
More informationNomograms for prostate cancer
Review Article NOMOGRAMS FOR PROSTATE CANCER STEPHENSON and KATTAN There are several papers in this section on various aspects of prostate cancer: predictive models, robotic radical prostatectomy in large
More informationMetachronous anterior urethral metastasis of prostatic ductal adenocarcinoma
http://dx.doi.org/10.7180/kmj.2016.31.1.66 KMJ Case Report Metachronous anterior urethral metastasis of prostatic ductal adenocarcinoma Jeong Hyun Oh 1, Taek Sang Kim 1, Hyun Yul Rhew 1, Bong Kwon Chun
More information