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10 pages, 374 KiB

Open AccessArticle

Rectum and Bladder Toxicity in Postoperative Prostate Bed Irradiation: Dose–Volume Parameters Analysis

by Maja Hasterok, Monika Szołtysik, Zuzanna Nowicka, Bartłomiej Goc, Donata Gräupner, Wojciech Majewski, Konrad Rasławski, Paweł Rajwa, Iwona Jabłońska, Łukasz Magrowski, Mikołaj Przydacz, Wojciech Krajewski, Oliwia Masri and Marcin Miszczyk

Cancers 2023, 15(22), 5334; https://doi.org/10.3390/cancers15225334 - 9 Nov 2023

Viewed by 1514

Abstract

Although prostate cancer treatment is increasingly effective, its toxicities pose a major concern. The aim of our study was to assess the rate of adverse events (AEs) and the prognostic value of dose–volume histogram (DVH) parameters for the occurrence of treatment toxicity in [...] Read more.

Although prostate cancer treatment is increasingly effective, its toxicities pose a major concern. The aim of our study was to assess the rate of adverse events (AEs) and the prognostic value of dose–volume histogram (DVH) parameters for the occurrence of treatment toxicity in patients treated with post-prostatectomy prostate bed radiotherapy (RT). The AEs were scored according to the CTCAE v.5.0. The rectum and bladder were contoured according to the RTOG Guidelines. The DVH parameters were assessed using data exported from the ECLIPSE treatment-planning system. Genitourinary (GU) and gastrointestinal (GI) toxicity were analysed using consecutive dose thresholds for the percentage of an organ at risk (OAR) receiving a given dose and the QUANTEC dose constraints. A total of 213 patients were included in the final analysis. Acute grade 2 or higher (≥G2) GU AEs occurred in 18.7% and late in 21.3% of patients. Acute ≥G2 GI toxicity occurred in 11.7% and late ≥G2 in 11.2% of the patients. Five patients experienced grade 4 AEs. The most common adverse effects were diarrhoea, proctitis, cystitis, and dysuria. The most significant predictors of acute ≥G2 GI toxicity were rectum V47 and V46 (p < 0.001 and p < 0.001) and rectum wall V46 (p = 0.001), whereas the most significant predictors of late ≥G2 GI AEs were rectum wall V47 and V48 (p = 0.019 and p = 0.021). None of the bladder or bladder wall parameters was significantly associated with the risk of acute toxicity. The minimum doses to bladder wall (p = 0.004) and bladder (p = 0.005) were the most significant predictors of late ≥G2 GU toxicity. Postoperative radiotherapy is associated with a clinically relevant risk of AEs, which is associated with DVH parameters, and remains even in patients who fulfil commonly accepted dose constraints. Considering the lack of survival benefit of postoperative adjuvant RT, our results support delaying treatment through an early salvage approach to avoid or defer toxicity. Full article

(This article belongs to the Special Issue Salvage Therapy for Recurrent Prostate Cancer—Optimizing Oncological and Functional Outcomes)

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12 pages, 3075 KiB

Open AccessArticle

Dose-Volume Histogram Parameters and Quality of Life in Patients with Prostate Cancer Treated with Surgery and High-Dose Volumetric-Intensity-Modulated Arc Therapy to the Prostate Bed

by Luca Hanke, Hongjian Tang, Christina Schröder, Paul Windisch, Ken Kudura, Mohamed Shelan, André Buchali, Stephan Bodis, Robert Förster and Daniel R. Zwahlen

Cancers 2023, 15(13), 3454; https://doi.org/10.3390/cancers15133454 - 30 Jun 2023

Cited by 2 | Viewed by 1917

Abstract

Introduction: Prostate bed radiotherapy (RT) is a major affecter of patients’ long-term quality of life (QoL). To ensure the best possible outcome of these patients, dose constraints are key for optimal RT planning and delivery. However, establishing refined dose constraints requires access to [...] Read more.

Introduction: Prostate bed radiotherapy (RT) is a major affecter of patients’ long-term quality of life (QoL). To ensure the best possible outcome of these patients, dose constraints are key for optimal RT planning and delivery. However, establishing refined dose constraints requires access to patient-level data. Therefore, we aimed to provide such data on the relationship between OAR and gastrointestinal (GI) as well as genitourinary (GU) QoL outcomes of a homogenous patient cohort who received dose-intensified post-operative RT to the prostate bed. Furthermore, we aimed to conduct an exploratory analysis of the resulting data. Methods: Patients who were treated with prostate bed RT between 2010 and 2020 were inquired about their QoL based on the Expanded Prostate Cancer Index Composite (EPIC). Those (n = 99) who received volumetric arc therapy (VMAT) of at least 70 Gy to the prostate bed were included. Dose-volume histogram (DVH) parameters were gathered and correlated with the EPIC scores. Results: The median age at the time of prostate bed RT was 68.9 years, and patients were inquired about their QoL in the median 2.3 years after RT. The median pre-RT prostate-specific antigen (PSA) serum level was 0.35 ng/mL. The median duration between surgery and RT was 1.5 years. The median prescribed dose to the prostate bed was 72 Gy. A total of 61.6% received prostate bed RT only. For the bladder, the highest level of statistical correlation (p < 0.01) was seen for V10-20Gy, Dmean and Dmedian with urinary QoL. For bladder wall, the highest level of statistically significant correlation (p < 0.01) was seen for V5-25Gy, Dmean and Dmedian with urinary QoL. Penile bulb V70Gy was statistically significantly correlated with sexual QoL (p < 0.05). A larger rectal volume was significantly correlated with improved bowel QoL (p < 0.05). Sigmoid and urethral DVH parameters as well as the surgical approach were not statistically significantly correlated with QoL. Conclusion: Specific dose constraints for bladder volumes receiving low doses seem desirable for the further optimization of prostate bed RT. This may be particularly relevant in the context of the aspiration of establishing focal RT of prostate cancer and its local recurrences. Our comprehensive dataset may aid future researchers in achieving these goals. Full article

(This article belongs to the Special Issue Salvage Therapy for Recurrent Prostate Cancer—Optimizing Oncological and Functional Outcomes)

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13 pages, 1427 KiB

Open AccessArticle

Long-Term Outcomes of Stereotactic Body Radiotherapy (SBRT) for Intraprostatic Relapse after Definitive Radiotherapy for Prostate Cancer: Patterns of Failure and Association between Volume of Irradiation and Late Toxicity

by Marcin Miszczyk, Małgorzata Kraszkiewicz, Matthias Moll, Konrad Kaminiów, Szymon Sobel, Łukasz Dolla, Piotr Wojcieszek, Paweł Rajwa, Takafumi Yanagisawa, Zuzanna Nowicka, Shahrokh F. Shariat, Gregor Goldner, Leszek Miszczyk and Wojciech Majewski

Cancers 2023, 15(4), 1180; https://doi.org/10.3390/cancers15041180 - 13 Feb 2023

Cited by 5 | Viewed by 2407

Abstract

The aim of this retrospective study was to assess the adverse effects and outcomes of salvage re-irradiation with stereotactic body radiotherapy (sSBRT) for local recurrence of prostate cancer (PCa) after definitive radiotherapy (RT). The study was focused on the adverse effects and prognostic [...] Read more.

The aim of this retrospective study was to assess the adverse effects and outcomes of salvage re-irradiation with stereotactic body radiotherapy (sSBRT) for local recurrence of prostate cancer (PCa) after definitive radiotherapy (RT). The study was focused on the adverse effects and prognostic factors for treatment toxicity, followed by an analysis of patterns of failure and survival. Patients treated with sSBRT between 2012 and 2020 at a tertiary institution were included. The exclusion criteria were a primary or salvage radical prostatectomy or a palliative sSBRT dose. Patients with oligorecurrence were eligible if all metastatic lesions were treated locally with curative intent. The Kaplan–Meier method was used to estimate time to grade ≥ 3 toxicity, local control (LC), freedom from distant metastases (FFDM), progression-free survival (PFS), biochemical control (BC) and overall survival (OS). The differences between groups (focal vs. whole-gland sSBRT) were compared using the log-rank test. The Cox proportional hazards model was used to assess prognostic factors for the listed endpoints. A total of 56 patients with a median age of 70.9 years and a median follow-up of 38.6 months were included in the analysis. The majority of them received local sSBRT only (45; 80.4%), while the rest were simultaneously treated for oligometastases (11; 19.6%). Overall, 18 (32.1%) patients experienced any grade ≥ 3 toxicity, including 1 (6.7%) patient who received focal sSBRT, and 17 (41.5%) patients treated with whole-gland sSBRT. The Planning Target Volume (per cc; HR 1.01; 95% CI 1–1.02; p = 0.025) and use of ADT (yes vs. no; HR 0.35; 95%CI 0.13–0.93; p = 0.035) were independent prognostic factors for the risk of grade ≥ 3 toxicity. The estimated rate of grade ≥ 3 adverse events was significantly higher (43.8% vs. 7.1% at 2 years; p = 0.006), and there was no improvement in the LC (92.9% vs. 85.3% at 2 years; p = 0.759) in patients treated with whole-gland sSBRT compared to focal sSBRT. The 2- and 5-year LC were 87.6% and 47.9%, respectively; the 2- and 5-year FFDM were 72.7% and 42.8%, respectively; and the 2- and 5-year PFS were 67.9% and 28.7%, respectively. The primary pattern of failure was distant metastasis. The sSBRT for local recurrence of PCa after definitive RT was associated with a high risk of severe grade ≥ 3 toxicity, which significantly increased with the volume and extent of re-irradiation. Full article

(This article belongs to the Special Issue Salvage Therapy for Recurrent Prostate Cancer—Optimizing Oncological and Functional Outcomes)

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Review

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11 pages, 657 KiB

Open AccessReview

Salvage Cryoablation for Recurrent Prostate Cancer Following Radiation—A Comprehensive Review

by Harry Lee, Sameer Thakker, Kevin Pineault, James Wysock and Wei Phin Tan

Cancers 2024, 16(15), 2717; https://doi.org/10.3390/cancers16152717 - 31 Jul 2024

Viewed by 875

Abstract

The treatment options for prostate cancer typically entail active surveillance, surgery, radiation, or a combination of the above. Disease recurrence remains a concern, with a wide range of recurrence rates having been reported in the literature. In the setting of recurrence, the salvage [...] Read more.

The treatment options for prostate cancer typically entail active surveillance, surgery, radiation, or a combination of the above. Disease recurrence remains a concern, with a wide range of recurrence rates having been reported in the literature. In the setting of recurrence, the salvage treatment options include salvage prostatectomy, salvage high-intensity focused ultrasound (HIFU), stereotactic body radiotherapy (SBRT), salvage brachytherapy, and salvage cryoablation. In this review, we analyze the currently available data related to salvage cryoablation for recurrent prostate cancer following radiation. Full article

(This article belongs to the Special Issue Salvage Therapy for Recurrent Prostate Cancer—Optimizing Oncological and Functional Outcomes)

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14 pages, 703 KiB

Open AccessReview

Evaluation of Recurrent Disease after Radiation Therapy for Patients Considering Local Salvage Therapy: Past vs. Contemporary Management

by Eric S. Adams, Sriram Deivasigamani, Mahdi Mottaghi, Jiaoti Huang, Rajan T. Gupta and Thomas J. Polascik

Cancers 2023, 15(24), 5883; https://doi.org/10.3390/cancers15245883 - 18 Dec 2023

Cited by 1 | Viewed by 1484

Abstract

Recurrent prostate cancer after primary treatment with radiation therapy is a common problem. Patients with localized recurrence may benefit from salvage therapy, but careful patient selection is crucial because not all patients will benefit from local salvage therapy, and salvage therapy has increased [...] Read more.

Recurrent prostate cancer after primary treatment with radiation therapy is a common problem. Patients with localized recurrence may benefit from salvage therapy, but careful patient selection is crucial because not all patients will benefit from local salvage therapy, and salvage therapy has increased morbidity compared to primary treatments for prostate cancer. This review aims to provide an overview of the evaluation of patients with recurrent disease after radiation therapy and how it is continuing to evolve with increasing data on outcomes, as well as improving technologies and techniques. Our enhanced understanding of treatment outcomes and risk stratification has influenced the identification of patients who may benefit from local salvage treatment. Advances in imaging and biopsy techniques have enhanced the accuracy of locating the recurrence, which affects treatment decisions. Additionally, the growing interest in image-targeted ablative therapies that have less morbidity and complications than whole-gland therapies for suitable patients influences the evaluation process for those considering focal salvage therapy. Although significant changes have been made in the diagnostic evaluation of patients with recurrent disease after radiation therapy, it remains unclear whether these changes will ultimately improve patient outcomes. Full article

(This article belongs to the Special Issue Salvage Therapy for Recurrent Prostate Cancer—Optimizing Oncological and Functional Outcomes)

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12 pages, 637 KiB

Open AccessReview

Artificial Urinary Sphincters for Moderate Post-Prostatectomy Incontinence: Current Research and Proposed Approach

by Andrew Johnson, Spencer Mossack and Peter Tsambarlis

Cancers 2023, 15(18), 4424; https://doi.org/10.3390/cancers15184424 - 5 Sep 2023

Cited by 1 | Viewed by 1468

Abstract

Male urinary incontinence is a common complication after radical prostatectomy. The severity of incontinence can be assessed in various ways and helps determine the best surgical intervention to restore continence. While most patients with mild incontinence receive a sling and those with severe [...] Read more.

Male urinary incontinence is a common complication after radical prostatectomy. The severity of incontinence can be assessed in various ways and helps determine the best surgical intervention to restore continence. While most patients with mild incontinence receive a sling and those with severe incontinence receive an artificial urinary sphincter (AUS), there are no clear guidelines on how to manage patients with moderate post-prostatectomy incontinence (PPI). Our discussion will focus on the current literature, which demonstrates that an AUS should be considered first-line in men with moderate PPI despite perceived concerns over complications and reintervention rates. Full article

(This article belongs to the Special Issue Salvage Therapy for Recurrent Prostate Cancer—Optimizing Oncological and Functional Outcomes)

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12 pages, 959 KiB

Open AccessReview

Pelvic Extirpative Surgery for the “End-Stage Irradiated Bladder”

by Nikolas Moring, Seamus Barrett, Andrew C. Peterson and Brian M. Inouye

Cancers 2023, 15(17), 4238; https://doi.org/10.3390/cancers15174238 - 24 Aug 2023

Cited by 1 | Viewed by 2031

Abstract

Men with prostate cancer have the daunting task of selecting from multiple modalities of treatment. The long-term effects of radiation therapy are only now being recognized. For both patients and surgeons, the end-stage irradiated bladder poses numerous problems and challenges. Specifically, irradiated bladders [...] Read more.

Men with prostate cancer have the daunting task of selecting from multiple modalities of treatment. The long-term effects of radiation therapy are only now being recognized. For both patients and surgeons, the end-stage irradiated bladder poses numerous problems and challenges. Specifically, irradiated bladders with urosymphyseal fistula, radiation cystitis, and rectourethral fistula are challenging to manage and treat. This review outlines the presentation, workup, and management including cystectomy for these three devastating late complications of radiation therapy. There are special considerations when performing benign cystectomy that are not typically considered during oncologic cystectomy. We discuss an overview of the current literature regarding the “end-stage bladder” resulting from radiation therapy and the important considerations that must be acknowledged when managing these patients. It is shown that many of the less invasive and conservative options ultimately lead to cystectomy. Indeed, our review concludes that cystectomy with urinary diversion is a safe and viable option in select irradiated patients with the goal to improve quality of life. Full article

(This article belongs to the Special Issue Salvage Therapy for Recurrent Prostate Cancer—Optimizing Oncological and Functional Outcomes)

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Graphical abstract

14 pages, 598 KiB

Open AccessReview

The Role of Salvage Radical Prostatectomy in Patients with Radiation-Resistant Prostate Cancer

by Jake Drobner, Alain Kaldany, Mihir S. Shah and Saum Ghodoussipour

Cancers 2023, 15(14), 3734; https://doi.org/10.3390/cancers15143734 - 23 Jul 2023

Cited by 3 | Viewed by 2326

Abstract

There are multiple treatment strategies for patients with localized prostate adenocarcinoma. In intermediate- and high-risk patients, external beam radiation therapy demonstrates effective long-term cancer control rates comparable to radical prostatectomy. In patients who opt for initial radiotherapy but have a local recurrence of [...] Read more.

There are multiple treatment strategies for patients with localized prostate adenocarcinoma. In intermediate- and high-risk patients, external beam radiation therapy demonstrates effective long-term cancer control rates comparable to radical prostatectomy. In patients who opt for initial radiotherapy but have a local recurrence of their cancer, there is no unanimity on the optimal salvage approach. The lack of randomized trials comparing surgery to other local salvage therapy or observation makes it difficult to ascertain the ideal management. A narrative review of existing prospective and retrospective data related to salvage radical prostatectomy after radiation therapy was undertaken. Based on retrospective and prospective data, post-radiation salvage radical prostatectomy confers oncologic benefits, with overall survival ranging from 84 to 95% at 5 years and from 52 to 77% at 10 years. Functional morbidity after salvage prostatectomy remains high, with rates of post-surgical incontinence and erectile dysfunction ranging from 21 to 93% and 28 to 100%, respectively. Factors associated with poor outcomes after post-radiation salvage prostatectomy include preoperative PSA, the Gleason score, post-prostatectomy staging, and nodal involvement. Salvage radical prostatectomy represents an effective treatment option for patients with biochemical recurrence after radiotherapy, although careful patient selection is important to optimize oncologic and functional outcomes. Full article

(This article belongs to the Special Issue Salvage Therapy for Recurrent Prostate Cancer—Optimizing Oncological and Functional Outcomes)

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