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The Role of SBRT/SABR in Prostate Cancer Radiotherapy
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The Role of SBRT/SABR in Prostate Cancer Radiotherapy

A special issue of Cancers (ISSN 2072-6694).

Deadline for manuscript submissions: closed (15 December 2022) | Viewed by 14658

Special Issue Editors

Dr. Amar U. Kishan

E-Mail Website
Guest Editor
1. Department of Radiation Oncology, University of California, Los Angeles, CA 90095, USA
2. Department of Urology, University of California, Los Angeles, CA 90095, USA
Interests: radiation therapy; prostate cancer treatment; MR guided radiotherapy; clinical outcomes research
Dr. Minsong Cao

E-Mail Website
Guest Editor
Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite # B265, Medical Plaza Driveway, Los Angeles, CA 90095, USA
Interests: image guidance in radiation oncology; functional and physiological imaging; stereotactic body radiation therapy
Special Issues, Collections and Topics in MDPI journals
Dr. Alison Claire Tree

E-Mail Website
Guest Editor
The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
Interests: urological malignancies; stereotactic body radiotherapy (SBRT) techniques for prostate and oligometastatic cancer

Special Issue Information

Dear Colleagues,

Stereotactic body radiotherapy (SBRT) or stereotactic ablative radiotherapy (SABR) is a rapidly emerging modality for the treatment of localized prostate cancer. By delivering large doses (>5 Gy) per fraction, SBRT leverages the unique radiobiology of prostate cancer with respect to its surrounding tissues, along with advances in radiation delivery technology, to create an effective, safe, and highly convenient form of curative therapy. With the publication of landmark trials, SBRT has now become widely accepted as a standard of care option.

Yet, numerous questions remain about multiple technical parameters, including the optimal dose, fractionation, delivery platform, intrafraction monitoring strategy, nodal radiotherapy, and simultaneous integrated boosting. Moreover, some questions remain unanswered about the expanded indications for SBRT, including its use for high-risk disease, node-positive disease, re-irradiation, and even in the post-operative setting.

The aim of this Special Issue of Cancers is to highlight studies that discuss all aspects of SBRT for the treatment of prostate cancer, including original research and comprehensive reviews focusing on patient selection for SBRT, indications and contraindications of SBRT, and SBRT delivery and planning.

Dr. Amar Kishan
Dr. Minsong Cao
Dr. Alison Claire Tree
Guest Editors

Manuscript Submission Information

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Cancers is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2900 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • prostate cancer
  • stereotactic body radiotherapy
  • stereotactic ablative radiotherapy
  • SBRT
  • SABR

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Published Papers (5 papers)

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Research

23 pages, 949 KiB  
Article
The Association between Acute and Late Genitourinary and Gastrointestinal Toxicities: An Analysis of the PACE B Study
by Ragu Ratnakumaran, Victoria Hinder, Douglas Brand, John Staffurth, Emma Hall, Nicholas van As and Alison Tree
Cancers 2023, 15(4), 1288; https://doi.org/10.3390/cancers15041288 - 17 Feb 2023
Cited by 7 | Viewed by 2545
Abstract
Several studies have demonstrated the association between acute and late radiotherapy toxicity in prostate cancer using older radiotherapy techniques. However, whether this association is present with newer techniques such as stereotactic body radiotherapy (SBRT), remains unclear. We use univariable and multivariable logistic regression [...] Read more.
Several studies have demonstrated the association between acute and late radiotherapy toxicity in prostate cancer using older radiotherapy techniques. However, whether this association is present with newer techniques such as stereotactic body radiotherapy (SBRT), remains unclear. We use univariable and multivariable logistic regression to analyse the association between grade 2 or worse acute gastrointestinal (GI) and genitourinary (GU) toxicities with equivalent late toxicities in patients treated with SBRT and conventional or moderately fractionated radiotherapy (CRT) within the PACE-B study. 842 patients were included in this analysis. Common Terminology Criteria for Adverse Events (CTCAE) was the primary clinician reported outcome measure used in this analysis. In univariable analysis, experiencing a grade 2+ acute GU toxicity was significantly associated with developing a grade 2+ late GU toxicity after SBRT (OR 4.63, 95% CI (2.96–7.25), p < 0.0001) and CRT (OR 2.83, 95% CI (1.69–4.71), p < 0.0001). This association remained significant in multivariable analysis. In univariable analysis, experiencing a grade 2+ acute GI toxicity was also associated with developing a grade 2+ late GI toxicity after SBRT (OR 3.67, 95% CI (1.91–7.03), p < 0.0001) and CRT (OR 4.4, 95% CI (2.04–9.47), p < 0.0001). This association also remained significant in multivariable analysis. Grade 2+ baseline GU symptoms were also associated with grade 2+ late urinary toxicity in both univariable and multivariable analysis. Overall, acute toxicity is an important predictor variable for late GU/GI toxicity after localised prostate radiotherapy using SBRT and CRT. Future work should test whether optimising symptoms pre-treatment and early intervention in those with significant acute toxicities could mitigate the development late of toxicity. Full article
(This article belongs to the Special Issue The Role of SBRT/SABR in Prostate Cancer Radiotherapy)
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12 pages, 3235 KiB  
Article
Clinical Practice Evolvement for Post-Operative Prostate Cancer Radiotherapy—Part 2: Feasibility of Margin Reduction for Fractionated Radiation Treatment with Advanced Image Guidance
by Brady S. Laughlin, Nathan Y. Yu, Stephanie Lo, Jingwei Duan, Zachary Welchel, Katie Tinnon, Mason Beckett, Steven E. Schild, William W. Wong, Sameer R. Keole, Jean-Claude M. Rwigema, Carlos E. Vargas and Yi Rong
Cancers 2023, 15(1), 40; https://doi.org/10.3390/cancers15010040 - 21 Dec 2022
Cited by 2 | Viewed by 1934
Abstract
Purpose: Planning target volume (PTV) expansion for post-prostatectomy radiotherapy is typically ≥5 mm. Recent clinical trials have proved the feasibility of a reduced margin of 2–3 mm for treatments on MRI-linac. We aim to study the minimum PTV margin needed using iterative cone-beam [...] Read more.
Purpose: Planning target volume (PTV) expansion for post-prostatectomy radiotherapy is typically ≥5 mm. Recent clinical trials have proved the feasibility of a reduced margin of 2–3 mm for treatments on MRI-linac. We aim to study the minimum PTV margin needed using iterative cone-beam CT (iCBCT) as image guidance on conventional linacs. Materials/Methods: Fourteen patients who received post-prostatectomy irradiation (8 with an endorectal balloon and 6 without a balloon) were included in this study. Treatment was delivered with volumetric modulated radiation therapy (VMAT). Fractional dose delivery was evaluated in 165 treatment fractions. The bladder, rectal wall, femoral heads, and prostate bed clinical tumor volume (CTV) were contoured and verified on daily iCBCT. PTV margins (0 mm, 2 mm, and 4 mm) were evaluated on daily iCBCT. CTV coverage and OAR dose parameters were assessed with each PTV margin. Results: CTV D100% was underdosed with a 0 mm margin in 32% of fractions in comparison with 2 mm (6%) and 4 mm (6%) PTV margin (p ≤ 0.001). CTV D95% > 95% was met in 93–94% fractions for all PTV expansions. CTV D95% > 95% was achieved in more patients with an endorectal balloon than those without: 0 mm—90/91 (99%) vs. 63/74 (85%); 2 mm—90/91 (99%) vs. 65/75 (87%); 4 mm—90/90 (100%) vs. 63/73 (86%). There was no difference in absolute median change in CTV D95% (0.32%) for 0-, 2-, and 4 mm margins. The maximum dose remained under 108% for 100% (0 mm), 97% (2 mm), and 98% (4 mm) of images. Rectal wall maximum dose remained under 108% for 100% (0 mm), 100% (2 mm), and 98% (4 mm) of images. Conclusions: With high-quality iCBCT image guidance, PTV margin accounting for inter-fractional uncertainties can be safely reduced for post-prostatectomy radiotherapy. For fractionated radiotherapy, an isotropic expansion of 2 mm and 4 mm may be considered for margin expansion with and without the endorectal balloon. Future application for margin reduction needs to be further evaluated and considered with the advent of shorter post-prostatectomy radiation courses. Full article
(This article belongs to the Special Issue The Role of SBRT/SABR in Prostate Cancer Radiotherapy)
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12 pages, 4246 KiB  
Article
Clinical Practice Evolvement for Post-Operative Prostate Cancer Radiotherapy—Part 1: Consistent Organs at Risk Management with Advanced Image Guidance
by Brady S. Laughlin, Stephanie Lo, Carlos E. Vargas, Todd A. DeWees, Charles Van der Walt, Katie Tinnon, Mason Beckett, Dean Hobbis, Steven E. Schild, William W. Wong, Sameer R. Keole, Jean-Claude M. Rwigema, Nathan Y. Yu, Edward Clouser and Yi Rong
Cancers 2023, 15(1), 16; https://doi.org/10.3390/cancers15010016 - 20 Dec 2022
Cited by 3 | Viewed by 2105
Abstract
Purpose: Post-operative prostate cancer patients are treated with full bladder instruction and the use of an endorectal balloon (ERB). We reassessed the efficacy of this practice based on daily image guidance and dose delivery using high-quality iterative reconstructed cone-beam CT (iCBCT). Methods: Fractional [...] Read more.
Purpose: Post-operative prostate cancer patients are treated with full bladder instruction and the use of an endorectal balloon (ERB). We reassessed the efficacy of this practice based on daily image guidance and dose delivery using high-quality iterative reconstructed cone-beam CT (iCBCT). Methods: Fractional dose delivery was calculated on daily iCBCT for 314 fractions from 14 post-operative prostate patients (8 with and 6 without ERB) treated with volumetric modulated radiotherapy (VMAT). All patients were positioned using novel iCBCT during image guidance. The bladder, rectal wall, femoral heads, and prostate bed clinical tumor volume (CTV) were contoured and verified on daily iCBCT. The dose-volume parameters of the contoured organs at risk (OAR) and CTV coverage were assessed for the clinical impact of daily bladder volume variations and the use of ERB. Minimum bladder volume was studied, and a straightforward bladder instruction was explored for easy clinical adoption. Results: A “minimum bladder” contour, the overlap between the original bladder contour and a 15 mm anterior and superior expansion from prostate bed PTV, was confirmed to be effective in identifying cases that might fail a bladder constraint of V65% <60%. The average difference between the maximum and minimum bladder volumes for each patient was 277.1 mL. The daily bladder volumes varied from 62.4 to 590.7 mL and ranged from 29 to 286% of the corresponding planning bladder volume. The bladder constraint of V65% <60% was met in almost all fractions (98%). CTVs (D90%, D95%, and D98%) remained well-covered regardless of the absolute bladder volume daily variation or the presence of the endorectal balloon. Patients with an endorectal balloon showed smaller variation but a higher average maximum rectal wall dose (D0.03mL: 104.3% of the prescription) compared to patients without (103.3%). Conclusions: A “minimum bladder” contour was determined that can be easily generated and followed to ensure sufficient bladder sparing. Further analysis and validation are needed to confirm the utility of the minimal bladder contour. Accurate dose delivery can be achieved for prostate bed target coverage and OAR sparing with or without the use of ERB. Full article
(This article belongs to the Special Issue The Role of SBRT/SABR in Prostate Cancer Radiotherapy)
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15 pages, 7565 KiB  
Article
A Prospective Study of Stereotactic Body Radiotherapy (SBRT) with Concomitant Whole-Pelvic Radiotherapy (WPRT) for High-Risk Localized Prostate Cancer Patients Using 1.5 Tesla Magnetic Resonance Guidance: The Preliminary Clinical Outcome
by Darren M. C. Poon, Jing Yuan, Bin Yang, Oi-Lei Wong, Sin-Ting Chiu, George Chiu, Kin-Yin Cheung, Siu-Ki Yu and Raymond W. H. Yung
Cancers 2022, 14(14), 3484; https://doi.org/10.3390/cancers14143484 - 18 Jul 2022
Cited by 6 | Viewed by 4912
Abstract
Background: Conventionally fractionated whole-pelvic nodal radiotherapy (WPRT) improves clinical outcome compared to prostate-only RT in high-risk prostate cancer (HR-PC). MR-guided stereotactic body radiotherapy (MRgSBRT) with concomitant WPRT represents a novel radiotherapy (RT) paradigm for HR-PC, potentially improving online image guidance and clinical outcomes. [...] Read more.
Background: Conventionally fractionated whole-pelvic nodal radiotherapy (WPRT) improves clinical outcome compared to prostate-only RT in high-risk prostate cancer (HR-PC). MR-guided stereotactic body radiotherapy (MRgSBRT) with concomitant WPRT represents a novel radiotherapy (RT) paradigm for HR-PC, potentially improving online image guidance and clinical outcomes. This study aims to report the preliminary clinical experiences and treatment outcome of 1.5 Tesla adaptive MRgSBRT with concomitant WPRT in HR-PC patients. Materials and methods: Forty-two consecutive HR-PC patients (72.5 ± 6.8 years) were prospectively enrolled, treated by online adaptive MRgSBRT (8 Gy(prostate)/5 Gy(WPRT) × 5 fractions) combined with androgen deprivation therapy (ADT) and followed up (median: 251 days, range: 20–609 days). Clinical outcomes were measured by gastrointestinal (GI) and genitourinary (GU) toxicities according to the Common Terminology Criteria for Adverse Events (CTCAE) Scale v. 5.0, patient-reported quality of life (QoL) with EPIC (Expanded Prostate Cancer Index Composite) questionnaire, and prostate-specific antigen (PSA) responses. Results: All MRgSBRT fractions achieved planning objectives and dose specifications of the targets and organs at risk, and they were successfully delivered. The maximum cumulative acute GI/GU grade 1 and 2 toxicity rates were 19.0%/81.0% and 2.4%/7.1%, respectively. The subacute (>30 days) GI/GU grade 1 and 2 toxicity rates were 21.4%/64.3% and 2.4%/2.4%, respectively. No grade 3 toxicities were reported. QoL showed insignificant changes in urinary, bowel, sexual, and hormonal domain scores during the follow-up period. All patients had early post-MRgSBRT biochemical responses, while biochemical recurrence (PSA nadir + 2 ng/mL) occurred in one patient at month 18. Conclusions: To our knowledge, this is the first prospective study that showed the clinical outcomes of MRgSBRT with concomitant WPRT in HR-PC patients. The early results suggested favorable treatment-related toxicities and encouraging patient-reported QoLs, but long-term follow-up is needed to confirm our early results. Full article
(This article belongs to the Special Issue The Role of SBRT/SABR in Prostate Cancer Radiotherapy)
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23 pages, 7440 KiB  
Article
Cellular Damage in the Target and Out-Of-Field Peripheral Organs during VMAT SBRT Prostate Radiotherapy: An In Vitro Phantom-Based Study
by Igor Piotrowski, Katarzyna Kulcenty, Wiktoria Suchorska, Marcin Rucinski, Karol Jopek, Marta Kruszyna-Mochalska, Agnieszka Skrobala, Piotr Romanski, Adam Ryczkowski, Dorota Borowicz, Natalia Matuszak and Julian Malicki
Cancers 2022, 14(11), 2712; https://doi.org/10.3390/cancers14112712 - 30 May 2022
Cited by 4 | Viewed by 1903
Abstract
Hypo-fractionated stereotactic body radiation therapy (SBRT) is an effective treatment for prostate cancer (PCa). Although many studies have investigated the effects of SBRT on the prostate and adjacent organs, little is known about the effects further out-of-field. The aim of this study was [...] Read more.
Hypo-fractionated stereotactic body radiation therapy (SBRT) is an effective treatment for prostate cancer (PCa). Although many studies have investigated the effects of SBRT on the prostate and adjacent organs, little is known about the effects further out-of-field. The aim of this study was to investigate, both in vitro and in a quasi-humanoid phantom, the biological effects (using a dose-scaling approach) of radiation in the out-of-field peripheral organs delivered by 6 MV volumetric modulated arc therapy (VMAT) SBRT in a prostate cancer model. Healthy prostate cells were irradiated in a phantom at locations corresponding to the prostate, intestine, lung, thyroid, and brain. Seven 10 Gy fractions of VMAT SBRT were delivered to the target in a single session without intermission (scaled-up method). Radiochromic films were used to measure the doses. The radiobiological response was assessed by measuring DNA breaks, the cell survival fraction, and differences in gene expression profile. Our results showed a strong, multiparametric radiobiological response of the cells in the prostate. Outside of the radiation field, the highest doses were observed in the intestine and lung. A small increase (not statistically significant) in DNA damage and cell death was observed in the intestines. Several gene groups (cell cycle, DNA replication) were depleted in the lung and thyroid (DNA replication, endocytosis), but further analysis revealed no changes in the relevant biological processes. This study provides extensive evidence of the types and extent of radiobiological responses during VMAT SBRT in a prostate cancer model. Additional research is needed to determine whether the radiobiological effects observed in the peripheral organs are validated in a clinical context. Full article
(This article belongs to the Special Issue The Role of SBRT/SABR in Prostate Cancer Radiotherapy)
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