Preliminary analysis of risk factors for late rectal toxicity after helical tomotherapy for prostate cancer

Tomita, Natsuo; Soga, Norihito; Ogura, Yuji; Hayashi, Norio; Shimizu, Hidetoshi; Kubôta, Takashi; Ito, Junji; Hirata, Kimiko; Ohshima, Yuichiro; Tachibana, Hideki; Kodaira, Takeshi

doi:10.1093/jrr/rrt025

Cited by 14 publications

(15 citation statements)

References 16 publications

(24 reference statements)

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“…The extra dose to the bladder due to an inappropriate IMRT planning is also of concern. Radiation oncologists usually pay more attention to the DVH of the rectum rather than of the bladder because the definite dose constraint of the bladder is unclear, whereas the recommended dose constraint of the rectum has been reported 32,33 . Several studies have reported conflicting results for the significance of IMRT in managing adverse effects of SRT 23,34,35 .…”

Section: Discussionmentioning

confidence: 99%

Impact of advanced radiotherapy techniques and dose intensification on toxicity of salvage radiotherapy after radical prostatectomy

Tomita

Uchiyama

Mizuno

et al. 2020

Sci Rep

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The safety and efficacy of dose-escalated radiotherapy with intensity-modulated radiotherapy (IMRT) and image-guided radiotherapy (IGRT) remain unclear in salvage radiotherapy (SRT) after radical prostatectomy. We examined the impact of these advanced radiotherapy techniques and dose intensification on the toxicity of SRT. This multi-institutional retrospective study included 421 patients who underwent SRT at the median dose of 66 Gy in 2-Gy fractions. IMRT and IGRT were used for 225 (53%) and 321 (76%) patients, respectively. At the median follow-up of 50 months, the cumulative incidence of late grade 2 or higher gastrointestinal (GI) and genitourinary (GU) toxicities was 4.8% and 24%, respectively. Multivariate analysis revealed that the non-use of either IMRT or IGRT, or both (hazard ratio [HR] 3.1, 95% confidence interval [CI] 1.8-5.4, p < 0.001) and use of whole-pelvic radiotherapy (HR 7.6, CI 1.0-56, p = 0.048) were associated with late GI toxicity, whereas a higher dose ≥68 Gy was the only factor associated with GU toxicities (HR 3.1, CI 1.3-7.4, p = 0.012). This study suggested that the incidence of GI toxicities can be reduced by IMRT and IGRT in SRT, whereas dose intensification may increase GU toxicity even with these advanced techniques.Prostate cancer patients with biochemical recurrence (BCR) after radical prostatectomy (RP) have a risk of metastasis and cancer death 1 . Approximately 30% of patients with an adverse feature, such as high Gleason score, develop BCR after RP 2 . Salvage radiotherapy (SRT) is the only curative option for these patients 3,4 . The target volume of SRT is the prostate bed with or without the seminal vesicle 5 , which is situated precisely between the bladder and rectum. In a dosimetric study using consensus guidelines for target volume delineations of SRT, intensity-modulated radiation therapy (IMRT) enabled dose increase within acceptable dose constraints of the organs at risk (OARs) such as the bladder and rectum 6 . Regarding definitive radiotherapy (RT) without RP, the ratio of IMRT markedly increased in the 2000s 7 due to benefits of high-dose prescription 8 . As systematic reviews and meta-analyses revealed that dose escalation improved biochemical control even in SRT 9,10 , dose escalation with IMRT has been employed for patients with BCR after RP [11][12][13] . However, dose-escalated RT, even with the IMRT technique, may increase toxicity. Image-guided radiation therapy (IGRT) enables more accurate setup by computed tomography (CT) immediately before treatment. IGRT is also one of the recent advanced RT techniques, as is IMRT, and is used more commonly with IMRT. However, the safety and efficacy of dose-escalated RT with IMRT and IGRT remain unclear. In addition, whether IMRT and IGRT reduce toxicity in SRT is still unknown. Thus, we examined the impact of advanced RT techniques and dose intensification on the toxicity of SRT after RP. Methods patient selection. We identified 421 patients who received SRT for BCR after RP between 2005 and 2017 at 15 institutions....

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Section: Discussionmentioning

confidence: 99%

Impact of advanced radiotherapy techniques and dose intensification on toxicity of salvage radiotherapy after radical prostatectomy

Tomita

Uchiyama

Mizuno

et al. 2020

Sci Rep

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“…reported on IMRT with helical tomotherapy for prostate cancer. They found that the maximum rectal doses, V70, and V60 of the RTOG toxicity ≥ Grade 2 group were significantly higher than those of the ≤ Grade 1 toxicity group according to univariate analysis, while V40 and V20 had no significant relationship with late rectal toxicity [ 13 ]. Thus, the trend for the risk of late rectal toxicity to be correlated with the percentage of the rectum receiving high doses such as V70 or V60 at other institutions was in agreement with our results.…”

Section: Discussionmentioning

confidence: 99%

Results and DVH analysis of late rectal bleeding in patients treated with 3D-CRT or IMRT for localized prostate cancer

Someya

Hori

Tateoka

et al. 2014

Journal of Radiation Research

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In patients undergoing radiotherapy for localized prostate cancer, dose–volume histograms and clinical variables were examined to search for correlations between radiation treatment planning parameters and late rectal bleeding. We analyzed 129 patients with localized prostate cancer who were managed from 2002 to 2010 at our institution. They were treated with 3D conformal radiation therapy (3D-CRT, 70 Gy/35 fractions, 55 patients) or intensity-modulated radiation therapy (IMRT, 76 Gy/38 fractions, 74 patients). All radiation treatment plans were retrospectively reconstructed, dose–volume histograms of the rectum were generated, and the doses delivered to the rectum were calculated. Time to rectal bleeding ranged from 9–53 months, with a median of 18.7 months. Of the 129 patients, 33 patients had Grade 1 bleeding and were treated with steroid suppositories, while 25 patients with Grade 2 bleeding received argon plasma laser coagulation therapy (APC). Three patients with Grade 3 bleeding required both APC and blood transfusion. The 5-year incidence rate of Grade 2 or 3 rectal bleeding was 21.8% for the 3D-CRT group and 21.6% for the IMRT group. Univariate analysis showed significant differences in the average values from V65 to V10 between Grades 0–1 and Grades 2–3. Multivariate analysis demonstrated that patients with V65 ≥ 17% had a significantly increased risk (P = 0.032) of Grade 2 or 3 rectal bleeding. Of the 28 patients of Grade 2 or 3 rectal bleeding, 17 patients (60.7%) were cured by a single session of APC, while the other 11 patients required two sessions. Thus, none of the patients had any further rectal bleeding after the second APC session.

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“…Previous studies reporting genitourinary toxicity after RT have, by and large, been limited by relatively short‐term follow‐up (<5 years) . These short‐term studies show that severe urinary adverse events (UAEs), defined as Radiation Therapy Oncology Group (RTOG) grades 3, 4 or 5, are rare . Unfortunately RT injury accumulates over time and severe complications can arise many years later .…”

Section: Introductionmentioning

confidence: 99%

Management of Radiation Therapy Oncology Group grade 4 urinary adverse events after radiotherapy for prostate cancer

et al. 2016

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ObjectiveTo describe the management of Radiation Therapy Oncology Group (RTOG) grade 4 urinary adverse events (UAEs) after radiotherapy (RT) for prostate cancer (PCa). MethodsWe conducted a single-centre retrospective review, over a 6-year period (2010)(2011)(2012)(2013)(2014)(2015), to identify men with RTOG grade 4 UAEs after RT for PCa. RT was classified as combined therapy (radical prostatectomy [RP] followed by external beam radiotherapy [EBRT], EBRT + low-dose-rate [LDR] brachytherapy, EBRT + high-dose-rate [HDR] brachytherapy or other combinations of RT) or monotherapy RT. UAEs were classified as outlet (urethral stricture, bladder neck contracture, prostate necrosis, or recto-urethral fistula) or bladder (contraction, necrosis, fistula, ureteric stricture or haemorrhage) UAEs. ResultsWe identified 73 men with a mean age of 73 years. Of these, 44 (60%) received combined therapy, consisting of RP + EBRT (n = 19), HDR brachytherapy + EBRT (n = 19), LDR brachytherapy + EBRT (n = 5), and other combined RT (n = 1). Twenty-nine (40%) patients had monotherapy consisting of EBRT (n = 4), HDR brachytherapy (n = 11), LDR brachytherapy (n = 12), or proton beam therapy (n = 2). UAEs were isolated to the bladder in six men (8%), the outlet in 52 men (71%), and to both in 15 men (21%). UAE management included: conservative in 21 (29%), indwelling catheters in 12 (16%), reconstructive in 19 (26%), and urinary diversion (UD) in 23 men (32%). Reconstruction included: ureteric (n = 4), recto-urethral fistula repair (n = 2), and posterior urethroplasty (n =13), of which 14/16 surgeries (88%) with follow-up >90 days were successful. ConclusionsAlthough the incidence of RTOG grade 4 UAEs after PCa radiation treatment is not well defined, their associated morbidity is significant, and approximately one third of patients with these high-grade complications require UD. Conversely, only about a quarter of patients can be managed with conservative strategies or local surgeries. Reconstruction is successful in selected patients.

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Preliminary analysis of risk factors for late rectal toxicity after helical tomotherapy for prostate cancer

Cited by 14 publications

References 16 publications

Impact of advanced radiotherapy techniques and dose intensification on toxicity of salvage radiotherapy after radical prostatectomy

Impact of advanced radiotherapy techniques and dose intensification on toxicity of salvage radiotherapy after radical prostatectomy

Results and DVH analysis of late rectal bleeding in patients treated with 3D-CRT or IMRT for localized prostate cancer

Management of Radiation Therapy Oncology Group grade 4 urinary adverse events after radiotherapy for prostate cancer

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