Dosimetry and acute toxicity in prostate cancer patients treated with image-guided intensity modulated radiotherapy: Preliminary results in the first 100 men

Abstract

OBJECTIVES We aimed to analyze the dosimetric criteria and preliminary acute toxicity in the first 100 men treated with image-guided intensity modulated radiotherapy (IG-IMRT) for localized prostate cancer. METHODS For image guidance, three fiducial gold markers were implanted in each patient under transurethral ultrasound guidance. According to the risk group classification, prostate and/or seminal vesicles and/or pelvic lymph nodes were defined as the clinical target volume. A median of 76 Gy (range, 74-78 Gy) was delivered to the planning target volume. The patients were evaluated once a week during the treatment and one month after the completion of the treatment. Acute toxicity was scored according to the RTOG scoring system. RESULTS Acute grade 2 gastrointestinal (GI) toxicity was observed in 9% of the patients, acute grade 2 genitourinary (GU) toxicity in 65%, and grade 3 GU toxicity in 1% of the patients. No breaks were given except for the patient with grade 3 GU toxicity. Logistic linear regression analysis revealed maximum rectal dose as a predisposing factor for the acute GI toxicity and previous history of transurethral resection (TUR) for the acute grade 2 and greater GU toxicity. CONCLUSION IG-IMRT is a safe method for dose escalation in localized prostate cancer, and is tolerated well by the patients.

Keywords

• -

Görüntü rehberliğinde yoğunluk ayarlı radyoterapi uygulanan prostat kanserli olgularda dozimetri ve akut toksisite: İlk 100 olguda erken sonuçlar

Öz

AMAÇ Lokalize prostat kanseri olgularında uygulanan görüntü rehberliğinde yoğunluk ayarlı radyoterapinin (YART) dozimetrik ölçütlerini ve erken dönem akut yan etkilerini araştırmak amacıyla ilk 100 olgunun dosyaları retrospektif olarak incelendi. GEREÇ VE YÖNTEM Görüntü rehberliği amacıyla her olguda prostat içersine transüretral ultrason eşliğinde üç adet altın marker yerleştirildi, her tedavi öncesi bu markerların lokalizasyonu verifiye edildikten sonra radyoterapi uygulandı. Olguların risk gruplarına göre prostat +/- seminal veziküller +/- pelvik lenf nodları klinik hedef volüme dahil edildi. Hedef volüme ortanca 76 Gy (aralık, 74-78 Gy) radyoterapi uygulandı. Tedavi sonrası en az üç ay takip edilen olgular tedavi sırasında her hafta, tedavi sonrasında da 1. ayda akut toksisite açısından değerlendirildi ve akut yan etkiler RTOG skorlamasına göre derecelendirildi. BULGULAR Olguların %9'unda grad 2 gastrointestinal (Gİ), %65'inde grad 2 genitoüriner (GÜ), %1'inde de grad 3 GÜ akut yan etki görüldü. Grad 3 yan etki gelişen olgu dışında hiçbir olgunun tedavisine ara verilmedi. Yapılan lojistik regresyon analizinde rektumun aldığı maksimum dozun akut Gİ yan etki gelişmesinde, TUR uygulamasının da akut grad 2 ve üzeri GÜ yan etki gelişiminde predispozan faktör olduğu gözlendi. SONUÇ Görüntü rehberliğinde yapılan YART doz yükseltilmesi için güvenilir bir yöntemdir ve erken dönemde olgular tarafından çok iyi tolere edilmektedir.

Anahtar Kelimeler

• Prostat kanseri, görüntü rehberliği, yoğunluk ayarlı radyoterapi, toksisite

Kaynakça

1. 1. Pollack A, Zagars GK, Starkschall G, Antolak JA, Lee JJ, Huang E, et al. Prostate cancer radiation dose response: results of the M. D. Anderson phase III randomized trial. Int J Radiat Oncol Biol Phys 2002;53(5):1097-105.
2. 2. Zietman AL, DeSilvio ML, Slater JD, Rossi CJ Jr, Miller DW, Adams JA, et al. Comparison of conventional-dose vs high-dose conformal radiation therapy in clinically localized adenocarcinoma of the prostate: a randomized controlled trial. JAMA 2005;294(10):1233-9.
3. 3. Peeters ST, Heemsbergen WD, van Putten WL, Slot A, Tabak H, Mens JW, et al. Acute and late complications after radiotherapy for prostate cancer: results of a multicenter randomized trial comparing 68 Gy to 78 Gy. Int J Radiat Oncol Biol Phys 2005;61(4):1019-34.
4. 4. Storey MR, Pollack A, Zagars G, Smith L, Antolak J, Rosen I. Complications from radiotherapy dose escalation in prostate cancer: preliminary results of a randomized trial. Int J Radiat Oncol Biol Phys 2000;48(3):635- 42.
5. 5. Zelefsky MJ, Fuks Z, Happersett L, Lee HJ, Ling CC, Burman CM, et al. Clinical experience with intensity modulated radiation therapy (IMRT) in prostate cancer. Radiother Oncol 2000;55(3):241-9.
6. 6. Skwarchuk MW, Jackson A, Zelefsky MJ, Venkatraman ES, Cowen DM, Levegrün S, et al. Late rectal toxicity after conformal radiotherapy of prostate cancer (I): multivariate analysis and dose-response. Int J Radiat Oncol Biol Phys 2000;47(1):103-13.
7. 7. Teh BS, Mai WY, Uhl BM, Augspurger ME, Grant WH 3rd, Lu HH, et al. Intensity-modulated radiation therapy (IMRT) for prostate cancer with the use of a rectal balloon for prostate immobilization: acute toxicity and dose-volume analysis. Int J Radiat Oncol Biol Phys 2001;49(3):705-12.
8. 8. Yeoh EE, Botten R, Russo A, McGowan R, Fraser R, Roos D, et al. Chronic effects of therapeutic irradiation for localized prostatic carcinoma on anorectal function. Int J Radiat Oncol Biol Phys 2000;47(4):915-24.

9. 9. Kupelian PA, Langen KM, Willoughby TR, Zeidan OA, Meeks SL. Image-guided radiotherapy for localized prostate cancer: treating a moving target. Semin Radiat Oncol 2008;18(1):58-66.
10. 10. Cox JD, Stetz J, Pajak TF. Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC). Int J Radiat Oncol Biol Phys 1995;31(5):1341-6.
11. 11. Langenhuijsen JF, van Lin EN, Kiemeney LA, van der Vight LP, McColl GM, Visser AG, et al. Ultrasoundguided transrectal implantation of gold markers for prostate localization during external beam radiotherapy: complication rate and risk factors. Int J Radiat On- col Biol Phys 2007;69(3):671-6.
12. 12. Shinohara K, Roach M 3rd. Technique for implantation of fiducial markers in the prostate. Urology 2008;71(2):196-200.
13. 13. Igdem S, Akpinar H, Alço G, Agacayak F, Turkan S, Okkan S. Implantation of fiducial markers for image guidance in prostate radiotherapy: patient-reported toxicity. Br J Radiol 2009 Jun 8.
14. 14. Zelefsky MJ, Leibel SA, Kutcher GJ, Kelson S, Ling CC, Fuks Z. The feasibility of dose escalation with three-dimensional conformal radiotherapy in patients with prostatic carcinoma. Cancer J Sci Am 1995;1(2):142-50.
15. 15. Kupelian PA, Reddy CA, Carlson TP, Altsman KA, Willoughby TR. Preliminary observations on biochemical relapse-free survival rates after short-course intensity-modulated radiotherapy (70 Gy at 2.5 Gy/fraction) for localized prostate cancer. Int J Radiat Oncol Biol Phys 2002;53(4):904-12.
16. 16. Pollack A, Zagars GK, Starkschall G, Childress CH, Kopplin S, Boyer AL, et al. Conventional vs. conformal radiotherapy for prostate cancer: preliminary results of dosimetry and acute toxicity. Int J Radiat Oncol Biol Phys 1996;34(3):555-64.
17. 17. Zelefsky MJ, Fuks Z, Hunt M, Yamada Y, Marion C, Ling CC, et al. High-dose intensity modulated radiation therapy for prostate cancer: early toxicity and biochemical outcome in 772 patients. Int J Radiat Oncol Biol Phys 2002;53(5):1111-6.
18. 18. Michalski JM, Purdy JA, Winter K, Roach M 3rd, Vijayakumar S, Sandler HM, et al. Preliminary report of toxicity following 3D radiation therapy for prostate cancer on 3DOG/RTOG 9406. Int J Radiat Oncol Biol Phys 2000;46(2):391-402.
19. 19. Peeters ST, Hoogeman MS, Heemsbergen WD, Slot A, Tabak H, Koper PC, et al. Volume and hormonal effects for acute side effects of rectum and bladder during conformal radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys 2005;63(4):1142-52.
20. 20. Pollack A, Hanlon AL, Horwitz EM, Feigenberg SJ, Konski AA, Movsas B, et al. Dosimetry and preliminary acute toxicity in the first 100 men treated for prostate cancer on a randomized hypofractionation dose escalation trial. Int J Radiat Oncol Biol Phys 2006;64(2):518-26.
21. 21. De Meerleer G, Vakaet L, Meersschout S, Villeirs G, Verbaeys A, Oosterlinck W, et al. Intensity-modulated radiotherapy as primary treatment for prostate cancer: acute toxicity in 114 patients. Int J Radiat Oncol Biol Phys 2004;60(3):777-87. 4 22. Al-Mamgani A, Heemsbergen WD, Peeters ST, Lebesque JV. Role of intensity-modulated radiotherapy in reducing toxicity in dose escalation for localized prostate cancer. Int J Radiat Oncol Biol Phys 2009;73(3):685-91.
22. 23. Seymore CH, el-Mahdi AM, Schellhammer PF. The effect of prior transurethral resection of the prostate on post radiation urethral strictures and bladder neck contractures. Int J Radiat Oncol Biol Phys 1986;12(9):1597-600.
23. 24. Lee WR, Schultheiss TE, Hanlon AL, Hanks GE. Urinary incontinence following external-beam radiotherapy for clinically localized prostate cancer. Urology 1996;48(1):95-9. 25. Green N, Treible D, Wallack H. Prostate cancer: postirradiation incontinence. J Urol 1990;144(2 Pt 1):307- 9.
24. 26. Sandhu AS, Zelefsky MJ, Lee HJ, Lombardi D, Fuks Z, Leibel SA. Long-term urinary toxicity after 3-dimensional conformal radiotherapy for prostate cancer in patients with prior history of transurethral resection. Int J Radiat Oncol Biol Phys 2000;48(3):643-7.