A review of rectal toxicity following permanent low dose-rate prostate brachytherapy and the potential value of biodegradable rectal spacers

Schutzer, M.E.; Orio, Peter F.; Biagioli, Matthew C.; Asher, David; Lomas, H.; Moghanaki, Drew

doi:10.1038/pcan.2015.4

Cited by 22 publications

(7 citation statements)

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“…The implanted rectum spacer remains in place over the course of the RT treatment, and the spacer biodegrades naturally within 6 months after implantation [ 44 ]. Different types of rectum spacers have been developed: an absorbable hydrogel, a hyaluronic acid, a collagen, and a saline-filled balloon [ 44 – 46 ]. Several studies are available on the dosimetry, acute outcome, and cost-effectiveness of a rectum spacer; however, no long-term results are available yet [ 47 – 56 ].…”

Section: Preventionmentioning

confidence: 99%

Chronic radiation proctitis: tricks to prevent and treat

Vanneste

Voorde

Ridder

et al. 2015

Int J Colorectal Dis

106

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ObjectiveThe purpose of this study was to give an overview of the measures used to prevent chronic radiation proctitis (CRP) and to provide an algorithm for the treatment of CRP.MethodsMedical literature databases including PubMed and Medline were screened and critically analyzed for relevance in the scope of our purpose.ResultsCRP is a relatively frequent late side effect (5–20%) and mainly dependent on the dose and volume of irradiated rectum. Radiation treatment (RT) techniques to prevent CRP are constantly improving thanks to image-guided RT and intensity-modulated RT. Also, newer techniques like protons and new devices such as rectum spacers and balloons have been developed to spare rectal structures. Biopsies do not contribute to diagnosing CRP and should be avoided because of the risk of severe rectal wall damage, such as necrosis and fistulas. There is no consensus on the optimal treatment of CRP. A variety of possibilities is available and includes topical and oral agents, hyperbaric oxygen therapy, and endoscopic interventions.ConclusionsCRP has a natural history of improving over time, even without treatment. This is important to take into account when considering these treatments: first be conservative (topical and oral agents) and be aware that invasive treatments can be very toxic.

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Section: Preventionmentioning

confidence: 99%

Chronic radiation proctitis: tricks to prevent and treat

Vanneste

Voorde

Ridder

et al. 2015

Int J Colorectal Dis

106

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“…However, we previously reported that the absolute differences in baseline scores between men enrolled in the CEASAR study who completed the baseline survey before versus after starting treatment were very small (range, 1‐3 points), and the Prostate Cancer Outcome Study validation study demonstrated most men accurately recall prediagnostic function 6 months after prostate cancer diagnosis 36,37 . Finally, this study did not account for the use of biodegradable rectal spacers, preoperative magnetic resonance imaging, or other technical advancements for LDR boost 38,39 . As such, the addition of biodegradable rectal spacers may lead to decreases in bowel toxicity, and preoperative magnetic resonance image planning allows better urethral delineation, which may translate to improved urinary toxicity.…”

Section: Discussionmentioning

confidence: 93%

Five‐year outcomes from a prospective comparative effectiveness study evaluating external‐beam radiotherapy with or without low‐dose‐rate brachytherapy boost for localized prostate cancer

Pasalic

Barocas

Huang

et al. 2021

Cancer

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Background To inform patients who are in the process of selecting prostate cancer treatment, the authors compared disease‐specific function after external‐beam radiotherapy (EBRT) alone versus EBRT plus a low‐dose‐rate (LDR) brachytherapy boost (EBRT‐LDR). Methods For this prospective study, men who had localized prostate cancer in 2011 and 2012 were enrolled. Assessments at baseline, 0.5, 1, 3, and 5 years included the patient‐reported Expanded Prostate Index Composite, the 36‐item Medical Outcomes Study Short‐Form Health Survey, and treatment‐related regret. Regression models were adjusted for baseline function and for patient and treatment characteristics. The minimum clinically important difference in scores on the Expanded Prostate Index Composite 26‐item instrument was from 5 to 7 for urinary irritation and from 4 to 6 for bowel function. Results Six‐hundred ninety‐five men met inclusion criteria and received either EBRT (n = 583) or EBRT‐LDR (n = 112). Patients in the EBRT‐LDR group were younger (median age, 66 years [interquartile range [IQR], 60‐71 years] vs 69 years [IQR, 64‐74 years]; P < .001), were less likely to receive pelvic radiotherapy (10% vs 18%; P = .040), and had higher baseline 36‐item Medical Outcomes Study Short‐Form Health Survey physical function scores (median score, 95 [IQR, 86‐100] vs 90 [IQR, 70‐100]; P < .001). Over a 3‐year period, compared with EBRT, EBRT‐LDR was associated with worse urinary irritative scores (adjusted mean difference at 3 years, −5.4; 95% CI, −9.3, −1.6) and bowel function scores (−4.1; 95% CI, −7.6, −0.5). The differences were no longer clinically meaningful at 5 years (difference in urinary irritative scores: −4.5; 95% CI, −8.4, −0.5; difference in bowel function scores: −2.1; 95% CI, −5.7, −1.4). However, men who received EBRT‐LDR were more likely to report moderate or big problems with urinary function bother (adjusted odds ratio, 3.5; 95% CI, 1.5‐8.2) and frequent urination (adjusted odds ratio, 2.6; 95% CI, 1.2‐5.6) through 5 years. There were no differences in survival or treatment‐related regret between treatment groups. Conclusions Compared with EBRT alone, EBRT‐LDR was associated with clinically meaningful worse urinary irritative and bowel function over 3 years after treatment and more urinary bother at 5 years. Lay Summary In men with prostate cancer who received external‐beam radiation therapy (EBRT) with or without a brachytherapy boost (EBRT‐LDR), EBRT‐LDR was associated with clinically worse urinary irritation and bowel function through 3 years but resolved after 5 years. Men who received EBRT‐LDR continued to report moderate‐to‐big problems with urinary function bother and frequent urination through 5 years. There was no difference in treatment‐related regret or survival between patients who received EBRT and those who received EBRT‐LDR. These intermediate‐term estimates of function may facilitate counseling for men who are selecting treatment.

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“…Currently, no guidelines exist for the use of spacers in radiotherapy. Reports in the literature describe the use of these techniques to minimize normal tissue dose in head and neck, cervical, and prostate cancer [6-8]. While short-term follow-up shows favorable safety profiles, long-term data is not presently available to evaluate the delayed complications of prophylactic spacer use in brachytherapy.…”

Section: Introductionmentioning

confidence: 99%

Laparoscopic Allograft Spacer Placement to Minimize Bowel Dose During Re-irradiation with Interstitial Brachytherapy

Dalwadi¹,

Suri²,

Kamat³

et al. 2019

Cureus

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In primary or re-irradiation of gynecologic malignancies, achieving optimal dosimetry with adjacent normal tissue becomes challenging. Surgical spacers are tissue-equivalent materials placed within the patient to protect organs at risk from long-term radiation effects and are commonly used in prostate cancer. We report the use of an allograft mesh to protect adhesed bowel from high-dose radiation for definitive treatment of recurrent endometrial cancer.An 88-year-old female was diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage II endometrial cancer after she developed urinary frequency, hesitancy, and hematuria. She underwent neoadjuvant chemoradiation, followed by laparoscopic hysterectomy with bilateral salpingo-oophorectomy and adjuvant vaginal cuff brachytherapy. She developed 1.8 cm bilateral vaginal cuff recurrence and was dispositioned for interstitial brachytherapy. An allograft mesh spacer was placed laparoscopically before repeat, high dose rate brachytherapy to protect nearby structures. Dose-escalation was achieved without compromising normal tissue constraints. The patient tolerated the procedure without evidence of long-term toxicity at one year.Multidisciplinary discussion may help identify patients who would benefit from spacer placement before select dose-escalated radiation therapy. Laparoscopic allograft mesh is one of many types of surgical spacers available for such patients.

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A review of rectal toxicity following permanent low dose-rate prostate brachytherapy and the potential value of biodegradable rectal spacers

Cited by 22 publications

References 100 publications

Chronic radiation proctitis: tricks to prevent and treat

Chronic radiation proctitis: tricks to prevent and treat

Five‐year outcomes from a prospective comparative effectiveness study evaluating external‐beam radiotherapy with or without low‐dose‐rate brachytherapy boost for localized prostate cancer

Laparoscopic Allograft Spacer Placement to Minimize Bowel Dose During Re-irradiation with Interstitial Brachytherapy

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