Rectal toxicity after intensity modulated radiotherapy for prostate cancer: Which rectal dose volume constraints should we use?

Fonteyne, Valérie; Ost, Piet; Vanpachtenbeke, Frank; Colman, Roos; Sadeghi, Simin; Villeirs, Geert; Decaestecker, Karel; Meerleer, Gert De

doi:10.1016/j.radonc.2014.10.014

Cited by 32 publications

(30 citation statements)

References 43 publications

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“…We acknowledge that many authors assessed rectal filling with more complex measurements such as the mean cross-sectional area [1,6,7]. In this study, we selected two surrogate measures for rectal distension using the rectal diameter (AP and lateral) taken at a mid-point level of the treatment volume, since in studies assessing PSA relapse [1] or prostate movement [8] where multiple parameters were calculated, the rectal diameter remained significant.…”

Section: Discussionmentioning

confidence: 99%

Degree of Rectal Distension Seen on Prostate Radiotherapy Planning CT Scan Is Not a Negative Prognostic Factor in the Modern Era of Image-Guided Radiotherapy

Silverman

Johnson²,

Perry³

et al. 2015

Oncology

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Background: Studies have shown that rectal distension has a significant impact on treatment failure in patients receiving radical radiotherapy for prostate cancer. A distended rectum contributes to excessive organ movement during treatment, resulting in significant underdosing of the target volume and higher treatment failure rates. The increasing use of highly conformal, precise radiotherapy techniques places greater importance on reducing this risk. We tested whether imaging during radiotherapy helps minimise the negative impact that rectal distension has on long-term tumour control. Findings: The rectal diameter (anterior/posterior and lateral) was prospectively measured at radiotherapy planning in 172 consecutive patients undergoing radical radiotherapy with three-dimensional conformal radiotherapy. Daily, and then weekly, imaging during radiotherapy ensured that prostate movement remained within predefined tolerances. Patients were followed up for a median of 72 months with regular prostate-specific antigen (PSA) measurements to ascertain biochemical PSA relapse and survival information. Conclusions: In this cohort of predominately high-risk localised prostate cancer, rectal distension had no significant impact on PSA relapse. We suggest that regular imaging during radiotherapy negates the risk caused by rectal distension on local treatment failure.

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Section: Discussionmentioning

confidence: 99%

Degree of Rectal Distension Seen on Prostate Radiotherapy Planning CT Scan Is Not a Negative Prognostic Factor in the Modern Era of Image-Guided Radiotherapy

Silverman

Johnson²,

Perry³

et al. 2015

Oncology

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“…[1][2][3][10][11][12][13][14][15][16][17][18][19][20][21][22][23] Distinctive anatomical features characterized the first nine definitions of the rectum as an OAR, whereas the last four were functional definitions, in which the rectum was exclusively considered with regard to the PTV. All the contouring throughout the entire study was performed by one experienced consultant (RMH) to exclude interobserver variability.…”

Section: Methodsmentioning

confidence: 99%

Comparison of different contouring definitions of the rectum as organ at risk (OAR) and dose–volume parameters predicting rectal inflammation in radiotherapy of prostate cancer: which definition to use?

Nitsche

Brannath

Brückner

et al. 2017

The British Journal of Radiology

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MN and RMH contributed to the conception, design, analysis and interpretation of data and helped with the final approval of the version to be published. MN, RMH and NT helped with the drafting of the article. WB and MB contributed to the statistics of the main study. DW contributed to the acquisition of data. AK contributed to the statistics of pre-study. NT helped with the planning and implementation of radiotherapy.Objective: The objective of this retrospective planning study was to find a contouring definition for the rectum as an organ at risk (OAR) in curative three-dimensional external beam radiotherapy (EBRT) for prostate cancer (PCa) with a predictive correlation between the dosevolume histogram (DVH) and rectal toxicity. Methods: In a pre-study, the planning CT scans of 23 patients with PCa receiving definitive EBRT were analyzed. The rectum was contoured according to 13 different definitions, and the dose distribution was correlated with the respective rectal volumes by generating DVH curves. Three definitions were identified to represent the most distinct differences in the shapes of the DVH curves: one anatomical definition recommended by the Radiation Therapy Oncology Group (RTOG) and two functional definitions based on the target volume. In the main study, the correlation between different relative DVH parameters derived from these three contouring definitions and the occurrence of rectal toxicity during and after EBRT was studied in two consecutive collectives. The first cohort consisted of 97 patients receiving primary curative EBRT and the second cohort consisted of 66 patients treated for biochemical recurrence after prostatectomy. Rectal toxicity was investigated by clinical investigation and scored according to the Common Terminology Criteria for Adverse Events. Candidate parameters were the volume of the rectum, mean dose, maximal dose, volume receiving at least 60 Gy (V 60 ), area under the DVH curve up to 25 Gy and area under the DVH curve up to 75 Gy in dependence of each chosen rectum definition. Multivariable logistic regression considered other clinical factors such as pelvine lymphatics vs local target volume, diabetes, prior rectal surgery, anticoagulation or haemorrhoids too.

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“…Disadvantages of the image guidance strategy directly focused on the organ are poor image quality (cone-beam computed tomography, ultrasound) and high costs (MRI). All this leads to the development of dose volume constraints to diminish the chance on rectal and urinary toxicity [13, 43]. …”

Section: Overview Of External Beam Radiation Treatmentsmentioning

confidence: 99%

Prostate Cancer Radiation Therapy: What Do Clinicians Have to Know?

Vanneste

Limbergen

Lin

et al. 2016

BioMed Research International

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Radiotherapy (RT) for prostate cancer (PC) has steadily evolved over the last decades, with improving biochemical disease-free survival. Recently population based research also revealed an association between overall survival and doses ≥ 75.6 Gray (Gy) in men with intermediate- and high-risk PC. Examples of improved RT techniques are image-guided RT, intensity-modulated RT, volumetric modulated arc therapy, and stereotactic ablative body RT, which could facilitate further dose escalation. Brachytherapy is an internal form of RT that also developed substantially. New devices such as rectum spacers and balloons have been developed to spare rectal structures. Newer techniques like protons and carbon ions have the intrinsic characteristics maximising the dose on the tumour while minimising the effect on the surrounding healthy tissue, but clinical data are needed for confirmation in randomised phase III trials. Furthermore, it provides an overview of an important discussion issue in PC treatment between urologists and radiation oncologists: the comparison between radical prostatectomy and RT. Current literature reveals that all possible treatment modalities have the same cure rate, but a different toxicity pattern. We recommend proposing the possible different treatment modalities with their own advantages and side-effects to the individual patient. Clinicians and patients should make treatment decisions together (shared decision-making) while using patient decision aids.

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Rectal toxicity after intensity modulated radiotherapy for prostate cancer: Which rectal dose volume constraints should we use?

Cited by 32 publications

References 43 publications

Degree of Rectal Distension Seen on Prostate Radiotherapy Planning CT Scan Is Not a Negative Prognostic Factor in the Modern Era of Image-Guided Radiotherapy

Degree of Rectal Distension Seen on Prostate Radiotherapy Planning CT Scan Is Not a Negative Prognostic Factor in the Modern Era of Image-Guided Radiotherapy

Comparison of different contouring definitions of the rectum as organ at risk (OAR) and dose–volume parameters predicting rectal inflammation in radiotherapy of prostate cancer: which definition to use?

Prostate Cancer Radiation Therapy: What Do Clinicians Have to Know?

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