Toxicity after moderately hypofractionated versus conventionally fractionated prostate radiotherapy: A systematic review and meta-analysis of the current literature

Detti, Beatrice; Becherini, Carlotta; Caini, Saverio; Ingrosso, Gianluca; Cataldo, Vanessa Di; Stocchi, G.; Salvestrini, Viola; Lancia, Andrea; Scartoni, D.; Giacomelli, Irene; Sardaro, Angela; Carbonara, Roberta; Borghesi, Simona; Aristei, Cynthia; Livi, Lorenzo

doi:10.1016/j.critrevonc.2021.103432

Cited by 12 publications

(15 citation statements)

References 20 publications

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“…However, concerns regarding the potential enhancement of long-term complications in the organs-at-risk do remain. According to a recent systematic review and meta-analysis (24), most -but not all-previous clinical trials have shown that moderate hypofractionation may be largely equivalent to conventional fractionation with regard to GI toxicity, while pooled analysis of their data showed a trend to increased GI toxicity associated with hypofractionation. The latter finding was attributed mostly to dose-escalation rather than the hypofractionation itself (24).…”

Section: Discussionmentioning

confidence: 99%

“…According to a recent systematic review and meta-analysis (24), most -but not all-previous clinical trials have shown that moderate hypofractionation may be largely equivalent to conventional fractionation with regard to GI toxicity, while pooled analysis of their data showed a trend to increased GI toxicity associated with hypofractionation. The latter finding was attributed mostly to dose-escalation rather than the hypofractionation itself (24). In line with these findings, an earlier meta-analysis showed that dose-escalated HRT may increase late GI toxicity, when compared to conventional RT, whereas no dose-escalated HRT may actually lower the rate of late toxicity events (25).…”

Section: Discussionmentioning

confidence: 99%

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Acute and Late Rectal Toxicity Following Hypofractionated Radiotherapy in Patients With Prostate Cancer: Results of a Prospective Study

Kounadis

Syrigos

Kougioumtzopoulou

et al. 2022

In Vivo

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Background/Aim: Previous randomized clinical trials have shown that moderate hypofractionation has a non-inferior or even superior efficacy to conventionally fractionated external beam radiation therapy (EBRT) in low and intermediate-risk prostate cancer. We herein aimed to evaluate the acute and late gastrointestinal (GI) toxicity of hypofractionated radiotherapy (HRT) in a real-world setting. Patients and Methods: Patients with intermediate-risk prostate adenocarcinoma eligible to receive HRT were prospectively enrolled. All patients were submitted to rectoscopy after completion of HRT, every three months after radiotherapy for the first year and every six months for the second year. Toxicity events were classified as acute, when presenting during radiotherapy or within the first three months following its completion, and as late when appearing three months to three years post-HRT. Results: Twenty prostate cancer patients participated in this study and received 22 sessions of HRT (5 sessions a week; 2.75 Gy per session) and an overall dose of 60.5 Gy. None of our patients developed acute GI toxicity; late GI toxicity (RTOG/EORTC grade 3 rectal bleeding) was observed in 1 patient only (1/20, 5%), at 6-and 12-months post-HRT. No rectal mucosa damage was observed on follow-up rectoscopy in the acute phase in any of our patients; five patients (5/20, 25%) developed late telangiectasias. Vienna retroscopy score (VRS) was 1 in 4/5 patients (80%) and 2 in 1/5 (20%). Conclusion: Minimal radiation-induced rectal mucosal damage was observed in our patient population, and only as a late event, further attesting to the safety of HRT in this setting.According to the latest epidemiological estimates, prostate cancer is the second commonest cancer type and the fifth leading cause of cancer-related deaths in men worldwide (1). Prognosis largely depends on disease stage at the time of diagnosis, with 10-year survival rates often exceeding 95% in organ-confined disease (2). External beam radiation therapy (EBRT) is a widely employed non-surgical treatment modality in localized prostate cancer, achieving largely comparable clinical outcomes to radical prostatectomy, particularly in low-and intermediate-risk patients (3, 4). Although EBRT is sparing the patient from surgical risks, it nevertheless carries its own risk of radiation-induced injury to pelvic organs, such as the bowel or the urinary bladder, a condition known as pelvic radiation disease (PRD) (5,6).Clinical symptoms and signs of PRD may vary significantly, depending on the time interval since the initiation of radiotherapy, the specific organ(s) involved, and 1875

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Acute and Late Rectal Toxicity Following Hypofractionated Radiotherapy in Patients With Prostate Cancer: Results of a Prospective Study

Kounadis

Syrigos

Kougioumtzopoulou

et al. 2022

In Vivo

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“…The patients were treated with conventional fractionation (76 Gy at 38fx), but if they had been treated with the hypofractionated virtual treatment that had been studied, would they have had the same rectal toxicity? A recently published meta-analysis has shown that the moderately hypofractionated radiotherapy schedules are equal, in terms of gastrointestinal (GI) and genitourinary (GU) adverse effects, to conventional fractionation, and that the increase in GI toxicity might be related to dose escalation rather than hypofractionation [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

The Usefulness of Adaptative Radiotherapy in Prostate Cancer: How, When, and Who?

et al. 2022

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The aim of this study was to develop a deformable image registration (DIR)-based offline ART protocol capable of identifying significant dosimetric changes in the first treatment fractions to determine when adaptive replanning is needed. A total of 240 images (24 planning CT (pCT) and 216 kilovoltage cone-beam CT (CBCT)) were prospectively acquired from 24 patients with prostate adenocarcinoma during the first three weeks of their treatment (76 Gy in 38 fractions). This set of images was used to plan a hypofractionated virtual treatment (57.3 Gy in 15 fractions); correlation with the DIR of pCT and each CBCT allowed to translate planned doses to each CBCT, and finally mapped back to the pCT to compare with those actually administered. In 37.5% of patients, doses administered in 50% of the rectum (D50) would have exceeded the dose limitation to 50% of the rectum (R50). We first observed a significant variation of the planned rectal volume in the CBCTs of fractions 1, 3, and 5. Then, we found a significant relationship between the D50 accumulated in fractions 1, 3, and 5 and the lack of compliance with the R50. Finally, we found that a D50 variation rate [100 × (administered D50 − planned D50/planned D50)] > 1% in fraction three can reliably identify variations in administered doses that will lead to exceeding rectal dose constraint.

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“…Treatment planning and image fusion was performed using Monaco (Elektra, Stockholm, Sweden). In the Pareto optimization to spare the organs at risk, the rectum was given priority over the urinary bladder because toxicity at the rectum is the largest problem in routine clinical practice [ 21 ]. The radiation exposure of the organs at risk was taken from the cumulative plans for the total cumulative dose of 74 Gy, and the following parameters were assessed as relevant: for the rectum and urinary bladder, the mean dose and the percentage of the organ volume higher exposed than 50 Gy V 50Gy , V 65Gy , and V 70Gy ; for the rectum, the V 60Gy was additionally compared.…”

Section: Methodsmentioning

confidence: 99%

Using a Further Planning MRI after Neoadjuvant Androgen Deprivation Therapy Significantly Reduces the Radiation Exposure of Organs at Risk in External Beam Radiotherapy of Prostate Cancer

Merten

Fischer

Christiansen

et al. 2023

JCM

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Radiotherapy for prostate cancer is often preceded by neoadjuvant androgen deprivation therapy (ADT), which leads to a reduction in the size of the prostate. This study examines whether it is relevant for treatment planning to acquire a second planning magnetic resonance imaging (MRI) after ADT (=MRI 2) or whether it can be planned without disadvantage based on an MRI acquired before starting ADT (=MRI 1). The imaging data for the radiotherapy treatment planning of 17 patients with prostate cancer who received two planning MRIs (before and after neoadjuvant ADT) were analyzed as follows: detailed comparable radiation plans were created separately, each based on the planning CT scan and either MRI 1 or MRI 2. After ADT for an average of 17.2 weeks, the prostate was reduced in size by an average of 24%. By using MRI 2 for treatment planning, the V60Gy of the rectum could be significantly relieved by an average of 15% with the same coverage of the target volume, and the V70Gy by as much as 33% (compared to using MRI 1 alone). Using a second MRI for treatment planning after neoadjuvant ADT in prostate cancer leads to a significant relief for the organs at risk, especially in the high dose range, with the same irradiation of the target volume, and should therefore be carried out regularly. Waiting for the prostate to shrink after a few months of ADT contributes to relief for the organs at risk and to lowering the toxicity. However, the use of reduced target volumes requires an image-guided application, and the oncological outcome needs to be verified in further studies.

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Toxicity after moderately hypofractionated versus conventionally fractionated prostate radiotherapy: A systematic review and meta-analysis of the current literature

Cited by 12 publications

References 20 publications

Acute and Late Rectal Toxicity Following Hypofractionated Radiotherapy in Patients With Prostate Cancer: Results of a Prospective Study

Acute and Late Rectal Toxicity Following Hypofractionated Radiotherapy in Patients With Prostate Cancer: Results of a Prospective Study

The Usefulness of Adaptative Radiotherapy in Prostate Cancer: How, When, and Who?

Using a Further Planning MRI after Neoadjuvant Androgen Deprivation Therapy Significantly Reduces the Radiation Exposure of Organs at Risk in External Beam Radiotherapy of Prostate Cancer

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