Vessel-sparing radiation and functional anatomy-based preservation for erectile function after prostate radiotherapy.

Treatment selection for men undergoing curative treatment for prostate cancer is often a challenging decision in view of the goal of maximising cure while maintaining quality of life. Previous quality-of-life comparisons suggest that specific outcomes are associated with type of treatment (surgery vs radiation); however, the functional anatomy approach, starting with nerve-sparing prostatectomy, assumes that quality-of-life outcomes are established by anatomic preservation. Emerging applications of the functional anatomy approach for prostate radiation will ultimately allow for individualised treatments that address the normal tissue variants visible on MRI. Such approaches will encompass all essential functions affected by treatment including genitourinary, rectal, and sexual functions. In this Review, we outline the current techniques in functional anatomy-based preservation related to sexual outcomes, and outline the capacity of vessel-sparing radiotherapy to preserve sexual function in 90% of patients at the 5 year follow-up while maintaining excellent cure rates.

ACR appropriateness Criteria® Postradical prostatectomy irradiation in prostate cancer.

The purpose of this article is to present an updated set of American College of Radiology consensus guidelines formed from an expert panel on the appropriate use of radiation therapy in postprostatectomy prostate cancer. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Recent and relevant literature reviewed by the panel led to establishment of criteria for appropriate use of radiation therapy in postprostatectomy prostate cancer. The discussion includes treatment technique, appropriate dose, field design, and the role of prostate-specific antigen (PSA). Ratings and commentary of the panel on multiple treatment parameters were used to reach consensus. Patients with high-risk pathologic features benefit from postprostatectomy radiation therapy.

Mortality reduction and cumulative excess incidence (CEI) in the prostate-specific antigen (PSA) screening era.

The extent to which PSA screening is related to prostate cancer mortality reduction in the United States (US) is controversial. US Surveillance, Epidemiology, and End Results Program (SEER) data from 1980 to 2016 were examined to assess the relationship between prostate cancer mortality and cumulative excess incidence (CEI) in the PSA screening era and to clarify the impact of race on this relationship. CEI was considered as a surrogate for the intensity of prostate cancer screening with PSA testing and subsequent biopsy as appropriate. Data from 163,982,733 person-years diagnosed with 544,058 prostate cancers (9 registries, 9% of US population) were examined. Strong inverse linear relationships were noted between CEI and prostate cancer mortality, and 317,356 prostate cancer deaths were avoided. Eight regions of the US demonstrated prostate cancer mortality reduction of 46.0-63.7%. On a per population basis, the lives of more black men than white men were saved in three of four registries with sufficient black populations for comparison. Factor(s) independent of CEI (potential effects of treatment advances) explained 14.6% of the mortality benefit (p-value = 0.3357) while there was a significant main effect of CEI (effect = -0.0064; CI: [-0.0088, -0.0040]; p-value < 0.0001). Therefore, there is a strong relationship between CEI and prostate cancer mortality reduction that was not related to factors independent of screening utilization. Minority populations have experienced large mortality reductions in the context of PSA mass utilization.

Quality rectal hydrogel placement allows for gel-enabled dose-escalated EBRT (GEDE-EBRT) without rectal interference in prostate cancer.

Multiple trials have shown that dose-escalation of radiation for prostate cancer provides a biochemical progression-free survival benefit (bPFS); however, rectal constraints are often limiting. In this dosimetric study, we hypothesized that a well-placed rectal hydrogel (RH) would permit improved dose-escalation and target coverage. We selected patients with good-quality RH and created plans with and without RH, prescribing 70 Gy in 28 fractions to the prostate and proximal seminal vesicles (PSV), and a peripheral zone (PZ) boost to 84 Gy, 98 Gy, or 112 Gy. We then compared plans with and without RH, prescribing a 112 Gy boost to 1 to 2 cm simulated dominant intraprostatic lesions (DIL). In the 18 plans created with a PZ boost, the PTV_boost D95% was higher in RH plans compared to non-RH plans (median 98.5 Gy vs 75.53 Gy, p < 0.01). The PSV planning target volume (PTV_PSV) D95% was also marginally higher with RH (71.87 Gy vs 71.04 Gy, p < 0.01). All rectal metrics were improved with RH. For the 32 plans created for simulated DILs treated to 112 Gy, the PTV_boost coverage (median D95% 112.48 Gy vs 102.63 Gy, p < 0.01) and rectal metrics were improved with RH. Four non-RH plans with at least a 4 mm rectal-PTV_boost gap achieved D95% > 98% of the prescription dose for the PTV_boost. Our study showed that placement of a high-quality RH allowed for GEDE-EBRT up to 112 Gy in 28 fractions (EQD2 160 Gy with α/ß = 2.5). This concept should be tested prospectively, particularly to assess for increases in nonrectal toxicities.

Novel needle cutting edge geometry for end-cut biopsy.

PURPOSE: To introduce and determine the biopsy length performance of the novel enhanced cutting edge (ECE) needle tip design, which contains high inclination angles that allow for more efficient tissue cutting. METHODS: ECE and regular two-plane symmetric needle tip's biopsy performance and cutting force are compared over a series of needle insertion experiments into bovine liver under varying levels of internal needle vacuum. An earlier developed needle tip force model is also applied. From these experiments and force model, the effect of needle tip geometry and vacuum on biopsy performance and force is studied. RESULTS: Biopsy sample length is on average 22%, 30%, and 49% longer for ECE needles compared to that of regular needles for the internal pressures of 0, -33.9, and -67.7 kPa, respectively. For ECE needles the vacuum level of -67.7 kPa produces on average biopsy lengths that are 41%, 31%, 29%, 45%, and 42% longer compared to no vacuum for two-plane needle tip bevel angles of 10°, 15°, 20°, 25°, and 30°, respectively. The force results show the ECE needle can be inserted with less initial insertion force than the regular two-plane needle for needles where the needle tip is fully contacting the tissue upon insertion. Vacuum is also showed to help lower insertion forces. CONCLUSIONS: The novel ECE needle tip design outperforms the regular two-plane symmetric needle by yielding longer biopsy samples and lower insertion forces, thereby demonstrating the benefits of needle geometries that contain higher inclination angles. The use of vacuum further improves the ECE needle tip biopsy sample length and lowers insertion forces.

Effects of insertion speed and trocar stiffness on the accuracy of needle position for brachytherapy.

PURPOSE: In prostate brachytherapy, accurate positioning of the needle tip to place radioactive seeds at its target site is critical for successful radiation treatment. During the procedure, needle deflection leads to seed misplacement and suboptimal radiation dose to cancerous cells. In practice, radiation oncologists commonly use high-speed hand needle insertion to minimize displacement of the prostate as well as the needle deflection. Effects of speed during needle insertion and stiffness of trocar (a solid rod inside the hollow cannula) on needle deflection are studied. METHODS: Needle insertion experiments into phantom were performed using a 2(2) factorial design (2 parameters at 2 levels), with each condition having replicates. Analysis of the deflection data included calculating the average, standard deviation, and analysis of variance (ANOVA) to find significant single and two-way interaction factors. RESULTS: The stiffer tungsten carbide trocar is effective in reducing the average and standard deviation of needle deflection. The fast insertion speed together with the stiffer trocar generated the smallest average and standard deviation for needle deflection for almost all cases. CONCLUSIONS: The combination of stiff tungsten carbide trocar and fast needle insertion speed are important to decreasing needle deflection. The knowledge gained from this study can be used to improve the accuracy of needle insertion during brachytherapy procedures.

Women, Infants, and Children Cash Value Benefit Redemption Choices in the Electronic Benefit Transfer Era.

PURPOSE: This study aims to examine the relationship between cash value benefit (CVB) redemption outcomes in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) across food processing types and socio-demographics. DESIGN: Cross-sectional and panel analyses. SETTING: Virginia. SUBJECTS: 98,067 Virginia WIC households. MEASURES: CVB redemption rate. RESULTS: The predominant share of CVB redemption was for fresh produce (77.3%). Non-Hispanic whites and blacks redeemed a smaller share of fresh produce than Hispanic participants (P < .001). Non-Hispanic black WIC households have a significantly lower CVB redemption rate than non-Hispanic white WIC households (ß = -.008, P < .001). Households with a child participant tend to have a higher redemption rate (ß = .01, P < .001). The redemption rates of fruits and of vegetables were positively correlated with household size. CONCLUSIONS: Minority status and household size were significantly related to CVB redemptions among Virginia WIC participants.

Rectal sparing in prostate radiotherapy with combination-brachytherapy and hydrogel spacer.

BACKGROUND: Though some techniques that facilitate rectal sparing such as brachytherapy and intensity modulated radiotherapy (IMRT) have been examined in detail, technical aspects of hydrogel spacer (HS) have been studied less exhaustively. We examined HS quality metrics and approaches to placement for superior dosimetric outcomes. MATERIALS AND METHODS: A single site retrospective review of radiation plans was conducted for patients who received combination-brachytherapy (CBT) with 90 Gy low-dose-rate implant followed by external beam radiotherapy (45 Gy/25 fractions) with operating room (OR) placed HS (2017-2021). A randomly selected set of patients that received CBT without HS over the same time period was used for comparison. Dosimetric outcomes included D1cc and D5% rectum. Dose gradients were quantified. Student's t-test was used for statistical comparisons. RESULTS: Sixty patients (30 with and 30 without HS) who received CBT for prostate cancer were examined. Those with HS had lower mean D1cc [65.31 Gy (SD = 13.53)] and D5% [53.20 Gy (SD = 10.18)] compared to those treated without HS [91.67 Gy (SD = 8.31) and 75.00 Gy (SD = 8.45), respectively, p < 0.001]. Patients with superior HS (average thickness ≥1 cm; n = 12) had lower mean D1cc [58.49 Gy (SD = 13.25, p = 0.026)] and D5% [48.69 Gy (SD = 9.85, p = 0.049)] than those with thinner HS. When dose gradients were considered, HS spanning the interface between the prostate and perirectal tissues to a thickness ≥1 cm can reduce rectal maximum dose to 50-60 Gy. CONCLUSIONS: Through effective use of CBT and HS, extreme rectal dose restriction is possible. The goal for HS placement should be thickness ≥1 cm from base to apex.

Precision grid and hand motion for accurate needle insertion in brachytherapy.

PURPOSE: In prostate brachytherapy, a grid is used to guide a needle tip toward a preplanned location within the tissue. During insertion, the needle deflects en route resulting in target misplacement. In this paper, 18-gauge needle insertion experiments into phantom were performed to test effects of three parameters, which include the clearance between the grid hole and needle, the thickness of the grid, and the needle insertion speed. Measurement apparatus that consisted of two datum surfaces and digital depth gauge was developed to quantify needle deflections. METHODS: The gauge repeatability and reproducibility (GR&R) test was performed on the measurement apparatus, and it proved to be capable of measuring a 2 mm tolerance from the target. Replicated experiments were performed on a 2(3) factorial design (three parameters at two levels) and analysis included averages and standard deviation along with an analysis of variance (ANOVA) to find significant single and two-way interaction factors. RESULTS: Results showed that grid with tight clearance hole and slow needle speed increased precision and accuracy of needle insertion. The tight grid was vital to enhance precision and accuracy of needle insertion for both slow and fast insertion speed; additionally, at slow speed the tight, thick grid improved needle precision and accuracy. CONCLUSIONS: In summary, the tight grid is important, regardless of speed. The grid design, which shows the capability to reduce the needle deflection in brachytherapy procedures, can potentially be implemented in the brachytherapy procedure.

The Magnitude and Determinants of Partial Redemptions of Food Benefits in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC).

PURPOSE: WIC provides food assistance to low-income pregnant and postpartum women, infants, and children ages 1- 4. A partial redemption (PR) occurs when a participant redeems only a portion of the prescribed benefit, thereby not obtaining the full nutritional benefit. We study the magnitude and determinants of PRs using electronic benefit transfer data. DESIGN/SETTING: Statistical analysis of all WIC transactions from Feb 2016 to Nov 2018. SUBJECTS: Oklahoma WIC participants. MEASURES: The probability of a WIC household fully redeeming a food category. A random effects probit model is used to study determinants of PRs. ANALYSIS: Estimate the marginal effects of key variables on households' likelihood of full redemption: location-urban/rural, number of members in WIC, duration in the program, number of shopping trips, shopping venue, and prescribed foods. RESULTS: Overall 18.5% of $ value of benefits are unredeemed, 29.3% excluding formula. Some foods have PRs > 40%. Only 17.3% of households fully redeem benefits in a given month. PRs increase with number of household members in WIC and duration of participation. PRs are lower for participants in rural locations, who shop more frequently, and who shop at WIC-specialized stores. CONCLUSIONS: Food packages with high PRs fail to impart prescribed benefits. Results pinpoint products and household characteristics associated with PRs, enabling targeted nutritional counseling and suggest food package choices need to be made with participant acceptance in mind.

Prostate radiotherapy in the setting of bilateral hip prostheses: All commonly used photon-based radiation approaches are feasible.

The prevalence of hip prostheses is increasing. Prostate radiation delivery in the setting of hip prostheses is complicated by both imaging artifacts that interfere with volume delineation and dosimetric effects that must be addressed in the planning process. We hypothesized that with specialized planning, any photon-based definitive prostate radiotherapy approach may be utilized in patients with bilateral hip prostheses. Imaging data from sequential patients with prostate cancer and bilateral hip prostheses treated definitively with radiation were retrospectively reviewed. Bimodality imaging was used to define targets and organs at risk (OARs) along with specialized MRI sequences and/or orthopedic metal artifact reduction (OMAR) for MRI and CT artifact suppression, respectively. Multiple VMAT plans were generated for each set of patient images to include three fractionation schemes (conventional, hypofractionated, and SBRT), each with hip avoidance and with simulated normal hip. The ability to meet standard dose constraints was assessed for each plan type. Differences in target and OAR dosing between plans accounting for prosthetic hips via avoidance vs plans with simulated absence of prosthetic hip were also assessed. T-tests were used to compare dosimetric parameters. Ten patients with bilateral hip prostheses were identified, and 6 plans were created for each patient for a total of 60 radiation plans. Prosthetic hip avoidance did not result in failure to meet dose constraints for any patient. Hip avoidance resulted in minimal increases in high dose to the rectum and bladder (increases in mean V80%, V90%, and V95% ranged from 0.1% to 2.4%). Larger increases were seen at lower dose levels, with rectal V50% significantly increased in all three plan types with hip avoidance (conventional: 26.0% [standard deviation, SD 13.9] vs 16.9% [SD 10.2, p = 0.003]; hypofractionation: 26.4% [SD 13.3] vs 17.1% [SD 10.1, p = 0.002]; SBRT: 18.3% [SD 10.7] vs 10.5% [SD 6.9, p = 0.008]). Similarly, hip avoidance resulted in increases in bladder V50% to 31.7% (SD 16.8) vs 23.3% (SD 14.0, p = 0.001), 31.3% (SD 17.0) vs 23.3% (SD 13.8, p = 0.002), and 22.7% (SD 12.3) vs 16.5% (SD 12.6, p < 0.001) for conventional, hypofractionated, and SBRT plans, respectively. Hydrogel spacer resulted in reductions in rectal dose. For example, V70% for hip avoidance plans decreased with spacer presence to 8.3% (SD 6.7) vs 21.1% (SD 5.8, p = 0.021), 8.6% (SD 6.5) vs 21% (SD 5.7, p = 0.022), and 3.7% (SD 3.2) vs 15% (SD 8.2, p = 0.010) for conventional, hypofractionated, and SBRT plans, respectively. Any photon-based definitive prostate radiotherapy approach can be used with bimodality imaging for target and OAR definition and planning techniques to avoid dose attenuation effects of hip prostheses. Hydrogel spacer is a useful adjunct.

Efficacy and Incontinence Rates After Urethroplasty for Radiation-induced Urethral Stenosis: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the efficacy of urethroplasty and rates of de novo stress urinary incontinence (SUI) in the specific setting of radiation-induced urethral stenosis. METHODS: A systematic search of databases (PubMed and EMBASE) was performed between 1980-2019 (CRD42020144845). Inclusion criteria were: (1) prior pelvic radiotherapy; (2) surgical urethroplasty; (3) rates of successful treatment and/or SUI development and (4) total case number provided. The pooled summary of stenosis resolution rate and SUI were calculated using the random-effects model weighted by the inverse variance. Accessory analyses were performed by reconstructive technique and type of RT. RESULTS: Ninety-six studies were identified, of which 8 retrospective studies met inclusion criteria, comprising 256 patients. The proportion of cases treated with external beam RT (EBRT), brachytherapy (BT), or combination (EBRT+BT) were 52%, 33%, and 15%, respectively, of studies that specified modality. Most strictures involved the bulbomembranous region (n = 212; 83%). Sixty-one percent of cases (n = 157) entailed primary anastomosis, while the remainder underwent augmentation reconstruction (graft or flap). The mean follow-up time after urethroplasty varied from 10 to 50.5 months. The pooled stenosis resolution rate was 80% (95% CI: 74%-86%). There were no significant associations between stenosis resolution rate and reconstructive technique (rho=0.20, P = .74) or RT modality (rho=-0.31, P = .53). Fifty-three cases developed subsequent SUI, with a pooled complication rate of 19% (95% CI: 10%-31%). CONCLUSIONS: Urethroplasty after radiation-induced urethral stenosis is effective for 80% of cases, independent of prior RT modality or urethroplasty technique; however, 1 out of every 5 patients develops SUI post-procedure.

Progress in Low Dose Rate Brachytherapy for Prostate Cancer.

Low dose rate (LDR) brachytherapy has a proven critical role in achieving the modern standard of successful prostate cancer treatment, cure with quality of life (QoL) preservation. In the past decade, cure has been demonstrated in the most lethal form of prostate cancer treated with combined external beam and LDR brachytherapy. Additionally, QoL has moved from toxicity avoidance to preservation of function, with unprecedented sexual function preservation proven with intensive combination therapy. The technical advances that have made such outcomes possible have defined the full, dynamic complexity of the permanent prostate implant procedure, as well as effective solutions. Progress in LDR brachytherapy as it relates to prostate cancer biology, local control, toxicity reduction with function preservation, external beam integration, medical event prevention, patient selection, and comparative brachytherapy is reviewed. As in all brachytherapy procedures, the final clinical outcomes of cure, and QoL depend entirely on a foundation of verifiable technical excellence.

WIC Households' Bread and Cold Cereal Purchases: When They Use Benefits Versus Paying Out of Pocket.

PURPOSE: The US Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) seeks to improve the health of participating women and children by providing nutrition education and a monthly package of supplemental foods including whole grain bread and cereal. While some studies confirm that participants consume more whole grains, others find no effect. In this study, we hypothesize that the positive association between WIC and whole grains is being reduced in size and consistency by several factors. DESIGN/SETTING/PARTICIPANTS: American households were surveyed about their food purchases. Overall response rate was 45.6%. A total of 4826 households completed the survey including 471 WIC households. MEASURES: The survey recorded households' purchases of refined and whole grains in bread and cereal over 1 week. ANALYSIS: T tests were used to compare the bread and cereal purchases of WIC and eligible, non-WIC households. Probit models were also estimated to assess a WIC household's likelihood to choose whole grain foods when using benefits versus other payment methods. RESULTS: On average, WIC households acquired more whole grains in bread than eligible, non-WIC households (1.33 vs 0.72 ounce equivalents per household member aged 1 year or older; P < .05). No difference is found for cereal ( P > .10). Moreover, when using payment methods other than WIC benefits, WIC participants are 19% less likely than other households to choose whole grain bread ( P < .05) and 20% less likely to choose a whole grain cold cereal ( P < .05), which suggests that WIC-provided foods may replace some whole grains participants would otherwise buy for themselves. CONCLUSION: WIC is positively associated with whole grains. However, the association is stronger for bread than cereal. Moreover, foods provided through the program may partially replace whole grains that WIC households would otherwise buy for themselves.

Trends in Breastfeeding Disparities in US Infants by WIC Eligibility and Participation.

OBJECTIVE: To examine the trends in breastfeeding disparities across Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) eligibility and participation statuses in the last 2 decades. DESIGN: Secondary analyses from multiple cross-sectional surveys. SETTING: United States. PARTICIPANTS: The National Health and Nutrition Examination Survey 1999-2014 included 10,696 children younger than 60 months. Birth cohorts in 4-year increments were created from 1994 to 2014. MAIN OUTCOME MEASURES: Ever-breastfed status and breastfed-at-6-months status. ANALYSIS: The prevalence rates of ever-breastfed and breastfed at 6 months were estimated between WIC-eligible vs non-eligible children and WIC-eligible participants vs eligible nonparticipants. Prevalence rates and their 95% confidence intervals were plotted across birth cohorts. Log-binomial regression was conducted to test the trends of breastfeeding in each subgroup. RESULTS: Ever-breastfeeding rates increased from 52% (WIC participants) vs 57% (WIC-eligible nonparticipants) in the 1994-1997 birth cohort to 71% vs 77% in the 2010-2014 birth cohort-a 36% vs 34% relative increase for participants vs eligible nonparticipants, respectively (P < .001). Breastfeeding-at-6-month rates increased from 28% (participants) vs 30% (eligible nonparticipants) to 34% vs 49% in the same time period-a 21% vs 66% relative increase, respectively (P < .001). CONCLUSION AND IMPLICATIONS: To meet the Healthy People 2020's goal for breastfeeding at 6 months, sustainable postpartum breastfeeding education and interventions may be needed among WIC participants. Future research focusing on identification of the causal relationship between WIC participation and breastfeeding outcomes is warranted.

Combined permanent implant and external-beam radiation therapy for prostate cancer.

A number of series have been published examining the utility of combining low-dose rate permanent interstitial implants with external-beam radiation (CMT). However, the data show conflicting results. Comparisons of these studies are confounded by the lack of similar biochemical failure definitions, inequities in risk groups between compared arms, variable implant quality, and differences in implant margins and techniques. Despite these limitations, the literature does suggest that CMT may help spare patients the need for androgen deprivation, overcome adverse pathologic factors, and correct for poor implant quality. We present the recent innovation and potential benefits of using implant dose-adjusted intensity-modulated radiation therapy.

Individual and Store Characteristics Associated with Brand Choices in Select Food Category Redemptions among WIC Participants in Virginia.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) often allows participants to redeem food benefits for various brands at different costs. To aid the program's food cost containment efforts, it is important to understand the individual and store characteristics associated with brand choices. This study used the WIC Electronic Benefit Transfer (EBT) data for 239,062 Virginia WIC participants' brand choices in infant fruits and vegetables (F&Vs) and whole grain bread in May 2014-February 2015, one of the first such data sets available in the U.S. for research purposes. Mixed effects logistic regression models were used to analyze the choice of higher-priced brands over lower-priced brands. Minority participants were significantly more likely to redeem higher-priced brands of infant F&Vs, but more likely to choose lower-priced brands of bread. Participants shopping in urban stores or midsized stores (with 5-9 registers) were less likely to choose higher-priced brands compared to rural stores or large stores (with 9+ registers). Race/ethnicity and store characteristics may be significant factors in participants' brand choices. The results can help develop interventions that encourage targeted participants to redeem lower-priced but equivalently healthy brands. This may not only help contain WIC program costs, but help participants manage their own non-WIC food expenses as well.

Magnetic resonance imaging-guided functional anatomy approach to prostate brachytherapy.

PURPOSE: To provide an MRI based functional anatomy guide to prostate brachytherapy. METHODS AND MATERIALS: We performed a narrative review of periprostatic functional anatomy and the significance of this anatomy in prostate brachytherapy treatment planning. RESULTS: MRI has improved delineation of gross tumor and critical periprostatic structures that have been implicated in toxicity. Furthermore, MRI has revealed the significant anatomic variants and the dynamic nature of these structures that can have significant implications for treatment planning and dosimetry. CONCLUSIONS: The MRI-based functional anatomy approach to prostate brachytherapy takes into account extent of disease, its relation to the patient's individual anatomy, and functional baseline to optimize the therapeutic ratio of prostate cancer treatment.

Advances in Prostate Cancer Magnetic Resonance Imaging and Positron Emission Tomography-Computed Tomography for Staging and Radiotherapy Treatment Planning.

Conventional prostate cancer staging strategies have limited accuracy to define the location, grade, and burden of disease. Evaluations have historically relied upon prostate-specific antigen levels, digital rectal examinations, random systematic biopsies, computed tomography, pelvic lymphadenectomy, or 99mtechnetium methylene diphosphonate bone scans. Today, risk-stratification tools incorporate these data in a weighted format to guide management. However, the limitations and potential consequences of their uncertainties are well known. Inaccurate information may contribute to understaging and undertreatment, or overstaging and overtreatment. Meanwhile, advances in multiparametric magnetic resonance imaging (MRI), whole-body MRI, lymphotropic nanoparticle-enhanced MRI, and positron emission tomography are now available to improve the accuracy of risk stratification to facilitate more informed medical decisions. They also guide radiation oncologists to develop more accurate treatment plans. This review provides a primer to incorporate these advances into routine clinical workflow.

American Brachytherapy Society Task Group Report: Combination of brachytherapy and external beam radiation for high-risk prostate cancer.

PURPOSE: To review outcomes for high-risk prostate cancer treated with combined modality radiation therapy (CMRT) utilizing external beam radiation therapy (EBRT) with a brachytherapy boost. METHODS AND MATERIALS: The available literature for high-risk prostate cancer treated with combined modality radiation therapy was reviewed and summarized. RESULTS: At this time, the literature suggests that the majority of high-risk cancers are curable with multimodal treatment. Several large retrospective studies and three prospective randomized trials comparing CMRT to dose-escalated EBRT have demonstrated superior biochemical control with CMRT. Longer followup of the randomized trials will be required to determine if this will translate to a benefit in metastasis-free survival, disease-specific survival, and overall survival. Although greater toxicity has been associated with CMRT compared to EBRT, recent studies suggest that technological advances that allow better definition and sparing of critical adjacent structures as well as increasing experience with brachytherapy have improved implant quality and the toxicity profile of brachytherapy. The role of androgen deprivation therapy is well established in the external beam literature for high-risk disease, but there is controversy regarding the applicability of these data in the setting of dose escalation. At this time, there is not sufficient evidence for the omission of androgen deprivation therapy with dose escalation in this population. Comparisons with surgery remain limited by differences in patient selection, but the evidence would suggest better disease control with CMRT compared to surgery alone. CONCLUSIONS: Due to a series of technological advances, modern combination series have demonstrated unparalleled rates of disease control in the high-risk population. Given the evidence from recent randomized trials, combination therapy may become the standard of care for high-risk cancers.