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1.
Eur Urol Oncol ; 2024 Sep 21.
Article in English | MEDLINE | ID: mdl-39307608

ABSTRACT

BACKGROUND AND OBJECTIVE: Local intraprostatic radiorecurrence of prostate cancer (IPR-PC) can be associated with an aggressive natural history and impact long-term disease-specific survival. While appropriate local salvage intervention can be curative, best practices for workup and local salvage of intraprostatic recurrence are poorly defined. The American Radium Society (ARS) Genitourinary Appropriate Use Criteria Committee sought to develop evidence-based recommendations to address this gap. METHODS: PubMed and Embase were searched to retrieve a comprehensive set of relevant peer-reviewed articles on four topics relevant to the workup and treatment of IPR-PC. The literature was evaluated and summarized by three investigators, and clinical variants were created for each of the four topics. The ARS Genitourinary AUC multidisciplinary expert panel voted on the most appropriate procedures for each variant, and a modified Delphi approach was used to summarize recommendations. KEY FINDINGS AND LIMITATIONS: The panel concluded that radiographic staging via prostate-specific membrane antigen positron emission tomography (PSMA PET) and multiparametric magnetic resonance imaging should be performed to exclude patients with metastatic disease and identify the local extent of radiorecurrence. Biopsy is required before local salvage to avoid excessive toxicity in patients whose radiographic recurrence represents a treatment effect. Consideration of local salvage is preferred in lieu of noncurative hormonal manipulation alone, although shared decision-making is critical. Salvage reirradiation approaches are recommended to limit toxicity. Hormonal therapy may be beneficial for radiosensitization when radiotherapeutic salvage is pursued, but only of short duration, and classic androgen deprivation therapies are preferred over novel hormonal agents. Focal salvage should be pursued when confidence in focal recurrence can be confirmed via multiple radiographic and tissue sampling modalities, although the toxicity associated with whole-gland salvage appears to be very tolerable. Several radiotherapeutic salvage regimens exist, most of which can be carried out in six or fewer fractions. The data informing this guideline are limited to individuals initially treated with conventionally fractionated external beam radiotherapy and with workup for recurrence before the PSMA PET era. CONCLUSIONS AND CLINICAL IMPLICATIONS: This consensus guideline provides evidence-based guidance on the appropriate procedures for workup and treatment of IPR-PC. Prospective evidence to enrich these guidelines is eagerly anticipated. PATIENT SUMMARY: We summarize evidence for the best workup and treatment for patients with local recurrence of prostate cancer after radiotherapy. A panel of experts evaluated previous studies and voted on the procedures that should be performed and those that should be avoided. This guideline is a useful tool for helping doctors to discuss the best treatment options that maximize the chance of cure while minimizing side effects.

2.
Int J Radiat Oncol Biol Phys ; 117(2): 505-514, 2023 10 01.
Article in English | MEDLINE | ID: mdl-37141982

ABSTRACT

PURPOSE: This study explored deep-learning-based patient-specific auto-segmentation using transfer learning on daily RefleXion kilovoltage computed tomography (kVCT) images to facilitate adaptive radiation therapy, based on data from the first group of patients treated with the innovative RefleXion system. METHODS AND MATERIALS: For head and neck (HaN) and pelvic cancers, a deep convolutional segmentation network was initially trained on a population data set that contained 67 and 56 patient cases, respectively. Then the pretrained population network was adapted to the specific RefleXion patient by fine-tuning the network weights with a transfer learning method. For each of the 6 collected RefleXion HaN cases and 4 pelvic cases, initial planning computed tomography (CT) scans and 5 to 26 sets of daily kVCT images were used for the patient-specific learning and evaluation separately. The performance of the patient-specific network was compared with the population network and the clinical rigid registration method and evaluated by the Dice similarity coefficient (DSC) with manual contours being the reference. The corresponding dosimetric effects resulting from different auto-segmentation and registration methods were also investigated. RESULTS: The proposed patient-specific network achieved mean DSC results of 0.88 for 3 HaN organs at risk (OARs) of interest and 0.90 for 8 pelvic target and OARs, outperforming the population network (0.70 and 0.63) and the registration method (0.72 and 0.72). The DSC of the patient-specific network gradually increased with the increment of longitudinal training cases and approached saturation with more than 6 training cases. Compared with using the registration contour, the target and OAR mean doses and dose-volume histograms obtained using the patient-specific auto-segmentation were closer to the results using the manual contour. CONCLUSIONS: Auto-segmentation of RefleXion kVCT images based on the patient-specific transfer learning could achieve higher accuracy, outperforming a common population network and clinical registration-based method. This approach shows promise in improving dose evaluation accuracy in RefleXion adaptive radiation therapy.


Subject(s)
Image Processing, Computer-Assisted , Radiotherapy Planning, Computer-Assisted , Humans , Radiotherapy Planning, Computer-Assisted/methods , Image Processing, Computer-Assisted/methods , Organs at Risk/diagnostic imaging , Organs at Risk/radiation effects , Radiometry , Tomography, X-Ray Computed
4.
JAMA Netw Open ; 5(7): e2223025, 2022 07 01.
Article in English | MEDLINE | ID: mdl-35900763

ABSTRACT

Importance: Shared decision-making is an important part of the treatment selection process among patients with prostate cancer. Updated information is needed regarding the long-term incidence and risk of second primary cancer after radiotherapy vs nonradiotherapy treatments, which may help to inform discussions of risks and benefits for men diagnosed with prostate cancer. Objective: To assess the current incidence and risk of developing a second primary cancer after receipt of radiotherapy vs nonradiotherapy treatments for prostate cancer. Design, Setting, and Participants: This retrospective cohort study used the Veterans Affairs Corporate Data Warehouse to identify 154 514 male veterans 18 years and older who had localized prostate cancer (tumor stages T1-T3) diagnosed between January 1, 2000, and December 31, 2015, and no cancer history. A total of 10 628 patients were excluded because of (1) incomplete treatment information for the year after diagnosis, (2) receipt of both radiotherapy and a surgical procedure in the year after diagnosis, (3) receipt of radiotherapy more than 1 year after diagnosis, (4) occurrence of second primary cancer or death within 1 year or less after diagnosis, (5) prostate-specific antigen value greater than 99 ng/mL within 6 months before diagnosis, or (6) no recorded Veterans Health Administration service after diagnosis. The remaining 143 886 patients included in the study had a median (IQR) follow-up of 9 (6-13) years. Data were analyzed from May 1, 2021, to May 22, 2022. Main Outcomes and Measures: Diagnosis of a second primary cancer more than 1 year after prostate cancer diagnosis. Results: Among 143 886 male veterans (median [IQR] age, 65 [60-71] years) with localized prostate cancer, 750 (0.5%) were American Indian or Alaska Native, 389 (0.3%) were Asian, 37 796 (26.3%) were Black or African American, 933 (0.6%) were Native Hawaiian or other Pacific Islander, 91 091 (63.3%) were White, and 12 927 (9.0%) were of unknown race; 7299 patients (5.1%) were Hispanic or Latino, 128 796 (89.5%) were not Hispanic or Latino, and 7791 (5.4%) were of unknown ethnicity. A total of 52 886 patients (36.8%) received primary radiotherapy, and 91 000 (63.2%) did not. A second primary cancer more than 1 year after prostate cancer diagnosis was present in 4257 patients (3.0%), comprising 1955 patients (3.7%) in the radiotherapy cohort and 2302 patients (2.5%) in the nonradiotherapy cohort. In the multivariable analyses, patients in the radiotherapy cohort had a higher risk of second primary cancer compared with those in the nonradiotherapy cohort at years 1 to 5 after diagnosis (hazard ratio [HR], 1.24; 95% CI, 1.13-1.37; P < .001), with higher adjusted HRs in the subsequent 15 years (years 5-10: 1.50 [95% CI, 1.36-1.65; P < .001]; years 10-15: 1.59 [95% CI, 1.37-1.84; P < .001]; years 15-20: 1.47 [95% CI, 1.08-2.01; P = .02). Conclusions and Relevance: In this cohort study, patients with prostate cancer who received radiotherapy were more likely to develop a second primary cancer than patients who did not receive radiotherapy, with increased risk over time. Although the incidence and risk of developing a second primary cancer were low, it is important to discuss the risk with patients during shared decision-making about prostate cancer treatment options.


Subject(s)
Neoplasms, Second Primary , Prostatic Neoplasms , Aged , Humans , Male , Middle Aged , Neoplasms, Second Primary/epidemiology , Prostatic Neoplasms/radiotherapy , Prostatic Neoplasms/surgery , Retrospective Studies , Risk Assessment
6.
Telemed Rep ; 3(1): 1-6, 2022.
Article in English | MEDLINE | ID: mdl-35720450

ABSTRACT

Purpose/Objectives: Medical documentation has become increasingly challenging for providers, particularly with changes to telemedicine visit formats during the ongoing COVID-19 pandemic. Medical scribes may help mitigate this burden. Our objective was to determine how scribes affect provider efficiency during the COVID-19 pandemic. Materials/Methods: Providers completed a survey in February 2020 (S1, prepandemic) and 1 year into the COVID-19 pandemic in February 2021 (S2, during pandemic). S1 evaluated perceived impact of scribes on clerical work, medical documentation, and efficiency during office visits using the Likert scale. S2 also addressed scribe use during telemedicine visits. Provider time spent on documentation with or without a scribe was evaluated using a five-level ordinal scale. Provider response was assessed using descriptive frequency statistics. Fisher's exact test was used to compare categorical variables. Analysis was performed using SAS version 9.4 (SAS Institute, Inc., Cary, NC). All tests were two sided with an alpha level of 0.05. Results: Fifty-eight providers responded to the surveys: 36 (62%) for S1 and 22 (38%) for S2. Scribe use decreased perceived clerical work and facilitated chart review, and recording of physical examination findings, note documentation, and improved efficiency, both before and during the pandemic (p = 0.5, p = 0.7, p = 0.8, p = 0.8, p = 0.9, respectively). Scribe use significantly decreased time to complete documentation prepandemic (p = 0.002) and during the pandemic for both in-person (p ≤ 0.0001) and telemedicine visits (p = 0.0004). More providers took >60 min to complete medical documentation without the use of a scribe prepandemic (72% vs. 30% with a scribe, p = 0.006) and during the pandemic, after both in-person (40% vs. 0% with a scribe, p = 0.002) and telemedicine visits (35% vs. 0% with a scribe, p = 0.002). Conclusions: Scribe use decreases provider time spent on medical documentation and improves overall efficiency before and during the COVID-19 pandemic for both in-person and telemedicine visits. Integration of scribes into radiation oncology in-person and telemedicine clinics may improve provider satisfaction by reducing burden of documentation.

8.
BMC Urol ; 22(1): 32, 2022 Mar 10.
Article in English | MEDLINE | ID: mdl-35272646

ABSTRACT

BACKGROUND: The syndrome of inappropriate secretion of antidiuretic hormone is a disorder characterized by the excess release of antidiuretic hormone and can result in hyponatremia. If managed inappropriately, severe hyponatremia can cause seizures, cerebral edema, and even death. There are various known causes of this inappropriate release of antidiuretic hormone, including malignancy, CNS disorders, and disturbances in the hypothalamic-pituitary-renal axis. However, reports of syndrome of inappropriate secretion of antidiuretic hormone after brachytherapy for prostate cancer are exceedingly rare. CASE PRESENTATION: We report a case of symptomatic hyponatremia secondary to the inappropriate secretion of antidiuretic hormone after prostate high-dose rate brachytherapy under general anesthesia in a patient with adenocarcinoma of the prostate. CONCLUSIONS: In rare instances, inappropriate secretion of antidiuretic hormone can occur after high-dose rate brachytherapy for prostate cancer. The cause is likely multifactorial, involving pain or discomfort ensuing from the surgical procedure, the general anesthesia or intraoperative drugs administered. However, due to the potential severity of the side effects, timely diagnosis is crucial to ensure prompt, and effective management.


Subject(s)
Adenocarcinoma/radiotherapy , Brachytherapy/adverse effects , Inappropriate ADH Syndrome/etiology , Prostatic Neoplasms/radiotherapy , Aged , Humans , Hyponatremia/etiology , Inappropriate ADH Syndrome/complications , Inappropriate ADH Syndrome/therapy , Male , Radiotherapy Dosage
9.
Int J Radiat Oncol Biol Phys ; 113(2): 278-289, 2022 06 01.
Article in English | MEDLINE | ID: mdl-34923058

ABSTRACT

Androgen deprivation therapy (ADT) is an integral component in the management of prostate cancer across multiple disease states. Traditionally, luteinizing hormone-releasing hormone (LHRH) agonists constituted the backbone of ADT. However, gonadotropin-releasing hormone receptor hormone (GnRH) antagonists also are available, which offer faster testosterone suppression and reduced likelihood of ADT-related adverse effects compared with LHRH agonists, including the potential for fewer ADT-associated major cardiac events. Until recently, all forms of LHRH agonists and GnRH antagonist formulations were of parenteral administration. However, recently relugolix gained Food and Drug Administration approval as the first oral GnRH antagonist. Relugolix achieves faster and more complete testosterone suppression compared with an LHRH agonist. This translates to more rapid prostate-specific antigen response compared with LHRH agonists. After discontinuation of relugolix, testosterone recovers faster than after GnRH agonists or injectable GnRH antagonist therapy. Overall, these factors provide opportunities for more precisely defined ADT duration when combined with radiation therapy. The rapid onset and offset of testosterone suppression with relugolix may require physicians to rethink the mechanism and goals of ADT when prescribing. As an oral formulation, relugolix enables patients to avoid pain and injection site reactions, limit extra office visits for injections, and achieve a shorter duration of experiencing the side effects of castrate testosterone levels. This convenience and tolerability may enhance physicians' willingness to prescribe ADT and patients' feeling of control during their ADT course, but the potential advantages are accompanied by the risks of patients choosing to discontinue therapy to escape side effects of ADT. This article focuses on different aspects of what is known and unknown regarding the optimal use of ADT and radiation therapy, and how relugolix, due to its properties, fit into our current treatment paradigms for localized prostate cancer.


Subject(s)
Prostatic Neoplasms , Androgen Antagonists/therapeutic use , Gonadotropin-Releasing Hormone/agonists , Humans , Male , Phenylurea Compounds , Prostatic Neoplasms/drug therapy , Prostatic Neoplasms/radiotherapy , Pyrimidinones , Testosterone
10.
Radiother Oncol ; 166: 1-7, 2022 01.
Article in English | MEDLINE | ID: mdl-34774650

ABSTRACT

BACKGROUND AND PURPOSE: The Phoenix definition for biochemical failure (BCF) after radiotherapy uses nadir PSA (nPSA) + 2 ng/mL to classify a BCF and was derived from conventionally fractionated radiotherapy, which produces significantly higher nPSAs than stereotactic body radiotherapy (SBRT). We investigated whether an alternative nPSA-based threshold could be used to define post-SBRT BCFs. MATERIALS AND METHODS: PSA kinetics data on 2038 patients from 9 institutions were retrospectively analyzed for low- and intermediate-risk PCa patients treated with SBRT without ADT. We evaluated the performance of various nPSA-based definitions. We also investigated the relationship of relative PSA decline (rPSA, PSA18month/PSA6month) and timing of reaching nPSA + 2 with BCF. RESULTS: Median follow-up was 71.9 months. BCF occurred in 6.9% of patients. Median nPSA was 0.16 ng/mL. False positivity of nPSA + 2 was 30.2%, compared to 40.9%, 57.8%, and 71.0% for nPSA + 1.5, nPSA + 1.0, and nPSA + 0.5, respectively. Among patients with BCF, the median lead time gained from an earlier nPSA + threshold definition over the Phoenix definition was minimal. Patients with BCF had significantly lower rates of early PSA decline (mean rPSA 1.19 vs. 0.39, p < 0.0001) and were significantly more likely to reach nPSA + 2 ≥ 18 months (83.3% vs. 21.1%, p < 0.0001). The proposed criterion (rPSA ≥ 2.6 or nPSA + 2 ≥ 18 months) had a sensitivity and specificity of 92.4% and 81.5%, respectively, for predicting BCF in patients meeting the Phoenix definition and decreased its false positivity to 6.4%. CONCLUSION: The Phoenix definition remains an excellent definition for BCF post-SBRT. Its high false positivity can be mitigated by applying additional criteria (rPSA ≥ 2.6 or time to nPSA + 2 ≥ 18 months).


Subject(s)
Brachytherapy , Prostatic Neoplasms , Radiosurgery , Humans , Male , Prostate-Specific Antigen , Prostatic Neoplasms/radiotherapy , Prostatic Neoplasms/surgery , Retrospective Studies
11.
Adv Radiat Oncol ; 6(6): 100759, 2021.
Article in English | MEDLINE | ID: mdl-34585025

ABSTRACT

PURPOSE: To evaluate the safety of stereotactic body radiation therapy (SBRT) for prostate cancer in men with inflammatory bowel disease (IBD). METHODS AND MATERIALS: We queried a consortium database for patients with IBD receiving SBRT for prostate cancer between 2006 and 2012. Identified patients were matched with patients without a history of IBD in a 3:1 fashion based on dose, fractionation, use of androgen deprivation therapy, and age distribution. Logistic regression was used to evaluate the association between having IBD and experiencing acute and late gastrointestinal (GI) and genitourinary (GU) toxicities as scored on the Common Terminology Criteria for Adverse Events scale. Time to late toxicity was evaluated using proportional hazard Cox models. Our study was limited by absence of data on prostate size, baseline International Prostate Symptom Score, and rectal dose-volume histogram parameters. RESULTS: Thirty-nine patients with flare-free IBD at time of treatment (median follow-up 83.9 months) and 117 matched controls (median follow-up 88.7 months) were identified. A diagnosis of IBD was associated with increased odds of developing any late grade GI toxicity (odds ratio [OR] 6.11, P <.001) and GU toxicity (odds ratio 6.14, P < .001), but not odds of developing late grade ≥2 GI (P = .08) or GU toxicity (P = .069). Acute GI and GU toxicity, both overall and for grade ≥2 toxicities, were more frequent in men with IBD (P < .05). Time to late GI and GU toxicity of any grade was significantly shorter in patients with IBD (P < .001). Time to late grade ≥2 GU, but not grade ≥2 GI toxicity, was also shorter in patients with IBD (P = .044 for GU and P = .144 for GI). CONCLUSIONS: Patients with IBD who received SBRT for PCa had a higher likelihood of developing acute GI and GU toxicity, in addition to experiencing lower grade late toxicities that occurred earlier. However, patients with IBD did not have a higher likelihood for late grade ≥2 GI or GU toxicity after SBRT compared with the control cohort. Interpretation of this data are limited by the small sample size. Thus, men with IBD in remission should be properly counseled about these risks when considering SBRT.

12.
Med Phys ; 48(6): 3074-3083, 2021 Jun.
Article in English | MEDLINE | ID: mdl-33905566

ABSTRACT

PURPOSE: Propagation of contours from high-quality magnetic resonance (MR) images to treatment planning ultrasound (US) images with severe needle artifacts is a challenging task, which can greatly aid the organ contouring in high dose rate (HDR) prostate brachytherapy. In this study, a deep learning approach was developed to automatize this registration procedure for HDR brachytherapy practice. METHODS: Because of the lack of training labels and difficulty of accurate registration from inferior image quality, a new segmentation-based registration framework was proposed for this multi-modality image registration problem. The framework consisted of two segmentation networks and a deformable registration network, based on the weakly -supervised registration strategy. Specifically, two 3D V-Nets were trained for the prostate segmentation on the MR and US images separately, to generate the weak supervision labels for the registration network training. Besides the image pair, the corresponding prostate probability maps from the segmentation were further fed to the registration network to predict the deformation matrix, and an augmentation method was designed to randomly scale the input and label probability maps during the registration network training. The overlap between the deformed and fixed prostate contours was analyzed to evaluate the registration accuracy. Three datasets were collected from our institution for the MR and US image segmentation networks, and the registration network learning, which contained 121, 104, and 63 patient cases, respectively. RESULTS: The mean Dice similarity coefficient (DSC) results of the two prostate segmentation networks are 0.86 ± 0.05 and 0.90 ± 0.03, for MR images and the US images after the needle insertion, respectively. The mean DSC, center-of-mass (COM) distance, Hausdorff distance (HD), and averaged symmetric surface distance (ASSD) results for the registration of manual prostate contours were 0.87 ± 0.05, 1.70 ± 0.89 mm, 7.21 ± 2.07 mm, 1.61 ± 0.64 mm, respectively. By providing the prostate probability map from the segmentation to the registration network, as well as applying the random map augmentation method, the evaluation results of the four metrics were all improved, such as an increase in DSC from 0.83 ± 0.08 to 0.86 ± 0.06 and from 0.86 ± 0.06 to 0.87 ± 0.05, respectively. CONCLUSIONS: A novel segmentation-based registration framework was proposed to automatically register prostate MR images to the treatment planning US images with metal artifacts, which not only largely saved the labor work on the data preparation, but also improved the registration accuracy. The evaluation results showed the potential of this approach in HDR prostate brachytherapy practice.


Subject(s)
Brachytherapy , Prostatic Neoplasms , Humans , Image Processing, Computer-Assisted , Magnetic Resonance Imaging , Male , Prostatic Neoplasms/diagnostic imaging , Prostatic Neoplasms/radiotherapy , Ultrasonography
13.
J Nucl Med ; 62(11): 1545-1549, 2021 11.
Article in English | MEDLINE | ID: mdl-33674398

ABSTRACT

Novel radiopharmaceuticals for PET are being evaluated for the diagnosis of biochemical recurrence (BCR) of prostate cancer (PC). We compared the gastrin-releasing peptide receptor-targeting 68Ga-RM2 with the prostate-specific membrane antigen (PSMA)-targeting 68Ga-PSMA11 and 18F-DCFPyL. Methods: Fifty patients underwent both 68Ga-RM2 PET/MRI and 68Ga-PSMA11 (n = 23) or 18F-DCFPyL (n = 27) PET/CT at an interval ranging from 1 to 60 d (mean ± SD, 15.8 ± 17.7 d). SUVmax was collected for all lesions. Results:68Ga-RM2 PET was positive in 35 and negative in 15 of the 50 patients. 68Ga-PSMA11/18F-DCFPyL PET was positive in 37 and negative in 13 of the 50 patients. Both scans detected 70 lesions in 32 patients. Forty-three lesions in 18 patients were identified on only 1 scan: 68Ga-RM2 detected 7 more lesions in 4 patients, whereas 68Ga-PSMA11/18F-DCFPyL detected 36 more lesions in 13 patients. Conclusion:68Ga-RM2 remains a valuable radiopharmaceutical even when compared with the more widely used 68Ga-PSMA11/18F-DCFPyL in the evaluation of BCR of PC. Larger studies are needed to verify that identifying patients for whom these 2 classes of radiopharmaceuticals are complementary may ultimately allow for personalized medicine.


Subject(s)
Prostatic Neoplasms , Humans , Male , Middle Aged , Positron Emission Tomography Computed Tomography , Receptors, Bombesin
14.
BMC Med Inform Decis Mak ; 21(1): 374, 2021 12 31.
Article in English | MEDLINE | ID: mdl-34972513

ABSTRACT

BACKGROUND: A shared decision-making model is preferred for engaging prostate cancer patients in treatment decisions. However, the process of assessing an individual's preferences and values is challenging and not formalized. The purpose of this study is to develop an automated decision aid for patient-centric treatment decision-making using decision analysis, preference thresholds and value elicitations to maximize the compatibility between a patient's treatment expectations and outcome. METHODS: A template for patient-centric medical decision-making was constructed. The inputs included prostate cancer risk group, pre-treatment health state, treatment alternatives (primarily focused on radiation in this model), side effects (erectile dysfunction, urinary incontinence, nocturia and bowel incontinence), and treatment success (5-year freedom from biochemical failure). A linear additive value function was used to combine the values for each attribute (side effects, success and the alternatives) into a value for all prospects. The patient-reported toxicity probabilities were derived from phase II and III trials. The probabilities are conditioned on the starting state for each of the side effects. Toxicity matrices for erectile dysfunction, urinary incontinence, nocturia and bowel incontinence were created for the treatment alternatives. Toxicity probability thresholds were obtained by identifying the patient's maximum acceptable threshold for each of the side effects. Results are represented as a visual. R and Rstudio were used to perform analyses, and R Shiny for application creation. RESULTS: We developed a web-based decision aid. Based on preliminary use of the application, every treatment alternative could be the best choice for a decision maker with a particular set of preferences. This result implies that no treatment has determinist dominance over the remaining treatments and that a preference-based approach can help patients through their decision-making process, potentially affecting compliance with treatment, tolerance of side effects and satisfaction with the decision. CONCLUSIONS: We present a unique patient-centric prostate cancer treatment decision aid that systematically assesses and incorporates a patient's preferences and values to rank treatment options by likelihood of achieving the preferred outcome. This application enables the practice and study of personalized medicine. This model can be expanded to include additional inputs, such as genomics, as well as competing, concurrent or sequential therapies.


Subject(s)
Decision Making, Shared , Prostatic Neoplasms , Decision Making , Decision Support Techniques , Genomics , Humans , Male , Patient Participation , Precision Medicine , Prostatic Neoplasms/therapy
15.
Int J Radiat Oncol Biol Phys ; 109(4): 953-963, 2021 03 15.
Article in English | MEDLINE | ID: mdl-33127490

ABSTRACT

PURPOSE: Definitive radiation therapy (RT), with or without concurrent chemotherapy, is an alternative to radical cystectomy for patients with localized, muscle-invasive bladder cancer (MIBC) who are either not surgical candidates or prefer organ preservation. We aim to synthesize an evidence-based guideline regarding the appropriate use of RT. METHODS AND MATERIALS: We performed a Preferred Reporting Items for Systematic Reviews and Meta-analyses literature review using the PubMed and Embase databases. Based on the literature review, critical management topics were identified and reformulated into consensus questions. An expert panel was assembled to address key areas of both consensus and controversy using the modified Delphi framework. RESULTS: A total of 761 articles were screened, of which 61 were published between 1975 and 2019 and included for full review. There were 7 well-designed studies, 20 good quality studies, 28 quality studies with design limitations, and 6 references not suited as primary evidence. Adjuvant radiation therapy after cystectomy was not included owing to lack of high-quality data or clinical use. An expert panel consisting of 14 radiation oncologists, 1 medical oncologist, and 1 urologist was assembled. We identified 4 clinical variants of MIBC: surgically fit patients who wish to pursue organ preservation, patients surgically unfit for cystectomy, patients medically unfit for cisplatin-based chemotherapy, and borderline cystectomy candidates based on age with unilateral hydronephrosis and normal renal function. We identified key areas of controversy, including use of definitive radiation therapy for patients with negative prognostic factors, appropriate radiation therapy dose, fractionation, fields and technique when used, and chemotherapy sequencing and choice of agent. CONCLUSIONS: There is limited level-one evidence to guide appropriate treatment of MIBC. Studies vary significantly with regards to patient selection, chemotherapy use, and radiation therapy technique. A consensus guideline on the appropriateness of RT for MIBC may aid practicing oncologists in bridging the gap between data and clinical practice.


Subject(s)
Radium/therapeutic use , Urinary Bladder Neoplasms/radiotherapy , Aged , Aged, 80 and over , Female , Humans , Lymph Nodes/pathology , Male , Radiotherapy Dosage , Radiotherapy, Intensity-Modulated , Urinary Bladder Neoplasms/mortality , Urinary Bladder Neoplasms/pathology
16.
Global Spine J ; 11(1): 44-49, 2021 Jan.
Article in English | MEDLINE | ID: mdl-32875859

ABSTRACT

STUDY DESIGN: This was an epidemiological study using national administrative data from the MarketScan database. OBJECTIVE: To investigate the impact of early versus delayed adjuvant radiotherapy (RT) on wound healing following surgical resection for spinal metastatic disease. METHODS: We queried the MarketScan database (2007-2016), identifying patients with a diagnosis of spinal metastasis who also underwent RT within 8 weeks of surgery. Patients were categorized into "Early RT" if they received RT within 4 weeks of surgery and as "Late RT" if they received RT between 4 and 8 weeks after surgery. Descriptive statistics and hypothesis testing were used to compare baseline characteristics and wound complication outcomes. RESULTS: A total of 540 patients met the inclusion criteria: 307 (56.9%) received RT within 4 weeks (Early RT) and 233 (43.1%) received RT within 4 to 8 weeks (Late RT) of surgery. Mean days to RT for the Early RT cohort was 18.5 (SD, 6.9) and 39.7 (SD, 7.6) for the Late RT cohort. In a 90-day surveillance period, n = 9 (2.9%) of Early RT and n = 8 (3.4%) of Late RT patients developed wound complications (P = .574). CONCLUSIONS: When comparing patients who received RT early versus delayed following surgery, there were no significant differences in the rates of wound complications. Further prospective studies should aim to identify optimal patient criteria for early postoperative RT for spinal metastases.

17.
Med Phys ; 47(12): 6421-6429, 2020 Dec.
Article in English | MEDLINE | ID: mdl-33012016

ABSTRACT

PURPOSE: Contouring intraprostatic lesions is a prerequisite for dose-escalating these lesions in radiotherapy to improve the local cancer control. In this study, a deep learning-based approach was developed for automatic intraprostatic lesion segmentation in multiparametric magnetic resonance imaging (mpMRI) images contributing to clinical practice. METHODS: Multiparametric magnetic resonance imaging images from 136 patient cases were collected from our institution, and all these cases contained suspicious lesions with Prostate Imaging Reporting and Data System (PI-RADS) score ≥ 4. The contours of the lesion and prostate were manually created on axial T2-weighted (T2W), apparent diffusion coefficient (ADC) and high b-value diffusion-weighted imaging (DWI) images to provide the ground truth data. Then a multiple branch UNet (MB-UNet) was proposed for the segmentation of an indistinct target in multi-modality MRI images. An encoder module was designed with three branches for the three MRI modalities separately, to fully extract the high-level features provided by different MRI modalities; an input module was added by using three sub-branches for three consecutive image slices, to consider the contour consistency among different image slices; deep supervision strategy was also integrated into the network to speed up the convergency of the network and improve the performance. The probability maps of the background, normal prostate and lesion were output by the network to generate the segmentation of the lesion, and the performance was evaluated using the dice similarity coefficient (DSC) as the main metric. RESULTS: A total of 162 lesions were contoured on 652 image slices, with 119 lesions in the peripheral zone, 38 in the transition zone, four in the central zone and one in the anterior fibromuscular stroma. All prostates were also contoured on 1,264 image slices. As for the segmentation of lesions in the testing set, MB-UNet achieved a per case DSC of 0.6333, specificity of 0.9993, sensitivity of 0.7056; and global DSC of 0.7205, specificity of 0.9993, sensitivity of 0.7409. All the three deep learning strategies adopted in this study contributed to the performance promotion of the MB-UNet. Missing the DWI modality would degrade the segmentation performance more markedly compared with the other two modalities. CONCLUSIONS: A deep learning-based approach with proposed MB-UNet was developed to automatically segment suspicious lesions in mpMRI images. This study makes it feasible to adopt boosting intraprostatic lesions in clinical practice to achieve better outcomes.


Subject(s)
Deep Learning , Prostatic Neoplasms , Diffusion Magnetic Resonance Imaging , Humans , Magnetic Resonance Imaging , Male , Prostatic Neoplasms/diagnostic imaging , Prostatic Neoplasms/radiotherapy
18.
Int J Radiat Oncol Biol Phys ; 108(2): 444-451, 2020 10 01.
Article in English | MEDLINE | ID: mdl-32890529

ABSTRACT

PURPOSE: We evaluated the impact of a virtual radiation oncology clerkship. METHODS AND MATERIALS: We developed a 2-week virtual radiation oncology clerkship that launched on April 27, 2020. Clerkship components included a virtual clinic with radiation oncology faculty and residents, didactic lectures, student talks, and supplemental sessions such as tumor boards and chart rounds. Medical students completed pre- and post-clerkship self-assessments. Faculty and resident participants also completed surveys on their experience with virtual lectures and clinics. Pre- and post-clerkship results were compared using a 2-sided paired t test. An analysis of variance model was used to analyze the clerkship components. RESULTS: Twenty-six medical students, including 4 visiting students, enrolled over 2 clerkship periods (4 weeks). All students completed the pre- and post-clerkship self-assessments and agreed that the clerkship improved their understanding of radiation oncology. Compared with 3 (11.5%) students who agreed that they understood the daily responsibilities of a radiation oncologist before the clerkship, 22 (84.6%) students agreed and 3 (11.5%) strongly agreed that they understood the daily responsibilities of a radiation oncologist after the clerkship (P < .0001). Although 15 students (57.7%) reported an increased interest in radiation oncology because of the clerkship, the mean level of interest in radiation oncology as a career remained the same, with pre- and post-clerkship scores of 3.0 (±0.9) and 3.0 (±1.1) on a 5-point scale, respectively (P = .7). Students found virtual clinic and didactic lectures to be the most valuable components of the clerkship. Most respondents agreed (30.8%) or strongly agreed (65.4%) to recommend the clerkship to their classmates. CONCLUSIONS: Our virtual clerkship was effective in increasing medical student interest in and knowledge about radiation oncology. These data will help optimize a new paradigm of virtual radiation oncology education for medical students during COVID-19 and beyond.


Subject(s)
Clinical Clerkship/methods , Coronavirus Infections/epidemiology , Pandemics , Pneumonia, Viral/epidemiology , Radiation Oncology/education , Adult , COVID-19 , Female , Health Knowledge, Attitudes, Practice , Humans , Male , User-Computer Interface , Young Adult
19.
Adv Radiat Oncol ; 5(4): 732-736, 2020.
Article in English | MEDLINE | ID: mdl-32775783

ABSTRACT

PURPOSE: Our institution cancelled all in-person clerkships owing to the coronavirus disease 2019 pandemic. In response, we designed a virtual radiation oncology medical student clerkship. METHODS AND MATERIALS: We convened an advisory panel to design a virtual clerkship curriculum. We implemented clerkship activities using a cloud-based learning management system, video web conferencing systems, and a telemedicine portal. Students completed assessments pre- and postclerkship to provide data to improve future versions of the clerkship. RESULTS: The virtual clerkship spans 2 weeks and is graded pass or fail. Students attend interactive didactic sessions during the first week and participate in virtual clinic and give talks to the department during the second week. Didactic sessions include lectures, case-based discussions, treatment planning seminars, and material adapted from the Radiation Oncology Education Collaborative Study Group curriculum. Students also attend virtual departmental quality assurance rounds, cancer center seminars, and multidisciplinary tumor boards. The enrollment cap was met during the first virtual clerkship period (April 27 through May 8, 2020), with a total of 12 students enrolling. CONCLUSIONS: Our virtual clerkship can increase student exposure and engagement in radiation oncology. Data on clerkship outcomes are forthcoming.

20.
Am J Clin Oncol ; 41(5): 492-496, 2018 05.
Article in English | MEDLINE | ID: mdl-27438690

ABSTRACT

OBJECTIVES: The objective is to determine localregional control (LRC), distant metastasis free survival, disease-free survival, overall survival (OS), and toxicity for patients with squamous cell carcinoma of the anus treated with definitive chemotherapy and intensity-modulated radiation therapy (IMRT). MATERIALS AND METHODS: We conducted a retrospective review of patients treated using IMRT for squamous cell carcinoma of the anus at our institution since 2005. Patients with local recurrences were identified and reviewed. The Kaplan-Meier curves were used for LRC and OS. RESULTS: From 2005 to 2014, 52 patients were treated with IMRT-based chemoradiation for squamous cell carcinoma of the anus. Median dose to the primary tumor was 54 Gy. LRC, distant metastasis free survival, OS, and disease-free survival were 92.3%, 88.5%, 86.5%, and 84.6%, respectively, with a median follow-up of 20 months. Two local failures occurred at the anal primary site and 2 in the vulva. Despite subsequent palliative radiotherapy and chemotherapy, neither patient with a vulvar recurrence achieved disease control. CONCLUSIONS: In a cohort of patients treated with IMRT-based chemoradiation, 2 vulvar recurrences were identified within the avoided external genitalia despite limited recurrence rates within the cohort overall. This experience suggests that for patients with a locally advanced primary tumor and bulky bilateral inguinal or pelvic disease, the in-transit vulvar dermal lymphatics may be at risk for subclinical involvement and subsequent recurrence. If substantiated by a similar pattern of recurrence at other institutions, the external genitalia may need to be reclassified from an avoidance structure to a clinical treatment volume in patients with locally advanced anal cancer.


Subject(s)
Anus Neoplasms/radiotherapy , Carcinoma, Squamous Cell/radiotherapy , Radiotherapy, Intensity-Modulated/adverse effects , Vulvar Neoplasms/diagnosis , Anus Neoplasms/pathology , Carcinoma, Squamous Cell/pathology , Female , Follow-Up Studies , Humans , Male , Middle Aged , Prognosis , Radiotherapy Dosage , Recurrence , Retrospective Studies , Survival Rate , Vulvar Neoplasms/secondary
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