Intensity-modulated radiotherapy for prostate cancer with seminal vesicle involvement (T3b): A multicentric retrospective analysis.

OBJECTIVES: No study has reported clinical results of external-beam radiotherapy specifically for T3b prostate cancer. The possibility of escalating the dose to the involved seminal vesicles (ISV) while respecting the dose constraints in the organs at risk is thus so far not clearly demonstrated. The objective of the study was to analyze the dose distribution and the clinical outcome in a large series of patients who received IMRT for T3b prostate cancer. MATERIALS AND METHODS: This retrospective analysis included all patients who received IMRT and androgen deprivation therapy for T3b prostate cancer, between 2008 and 2017, in six French institutions, with available MRI images and dosimetric data. RESULTS: A total of 276 T3b patients were included. The median follow-up was 26 months. The median (range) prescribed doses (Gy) to the prostate and to the ISV were 77 (70-80) and 76 (46-80), respectively. The dose constraint recommendations were exceeded in less than 12% of patients for the rectum and the bladder. The 5-year risks of biochemical and clinical recurrences and cancer-specific death were 24.8%, 21.7%, and 10.3%, respectively. The 5-year risks of local, pelvic lymph node, and metastatic recurrences were 6.4%, 11.3%, and 15%, respectively. The number of involved lymph nodes (≤ 2 or ≥ 3) on MRI was the only significant prognostic factor in clinical recurrence (HR 9.86) and death (HR 2.78). Grade ≥ 2 acute and 5-year late toxicity rates were 13.2% and 12% for digestive toxicity, and 34% and 31.5% for urinary toxicity, respectively. The dose to the pelvic lymph node and the age were predictive of late digestive toxicity. CONCLUSION: IMRT for T3b prostate cancer allows delivery of a curative dose in the ISV, with a moderate digestive toxicity but a higher urinary toxicity. Lymph node involvement increases the risk of recurrence and death.

Monte Carlo evaluation of the effect of inhomogeneities on dose calculation for low energy photons intra-operative radiation therapy in pelvic area.

The aim of this study was to evaluate the effect of inhomogeneities on dose calculation for low energy photons intra-operative radiation therapy (IORT) in pelvic area. A GATE Monte Carlo model of the INTRABEAM® was adapted for the study. Simulations were performed in the CT scan of a cadaver considering a homogeneous segmentation (water) and an inhomogeneous segmentation (5 tissues from ICRU44). Measurements were performed in the cadaver using EBT3 Gafchromic® films. Impact of inhomogeneities on dose calculation in cadaver was 6% for soft tissues and greater than 300% for bone tissues. EBT3 measurements showed a better agreement with calculation for inhomogeneous media. However, dose discrepancy in soft tissues led to a sub-millimeter (0.65 mm) shift in the effective point dose in depth. Except for bone tissues, the effect of inhomogeneities on dose calculation for low energy photons intra-operative radiation therapy in pelvic area was not significant for the studied anatomy.

Preclinical Evaluation of Intraoperative Low-Energy Photon Radiotherapy Using Spherical Applicators in Locally Advanced Prostate Cancer.

BACKGROUND: Surgery plus adjuvant radiotherapy is standard care for locally advanced prostate cancer (stage pT3R1). Intraoperative low-energy photon radiotherapy offers several advantages over external beam radiotherapy, and several systems are now available for its delivery, using spherical applicators, which require only limited shielding. The aim of this study was to evaluate the feasibility of this technique for the prostate bed. MATERIALS AND METHODS: Applicators were assessed using MRI image data and cadaveric dissection. In cadavers, targeted tissues, defined as a urethral section, both neurovascular bundle sections, the bladder neck and the beds of the seminal vesicles, were marked with metallic surgical clips. Distances between clips and applicator were measured using CT. A dosimetric study of the application of 12 Gy at 5 mm depth was performed using CT images of prostatectomized cadavers. RESULTS: Using MRI images from 34 prostate cancer patients, we showed that the ideal applicator diameter ranges from 45 to 70 mm. Using applicators of different sizes to encompass the prostate bed in nine cadavers, we showed that the distance between target tissues and applicator was <2 mm for all target tissues except the upper extremity of the seminal vesicles (19 mm). Dosimetric study showed a good dose distribution in all target tissues in contact with the applicator, with a low probability of rectum and bladder complication. CONCLUSION: Intraoperative radiotherapy of the prostate bed is feasible, with good coverage of targeted tissues. Clinical study of safety and efficacy is now required.