Elective Pelvic Nodal Irradiation Research Articles

Dosimetric Correlates for Acute Toxicity in Prostate Cancer Treated With Hypofractionated Radiation Therapy: Absolute Volumes Are Better Predictors Than Relative Volumes

Dosimetric Correlates for Acute Toxicity in Prostate Cancer Treated With Hypofractionated Radiation Therapy: Absolute Volumes Are Better Predictors Than Relative Volumes

When is Elective Pelvic Lymph Node Irradiation Indicated in Definitive Radiotherapy for Localized Prostate Cancer?

The objective is to define the role of elective pelvic node irradiation (EPNI) in patients treated with definitive radiotherapy for clinically localized prostate cancer. Review of the pertinent literature revealed few prospective randomized trials that evaluated the efficacy of EPNI. Although EPNI may reduce the risk of regional recurrence, its impact on biochemical progression-free survival and overall survival is unclear. Depending on the extent of the radiotherapy fields, EPNI may result in a modest increase in acute toxicity and an even smaller increase in late toxicity. EPNI may reduce the risk of regional failure in patients with high-risk prostate cancer with a likelihood of lymph node positivity of ≥15%. Although it may result in improved biochemical progression-free survival, its impact is likely modest, at best. However, EPNI should be considered for patients with a high risk of regional disease.

The effect of radiation technique and bladder filling on the acute toxicity of pelvic radiotherapy for localized high risk prostate cancer

PurposeThe goal of this project was to see if using IMRT to deliver elective pelvic nodal irradiation (EPNI) for prostate cancer reduced acute treatment toxicity. MethodsTwo hundred and thirty patients were enrolled into prospective trials delivering EPNI with a concomitant hypofractionated IMRT boost to the prostate. During accrual, the method of EPNI delivery changed as new literature emerged. Three methods were used (1) 4FB, (2) IMRT with 2cm CTV margins around the pelvic vessels as suggested by Shih et al. (2005) [7] (IMRT-Shih), and (3) IMRT with nodal volumes suggested by the RTOG (IMRT-RTOG). Initially patients were treated with an empty bladder, with the remainder treated with bladder full. ResultsPatients in the 4FB group had higher rates of grade 2 acute GI toxicities compared to the IMRT-Shih and IMRT-RTOG groups (31.9% vs 20.8% vs 7.2%, p=0.0009). Patients in the 4FB group had higher rates of grade 3 urinary frequency compared to the two IMRT groups (8.5% vs 0% vs 0%, p=0.027). However, multivariate analysis suggested the factor that most influenced toxicity was bladder filling followed by IMRT. ConclusionsBladder filling appeared to be the dominant factor which predicted for acute toxicity, followed by the use of IMRT.

801P - Comparison Between Standard and Reduced Volume Radiotherapy in Bladder Preservation Trimodality Protocol for Muscle Invasive Bladder Cancer Patient

ABSTRACT Invasive bladder cancer is the most common tumor in Egypt. Preservation protocol consists of transurethral resection followed by concomitant chemo/ radiotherapy. The induction part of Radiotherapy is usually delivered to the whole pelvis, The role of omitting pelvic nodal irradiation has not been addressed before. Aim To compare the toxicity, pelvic nodal relapse and overall survival of whole bladder irradiation only to standard technique of whole pelvis irradiation followed by bladder boost in patients with muscle invasive bladder carcinoma undergoing bladder preservation protocol. Material and method A total of 63 patients with transitional cell carcinoma, stage T2-3,N0,M0 bladder cancer were subjected to maximal TURB. Then, patients randomized into two groups: group I (32 patients) to receive whole pelvis radiotherapy 44Gy followed by 20 Gy bladder boost. While Group II (31 patients) were randomized to receive whole bladder radiotherapy alone for a total dose of 64 Gy. In both groups, concomittant cisplatin and paclitaxel were given weekly throughout the whole course of radiotherapy where conventional 2 Gy/ fraction were used. additionally, 4 cycles of Adjuvant cisplatin and paclitaxel were given after the end of chemo radiotherapy induction course. Results Three patients, two in group I and one in group II discontinued due to grade 3 toxicity. After a median follow up of 2 years, regional relapse occurred in 7.1% of patients in group I and 10.3% in group II. (p = 1). Distant metastases were detected in 17.9% of patient in group 1 and 13.8% in group II.(p = 0.73). The 2-year disease free survival was 60% in group I and 63.3% in group II (p = 0.79). The whole 2-years overall survival was 75% in group I and 79.3% in group II (p = 0.689). Radiation gastrointestinal (GI) Acute toxicity was higher in group I than in group II (p = 0.001), while late GI radiation toxicity was comparable in both groups. Conclusion treating the bladder only without elective pelvic nodal irradiation, did not compromise pelvic control rate, but significantly decreased the acute radiation toxicity. Disclosure All authors have declared no conflicts of interest.

Comparison of acute toxicity in patients treated with a 4-field box or IMRT to deliver elective pelvic nodal irradiation for localized high-risk prostate cancer.

69 Background: To deliver elective pelvic nodal irradiation (EPNI), a 4-field box (4FB) has been a common technique. More recently, there are increasing reports of using IMRT to deliver EPNI. Even though studies show a clear dosimetric benefit to bowel and bladder, there is a lack of good data demonstrating decreased toxicity with the use of IMRT in this setting. Methods: From 2004-2010, 230 patients with localized high risk prostate cancer were enrolled into 3 sequential prospective phase I/II trials of delivering EPNI (45 Gy) along with a concomitant hypofractionated IMRT boost to the prostate (67.5 Gy total) in 25 fractions over 5 weeks time. All patients were to receive 3 years of adjuvant androgen deprivation. During the accrual period, the method used to deliver the EPNI portion of the treatment changed as new literature emerged about target volumes for EPNI. The 3 methods used to deliver EPNI in this large cohort were 1) 4FB, 2) IMRT with 2cm CTV margins around the pelvic vessels as suggested by Shih et al (IMRT-Shih), and 3) IMRT with nodal volumes as suggested by RTOG (IMRT-RTOG). Common Terminology Criteria for Adverse Events v3.0 was used to assess acute toxicity prospectively during treatment and then at 3 months. Results: For EPNI, 94 patients were treated with a 4FB, 53 were treated with IMRT-Shih, and 83 were treated with IMRT-RTOG. There were no acute grade 3 GI toxicities. Patients in the 4FB group had higher rates of acute grade ≥ 2 proctitis compared to the IMRT-Shih and IMRT-RTOG groups (16.0% vs 2.0% vs 2.4%, p=0.0009). The 4FB group also had higher rates of grade ≥ 2 flatulence compared to the 2 other IMRT groups (17.0% vs 7.6% vs 0%, p<0.0001). With regards to acute GU toxicities, patients in the 4FB group had higher rates of grade ≥ 3 urinary frequency compared to the 2 other IMRT groups (5.3% vs 0% vs 0%, p=0.027). Conclusions: In this non-randomized comparison, IMRT resulted in statistically significant decreases in acute proctitis, flatulence, and urinary frequency when compared to a 4FB technique to deliver EPNI in localized high risk prostate cancer. Analysis for possible confounding factors will be performed.

The Toxicity of Dose Escalated External Beam Radiation Therapy after Elective Pelvic Nodal Irradiation: Evaluating the Utility of the QUANTEC Rectal Dose Thresholds

The Toxicity of Dose Escalated External Beam Radiation Therapy after Elective Pelvic Nodal Irradiation: Evaluating the Utility of the QUANTEC Rectal Dose Thresholds

7031 POSTER The Toxicity of Dose Escalated External Beam Radiation Therapy After Elective Pelvic Nodal Irradiation – Evaluating the Utility of the QUANTEC Rectal Dose Thresholds

7031 POSTER The Toxicity of Dose Escalated External Beam Radiation Therapy After Elective Pelvic Nodal Irradiation – Evaluating the Utility of the QUANTEC Rectal Dose Thresholds

Hypofractionated Accelerated Radiotherapy Using Concomitant Intensity-Modulated Radiotherapy Boost Technique for Localized High-Risk Prostate Cancer: Acute Toxicity Results

To evaluate the acute toxicities of hypofractionated accelerated radiotherapy (RT) using a concomitant intensity-modulated RT boost in conjunction with elective pelvic nodal irradiation for high-risk prostate cancer. This report focused on 66 patients entered into this prospective Phase I study. The eligible patients had clinically localized prostate cancer with at least one of the following high-risk features (Stage T3, Gleason score >or=8, or prostate-specific antigen level >20 ng/mL). Patients were treated with 45 Gy in 25 fractions to the pelvic lymph nodes using a conventional four-field technique. A concomitant intensity-modulated radiotherapy boost of 22.5 Gy in 25 fractions was delivered to the prostate. Thus, the prostate received 67.5 Gy in 25 fractions within 5 weeks. Next, the patients underwent 3 years of adjuvant androgen ablative therapy. Acute toxicities were assessed using the Common Terminology Criteria for Adverse Events, version 3.0, weekly during treatment and at 3 months after RT. The median patient age was 71 years. The median pretreatment prostate-specific antigen level and Gleason score was 18.7 ng/L and 8, respectively. Grade 1-2 genitourinary and gastrointestinal toxicities were common during RT but most had settled at 3 months after treatment. Only 5 patients had acute Grade 3 genitourinary toxicity, in the form of urinary incontinence (n = 1), urinary frequency/urgency (n = 3), and urinary retention (n = 1). None of the patients developed Grade 3 or greater gastrointestinal or Grade 4 or greater genitourinary toxicity. The results of the present study have indicated that hypofractionated accelerated RT with a concomitant intensity-modulated RT boost and pelvic nodal irradiation is feasible with acceptable acute toxicity.

Laparoscopic Transposition of the Ovaries: Is It Effective to Preserve Ovarian Function Before Pelvic Node Irradiation in Pediatric Patients?

The potential disadvantages of elective pelvic node irradiation in young girls with Hodgkin's disease include ovarian failure and possible future infertility. Prophylactic laparoscopic transposition of the ovaries from the radiation field, or oophoropexy, can spare ovarian function in many girls. The authors report the case of a laparoscopic bilateral oophoropexy performed in a 9-year old girl suffering from mixed-cellularity Hodgkin's disease. Laparoscopy was performed using four trocars: one for a 10-mm 0° telescope placed infraumbilically, a 10-mm trocar above the symphysis pubis, and two 5-mm trocars at the lower left and right quadrants. The ovaries were transposed by placing two nonresorbable sutures through the utero-ovarian ligaments and posterior part of the uterus. Two titanium clips were placed to help locate the ovaries postoperatively. Surgery lasted 45 min. There were no intra- or postoperative complications. The patient was discharged from the hospital after 24 h. One year after the first intervention, at the end of radiotherapy, a second laparoscopic exploration was performed to evaluate and reposition the ovaries under visual guide. After a 3-year follow-up, hematologic evaluation of the patient's hormone levels and an ultrasonographic exam showed severe impairment of the ovarian function. The authors believe that laparoscopic oophoropexy is a feasible and easy procedure to use on children, although on the basis of these data, it may not always be sufficient to prevent ovarian failure secondary to radiotherapy.

1003 Elective pelvic nodal irradiation in patients with clinically localized prostate cancer at high risk for pelvic nodal involvement

1003 Elective pelvic nodal irradiation in patients with clinically localized prostate cancer at high risk for pelvic nodal involvement

The role of lymphangiography in designing fields for elective pelvic node irradiation in Hodgkin's disease

Purpose: We attempted to design a standard pelvic nodal treatment field such that all lymph nodes usually visualized on lymphangiogram would be irradiated with optimal midline blocking of normal tissues. Methods and Materials: Two standard fields for treatment of pelvic lymph nodes were designed, based on bony landmarks. The standard fields were applied to the anterior-posterior view of 35 pretherapy lymphangiograms, and the fields were then assessed for inclusion of visible lymph nodes. Measurements were done on the lymphangiograms to assess the amount of additional midline blocking that could be added. Results: All visualized nodes were included in 30 patients (86%) using Standard Field I and in 33 patients (94%) using Standard Field 11, but visualized nodes plus a 1.5-cm minimum margin were included in only two patients (6%) with Field I and 24 patients (69%) with Field 11. The most frequent sites of close margins were the lateral and medial borders adjacent to the external iliac nodes. Based on the lymphangiograms, a mean of 1.6 cm in male patients and 3.1 cm in female patients could be added to the width of the midline blocks. Conclusion: Lymph angiography is useful in designing fields for pelvic node irradiation, both to improve coverage of nodes with a 1.5 cm margin and to increase the amount of central shielding of normal tissues.

Stage C adenocarcinoma of the prostate. An analysis of 551 patients treated with external beam radiation

We retrospectively reviewed records of 551 patients with clinical Stage C prostatic adenocarcinoma treated with 60 to 70 Gy external beam radiation. Elective pelvic node irradiation was given to 247 patients (45%). Follow-up for all surviving patients ranged from 16 to 201 months (median, 6.5 years; mean, 7 years). The 5-, 10-, and 15-year uncorrected actuarial survival rates were 72%, 47%, and 27%, respectively. Disease-free survival rates were 59%, 46%, and 40% at the corresponding times. Actuarial local control rates were 88%, 81%, and 75% at 5, 10, and 15 years, respectively. Disease-free survival was adversely affected by high pathologic grade, disease fixed to the pelvic sidewall, invasion of the bladder, prior transurethral resection, hydronephrosis, and elevated serum levels of prostatic acid phosphatase and creatinine. Elective pelvic node irradiation did not improve the outcome. Complications of treatment were acceptable: minor anorectal and/or urinary symptoms, 11%; mild to moderate complications, 19%; serious problems requiring surgery, 3%. It is concluded that localized, high-energy external beam irradiation provides excellent local control of disease, low morbidity, and 5-, 10-, and 15-year survival rates that have not been rivaled by other treatment.