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Stereotactic Body Radiotherapy For Prostate Cancer

What Is Stereotactic Body Radiotherapy

Stereotactic Body Radiotherapy for Prostate Cancer | Amar Kishan, MD | UCLAMDChat

Traditionally, prostate cancer radiotherapy has been delivered over the course of multiple treatment sessions with a low dose per treatment session. In order to deliver the total dose needed to eradicate prostate cancer, up to 45 treatments were needed, which translates to nine weeks of daily treatments . It has since become appreciated that prostate cancer appears to be uniquely sensitive to a higher dose per treatment session, such that prostate cancer could be eradicated in a much shorter amount of time with significantly fewer treatments. Various ways of doing this have been explored. Among them, stereotactic body radiotherapy , also known as stereotactic ablative radiotherapy, is a radiation therapy technique that allows the prostate radiotherapy course to be condensed to just five treatment sessions. With SBRT, advanced treatment delivery technologies and radiation planning parameters are used to deliver higher doses per day in a safe and effective manner.

SBRT is now supported by high level evidence as a safe and effective treatment for low and intermediate risk prostate cancer. The UCLA SBRT Prostate Cancer program is led by Dr. Amar Kishan and Dr. Michael Steinberg.

Stereotactic Body Radiation Therapy

Stereotactic body radiation therapy , also known as stereotactic ablative radiotherapy, or stereotactic ablative body radiation precisely targets tumors with very high doses of radiation.

SBRT is used to treat smaller tumors. Among these are many types of primary tumors, often prostate cancer, lung cancer and kidney cancer.

In addition, doctors use SBRT to treat tumors that have spread, or metastasized, from another site. This includes oligometastatic disease, in which a patient has just a few metastatic spots. In these cases, SBRT may halt further spread of metastatic disease.

Patients may choose SBRT instead of surgery in some cases. This lets them avoid a hospital stay, a recovery period and other aspects of a surgical procedure. The treatment also may be an option for those who are not healthy enough for surgery.

One common side effect of SBRT is fatigue. Other possible side effects depend on the tumors location. For example, a patient with an abdominal tumor may have SBRT-related gastrointestinal problems. A patient with a tumor near a bone could experience bone damage.

Stereotactic Body Radiotherapy For Low

Purpose Hypofractionated, stereotactic body radiotherapy is an emerging treatment approach for prostate cancer. We present the outcomes for low-risk prostate cancer patients with a median follow-up of 5 years after SBRT. Method and Materials Between Dec. 2003 and Dec. 2005, a pooled cohort of 41 consecutive patients from Stanford, CA and Naples, FL received SBRT with CyberKnife for clinically localized, low-risk prostate cancer. Prescribed dose was 35-36.25 Gy in five fractions. No patient received hormone therapy. Kaplan-Meier biochemical progression-free survival and RTOG toxicity outcomes were assessed. Results At a median follow-up of 5 years, the biochemical progression-free survival was 93% . Acute side effects resolved within 1-3 months of treatment completion. There were no grade 4 toxicities. No late grade 3 rectal toxicity occurred, and only one late grade 3 genitourinary toxicity occurred following repeated urologic instrumentation. Conclusion Five-year results of SBRT for localized prostate cancer demonstrate the efficacy and safety of shorter courses of high dose per fraction radiation delivered with SBRT technique. Ongoing clinical trials are underway to further explore this treatment approach.

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Doseresponse With Stereotactic Body Radiotherapy For Prostate Cancer: A Multi

  • Department of Human Genetics, University of California, Los Angeles, USADepartment of Urology, University of California, Los Angeles, USA
  • Department of Radiation Oncology, University of California, Los Angeles, USADepartment of Radiation Oncology, West Los Angeles Veterans Health Administration, USA
  • Amar U. KishanCorrespondenceCorresponding author at: Department of Radiation Oncology, Suite B265, 200 Medical Plaza, Los Angeles, CA 90095, USA.Department of Radiation Oncology, University of California, Los Angeles, USADepartment of Urology, University of California, Los Angeles, USA
  • Dose-escalation was associated with greater prostate ablation and PSA decay.
  • All dose groups in our study achieved median nPSAs of 0.2 ng/mL.
  • Dose-escalation to 40/5, but not beyond, was associated with improved BCRFS.
  • Rates of BCR were low across all dose groups, with 5-year BCRFS estimates of at least 93%.

Stereotactic Radiotherapy With A Linac

Stereotactic Body Radiotherapy for Prostate Cancer

Once you are in the right position the radiographers leave the room. This is so they are not exposed to radiation.

You will be alone for the treatment, which lasts between 15 minutes to 2 hours. It can sometimes last longer than this. You might have the treatment in one go or it may be broken up with short breaks.

Your radiographers can see and hear you the whole time and can speak to you by intercom. It is important that you stay very still throughout the treatment.

You won’t feel anything while you have the treatment and the machine doesn’t touch you. The machine will beep from time to time.

Once the treatment is over your radiographers go back into the room and help you get down from the treatment couch.

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What Happens During Sbrt

Before treatment, your bowels must be emptied, yet your bladder should be full.

When you arrive for SBRT, youre positioned on a table, and the radiation therapist aligns you to small tattoos that are dotted on your skin. Next, a CT scanner built onto the radiation therapy machine takes a 3D image of your anatomy.

We usually implant markers into the prostate that can act like a GPS device, says Dr. Tendulkar.

Because of the high doses, a radiation oncologist, physicist and radiation therapist must all be present to verify that your position is perfect. If needed, they make millimeter adjustments to ensure the bladder and rectum are safely out of range.

Once the beam is turned on, treatment takes only three to four minutes, he says. If the markers show us that youre moving, well pause the treatment.

Our patients are typically in and out within half an hour.

How Does Sbrt Compare With Longer Courses Of Radiation

The first patient to be treated with modern prostate SBRT was treated in December 2000. Since then, a large amount of data and evidence have amassed demonstrating the safety and efficacy of SBRT. UCLA investigators have played a leading role in accumulating and publishing these data. To date, the best data available to support SBRT for prostate cancer are:

A study led by Dr. Amar Kishan that compiled the outcomes of 2142 men treated with SBRT between 2000-2012, showing low rates of toxicity and high efficacy with a median follow-up of nearly 7 years. The article can be found here:

The HYPO-RT-PC randomized trial, which directly compared conventional radiation against a high-dose-per-day treatment across seven sessions in 1200 Swedish men. Importantly, this trial used older radiation planning techniques and did not deliver modern SBRT. Regardless, the efficacy and long-term side effects were equivalent in both arms of the trial. The article can be found here:

The PACE-B randomized trial, which directly compared modern, longer course radiation against modern SBRT in 874 men in the United Kingdom. No differences in short term side effects were found. The article can be found here:

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Stereotactic Body Radiotherapy To Lymph Nodes In Oligoprogressive Castration

Clinical & experimental metastasis. 2021 Oct 15

D Pezzulla, G Macchia, S Cilla, M Buwenge, M Ferro, P Bonome, C Romano, A Zamagni, V Valentini, A G Morganti, F Deodato

Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy., Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy. ., Medical Physics Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, Campobasso, Italy., Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy., Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, IRCCS, UOC di Radioterapia, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy.

About This Research Topic

Prostate Stereotactic Body Radiation Therapy (SBRT)

Stereotactic Body Radiotherapy is now a standard of care for the treatment for clinically localized prostate cancer by NCCN guidelines with emerging data for regional and oligometastatic disease sufficiently justifying its use for these indications also. Additionally, data …

Stereotactic Body Radiotherapy is now a standard of care for the treatment for clinically localized prostate cancer by NCCN guidelines with emerging data for regional and oligometastatic disease sufficiently justifying its use for these indications also. Additionally, data suggest that SBRT in the post-prostatectomy setting can be delivered safely. Due to the biological properties, prostate cancer behaves more like late reacting tissue with a low ratio. Hence, increasing fraction size may increase the therapeutic ratio with increasing fraction size.Thousands of patients have now been treated in prospective trials with SBRT for prostate cancer with excellent long-term efficacy and toxicity, although the acute toxicity might be increased as compared to conventional fractionation. New radiation techniques, fractionation schemes, and devices have been implemented which have resulted in reductions in acute and late toxicity.The goal of this Research Topic is to provide a single source for clinicians in academics and in private practice. This Research Topic welcomes manuscripts which cover all aspects of SBRT for the prostate. This involves:-Clinical Trials

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Availability Of Data And Materials

The data that support the findings of this study are available from the patient records of the Kuopio University Hospital, but restrictions apply to the availability of these data, which was used under license for the purposes of the current study only, and so are not publicly available. The data in anonymized form is available from the authors upon reasonable request and with permission of Kuopio University Hospital.

Stereotactic Body Radiation Therapy For Prostate Cancera Review

Waqar Haque1, E. Brian Butler2, Bin S. Teh2

1Department of Radiation Oncology, CHI St. Lukes Health, The Woodlands, TX , USA

Contributions: Conception and design: All authors Administrative support: All authors Provision of study materials or patients: All authors Collection and assembly of data: All authors Data analysis and interpretation: All authors Manuscript writing: All authors Final approval of manuscript: All authors.

Correspondence to:

Abstract: Prostate cancer can be managed with external beam radiation therapy, delivered with either protons or photons, brachytherapy, surgery, or active surveillance. Advances in imaging and radiation therapy delivery have allowed treatment of prostate cancer using ultra-hypofractionated radiation therapy with a high dose per fraction using a technique called stereotactic body radiation therapy . While no randomized trials have compared the efficacy of SBRT to conventionally fractionated radiation therapy , numerous prospective trials and retrospective reviews have demonstrated the safety and efficacy of SBRT for localized prostate cancer, used either definitively or as a boost along with CFRT. Prostate cancer SBRT may be more cost effective than CFRT using intensity modulated radiation therapy or proton based radiation therapy.

Keywords: Prostate cancer stereotactic body radiation therapy hypofractionated radiation therapy

Submitted Apr 21, 2017. Accepted for publication May 15, 2017.

doi: 10.21037/cco.2017.06.05

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Historical Perspective Toward Hypofractionation

Although there is literature dating back several decades of patients successfully receiving dosing regimens similar to modern hypofractionation schedules and even ultrahypofractionation schedules , randomized data regarding hypofractionation compared to conventional fractionation have only been available for the last 15 years. Numerous trials have now demonstrated comparable efficacy of hypofractionated regimens to conventionally fractionated regimens including the large RTOG 0415 , CHHiP , and PROFIT trials , with one trial even reporting superior efficacy . Late toxicity in the aforementioned trials was overall comparable, except in PROFIT and in RTOG 0415 . As of 2018, the American Society of Radiation Oncology, the American Society of Clinical Oncology, and the American Urological Association have endorsed hypofractionation as a standard of care option for all patients with localized prostate cancer .

Stereotactic Body Radiotherapy For Prostate Cancer: Current Results Of A Phase Ii Trial

Research shows 98% cure rate for prostate cancer using ...

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Clinical Translation In Prostate Cancer

A Phase I/II study in patients with metastatic castration-resistant prostate cancer explored ipilimumab treatment alone or in combination with 8 Gy radiation given in a single fraction to metastatic lesions. The study tested the hypothesis that ipilimumab would potentiate antitumor immunity following radiation by converting the tumor into an in situ vaccine via induction of immunogenic cell death and exposure of cryptic tumor antigens. In the highest dose group of 10 mg/kg, 8 of 50 patients, exhibited a PSA decline of at least 50%, and 1 patient experienced a complete response, while 6 patients had stable disease. Kwon, et al, recently reported long term follow up of the large multi-institutional, prospective, phase III randomized trial of radiation combined ipilimumab. This phase III study of men with mCRPC prostate cancer was very close to meeting its primary endpoint of improved median overall survival with a p=0.053 . However, in a subset analysis there appeared to be clinically meaningful benefit in men without good performance status without visceral metastases. A subsequent clinical trial is enrolling men without visceral metastases.

Clinical Translation In Gbm

Given the promising results of these pre-clinical studies a phase I/II trial of anti-PD-1 therapy in relapsed GBM is currently underway . In this study Pidilizumab will be administered to eligible patients at 6.0mg/kg every other week until disease progression or a serious adverse event. Additionally BMS sponsored Phase III randomized open label trial of Nivolumab Versus Bevacizumab and a Safety Study of Nivolumab or Nivolumab in Combination With Ipilimumab in Adults with Recurrent GBM is currently recruiting . Clearly additional combinatorial therapies are needed to help improve outcomes in this highly lethal disease.

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When You Might Have Stereotactic Radiotherapy

This type of radiotherapy is mainly used to treat very small cancers, including:

  • cancer in the lung
  • cancer that started in the liver or cancer that has spread to the liver
  • cancers in the lymph nodes
  • spinal cord tumours
  • cancer spread in the brain

Stereotactic radiotherapy can also treat areas of the body that have been treated with radiotherapy before. For example, if someone has already had radiotherapy to their pelvis they usually wouldn’t be able to have radiotherapy to the same area again. But because stereotactic treatment is so precise it can often mean re-treatment is possible.

Research is being carried out to see what other cancers stereotactic treatment will be helpful for.

Androgen Deprivation Therapy With Prostate Sbrt

5-Session Radiation Treatment For Prostate Cancer (SBRT or Stereotactic Body Radiation Therapy)

The addition of ADT to EBRT has been shown to improve overall survival for patients with intermediate- and high-risk prostate cancer, though these studies were conducted before the era of dose-escalated EBRT . In a modern trial by Bolla et al. demonstrating the superiority of ADT with EBRT compared to patients treated with EBRT alone, only 197/819 patients received dose-escalated EBRT, and though the study did demonstrate improved clinical outcomes for these patients, the study was not powered to show improvements for the patients receiving dose-escalation . Whether or not ADT has a role in the era of dose-escalated EBRT for patients with intermediate risk prostate cancer is currently an active research question, and is being investigated by RTOG 0815. The indications of ADT for patients undergoing prostate SBRT are similarly unclear. In a multi-institutional pooled data set of patients undergoing SBRT for prostate cancer, 147 patients underwent ADT in conjunction with SBRT . There was no difference in 5-year FFBF between patients receiving ADT and those not receiving ADT, though there was no uniform criteria for ADT use. The relatively poor results with SBRT alone for patients with high-risk prostate cancer suggest that some additional form of systemic therapy may prove beneficial. However, there are at this time no clear indications for the use of ADT with SBRT for patients with prostate cancer.

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Overview Of Sbrt For Prostate Cancer

SBRT is defined by the American Society of Radiation Oncology as an external beam radiation therapy method used to precisely deliver a high dose of radiation to an extracranial target within the body, using either a single dose or a small number of fractions. Specialized treatment planning results in high target dose and steep dose gradients beyond the target . SBRT can be delivered using non-coplanar, non-opposing arcs with either a conventional linear accelerator or with a robotic-based radiosurgery system, as used in the Cyberknife® device . While most studies involving SBRT for prostate cancer to date have been conducted using a robotic-based radiosurgery system, there are no differences in outcomes for patients treated with either a gantry linear accelerator or a robotic-based radiosurgery system. Dosimetric studies demonstrate that isocentric RapidArc treatment using a gantry linear accelerator can provide superior coverage to the planning target volume with better rectum sparing, while delivering the treatment in a shorter period of time than SBRT delivered with a robotic-based radiosurgery system .

Psa Kinetics Following Prostate Sbrt

The PSA kinetics following prostate SBRT are distinct and may suggest a greater degree of efficacy when compared to those following treatment with CF-EBRT. One study from UCLA compared patterns of PSA response for 439 patients with low- or intermediate-risk prostate cancer following treatment with SBRT, high-dose-rate brachytherapy, or CF-intensity modulated radiation therapy . The authors found that significantly more patients treated with SBRT or HDR brachytherapy had PSA nadirs of < 0.5 ng/mL than those treated with IMRT and that overall, SBRT and HDR brachytherapy caused significantly larger PSA decay rates than IMRT, leading the authors to conclude that this difference in PSA kinetics may present a distinct radiobiological effect, and may be predictive of superior clinical outcomes. Other studies have confirmed that after one year of treatment, when compared to patients receiving treatment with CF-EBRT, the median PSA slope and nadir are lower for patients treated with SBRT .

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