Prostate Cancer

  • Hiromichi Ishiyama
  • Alan Katz
  • Angel I. Blanco
  • Jose Hinojosa
  • Simon S. Lo
  • Rodney J. Ellis
  • Bo Xu
  • Robert J. Amato
  • E. Brian Butler
  • Bin S. Teh
Part of the Medical Radiology book series (MEDRAD)


Stereotactic body radiation therapy (SBRT) is a promising treatment option for prostate cancer. Hypofractionation regimens such as SBRT may be more advantageous compared to conventional regimens because low α/β ratio of prostate cancer has high sensitivity to dose per fraction. In addition, the estimated higher α/β ratio of rectum and a smaller and tighter margin with SBRT is expected to provide acceptable toxicity despite higher dose per fraction. The successful implementation of SBRT for prostate cancer requires accurate target and normal tissues delineation, patient/tumor immobilization, image guidance or tumor tracking, advanced treatment planning and delivery. Here we describe the rationale and effectiveness of SBRT in the management of prostate cancer, its technical aspects, clinical applications, and treatment toxicities. Clinical case examples will be included with clinical settings, treatment plans, and outcomes.


Prostate Cancer Stereotactic Body Radiation Therapy Rectal Toxicity High Dose Rate Brachytherapy Planning Treatment Volume 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Akimoto T, Muramatsu H, Takahashi M, Saito J, Kitamoto Y, Harashima K, Miyazawa Y, Yamada M, Ito K, Kurokawa K, Yamanaka H, Nakano T, Mitsuhashi N, Niibe H (2004) Rectal bleeding after hypofractionated radiotherapy for prostate cancer: correlation between clinical and dosimetric parameters and the incidence of grade 2 or worse rectal bleeding. Int J Radiat Oncol Biol Phys 60(4):1033–1039. doi: 10.1016/j.ijrobp.2004.07.695, S0360-3016(04)02091-7 [pii]PubMedCrossRefGoogle Scholar
  2. Asano Y, Inoue Y, Ikeda Y, Kikuchi K, Hara T, Taguchi C, Tokushige T, Maruo H, Takeda T, Nakamura T, Fujita T, Kumagai Y, Hayakawa K (2011) Phase I clinical study of NMK36: a new PET tracer with the synthetic amino acid analogue anti-[18F]FACBC. Ann Nucl Med 25(6):414–418. doi: 10.1007/s12149-011-0477-z PubMedCrossRefGoogle Scholar
  3. Boike TP, Lotan Y, Cho LC, Brindle J, Derose P, Xie XJ, Yan J, Foster R, Pistenmaa D, Perkins A, Cooley S,Timmerman R (2011) Phase I dose-escalation study of stereotactic body radiation therapy for low- and intermediate-risk prostate cancer. J Clin Oncol. doi: 10.1200/JCO.2010.31.4377, JCO.2010.31.4377 [pii]
  4. Bolzicco G, Favretto MS, Scremin E, Tambone C, Tasca A (2010) Guglielmi R Image-guided stereotactic body radiation therapy for clinically localized prostate cancer: preliminary clinical results. Technol Cancer Res Treat 9(5): 473–477Google Scholar
  5. Brenner DJ (2004) Fractionation and late rectal toxicity. Int J Radiat Oncol Biol Phys 60(4):1013–1015. doi: 10.1016/j.ijrobp.2004.04.014, S0360301604006480 [pii]PubMedCrossRefGoogle Scholar
  6. Brenner DJ, Hall EJ (1999) Fractionation and protraction for radiotherapy of prostate carcinoma. Int J Radiat Oncol Biol Phys 43(5):1095–1101. S0360-3016(98)00438-6 [pii]PubMedCrossRefGoogle Scholar
  7. Brenner D, Armour E, Corry P, Hall E (1998) Sublethal damage repair times for a late-responding tissue relevant to brachytherapy (and external-beam radiotherapy): implications for new brachytherapy protocols. Int J Radiat Oncol Biol Phys 41(1):135–138. S0360-3016(98)00029-7[pii]PubMedCrossRefGoogle Scholar
  8. Dasu A (2007) Is the alpha/beta value for prostate tumours low enough to be safely used in clinical trials? Clin Oncol (R Coll Radiol) 19(5):289–301. doi: 10.1016/j.clon.2007.02.007, S0936-6555(07)00518-3 [pii]CrossRefGoogle Scholar
  9. Dewit L, Oussoren Y, Bartelink H, Thames HD (1989) The effect of cis-diamminedichloroplatinum(II) on radiation damage in mouse rectum after fractionated irradiation. Radiother Oncol 16(2):121–128. 0167-8140(89)90029-7 [pii]PubMedCrossRefGoogle Scholar
  10. Dubray BM, Thames HD (1994) Chronic radiation damage in the rat rectum: an analysis of the influences of fractionation, time and volume. Radiother Oncol 33(1):41–47. 0167-8140(94)90084-1 [pii]PubMedCrossRefGoogle Scholar
  11. Fowler JF, Ritter MA, Chappell RJ, Brenner DJ (2003) What hypofractionated protocols should be tested for prostate cancer? Int J Radiat Oncol Biol Phys 56(4):1093–1104. S0360301603001329 [pii]PubMedCrossRefGoogle Scholar
  12. Freeman DE,King CR (2011) Stereotactic body radiotherapy for low-risk prostate cancer: five-year outcomes. Radiat Oncol 6(1):3. doi: 10.1186/1748-717X-6-3, 1748-717X-6-3 [pii]Google Scholar
  13. Friedland JL, Freeman DE, Masterson-McGary ME, Spellberg DM (2009) Stereotactic body radiotherapy: an emerging treatment approach for localized prostate cancer. Technol Cancer Res Treat 8(5):387–392PubMedGoogle Scholar
  14. Gasinska A, Dubray B, Hill SA, Denekamp J, Thames HD, Fowler JF (1993) Early and late injuries in mouse rectum after fractionated X-ray and neutron irradiation. Radiother Oncol 26(3):244–253. PubMedCrossRefGoogle Scholar
  15. Jabbari S, Weinberg VK, Kaprealian T, Hsu IC, Ma L, Chuang C, Descovich M, Shiao S, Shinohara K, Roach M, 3rd, Gottschalk AR (2012) Stereotactic body radiotherapy as monotherapy or post-external beam Radiotherapy boost for prostate cancer: technique, early toxicity, and PSA response. Int J Radiat Oncol Biol Phys. doi: 10.1016/j.ijrobp.2010.10.026, S0360-3016(10)03447-4 [pii]
  16. Katz AJ, Santoro M, Ashley R, Diblasio F, Witten M (2010) Stereotactic body radiotherapy for organ-confined prostate cancer. BMC Urol 10:1. doi: 10.1186/1471-2490-10-1, 1471-2490-10-1 [pii]
  17. Katz AJ, Santoro M, Ashley R, Diblasio F, Witten M (2011) Stereotactic body radiotherapy as boost for organ-confined prostate cancer. Technol Cancer Res Treat 9(6): 575–582. doi:c4310/Stereotactic-Body-Radiotherapy-as-Boost-for-Organ-confined-Prostate-Cancer-575-582-p17824.html [pii]Google Scholar
  18. King CR, Brooks JD, Gill H, Pawlicki T, Cotrutz C, Presti JC Jr (2009) Stereotactic body radiotherapy for localized prostate cancer: interim results of a prospective phase II clinical trial. Int J Radiat Oncol Biol Phys 73(4):1043–1048. doi: 10.1016/j.ijrobp.2008.05.059, S0360-3016(08)02459-0 [pii]PubMedCrossRefGoogle Scholar
  19. King CR, Brooks JD, Gill H, Presti JC Jr (2011) Long-term outcomes from a prospective trial of stereotactic body radiotherapy for low-risk prostate cancer. Int J Radiat Oncol Biol Phys. doi: 10.1016/j.ijrobp.2010.11.054, S0360-3016(10)03677-1 [pii]Google Scholar
  20. Kupelian PA, Willoughby TR, Reddy CA, Klein EA,Mahadevan A (2007) Hypofractionated intensity-modulated radiotherapy (70 Gy at 2.5 Gy per fraction) for localized prostate cancer: Cleveland clinic experience. Int J Radiat Oncol Biol Phys 68(5): 1424–1430. doi: 10.1016/j.ijrobp.2007.01.067, S0360-3016(07)00535-4 [pii]Google Scholar
  21. Lindner U, Lawrentschuk N, Trachtenberg J (2010) Image guidance for focal therapy of prostate cancer. World J Urol 28(6):727–734. doi: 10.1007/s00345-010-0604-9 PubMedCrossRefGoogle Scholar
  22. Livsey JE, Cowan RA, Wylie JP, Swindell R, Read G, Khoo VS, Logue JP (2003) Hypofractionated conformal radiotherapy in carcinoma of the prostate: five-year outcome analysis. Int J Radiat Oncol Biol Phys 57(5):1254–1259. S0360301603007521 [pii]PubMedCrossRefGoogle Scholar
  23. Lloyd-Davies RW, Collins CD, Swan AV (1990) Carcinoma of prostate treated by radical external beam radiotherapy using hypofractionation. Twenty-two years’ experience (1962–1984). Urology 36(2):107–111. doi: 10.1016/0090-4295(90)80207-4, 0090-4295(90)80207-4 [pii]
  24. Lotan Y, Stanfield J, Cho LC, Sherwood JB, Abdel-Aziz KF, Chang CH, Forster K, Kabbani W, Hsieh JT, Choy H, Timmerman R (2006) Efficacy of high dose per fraction radiation for implanted human prostate cancer in a nude mouse model. J Urol 175(5):1932–1936. doi: 10.1016/S0022-5347(05)00893-1, S0022-5347(05)00893-1 [pii]PubMedCrossRefGoogle Scholar
  25. Lukka H, Hayter C, Julian JA, Warde P, Morris WJ, Gospodarowicz M, Levine M, Sathya J, Choo R, Prichard H, Brundage M, Kwan W (2005) Randomized trial comparing two fractionation schedules for patients with localized prostate cancer. J Clin Oncol 23(25):6132–6138. doi: 10.1200/JCO.2005.06.153, 23/25/6132 [pii]PubMedCrossRefGoogle Scholar
  26. Maciejewski B (2009) Boost in radiotherapy: external beam sunset, brachytherapy sunrise. J Contemp Brachyther 1(1):5–10Google Scholar
  27. Madsen BL, Hsi RA, Pham HT, Fowler JF, Esagui L,Corman J (2007) Stereotactic hypofractionated accurate radiotherapy of the prostate (SHARP), 33.5 Gy in five fractions for localized disease: first clinical trial results. Int J Radiat Oncol Biol Phys 67(4):1099–1105. doi: 10.1016/j.ijrobp.2006.10.050, S0360-3016(06)03369-4 [pii]Google Scholar
  28. Martinez AA, Gonzalez J, Ye H, Ghilezan M, Shetty S, Kernen K, Gustafson G, Krauss D, Vicini F, Kestin L (2011) Dose escalation improves cancer-related events at 10 years for intermediate- and high-risk prostate cancer patients treated with hypofractionated high-dose-rate boost and external beam radiotherapy. Int J Radiat Oncol Biol Phys 79(2):363–370. doi: 10.1016/j.ijrobp.2009.10.035, S0360-3016(09)03428-2 [pii]PubMedCrossRefGoogle Scholar
  29. McNeal JE, Redwine EA, Freiha FS, Stamey TA (1988) Zonal distribution of prostatic adenocarcinoma. Correlation with histologic pattern and direction of spread. Am J Surg Pathol 12(12):897–906PubMedCrossRefGoogle Scholar
  30. Oermann EK, Suy S, Hanscom HN, Kim JS, Lei S, Yu X, Zhang G, Ennis B, Rohan JP, Piel N, Sherer BA, Borum D, Chen VJ, Batipps GP, Constantinople NL, Dejter SW, Bandi G, Pahira J, McGeagh KG, Adams-Campbell L, Jha R, Dawson NA, Collins BT, Dritschilo A, Lynch JH, Collins SP (2011) Low incidence of new biochemical and clinical hypogonadism following hypofractionated stereotactic body radiation therapy (SBRT) monotherapy for low- to intermediate-risk prostate cancer. J Hematol Oncol 4:12. doi: 10.1186/1756-8722-4-12, 1756-8722-4-12 [pii]PubMedCrossRefGoogle Scholar
  31. Park C, Papiez L, Zhang S, Story M, Timmerman RD (2008) Universal survival curve and single fraction equivalent dose: useful tools in understanding potency of ablative radiotherapy. Int J Radiat Oncol Biol Phys 70(3):847–852. doi: 10.1016/j.ijrobp.2007.10.059, S0360-3016(07)04460-4 [pii]PubMedCrossRefGoogle Scholar
  32. Pawlicki T, Cotrutz C, King C (2007) Prostate cancer therapy with stereotactic body radiation therapy. Front Radiat Ther Oncol 40:395–406. doi: 10.1159/0000106049, 10.1159/0000106049 [pii]PubMedCrossRefGoogle Scholar
  33. Perez CA (2004) Principles and practice of radiation oncology. Philadelphia, Lippincott Williams & WilkinsGoogle Scholar
  34. Pollack A, Hanlon AL, Horwitz EM, Feigenberg SJ, Konski AA, Movsas B, Greenberg RE, Uzzo RG, Ma CM, McNeeley SW, Buyyounouski MK, Price RA Jr (2006) Dosimetry and preliminary acute toxicity in the first 100 men treated for prostate cancer on a randomized hypofractionation dose escalation trial. Int J Radiat Oncol Biol Phys 64(2):518–526. doi: 10.1016/j.ijrobp.2005.07.970, S0360-3016(05)02228-5 [pii]PubMedCrossRefGoogle Scholar
  35. Pollack A, Buyyounouski M, Horwitz E, Price S, Feigenberg S, Konski A, Greenberg R, Uzzo R, Ma C (2009) Hypofractionation for Prostate cancer: interim results of a randomized trial. Int J Radiat Oncol Biol Phys 75(3):S81–82CrossRefGoogle Scholar
  36. Rene N, Faria S, Cury F, David M, Duclos M, Shenouda G, Souhami L (2010) Hypofractionated radiotherapy for favorable risk prostate cancer. Int J Radiat Oncol Biol Phys 77(3):805–810. doi: 10.1016/j.ijrobp.2009.05.047, S0360-3016(09)00829-3 [pii]PubMedCrossRefGoogle Scholar
  37. Ritter M (2008) Rationale, conduct, and outcome using hypofractionated radiotherapy in prostate cancer. Semin Radiat Oncol 18(4):249–256. doi: 10.1016/j.semradonc.2008.04.007, S1053-4296(08)00036-2 [pii]PubMedCrossRefGoogle Scholar
  38. Schuster DM, Votaw JR, Nieh PT, Yu W, Nye JA, Master V, Bowman FD, Issa MM, Goodman MM (2007) Initial experience with the radiotracer anti-1-amino-3-18F-fluorocyclobutane-1-carboxylic acid with PET/CT in prostate carcinoma. J Nucl Med 48(1):56–63. 48/1/56 [pii]PubMedGoogle Scholar
  39. Siegel R, Naishadham MA, Jemal A (2012) Cancer Statistics. J Clin 62:10–29Google Scholar
  40. Soete G, Arcangeli S, De Meerleer G, Landoni V, Fonteyne V, Arcangeli G, De Neve W, Storme G (2006) Phase II study of a four-week hypofractionated external beam radiotherapy regimen for prostate cancer: report on acute toxicity. Radiother Oncol 80(1):78–81. doi: 10.1016/j.radonc.2006.06.005, S0167-8140(06)00247-7 [pii]PubMedCrossRefGoogle Scholar
  41. Takashima R, Egawa S, Kuwao S, Baba S (2002) Anterior distribution of Stage T1c nonpalpable tumors in radical prostatectomy specimens. Urology 59(5):692–697. S009042950201525X [pii]PubMedCrossRefGoogle Scholar
  42. Tang CI, Loblaw DA, Cheung P, Holden L, Morton G, Basran PS, Tirona R, Cardoso M, Pang G, Gardner S, Cesta A (2008) Phase I/II study of a five-fraction hypofractionated accelerated radiotherapy treatment for low-risk localised prostate cancer: early results of pHART3. Clin Oncol (R Coll Radiol) 20(10):729–737. doi: 10.1016/j.clon.2008.08.006, S0936-6555(08)00357-9 [pii]CrossRefGoogle Scholar
  43. Tanyi JA, He T, Summers PA, Mburu RG, Kato CM, Rhodes SM, Hung AY, Fuss M (2010) Assessment of planning target volume margins for intensity-modulated radiotherapy of the prostate gland: role of daily inter- and intra-fraction motion. Int J Radiat Oncol Biol Phys 78(5):1579–1585. doi: 10.1016/j.ijrobp.2010.02.001, S0360-3016(10)00223-3 [pii]PubMedCrossRefGoogle Scholar
  44. Teh BSGY, Wang X, Zhu J, Mai W, Huang Y, Paulino AC, Ittmann MBE (2008) In vitro and in vivo efficacy of ablative hypfractionation radiation/stereotactic body radiation therapy (SBRT) for human prostate cancer. Proceedings Radiological Society of North America Annual Meeting abstr # SSA22-01Google Scholar
  45. Terry NH, Denekamp J (1984) RBE values and repair characteristics for colo-rectal injury after caesium 137 gamma-ray and neutron irradiation. II. Fractionation up to ten doses. Br J Radiol 57(679):617–629PubMedCrossRefGoogle Scholar
  46. van der Kogel AJ, Jarrett KA, Paciotti MA, Raju MR (1988) Radiation tolerance of the rat rectum to fractionated X-rays and pi-mesons. Radiother Oncol 12(3):225–232. doi: 10.1016/0167-8140(88)90265-4, 0167-8140(88)90265-4 [pii]PubMedCrossRefGoogle Scholar
  47. Verma S, Rajesh A (2011) A clinically relevant approach to imaging prostate cancer: review. Am J Roentgenol 196(3 Suppl): S1-10 Quiz S11-14. doi: 10.2214/AJR.09.7196, 196/3_Supplement/S1 [pii]
  48. Wang JZ, Huang Z, Lo SS, Yuh WT, Mayr NA (2010) A generalized linear-quadratic model for radiosurgery, stereotactic body radiation therapy, and high-dose rate brachytherapy. Sci Transl Med 2(39): 39ra48. doi: 10.1126/scitranslmed.3000864, 2/39/39ra48 [pii]
  49. Wiegner EA, King CR (2010) Sexual function after stereotactic body radiotherapy for prostate cancer: results of a prospective clinical trial. Int J Radiat Oncol Biol Phys 78(2): 442–448. doi: 10.1016/j.ijrobp.2009.07.1748, S0360-3016(09)02950-2 [pii]Google Scholar
  50. Yeoh EE, Botten RJ, Butters J, Di Matteo AC, Holloway RH, Fowler J (2010) Hypofractionated versus conventionally fractionated radiotherapy for prostate carcinoma: final results of phase III randomized trial. Int J Radiat Oncol Biol Phys. doi: 10.1016/j.ijrobp.2010.07.1984, S0360-3016(10)03031-2 [pii]Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Hiromichi Ishiyama
    • 1
    • 2
  • Alan Katz
    • 5
  • Angel I. Blanco
    • 1
  • Jose Hinojosa
    • 6
  • Simon S. Lo
    • 3
  • Rodney J. Ellis
    • 3
  • Bo Xu
    • 1
  • Robert J. Amato
    • 4
  • E. Brian Butler
    • 1
  • Bin S. Teh
    • 1
  1. 1.Department of Radiation OncologyThe Methodist Hospital, Cancer Center and Research InstituteHoustonUSA
  2. 2.Department of Radiology and Radiation OncologyKitasato University School of MedicineKanagawaJapan
  3. 3.Department of Radiation OncologyUniversity Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve UniversityOHUSA
  4. 4.Department of Internal Medicine, Division of OncologyUniversity of Texas Health Sciences CenterHoustonUSA
  5. 5.Flushing Radiation OncologyFlushingUSA
  6. 6.ABC Cancer CenterMexico CityMexico

Personalised recommendations