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Dose-escalated simultaneous integrated-boost treatment of prostate cancer patients via helical tomotherapy

Dosiseskalation aufgrund simultan integrierter Boost-Behandlung bei Prostatakarzinompatienten mittels helikaler Tomotherapie

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Abstract

Purpose

The goal of this work was to assess the feasibility of moderately hypofractionated simultaneous integrated-boost intensity-modulated radiotherapy (SIB-IMRT) with helical tomotherapy in patients with localized prostate cancer regarding acute side effects and dose–volume histogram data (DVH data).

Methods

Acute side effects and DVH data were evaluated of the first 40 intermediate risk prostate cancer patients treated with a definitive daily image-guided SIB-IMRT protocol via helical tomotherapy in our department. The planning target volume including the prostate and the base of the seminal vesicles with safety margins was treated with 70 Gy in 35 fractions. The boost volume containing the prostate and 3 mm safety margins (5 mm craniocaudal) was treated as SIB to a total dose of 76 Gy (2.17 Gy per fraction). Planning constraints for the anterior rectal wall were set in order not to exceed the dose of 76 Gy prescribed to the boost volume. Acute toxicity was evaluated prospectively using a modified CTCAE (Common Terminology Criteria for Adverse Events) score.

Results

SIB-IMRT allowed good rectal sparing, although the full boost dose was permitted to the anterior rectal wall. Median rectum dose was 38 Gy in all patients and the median volumes receiving at least 65 Gy (V65), 70 Gy (V70), and 75 Gy (V75) were 13.5%, 9%, and 3%, respectively. No grade 4 toxicity was observed. Acute grade 3 toxicity was observed in 20% of patients involving nocturia only. Grade 2 acute intestinal and urological side effects occurred in 25% and 57.5%, respectively. No correlation was found between acute toxicity and the DVH data.

Conclusion

This institutional SIB-IMRT protocol using daily image guidance as a precondition for smaller safety margins allows dose escalation to the prostate without increasing acute toxicity.

Zusammenfassung

Ziel

Die Verträglichkeit des simultan integrierten Boost-Protokolls unserer Klinik als primäre Therapie für Patienten mit lokal begrenztem Prostatakarzinom sollte bezüglich der Akuttoxizität unter Berücksichtigung der individuellen DVH-Daten evaluiert werden.

Methoden

Untersucht wurden die ersten 40 Patienten mit intermediärem Risiko bei lokal begrenztem Prostatakarzinom, die mit vorgestelltem SIB-IMRT-Protokoll mittels helikaler Tomotherapie an unserer Klinik behandelt wurden. Die definitive Strahlentherapie bis zu einer Gesamtdosis von 76 Gy (Einzeldosis 2,17 Gy) erfolgte unter täglicher Bildanleitung („Image Guidance“). Das Planungszielvolumen (Prostata und Samenblasenbasis mit Sicherheitssaum) wurde mit 70 Gy (Einzeldosis 2 Gy) behandelt, während das Boostvolumen des simultan integrierten Boosts (Prostata mit 3 mm Sicherheitssaum bzw. 5 mm kraniokaudal) mit 2,17 Gy Einzeldosis therapiert wurde. Das erlaubte Dosismaximum im Bereich der vom Boostvolumen erfassten Rektumvorderwand entsprach den verordneten 76 Gy des Boosts. Die gastrointestinale und urogenitale Akuttoxizität wurden prospektiv mittels eines modifizierten CTCAE (Common Terminology Criteria for Adverse Events)-Scoringsystems evaluiert (Tab. 1). Die DVH-Daten der Patienten wurden mit den Akuttoxizitätsdaten korreliert.

Ergebnisse

Das vorgestellte SIB-Therapieprotokoll ermöglicht eine gute Rektumschonung, obwohl die verordnete Boostdosis als Dosismaximum im Bereich der Rektumvorderwand akzeptiert wurde. Die mediane Rektumdosis betrug 38 Gy. V65, V70 und V75 waren entsprechend 13,5%, 9% und 3% (Tab. 3). Neben drittgradiger Nykturie bei 20% der Patienten wurden zweitgradige gastrointestinale und urogenitale Nebenwirkungen bei 25% bzw. 57,5% der Patienten beobachtet (Fig. 3, Tab. 4). Signifikante Zusammenhänge zwischen den DVH-Daten und der Akuttoxizität konnten nicht gezeigt werden.

Zusammenfassung

Das vorgestellte SIB-IMRT-Protokoll mit täglicher Bildführng – als Voraussetzung für verkleinerte Sicherheitssäume – ermöglicht eine leicht hypofraktionierte, mäßige Dosiseskalation an der Tomotherapie ohne Erhöhung der Akutnebenwirkungen. Die chronische Toxizität ist Gegenstand laufender Nachbeobachtung.

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Conflict of interest

The corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Klinik und Poliklinik für Strahlentherapie und Radiologische Onkologie, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany

    M. Geier, S.T. Astner, M.N. Duma, J. Putzhammer, C. Winkler, M. Molls &  H. Geinitz

  2. Klinik für Strahlenheilkunde, Universitätsklinikum Albert-Ludwigs-Universität Freiburg, Freiburg, Germany

    V. Jacob

  3. Department of Oncology and Palliative Care, Nordland Hospital, Bodø, Norway

    C. Nieder

  4. Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway

    C. Nieder

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  1. M. Geier
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  2. S.T. Astner
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Correspondence to H. Geinitz.

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Geier, M., Astner, S., Duma, M. et al. Dose-escalated simultaneous integrated-boost treatment of prostate cancer patients via helical tomotherapy. Strahlenther Onkol 188, 410–416 (2012). https://doi.org/10.1007/s00066-012-0081-8

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  • DOI: https://doi.org/10.1007/s00066-012-0081-8

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