Radiation therapy in prostate cancer: Whole pelvis with prostate boost or small field to prostate?

doi:10.1016/0090-4295(92)90430-5

Urology

Volume 40, Issue 1, July 1992, Pages 18-26

https://doi.org/10.1016/0090-4295(92)90430-5 Get rights and content

Abstract

The purpose of this retrospective study is to identify prostate cancer patients who would benefit from pelvic nodes irradiation (whole pelvis) as opposed to the small-field irradiation to the prostate only. Between 1975 and 1983, 126 patients were treated by whole pelvis (4,600–5,000 cGY) with prostate boost (2,000 cGY) radiation (WP + P). Median follow-up was six years and six months. Comparison was made with historic control of 116 patients irradiated at the same institutions between 1971 and 1977 by small field to the prostate (P) to a dose of 7,000–7,500 cGY There was a significant five-year survival improvement in the current WP + P radiation in Stage C (72 % vs 40%, p = 0.0004) and Stage B (92 % vs 70 %, p = 0.025) but not in Stage A2 patients. However, WP + P radiation significantly improved disease-free survival (DFS) in only well and moderately but not in poorly differentiated carcinoma with a combined well and moderately differentiated five-year DFS of 63 percent compared with the 45 percent in P radiation (p = 0.0228). Local tumor control was significantly improved in WP + P radiation in only Stage C cancers with their local recurrence rate 16 percent as compared with the 34 percent in P radiation (p = 0.0172). Although acute radiation reactions were more frequent in WP + P than P radiation (61 % vs 41 %, p = 0.0022), chronic radiation morbidity in both series were similar. Thus, whole pelvis with prostate boost radiation should be utilized in Stage B and Stage C cancers as this has shown to increase the survival of the patient without increasing chronic radiation morbidity.

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This study showed a favourable interaction between pelvic EBRT and neo-adjuvant hormone therapy, and an impact of the size of pelvic fields on biological recurrence-free survival [11]. The results of these phase III trials are consistent with data from retrospective studies [17,18]. Only patients with a risk of LN involvement above 15% and a low risk of extra-pelvic metastases could benefit from pelvic EBRT.
Recommendations for pelvic lymph node (LN) contouring rely on relatively dated studies that defined the Clinical Target Volume (CTV) of interest proposed for radiotherapy. The aim of this article was to review these recommendations with a critical analysis of published data on prostate cancer drainage.
We performed a review of data on LN drainage in prostate cancer, based on anatomy texts and studies on lymphography, pelvic LN dissections, sentinel LN techniques, magnetic resonance imaging, computed tomography and functional imaging. We also present the GETUG experts’ opinion, based on a survey on nodal CTV definition.
For lymphatic drainage of prostate cancers, pelvic LN areas classically considered are: distal common iliac, external iliac, internal iliac and obturator regions. Recently published data allow a mapping of sites at risk of pathological LN invasion. In 10–70% of cases, these sites are not included in the pelvic LN CTVs defined in consensuses. In accordance with other cooperative groups, the GETUG experts’ survey showed that proximal common iliac, para-aortic, para-rectal and pre-sacral regions could include sites at risk of invasion in extended LN CTV, but were not considered in CTV contouring common practice. New recommendations are needed for nodal CTV in radiotherapy of prostate cancer.
The assessment of the efficacy and safety of LN radiotherapy is still the subject of several randomised studies. Whether or not meaningful results are obtained depends directly on the quality and homogeneity of the data analysed. A new consensus for delineation of LN regions appears necessary.
The role of elective pelvic radiotherapy in clinically node-negative prostate cancer: A systematic review
2014, Radiotherapy and Oncology
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These cancer cells in lymph nodes can have clinical significance, but do not necessarily result in distant metastases, provided that adequate loco-regional treatment is delivered. Six retrospective analyses were published in the pre-PSA era, often including patients that would now be considered low-risk [95–101]. The relevance of these studies for current clinical practice is therefore probably limited.
The role of elective radiotherapy of the pelvic nodal regions in clinically node-negative prostate cancer patients remains highly controversial. This review will address the difficulty of non-invasive nodal staging, even with more advanced imaging techniques, and will show that surgical staging still finds a relatively high percentage of patients with intermediate- or high-risk prostate cancer that have microscopic tumor invasion in the pelvic nodes. Finally, an overview of the current literature on elective pelvic irradiation will be provided.
Pelvic irradiation in prostate cancer: What place for what volumes?
2013, Cancer/Radiotherapie
La radiothérapie externe exclusive est un traitement de référence des cancers de la prostate. Selon les caractéristiques cliniques, histologiques et biologiques de la tumeur, une irradiation des aires ganglionnaires peut être proposée en association à celle de la prostate. La réalisation de cette irradiation pelvienne reste controversée et peut être source de complications par l’augmentation des volumes de tissus sains irradiés. L’exactitude de la délinéation des aires ganglionnaires devient donc un enjeu important. Cet article propose de faire le point sur les caractéristiques du drainage ganglionnaire pelvien de la prostate, les données de la littérature sur la place de l’irradiation pelvienne et la définition des volumes à irradier.
External beam radiotherapy alone is a standard treatment for prostate cancer. According to clinical, histological and biological characteristics of the tumour, lymph node irradiation can be done in combination with irradiation of the prostate. The completion of pelvic irradiation remains controversial and may cause complications by increasing volumes of irradiated healthy tissues. The accuracy of the delineation of lymph node becomes an important issue. This article proposes to take on the characteristics of the pelvic lymph node drainage of the prostate, to review the literature on pelvic irradiation and the definition of volumes to be irradiated.
Effect of whole pelvic radiotherapy for patients with locally advanced prostate cancer treated with radiotherapy and long-term androgen deprivation therapy
2011, International Journal of Radiation Oncology Biology Physics
To evaluate the effect of whole pelvic radiotherapy (WPRT) in prostate cancer patients treated with RT and long-term (>1 year) androgen deprivation therapy (ADT).
Prostate cancer patients with high-risk features (Stage T3-T4 and/or Gleason score ≥7 and/or prostate-specific antigen level ≥20 ng/mL) who had undergone RT and long-term ADT were included in the present analysis. Patients with bowel inflammatory disease, colon diverticula, and colon diverticulitis were excluded from WPRT and treated with prostate-only radiotherapy (PORT). Patients were grouped according to nodal risk involvement as assessed by the Roach formula using different cutoff levels (15%, 20%, 25%, and 30%). Biochemical disease-free survival (bDFS) was analyzed in each group according to the RT type (WPRT or PORT).
A total of 358 patients treated between 1994 and 2007 were included in the analysis (46.9% with WPRT and 53.1% with PORT). The median duration of ADT was 24 months (range, 12–38). With a median follow-up of 52 months (range, 20–150), the overall 4-year bDFS rate was 90.5%. The 4-year bDFS rate was similar between the patients who had undergone WPRT or PORT (90.4% vs. 90.5%; p = NS). However, in the group of patients with the greatest nodal risk (>30%), a significant bDFS improvement was recorded for the patients who had undergone WPRT (p = .03). No differences were seen in acute toxicity among the patients treated with WPRT or PORT. The late gastrointestinal toxicity was similar in patients treated with PORT or WPRT (p = NS).
Our analysis has supported the use of WPRT in association with long-term ADT for patients with high-risk nodal involvement (>30%), although a definitive recommendation should be confirmed by a randomized trial.
Intensity-modulated radiotherapy allows escalation of the radiation dose to the pelvic lymph nodes in patients with locally advanced prostate cancer: Preliminary results of a phase i dose escalation study
2010, Clinical Oncology
Citation Excerpt :
The role of whole pelvic radiotherapy (WPRT) in this group of patients remains controversial. Some retrospective studies have suggested a benefit for patients with intermediate or high risk of lymph node involvement in terms of prostate-specific antigen (PSA) failure-free [7,8] or overall survival [9]. More recently, however, North American and European phase III trials [10,11] have failed to show an advantage to pelvic and prostate radiotherapy compared with prostate radiotherapy alone, except in a subset of patients treated with neoadjuvant hormonal therapy in Radiation Therapy Oncology Group (RTOG) trial 9413 [10].
Pelvic irradiation in addition to prostate irradiation may improve outcome in locally advanced prostate cancer, but is associated with dose-limiting bowel toxicity. We report the preliminary results of a dose escalation study using intensity-modulated radiotherapy.
Eligible patients had high-risk (T3, Gleason ≥8 or prostate-specific antigen ≥20 ng/ml) or lymph node-positive disease. Intensity-modulated radiotherapy was inverse planned giving 70 Gy/35 fractions to the prostate and 50 Gy/55 Gy/60 Gy in sequential cohorts to the pelvis with a 5 Gy boost to positive lymph nodes. Acute and late toxicity were recorded with Radiation Therapy Oncology Group (RTOG) and Late Effects Normal Tissue - Subjective Objective Management LENT-SOM scales. Neoadjuvant androgen suppression was given for 3 years. This report concerns the 50 and 55 Gy cohorts.
Seventy-nine men were recruited (25 to 50 Gy/54 to 55 Gy) with a median follow-up of 2 years. Patients were divided into two groups according to the total bowel volume outlined (median 450 cm³). Acute RTOG (≥2) bowel toxicity was 40 and 50% for the 50 and 55 Gy groups and 38 and 51% for bowel volume <450 cm³ and ≥450 cm³, respectively, suggesting both volume and dose relationships for acute effects. Late RTOG diarrhoea ≥grade 2 was only seen with bowel volume ≥450 cm³, but no dose effect was apparent (12%/50 Gy and 10%/55 Gy). LENT-SOM bowel ≥grade 2 toxicity occurred in 22%/50 Gy and 15%/55 Gy. Only one patient had grade 3 toxicity. A dose volume histogram analysis showed increased late RTOG diarrhoea ≥grade 2 with larger bowel volume irradiated, significant for BV40 >124 cm³ (P = 0.04), BV45 >71 cm³ (P = 0.03) and BV60 >2 cm³ (P = 0.01).
Acute and late bowel toxicity was acceptably low using a pelvic dose of up to 55 Gy over 7 weeks. Both relate to total pelvic bowel volume and dose volume constraints have been defined.
Cancer of the Prostate
2010, Leibel and Phillips Textbook of Radiation Oncology, Third Edition

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^☆: Presented at 75th Annual Meeting of American Radium Society, May 4–8, 1991, Montreal, Canada.

^∗: Radiation Oncology Department Cancer Center The Christ Hospital 2139 Auburn Avenue Cincinnati, Ohio 45219

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Scientific articleRadiation therapy in prostate cancer: Whole pelvis with prostate boost or small field to prostate?☆

Abstract

J Urol

Urology

Urology

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Urology

Radiotherapy in the conservative treatment of operable and locally inoperable cancer of the prostate

Radiology

Radiation therapy in the treatment of localized carcinoma of the prostate

Cancer

The role of mega-voltage radiation therapy in the treatment of prostatic carcinoma

Sem Oncol

Scientific article
Radiation therapy in prostate cancer: Whole pelvis with prostate boost or small field to prostate?☆