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Long-term intra-fractional motion of the prostate using hydrogel spacer during Cyberknife® treatment for prostate cancer--a case report.

Sumila M, Mack A, Schneider U, Storelli F, Curschmann J, Gruber G - Radiat Oncol (2014)

Bottom Line: After each beam the corresponding data reporting on the intra-fractional movement were pre-processed, the generated log-files extracted and the data analysed according to different directions: left -right (LR); anterior - posterior (AP); inferior -superior (IS).On 1-, 6- and 12-months follow-up the patient was free of any symptoms with only slight decrease of erectile function (grade 1).There was a continuous PSA decline.

View Article: PubMed Central - PubMed

Affiliation: Institute of Radiotherapy, Klinik Hirslanden, Witellikerstrasse 40, Zürich CH-8032, Switzerland. guenther.gruber@hirslanden.ch.

ABSTRACT

Background: There is a trend towards hypofractionated stereotactic radiotherapy (RT) in prostate cancer to apply high single doses in a few fractions. Using the Cyberknife® robotic system multiple non-coplanar fields are usually given with a treatment time of one hour or more. We planned to evaluate organ motion in this setting injecting a hydrogel spacer to protect the anterior rectal wall during treatment.

Methods: A 66 years old man with low risk prostate cancer was planned for robotic hypofractionated stereotactic RT. After implantation of fiducial markers and a hydrogel spacer a total dose of 36.25 Gy in 5 fractions was given to the planning target volume (clinical target volume + 3 mm). After each beam the corresponding data reporting on the intra-fractional movement were pre-processed, the generated log-files extracted and the data analysed according to different directions: left -right (LR); anterior - posterior (AP); inferior -superior (IS). Clinical assessments were prospectively done before RT start, one week after the end of treatment as well as 1, 6 and 12 months afterwards. Symptoms were documented using Common Toxicity and Adverse Events Criteria 4.0.

Results: Tolerability of marker and hydrogel implantation was excellent. A total of 284 non-coplanar fields were used per fraction. The total treatment time for all fields per fraction lasted more than 60 minutes. The detected and corrected movements over all 5 fractions were in a range of +/- 4 mm in all directions (LR: mean 0,238 - SD 0,798; AP: mean 0,450 - SD 1,690; and IS: mean 0,908 - SD 1,518). V36Gy for the rectum was 0.062 ccm. After RT, grade 1-2 intestinal toxicity and grade 1 genitourinarytoxicity occurred, but resolved completely after 10 days. On 1-, 6- and 12-months follow-up the patient was free of any symptoms with only slight decrease of erectile function (grade 1). There was a continuous PSA decline.

Conclusions: Prostate movement was relatively low (+/- 4 mm) even during fraction times of more than 60 minutes. The hydrogel spacer might serve as a kind of stabilisator for the prostate, but this should be analysed in a larger cohort of patients.

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Related in: MedlinePlus

Plot of the prostate movement during one course of Cyberknife®treatment in the left-right- (a), anterior-posterior- (b) and inferior-superior-direction (c). The movement was measured using two orthogonal x-ray projections and the implanted gold markers. The different colours indicate the different fractions (F): 1st F black, 2nd F red, 3rd F magenta, 4th F blue, 5th F green. It should be noted that during the actual treatment the position of the treatment table was adjusted after each measurement.
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Fig2: Plot of the prostate movement during one course of Cyberknife®treatment in the left-right- (a), anterior-posterior- (b) and inferior-superior-direction (c). The movement was measured using two orthogonal x-ray projections and the implanted gold markers. The different colours indicate the different fractions (F): 1st F black, 2nd F red, 3rd F magenta, 4th F blue, 5th F green. It should be noted that during the actual treatment the position of the treatment table was adjusted after each measurement.

Mentions: Before treatment pelvic functions were normal without any genitourinary or gastrointestinal problems. Few days after the completion of RT grade 2 proctitis and grade 2 diarrhoea with grade 1 faecal incontinence and grade 1 rectal hemorrhage occurred. In addition, there were grade 1 urinary urgency, grade 1 urinary frequency and grade 1 cystitis noninfectiva. All these symptoms disappeared completely after ten days. During this time period the patient used only Scheriproct® suppositories (prednisolon and cinchocain) but no other drugs. On 1-, 6- and 12-months follow-up he was free of any symptoms with only slight decrease of erectile function (grade 1). We observed very good PSA-response with 0.95 ng//ml, 0.57 ng/ml respective 0.34 ng/ml at 3, 6 respective 12 months after RT.The evaluation of the log-files showed following results: The detected and corrected movements over all 5 fractions are in a range of +/- 4 mm in all orientations (LR: mean 0,238 – SD 0,798; AP: mean 0,450 – SD 1,690; and IS: mean 0,908 – SD 1,518). Details of the prostate movements over time are given in Figure 2a-c.Figure 2


Long-term intra-fractional motion of the prostate using hydrogel spacer during Cyberknife® treatment for prostate cancer--a case report.

Sumila M, Mack A, Schneider U, Storelli F, Curschmann J, Gruber G - Radiat Oncol (2014)

Plot of the prostate movement during one course of Cyberknife®treatment in the left-right- (a), anterior-posterior- (b) and inferior-superior-direction (c). The movement was measured using two orthogonal x-ray projections and the implanted gold markers. The different colours indicate the different fractions (F): 1st F black, 2nd F red, 3rd F magenta, 4th F blue, 5th F green. It should be noted that during the actual treatment the position of the treatment table was adjusted after each measurement.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4150956&req=5

Fig2: Plot of the prostate movement during one course of Cyberknife®treatment in the left-right- (a), anterior-posterior- (b) and inferior-superior-direction (c). The movement was measured using two orthogonal x-ray projections and the implanted gold markers. The different colours indicate the different fractions (F): 1st F black, 2nd F red, 3rd F magenta, 4th F blue, 5th F green. It should be noted that during the actual treatment the position of the treatment table was adjusted after each measurement.
Mentions: Before treatment pelvic functions were normal without any genitourinary or gastrointestinal problems. Few days after the completion of RT grade 2 proctitis and grade 2 diarrhoea with grade 1 faecal incontinence and grade 1 rectal hemorrhage occurred. In addition, there were grade 1 urinary urgency, grade 1 urinary frequency and grade 1 cystitis noninfectiva. All these symptoms disappeared completely after ten days. During this time period the patient used only Scheriproct® suppositories (prednisolon and cinchocain) but no other drugs. On 1-, 6- and 12-months follow-up he was free of any symptoms with only slight decrease of erectile function (grade 1). We observed very good PSA-response with 0.95 ng//ml, 0.57 ng/ml respective 0.34 ng/ml at 3, 6 respective 12 months after RT.The evaluation of the log-files showed following results: The detected and corrected movements over all 5 fractions are in a range of +/- 4 mm in all orientations (LR: mean 0,238 – SD 0,798; AP: mean 0,450 – SD 1,690; and IS: mean 0,908 – SD 1,518). Details of the prostate movements over time are given in Figure 2a-c.Figure 2

Bottom Line: After each beam the corresponding data reporting on the intra-fractional movement were pre-processed, the generated log-files extracted and the data analysed according to different directions: left -right (LR); anterior - posterior (AP); inferior -superior (IS).On 1-, 6- and 12-months follow-up the patient was free of any symptoms with only slight decrease of erectile function (grade 1).There was a continuous PSA decline.

View Article: PubMed Central - PubMed

Affiliation: Institute of Radiotherapy, Klinik Hirslanden, Witellikerstrasse 40, Zürich CH-8032, Switzerland. guenther.gruber@hirslanden.ch.

ABSTRACT

Background: There is a trend towards hypofractionated stereotactic radiotherapy (RT) in prostate cancer to apply high single doses in a few fractions. Using the Cyberknife® robotic system multiple non-coplanar fields are usually given with a treatment time of one hour or more. We planned to evaluate organ motion in this setting injecting a hydrogel spacer to protect the anterior rectal wall during treatment.

Methods: A 66 years old man with low risk prostate cancer was planned for robotic hypofractionated stereotactic RT. After implantation of fiducial markers and a hydrogel spacer a total dose of 36.25 Gy in 5 fractions was given to the planning target volume (clinical target volume + 3 mm). After each beam the corresponding data reporting on the intra-fractional movement were pre-processed, the generated log-files extracted and the data analysed according to different directions: left -right (LR); anterior - posterior (AP); inferior -superior (IS). Clinical assessments were prospectively done before RT start, one week after the end of treatment as well as 1, 6 and 12 months afterwards. Symptoms were documented using Common Toxicity and Adverse Events Criteria 4.0.

Results: Tolerability of marker and hydrogel implantation was excellent. A total of 284 non-coplanar fields were used per fraction. The total treatment time for all fields per fraction lasted more than 60 minutes. The detected and corrected movements over all 5 fractions were in a range of +/- 4 mm in all directions (LR: mean 0,238 - SD 0,798; AP: mean 0,450 - SD 1,690; and IS: mean 0,908 - SD 1,518). V36Gy for the rectum was 0.062 ccm. After RT, grade 1-2 intestinal toxicity and grade 1 genitourinarytoxicity occurred, but resolved completely after 10 days. On 1-, 6- and 12-months follow-up the patient was free of any symptoms with only slight decrease of erectile function (grade 1). There was a continuous PSA decline.

Conclusions: Prostate movement was relatively low (+/- 4 mm) even during fraction times of more than 60 minutes. The hydrogel spacer might serve as a kind of stabilisator for the prostate, but this should be analysed in a larger cohort of patients.

Show MeSH
Related in: MedlinePlus