Active surveillance (AS) is currently accepted as a good management option for men with low-risk prostate cancer (PCa). Moreover, given the grade migration following the 2005 International Society of Urologic Pathology consensus conference, AS may be appropriate for men presenting with favorable intermediate-risk PCa. Three contemporary experiences of AS for men with intermediate-risk features suggest that although these men are at higher risk for radical treatment, most of them are not significantly compromising chances for long-term cure. From the long-term randomized ProtectT trial, 10-year outcomes after active monitoring, surgery, or radiotherapy for localized PCa revealed that PCa specific mortality was low irrespective of the treatment assigned, with no significant difference among treatments. Multiparametric magnetic resonance imaging, molecular biomarkers, and new Gleason grading system could enhance diagnostic accuracy and decrease the demerits of current AS protocols. Particularly, uniform recording of the percentage pattern 4 in Gleason 7 cancers will enable better understanding of prognostic risks and consideration of careful expansion of AS to populations with minimal Gleason pattern 4 disease.
Biomarkers ; Clothing ; Consensus ; Humans ; Magnetic Resonance Imaging ; Male ; Mortality ; Neoplasm Grading ; Passive Cutaneous Anaphylaxis ; Pathology ; Prostate* ; Prostatic Neoplasms* ; Radiotherapy

Over 80% of the patients with prostate cancer (PCa) develop bone metastasis, which seriously affects the patients' quality of life and remains a major cause of morbidity. Radium-223 (Ra-223), a newly approved agent targeting bone metastasis of PCa, can improve the quality of life and prolong the overall survival of the PCa patients with bone metastasis. This article presents an overview of the clinical trials recently published on the management of bone metastasis of PCa with Ra-223.
Bone Neoplasms ; radiotherapy ; secondary ; Clinical Trials as Topic ; Humans ; Male ; Prostatic Neoplasms ; pathology ; Quality of Life ; Radioisotopes ; Radium ; therapeutic use

BACKGROUNDImage-guided radiation therapy (IGRT) is the preferred method for curative treatment of localized prostate cancer, which could improve disease outcome and reduce normal tissue toxicity reaction. IGRT using cone-beam computed tomography (CBCT) in combination with volumetric-modulated arc therapy (VMAT) potentially allows smaller treatment margins and dose escalation to the prostate. The aim of this study was to compare the difference of dosimetric diffusion in conventional IGRT using 7-field, step-and-shoot intensity-modulated radiation therapy (IMRT) and hypofractionated IGRT using VMAT for patients with localized prostate cancer.

METHODSWe studied 24 patients who received 78 Gy in 39 daily fractions or 70 Gy in 28 daily fractions to their prostate with/without the seminal vesicles using IMRT (n = 12) or VMAT (n = 12) for prostate cancer between November 2013 and October 2015. Image guidance was performed using kilovoltage CBCT scans equipped on the linear accelerator. Offline planning was performed using the daily treatment images registered with simulation computed tomography (CT) images. A total of 212 IMRT plans in conventional cohort and 292 VMAT plans in hypofractionated cohort were enrolled in the study. Dose distributions were recalculated on CBCT images registered with the planning CT scanner.

RESULTSCompared with 7-field, step-and-shoot IMRT, VMAT plans resulted in improved planning target volume (PTV) D95% (7663.17 ± 69.57 cGy vs. 7789.17 ± 131.76 cGy, P < 0.001). VMAT reduced the rectal D25 (P < 0.001), D35 (P < 0.001), and D50 (P < 0.001), bladder V50 (P < 0.001), D25 (P = 0.002), D35 (P = 0.028), and D50 (P = 0.029). However, VMAT did not statistically significantly reduce the rectal V50, compared with 7-field, step-and-shoot IMRT (25.02 ± 5.54% vs. 27.43 ± 8.79%, P = 0.087).

CONCLUSIONSTo deliver the hypofractionated radiotherapy in prostate cancer, VMAT significantly increased PTV D95% dose and decreased the dose of radiation delivered to adjacent normal tissues comparing to 7-field, step-and-shoot IMRT. Daily online image-guidance and better management of bladder and rectum could make a more precise treatment delivery.

Aged ; Aged, 80 and over ; Humans ; Male ; Prostate ; pathology ; radiation effects ; Prostatic Neoplasms ; pathology ; radiotherapy ; Radiotherapy Dosage ; Radiotherapy, Image-Guided ; methods ; Radiotherapy, Intensity-Modulated ; methods ; Retrospective Studies

Recently, the D'Amico classification system is widely used for the risk stratification of prostate cancer (PCa) , although no consensus has been reached for the definition of high-risk PCa. This system defines high-risk PCa as a prostate-specific antigen (PSA) level > 20 ng/ml, a Gleason score of 8-10, or a clinical stage ≥ T2c. Because high-risk PCa is prone to recurrence and metastasis after treatment, a proper initial therapy plays a crucial role. Currently, radical prostatectomy and radiation therapy are considered to be two most important options for the initial treatment of high-risk PCa although it remains controversial which is better.
Humans ; Male ; Neoplasm Grading ; Neoplasm Recurrence, Local ; Prostate-Specific Antigen ; blood ; Prostatectomy ; methods ; Prostatic Neoplasms ; blood ; pathology ; radiotherapy ; surgery ; Risk

PURPOSE: To investigate the difference in rectal complications rate following prostate low dose rate (LDR) brachytherapy based on prostate-rectum distance and prostate longitudinal length among early prostate cancer patients. MATERIALS AND METHODS: From March 2008 to February 2013, 245 prostate cancer patients with a Gleason score < or =7 were treated with 125-I LDR brachytherapy. Among them, 178 patients with prostate volume 20-35 mL and a follow-up period > or =6 months were evaluated for radiation proctitis. Magnetic resonance imaging (MRI) was performed for a prebrachytherapy evaluation, and prostate-rectum distance and prostate longitudinal length were measured. The radiation proctitis was confirmed and graded via colonoscopy based on the radiation therapy oncology group (RTOG) toxicity criteria. RESULTS: Twenty-three patients received a colonoscopy for proctitis evaluation, and 12 were identified as grade 1 on the RTOG scale. Nine patients were diagnosed as grade 2 and 2 patients were grade 3. No patient developed grade 4 proctitis. The rectal-complication group had a mean prostate-rectum distance of 2.51+/-0.16 mm, while non-rectal-complication control group had 3.32+/-0.31 mm. The grade 1 proctitis patients had a mean prostate-rectum distance of 2.80+/-0.15 mm, which was significantly longer than 2.12+/-0.31 mm of grades 2 and 3 patient groups (p=0.045). All 11 patients of grades 2 and 3 had a prostate longitudinal length of 35.22+/-2.50 mm, which was longer than group 1, but the difference was not statistically significant (p=0.214). CONCLUSIONS: As the prostate-rectum distance increased, fewer postimplantation rectal symptoms were observed. Patients with a shorter prostate-rectum distance in MRI should receive modified implantation techniques or radical prostatectomy.
Aged ; Brachytherapy/*adverse effects ; Carcinoma/*radiotherapy ; Colonoscopy ; Humans ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Organ Size ; Proctitis/diagnosis/*etiology ; Prostate/*pathology ; Prostatic Neoplasms/*radiotherapy ; Radiation Injuries/diagnosis/*etiology ; Severity of Illness Index

PURPOSE: We evaluated the biochemical recurrence (BCR) of prostate cancer patients treated by radical prostatectomy (RP) or radiotherapy (RT). MATERIALS AND METHODS: Patients who underwent RP or RT as primary definitive treatment from 2007 were enrolled for this study. They were divided into two groups; the low-intermediate risk group and the high risk group according to the National Comprehensive Cancer Network guidelines. We compared differences such as age, prostate specific antigen, Gleason score, follow-up duration, clinical T staging, and BCR. Their BCR-free survival rates were analyzed. RESULTS: A total of 165 patients were enrolled. There were 115 patients in the low-intermediate risk. Among them, 88 received RP and 27 underwent RT. BCR occurred in 9 of the RP patients (10.2%) and 3 of the RT patients (11.1%). For the high risk group, 50 patients were included. RP was performed in 25 patients and RT in 25 patients. BCR was observed in 4 of the RP patients (16%) and 12 of the RT patients (48%). There were no differences in BCR-free survival for the low-intermediate group (p=0.765). For the high risk group, the RP group had a higher BCR free survival rate (p=0.032). CONCLUSIONS: No difference of BCR and BCR-free survival was seen in the low-intermediate risk group but lower BCR and better BCR-free survival were observed for patients that received RP in the high risk group. RP should be a more strongly considered option when deciding the treatment method for selected high risk patients.
Aged ; Humans ; Kaplan-Meier Estimate ; Male ; Middle Aged ; Neoplasm Grading ; Neoplasm Recurrence, Local ; Neoplasm Staging ; Prostate-Specific Antigen/blood ; Prostatectomy/*methods ; Prostatic Neoplasms/blood/pathology/*radiotherapy/*surgery ; Retrospective Studies

PURPOSE: The validity of tomotherapy-based simultaneous integrated boost (TOMOSIB) was assessed in terms of acute intestinal/urinary toxicity by comparing with 3-dimensional conformal radiotherapy (3DCRT) in cases of whole-pelvis radiation therapy (WPRT) for prostate cancer. MATERIALS AND METHODS: Thirty-eight consecutive patients who underwent curative WPRT were retrospectively reviewed. Twenty six (68.4%) received 3DCRT and the others (31.6%) were treated with TOMOSIB. A local boost to the prostate circumferential area was added to WPRT sequentially for 3DCRT and concomitantly for TOMOSIB. The total median prostate or prostatic bed dose was 64.8 Gy including median 45.0 Gy of WPRT. Acute toxicities were assessed according to RTOG criteria. RESULTS: Overall intestinal toxicity was lower in TOMOSIB group than 3DCRT group (p=0.008). When it was divided into rectum and non-rectum intestine (NRI), TOMOSIB showed borderline superiority only in NRI toxicity (p=0.047). For the urinary toxicity, there was no significant difference between two groups (p=0.796). On dosimetric analysis for the rectum and bladder, dose delivered to 80% (p<0.001) and volume receiving 25-40 Gy (p<0.001) were remarkably higher in 3DCRT. For the NRI, only maximum dose showed significant results between two groups (p<0.001). CONCLUSION: Intestinal toxicity should be verified with more detailed anatomic categorization such as rectum and NRI. TOMOSIB could not reduce urinary toxicity because of inevitably high dose exposure to the prostatic urethra. Current dosimetry system did not properly reflect intestinal/urinary toxicity, and suitable dosimetric guidelines are needed in TOMOSIB.
Adenocarcinoma/pathology/*radiotherapy ; Aged ; Humans ; Intestine, Small/*radiation effects ; Male ; Middle Aged ; Pelvis/*radiation effects ; Prostatic Neoplasms/pathology/*radiotherapy ; Radiation Injuries ; Radiotherapy Dosage ; Radiotherapy, Intensity-Modulated/*adverse effects/methods ; Rectum/radiation effects ; Retrospective Studies ; Urinary Bladder/*radiation effects

PURPOSE: The validity of tomotherapy-based simultaneous integrated boost (TOMOSIB) was assessed in terms of acute intestinal/urinary toxicity by comparing with 3-dimensional conformal radiotherapy (3DCRT) in cases of whole-pelvis radiation therapy (WPRT) for prostate cancer. MATERIALS AND METHODS: Thirty-eight consecutive patients who underwent curative WPRT were retrospectively reviewed. Twenty six (68.4%) received 3DCRT and the others (31.6%) were treated with TOMOSIB. A local boost to the prostate circumferential area was added to WPRT sequentially for 3DCRT and concomitantly for TOMOSIB. The total median prostate or prostatic bed dose was 64.8 Gy including median 45.0 Gy of WPRT. Acute toxicities were assessed according to RTOG criteria. RESULTS: Overall intestinal toxicity was lower in TOMOSIB group than 3DCRT group (p=0.008). When it was divided into rectum and non-rectum intestine (NRI), TOMOSIB showed borderline superiority only in NRI toxicity (p=0.047). For the urinary toxicity, there was no significant difference between two groups (p=0.796). On dosimetric analysis for the rectum and bladder, dose delivered to 80% (p<0.001) and volume receiving 25-40 Gy (p<0.001) were remarkably higher in 3DCRT. For the NRI, only maximum dose showed significant results between two groups (p<0.001). CONCLUSION: Intestinal toxicity should be verified with more detailed anatomic categorization such as rectum and NRI. TOMOSIB could not reduce urinary toxicity because of inevitably high dose exposure to the prostatic urethra. Current dosimetry system did not properly reflect intestinal/urinary toxicity, and suitable dosimetric guidelines are needed in TOMOSIB.
Adenocarcinoma/pathology/*radiotherapy ; Aged ; Humans ; Intestine, Small/*radiation effects ; Male ; Middle Aged ; Pelvis/*radiation effects ; Prostatic Neoplasms/pathology/*radiotherapy ; Radiation Injuries ; Radiotherapy Dosage ; Radiotherapy, Intensity-Modulated/*adverse effects/methods ; Rectum/radiation effects ; Retrospective Studies ; Urinary Bladder/*radiation effects

INTRODUCTIONMost international clinical practice guidelines for prostate cancer (PCa) are driven by data derived in a Western setting. However, tumour biology and clinical disease progression are likely to differ in the Asian population. We compare the performance of the revised American Joint Committee on Cancer (AJCC) prognostic groups with the commonly used D'Amico Risk Classification and conventional predictors for PCa, in a large cohort of Asian patients.

MATERIALS AND METHODSWe retrospectively reviewed data for 404 consecutive Singaporean patients receiving definitive radiotherapy at our centre between December 1996 and October 2006. The primary outcome was biochemical relapse-free survival (BRFS), defined using the Phoenix definition. The secondary outcome was overall survival (OS). Prognostic risk groups were defined using AJCC 7th edition (AJCC7) and 6th edition (AJCC6). Univariate analysis (UVA) and multivariate analysis (MVA) were performed for the following putative risk factors: age, Gleason score, prognostic grouping, tumour classification, radiation delivery technique, radiotherapy dose, hormonal therapy and initial PSA value.

RESULTSFor the cohort, median age was 69 years. Median follow-up was 66.3 months. Five-year BRFS rate was 84.3% with 71 biochemical relapses and 5-year OS rate was 89.1% with 54 deaths. The concordance-indices for BRFS prediction were 0.588, 0.550 and 0.567 for AJCC7, AJCC6 and D'Amico respectively. Initial PSA, T-stage and AJCC7 were prognostic for BRFS on UVA. Comparison of AJCC7 vs. D'Amico showed no statistical additional value of either classification system although D'Amico was superior when compared to AJCC6 in predicting BRFS. T-stage ≥3 and D'Amico were significant prognostic factors for BRFS on MVA.

CONCLUSIONIn our local, predominantly Chinese population, neither AJCC6 nor AJCC7 demonstrated a high predictive accuracy for BRFS although AJCC7 has a slightly better predictive ability than AJCC6.

Aged ; Aged, 80 and over ; Asia ; Humans ; Male ; Middle Aged ; Neoplasm Staging ; Practice Guidelines as Topic ; Prognosis ; Prostatic Neoplasms ; pathology ; radiotherapy ; Radiotherapy ; methods ; Retrospective Studies ; United States

Multiple bone metastases are common manifestation of many malignant tumors such as lung cancer, breast cancer, prostate cancer and renal cell carcinoma. Bone metastasis is secondary cancer in the bone, and it can lead to bone pain, fracture, and instability of the weight bearing bones, all of which may profoundly reduce physical activity and life quality. Treatment for bone metastasis is determined by multiple factors including pathology, performance status, involved site, and neurologic status. Treatment strategies for bone metastasis are analgesics, surgery, chemotherapy and radiotherapy. External beam radiotherapy has traditionally been an effective palliative treatment for localized painful bone metastasis. However, in some cases such as multiple bone metastases, especially osteoblastic bone metastasis originated from breast or prostate cancer, the radiopharmaceutical therapy using (89)Sr, (186)Re, (188)Re, (153)Sm and (117m)Sn are also useful treatment option because of administrative simplicity (injection), few side effects, low risk of radiation exposure and high response rate. This article offers a concise explanation of the radiopharmaceutical therapy for multiple bone metastases.
Analgesics ; Breast ; Breast Neoplasms ; Carcinoma, Renal Cell ; Drug Therapy ; Lung Neoplasms ; Motor Activity ; Neoplasm Metastasis* ; Osteoblasts ; Palliative Care ; Pathology ; Prostatic Neoplasms ; Quality of Life ; Radiation Oncology ; Radiopharmaceuticals ; Radiotherapy ; Weight-Bearing