Late rectal bleeding following combined x-ray and proton high dose irradiation for patients with stages T3–T4 prostate carcinoma (original) (raw)

Abstract

MeV perineal proton beam that reduces the volume of rectum irradiated. We correlated the total doses received to portions of the anterior rectum to study the possible relationship of the volume irradiated to the incidence of late rectal toxicity. Methods: We have randomized 191 patients with stages T3 and T4 prostatic carcinoma to one of two treatment dose arms. These were: 1) 75.6 Cobalt-Gy-equivalent (CGE), 50.4 Gy delivered by 107-25 MV photons followed by 25.2 CGE delivered perineally by protons (Arm 1) or 2) 67.2 CGE delivered by lo-25 MV photons (Arm 2). Results: With a median follow-up of 3.7 years, post-irradiation rectal bleeding (grades 1 and 2 only, none requiring surgery or hospitalization) from telangietatic rectal mucosal vessels has occurred in 34% of 99 Arm-l patients and 16% of 92 Arm-2 patients (p = 0.013). Dose-volume histograms (DVHs) for the anterior rectal wall, the posterior rectal wall and the total rectum in 41 patients treated on Arm 1 were calculated from the three dimensional dose distributions. Rectal bleeding has occurred in 14 or 34% of the 41 DVH-analyzed subset of Arm-l patients. Both the fractional volume of the anterior rectum and the total dose received by fractional volumes of the anterior rectum significantly correlate with the actuarial probability of bleeding. Conclusions: Clinicians planning dose escalation to men with localized prostate cancer should approve with caution treatment plans raising more than 40% of the anterior rectum to more than 75 CGE without additional effort to protect the rectal mucosa because this late sequela data indicate that more than half of these men will otherwise have rectal bleeding.

Loading...

Loading Preview

Sorry, preview is currently unavailable. You can download the paper by clicking the button above.

References (29)

  1. Bagshaw, M. A. External radiation in carcinoma of the prostate. Cancer 45: 19 12-1922; 1980.
  2. Bagshaw, M. A.; Cox, R. S.; Ray, G. R. Status of radiation treatment of prostatic cancer at Stanford University. NC1 Monographs 7:47-60; 1988.
  3. Biggs, P. A.; Shipley, W. U. A beam with improving device for a 25 MV x-ray beam. Int. J. Radiat. Oncol. Biol. Phys. 12:131-135; 1986.
  4. Cox, J. D.; Stoffel, T. J. The significance of needle biopsy 5.
  5. 15. after irradiation for stage C adenocarcinoma of the prostate. Cancer 40:156-159; 1977.
  6. Dugan, T. C.; Shipey, W. U.; Young, R. H.; Verhey, L. J.; Althausen, A. F.; Heney, N. M.; McManus, P. L.; Abraham, E. H. Biopsy after external beam radiation therapy for ad- enocarcinoma of the prostate: Correlation with original his- tologic grade and current prostate specific antigen levels. J. Urol. 146:1313-1316; 1991.
  7. Duttenhaver, J. R.; Shipley, W. U.; Perrone, T.; Verhey, L. J.; Goitein, M.; Munzenrider, J. E.; Prout, G. R.; Park- hurst, E. C.; Suit, H. D. Protons or megavoltage x-rays as boost therapy for patients irradiated for localized prostatic carcinoma. An early phase I/II comparison. Cancer 5 1: 1599-1604: 1983.
  8. Fuks, Z.; Leibel, S. A.; Wallner, K. E.; Begg, C. B.; Fair, W. R.; Anderson, L. L.; Hilaris, B. S.; Whitmore, W. F. The impact of local control on metastatic dissemination in carcinoma of the prostate: Long-term in patients treated with 125-iodine implantation. Int. J. Radiat. Oncol. Biol. Phys. 21:537-547; 1991.
  9. Greskovich, F. J.; Zagars, G. K.; Sherman, N. E.; Johnson, D. E. Complications following external beam radiation therapy for prostate cancer. An analysis of patients treated with and without staging pelvic lymphadenectomy. J. Urol. 146:798-802; 1991.
  10. Goitein, M.; Abrams, M.; Rowell, D.; Pollari, H.; Wiles, J. Multi-dimensional treatment planning: II. Beam's eye-view, back projection and projection through CT sections. Int. J. Radiat. Oncol. Biol. Phys. 9:789-797; 1983.
  11. Hanks, G. E.; Krall, J. M.; Martz, K. L.; Diamond, J. J.; Kramer, S. The outcome of treatment of 3 13 patients with prostate cancer treated with external beam irradiation. Int. J. Radiat. Oncol. Biol. Phys. 14:243-248; 1988.
  12. Hanks, G. E. External beam radiation therapy for clinically localized prostate cancer: Patterns of care studies in the United States. NC1 Monographs 7:75-84; 1988.
  13. Kaplan, I. E.; Prestidge, B. R.; Bagshaw, M. A.; Cox, R. S. The importance of local control in the treatment of prostatic cancer. J. Urol. 147:917-921; 1992.
  14. Kaplan, E. L.; Meier, P. Nonparametric estimation from incomplete observations. J. Amer. Stat. Assoc. 53:457-481; 1958.
  15. Lawton, C. A.; Won, M.; Pilepich, M. V.; Asbell, S. 0.; Shipley, W. U.; Hanks, G. E.; Cox, J. D.; Perez, C. A.; Sause, W. T.; Doggett, S. R. L.; Rubin, P. Long-term treatment sequalae following external beam irradiation for adencar- cinema of the prostate -analysis of RTOG study 7506 and study 7706. Int. J. Radiat. Oncol. Biol. Phys. 21:935- 939; 1991.
  16. Marinelli, D.; Shanberg, A. M.; Tanzey, L. A.; Sawyer, D. E.; Syed, N.; Puthawala, A. Follow-up prostate biopsy 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. in patients with carcinoma of the prostate treated by 192- iridium template irradiation plus supplemental external beam radiation. J. Urol. 147:922-925; 1992.
  17. Perez, C. A.; Pilepich, M. V.; Garcia, D.; Simpson, J. R.; Zivnuska, F.; Hederman, M. A. Definitive radiation therapy in carcinoma of the prostate: Experience at Mallinckrodt Institute of Radiology. NC1 Monographs 7:85-94; 1988.
  18. Pilepich, M. V. Radiation Therapy Oncology Group Studies in carcinoma of the prostate. NC1 Monographs 7:61-65; 1988.
  19. Sandler, H.M.; Perez-Tamayo, C.; Ten Haken, R. K.; Lich- ter, A. S. Dose escalation for stage C (T3) prostate cancer: Minimal rectal toxicity observed using conformal therapy. Radiother. Oncol. 23:53-54; 1992.
  20. Scardino, P. T.; Wheeler, T. M. Local control of prostate cancer with radiotherapy: Frequency and prognostic signif- icance of positive results of post-irradiation prostate biopsy. NC1 Monographs. 7:95-103; 1988.
  21. Shipley, W. U.; Tepper, J. E.; Prout, G. R., Jr.; Verhey, L. J.; Mendiondo, 0. A.; Goitein, M.; Koehler, A. M.; Suit, H. D. Proton radiation as boost therapy for localized pros- tatic carcinoma. JAMA 241:1912-1915; 1979.
  22. Shipley, W. U.; Prout, G. R.; Coachman, N. M.; McManus, P. L.; Healey, E. A.; Althausen, A. F.; Heney, N. M.; Park- urst, E. C.; Young, H. H., II; Shipley, J. W.; Kaufman, S. D. Radiation therapy for localized prostatic carcinoma: Experience at the Massachusetts General Hospital (1973- 198 1). NC1 Monographs 7:67-73; 1988.
  23. Smit, W. G. J. M.; Helle, P. A.; van Putten, W. L. J.; Wijnmaalen, A. J.; Seldenrath, J. J.; van der Werf-Messing, B. H. P. Late radiation damage in prostate cancer patients treated by high dose external radiotherapy in relation to rectal dose. Int. J. Radiat. Oncol. Biol. Phys. 18:23-29; 1990.
  24. Soffen, E. M.; Epstein, B. E.; Hunt, M. A.; Hanks, G. E. Decreased acute morbidity with conformal static field ra- diation therapy of early prostate cancer as compared to non- conformal techniques. (Abstr.) Int. J. Radiat. Oncol. Biol. Phys. 21(Suppl 1):152; 1991.
  25. Urano, M.; Goitein, M.; Verhey, L.; Munzenrider, J.; Suit,
  26. H. D.; Koehler, A. M. Proton beam irradiation: An energy modulated proton beam using a spontaneous murine tumor in vivo. Int. J. Radiat. Oncol. Biol. Phys. 6:1187-l 193; 1980.
  27. Urie, M.; Sisterson, J.; Koehler, A.; Goitein, M.; Zoesman, J. Proton beam penumbra: Effects of separation between patient and beam modifying devices. Med. Phys. 5:731- 734; 1986.
  28. Verhey, L. J.; Koehler, A. M.; McDonald, J. C.; Goitein, M.; Ma, I.; Schneider, R. J.; Wagner;
  29. M. The determination of absorbed dose in a proton beam for purposes of charged- particle radiation therapy. Radiat. Res. 79:34-54; 1979.