Cédric Panje

Consensus and differences in primary radiotherapy for localized and locally advanced prostate cancer in Switzerland: A survey on patterns of practice.

IntroductionExternal beam radiotherapy (EBRT), with or without androgen deprivation therapy (ADT), is an established treatment option for nonmetastatic prostate cancer. Despite high-level evidence from several randomized trials, risk group stratification and treatment recommendations vary due to contradictory or inconclusive data, particularly with regard to EBRT dose prescription and ADT duration. Our aim was to investigate current patterns of practice in primary EBRT for prostate cancer in Switzerland.Materials and methodsTreatment recommendations on EBRT and ADT for localized and locally advanced prostate cancer were collected from 23xa0Swiss radiation oncology centers. Written recommendations were converted into center-specific decision trees, and analyzed for consensus and differences using a dedicated software tool. Additionally, specific radiotherapy planning and delivery techniques from the participating centers were assessed.ResultsThe most commonly prescribed radiation dose was 78xa0Gy (range 70–80xa0Gy) across all risk groups. ADT was recommended for intermediate-risk patients for 6xa0months in over 80u2009% of the centers, and for high-risk patients for 2xa0or 3xa0years in over 90u2009% of centers. For recommendations on combined EBRT and ADT treatment, consensus levels did not exceed 39u2009% in any clinical scenario. Arc-based intensity-modulated radiotherapy (IMRT) is implemented for routine prostate cancer radiotherapy by 96u2009% of the centers.ConclusionAmong Swiss radiation oncology centers, considerable ranges of radiotherapy dose and ADT duration are routinely offered for localized and locally advanced prostate cancer. In the vast majority of cases, doses and durations are within the range of those described in current evidence-based guidelines.ZusammenfassungEinleitungDie Radiotherapie (RT) ist als Monotherapie oder in Kombination mit einer Androgendeprivationstherapie (ADT) eine etablierte Behandlungsoption für das lokalisierte und lokal fortgeschrittene Prostatakarzinom. Trotz der guten Evidenzlage durch zahlreiche randomisierte Studien bestehen weiterhin unterschiedliche Behandlungskonzepte, die besonders hinsichtlich der Gesamtdosis der RT sowie der Dauer der ADT variieren. Das Ziel der vorliegenden Studie ist eine Analyse der Behandlungskonzepte für die kurative RT des Prostatakarzinoms in der Schweiz.Material und MethodenDie Behandlungsempfehlungen für das lokalisierte und lokal fortgeschrittene Prostatakarzinom bezüglich Bestrahlungsdosis und ADT-Dauer wurden von 23xa0Schweizer Zentren für Strahlentherapie eingeholt. Die einzelnen Empfehlungen wurden mittels einer speziellen Software in zentrumsspezifische Therapiealgorithmen umgewandelt und automatisch auf Konsens und Differenzen mit den übrigen Zentren verglichen. Zusätzlich erfolgte eine Umfrage über den Einsatz besonderer Behandlungstechniken.ErgebnisseDie am häufigsten verschriebene Gesamtdosis war 78xa0Gy für alle Risikogruppen (Spanne 70–80xa0Gy). Eine ADT wurde für Patienten der mittleren Risikogruppe für 6xa0Monate von über 80u2009% der Zentren und für Hochrisiko-Patienten für 2–3xa0Jahre von über 90u2009% der Zentren empfohlen. Für die kombinierten Therapieempfehlungen bezüglich RT-Gesamtdosis und ADT-Dauer ergab sich in keinem klinischen Szenario ein Konsens von mehr als 39u2009%. Intensitätsmodulierte Rotationstechniken werden in 96u2009% der Zentren als Standard für die RT des Prostatakarzinoms verwendet.SchlussfolgerungIn der Therapie des lokalisierten und lokal fortgeschrittenen Prostatakarzinoms werden in der Schweiz verschiedene Therapiekonzepte bezüglich RT-Gesamtdosis und ADT-Dauer angeboten, die in der überwiegenden Mehrheit innerhalb der von evidenzbasierten Leitlinien empfohlenen Spanne liegen.

Guidance of treatment decisions in risk-adapted primary radiotherapy for prostate cancer using multiparametric magnetic resonance imaging: a single center experience

BackgroundMagnetic resonance imaging (MRI) of the prostate is considered to be the most precise noninvasive staging modality for localized prostate cancer. Multiparametric MRI (mpMRI) dynamic sequences have recently been shown to further increase the accuracy of staging relative to morphological imaging alone. Correct radiological staging, particularly the detection of extraprostatic disease extension, is of paramount importance for target volume definition and dose prescription in highly-conformal curative radiotherapy (RT); in addition, it may affect the risk-adapted duration of additional antihormonal therapy. The purpose of our study was to analyze the impact of mpMRI-based tumor staging in patients undergoing primary RT for prostate cancer.MethodsA total of 122 patients admitted for primary RT for prostate cancer were retrospectively analyzed regarding initial clinical and computed tomography-based staging in comparison with mpMRI staging. Both tumor stage shifts and overall risk group shifts, including prostate-specific antigen (PSA) level and the Gleason score, were assessed. Potential risk factors for upstaging were tested in a multivariate analysis. Finally, the impact of mpMRI-based staging shift on prostate RT and antihormonal therapy was evaluated.ResultsOverall, tumor stage shift occurred in 55.7% of patients after mpMRI. Upstaging was most prominent in patients showing high-risk serum PSA levels (73%), but was also substantial in patients presenting with low-risk PSA levels (50%) and low-risk Gleason scores (45.2%). Risk group changes occurred in 28.7% of the patients with consequent treatment adaptations regarding target volume delineation and duration of androgen deprivation therapy. High PSA levels were found to be a significant risk factor for tumor upstaging and newly diagnosed seminal vesicle infiltration assessed using mpMRI.ConclusionsOur findings suggest that mpMRI of the prostate leads to substantial tumor upstaging, and can considerably affect treatment decisions in all patient groups undergoing risk-adapted curative RT for prostate cancer.

Role of 18F-FDG PET/CT Imaging in Intrahepatic Cholangiocarcinoma.

Purpose Although intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy after hepatocellular carcinoma, there are limited data available on PET/CT imaging in ICC. This retrospective study analyzed the role of PET/CT imaging in the evaluation of ICC. Methods FDG PET/CT findings were reviewed in 65 patients with histologically confirmed ICC. PET/CT was evaluated based on visual interpretation and the semiquantitative index of SUVmax and tumor-to-normal liver tissue ratio (TNR), which were consequently further analyzed and correlated with tumor localization, differentiation, size, and serum levels of tumor markers. Forty-five cases also underwent abdominal MRI examinations. Results Nineteen patients had hilar ICC, whereas 46 patients had peripheral ICC. Sixty cases of ICC showed elevated FDG uptake with an average SUVmax of 8.3 ± 4.7 and TNR of 3.1 ± 1.7. Five cases located in the hilum were false negative on PET/CT imaging. Compared with hilar ICC, SUVmax and TNR of peripheral ICC were significantly higher (P < 0.05). FDG accumulation correlated with the degree of ICC differentiation. SUVmax and TNR correlated with tumor size, whereas there was no correlation observed with serum levels of carbohydrate antigen 19-9. The sensitivity, specificity, and accuracy of PET/CT and MRI in the diagnosis of regional lymph node metastases were 70.0% versus 50%, 91.7% versus 83.3%, and 81.8% versus 68.2%, respectively. PET/CT upstaged 12.3% and downstaged 3.1% of cases and had no impact on patient management in the remaining 84.6% of cases. Conclusions Combination of FDG PET/CT and abdominal MRI might improve the diagnostic accuracy for ICC.

Stereotactic body radiotherapy for renal cell cancer and pancreatic cancer : Literature review and practice recommendations of the DEGRO Working Group on Stereotactic Radiotherapy

AbstractPurposeThis report of the Working Group on Stereotactic Radiotherapy of the German Society of Radiation Oncology (DEGRO) aims to provide axa0literature review and practice recommendations for stereotactic body radiotherapy (SBRT) of primary renal cell cancer and primary pancreatic cancer.MethodsAxa0literature search on SBRT for both renal cancer and pancreatic cancer was performed with focus on prospective trials and technical aspects for clinical implementation.ResultsData on renal and pancreatic SBRT are limited, but show promising rates of local control for both treatment sites. For pancreatic cancer, fractionated SBRT should be preferred to single-dose treatment to reduce the risk of gastrointestinal toxicity. Motion-compensation strategies and image guidance are paramount for safe SBRT delivery in both tumor entities.ConclusionSBRT for renal cancer and pancreatic cancer have been successfully evaluated in phasexa0I and phasexa0II trials. Pancreatic SBRT should be practiced carefully and only within prospective protocols due to the risk of severe gastrointestinal toxicity. SBRT for primary renal cell cancer appears axa0viable option for medically inoperable patients but future research needs to better define patient selection criteria and the detailed practice of SBRT.ZusammenfassungZielDie Arbeitsgruppe „Stereotaktische Radiotherapie“ der Deutschen Gesellschaft für Radioonkologie (DEGRO) legt eine Zusammenfassung der aktuellen Literatur und daraus resultierende Empfehlungen zur Durchführung der stereotaktischen Strahlentherapie (SBRT) beim Nierenzellkarzinom und beim Pankreaskarzinom vor.MethodenEs erfolgte eine Literaturrecherche zur Evidenz der SBRT beim Nierenzell- und Pankreaskarzinom, wobei der Schwerpunkt auf prospektive Studien und technische Aspekte für die klinische Umsetzung gelegt wurde.ErgebnisseFür die SBRT beim Pankreaskarzinom und Nierenzellkarzinom sind bisher nur wenige Studien veröffentlicht worden, die jedoch konsistent eine hohe Rate an lokaler Tumorkontrolle berichten. Für das Pankreaskarzinom sollten fraktionierte Schemata einer einzeitigen Stereotaxie bevorzugt werden, um die gastrointestinale Toxizität zu reduzieren. Für beide Tumorentitäten sind Strategien zur Bewegungskompensation und bildgeführte Strahlentherapie für die sichere Durchführung der Behandlung zwingend notwendig.SchlussfolgerungDie SBRT zur Behandlung des Pankreaskarzinoms und des Nierenzellkarzinoms ist erfolgreich in Phase-I/II-Studienn durchgeführt worden. Pankreas-SBRT sollte aktuell nur in prospektiven Studienprotokollen praktiziert werden, da ein potentielles Risiko für schwerwiegende gastrointestinale Nebenwirkungen besteht. Für das Nierenzellkarzinom stellt die SBRT eine Behandlungsoption für inoperable Patienten dar, wobei insbesondere die optimale Patientenselektion und technische Aspekte in zukünftigen Studien untersucht werden sollten.

A cost-effectiveness analysis of consolidative local therapy in oligometastatic non-squamous non-small cell lung cancer (NSCLC)

BACKGROUNDnNovel systemic therapies have improved the prognosis of metastatic non-small cell lung cancer (NSCLC), but costs of some of these drugs are a matter of ongoing debate. More recently, local therapies (LT) such as radiotherapy and surgery have been suggested as additional treatment in oligometastatic NSCLC demonstrating an improved progression-free survival (PFS) in a phase II trial compared to maintenance chemotherapy (MC) alone. The aim of this analysis was to assess the cost-effectiveness of local therapies in oligometastatic NSCLC.nnnMETHODSnWe constructed a Markov model comparing the cost-effectiveness of LT versus MC for oligometastatic NSCLC from the Swiss healthcare payers perspective. Treatment specifications and PFS were based on the phase II trial (NCT01725165). Overall survival (OS) was inferred from a recent phase III trial. Utilities were taken from published data. Primary outcome was the incremental cost-effectiveness-ratio (ICER, costs in Swiss Francs (CHF) per quality-adjusted life-year (QALY) gained).nnnRESULTSnPFS in the model was 3.8u202fmonths for MC and 11.4u202fmonths for LT (compared to 3.9u202fmonths and 11.9u202fmonths in the trial). OS in the model was 15.5u202fmonths in both arms. LT was cost-effective with a gain of 0.24 QALYs at an additional cost of CHF 9641, resulting in an ICER of CHF 40,972/QALY gained. Probabilistic sensitivity analyses demonstrated that LT was dominant or cost-effective at a willingness-to-pay threshold of CHF 100,000 per QALY in 61.7% of the simulations.nnnCONCLUSIONSnLT may be cost-effective for selected patients with oligometastatic NSCLC responding to first-line systemic therapy.

Assessment of pancreatic colloid carcinoma using 18F‑FDG PET/CT compared with MRI and enhanced CT

Pancreatic colloid carcinoma (CC) is a rare sub-type of pancreatic adenocarcinoma which has an improved prognosis compared with pancreatic ductal carcinoma. Consequently, the early detection of CC by imaging may be of great significance in guiding patient management and therapeutic decisions. The present study aimed to analyze 18F-FDG PET/CT findings of CC in comparison to MRI and CT. PET/CT findings in 5 patients with CC were retrospectively reviewed based on visual interpretation and semi-quantitative index of SUVmax and TNR. Four patients received dual-time-point PET/CT scans. Additionally, one patient underwent contrast-enhanced CT scan, one MRI, and three received both. A total of five lesions were detected in five patients. Visually, two cases presented with mild FDG uptake, two with moderate and one with high. The mean of SUVmax and TNR was 5.1±2.2 and 2.8±0.7, respectively. Compared with CCs with low SUVmax, CCs with high SUVmax were more aggressive. No distant metastases were observed in five cases. Among four patients with dual-time-point PET/CT imaging, SUVmax increased in three cases and decreased in one case. The mean early and delayed SUVmax were 4.2±1.1 and 4.7±1.9, respectively (P>0.05). Radiological findings mainly included septated cystic components, internal sponge-like contrast-enhancement, calcification and ‘salt-and-pepper sign’ on MRI T2-weighted imaging. Thus, PET/CT provided additional information on metabolic tumor activity as well as locoregional and distant staging, which are important prognostic markers and may improve further patient management. However, PET/CT did not show any findings in addition to MRI and contrast-enhanced CT that were unique to CC and allowed a clear differentiation from other pancreatic malignancies.

Decision Making Criteria in Oncology

Decision making is one of the most complex skills required of an oncologist and is affected by a broad range of parameters. For example, the wide variety of treatment options, with various outcomes, side-effects and costs present challenges in selecting the most appropriate treatment. Many treatment choices are affected by limited scientific evidence, availability of therapies or patient-specific factors. In the decision making process, standardized approaches can be useful, but a multitude of criteria are relevant to this process. Thus, the aim of this review is to summarize common types of decision criteria used in oncology by focusing on 3 main categories: criteria associated with the decision maker (both patient and doctor), decision specific criteria, and the often-overlooked contextual factors. Our review aims to highlight the broad range of decision criteria in use, as well as variations in their interpretation.

Salvage radiotherapy for macroscopic local recurrences after radical prostatectomy : A national survey on patterns of practice

IntroductionAlthough salvage radiotherapy (SRT) for PSA recurrence after radical prostatectomy provides better oncological outcomes when delivered early, in the absence of detectable disease many patients are treated for macroscopic locally recurrent tumors. Due to limited data from prospective studies, we hypothesized an important variability in the SRT management of these patients. Our aim was to investigate current practice patterns of SRT for local macroscopic recurrence after radical prostatectomy.Material and methodsA total of 14 Swiss radiation oncology centers were asked to complete axa0survey on treatment specifications for macroscopic locally recurrent disease including information on pretherapeutic diagnostic procedures, dose prescription, radiation delivery techniques and androgen deprivation therapy (ADT). Treatment recommendations on ADT were analyzed using the objective consensus methodology.ResultsThe majority of centers recommended pretreatment magnetic resonance imaging (MRI) of the pelvis and choline positron emission tomography (PET). The median prescribed dose to the prostate bed was 66u2009Gy (range 65–72u2009Gy) with axa0boost to the macroscopic lesion used by 79% of the centers with axa0median total dose of 72u2009Gy (range 70–80u2009Gy). Intensity-modulated rotational techniques were used by all centers and daily cone beam computed tomography (CT) was recommended by 43%. The use of concomitant ADT for any macroscopic recurrence was recommended by 43% of the centers while the remaining centers recommended it only for high-risk disease, which was not consistently defined.ConclusionWe observed axa0high variability of treatment paradigms when SRT is indicated for macroscopic local recurrences after prostatectomy. These data reflect the need for more standardized approaches and ultimately further research in this field.ZusammenfassungEinleitungObwohl die Evidenz für eine frühzeitige Salvage-Radiotherapie (SRT) bei einem PSA-Rezidiv nach radikaler Prostatektomie spricht, werden viele Patienten erst bei einem makroskopischen Lokalrezidiv behandelt. Hier scheint es jedoch aufgrund der fehlenden Daten aus prospektiven Studien eine Variabilität der Behandlungskonzepte zu geben. Das Ziel der Studie war es, die aktuelle Behandlungspraxis in der SRT des makroskopischen Rezidivs eines Prostatakarzinoms zu untersuchen.Material und MethodenInsgesamt 14 Schweizer Strahlentherapiezentren wurden für eine Umfrage zu den Behandlungsparametern beim makroskopischen Lokalrezidiv eines Prostatakarzinoms kontaktiert und nach diagnostischen Maßnahmen, Dosisverschreibung, Strahlentherapietechniken und antihormoneller Therapie (ADT) befragt. Die variierenden Indikationen zur ADT wurden mittels der Objective-konsensus-Methodologie ausgewertet.ErgebnisseDie Mehrheit der Zentren empfahl vor der Therapie eine Magnetresonanztomographie (MRT) des Beckens und eine Cholin-Positronenemissionstomographie (PET). Die mediane verschriebene Dosis für die Prostataloge war 66u2009Gy (65–72u2009Gy) mit einem Boost auf das makroskopische Lokalrezidiv in 79u2009% der Zentren bis zu einer medianen Dosis von 72u2009Gy (70–80u2009Gy). Alle Zentren verwendeten intensitätsmodulierte Rotationstechniken, ein tägliches Cone-beam-CT wurde in 43u2009% der Zentren empfohlen. Eine begleitende ADT wurde von 43u2009% für jedes makroskopische Lokalrezidiv empfohlen, während die übrigen Zentren dies nur bei Hochrisikogruppen (mit unterschiedlichen Definitionen) durchführten.SchlussfolgerungEs wurde eine hohe Variabilität der Behandlungskonzepte für die SRT des makroskopischen Lokalrezidivs nach Prostatektomie beobachtet. Dies zeigt den Bedarf an standardisierten Behandlungskonzepten und weiteren Studien in diesem Bereich auf.

Surgical management of urolithiasis – a systematic analysis of available guidelines

BackgroundSeveral societies around the world issue guidelines incorporating the latest evidence. However, even the most commonly cited guidelines of the European Association of Urology (EAU) and the American Urological Association (AUA) leave the clinician with several treatment options and differ on specific points. We aimed to identify discrepancies and areas of consensus between guidelines to give novel insights into areas where low consensus between the guideline panels exists, and therefore where more evidence might increase consensus.MethodsThe webpages of the 61 members of the Societé Internationale d’Urologie were analysed to identify all listed or linked guidelines. Decision trees for the surgical management of urolithiasis were derived, and a comparative analysis was performed to determine consensus and discrepancies.ResultsFive national and one international guideline (EAU) on surgical stone treatment were available for analysis. While 7 national urological societies refer to the AUA guidelines and 11 to the EAU guidelines, 43 neither publish their own guidelines nor refer to others. Comparative analysis revealed a high degree of consensus for most renal and ureteral stone scenarios. Nevertheless, we also identified a variety of discrepancies between the different guidelines, the largest being the approach to the treatment of proximal ureteral calculi and larger renal calculi.ConclusionsSix guidelines with recommendations for the surgical treatment of urolithiasis to support urologists in decision-making were available for inclusion in our analysis. While there is a high grade of consensus for most stone scenarios, we also detected some discrepancies between different guidelines. These are, however, controversial situations where adequate evidence to assist with decision-making has yet to be elicited by further research.

Salvage radiotherapy for macroscopic local recurrences after radical prostatectomy Salvage-Radiotherapie bei makroskopischen Lokalrezidiven nach radikaler Prostatektomie

IntroductionAlthough salvage radiotherapy (SRT) for PSA recurrence after radical prostatectomy provides better oncological outcomes when delivered early, in the absence of detectable disease many patients are treated for macroscopic locally recurrent tumors. Due to limited data from prospective studies, we hypothesized an important variability in the SRT management of these patients. Our aim was to investigate current practice patterns of SRT for local macroscopic recurrence after radical prostatectomy.Material and methodsA total of 14 Swiss radiation oncology centers were asked to complete axa0survey on treatment specifications for macroscopic locally recurrent disease including information on pretherapeutic diagnostic procedures, dose prescription, radiation delivery techniques and androgen deprivation therapy (ADT). Treatment recommendations on ADT were analyzed using the objective consensus methodology.ResultsThe majority of centers recommended pretreatment magnetic resonance imaging (MRI) of the pelvis and choline positron emission tomography (PET). The median prescribed dose to the prostate bed was 66u2009Gy (range 65–72u2009Gy) with axa0boost to the macroscopic lesion used by 79% of the centers with axa0median total dose of 72u2009Gy (range 70–80u2009Gy). Intensity-modulated rotational techniques were used by all centers and daily cone beam computed tomography (CT) was recommended by 43%. The use of concomitant ADT for any macroscopic recurrence was recommended by 43% of the centers while the remaining centers recommended it only for high-risk disease, which was not consistently defined.ConclusionWe observed axa0high variability of treatment paradigms when SRT is indicated for macroscopic local recurrences after prostatectomy. These data reflect the need for more standardized approaches and ultimately further research in this field.ZusammenfassungEinleitungObwohl die Evidenz für eine frühzeitige Salvage-Radiotherapie (SRT) bei einem PSA-Rezidiv nach radikaler Prostatektomie spricht, werden viele Patienten erst bei einem makroskopischen Lokalrezidiv behandelt. Hier scheint es jedoch aufgrund der fehlenden Daten aus prospektiven Studien eine Variabilität der Behandlungskonzepte zu geben. Das Ziel der Studie war es, die aktuelle Behandlungspraxis in der SRT des makroskopischen Rezidivs eines Prostatakarzinoms zu untersuchen.Material und MethodenInsgesamt 14 Schweizer Strahlentherapiezentren wurden für eine Umfrage zu den Behandlungsparametern beim makroskopischen Lokalrezidiv eines Prostatakarzinoms kontaktiert und nach diagnostischen Maßnahmen, Dosisverschreibung, Strahlentherapietechniken und antihormoneller Therapie (ADT) befragt. Die variierenden Indikationen zur ADT wurden mittels der Objective-konsensus-Methodologie ausgewertet.ErgebnisseDie Mehrheit der Zentren empfahl vor der Therapie eine Magnetresonanztomographie (MRT) des Beckens und eine Cholin-Positronenemissionstomographie (PET). Die mediane verschriebene Dosis für die Prostataloge war 66u2009Gy (65–72u2009Gy) mit einem Boost auf das makroskopische Lokalrezidiv in 79u2009% der Zentren bis zu einer medianen Dosis von 72u2009Gy (70–80u2009Gy). Alle Zentren verwendeten intensitätsmodulierte Rotationstechniken, ein tägliches Cone-beam-CT wurde in 43u2009% der Zentren empfohlen. Eine begleitende ADT wurde von 43u2009% für jedes makroskopische Lokalrezidiv empfohlen, während die übrigen Zentren dies nur bei Hochrisikogruppen (mit unterschiedlichen Definitionen) durchführten.SchlussfolgerungEs wurde eine hohe Variabilität der Behandlungskonzepte für die SRT des makroskopischen Lokalrezidivs nach Prostatektomie beobachtet. Dies zeigt den Bedarf an standardisierten Behandlungskonzepten und weiteren Studien in diesem Bereich auf.