Milos Brodak

Dose escalation in prostate radiotherapy up to 82 Gy using simultaneous integrated boost: direct comparison of acute and late toxicity with 3D-CRT 74 Gy and IMRT 78 Gy.

Purpose:To compare acute and late toxicity after three-dimensional conformal radiotherapy to the prostate to 74 Gy (3D-CRT) with intensity-modulated radioterapy to 78 Gy (IMRT 78) and IMRT using simultaneous integrated boost to 82 Gy (IMRT/SIB 82).Patients and Methods:94 patients treated with 3D-CRT to the prostate and base of seminal vesicles to 74 Gy represented the first group. The second group consisted of 138 patients subjected to IMRT covering the prostate and base of seminal vesicles to 78 Gy. The last group was treated with IMRT using SIB. The prescribed doses were 82 Gy and 73.8 Gy in 42 fractions to the prostate and seminal vesicles. Late toxicity was prospectively scored according to the RTOG/FC-LENT scale.Results:Acute gastrointestinal toxicity ≥ grade 2 occurred in 35.1% of patients treated with 3D-CRT, in 16% subjected to IMRT 78, and in 7.7% receiving IMRT/SIB 82. Acute genitourinary toxicity ≥ grade 2 was observed in 26.6% (3D-CRT), 33% (IMRT 78), and 30.7% (IMRT/SIB 82). At 3 years, the estimated cumulative incidence of grade 3 late gastrointestinal toxicity was 14% for 3D-CRT, 5% for IMRT 78, and 2% for IMRT/SIB 82. The difference became significant (log rank p = 0.02). The estimated cumulative incidence of grade 3 late genitourinary toxicity was 9% (3D-CRT), 7% (IMRT 78), and 6% (IMRT/SIB 82) without statistical differences (log rank p = 0.32)Conclusion:SIB enables dose escalation up to 82 Gy with a lower rate of gastrointestinal toxicity grade 3 in comparison with 3D-CRT up to 74 Gy.ZusammenfassungZiel:Vergleich der Akut- und Spättoxizität nach dreidimensionaler konformaler Strahlentherapie der Prostata bis 74 Gy (3D-CRT) mit intensitätsmodulierter Radiotherapie bis 78 Gy (IMRT 78) und mit IMRT mit simultanem integrierten Boost bis 82 Gy (IMRT/ SIB 82).Patienten und Methodik:Die erste Gruppe bestand aus 94 Patienten, die eine 3D-CRT der Prostata und der Bläschendrüsenbasis bis 74 Gy erhielten. Die zweite Gruppe umfasste 138 Patienten, welche mit IMRT der Prostata und der Bläschendrüsenbasis bis 78 Gy behandelt wurden. Die letzte Gruppe erhielt eine IMRT mit SIB. Die verschriebenen Strahlendosen betrugen 82 Gy und 73,8 Gy in 42 Fraktionen auf die Prostata und die Bläschendrüsenbasis. Die Spättoxizität wurde anhand der RTOG/FC-LENT-Skala bewertet.Ergebnisse:Akute gastrointestinale Nebenwirkungen ≥ Grad 2 entwickelten 35,1% der Patienten mit 3D-CRT, 16% mit IMRT 78 und 7,7% mit IMRT/SIB 82. Akute urogenitale Nebenwirkungen ≥ Grad 2 traten bei 26,6% der Patienten mit 3D-CRT, 33% mit IMRT 78 und 30,7% mit IMRT/SIB 82 auf. Nach 3 Jahren betrug die geschätzte kumulative Inzidenz gastrointestinaler Spättoxizität Grad 3 14% für 3D-CRT, 5% für IMRT 78 und 2% für IMRT/SIB 82. Der Unterschied war signifikant (Log-Rank p = 0,02). Die geschätzte kumulative Inzidenz urogenitaler Spättoxizität Grad 3 lag bei 9% (3D-CRT), 7% (IMRT 78) und 6% (IMRT/ SIB 82) und zeigte keine Signifikanz (Log-Rank p = 0,32).Schlussfolgerung:Die Dosissteigerung auf 82 Gy mit SIB führt im Vergleich mit der 3D-CRT bis 74 Gy zu einer geringeren Rate an gastrointestinaler Spättoxizität Grad 3.

High-dose rate brachytherapy in the treatment of penile carcinoma--first experience.

PURPOSE Interstitial low-dose rate brachytherapy (BRT) allows a conservative treatment of T1-T2 penile carcinoma. High-dose rate (HDR) BRT is often considered as a dangerous method for interstitial implants because of higher risk of complications. However, numerous reports suggest that results of HDR-BRT may be comparable to low-dose rate BRT. There are no data available in the literature regarding HDR interstitial BRT for carcinoma of the penis. METHODS AND MATERIALS Ten patients with early penile carcinoma were treated by interstitial hyperfractionated HDR-BRT at the dose of 18 times 3Gy twice daily between years 2002 and 2009. Breast interstitial BRT template was used for fixation and precise geometry reconstruction of stainless hollow needles. RESULTS Median followup was 20 months. Our BRT technique and fractionation schedule was well tolerated by all patients. Acute reaction consisted predominantly of penis edema and Grade 2 radiation mucositis that dissolved during 8 weeks after the treatment. We neither observed any postradiation necrosis nor urethral stenosis. The worst late side effects recorded were mild telanagiectasias in the treatment region. At the last followup, all patients were alive without evidence of the tumor and with fully functional organ. CONCLUSIONS Hyperfractionated interstitial HDR-BRT with 18 times 3 Gy per fraction twice daily is a promising method in selected patients of penile carcinoma and deserves further evaluation in a larger prospective study.

Magnetic Resonance Imaging in Postprostatectomy Radiotherapy Planning

PURPOSE To investigate whether the use of magnetic resonance imaging (MRI) in prostate bed treatment planning could influence definition of the clinical target volume (CTV) and organs at risk. METHODS AND MATERIALS A total of 21 consecutive patients referred for prostate bed radiotherapy were included in the present retrospective study. The CTV was delineated according to the European Organization for Research and Treatment of Cancer recommendations on computed tomography (CT) and T(1)-weighted (T(1)w) and T(2)-weighted (T(2)w) MRI. The CTV magnitude, agreement, and spatial differences were evaluated on the planning CT scan after registration with the MRI scans. RESULTS The CTV was significantly reduced on the T(1)w and T(2)w MRI scans (13% and 9%, respectively) compared with the CT scans. The urinary bladder was drawn smaller on the CT scans and the rectum was smaller on the MRI scans. On T(1)w MRI, the rectum and urinary bladder were delineated larger than on T(2)w MRI. Minimal agreement was observed between the CT and T(2)w images. The main spatial differences were measured in the superior and superolateral directions in which the CTV on the MRI scans was 1.8-2.9 mm smaller. In the posterior and inferior border, no difference was seen between the CT and T(1)w MRI scans. On the T(2)w MRI scans, the CTV was larger in these directions (by 1.3 and 1.7 mm, respectively). CONCLUSIONS The use of MRI in postprostatectomy radiotherapy planning resulted in a reduction of the CTV. The main differences were found in the superior part of the prostate bed. We believe T(2)w MRI enables more precise definition of prostate bed CTV than conventional planning CT.

Late toxicity after conformal and intensity-modulated radiation therapy for prostate cancer: Impact of previous surgery for benign prostatic hyperplasia

Objectives:  To retrospectively compare late toxicity of conventional‐dose three‐dimensional conformal radiation therapy (3D‐CRT) and high‐dose intensity‐modulated radiation therapy (IMRT) for prostate cancer.

Dose Escalation in Prostate Radiotherapy up to 82 Gy Using Simultaneous Integrated Boost

Purpose:To compare acute and late toxicity after three-dimensional conformal radiotherapy to the prostate to 74 Gy (3D-CRT) with intensity-modulated radioterapy to 78 Gy (IMRT 78) and IMRT using simultaneous integrated boost to 82 Gy (IMRT/SIB 82).Patients and Methods:94 patients treated with 3D-CRT to the prostate and base of seminal vesicles to 74 Gy represented the first group. The second group consisted of 138 patients subjected to IMRT covering the prostate and base of seminal vesicles to 78 Gy. The last group was treated with IMRT using SIB. The prescribed doses were 82 Gy and 73.8 Gy in 42 fractions to the prostate and seminal vesicles. Late toxicity was prospectively scored according to the RTOG/FC-LENT scale.Results:Acute gastrointestinal toxicity ≥ grade 2 occurred in 35.1% of patients treated with 3D-CRT, in 16% subjected to IMRT 78, and in 7.7% receiving IMRT/SIB 82. Acute genitourinary toxicity ≥ grade 2 was observed in 26.6% (3D-CRT), 33% (IMRT 78), and 30.7% (IMRT/SIB 82). At 3 years, the estimated cumulative incidence of grade 3 late gastrointestinal toxicity was 14% for 3D-CRT, 5% for IMRT 78, and 2% for IMRT/SIB 82. The difference became significant (log rank p = 0.02). The estimated cumulative incidence of grade 3 late genitourinary toxicity was 9% (3D-CRT), 7% (IMRT 78), and 6% (IMRT/SIB 82) without statistical differences (log rank p = 0.32)Conclusion:SIB enables dose escalation up to 82 Gy with a lower rate of gastrointestinal toxicity grade 3 in comparison with 3D-CRT up to 74 Gy.ZusammenfassungZiel:Vergleich der Akut- und Spättoxizität nach dreidimensionaler konformaler Strahlentherapie der Prostata bis 74 Gy (3D-CRT) mit intensitätsmodulierter Radiotherapie bis 78 Gy (IMRT 78) und mit IMRT mit simultanem integrierten Boost bis 82 Gy (IMRT/ SIB 82).Patienten und Methodik:Die erste Gruppe bestand aus 94 Patienten, die eine 3D-CRT der Prostata und der Bläschendrüsenbasis bis 74 Gy erhielten. Die zweite Gruppe umfasste 138 Patienten, welche mit IMRT der Prostata und der Bläschendrüsenbasis bis 78 Gy behandelt wurden. Die letzte Gruppe erhielt eine IMRT mit SIB. Die verschriebenen Strahlendosen betrugen 82 Gy und 73,8 Gy in 42 Fraktionen auf die Prostata und die Bläschendrüsenbasis. Die Spättoxizität wurde anhand der RTOG/FC-LENT-Skala bewertet.Ergebnisse:Akute gastrointestinale Nebenwirkungen ≥ Grad 2 entwickelten 35,1% der Patienten mit 3D-CRT, 16% mit IMRT 78 und 7,7% mit IMRT/SIB 82. Akute urogenitale Nebenwirkungen ≥ Grad 2 traten bei 26,6% der Patienten mit 3D-CRT, 33% mit IMRT 78 und 30,7% mit IMRT/SIB 82 auf. Nach 3 Jahren betrug die geschätzte kumulative Inzidenz gastrointestinaler Spättoxizität Grad 3 14% für 3D-CRT, 5% für IMRT 78 und 2% für IMRT/SIB 82. Der Unterschied war signifikant (Log-Rank p = 0,02). Die geschätzte kumulative Inzidenz urogenitaler Spättoxizität Grad 3 lag bei 9% (3D-CRT), 7% (IMRT 78) und 6% (IMRT/ SIB 82) und zeigte keine Signifikanz (Log-Rank p = 0,32).Schlussfolgerung:Die Dosissteigerung auf 82 Gy mit SIB führt im Vergleich mit der 3D-CRT bis 74 Gy zu einer geringeren Rate an gastrointestinaler Spättoxizität Grad 3.

Bipolar Transurethral Resection of Anastomotic Strictures After Radical Prostatectomy

PURPOSE The efficacy of the bipolar endoscopic resection for anastomotic stricture was assessed and compared with holmium laser treatment. PATIENTS AND METHODS We studied a cohort of 39 patients with anastomotic strictures in years 1999 to 2007. Twenty-two patients had undergone bipolar resection, and 17 patients had undergone holmium laser treatment. The mean age of the bipolar cohort was 63.8 years; initial prostate-specific antigen (PSA) level was 10.7 ng/mL. The mean age of the laser cohort was 64 years; initial PSA level was 7.8 ng/mL. The results were evaluated by measurement of the maximum urinary flow (Qmax) and the postvoid residual volume of urine (PVR) before surgery, and at 6 weeks and 6 months after surgery. The Wilcoxon rank-sum test was used for statistical analysis, and a P value <0.05 was considered significant. RESULTS The mean follow-up period was 42 (14-74) months. Improvements in Qmax and PVR were recorded in the two cohorts. In the bipolar cohort, the mean values of Qmax were 3.9 mL/s, 14 mL/s, and 13 ml/s, while PVR values were 46 mL, 10 mL, and 11 mL. The mean values of Qmax in the laser cohort were 3.7 mL/s, 11 mL/s and 6.1 mL/s; PVR were 25 mL, 16 mL, and 19 mL. Statistically significantly better results of Qmax over 6 months were in the bipolar cohort (P < 0.001). No perioperative complications and no deterioration of urinary continence were recorded. CONCLUSION The bipolar resection of an anastomotic stricture is a highly effective method that produces better long-term results than the holmium laser treatment.

Bi-weekly epirubicin, etoposide and low-dose dexamethasone for hormone-refractory prostate cancer

Background: Recent studies have demonstrated the efficacy and favorable toxicity profile of chemotherapy regimens given at lower doses and frequent intervals. The aim of our study was to evaluate the efficacy and toxicity of a bi‐weekly chemohormonal regimen consisting of epirubicin, etoposide, and low‐dose dexamethasone (EED) in patients with hormone‐refractory prostate cancer (HRPC).

Radical prostatectomy in high-grade prostate cancer, salvage and adjuvant radiotherapy.

Introduction: Prostate cancer with a Gleason score (GS) of 8–10 is linked to a higher risk of recurrence and progression. The aim of this paper is to evaluate treatment results of our high-risk patient cohort.Patients and Methods: The cohort of 42 patients with radical prostatectomy (RP) specimen histology GS 8–10 was assessed. The patients were followed up after RP and radiotherapy (RT) was delivered in case of a biochemical relapse. Adjuvant radiotherapy (aRT) was delivered only in case of a positive surgical margin (PSM). The following parameters were evaluated: biochemical progression-free survival (BPFS), overall survival (OS) and cancer-specific survival (CSS). The second objective was to evaluate adverse effects of RP and RT. Results: The median follow-up time was 88 months (18–168). RP led to BPFS in 16 patients (38%). Five patients with PSM underwent aRT and 20 underwent salvage radiotherapy (sRT). One patient died of myocardial infarction and 1 patient died of metastatic disease. Skeletal metastases were recorded in 2 patients. The BPFS in RP combinations with sRT or aRT was reached in 29 patients (69%). The OS and CSS in our cohort reached 95 and 98%, respectively. Conclusion: Management with aRT only in PSM was very effective, according to our retrospective study.

The estimation of post-transplant lymphocele origin using creatine kinase activity

Abstract Introduction. The aim of this research was to create a laboratory instrument for the estimation of post-transplant lymphocele origin. It is based on the enzymatic activity of creatine kinase (CK) in the lymphocele content. Material and methods. A total of 120 lymph samples from different retroperitoneal regions were obtained from non-transplanted patients; equal numbers from the iliac region, renal cysts, and the subdiaphragmatic retroperitoneum. Activities of creatine kinase (CK) and γ-glutamyl transpeptidase (GGT) were determined in all samples and statistically analyzed against their activity in serum from patients without surgery. Results. Activities of CK in the pelvis, retroperitoneum, renal cysts, and serum were 5.06, 0.83, 6.48 (P < 0.001), 2.50, 0.73, 3.60 (P < 0.001), 0.02, 0.01, 0.05 (P < 0.001), and 0.66, 0.41, 0.79 μkat/l, respectively. Activities of GGT in the same lymph samples were 0.26, 0.16, 0.36 (P = 0.048), 0.41, 0.25, 0.48 (non-significant), 0.11, 0.07, 1.17 (P = 0.003) and 0.34, 0.24, 0.55 μkat/l, respectively. A graph was constructed relating CK activity to lymph origin. Conclusion. Significantly different CK enzyme activity was observed in different regions of the retroperitoneum. The presented graph is a simple instrument for the estimation of the lymphocele content origin. The method requires percutaneous aspiration of the lymphocele and evaluation of the CK and GGT activity in the sample. From the graph the estimated proportion of renal lymph in the lymphocele can be read directly. This instrument can provide better understanding of post-transplant lymphocele fluid source.

Urological surgery in elderly patients: results and complications

Purpose Owing to the large aging population, a growing number of elderly patients are undergoing surgical treatment. Surgical procedures in elderly patients are associated with a higher risk of complications. The aim of this study was to evaluate the efficacy and safety of urological surgeries in old patients. Methods The authors carried out a retrospective study, evaluating results and early postoperative complications in patients aged 75 years and older. The cohort of patients included 221 patients who underwent surgical procedures in the department of urology between January 2011 and December 2012. The average age of patients was 78. The results and complications were categorized based on the type of surgery performed, and the Dindo–Clavien scale. Results The median follow-up was 18 months. All surgeries for malignant tumors were performed successfully with no residual disease. Totally, 48 (22%) complications were recorded. The most serious were as follows: one patient (<0.5%) died; and four (<2%) patients underwent reoperation. The most common complications involved infection, mainly sepsis and surgical site infections. Other complications included mild respiratory insufficiency, delirium, bleeding, etc. Conclusion Surgeries in elderly patients were effective and safe. The cornerstone of safety is careful preparation and treatment of comorbidities. Complications occurred mainly as a result of emergency procedures during emergency procedures and in major surgeries such as cystectomy and nephrectomy. The standard use of low molecular-weight heparin caused no incidence of thromboembolic disease.