Stereotactic Body Radiation Therapy for Prostate Cancer

Hiromichi Ishiyama; Bin S Teh; Simon S Lo; Thomas Mathews; Angel Blanco; Robert Amato; Rodney J Ellis; Nina A Mayr; Arnold C Paulino; Bo Xu; Brian E Butler

Disclosures

Future Oncol. 2011;7(9):1077-1086.

Preclinical Data

Lotan et al. demonstrated that the dose–response relationship for a range of SBRT at dose level (15, 22.5 and 45 Gy, all in three fractions, respectively) using a subcutaneous model of C4–2 human prostate cancer cells.^[4] Similarly, we previously demonstrated the efficacy of SBRT resulting in a sustained antitumor control both in vitro and in vivo, when compared with standard fractionation and control groups using the CWR22RV1 prostate cancer cell line.^[5]

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Cite this: Stereotactic Body Radiation Therapy for Prostate Cancer - Medscape - Sep 01, 2011.

Table 1. Reported hypofractionation schedules.
Study	n	Median follow-up (months)	Total dose (Gy)	Dose per fraction (Gy)	Free from PSA failure	Definition of failure	Late toxicity		Hormone (%)	Ref.
Study	n	Median follow-up (months)	Total dose (Gy)	Dose per fraction (Gy)	Free from PSA failure	Definition of failure	GU ≥2 (%)	GI ≥2 (%)	Hormone (%)	Ref.
Hypofractionation in 2D era
Lloyd-Davies	209	NA	55/36	4.6/6	NA	NA	NA	NA	NA	[6]
Hypofractionation with 3D-CRT
Lukka	466	68.4	52.5	2.625	Early stage, 40.05% (5 years)^†‡	Nadir+2	1.9^§	1.3^§	no	[7]
Soete^¶	36	2	56	3.5	NA	NA	NA	NA	NA	[8]
Yeoh	108	90	55	2.75	Early stage, 53% (7.5 years)^‡	Nadir+2/ASTRO^#	NA	NA	No	[9]
Lyvsey	705	48	50	3.125	Low, 82%; Int, 56%; High, 39% (5 years)	ASTRO	10^††	5^††	No	[10]
Akimoto	52	31	69	3	NA	NA	NA	25	All	[11]
Rene	129	51	66	3	Low and Int, 98% (5 years)	Nadir+2	32	25	NA	[12]
Hypofractionation with IMRT
Pollack	50	39	70.2	2.7	Int and High, 83% (5 years)	Nadir+2	25 (5years)	6 (5 years)	44	[13,14]
Kupelian	770	45	70	2.5	Low, 94; Int, 83%; High, 72% (5 years)	Nadir+2/ASTRO^#	7 (5 years)	6 (5 years)	60	[15]
SBRT
Madsen	40	41	33.5	6.7	Low, 90% (4 years)	Nadir+2/ASTRO^#	20	8	No	[20]
Freeman	41	60	36.25	7.25	Low, 92.7% (5 years)	Nadir+2	9.5	2.5	No	[19]
Tang	30	12	35^‡‡	7	NA	NA	13 at 6 months	13 at 6 months	3	[21]
Friedland	112	24	35–36	7–7.2	NA	NA	0	0.9	19	[22]
Katz	50, 254^§§	17, 30	35, 36.25	7, 7.25	Low, 99%, Int, 100%, High,83% (last follow-up)	Nadir+2	2, 6.3	0, 2.9	19	[23]
Bolzicco	45	20	35	7	Low and Int, 100%	NA	2.2	2.2	38	[24]
Jabbari	20	18.3	38	9.5	All risk groups, 100%	NA	13^¶¶	8^¶¶	47%	[27]
Boike	15, 15, 15^##	30, 18, 12	45, 47.5, 50	9, 9.5, 10	100%	Nadir+2	13, 20, 7	7, 7, 0	22	[25]
SBRT as a boost of EBRT
Katz	73	33	18–21 + EBRT 45	6–7	Int, 89.5%; high, 77.7% (3 years)	Nadir+2	5.5	8.2	50.6	[26]
Jabbari	18	18.3	19 + EBRT 45–50	9.5	All risk groups, 100%	NA	13^¶¶	8^¶¶	47	[27]

^†Including clinical failure.
^‡Risk criteria is not available.
^§Grade 3 or more. ^¶Including IMRT.
^#Result from nadir+2 is shown in this table.
^††n = 101 for toxicity assessment. ^‡‡Once a week over 29 days.
^§§Divided into two schedules.
^¶¶Including combination with EBRT. ^##Divided into three schedules.
CRT: Conformal radiation therapy; EBRT: External beam radiation therapy; GI: Gastrointestinal; GU: Genitourinary; High: High risk; IMRT: Intensity-modulated radiation therapy; Int: Intermediate risk; Low: Low risk; NA: Not applicable; PSA: Prostate-specific antigen; SBRT: Stereotactic body radiation therapy.

Table 2. Reported margin size, PTV constraints and type of machine.
Study	Institution	Machine	Margin size	PTV constraints	Ref.
Madsen	VMMC	Conventional linear accerelator	4–5 mm from prostate to block edge	100% to isocenter Prostate covered by 90% isodose line	[20]
Freeman	Stanford University and Naples RO	CyberKnife	GTV = prostate and proximal 1cm of seminal vesicle CTV = GTV + 3 mm anteriorly and laterally, 1 mm posteriorly PTV = CTV + 2 mm anteriorly, laterally and posteriorly	95% of PTV covered by prescription dose	[19]
Tang	University of Toronto	Conventional linear accerelator	CTV = prostate PTV = CTV + 4 mm	100% of CTV ≥35 Gy 99% of PTV ≥33.25 Gy Max≤105%	[21]
Friedland	Naples RO	CyberKnife	GTV = prostate and proximal 1 cm of seminal vesicle PTV = GTV + 3 mm posteriorly and 5 mm all other directions	95% of PTV covered by prescription dose	[22]
Katz	Winthrop University Hospital	CyberKnife	GTV for low risk = prostate GTV for intermediate, high risk = prostate + half of seminal vesicle PTV for low, intermediate risk = GTV + 3 mm posteriorly and 5mm all other directions PTV for high risk = GTV + 3 mm posteriorly, 8 mm involved side, 5 mm all other directions	96% of PTV covered by prescription dose	[23]
Bolzicco	San Bortolo Hospital	CyberKnife	GTV = prostate PTV = GTV + 3 mm posteriorly and 5 mm all other directions	95% of PTV covered by prescription dose	[24]
Jabbari	UCSF	CyberKnife	CTV = prostate ± seminal vesicle PTV = CTV + 2 mm (no overlap with rectum is allowed)	HDR-like plannning prescription isodose is in 60–80% range	[27]
Boike	University of Texas Southwestern	Tomotherapy or conventional linear accerelator	CTV = prostate PTV = GTV + 3 mm	95% of PTV covered by prescription dose	[25]

HDR: High-dose rate; Naples RO: Naples Radiation Oncology; PTV: Planning target volume; UCSF: University of California San Francisco; VMMV: Virginia Mason Medical Center.

Table 3. Isoeffective prescription for late complication at α:β = 3 Gy.
No. of fractions	Dose per fraction (Gy)	Total dose (Gy)	Normal tissue (α:β=3 Gy) normalized total dose (Gy)	Tumor (α:β=1.5 Gy) normalized total dose (Gy)
35	2.00	70.00	70.00	70.00
30	2.23	66.92	70.00	71.32
25	2.53	63.28	70.00	72.88
20	2.94	58.88	70.00	74.77
15	3.56	53.37	70.00	77.13
10	4.60	46.03	70.00	80.27
5	7.00	35.00	70.00	85.00

Table 4. Reported constraits in stereotactic body radiation therapy.
Study	Rectum	Bladder	Penile bulb	Urethra	Ref.
Madsen	NA				[20]
Freeman	V50% <50% V80% <20% V90% <10% V100% <5% V36 Gy <1 cm³	V37 Gy <10 cm³			[19]
Tang	V28 Gy ≤40% V32 Gy ≤33%	V32 Gy ≤40%	V20 Gy ≤ 90%		[21]
Friedland	V36 Gy <1 cm³	V37 Gy <10 cm³			[22]
Katz	NA				[23]
Bolzicco	D5% <38 Gy	D5% <40 Gy	D25% < 29 Gy	D5% <41 Gy	[24]
Jabbari	Max of wall <38 Gy Max of mucosa <28.5 Gy	Max <45.6 Gy		Max <45.6 Gy	[27]
Boike	Anterior wall <105% V90% of lateral wall <3 cm³ Posterior wall ≤45%	Max ≤105% V18.3 Gy <10 cm³		Max ≤105%	[25]

D: Dose; V: Volume.

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