Second brazilian consensus on the treatment of advanced prostate cancer: a SBOC-SBU-SBRT panel review

ABSTRACT Prostate cancer is the second most common cancer and the fifth leading cause of cancer deaths. In Brazil, it is likewise the second most common cancer among men, second only to non-melanoma skin cancers. The aim of this consensus is to align different opinions and interpretations of the medical literature in a practical and patient-oriented approach. The first Brazilian Consensus on the Treatment of Advanced Prostate Cancer was published in 2017, with the goal of reducing the heterogeneity of therapeutic conduct in Brazilian patients with metastatic prostate cancer. We acknowledge that in Brazil the incorporation of different technologies is a big challenge, especially in the Sistema Único de Saúde (SUS), which allows for the disparity in the options available to patients treated in different institutions. In order to update the recommendations and to make them objective and easily accessible, once more a panel of specialists was formed in order to discuss and elaborate a new Brazilian Consensus on Advanced Prostate Cancer. This Consensus was written through a joint initiative of the Brazilian Society of Clinical Oncology (SBOC) and the Brazilian Society of Urology (SBU) to support the clinical decisions of physicians and other health professionals involved in the care of patients with prostate cancer.

Prostate brachytherapy with iodine-125 seeds: analysis of a single institutional cohort

ABSTRACT Objectives: Brachytherapy (BT) with iodine-125 seeds placement is a consolidated treatment for prostate cancer. The objective of this study was to assess the clinical outcomes in patients with prostate cancer who underwent low-dose-rate (LDR) -BT alone in a single Brazilian institution. Materials and Methods: Patients treated with iodine-125 BT were retrospectively assessed after at least 5 years of follow-up. Patients who received combination therapy (External beam radiation therapy-EBRT and BT) and salvage BT were not included. Results: 406 men were included in the study (65.5% low-risk, 30% intermediate-risk, and 4.5% high-risk patients). After a median follow-up of 87.5 months, 61 (15.0%) patients developed biochemical recurrence. The actuarial biochemical failure-free survival (BFFS) at 5 and 10 years were 90.6% and 82.2%, respectively. A PSA nadir ≥ 1 ng / mL was associated with a higher risk of biochemical failure (HR = 5.81; 95% CI: 3.39 to 9.94; p ≤ 0.001). The actuarial metastasis-free survival (MFS) at 5 and 10 years were 98.3% and 94%, respectively. The actuarial overall survival (OS) at 5 and 10 years were 96.2% and 85.1%, respectively. Acute and late grade 2 and 3 gastrointestinal toxicities were observed in 5.6%, 0.5%, 4.6% and 0.5% of cases, respectively. For genitourinary the observed acute and late grade 2 and 3 toxicities rates were 57.3%, 3.6%, 28% and 3.1%, respectively. No grade 4 and 5 were observed. Conclusions: BT was effective as a definitive treatment modality for prostate cancer, and its endpoints and toxicities were comparable to those of the main series in the literature.

Incidental irradiation of internal mammary lymph nodes in breast cancer: conventional two-dimensional radiotherapy versus conformal three-dimensional radiotherapy / Irradiação incidental da cadeia mamária interna no câncer de mama: comparação entre a técnica convencional (bidimensional) e a técnica tridimensional

Abstract Objective: To evaluate incidental irradiation of the internal mammary lymph nodes (IMLNs) through opposed tangential fields with conventional two-dimensional (2D) or three-dimensional (3D) radiotherapy techniques and to compare the results between the two techniques. Materials and Methods: This was a retrospective study of 80 breast cancer patients in whom radiotherapy of the IMLNs was not indicated: 40 underwent 2D radiotherapy with computed tomography for dosimetric control, and 40 underwent 3D radiotherapy. The total prescribed dose was 50.0 Gy or 50.4 Gy (2.0 or 1.8 Gy/day, respectively). We reviewed all plans and defined the IMLNs following the Radiation Therapy Oncology Group recommendations. For the IMLNs, we analyzed the proportion of the volume that received 45 Gy, the proportion of the volume that received 25 Gy, the dose to 95% of the volume, the dose to 50% of the volume, the mean dose, the minimum dose (Dmin), and the maximum dose (Dmax). Results: Left-sided treatments predominated in the 3D cohort. There were no differences between the 2D and 3D cohorts regarding tumor stage, type of surgery (mastectomy, breast-conserving surgery, or mastectomy with immediate reconstruction), or mean delineated IMLN volume (6.8 vs. 5.9 mL; p = 0.411). Except for the Dmin, all dosimetric parameters presented higher mean values in the 3D cohort (p < 0.05). The median Dmax in the 3D cohort was 50.34 Gy. However, the mean dose to the IMLNs was 7.93 Gy in the 2D cohort, compared with 20.64 Gy in the 3D cohort. Conclusion: Neither technique delivered enough doses to the IMLNs to achieve subclinical disease control. However, all of the dosimetric parameters were significantly higher for the 3D technique.

Resumo Objetivo: Avaliar a irradiação incidental dos linfonodos da cadeia mamária interna (LCMIs) com campos tangenciais opostos por meio de radioterapia bidimensional (2D) convencional ou tridimensional (3D) e comparar as duas técnicas quanto aos resultados obtidos. Materiais e Métodos: Trata-se de um estudo retrospectivo com 80 pacientes com câncer de mama sem indicação de radioterapia dos LCMIs: 40 foram submetidos a radioterapia 2D com tomografia computadorizada para controle dosimétrico e 40 foram submetidos a radioterapia 3D. A dose total prescrita foi 50,0 Gy ou 50,4 Gy (2,0 ou 1,8 Gy/dia, respectivamente). Os planos de tratamento foram analisados e os LCMIs foram definidos conforme as recomendações do Radiation Therapy Oncology Group. No tocante aos LCMIs, foram analisadas a proporção do volume que recebeu 45 Gy, a proporção do volume que recebeu 25 Gy, a dose para 95% do volume, a dose para 50% do volume, a dose média, a dose mínima (Dmín) e a dose máxima (Dmáx). Resultados: Tratamentos do lado esquerdo predominaram na coorte 3D. Não houve diferenças entre as coortes 2D e 3D quanto ao estágio do tumor, ao tipo de cirurgia (mastectomia, cirurgia conservadora ou mastectomia com reconstrução imediata) ou à média do volume delineado dos LCMIs (6,8 vs. 5,9 mL; p = 0,411). À exceção da Dmín, todos os parâmetros dosimétricos apresentaram médias maiores na coorte 3D (p < 0,05). A mediana da Dmáx na coorte 3D foi 50,34 Gy. No entanto, a dose média nos LCMIs foi 7,93 Gy na coorte 2D e 20,64 Gy na coorte 3D. Conclusão: Nenhuma das duas técnicas emitiu doses suficientes aos LCMIs para que se alcançasse o controle subclínico da doença. No entanto, todos os parâmetros dosimétricos foram significativamente maiores com a técnica 3D.

Change in the risk stratification of prostate cancer after Slide Review by a uropathologist: the experience of a reference center for the treatment of prostate cancer

Introduction Brachytherapy is an option for treating low-risk prostate cancer (PC). Biochemical control of low-risk disease can reach 95%. The practice advocated is that a review of prostate biopsies should be mandatory before choosing the best treatment for patients with PC. Our objective was to evaluate the change in PC risk after review of a prostate biopsy by an experienced uropathologist at a reference hospital. Materials and Methods Between December 2003 and August 2012, 182 men were referred to our institution for brachytherapy to treat PC. Their slides were reviewed by the same uropathologist. Results and Discussion Classification risk disagreement occurred in 71 (39%) cases, including one in which no tumor was observed. The main cause of risk change was related to the Gleason score (GS), with 57 (81.4%) cases upgraded to GS 7 or 8. Tumor volume was also compared, although only the number of fragments was reported in most original reports. The concordance of the number of cores affected by tumor was 43.9%, and in 49% of the cases, the number was decreased by the uropathologist. Perineural invasion (PNI) was reported in one quarter of original reports, and the agreement was 58%. Conclusion Slide review by an uropathologist remains essential at reference radiotherapy centers for the treatment of PC. The change in PC risk evaluation is mainly due to the GS, but tumor volume and PNI, which are important for the characterization of tumor aggressiveness, are also misinterpreted and could drive a change in the therapy choice. .