RESUMEN
In 1998, an editorial from the International Journal of Radiation Oncology - Biology - Physics (IJROBP) on the occasion of the publication of Phase I by Zelefsky et al. on 3D radiotherapy dose escalation asked the question: "will more prove better?". More than 20 years later, several prospective studies have supported the authors' conclusions, making dose escalation a new standard in prostate cancer. The data from prospective randomized studies were ultimately disappointing in that they failed to show an overall survival benefit from dose escalation. However, there is a clear and consistent benefit in biochemical recurrence-free survival, which must be weighed on an individual patient basis against the potential additional toxicity of dose escalation. Techniques and concepts have become more and more precise, such as intensity modulated irradiation, simultaneous integrated boost, hypofractionated dose-escalation, pelvic irradiation with involved node boost or focal dose-escalation on gross recurrence after prostatectomy. The objective here was to summarize the prospective data on dose escalation in prostate cancer and in particular on recent advances in the field. In 2022, can we finally say that more has proven better?
Asunto(s)
Braquiterapia , Neoplasias de la Próstata , Radioterapia de Intensidad Modulada , Braquiterapia/métodos , Humanos , Masculino , Estudios Prospectivos , Prostatectomía , Neoplasias de la Próstata/tratamiento farmacológico , Radioterapia de Intensidad Modulada/métodos , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
Because of the physical properties of proton beam radiation therapy (PT), which allows energy to be deposited at a specific depth with a rapid energy fall-off beyond that depth, PT has several theoretical advantages over photon radiation therapy for esophageal cancer (EC). Protons have the potential to reduce the dose to healthy tissue and to more safely allow treatment of tumors near critical organs, dose escalation, trimodal treatment, and re-irradiation. In recent years, larger multicenter retrospective studies have been published showing excellent survival rates, lower than expected toxicities and even better outcomes with PT than with photon radiotherapy even using IMRT or VMAT techniques. Although PT was associated with reduced toxicities, postoperative complications, and hospital stays compared to photon radiation therapy, these studies all had inherent biases in relation with patient selection for PT. These observations were recently confirmed by a randomized phase II study in locally advanced EC that showed significantly reduced toxicities with protons compared with IMRT. Currently, two randomized phase III trials (NRG-GI006 in the US and PROTECT in Europe) are being conducted to confirm whether protons could become the standard of care in locally advanced and resectable esophageal cancers.
Asunto(s)
Neoplasias Esofágicas , Terapia de Protones , Radioterapia de Intensidad Modulada , Reirradiación , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/radioterapia , Humanos , Terapia de Protones/efectos adversos , Protones , Dosificación Radioterapéutica , Radioterapia de Intensidad Modulada/efectos adversos , Radioterapia de Intensidad Modulada/métodos , Estudios RetrospectivosAsunto(s)
Adenocarcinoma/secundario , Ácidos Carboxílicos , Ciclobutanos , Radioisótopos de Flúor , Tomografía Computarizada por Tomografía de Emisión de Positrones , Neoplasias de la Próstata/patología , Radiofármacos , Radiocirugia , Radioterapia Guiada por Imagen , Neoplasias de la Columna Vertebral/secundario , Vértebras Torácicas/diagnóstico por imagen , Adenocarcinoma/sangre , Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/radioterapia , Anciano , Diagnóstico Diferencial , Humanos , Calicreínas/sangre , Imagen por Resonancia Magnética , Masculino , Antígeno Prostático Específico/sangre , Prostatectomía , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/radioterapia , Neoplasias de la Próstata/cirugía , Terapia Recuperativa , Neoplasias de la Columna Vertebral/sangre , Neoplasias de la Columna Vertebral/diagnóstico por imagen , Neoplasias de la Columna Vertebral/radioterapiaRESUMEN
Whole-breast normofractionated irradiation following breast-conserving surgery is the reference treatment. It delivers a dose of 50Gy in 25 fractions of 2Gy to the reference point, and, in some patients, an additional dose of 16Gy in 8 fractions of 2Gy in the tumor bed. Long-term results and toxicity of this irradiation scheme was prospectively evaluated in several randomised trials and meta-analyses, in invasive cancers as well as in ductal carcinoma in situ. The average 10-year rate of in breast recurrences was 6 % in these trials, with limited cardiac and pulmonary toxicity and limited rate of severe fibrosis. Identification of risk factors of recurrences may help to design new irradiation schemes adapted to tumor biology. The new irradiation schemes must be rigorously evaluated in the long-term in the frame of prospective clinical trials, in order to validate them as new standards of treatment.