Prostate cancer and elective nodal radiation therapy for cN0 and pN0-a never ending story? : Recommendations from the prostate cancer expert panel of the German Society of Radiation Oncology (DEGRO).

For prostate cancer, the role of elective nodal irradiation (ENI) for cN0 or pN0 patients has been under discussion for years. Considering the recent publications of randomized controlled trials, the prostate cancer expert panel of the German Society of Radiation Oncology (DEGRO) aimed to discuss and summarize the current literature. Modern trials have been recently published for both treatment-naïve patients (POP-RT trial) and patients after surgery (SPPORT trial). Although there are more reliable data to date, we identified several limitations currently complicating the definitions of general recommendations. For patients with cN0 (conventional or PSMA-PET staging) undergoing definitive radiotherapy, only men with high-risk factors for nodal involvement (e.g., cT3a, GS ≥ 8, PSA ≥ 20 ng/ml) seem to benefit from ENI. For biochemical relapse in the postoperative situation (pN0) and no PSMA imaging, ENI may be added to patients with risk factors according to the SPPORT trial (e.g., GS ≥ 8; PSA > 0.7 ng/ml). If PSMA-PET/CT is negative, ENI may be offered for selected men with high-risk factors as an individual treatment approach.

Treatment planning after hydrogel injection during radiotherapy of prostate cancer.

PURPOSE: Imaging for treatment planning shortly after hydrogel injection is optimal for practical purposes, reducing the number of appointments. The aim was to evaluate the actual difference between early and late imaging. PATIENTS AND METHODS: Treatment planning computed tomography (CT) was performed shortly after injection of 10 ml hydrogel (CT1) and 1-2 weeks later (CT2) for 3 patients. The hydrogel was injected via the transperineal approach after dissecting the space between the prostate and rectum with a saline/lidocaine solution of at least 20-ml. Hydrogel volume and distances between the prostate and rectal wall were compared. Intensity-modulated radiotherapy (IMRT) plans up to a dose of 78 Gy were generated (rectum V70 < 20 %, rectum V50 < 50 %; with the rectum including hydrogel volume for planning). RESULTS: A mean planning treatment volume of 104 cm(3) resulted for a prostate volume of 37 cm(3). Hydrogel volumes of 30 and 10 cm(3) were determined in CT1 and CT2, respectively. Distances between the prostate and rectal wall at the levels of the base, middle, and apex were 1.7 cm, 1.6 cm, 1.5 cm in CT1 and 1.3 cm, 1.2 cm, 0.8 cm in CT2, respectively, corresponding to a mean decrease of 24, 25, and 47 %. A small overlap between the PTV and the rectum was found only in 1 patient in CT2 (0.2 cm(3)). The resulting mean rectum (without hydrogel) V75, V70, V60, V50 increased from 0 %, 0 %, 0.6 %, 10 % in CT1 to 0.1 %, 1.2 %, 6 %, 20 % in CT2, respectively. CONCLUSION: Treatment planning based on imaging shortly after hydrogel injection overestimates the actual hydrogel volume during the treatment as a result of not-yet-absorbed saline solution and air bubbles.

Quality of life after intensity-modulated radiotherapy for prostate cancer with a hydrogel spacer. Matched-pair analysis.

BACKGROUND: Hydrogel spacer is an innovative method to protect the rectal wall during prostate cancer radiotherapy. Clinical effects are not well known. METHODS: Patients have been surveyed before, at the last day, and 2-3 months after radiotherapy using a validated questionnaire (Expanded Prostate Cancer Index Composite). Median dose to the prostate in the spacer subgroup (SP) was 78 Gy in 2 Gy fractions. The results were independently compared with two matched-pair subgroups (treated conventionally without spacer): 3D conformal 70.2 Gy in 1.8 Gy fractions (3DCRT) and intensity-modulated radiotherapy (IMRT) 76 Gy in 2 Gy fractions. There were 28 patients in each of the three groups. RESULTS: Baseline mean bowel bother scores were 96 points in all subgroups. Similar mean changes (SP 16, 3DCRT 14, IMRT 17 points) were observed at the end of radiotherapy. The smallest difference resulted in the spacer subgroup 2-3 months after radiotherapy (SP 2, 3DCRT 8, IMRT 6 points). Bowel bother scores were only significantly different in comparison to baseline levels in the spacer subgroup. The percentage of patients reporting moderate/big bother with specific symptoms did not increase for any item (urgency, frequency, diarrhoea, incontinence, bloody stools, pain). CONCLUSION: Moderate bowel quality-of-life changes can be expected during radiotherapy irrespective of spacer application or total dose. Advantages with a spacer can be expected a few weeks after treatment.

Integrated boost IMRT with FET-PET-adapted local dose escalation in glioblastomas. Results of a prospective phase II study.

PURPOSE: Dose escalations above 60 Gy based on MRI have not led to prognostic benefits in glioblastoma patients yet. With positron emission tomography (PET) using [(18)F]fluorethyl-L-tyrosine (FET), tumor coverage can be optimized with the option of regional dose escalation in the area of viable tumor tissue. METHODS AND MATERIALS: In a prospective phase II study (January 2008 to December 2009), 22 patients (median age 55 years) received radiochemotherapy after surgery. The radiotherapy was performed as an MRI and FET-PET-based integrated-boost intensity-modulated radiotherapy (IMRT). The prescribed dose was 72 and 60 Gy (single dose 2.4 and 2.0 Gy, respectively) for the FET-PET- and MR-based PTV-FET((72 Gy)) and PTV-MR((60 Gy)). FET-PET and MRI were performed routinely for follow-up. Quality of life and cognitive aspects were recorded by the EORTC-QLQ-C30/QLQ Brain20 and Mini-Mental Status Examination (MMSE), while the therapy-related toxicity was recorded using the CTC3.0 and RTOG scores. RESULTS: Median overall survival (OS) and disease-free survival (DFS) were 14.8 and 7.8 months, respectively. All local relapses were detected at least partly within the 95% dose volume of PTV-MR((60 Gy)). No relevant radiotherapy-related side effects were observed (excepted alopecia). In 2 patients, a pseudoprogression was observed in the MRI. Tumor progression could be excluded by FET-PET and was confirmed in further MRI and FET-PET imaging. No significant changes were observed in MMSE scores and in the EORTC QLQ-C30/QLQ-Brain20 questionnaires. CONCLUSION: Our dose escalation concept with a total dose of 72 Gy, based on FET-PET, did not lead to a survival benefit. Acute and late toxicity were not increased, compared with historical controls and published dose-escalation studies.

External beam radiotherapy for prostate cancer.

External beam radiotherapy (EBRT) is a well established curative treatment for prostate cancer. Retrospective studies demonstrate similar biochemical recurrence free survival rates of radical prostatectomy and EBRT for patients in comparable prognostic subgroups, so that patient information should particularly include the respective toxicity spectrum. In principle, EBRT can be offered to every patient without distant metastases and a life expectancy of at least 5-10 years. The decision involves the selection of a suitable technique, dose, target volume and the option of a combination with antiandrogen therapy. Prospective randomized studies showed the advantage of a dose escalation up to total doses of 76-78Gy concerning biochemical tumor control; additionally concerning disease-specific survival for high risk patients. Other randomized trials demonstrated a survival benefit for patients with locally advanced or high risk cancers who received an additional adjuvant antiandrogen therapy to EBRT. Based on the results of randomized studies, an adjuvant post-prostatectomy EBRT of the prostatic fossa with doses in the range of 60-66 Gy can be recommended in case of positive surgical margins or pT3 tumors - reducing the risk of metastases and increasing survival. In case of a biochemical (or macroscopic) recurrence after radical prostatectomy, EBRT is the only curative treatment option for the patient - favorable prognostic factors are low pre-EBRT PSA (prostate-specific antigen) levels, long PSA doubling doubling time, long interval between prostatectomy and recurrence, low Gleason score, positive margins and an absent seminal vesicle involvement. Total doses of at least 70 Gy should be administered in case of macroscopic recurrences, but the curative chances are considerably lower in comparison to a biochemical recurrence alone.

[Effect of Pseudomonas immunoglobulin on the antibacterial activity of human phagocytes]. / Einfluss von Pseudomonas-Immunglobulin auf die antibakterielle Aktivität menschlicher Phagozyten.

The in vitro influence of a pseudomonas immunoglobulin in active and inactivated serum on the bactericidal activity and phagocytosis of human polymorphonuclear leukocytes was evaluated against Pseudomonas aeruginosa. No lysis of the bacteria could be found in either serum, however, the bactericidal activity of the leukocytes was significantly enhanced in active serum (p less than or equal to 0.05); whereas no effect was measurable in inactivated serum. Phagocytosis could be increased in concentrations of 10% immunoglobulin, (equivalent to 5 mg IgG/ml); however, a concentration of 15% showed a lower phagocytosis index which was comparable to that in the 5% preparation. This immunoglobulin proved to be able to support the bacterial phagocytosis and killing of P. aeruginosa by human polymorphonuclear leukocytes in vitro.

[Effect of Pseudomonas immunoglobulin on the antibacterial activity of human phagocytes]. / Einfluss von Pseudomonas-Immunglobulin auf die antibakterielle Aktivität menschlicher Phagozyten.

The in vitro influence of a pseudomonas immunoglobulin in active and inactivated serum on the bactericidal activity and phagocytosis of human polymorphonuclear leukocytes was evaluated against Pseudomonas aeruginosa. No lysis of the bacteria could be found in either serum, however, the bactericidal activity of the leukocytes was significantly enhanced in active serum (p less than or equal to 0.05), whereas no effect was measurable in inactivated serum. Phagocytosis could be increased in concentrations of 10% immunoglobulin, (equivalent to 5 mg IgG/ml); however, a concentration of 15% showed a lower phagocytosis index which was comparable to that in the 5% preparation. This immunoglobulin proved to be able to support the bacterial phagocytosis and killing of P. aeruginosa by human polymorphonuclear leukocytes in vitro.