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Evaluating Acute Toxicity in Prostate Cancer Patients with Hydrogel Spacer during Proton Therapy

Retrospective study on GU and GI toxicity in prostate cancer patients undergoing PBRT with hydrogel spacer. Low toxicity rates observed. Further follow-up needed for late rectal toxicity effects.

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Evaluating Acute Toxicity in Prostate Cancer Patients with Hydrogel Spacer during Proton Therapy

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  1. Assessment of Acute Toxicity in Prostate Cancer Patients using Hydrogel Spacer During Proton Therapy Jesse Conterato, BA&Sc. RSNA 2016

  2. Hydrogel Spacers: MRI Comparison Pinkawa et al. WJCO 2015 • Absorbable polyethylene glycol hydrogel spacers are injected into the peri-rectal space. • Moves the anterior rectal wall outside of high dose volumes Without Spacer With Spacer Axial View Rectum Hydrogel Spacer Sagittal View Prostate

  3. Hydrogel Spacers During Proton Therapy? Prospective IMRT trials demonstrate advantage of hydrogel spacer during treatment for prostate cancer: Rectal dose reduction Severity of rectal toxicity reduced (Song et al. 2013, Mariados et al. 2015, Uhl et al. 2014) Mariados et al. Int J Radiation OncolBiolPhys 2015 • Few studies have examined the use of hydrogel spacers in patients treated with proton therapy

  4. Purpose To evaluate the acute toxicity outcomes in prostate cancer patients treated with definitive proton beam radiotherapy (PBRT) with a hydrogel spacer (HS) in place

  5. Methods Retrospective review of prostate cancer patients undergoing definitive PBRT at a single institution Patient data collected from: Prospective Proton Collaborative Group Registry Our institutional Advancements Through Outcomes Measures protocol 63 consecutive patients with hydrogel spacer in place Treatment era: April 2015 – February 2016 All patients completed treatment of 79.2 Cobalt Gray Equivalent (CGE) in 44 fractions Acute Toxicity was defined as occurring during the PBRT treatment period

  6. Methods and Patient Characteristics • Toxicity was prospectively assessed weekly during PBRT and scored according to CTCAE v4.0 in 6 genitourinary (GU) and 4 gastrointestinal (GI) categories: • GU: Urinary Tract Pain, Urinary Frequency, Urinary Retention, Urinary Incontinence, Urinary Urgency, Hematuria • GI: Fecal Incontinence, Rectal Hemorrhage, Proctitis, and Diarrhea.

  7. Methods and Patient Characteristics

  8. Results: Spacer Placement Safety Müller et al. RadiolOncol 2016 • No infections were observed after hydrogel injection, performed under trans-rectal ultrasound guidance Prostate Prostate Prostate Prostate

  9. Results: Overall GU Toxicity • Most common forms of Grade 2 GU toxicity: • Urinary frequency, retention, and urgency • Grade 3 GU toxicity: • During PBRT, one patient experienced GR3 urinary tract pain while being treated for UTI • One patient, with prostate volume of 253.014 mL, underwent Green Light procedure for urinary retention prior to starting PBRT

  10. Results: Overall GI Toxicity • Grade 2 Toxicities: • One patient experienced GR2 Fecal Incontinence during PBRT • One patient with pre-existing hemorrhoids experienced GR2 Rectal Hemorrhage and was treated with Proctocream

  11. Results: GU Toxicity by Proton Target

  12. Results: GI Toxicity by Proton Target

  13. Conclusion The use of hydrogel spacers during definitive PBRT for prostate cancer resulted in acceptably low rates of acute GU and GI toxicity Additional follow-up is needed to assess effects of hydrogel spacer placement on late rectal toxicity

  14. Acknowledgements Lisa McGee, MD William Hartsell, MD Dean Conterato, MD Vinai Gondi, MD John Chang, MD ShaeGans, CMD Megan Dunn, PhD, MSHS Steven Laub, MMP Chicago Proton Center Staff Proton Collaborative Group

  15. Works Cited Deville C, Both S, Bui V et al. Acute gastrointestinal and genitourinary toxicity of image-guided intensity modulated radiation therapy for prostate cancer using a daily water-filled endorectal balloon. Radiation Oncology 2012; 7: 1. Mariados N, Sylvester J, Shah D et al. Hydrogel spacer prospective multicenter randomized controlled pivotal trial: dosimetric and clinical effects of perirectal spacer application in men undergoing prostate image guided intensity modulated radiation therapy. International Journal of Radiation Oncology* Biology* Physics 2015; 92: 971-977. Müller A-C, Mischinger J, Klotz T et al. Interdisciplinary consensus statement on indication and application of a hydrogel spacer for prostate radiotherapy based on experience in more than 250 patients. Radiology and Oncology 2016. Pinkawa M. Current role of spacers for prostate cancer radiotherapy. World journal of clinical oncology 2015; 6: 189. Song DY, Herfarth KK, Uhl M et al. A multi-institutional clinical trial of rectal dose reduction via injected polyethylene-glycol hydrogel during intensity modulated radiation therapy for prostate cancer: analysis of dosimetric outcomes. International Journal of Radiation Oncology* Biology* Physics 2013; 87: 81-87. Uhl M, Herfarth K, Eble MJ et al. Absorbable hydrogel spacer use in men undergoing prostate cancer radiotherapy: 12 month toxicity and proctoscopy results of a prospective multicenter phase II trial. Radiation Oncology 2014; 9: 1.

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