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Ponsky, Lee E.

We hope to investigate patient preferences for SBRT, but trading off potential risks versus benefits would require a more formal and structured evaluation than we have done here. There was no significant negative effect on the quality of life of patients in our study. National Center for Biotechnology Information , U. J Med Radiat Sci. Published online Mar 8. Author information Article notes Copyright and License information Disclaimer.

Robotic Radiosurgery Treating Prostate Cancer and Related Genitourinary Applications

Ashutosh Dixit, Email: zn. Corresponding author. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Conclusions Early results show promising PSA response. Keywords: CyberKnife, prostate cancer, quality of life, stereotactic radiotherapy.

Introduction Stereotactic body radiation therapy SBRT is a relatively new treatment option for clinically localised prostate cancer whereby radical treatment is complete in five fractions. Treatment planning and delivery Patients were given instructions for bladder and bowel preparation to be used before the planning CT scan and before every fraction. Open in a separate window.

Figure 1. Table 1 Typical dose targets and constraints. Table 2 Patient characteristics. Age at diagnosis Years Mean Figure 2. Table 3 PSA response. Acute toxicity Acute toxicity data for this study and other studies are summarised in Table 4. Table 4 Acute toxicity data comparison with other studies. Quality of life Summary statistics for QOL scales of interest by visit are shown in Table 5 and the change in the scores from baseline to 6 weeks and baseline to 6 months are shown in Table 6.

Table 5 Summary statistics for QOL scales by visit. Median Max. Baseline GHS 44 Conflict of Interest The authors declare no conflict of interest. References 1. Stereotactic body radiotherapy for primary prostate cancer: A systematic review.

Robotic Radiosurgery. Treating prostata cancer and related ge..|INIS

J Med Imaging Radiat Oncol ; 5 : — Prostate stereotactic ablative body radiotherapy using a standard linear accelerator: Toxicity, biochemical, and pathological outcomes. Radiother Oncol ; 2 : —8. Cureus ; 7 : e Core Team R. Radiother Oncol ; 2 : — Radiat Oncol ; 8 : Katz AJ, Kang J. Front Oncol ; 4 : Radiat Oncol ; 6 : J Clin Oncol ; 12 : — J Clin Oncol ; 32 : Robotic radiosurgery offers a novel, rapid, non-invasive outpatient treatment option that combines robotics, advanced image-guided spatial positioning, and motion detection with submillimeter precision.

This book examines all aspects of the treatment of prostate cancer with robotic radiosurgery. It explains how image-guided robotic radiosurgery overcomes the problem of patient motion during radiation therapy by continuously identifying the precise location of the prostate tumor throughout the course of treatment. Hypofractionated radiation delivery by means of robotic radiosurgery systems is also discussed in detail.

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The book closes by examining other emerging genitourinary applications of robotic radiosurgery. All of the authors are experts in their field who present a persuasive case for this fascinating technique. The book provides a good overview of the subject, which will undoubtedly be useful in the clinic when patients enquire about stereotactic treatment and where it fits into the standard armamentarium of treatment options.

This is a very useful, revealing book for all those dealing with prostate cancer diagnosis and treatment, as well for those radiologists who want to be kept abreast of the continuous evolution and improvements in the field of Medicine …. The first part provided the reader with general information. Undoubtedly, this textbook is intended for radiotherapists and oncologists. A A fixed-frame system with needles is used to place fiducials under trans-rectal ultrasound guidance.

B Axial and C sagittal views of ultrasound image guidance. Precautions were taken to minimize prostate motion during the planning scans and treatment. All patients were imaged and treated in the supine treatment position with a knee cushion to maximize patient comfort and limit prostate motion in response to respiration Malone et al.

Fused thin cut CT images 1. MRI imaging was employed to define the target volume Roach et al. Intra-prostatic fiducials were employed to guide image co-registration and limit fusion errors Parker et al. MR images were obtained on a 1. Two MRI sequences were employed to maximize visualization of the fiducials susceptibility-weighted gradient-echo images and the soft tissues axial high-resolution turbo T2-weighted spin-echo images.

Treatment planning included the prostate as the gross target volume GTV. The CTV included the prostate and the proximal seminal vesicles. Axial images through the mid-prostate. A Thin cut CT scan visualizes fiducials well, but glandular tissue is indistinguishable from adjacent soft tissues. C Axial high-resolution turbo T2-weighted spin-echo MR images to assess prostatic soft tissues. A minimum of three properly placed fiducials is required to accommodate 6D tracking. Using the stranded fiducials, four fiducials are implanted which accommodates four separate fiducial triplets, although only one triplet that meets threshold criteria is required.

The distances between individual fiducials six lines were determined for each patient to assure that the fiducial spacing threshold was met. Likewise, the angles formed by the triplets 12 angles were determined to assure that the co-linearity threshold was met.

Radical Prostatectomy (Prostate Cancer Surgery)

A The coordinates for the four implanted fiducials. B The calculated distances between fiducials.

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C Assessment of four possible fiducial triplets. Thus, fiducial triplets 1 and 2 failed the spacing criteria. However, fiducial triplets 3 fiducials 1,3,4 and 4 fiducials 2,3,4 exceeded both the spacing and collinearity thresholds, thus allowing 6D target tracking.

The interval between successive image acquisitions and alignment corrections is adapted throughout each treatment fraction based on the intra-fraction stability of the target position translation and orientation rotation. In the subset of patients with a high frequency of excursions, the treating clinician is capable of increasing the imaging frequency to maintain this accuracy.

Six-dimensional fiducial tracking for stereotactic body radiation therapy with the CyberKnife system. Shown are digitally reconstructed radiographs left column , real time orthogonal X-ray images middle column , and co-registered overlay images right column.

From July to July , 88 patients underwent trans-perineal implantation of four gold fiducials using TRUS guidance at our institution. No grade 3 or higher complications per the CTC v3 criteria. There were no post-implant urinary tract infections or episodes of urinary retention. Analysis of the treatment planning CT scans verified the presence of at least three fiducials in all cases. There were no cases of fiducial overlap on orthogonal imaging. As a result, CyberKnife treatment was limited to 3D tracking for those two patients. Fiducial tracking was also utilized for patient set-up in 19 patients treated in combination with conventional external beam radiation therapy.

The ability of dose escalation to improve disease control in clinically localized prostate cancer has been supported by several clinical studies and is accepted as a goal in prostate cancer treatment Pollack et al. A concern with dose escalation, however, is the possibility of increasing acute and late toxicities.

For this reason, PTV margins are typically minimized thereby limiting dose to surrounding normal tissues Dearnaley et al. Reduced PTV margins require accurate beam positioning and verification to ensure delivery of the planned dose to the target. Fiducials are accurate and reproducible surrogates for prostate location and allow for correction of both inter-fraction and intra-fraction prostate motions Deurloo et al.


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High-dose IMRT using fiducial-based correction of translational motion prior to treatment is well tolerated with a low incidence of acute and late gastrointestinal and genitourinary side effects Lips et al. Such positional verification also allows the delivery of increased radiation doses without deterioration in quality of life compared with lower doses using less accurate conformal radiotherapy Lips et al.

Early results with CyberKnife SBRT suggest that the addition of 6D correction of intra-fraction prostate motion allows hypo-fractionated radiobiologic dose escalation while maintaining quality of life Fuller et al. The optimal number and location of implanted markers for image guided radiation therapy has been investigated Kudchadker et al. In previous studies, one to six fiducials were implanted Poggi et al. At least three properly positioned fiducials are required for translational and rotational correction with the CyberKnife system.

It is unclear whether the accuracy of targeted radiation therapy is improved by placing additional fiducials. However, placement of greater than four fiducials may increase the risk of fiducial mis-identification due to their close proximity Mu et al. Intra-fractional motion correction should accommodate further investigational dose escalation by limiting dose to normal structures. It is well known that the extent of intra-fraction motion increases with increasing duration of treatment Ghilezan et al.

Unfortunately, large prostate motions are not predictable and commonly occur early in the course of a treatment Langen et al. The added benefit of correcting for rotational movement is the subject of investigation Mutanga et al. Some argue that small deformations interpreted as rotations could actually increase the risk of geometric miss Wu et al.

The smaller treatment margins required for hypo-fractionation increase the importance of correcting for even small treatment errors. The appropriate PTV margins necessary to accommodate rotations are both challenging to determine and likely patient specific Langer et al. Intra-fractional rotational correction eliminates the need for these complex and potentially large PTV expansions. When treating the prostate alone, the target volume approximates a sphere making rotational correction likely of little benefit. However, when the target volume is the prostate and the proximal seminal vesicle, rotational corrections may be important to prevent under-dosing of the seminal vesicles Lips et al.

Hypo-fractionated SBRT with 6D correction of prostate motion is a promising new treatment option for men with low- and intermediate-risk prostate cancer. Early results suggest encouraging biochemical responses with low toxicities Fuller et al. Our experience shows that with accurate fiducial placement, 6D correction of prostate motion with CyberKnife SBRT is feasible in the majority of patients. Investigation of additional patients with longer follow-up will be required to validate the clinical benefits of such an approach. Brian T. Collins and S. Collins serve as a clinical consultants to Accuray Inc.

The other authors declare that they have no competing interests. National Center for Biotechnology Information , U. Journal List Front Oncol v. Front Oncol. Published online Dec 8. Prepublished online Oct Oermann , 1 Viola Chen , 1 Andrew W. Ju , 1 Kedar N. Dahal , 1 Heather N.