Localized Prostate Carcinoma
Conditions
Keywords
Prostate Cancer, Single fraction SBRT, Urethral sparing HDR like, PSMA PET/CT, Organ movement, Radiomics
Brief summary
Patients with prostate cancer who are candidates for stereotactic radiotherapy to the prostate and seminal vesicles will undergo staging exams, which will include prostate specific membrane antigen (PSMA) positron emission tomography-computed tomography (PET-CT). If the PET scan is negative and the uroflowmetry is acceptable, the patients will perform the treatment, after fiducial implantation, simulation CT and magnetic resonance (MR), in a single fraction, delivered with a high-dose-rate (HDR)-like urethral sparing technique. In 70 patients, acute and late toxicity, biochemical control, overall survival, cancer specific-survival, and quality of life (through specific questionnaires) will be evaluated.
Detailed description
This is an interventional prospective non-randomised single-center trial that will enroll, 13 patients for the first phase of the study, according to the optimal design of Simon. The hypothesis is that the proportion of patients free from acute cumulative G3-G4 toxicity (Common Terminology Criteria for Adverse Events-CTCAE v5.0 scale) 1 month after the end of treatment must be \< 85% to suspend treatment and \> 95% to consider the treatment as safe. The treatment will be interrupted if G3-G4 toxicities and/or biochemical recurrences are recorded within a month in 2 or more patients; otherwise the study will continue with the second phase. Another 52 patients will be added, for a total of 65 patients. The treatment consists in a single fraction of 24 Gy with the urethral sparing HDR like technique. Assuming a minimal drop-out, given that the primary endpoint is toxicity one month after treatment, we will enroll 5 more patients in total, thus reaching a total number of 70 patients (65 necessary + 5 for any drop-outs). In the absence of worse subsequent toxicity, and with biochemical control comparable to that in the literature as well as historical treatments in our Radiation Oncology, the scheme will be considered safe, and the enrollment will continue open label. Patients with negative lymph nodes and without distant metastases will be enrolled and treated on the prostate/prostate and tumor vesicles (depending on the stage) at a total dose of 24 Gy delivered in a single fraction, sparing the urethra and with a dose distribution similar to high dose rate brachytherapy. Androgen Deprivation Therapy (ADT) will be prescribed according to the guidelines for the stages of the disease. Short-term cortisone and alpha lytics will be prescribed, for prophylactic purposes. Follow-up visits will be performed at 1, 3, 6,12,18, 24, 36, 48, 60 months with blood tests including prostate specific antigen (PSA) and testosterone (performed every 3 months in the first two years, every 6 months in the next 3 years), imaging, when needed, and quality of life questionnaires: European Organization for Research and Treatment of cancer (EORTC) quality of life questionnaire (QLQ) C30 and QLQ-PR25, International Prostate symptoms score (IPSS), International Index of Erectile Function (IIEF)-5, Expanded Prostate Cancer Index Composite (EPIC)- 26.
Interventions
RADIATIONprostate SBRT
Patients with prostate cancer will be treated with high-dose SBRT to prostate and seminal vesicles, delivered in one fraction, sparing the urethra and generating a dose distribution similar to HDR brachytherapy
Sponsors
IRCCS San Raffaele
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Intervention model description
According to the optimal design of Simon, 13 pts will be enrolled for the first phase of the study. Hypothesis: the proportion of pts free from acute cumulative G ≥3 toxicity (CTCAE v5.0 scale) 1 month after the end of treatment must be \< 85% to suspend treatment and \> 95% to consider the treatment as safe. The treatment will be interrupted if G3-G4 toxicities and/or biochemical recurrences are recorded within a month in 2 or more pts, otherwise the study will continue with the second phase enrolling another 52 pts for a total of 65 pts. A single fraction SBRT of 24 Gy with the urethral sparing HDR like technique will be delivered. Assuming a minimal drop-out, 5 more pts will be enrolled, thus reaching a total number of 70 pts (65 necessary + 5 for any drop-outs). In the absence of worse subsequent toxicity and with a biochemical control comparable to that in the literature as well as historical treatments of our department, the scheme will be considered as safe and effective.
Eligibility
Sex/Gender
MALE
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Histological diagnosis of prostate adenocarcinoma, International Society of Urological Pathology (ISUP) grade groups 1-5 * Patients over 18 years of age * Signed informed consent * Negative lymph nodes confirmed by imaging (PSMA PET/CT and/or pelvic MRI with and without contrast medium) where recommended by guidelines (intermediate and high risk patients, according to National Comprehensive Cancer Network (NCCN) guidelines) in the previous 3 months * Clinical M0 (PSMA PET/CT and/or bone scan and/or pelvic MRI with and without contrast medium in suspected patients and unfavorable intermediate and high risk patients, according to NCCN guidelines), in the previous 3 months * Acceptable uroflowmetry: peak urine flow index (peak flow preferably ≥ 15 ml/s), post voiding residue (PVR) ≤50 cc. If lower, acceptable if, by carrying out 3 months of neoadjuvant hormone therapy + alpha-lytic for the reduction of prostate volume, uroflowmetry is reset to at least ≥ 12 ml/s. * PS (ECOG) ≤2 * No previous pelvic radiotherapy * Other conditions necessary for the correct execution of the proposed treatment (ability to fill in the questionnaires for the evaluation of the Quality of Life EORTC QLQ-C30, EORTC QLQ-PR25, IPSS, IIEF-5, EPIC 26)
Exclusion criteria
* Serious systemic diseases * Psychic or other disorders that may prevent the patient from signing the informed consent * Previous invasive cancer, except skin cancer (excluding melanoma) unless patient free of disease for at least 3 years (e.g. carcinoma in situ of the oral cavity or bladder) * Lymph node disease (N1) * Evidence of distant metastases (M1) * IPSS questionnaire data \> 20 points * Uroflowmetry with maximum basal flow ≤ 11 ml/sec and/or PVR \>100 ml * Concomitant urinary/gastrointestinal inflammatory diseases (e.g. ulcerative colitis, Crohn's disease) * Overactive bladder * Impossibility of implantation of fiducials * Inability or refusal to place bladder catheter for simulation CT and MR * Inability to perform simulation MRI * Contraindication for hormonal treatment for patients with unfavorable intermediate, high or very high risk disease * Non-compliance with dose limits established in the treatment plan
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Acute toxicity | one month | Incidence of acute toxicity of grade 3 or 4 as maximum toxicity value during the radiation treatment or in any case within a month of the end of SBRT, using Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 scale (toxicity from 0- patients without toxicity to 5-death from toxicity) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Biochemical control | 5 years (with interim analyzes at 1 and 3 years) | Biochemical control rate at 1,3 and 5 years by measuring Prostate Specific Antigen-PSA- value which must be below (2+nadir) ng/ml |
| Biochemical relapse | 5 years (with interim analyzes at 1 and 3 years) | Biochemical Relapse-Free survival |
| Local Control | 5 years (with interim analyzes at 1 and 3 years) | Local Relapse-Free survival |
| Distant Disease Control | 5 years (with interim analyzes at 1 and 3 years) | Distant Metastases-Free Survival |
| Survival | 5 years (with interim analyzes at 1 and 3 years) | Overall Survival |
| Subacute Toxicity | 3 months | Subacute toxicity rated on CTCAE v5.0 scale (see Outcome 1 for details) |
| Incidence of Treatment-Emergent Adverse Events as assessed with erectile quality of life questionnaires | 5 years | Survey with the questionnaire IIEF-5 (International Index of Erectile Function). The IIEF-5 score is the sum of the ordinal responses to the 5 items, with higher scores indicating no erectile dysfunction and lower scors indicating severe erectile dysfunction. |
| Incidence of Treatment-Emergent Adverse Events as assessed with composite quality of life questionnaires | 5 years | Survey with the questionnaire EPIC-26 (The Expanded Prostate Cancer Index Composite) a questionnaire designed to measure Quality of Life issues in patients with Prostate cancer, through 13 questions with answers from 1 to 5, with 1 indicating the absence of the problem and 5 indicating an important problem. Lower scores indicate a better outcome |
| Late Toxicity | 5 years (with interim analyzes at 1 and 3 years) | Late toxicity rated on using CTCAE v5.0 scale (see Outcome 1 for details) |
| Incidence of Treatment-Emergent Adverse Events as assessed with general quality of life questionnaires | 5 years | Survey with the questionnaire of European Organisation for Research and Treatment of Cancer (EORTC) Quality of life of cancer patients (QLQ C30) which contains 30 questions on patients' quality of life with answers from 1, lowest grade, to 4, highest grade |
| Incidence of Treatment-Emergent Adverse Events as assessed with prostate specific quality of life questionnaires | 5 years | Survey with the questionnaire of European Organisation for Research and Treatment of Cancer (EORTC) Quality of life of prostate cancer patients (QLQ PR25) which contains 25 questions on patients' quality of life with answers from 1, lowest grade, to 4, highest grade |
| Incidence of Treatment-Emergent Adverse Events as assessed with urinary quality of life questionnaires | 5 years | Survey with the questionnaire International Prostatic Symptoms Score (IPSS) which has 8 questions with answers rom never (0) to almost every time (5). The score is obtained by summing the answers |
Other
| Measure | Time frame | Description |
|---|---|---|
| Organ movement | 3 years | Modeling of organ movements during treatment: Movements of the target and neighboring organs between the treatment fractions and during the treatment will be quantified in millimeters, the median value will be recorded with the range and mean with the standard deviation, and the contributing factors will be identified to find a useful solution |
| Radiomics | 5 years ( with interim analyzes at 3 years) | Evaluation of radiomic characteristics: Mathematical extraction of the spatial distribution of signal intensities and pixel interrelationships of medical images of the patients, to quantify textural information resampled according to International Biomarker Standardization Initiative (IBSI). |
Countries
Italy
Contacts
Primary ContactAndrei Fodor, MD
Backup ContactNadia Di Muzio, Prof
Outcome results
None listed