Phase II Study of Single-Dose Image-Guided Radiotherapy (SDRT) With Urethral Sparing and Dose-Escalated Dominant Intraprostatic Lesion Simultaneous Integrated Boost for Intermediate-Risk Prostate Cancer (PROSINT II)

This prospective phase II study evaluates the safety, feasibility, quality-of-life effects, prostate-specific antigen kinetics, imaging response, and clinical outcomes of definitive ultra-high-dose single-fraction external beam radiotherapy in patients with biopsy-proven NCCN intermediate-risk localized adenocarcinoma of the prostate.

The study investigates single-dose image-guided radiotherapy using image-guided volumetric modulated arc therapy with urethral sparing, organ-motion mitigation, and online target tracking. All eligible participants receive single-fraction radiotherapy to the prostate gland and proximal seminal vesicles. The whole-gland prescription dose is 24 Gy delivered in one treatment session. Participants with NCCN unfavorable intermediate-risk disease and an imaging-defined dominant intraprostatic lesion may also receive a prostate-specific membrane antigen PET/CT-guided simultaneous integrated boost to the dominant intraprostatic lesion. The boost is delivered in sequential dose-escalation cohorts up to a target dose of 30 Gy, while maintaining protocol-defined organ-at-risk dose constraints.

The rationale for the study is based on the radiobiological sensitivity of prostate cancer to large radiation fraction sizes, the clinical experience with extreme hypofractionation in localized prostate cancer, and prior institutional experience with prostate image-guided radiotherapy using target immobilization, urethral localization, and online tracking. Prior studies at the study institution have suggested that ultra-hypofractionated and single-fraction prostate radiotherapy can be delivered with acceptable toxicity when careful target stabilization, urethral sparing, and treatment-planning quality assurance procedures are used. In unfavorable intermediate-risk disease, intraprostatic recurrence may occur preferentially at the site of the dominant lesion, supporting the investigation of dose escalation to the dominant intraprostatic lesion while preserving strict normal tissue constraints.

Participants undergo pretreatment evaluation including history and physical examination, pathology confirmation, serum PSA assessment, laboratory testing, and multiparametric MRI of the prostate. PSMA PET/CT is required for participants being considered for PSMA-guided dominant intraprostatic lesion boost and may also be used when clinically indicated for staging. Imaging datasets are used for treatment planning and, when applicable, dominant intraprostatic lesion definition.

Radiotherapy is delivered using image-guided volumetric modulated arc therapy. A rectal balloon filled with air is used to improve prostate immobilization and anatomical reproducibility. A Foley catheter loaded with beacon transponders is used to identify the urethra, support urethral-sparing treatment planning, and enable setup reproducibility and online target tracking. Treatment planning includes delineation of the prostate, proximal seminal vesicles, urethra, rectal wall, bladder wall, bowel, urogenital diaphragm, penile bulb, neurovascular bundles, femoral heads, and other protocol-specified organs at risk. Urethral sparing is incorporated using an avoidance structure around the catheter-defined urethra. Erectile-related structures are contoured and recorded for quality-of-life and dosimetric analyses when compatible with target coverage and disease anatomy.