To assess the impact of experience and technical changes on morbidity during the first year after permanent prostate brachytherapy.
Methods and materials:
From July 2003 to May 2010, 150 patients with prostate cancer underwent low-dose iodine-125 prostate brachytherapy as a monotherapy by the same medical team (one urologist and one radiation oncologist). Patients were divided into three periods: P1 (n = 64), P2 (n = 45), and P3 (n = 41) according to technical changes: use of an automatic stepper from P2, use of a high-frequency ultrasound probe in P3. Urinary toxicity was analyzed according to the incidence of acute urinary retention (AUR), Delta International Prostate Symptom Score (Δ IPSS) defined as IPPS maximal - IPSS at baseline, and proportion of patients with Δ IPSS ≥5 and IPSS total >15. The Radiation Therapy Oncology Group classification was used to evaluate the rectal morbidity.
The incidence of AUR (6% overall) decreased significantly with time: 12.5% (8/64) during P1, 2.2% (1/45) in P2, and 0% in P3 (p = 0.014). Mean Δ IPSS (11.6) remained stable during the three periods. Patients with Δ IPSS ≥5 and IPSS total >15 were 58.7%, 58.1%, and 56.1% for P1, P2, and P3 (p = 0.96), respectively. Grade 1 and 2 proctitis were observed in 15.3% and 9.3% of the patients without any significant difference between the three periods.
The incidence of AUR decreased significantly with time. This was probably because of the experience of the practitioner and the use of an automatic stepper that allowed reducing prostatic traumatism. Experience and technical changes did not seem to affect rectal morbidity.
[Show abstract][Hide abstract] ABSTRACT: Prostate stereotactic body radiotherapy (SBRT) may substantially recapitulate the dose distribution of high-dose-rate (HDR) brachytherapy, representing an externally delivered "Virtual HDR" treatment method. Herein, we present 5-year outcomes from a cohort of consecutively treated virtual HDR SBRT prostate cancer patients.
Seventy-nine patients were treated from 2006 to 2009, 40 low-risk, and 39 intermediate-risk, under IRB-approved clinical trial, to 38 Gy in four fractions. The planning target volume (PTV) included prostate plus a 2-mm volume expansion in all directions, with selective use of a 5-mm prostate-to-PTV expansion and proximal seminal vesicle coverage in intermediate-risk patients, to better cover potential extraprostatic disease; rectal PTV margin reduced to zero in all cases. The prescription dose covered >95% of the PTV (V100 ≥95%), with a minimum 150% PTV dose escalation to create "HDR-like" PTV dose distribution.
Median pre-SBRT PSA level of 5.6 ng/mL decreased to 0.05 ng/mL 5 years out and 0.02 ng/mL 6 years out. At least one PSA bounce was seen in 55 patients (70%) but only 3 of them subsequently relapsed, biochemical-relapse-free survival was 100 and 92% for low-risk and intermediate-risk patients, respectively, by ASTRO definition (98 and 92% by Phoenix definition). Local relapse did not occur, distant metastasis-free survival was 100 and 95% by risk-group, and disease-specific survival was 100%. Acute and late grade 2 GU toxicity incidence was 10 and 9%, respectively; with 6% late grade 3 GU toxicity. Acute urinary retention did not occur. Acute and late grade 2 GI toxicity was 0 and 1%, respectively, with no grade 3 or higher toxicity. Of patient's potent pre-SBRT, 65% remained so at 5 years.
Virtual HDR prostate SBRT creates a very low PSA nadir, a high rate of 5-year disease-free survival and an acceptable toxicity incidence, with results closely resembling those reported post-HDR brachytherapy.
Frontiers in Oncology 11/2014; 4:321. DOI:10.3389/fonc.2014.00321
[Show abstract][Hide abstract] ABSTRACT: As clinical outcomes for patients with clinically localized prostate cancer continue to improve, patients and physicians are increasing making treatment decisions based on concerns regarding long-term morbidity. A primary concern is late radiation proctitis, a clinical entity embodied by various signs and symptoms, ranging from diarrhea to rectal fistulas. Here, we present a comprehensive literature review examining the clinical manifestations and pathophysiology of late radiation proctitis after low-dose-rate brachytherapy (BT), as well as its incidence and predictors. The long-term risks of rectal bleeding after BT are on the order of 5–7%, whereas the risks of severe ulceration or fistula are on the order of 0.6%. The most robust predictor appears to be the volume of rectum receiving the prescription dose. In certain situations (e.g., salvage setting, for patients with increased radiosensitivity, and following aggressive biopsy after BT), the risk of these severe toxicities may be increased by up to 10-fold. A variety of excellent management options exist for rectal bleeding, with endoscopic methods being the most commonly used.
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