Treatment options are limited for patients with localized prostate cancer and a prior history of abdominoperineal resection (APR) and pelvic irradiation. We have previously reported on the successful utility of high-dose-rate (HDR) brachytherapy salvage for prostate cancer failing definitive external beam radiation therapy (EBRT). In this report, we describe our technique and early experience with definitive HDR brachytherapy in patients post APR and pelvic EBRT.
Six men with newly diagnosed localized prostate cancer had a prior history of APR and pelvic EBRT. Sixteen to 18 HDR catheters were placed transperineally under transperineal ultrasound-guidance. The critical first two catheters were placed freehand posterior to the inferior rami on both sides of the bulbar urethra under cystoscopic visualization. A template was used for subsequent catheter placement. Using CT-based planning, 5 men received 36Gy in six fractions as monotherapy. One patient initially treated with EBRT to 30Gy, received 24Gy in four fractions.
Median age was 67.5 (56-74) years. At a median followup of 26 (14-60) months, all patients are alive and with no evidence of disease per the Phoenix definition of biochemical failure, with a median prostate-specific antigen nadir of 0.19ng/mL. Three men have reported grade 2 late genitourinary toxicity. There has been no report of grade 3-5 toxicity.
Transperineal ultrasound-guided HDR brachytherapy using the above technique should be considered as definitive therapy for patients with localized prostate cancer and a prior history of APR and pelvic EBRT.
[Show abstract][Hide abstract] ABSTRACT: PURPOSE: To describe the use of a temporary spacer to reduce rectal dose prior to prostate radiation in a man with prior pelvic radiotherapy and review the relevant literature. METHODS AND MATERIALS: A healthy 57-year-old man presented with high-risk prostate cancer (Gleason score of 8, prostate-specific antigen level [PSA] 12.6 ng/mL, T3a by magnetic resonance imaging [MRI]), only 2.5 years after a low anterior resection followed by pelvic chemo-radiotherapy to 50.4 Gy for a locally advanced rectal cancer. Due to the prior radiation, he was not felt to be a candidate for surgery or external beam radiation, so he chose long-term androgen deprivation therapy (ADT) plus high-dose-rate brachytherapy to 36 Gy in 6 fractions. To reduce the radiation dose to the anterior rectal wall, 10 mL of a polyethylene glycol hydrogel spacer was injected between the prostate and rectum and created between 1.4 and 1.5 cm of separation along the length of the prostate. RESULTS: Two randomized trials demonstrating that local therapy plus ADT improves overall survival compared to ADT alone provided the rationale for additional prostate radiotherapy in this otherwise healthy patient. Salvage brachytherapy is associated with a 3.4% rate of rectal fistula among the 251 cases reported in the literature from 2000-2007, with rates as high as 12% in one series. The spacer allowed the rectal dose constraint goals to be easily met. CONCLUSIONS: Injecting an absorbable polyethylene glycol hydrogel to separate the prostate and rectum appears to be associated with decreased maximum and mean rectal doses, and may have particular utility in previously irradiated patients.
[Show abstract][Hide abstract] ABSTRACT: This chapter reviews the role of Magnetic Resonance (MR) imaging in prostate cancer with emphasis on functional imaging techniques and roles in focal therapy. Multiparametric MR imaging sequences applied for prostate cancer imaging include T2-weighted MR, proton MR spectroscopic imaging, diffusion-weighted imaging, dynamic contrast-enhanced MR, and quantitative T2-weighted imaging. These techniques provide information on independent characteristics of normal and cancerous prostate tissue, including normal/abnormal ductal morphology, concentrations of metabolites relevant to prostate cancer, water diffusion rates which are affected by cellularity, blood flow rates and volumes and therefore vascularity, and quantitative morphology, respectively. The information provided by these independent MR imaging methods can be used to determine the presence and location of prostate cancers with high sensitivity and specificity. Prostate MRI can be applied to diagnosing prostate cancer, predicting organ-confined prostate cancer, localization of intra-glandular prostate cancer, and estimation of intra-glandular prostate cancer volume. It has been applied to MR directed transrectal ultrasound-guided biopsy, direct MR-guided biopsy, MR-transrectal ultrasound fusion biopsy, and MR-guided focal therapy. The chapter describes what is known about the potential for combining these imaging techniques to improve selection, guidance, and subsequent monitoring of the effectiveness of focal therapy.
Imaging and Focal Therapy of Early Prostate Cancer, 01/2013: pages 173-202; , ISBN: 978-1-62703-181-3
[Show abstract][Hide abstract] ABSTRACT: The goal of this study was to correlate prostatic metabolite concentrations from snap-frozen patient biopsies of recurrent cancer after failed radiation therapy with histopathological findings, including Ki-67 immunohistochemistry and pathologic grade, in order to identify quantitative metabolic biomarkers that predict for residual aggressive versus indolent cancer. A total of 124 snap-frozen transrectal ultrasound (TRUS)-guided biopsies were acquired from 47 men with untreated prostate cancer and from 39 men with a rising prostate-specific antigen and recurrent prostate cancer following radiation therapy. Biopsy tissues with Ki-67 labeling index≤5% were classified as indolent cancer, while biopsy tissues with Ki-67 labeling index>5% were classified as aggressive cancer. The majority (15 out of 17) of cancers classified as aggressive had a primary Gleason 4 pattern (Gleason score≥4+3). The concentrations of choline-containing phospholipid metabolites (PC, GPC, and free Cho) and lactate were significantly elevated in recurrent cancer relative to surrounding benign tissues. There was also a significant increase in [PC] and reduction in [GPC] between untreated and irradiated prostate cancer biopsies. The concentration of the choline-containing phospholipid metabolites was significantly higher in recurrent aggressive (≈twofold) than in recurrent indolent cancer biopsies, and the receiver operating characteristic (ROC) curve analysis of total choline to creatine ratio (tCho/Cr) demonstrated an accuracy of 95% (confidence interval=0.88-1.00) for predicting aggressive recurrent disease. The tCho/Cr was significantly higher for identifying recurrent aggressive versus indolent cancer (tCho/Cr=2.4±0.4 versus 1.5±0.2), suggesting that use of a higher threshold tCho/Cr ratio in future in vivo 1H MRSI studies could improve the selection and therapeutic planning for patients who would benefit most from salvage focal therapy after failed radiation therapy.
NMR in Biomedicine 01/2014; 27(1). DOI:10.1002/nbm.3007 · 3.04 Impact Factor
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