Article

Salvage permanent perineal radioactive-seed implantation for treating recurrence of localized prostate adenocarcinoma after external beam radiotherapy

Department of Urology, University of California, San Francisco, CA 94117, USA.
BJU International (Impact Factor: 3.53). 02/2009; 104(5):600-4. DOI: 10.1111/j.1464-410X.2009.08445.x
Source: PubMed

ABSTRACT

To assess our experience with salvage permanent perineal radioactive-seed implantation (SPPI) as a possible therapeutic option for recurrent prostate adenocarcinoma, as salvage therapies for recurrences after definitive external beam radiotherapy (EBRT) for localized adenocarcinoma of the prostate are associated with significant morbidity and biochemical failure.
We retrospectively analysed on patients who had SPPI for localized recurrent prostate adenocarcinoma from 1996 to 2007 after primary treatment with EBRT. Excluded were patients who had other primary treatment or had no follow-up. Primary outcomes were time to biochemical relapse-free survival, using the Phoenix definition of a prostate-specific antigen (PSA) nadir +2 ng/mL, and cancer-specific survival. Secondary outcomes were the International Prostate Symptom Score (IPSS), the International Index of Erectile Function-5 score (IIEF-5), and complications based on Common Terminology Criteria for Adverse Events (version 3).
In all, 37 patients had SPPI during this period; after applying inclusion and exclusion criteria, 24 remained for analysis. At the time of salvage therapy, the median time to the diagnosis of local recurrence was 49 months, the median PSA level was 3.36 ng/mL, the median PSA doubling time was 20 months, and all patients were clinically re-staged at <or=T2 with negative transrectal ultrasonography and/or magnetic resonance spectroscopy. The original Gleason score was <or=6 in nine patients, 7 in eight and >or=8 in three (not recorded in two). The median follow-up after SPPI was 30 months; the cancer-free survival was 96% (one death) and biochemical relapse-free survival was 88% (three patients). The PSA level was higher than the levels before SPPI at 3 months in all three failures, but lower in all 21 patients considered relapse-free. Complications included one urethral stricture, one grade 3 rectal haemorrhage and five grade 2 gross haematuria that resolved with conservative management. Insufficient data were available to assess the IPSS or IIEF-5 scores.
With a short-term follow-up SPPI appears to provide excellent prostate cancer control with an acceptable rate of complications for patients with local recurrence of prostate cancer after EBRT. An extended follow-up is necessary to determine the long-term durability and safety of SPPI.

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Available from: I-Chow Hsu, Oct 27, 2014
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    • "References Type of prostate brachytherapy Salvage dose prescription Primary treatment (EBRT/ brachytherapy) Primary radiation dose prescription Median (range) Follow-up (months) Biochemical control Late toxicity Beyer et al. (1999) [22] LDR whole gland 88% 125 I: 120 Gy 22% 103 Pd: 90 Gy Activity: NR 17 (17/0) 63.6 Gy (NR) 62 53% (5 years) GU: 24% incontinence GI: 0 Grado et al. (1999) [24] LDR whole gland 76% 103 Pd: 120 Gy (range 80 to 180), 24% 125 I: 160 Gy (range 80 to 180) Activity: NR 49 (46/3) 66.2 Gy (range 20.0–70.2) 64 34% (5 years) GU: 4% hematuria 6% painful penile dysuria GI: 4% rectal ulcers 2% colostomy Allen et al. (2007) [21] LDR whole gland 125 I: 109–112.5 Gy 103 Pd: 90–97 Gy Activity: NR 12 (12/0) 70 Gy (range, 59.4–70.2) 45 63% (4 years) GU: 16% grade 2 incontinence 8% grade 1 hematuria GI: 0 Nguyen et al. (2007) [73] LDR partial gland 125 I: 137 Gy Activity: 0.40 mCi/seed 25 (13/12) EBRT: (66–70.2) Brachytherapy: 137 Gy; MRI-guided 47 70% (4 years) GI: 8% Argon for proctitis GU: 8% 12% fistula Lee et al. (2007) [74] HDR whole gland 36 Gy/6fractions 21 (21/0) EBRT 72 Gy (63–78) 19 89% (2 years) GU: 14% grade 3/0 grade 4 GI: 0 grade 3/grade 4 Aaronson et al. (2009) [20] LDR whole gland + SIB 108 Gy whole gland + 144 Gy focal boost Activity: 13.32 MBq/seed 24 (24/0) EBRT 72 Gy (65–80) 30 89.5% (3 years) GU: 1 grade 3 hematochezia/0 grade 4 GI: 0 grade 3/0 grade 4 Burri et al. (2010) [23] "
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    ABSTRACT: Even in the current era of dose-escalated radiotherapy for prostate cancer, biochemical recurrence is not uncommon. Furthermore, biochemical failure is not specific to the site of recurrence. One of the major challenges in the management of prostate cancer patients with biochemical failure after radiotherapy is the early discrimination between those with locoregional recurrence only and those with metastatic disease. While the latter are generally considered incurable, patients with locoregional disease may benefit from emerging treatment options. Ultimately, the objective of salvage therapy is to control disease while ensuring minimal collateral damage, thereby optimizing both cancer and toxicity outcomes. Advances in functional imaging, including multiparametric prostate MRI, abdominopelvic lymphangio-MRI, sentinel node SPECT-CT and/or whole-body PET/CT have paved the way for salvage radiotherapy in patients with local recurrence, microscopic nodal disease limited to the pelvis or oligometastatic disease. These patients may be considered for salvage reirradiation using different techniques: prostate low-dose or high-dose rate brachytherapy, pelvic and/or lomboaortic image-guided radiotherapy with elective nodal irradiation, focal nodal or bone stereotactic body radiation therapy (SBRT). An individualized approach is recommended. The decision about which treatment, if any, to use will be based on the initial characteristics of the disease, relapse patterns and the natural history of the rising prostate specific antigen (PSA). Preliminary results suggest that more than 50% of patients who have undergone salvage reirradiation are biochemically relapse-free with very low rates of severe toxicity. Large prospective studies with a longer follow-up are needed to confirm the promising benefit/risk ratio observed with salvage brachytherapy and or salvage nodal radiotherapy and/or bone oligometastatic SBRT when compared with life-long palliative hormones.
    Full-text · Article · Sep 2014 · Cancer/Radiothérapie
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    • "Actually, there is not prospectively data available in QoL in patients treated with salvage treatment. Most of data reported are based on functional outcomes instead of validated QoL instruments [10,11]. "
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    ABSTRACT: Purpose: To evaluate efficacy and toxicity after salvage brachytherapy (BT) in prostate local recurrence after radiation therapy. Methods and materials: Between 1993 and 2007, we retrospectively analyzed 56 consecutively patients (pts) undergoing salvage brachytherapy. After local biopsy-proven recurrence, pts received 145 Gy LDR-BT (37 pts, 66%) or HDR-BT (19 pts, 34%) in different dose levels according to biological equivalent doses (BED(2 Gy)). By the time of salvage BT, only 15 pts (27%) received ADT. Univariate and multivariate analyses were performed to identify predictors of biochemical control and toxicities. Acute and late genitourinary (GU) and gastrointestinal (GI) toxicities were graded using Common Terminology Criteria for Adverse Events (CTCv3.0). Results: Median follow-up after salvage BT was 48 months. The 5-year FFbF was 77%. HDR and LDR late grade 3 GU toxicities were observed in 21% and 24%. Late grade 3 GI toxicities were observed in 2% (HDR) and 2.7% (LDR). On univariate analysis, pre-salvage prostate-specific antigen (PSA) > 10 ng/ml (p = 0.004), interval to relapse after initial treatment < 24 months (p = 0.004) and salvage HDR-BT doses BED(2 Gy) level < 227 Gy (p = 0.012) were significant in predicting biochemical failure. On Cox multivariate analysis, pre-salvage PSA, and time to relapse were significant in predicting biochemical failure. HDR-BT BED(2 Gy) (α/β 1.5 Gy) levels ≥ 227 (p = 0.013), and ADT (p = 0.049) were significant in predicting grade ≥ 2 urinary toxicity. Conclusions: Prostate BT is an effective salvage modality in some selected prostate local recurrence patients after radiation therapy. Even, we provide some potential predictors of biochemical control and toxicity for prostate salvage BT, further investigation is recommended.
    Full-text · Article · Apr 2014 · Radiation Oncology
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    • "References Type of prostate brachytherapy Salvage dose prescription Primary treatment (EBRT/ brachytherapy) Primary radiation dose prescription Median (range) Follow-up (months) Biochemical control Late toxicity Beyer et al. (1999) [22] LDR whole gland 88% 125 I: 120 Gy 22% 103 Pd: 90 Gy Activity: NR 17 (17/0) 63.6 Gy (NR) 62 53% (5 years) GU: 24% incontinence GI: 0 Grado et al. (1999) [24] LDR whole gland 76% 103 Pd: 120 Gy (range 80 to 180), 24% 125 I: 160 Gy (range 80 to 180) Activity: NR 49 (46/3) 66.2 Gy (range 20.0–70.2) 64 34% (5 years) GU: 4% hematuria 6% painful penile dysuria GI: 4% rectal ulcers 2% colostomy Allen et al. (2007) [21] LDR whole gland 125 I: 109–112.5 Gy 103 Pd: 90–97 Gy Activity: NR 12 (12/0) 70 Gy (range, 59.4–70.2) 45 63% (4 years) GU: 16% grade 2 incontinence 8% grade 1 hematuria GI: 0 Nguyen et al. (2007) [73] LDR partial gland 125 I: 137 Gy Activity: 0.40 mCi/seed 25 (13/12) EBRT: (66–70.2) Brachytherapy: 137 Gy; MRI-guided 47 70% (4 years) GI: 8% Argon for proctitis GU: 8% 12% fistula Lee et al. (2007) [74] HDR whole gland 36 Gy/6fractions 21 (21/0) EBRT 72 Gy (63–78) 19 89% (2 years) GU: 14% grade 3/0 grade 4 GI: 0 grade 3/grade 4 Aaronson et al. (2009) [20] LDR whole gland + SIB 108 Gy whole gland + 144 Gy focal boost Activity: 13.32 MBq/seed 24 (24/0) EBRT 72 Gy (65–80) 30 89.5% (3 years) GU: 1 grade 3 hematochezia/0 grade 4 GI: 0 grade 3/0 grade 4 Burri et al. (2010) [23] LDR whole gland − 97% 103 Pd: 110 Gy Activity: 0.9–1.7 mCi/seed − 3% 125 I: 135 Gy Activity: 0.4 mCi/seed 37 (32/5) EBRT: 67.8 Gy (range, 63.0–75.6 Gy) Brachytherapy: 47.5 to 113.1 Gy 86 54% (10 years) GU: 5% TURP 3% hematuria 3% fistula Moman et al. (2010) [26] LDR whole gland 145 Gy Activity: NR 31 (20/11) EBRT: 66 Gy (NR) 73 23% (5 years) GU: 19% grade 3/0 grade 4 GI: 6% grade 3/0 grade 4 Hsu et al. (2013) [25] LDR partial gland 125 I: 144 Gy 103 Pd: 125 Gy 15 (0/15) LDR seeds 23 71.4% (3 years) GI: 13% grade 1 GU: 33% grade 2 No grade 3+ GI/GU Peters M et al. (2014) [32] "

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