Prostate preservation by combined external beam and HDR brachytherapy in nodal negative prostate cancer

Abstract

Purpose:The combined external beam-and high-dose rate brachytherapy (HDR-BT) of localized prostate cancer was introduced at Kiel University in 1986. The aim of this intermediate analysis was to judge the Kiel method of localized prostate cancer radiation treatment after ten years experience. Patients and Methods: In the past ten years 174 patients with histological proven localized prostate cancer were subjected to combined tele-/HDR-brachytherapy. Local staging in all of the cases by transrectal ultrasound, nodal staging in the majority of the cases by CT or MRI. Average age of the patients was 68.2 years (44-84). According to AJCC/UICC staging T1B, T2, T3 was found in 2, 113 and 59 cases, respectively. Highly differentiated tumors (G1) were found in 27, moderately differentited (G2) in 87, poorly differentiated (G3) in 60 cases. The mean follow-up was 47.1 months with the median of 51.7 months. Total prescribed dose 50 Gy on the small pelvis and 70 Gy on the prostate capsule due to the integration of two, 15 Gy each, HDR-brachytherapy fractions in 6 weeks. Results: Ten patients died of prostate cancer and 18 of intercurrent diseases resulting in a 5 years overall survival rate of 83% and tumor specific survival rate of 94%. Twenty-one patients showed a clinical progression, of these 14 systemic, 5 local and 2 both systemic and local. Additional 16 patients had PSA elevation only. The 5-years biochemical and/or clinical progression-free survival in the cohort was 79% and 73% for the T3 tumors. Side effects were 27 cases of proctitis/colitis and 20 cases of dysuria/cystitis. Conclusion:The integrated HDR-BT combined with external beam radiation treatment is a method with excellent tumor control rates at five years superior to those of external beam treatment alone or external beam combined with iodine-125 implants. This form of radiotherapy would appear to be particularly well-suited to treatment of advanced localized (T3) tumors.Key Words: Prostate cancer 9 Radiation therapy. HDR-brachytherapy 9 PSA 9 Dose escalation. Transrectal ultrasound R adiotherapy has an established role in the curative management of the patients with prostate cancer, however, the management of organ-confined carcinoma of the prostate remains one of the most controversial issues in contemporary oncology. External beam radiation (EBRT) alone can produce acceptable results in patients with clinically organ-confined tumors and a pretreatment PSA level < 15 ng/ml. To produce good results in patients with higher pretreatment PSA level than 15 ng/ml, aggressive local treatment and/or effective adjuvant treatments are necessary. Combined external beam and interstitial brachytherapy treatment schedules were found succesful also in bulky prostate carcinoma causing moderate toxicity and improved survival.

Phase II Trial of Combined High Dose Rate Brachytherapy and External Beam Radiotherapy for Adenocarcinoma of the Prostate: Preliminary Results of RTOG 0321

“…The median number of patients accrued per institution was 8 (range [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20], and the average was 9 patients. The average monthly accrual for the study was 5.9 patients.…”

“…(6-10) Kovacs et al reported one of the earliest experiences using HDR brachytherapy boost at University of Kiel. (10)(11)(12) Patients treated were mostly T2b-T3 tumors and high grade tumors. They used a combination of split course external beam radiotherapy and two 15 Gy HDR treatments.…”

Erste Erfahrungen mit einem nichtinvasiven Patientenfixieungssystem für die stereotaktische Strahlentherapie der Prostata

“…Im Rahmen von Dosiseskalationsstudien sind jedoch tumorkonforme Bestrahlungstechniken unverzichtbar für die Schonung der umliegenden Normalgewebe [11,30]. Auf invasivem Wege kann das mittels Brachy- therapie erreicht werden [1,15]. Eine vielversprechende nichtinvasive Methode stellt die intensitätsmodulierte Strahlentherapie als komplexeste Form der dreidimensional geplanten Strahlentherapie mit Photonen dar [28].…”

High dose-rate brachytherapy of prostate cancer utilising Iridium-192 after-loading technique: Technical and methodological aspects

“…These reports resulted in a renaissance for prostate BT. In 1977, Court and Chassangne (18) began treating prostate cancer with after-loading techniques, and since then several reports have been published (13,14,(19)(20)(21)(22)(23)(24)(25)(26)(27)(28). Although the data presented were encouraging, no randomised study has been published, and there are criticisms concerning some of the BT treatment studies (29,30).…”