PURPOSEProstate multiparametric magnetic resonance imaging (mpMRI) has utility in detecting post-radiotherapy local recurrence. We conducted a multireader study to evaluate the diagnostic performance of mpMRI for local recurrence after low dose rate (LDR) brachytherapy. METHODSA total of 19 patients with biochemical recurrence after LDR brachytherapy underwent 3T endorectal coil mpMRI with T2-weighted imaging, dynamic contrast-enhanced imaging (DCE) and diffusion-weighted imaging (DWI) with pathologic confirmation. Prospective reads by an experienced prostate radiologist were compared with reads from 4 radiologists of varying experience. Readers identified suspicious lesions and rated each MRI detection parameter. MRI-detected lesions were considered true-positive with ipsilateral pathologic confirmation. Inferences for sensitivity, specificity, positive predictive value (PPV), kappa, and index of specific agreement were made with the use of bootstrap resampling. RESULTSPathologically confirmed recurrence was found in 15 of 19 patients. True positive recurrences identified by mpMRI were frequently located in the transition zone (46.7%) and seminal vesicles (30%). On patient-based analysis, average sensitivity of mpMRI was 88% (standard error [SE], 3.5%). For highly suspicious lesions, specificity of mpMRI was 75% (SE, 16.5%). On lesion-based analysis, the average PPV was 62% (SE, 6.7%) for all lesions and 78.7% (SE, 10.3%) for highly suspicious lesions. The average PPV for lesions invading the seminal vesicles was 88.8% (n=13). The average PPV was 66.6% (SE, 5.8%) for lesions identified with T2-weighted imaging, 64.9% (SE, 7.3%) for DCE, and 70% (SE, 7.3%) for DWI. CONCLUSIONThis series provides evidence that mpMRI after LDR brachytherapy is feasible with a high patient-based cancer detection rate. Radiologists of varying experience demonstrated moderate agreement in detecting recurrence.You may cite this article as: Valle LF, Greer MD, Shih JH, et al. Multiparametric MRI for the detection of local recurrence of prostate cancer in the setting of biochemical recurrence after low dose rate brachytherapy. Diagn Interv Radiol 2018; 24: 46-53.
proton beam therapy (PBT) compared to alternative forms of EBRT for localized prostate cancer. Materials/Methods: The National Cancer Data Base (NCDB) was queried for men with localized (N0, M0) prostate cancer diagnosed between 2004 and 2013, treated with EBRT, with available data on EBRT modality (photon vs. PBT). Binary multiple logistic regression identified variables associated with EBRT modality. Results: In total 143,702 patients were evaluated with relatively few men receiving PBT [5,709 (4.0%)]. Significant differences in patient and clinical characteristics were identified between those men treated with PBT compared to photons (odds ratio; 95% confidence interval). Patients treated with PBT were generally younger (OR 0.73; 0.67-0.82), NCCN low-risk compared to intermediate (0.71; 0.65-0.78) or high (0.44; 0.38-0.50) risk, white vs. black race (0.66; 0.58-0.77), and with less comorbidity (Charlson-Deyo 0 vs. 2+; 0.70; 0.50-0.98). Patients treated with PBT were also more likely to travel >100 miles to the treatment facility (202; 182-224), live in higher income counties (1.55; 1.36-1.78), and live in metropolitan areas compared to urban (0.21; 0.18-0.23) or rural (0.14; 0.10-0.19) areas. Annual PBT utilization during the study time period significantly increased in both total number and percentage of EBRT over time (2.7% to 5.6%; P<0.001). PBT utilization increased most in men classified as NCCN low-risk (4% to 10.2%). The southern region showed the largest PBT utilization increase over time (0% to 44% of all PBT). Conclusion: PBT for men with localized prostate cancer significantly increased in the United States from 2004-2013. Men with NCCN lowrisk prostate cancer and treatments in the southern region primarily accounted for the national increase in PBT utilization. Multiple demographic and prognostic differences between those men treated with photons and PBT were identified. These data raise concerns regarding access to advanced technologies and reliability of non-randomized treatment outcome data comparing EBRT modalities for localized prostate cancer.
Purpose/Objective(s): Erectile dysfunction (ED) is the most common side effect following radiation therapy for prostate cancer. If this problem develops, many men respond to 5 phosphodiesterase inhibitors. However, these drugs are prohibitively expensive, and often not covered by insurance, leaving most men with few affordable non-invasive treatment options for ED. We conducted a prospective phase II study of the HMG-CoA-reductase inhibitor, lovastatin, as a possible means to reduce the incidence of late rectal injury in men receiving RT for prostate cancer. Herein we report a secondary analysis of the potential impact of lovastatin on ED. Materials/Methods: Patients with adenocarcinoma of the prostate receiving radiation therapy with curative intent were eligible. Radiation therapy consisted of external beam radiation, brachytherapy alone or external beam radiation plus brachytherapy. Gastrointestinal, genitourinary and sexual functioning was assessed using both physician reported (CTCAE V3) and patient reported instruments (IIEF and EPIC) at baseline and at prescribed intervals during and after treatment. Lovastatin (20-80 mg/d) was started on day 1 of radiation and continued for 12 months. Patients were followed for an additional 12 months. The primary endpoint was physician reported rectal toxicity Grade 2 during the first 2 years after treatment. The historical rate of rectal injury was estimated to be 30%. A 50% reduction was predicted with lovastatin. For a 5% level of significance, and a power of 83%, 53 patients were required. Secondary endpoints included incidence of ED. Results: 53 patients were evaluable. There were 31 (58%) whites and 22 (42%) African Americans. Median age was 63 years (range 47-80). Median follow-up was 26 months (range 20-60), and only 2 patients were followed for less than 24 months (20 and 23 months, respectively). Fortyfive (85%) were treated with external beam radiation alone, 2 (4%) were treated with external beam radiation plus brachytherapy and the remaining 6 (11%) were treated with brachytherapy alone. Twenty-three patients (43%) received androgen deprivation therapy in conjunction with radiation. By 24 months after RT, there was no significant change from baseline in the IIEF subdomains of erectile function, orgasmic function, or intercourse satisfaction. Significant declines from baseline were noted in sexual desire and overall satisfaction. Conclusion: At 24 months following radiation therapy, lovastatin as prescribed in this trial had a mixed impact on the development of erectile dysfunction, with no significant change from baseline noted in the majority of domains. Thus, this drug may warrant further study as a means of preserving erectile function after pelvic RT.
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