Salvage high-dose-rate brachytherapy for histologically confirmed macroscopic local relapsed prostate cancer after radical prostatectomy

Abstract

PurposeTo evaluate the feasibility of the use of real-time magnetic resonance imaging (MRI)-transrectal ultrasound (TRUS) fusion guided high-dose-rate brachytherapy (HDR-BT) +/– external beam radiation therapy (EBRT) in patients with histologically-proven local relapse after radical prostatectomy.Material and methodsWe retrospectively reviewed 13 patients treated with real-time MRI-TRUS fusion HDR-BT for a local relapse of prostate cancer after radical surgery. All patients underwent multiparametric magnetic resonance imaging (mpMRI) to confirm the presence of macroscopic lesions in prostate bed, and choline positron emission tomography/computed tomography (PET/CT) to rule out nodal or distant metastases. Local failure was confirmed by transrectal biopsy. Patients without previous EBRT received 1 fraction of 15 Gy with HDR-BT plus hypofractionated EBRT (37.5 Gy in 15 fractions). Two patients received 2 fractions of 12 Gy with HDR-BT without EBRT. Follow-up visits were at 1, 3, 6 months, and every 6 months thereafter.ResultsAfter a median follow-up of 7 months, all patients showed an appropriate biochemical response. Median prostate-specific antigen (PSA) levels before treatment, 1 month, and 6 months after HDR-BT were 2.62 ng/ml (range: 1.55-9.61), 0.97 ng/ml (range: 0.12-3.14), 0.23 ng/ml (range: 0.1-0.74), respectively. Five patients (42%) experienced acute grade 1 GU toxicity and 1 patient (8%) suffered from grade 2 GU toxicity. Regarding gastrointestinal (GI) toxicity, 5 patients referred grade 1 acute toxicity and 1 grade 2 (proctitis). No late toxicity has been observed so far.ConclusionsMRI-TRUS fusion guided salvage HDR-BT +/– EBRT is a feasible procedure for patients with local macroscopic relapse in tumor bed after radical prostatectomy. Exquisite selection of patients through mpMRI and choline PET/CT is crucial to avoid overtreatment. A larger number of patients and longer follow-up are required in order to draw more solid conclusions regarding the effectiveness of this strategy.

A Phase 1 Trial of Highly Conformal, Hypofractionated Postprostatectomy Radiation Therapy

“… 42 This study reported a favorable rate of biochemical remission in patients who did not receive ADT despite otherwise unfavorable baseline characteristics such as a mean presalvage PSA of 2.3 ng/mL. These results are somewhat more favorable than older, small, retrospective series reporting on the efficacy of focal brachytherapy in the salvage setting 43 , 44 likely owing to the sensitivity of positron emission tomography to detect local recurrences earlier in their natural history in the contemporary reports.…”

A case of CRPC with multiple bladder invasions treated with EBRT followed by HDR-BT boost

“…Buchser et al reported 11 patients who received salvage HDR-BT (15 Gy/1 fraction) with EBRT (37.5 Gy/15 fractions) for histologically confirmed, locally relapsed macroscopic prostate cancer after radical prostatectomy with a median volume of 3.34 cc (range: 1.98–6.76 cc). 17 At a median follow-up of 7 months, all patients showed an appropriate biochemical response, and the acute GU/gastrointestinal toxicity levels were acceptable; there were no cases of late toxicity.…”

Second salvage high-dose-rate brachytherapy for radiorecurrent prostate cancer

“…Unfortunately, no such restrictions are available for salvage HDR-BT [ 11 ]. As an accurate spatial dose delivery in salvage treatments is essential, many clinical groups prefer HDR-BT for treatment delivery [ 22 ]. 125 I seeds have the tendency to migrate from their original position and this phenomenon may have a negative effect on the intended dose delivery to the GTV.…”