The results of real‐time brachytherapy for the management of low‐ and intermediate‐risk prostate cancer in patients with prostate volumes up to 100 mL

Abstract

What ' s known on the subject? and What does the study add? Historically, the majority of centres in the UK practise a pre-plan brachytherapy technique which is limited to prostate volumes < 50 ml. This study provides further evidence that it is technically possible to deliver a quality implant in a large prostate using real-time brachytherapy and that the treatment is well tolerated. It has emphasized the value of functional parameters in selecting appropriate patients and concluded that prostate volumes up to 100 ml should not exclude patients from brachytherapy. OBJECTIVES• To report the results of real-time brachytherapy in the management of low-risk and intermediate-risk prostate cancer in patients with prostate volumes up to 100 mL, over a 6-year period.• To prospectively determine whether prostate volume infl uences the ability to achieve a quality implant and therefore impact upon prostate-specifi c antigen (PSA) relapse-free survival, and urinary and rectal toxicity. SUBJECTS AND METHODS• In all, 216 men with localized prostate cancer were treated with real-time prostate brachytherapy using • Patients had computed tomography imaging at 1 month to assess post-implant dosimetry. PSA, IPSS and Radiation Therapy Oncology Group rectal toxicity scores were recorded prospectively over the follow-up period.• Patients with prostate volumes ≤ 50 mL and those with volumes > 50 mL were compared. RESULTS• Overall PSA relapse-free survival was 98.8%; 97.0% for intermediate-risk patients and 100.0% for low-risk patients. By volume, 98.5% of men with standard prostates were free from PSA relapse compared with 100.0% of men with large prostates.• The mean post-implant D90 was 177.0 Gy; 175.5 Gy in standard prostates and 183.5 Gy in large prostates.• The overall acute urinary retention rate was 1.9%; 1.7% in standard prostates and 2.4% in large prostates. There were three urethral strictures, all in the standard prostate group. The mean IPSS increased to 11 and 14 at 3 months for the standard and large prostate groups, respectively, before settling to 2 above baseline for both groups at 12 months.• There were no rectovesical fi stulae. Persistent rectal bleeding was reported by one (0.5%) patient in the standard prostate group. CONCLUSIONS• Prostate brachytherapy is effective in the treatment of low-risk and intermediate-risk prostate cancer.• It is technically possible to deliver a quality implant in a large prostate using real-time brachytherapy.• The treatment itself is well tolerated. Prostate volumes up to 100 mL should not exclude patients from brachytherapy providing either fl ow rate ≥ 14 mL/s or symptom score (IPSS) ≤ 10. KEYWORDSprostate cancer , real time brachytherapy , large prostates , urinary retention , neoadjuvant hormone therapy Study Type -Therapy (case series) Level of Evidence 4

Modified transurethral resection of the prostate (TURP) for men with moderate lower urinary tract symptoms (LUTS) before brachytherapy is safe and feasible

“…These IPSS changes are very similar to those of our TURP BXT , who, with higher pre‐treatment symptom scores, would be expected to have higher IPSS scores after implantation than those patients mentioned in the Dallas et al. study. It is unlikely, therefore, that the stable IPSS findings in our present cohort of ‘higher risk’ patients (of LUTS deterioration) could be explained by improvement in brachytherapy technique.…”

“…Current European guidelines identify men with an IPSS of ≥12 or a prostate volume of ≥50 mL as inappropriate for this method of treatment . Whereas published data exists to justify use of brachytherapy in larger prostates , the mantra still remains that pre‐implant urethral toxicity strongly correlates to post‐implant morbidity with respect to LUTS. This technique gives men the option of brachytherapy previously considered inappropriate because of their LUTS.…”

“…Others have adopted ‘real‐time brachytherapy’; Dallas et al. report a change in IPSS at 1 year of between 0 and 1 compared with the pre‐implant baseline value with this technique. These IPSS changes are very similar to those of our TURP BXT , who, with higher pre‐treatment symptom scores, would be expected to have higher IPSS scores after implantation than those patients mentioned in the Dallas et al.…”

Comparative analysis of short - term functional outcomes and quality of life in a prospective series of brachytherapy and Da Vinci robotic prostatectomy

“…The preoperative characteristics of the patients included in each group can be compared with those of the series so far published (9-13, 17-18). In our series, we found differences regarding mean age which can be explained by a tendency of ageing patients to choose BT to avoid the anesthetic complications of surgery.…”

Long term outcome and side effects in patients receiving low-dose I125 brachytherapy: a retrospective analysis

“…IPSS score was 3.5 in patients without urinary morbidity and 5 in the other group. Nicola et al described a good postoperative flow rate and IPSS score in patients with a prostate volume up to 100mL ( 35 ). These findings were confirmed by Meyer et al, who stated that patients with a prostate volume >50mL had a similar postoperative IPSS score compared to volumes <50mL ( 36 ).…”