Does hormonal manipulation in conjunction with permanent interstitial brachytherapy, with or without supplemental external beam irradiation, improve the biochemical outcome for men with intermediate or high-risk prostate cancer?

A retrospective analysis after low-dose-rate prostate brachytherapy with permanent 125I seed implant: clinical and dosimetric results in 70 patients

Aims and background

To evaluate the biochemical disease-free survival (bDFS) rate after 125I permanent-implant prostate brachytherapy.

Methods

Patients with a diagnosis of prostate adenocarcinoma and adequate PSA follow-up were selected for this retrospective study. Brachytherapy with permanent 125I seeds was performed as monotherapy, with a prescribed dose of 145 Gy to the prostate. Patients were stratified into recurrence risk groups according to the National Comprehensive Cancer Network (NCCN) guidelines. Biochemical failure was defined using the American Society of Therapeutic Radiology and Oncology (ASTRO) guidelines. The post-implant D90 (defined as the minimum dose covering 90% of the prostate) was obtained for each patient. Two cutoff points were used to test the correlation between D90 and bDFS results: 130 Gy and 140 Gy. bDFS was calculated from the implant date to the date of biochemical recurrence. Univariate and multivariate analysis were performed using the SPSS software and included clinical stage, pretreatment PSA, Gleason score (GS), androgen deprivation therapy, D90, and risk groups. In the univariate analysis we used a cutoff point of 5.89 ng/mL for PSA and 5 for GS.

Results

From June 2003 to April 2007, 70 patients were analyzed. The patients' distribution into recurrence risk groups was as follows: 39 patients (56%) in the low-risk group, 23 patients (33%) in the intermediate-risk group, and 8 patients (11%) in the high-risk group. At a median follow-up of 47 months (range, 19–70 months) bDFS was 88.4%, with a global actuarial 5-year bDFS of 86%. Disease-related factors including initial PSA level, GS and risk group were significant predictors of biochemical failure (P = 0.01, P = 0.01, P = 0.006, respectively). In multivariate analysis, risk group (P = 0.005) and GS (P = 0.03) were statistically significant.

Conclusion

Our data are in agreement with those in the literature and, despite the short follow-up, confirm the advantage of brachytherapy for patients at low and intermediate risk of recurrence.

Clinical Significance of Neoadjuvant Combined Androgen Blockade for More Than Six Months in Patients with Localized Prostate Cancer Treated with Prostate Brachytherapy

INTRODUCTION

The aim of this study is to clarify the clinical significance of neoadjuvant combined androgen blockade (CAB) for ≥ 6 months in patients with localized prostate cancer.

PATIENTS AND METHODS

A total of 431 patients with localized prostate cancer who underwent prostate brachytherapy (BT) with or without neoadjuvant CAB for ≥ 6 months with mean follow-up time of 64.6 months (range 24-108 months) were evaluated retrospectively. Of those 431, 232 patients received BT in combination with neoadjuvant CAB for ≥ 6 months. Biochemical recurrence-free rates (BRFRs) in 364 patients with at least 3 years of follow-up were evaluated by log-rank test.

RESULTS

BRFR in patients with low-, intermediate- and high-risk prostate cancer were 98.1, 94.2 and 89.1%, respectively. In patients with intermediate-risk prostate cancer only, neoadjuvant CAB was significantly associated with BRFR (p = 0.0468). Especially in patients with intermediate-risk prostate cancer with radiation dose received by 90% of the prostate (D90) < 180 Gy, neoadjuvant CAB exerted a favorable impact on BRFR (p = 0.0429). On multivariate analyses, neoadjuvant CAB and D90 were independent predictors of BRFR (p = 0.0061 and p < 0.0001, respectively).

CONCLUSIONS

Neoadjuvant CAB for ≥ 6 months has a favorable impact on BRFR in patients with intermediate-risk prostate cancer, particularly in patients with relatively low radiation doses of D90.

Long-term biochemical results after high-dose-rate intensity modulated brachytherapy with external beam radiotherapy for high risk prostate cancer

Background

Biochemical control from series in which radical prostatectomy is performed for patients with unfavorable prostate cancer and/or low dose external beam radiation therapy are given remains suboptimal.

The treatment regimen of HDR brachytherapy and external beam radiotherapy is a safe and very effective treatment for patients with high risk localized prostate cancer with excellent biochemical control and low toxicity.

Biochemical outcome after high-dose-rate intensity modulated brachytherapy with external beam radiotherapy: 12 years of experience

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Biochemical control from series in which radical prostatectomy is performed for patients with unfavorable prostate cancer and/or low dose external beam radiation therapy are given remains suboptimal. The treatment regimen of HDR brachytherapy and external beam radiotherapy is a safe and very effective treatment for patients with high risk localized prostate cancer with excellent biochemical control and low toxicity.

OBJECTIVE

• To investigate the long-term oncological outcome, during the PSA era, of patients with prostate cancer who were treated using high-dose-rate (HDR) brachy therapy (BT) combined with external beam radiation therapy (EBRT).

PATIENTS AND METHODS

• From June 1998 to April 2007, 313 patients with localized prostate cancer were treated with 46 Gy of EBRT to the pelvis with a HDR-BT boost. • The mean (median) follow-up was 71 (68) months. • Toxicity was reported according to the Common Toxicity Criteria for Adverse Event, V.4.

RESULTS

• The 10-year actuarial biochemical control was 100% for patients with no high-risk criteria, 88% for patients with two intermediate-risk criteria, 91% with one high-risk criterion and 79% for patients with two to three high-risk criteria (P= 0.004). • The 10-year cancer-specific survival was 97% (standard deviation ± 1%). • The multivariate Cox regression analyses identified, Gleason score and T stage as independent prognostic factors for biochemical failure. • Gleason score was the only factor to significantly affect distant metastases. • Grade ≥ 3 late toxicity was not detected.

CONCLUSION

• The 10-year results confirm the feasibility and effectiveness of EBRT with conformal HDR-BT boost for patients with localised prostate cancer.

Timing of postseed imaging influences rectal dose-volume parameters for cesium-131 prostate seed implants

PURPOSE

To study the influence of timing of postseed implant imaging on rectal dose-volume parameters for cesium-131 ((131)Cs) seed prostate implants.

METHODS AND MATERIALS

Fifteen patients were treated in our institution with combination (131)Cs brachytherapy followed by pelvic external beam radiation therapy for intermediate to high-risk prostate cancers. For all patients, CT scans were scheduled at 7 days (CT(7)) and again at 2 months for external beam radiation therapy simulation purpose (CT(60)) postseed implantation. Comprehensive postseed implant dosimetry was performed for both CT(7) and CT(60) scans. In each case, dose-volume histogram parameters, rectal separation (the distance between the center of posterior most seed and most anterior rectal wall), and posterior row activity (the total activity implanted within 2-4mm anterior to the posterior wall of the prostate) data were collected. The absolute rectal volumes receiving 100% and 110% prescription dose were also collected.

RESULTS

Rectal dose correlated strongly with rectal separation (p<0.001). The mean change in rectal separation between CT(7) and CT(60) scans was 1.1 (±1.7) mm, and the corresponding change in 0.1-cc rectal dose was 18 (±26.5) Gy. Posterior row activity did not correlate with rectal dose (p=0.51). The mean volume of rectum that receives between 100% and 110% of the prescription dose (RV(100) and RV(110)) increased twofold, between CT(7) and CT(60) evaluations (0.03 [±0.06] cc vs. 0.07 (±0.05) cc, respectively, p=0.06).

CONCLUSIONS

Our study has demonstrated that rectal doses after (131)Cs seed implants are influenced by the timing of postseed imaging. This may be a consequence of prostatic and periprostatic edema resolution.

Androgen deprivation therapy does not impact cause-specific or overall survival in high-risk prostate cancer managed with brachytherapy and supplemental external beam

PURPOSE

To determine cause-specific survival (CSS), biochemical progression-free survival (bPFS), and overall survival (OS) in high-risk prostate cancer patients undergoing brachytherapy with or without supplemental therapies.

METHODS AND MATERIALS

Between April 1995 and July 2002, 204 patients with high-risk prostate cancer (Gleason score > or = 8 or prostate-specific antigen [PSA] >20 ng/mL or clinical stage > or = T2c) underwent brachytherapy. Median follow-up was 7.0 years. The bPFS was defined by a PSA < or = 0.40 ng/mL after nadir. Multiple clinical, treatment, and dosimetric parameters were evaluated for the impact on survival.

RESULTS

The 10-year CSS, bPFS, and OS were 88.9%, 86.6%, and 68.6%, respectively. A statistically significant difference in bPFS was discerned between hormone naive, ADT < or = 6 months, and ADT >6 month cohorts (79.7% vs. 95.% vs. 89.9%, p = 0.032). Androgen deprivation therapy (ADT) did not impact CSS or OS. For bPFS patients, the median posttreatment PSA was <0.04 ng/mL. A Cox linear regression analysis demonstrated that Gleason score was the best predictor of CSS, whereas percent positive biopsies and duration of ADT best predicted for bPFS. The OS was best predicted by Gleason score and diabetes. Thirty-eight patients have died, with 26 of the deaths from cardiovascular/pulmonary disease or second malignancy. Eleven patients have died of metastatic prostate cancer.

CONCLUSIONS

The ADT improved 10-year bPFS without statistical impact on CSS or OS. Death as a result of cardiovascular/pulmonary disease and second malignancies were more than twice as common as prostate cancer deaths. Strategies to improve cardiovascular health should positively impact OS.

Approaching clinical problems in prostate cancer radiotherapy using the number needed to treat (NNT) technique

The goals of this article are to review the application of the number needed to treat (NNT) concept to selected clinical problems in prostate cancer radiotherapy. Particular emphasis will be placed on (1) comparison of radiotherapy with other treatment options for early-stage disease, (2) the role of hormone therapy in addition to radiotherapy over a spectrum of disease presentation, and (3) systematic comparison of adjuvant versus salvage radiotherapy in the post-prostatectomy setting. Limitations of NNT calculations based on non-randomized comparisons also are discussed.

Evolving Role of Surgery, Radiation, Hormone Therapy, and Chemotherapy in High-Risk Locally Advanced Prostate Cancer

Locally advanced prostate cancer encompasses several disease states that vary in the risk for progression and recurrence after initial treatment. Further, the optimal treatment strategies for locally advanced prostate cancer are continuing to evolve, reflecting the complex nature of this disease state. For many patients, clinical experience demonstrates that a combined approach of locally directed therapy and systemic therapy is likely to provide better long-term outcome than single-modality therapy. Randomized studies have established hormone ablation with external-beam radiation as an important form of treatment for this group of patients. However, additional progress needs to be made, particularly in the subgroup of patients with very high-risk disease features. As the optimal integration of local and systemic treatments becomes more clearly defined, the long-term prognosis for patients with high-risk locally advanced prostate cancer will improve.

Impact of hormone therapy on acute radiotherapy toxicity in the treatment of prostate cancer

PURPOSE

To analyze the impact of neoadjuvant hormone therapy (HT) on acute gastrointestinal (GI) and genitourinary (GU) toxicity from radiotherapy (RT).

SCOPE

The toxicity rates of 480 consecutive prostate cancer patients were reviewed and compared using the chi2 test. Ordered logit regression analyses were performed including the major demographic, disease, and treatment factors. Although no reduction in acute GI toxicity from HT use was observed (P=0.067), a lower rate of acute GU toxicity was observed (P=0.002). No factor reached statistical significance on regression analysis.

CONCLUSIONS

Observed toxicity rates were similar or lower in patients receiving HT. Thus, increased RT toxicity should not be a concern when deciding to add neoadjuvant HT to RT for prostate cancer.

The impact of hormone therapy on post-implant dosimetry and outcome following Iodine-125 implant monotherapy for localised prostate cancer

BACKGROUND AND PURPOSE

Many patients with localised prostate cancer present with symptoms of benign prostatic hypertrophy (BPH) and require neoadjuvant hormone therapy to shrink the gland before brachytherapy. The impact of this hormone therapy has been evaluated in 667 patients treated with Iodine seed monotherapy.

PATIENTS AND METHODS

Prospective data from 667 patients treated between 1995 and 2001 by I-125 seeds prostate implant as monotherapy were analysed. The mean age was 63 years (42--77 years). Three hundred and forty-six (51.9%) patients had a short course of neo adjuvant hormone therapy and 321 (49.1%) did not. The prescribed minimum peripheral dose was 145 Gy (TG 43). Patients were followed up to a maximum of 8.2 years and a minimum of 18 months. Statistical analysis was performed to identify factors that would predict PSA relapse-free survival (PSA-RFS) defined by the American Society for Therapeutic Radiology and Oncology (ASTRO).

RESULTS

Overall the PSA relapse-free survival is 76.1 and 72.6% for patient cohorts being on pre-treatment hormones and not, respectively (P=0.107). Subdivided into risk groups the low risk group showed 92.5% PSA-RFS with hormones and 75.1% without (P=0.327). The intermediate group 75.7% with hormones and 72.9% without (P=0.148) and for the high-risk group 51.1% with and 51.1% without hormones (P=0.942). Evaluation of post-implant dosimetry in patients with and without hormone therapy showed that the D90 for those who received hormone therapy was 130.8 Gy compared with 145.1 Gy for those who did not (P<0.001). This may be related to the degree of oedema at the time of post-implant dosimetry. The CT to ultrasound prostate volume ratio was 1.17 for patients who received hormone therapy and 0.98 for those who did not (P<0.001). It is suggested that in the interval between stopping hormone therapy and doing post-implant dosimetry there was an increase in prostate volume, which results in a lower D90. Significant correlation was found between D90 and prostate volume on post-implant CT dosimetry with higher D90s for small volume prostates (P<0.001).

CONCLUSIONS

Overall hormone therapy had no significant effect on outcome. The apparent lower D90 in hormone treated patients may be related to a change in volume between pre-implant and post-implant dosimetry.

Prostate cancer and the principles of hormone therapy treatment

This article discusses the use of hormone therapy for the treatment of prostate cancer, the most common male cancer. Key to managing this disease is understanding the processes responsible for maintaining prostate growth and hormonal homeostasis in male development. The individual mechanisms of action are outlined and demonstrated for each type of treatment, alongside the effects of these treatments. Each therapeutic option is discussed in conjunction with current key research findings and implications for practice are outlined.

Impact of short course hormonal therapy on overall and cancer specific survival after permanent prostate brachytherapy

PURPOSE

To review the impact of prior hormonal therapy on 10-year overall and prostate cancer specific survival after primary brachytherapy.

METHODS AND MATERIALS

A retrospective review was performed on the Arizona Oncology Services tumor registry for 2,378 consecutive permanent prostate brachytherapy cases from 1988 through 2001. Hormonal therapy was administered before the implant in 464 patients for downsizing of the prostate or at the discretion of the referring physician. All deceased patients with known clinical recurrence were considered to have died of prostate cancer, irrespective of the immediate cause of death. Risk groups were defined, with 1,135 favorable (prostate-specific antigen [PSA] < 10, Gleason < 7, Stage T1-T2a), 787 intermediate (single adverse feature), and 456 unfavorable (two or more adverse features) patients. Kaplan-Meier actuarial survival curves were generated for both overall and cause-specific survival from the time of treatment. Multivariate analysis was performed to assess the impact of hormonal intervention in comparison with known risk factors of grade, PSA, and age.

RESULTS

With follow-up ranging up to 12.6 years and a median of 4.1 year, a total of 474 patients died, with 67 recorded as due to prostate cancer. Overall and cause-specific 10-year survival rates are 43% and 88%, respectively. Overall survival is 44% for the hormone naive patients, compared with 20% for the hormone-treated cohort (p = 0.02). The cancer-specific survival is 89% vs. 81% for the same groups (p = 0.133). Multivariate analysis confirms the significance of age > 70 years (p = 0.0013), Gleason score >/= 7 (p = 0.0005), and prior hormone use (p = 0.0065) on overall survival.

CONCLUSIONS

At 10 years, in prostate cancer patients receiving brachytherapy, overall survival is worse in men receiving neoadjuvant hormonal therapy, compared with hormone naive patients. This does not appear to be due to other known risk factors for survival (i.e., stage, grade, PSA, age) on multivariate analysis. The leading causes of death were cardiovascular, prostate cancer, and other cancers with no obvious discrepancy between the two groups. This finding is unexpected and requires confirmation from other centers.

[Retrospective study of 130 patients with organconfined prostate cancer treated with brachytherapy]

INTRODUCTION

The prostate brachytherapy with I 125 seeds has an indication in patients with organconfined prostate cancer. Our objective is to describe the population treated in our institution with permanent I125 seeds implants, the dosimetric characteristics of the technique and the preliminary results of our group-study in terms of evolution and toxicity.

MATERIAL AND METHODS

Between May 2000 and March 2003, 130 patients with permanent implants of I125 seeds were treated. Beforehand we did prostate volumetric with transrectum prostate echography in order to assess the configuration of the implant, number of seeds and their place in the prostate with the objective to get a fine coverage of PTV (planet target volume). Stage distribution: 75.72% T1c; 24.28% T2a; Gleason<6, 94%. The PSA pretreatment average was 6.38 ng/ml. The average prostate volume was 30 cc. The 16.67% of the patients included had hormonal treatment previously to get the implants. The average age was 64 years. The characteristic techniques of the implants were: the average width of the needle as 24 (14-35) and the average of the seeds 76 (46-111). Finally the average activity was 0.39 mCi/seed, which means average total implant activity of 80 mCi.

RESULTS

We analyzed 130 patients with average follow up 6 months. A 1 to 2 year surveillance was carried out on 98.9% and the global free disease surveillance (biochemic relapse) of 98.9% at the year and of the 87.8% at the end of the 2 years. The relapse in the low risk patients was 98.8% after the first year and 88.7% at the end of 2 year. On the contrary in the middle risk was of 100% and 83% respectively, although the amount of patients in significantly less. As a relevant acute secondary effects we found slight rectitys or GI (RTOG scale) in 1.4 and that needs synthomatic medication or GII (RTOG scale) in 0.8%. We found slide hematuria or GI (RTOG scale) in the 53% and other measures or GII (RTOG scale) in the 2.64% was needed. Finally we had to set a urinary prove for acute retention in 4.3%.

CONCLUSION

The prostate brachyterapy is a complex procedure that needs a multidisciplinary team participation in order to be able to carry out. It avoids a long term hospitalization and allows for the patient to have daily activity within a short period of time. Despite the fact of the brief follow-up, the results over biochemical relapse and toxicity were similar to the ones in the literature. Tolerance to the implant was good. It would necessary a longer follow-up in order to be able to come to long term conclusions.

Hormone therapy and radiotherapy for early prostate cancer: a utility-adjusted number needed to treat (NNT) analysis

PURPOSE

To quantify, using the number needed to treat (NNT) methodology, the benefit of short-term (< or =6 months) hormone therapy adjuvant to radiotherapy in the group of patients with early (clinical stage T1-T2c) prostate cancer.

METHODS AND MATERIALS

The absolute biochemical control benefit for the use of hormones adjuvant to radiotherapy in early-stage disease was determined by literature review. A model was developed to estimate the utility-adjusted survival detriment due to the side effects of hormone therapy. The NNTs before and after the incorporation of hormone sequelae were computed; the sign and magnitude of the NNTs were used to gauge the effect of the hormones.

RESULTS

The absolute NNT analysis, based on summarizing the results of 8 reports including a total of 3652 patients, demonstrated an advantage to the addition of hormones for the general early-stage prostate cancer population as well as for all prognostic groups. After adjustment for hormone-induced functional loss, the advantage of hormones remained considerable in the high- and intermediate-risk groups, with the utility-adjusted NNT becoming weakened in the low-risk group when the utility compromise from complications of hormones was assumed to be considerable.

CONCLUSIONS

Short-term hormone therapy seems to be beneficial for selected early-stage prostate cancer patients. The advantage seems to be greatest in the intermediate- and high-risk groups; with current follow-up, the side effects of hormones may outweigh their benefit in certain clinical situations in the favorable group. The present investigation demonstrates the significant role of the NNT technique for oncologic and radiotherapeutic management decisions when treatment complications need to be considered and balanced with the beneficial effects of the treatment.

Impact of supplemental external beam radiotherapy and/or androgen deprivation therapy on biochemical outcome after permanent prostate brachytherapy

PURPOSE

To evaluate the impact of supplemental external beam radiotherapy (EBRT) and/or androgen deprivation therapy (ADT) on 8-year biochemical outcome after permanent prostate brachytherapy.

METHODS AND MATERIALS

Between April 1995 and January 2001, 668 consecutive patients underwent brachytherapy using either (103)Pd or (125)I for clinical Stage T1b-T3aNxM0 (2002 American Joint Committee on Cancer) adenocarcinoma of the prostate gland. No patient underwent seminal vesicle biopsy or pathologic lymph node staging. The median follow-up was 58.6 months. Biochemical progression-free survival was defined by the American Society for Therapeutic Radiology and Oncology consensus definition. The clinical, treatment, and dosimetric parameters evaluated for biochemical progression-free survival included supplemental EBRT, ADT, patient age, clinical stage, Gleason score, preimplant prostate specific antigen (PSA), risk group, percentage of positive biopsies, isotope used, prostate volume, planning volume, percentage of target volume receiving 100%, 150%, and 200% of prescribed dose, minimal percentage of dose covering 90% of target volume, tobacco status, hypertension, and diabetes.

RESULTS

For the entire group, the actuarial 8-year biochemical progression-free survival rate was 98.2%, 98.4%, and 88.2% for low-, intermediate-, and high-risk patients, respectively, with a median PSA level of <0.1 ng/mL for all risk groups and ADT and EBRT subgroups. At last follow-up, only 5 patients (0.8%) had died of metastatic prostate cancer. In multivariate analysis, Gleason score, percentage of positive biopsies, and ADT predicted for biochemical outcome in high-risk patients. In low- and intermediate-risk patients, none of the evaluated variables predicted for biochemical outcome. For the entire population, pretreatment PSA level, Gleason score, ADT, and clinical stage predicted for 8-year biochemical progression-free survival, with the percentage of positive biopsies approaching statistical significance.

CONCLUSION

Prostate brachytherapy results in a high probability of 8-year biochemical progression-free survival for low-, intermediate-, and high-risk patients. Although the role of supplemental EBRT could not be adequately evaluated in high-risk patients, it did not improve biochemical outcome in low- and intermediate-risk patients. However, ADT resulted in a statistically significant improvement in progression-free survival for high-risk patients.

European Collaborative Group on Prostate Brachytherapy: Preliminary Report in 1175 Patients

OBJECTIVE

To establish a multi-centre database of a large number of patients treated with brachytherapy across Europe.

METHODS

A total of 1175 patient files were registered in the database and the completeness of the data on these patients resulted in the majority being included in the analysis.

RESULTS

The database of patients treated with brachytherapy across Europe indicates that optimal patient selection for this procedure has been made, both in terms of outcome and side-effects, which will be subject of future analyses. This should enable refinement of the treatment choice and administration as well as provide useful guidance to other centres that want to establish this procedure for their patients. It will also set the ground for prospective studies.

CONCLUSIONS

The established database indicates that brachytherapy as a treatment option for prostate cancer is well established in many centres.

Androgen deprivation–induced changes in prostate anatomy predict urinary morbidity after permanent interstitial brachytherapy

PURPOSE

To evaluate the cytoreductive consequences of neoadjuvant androgen deprivation therapy on International Prostate Symptom Score (IPSS) normalization, catheter dependency, and the need for surgical intervention secondary to bladder outlet obstruction after permanent interstitial brachytherapy.

METHODS AND MATERIALS

A total of 116 patients (median follow-up, 30 months) with preandrogen and postandrogen deprivation therapy ultrasound studies and no history of preimplant transurethral resection of the prostate were evaluated. Androgen deprivation-induced changes in prostate volume, transition zone (TZ) volume, and urethral location were correlated with IPSS resolution, catheter dependency, and the need for postimplant surgical intervention. Prostate gland and TZ dimensions and volumes were measured by prolate ellipsoid calculation from the static ultrasound images. The urethral location was determined by identification of a urinary catheter. Additional clinical, treatment, and dosimetric parameters evaluated included patient age, pretreatment prostate-specific antigen, Gleason score, clinical T stage, preimplant IPSS, pre- and postandrogen deprivation ultrasound studies, treatment planning volume, supplemental external beam RT, isotope, total implant activity, Day 0 maximal dose received by 90% of the prostate gland, Day 0 percentage of prostate volume receiving 100%, 150%, and 200% of the prescribed minimal peripheral dose, and urethral dose.

RESULTS

For hormonally manipulated patients, the prostate volume at implantation did not have a statistical influence on the percentage of patients returning to IPSS baseline, the time for IPSS normalization, the incidence of catheter dependency, the catheter-dependency time, or the need for postimplant surgical intervention. However, when compared with the hormone-naive cohort, hormonally manipulated patients were more likely to undergo postimplant surgical intervention (5.2% vs. 0.3%, p = 0.001). Greater androgen deprivation-induced reductions in prostate and TZ volumes, along with movement of the urethra closer to the posterior border of the prostate gland, resulted in a decreased incidence of postimplant urinary morbidity. Using Cox regression analysis, the time to IPSS resolution was best predicted by the percentage of TZ volume reduction. Stepwise linear regression analysis demonstrated that the catheter-dependency time was best predicted by the prehormonal therapy prostate volume, posthormonal therapy TZ volume, and the change in the urethral position; prolonged catheter dependency by the percentage of TZ volume reduction, prehormonal therapy TZ index, and the change in the urethral position; and the need for postimplant surgical intervention by the posthormonal therapy TZ index and the change in the urethral location.

CONCLUSION

After neoadjuvant androgen deprivation therapy for volume reduction, some brachytherapy-related urinary morbidity parameters are highly related to the preandrogen deprivation prostate volume, variants in the TZ volume, and changes in the urethral location.

The Impact of Prostate Volume and Neoadjuvant Androgen-Deprivation Therapy on Urinary Function Following Prostate Brachytherapy

PURPOSE

The purpose of this article is to evaluate the impact of prostate size and the magnitude of cytoreduction after neoadjuvant androgen-deprivation therapy (ADT) on catheter dependency, urinary symptomatology, and need for postbrachytherapy surgical intervention.

MATERIALS AND METHODS

From February 1998 to August 2002, 186 consecutive patients under went monotherapeutic brachytherapy (no supplemental external-beam radiotherapy or ADT), and 101 consecutive patients received < or = 6 months of ADT (a luteinizing hormone-releasing hormone agonist and an anti-androgen) in conjunction with brachytherapy without supplemental external-beam radiotherapy for clinical Tlc-T2b (2002 American Joint Committee on Cancer) prostate cancer. ADT was initiated approximately 3 months before brachytherapy. The median follow-up was 38.6 months. An alpha-blocker was initiated before implantation and continued at least until the International Prostate Symptom Score (IPSS) returned to baseline levels. Evaluated parameters included patient age, pretreatment prostate-specific antigen, Gleason score, clinical T stage, preimplantation IPSS, ultrasound volume, hormonal status, isotope, D(90), V(100/150/200), and urethral dose (average and maximum).

RESULTS

Patients receiving neoadjuvant ADT were statistically older, presented with higher preimplantation IPSS scores, and larger prostate volumes. Patients receiving ADT were likelier to require a urinary catheter for the first 3 days after implantation; however, by day 4, no statistical difference in catheter dependency could be discerned between the two cohorts. Hormonal status did not predict for postbrachytherapy surgical intervention. IPSS returned to baseline at a mean of 1.8 and 1.7 months in hormone-naive and ADT patients, respectively. In multivariate Cox regression analysis, the preimplantation IPSS and the maximum postimplantation IPSS predicted for IPSS normalization overall and in both cohorts. Ultrasound prostate volume did not predict for IPSS normalization, catheter dependency, or need for postimplantation surgical intervention.

CONCLUSION

Although patients receiving ADT were likelier to require a urinary catheter for the first three days after implantation, hormonal manipulation did not affect IPSS normalization, prolonged catheter dependency, or need for postbrachytherapy surgical intervention in these patients treated with brachytherapy without supplemental external-beam radiotherapy.

Influence of hormonal therapy on late rectal function after permanent prostate brachytherapy with or without supplemental external beam radiotherapy

PURPOSE

Recent clinical studies have reported a relationship between the use of hormonal therapy and degradation in rectal function after external beam radiotherapy. Using a patient-administered quality-of-life instrument, we evaluated the effect of hormonal therapy on late rectal function after permanent prostate brachytherapy with or without supplemental external beam radiotherapy.

METHODS AND MATERIALS

A total of 189 patients were mailed the Rectal Function Assessment Score (R-FAS), which consists of nine questions (score range 0-27, with higher scores indicative of poorer bowel function). Of the 189 surveys sent out, 187 (98.4%) were returned. Of the 187 patients, 149 (79.7%) were hormone naive, and 38 (20.3%) had received hormonal manipulation (median duration 4 months, range 3-36). The median follow-up for the entire group was 66.3 months. The effect of hormonal therapy on bowel function was evaluated by comparing the R-FAS scores across time, by each of the individual nine questions, and by means of a summary question evaluating the patient's perception of overall bowel function. The two groups were also evaluated in terms of clinical, treatment, and dosimetric parameters, including follow-up, age, Gleason score, clinical stage, pretreatment prostate-specific antigen level, number of pretreatment bowel movements/d, prostate volume, and rectal dosimetry.

RESULTS

The two groups were well matched in all clinical, treatment, and dosimetric parameters, except the patients receiving hormonal therapy had a statistically shorter follow-up (63.9 vs. 69.4 months, p <0.001) and higher pretreatment prostate-specific antigen level (12.0 vs. 9.8 ng/mL, p = 0.024). The R-FAS scores for the hormone-naive and hormonally manipulated patients were comparable (3.76 vs. 4.55, p = 0.083). In terms of the nine individual R-FAS questions, no statistically significant difference was reported for any question when stratified by hormonal status, including rectal bleeding (p = 0.735). Only 12% and 13% of hormone-naive and hormonally manipulated patients, respectively, reported bowel function to be worse after implantation. With time, a trend for improvement in the R-FAS was noted in both cohorts.

CONCLUSION

After permanent prostate brachytherapy, no statistically significant difference in bowel habits was discerned when stratified by hormonal status. In addition, only 12% of brachytherapy patients reported deterioration in bowel function after implantation.

The effect of hormonal manipulation on urinary function following permanent prostate brachytherapy

PURPOSE

To evaluate the effect of hormonal manipulation on catheter dependency, the resolution of urinary symptomatology, and the need for postbrachytherapy transurethral/transincisional resection (TURP/TUIP).

METHODS AND MATERIALS

Seven hundred sixteen consecutive patients (median follow-up, 29 months) underwent brachytherapy for clinical T1b-T3a (1997 AJCC) prostate cancer from January 1998 through August 2002. Of the evaluated cohort, 400 patients were hormone naïve, 227 received short-course cytoreductive (< or = 6 months) hormonal therapy, and 89 received extended (>6 months) hormonal therapy. An alpha-blocker was initiated prior to implantation and continued at least until the International Prostate Symptom Score (I-PSS) returned to baseline levels. Evaluated parameters included age, T-stage, preimplant I-PSS, ultrasound volume, treatment planning volume, hormonal status, supplemental external beam radiation therapy (XRT), isotope, urethral dose, total implant activity, D90, and V100/150/200. Catheter dependency and the incidence of TURP/TUIP were also evaluated.

RESULTS

Six hundred fifty three patients (91.2%) had the urinary catheter permanently removed on day 0 with 15 patients (2.1%) requiring a catheter beyond 4 days. The I-PSS returned to within 1 point of the antecedent value at a median of 4 months. Sixteen patients (2.2%) underwent postimplant TURP/TUIP. A Cox regression indicated that preimplant I-PSS, supplemental XRT, planning target volume, hormonal therapy, and number of seeds were the strongest predictors for I-PSS resolution. Using all available data, the strongest predictors for I-PSS at 18 months following brachytherapy included variants of I-PSS, isotope, and days of catheter dependency. The maximum I-PSS, planning target volume, and XRT best predicted for prolonged (#10878;4 days) catheter dependency. The need for postimplant TURP/TUIP was most closely associated with days of catheter dependency and the maximum increase in I-PSS. However, when only data available prior to implantation was entered into the model, hormonal therapy predicted for postsurgical intervention.

CONCLUSIONS

In this retrospective evaluation, hormonal manipulation did not statistically impact short-term or prolonged urinary catheter dependency or I-PSS at 18 months, but did influence time to I-PSS normalization and the need for postbrachytherapy surgical intervention.

Temporal effect of neoadjuvant androgen deprivation therapy on PSA kinetics following permanent prostate brachytherapy with or without supplemental external beam radiation

PURPOSE

To evaluate the effect of neoadjuvant androgen deprivation therapy on PSA kinetics following brachytherapy with or without supplemental external beam radiation therapy (XRT), to evaluate the magnitude and duration of the peak PSA, and to compare potential differences in PSA response curves between biochemically disease-free and failed patients.

MATERIALS AND METHODS

From November 1995 through August 2000, 179 consecutive patients with clinical T1b-T3a NxM0 (2002 AJCC) prostate cancer received neoadjuvant androgen deprivation therapy (median, 4 months) prior to brachytherapy using (103)Pd or (125)I with or without supplemental XRT. The median follow-up was 56 months. Following brachytherapy, PSA determinations were obtained at 3 months and then every 6 months thereafter. A median and mean of 9 and 9.5 PSA determinations, respectively, were obtained per patient. Biochemical disease-free survival was defined by the ASTRO and Houston definitions with both definitions used to determine the rate of overestimation of early biochemical failure secondary to testosterone recovery.

RESULTS

Although a trend for higher baseline and peak PSA was noted in (125)I monotherapy patients, the difference between the 4 groups was not statistically significant (p = 0.088). Changes in PSA over time, however, were statistically significant (p = 0.042). For all 4 groups, the peak PSA occurred approximately 15-21 months following brachytherapy. For biochemically disease-free patients, the median PSA increase above nadir was 0.1 ng/mL, and the median number of consecutive rises in PSA was 1. Using the ASTRO and Houston definitions, only 2.3% and 0.6% of patients would have been inadvertently scored as failures.

CONCLUSIONS

In brachytherapy patients receiving 3-6 months of neoadjuvant androgen deprivation therapy, the median PSA increase above nadir was 0.1 ng/mL. The ASTRO and Houston definitions of biochemical failure inadvertently scored only 2.3% and 0.6% of patients as failures.