169Yb-based high dose rate intensity modulated brachytherapy for focal treatment of prostate cancer

PURPOSE

This study compares conventional 192Ir-based high dose rate brachytherapy (HDR-BT) with 169Yb-based HDR intensity modulated brachytherapy (IMBT) for focal prostate cancer treatment. Additionally, the study explores the potential to generate less invasive treatment plans with IMBT by reducing the number of catheters needed to achieve acceptable outcomes.

METHODS AND MATERIALS

A retrospective dosimetric study of ten prostate cancer patients initially treated with conventional 192Ir-based HDR-BT and 5-14 catheters was employed. RapidBrachyMCTPS, a Monte Carlo-based treatment planning system was used to calculate and optimize dose distributions. For 169Yb-based HDR IMBT, a custom 169Yb source combined with 0.8 mm thick platinum shields placed inside 6F catheters was used. Furthermore, dose distributions were investigated when iteratively removing catheters for less invasive treatments.

RESULTS

With IMBT, the urethra D10 and D0.1cc decreased on average by 15.89 and 15.65 percentage points (pp) and the rectum V75 and D2cc by 1.53 and 11.54 pp, respectively, compared to the conventional clinical plans. Similar trends were observed when the number of catheters decreased. On average, there was an observed increase in PTV V150 from 2.84 pp with IMBT when utilizing all catheters to 8.83 pp when four catheters were removed. PTV V200 increased from 0.42 to 2.96 pp on average. Hotspots in the body were however lower with IMBT compared to conventional clinical plans.

CONCLUSIONS

169Yb-based HDR IMBT for focal treatment of prostate cancer has the potential to successfully deliver clinically acceptable, less invasive treatment with reduced dose to organs at risk.

A Randomized Trial Comparing Quality of Life After Low-Dose Rate or High-Dose Rate Prostate Brachytherapy Boost With Pelvic External Beam Radiation Therapy

PURPOSE

To compare health-related quality of life (QoL) in urinary, bowel, and sexual domains after combined external beam radiation therapy (EBRT) and either low-dose rate (LDR) or high-dose rate (HDR) prostate brachytherapy (BT).

METHODS AND MATERIALS

Eligible men with intermediate or high-risk prostate cancer treated with combined pelvic EBRT and BT were randomly assigned to either HDR (15 Gy) or LDR (110 Gy) boost. International Prostate Symptom Score, Index of Erectile Function, and Expanded Prostate Cancer Composite were collected at baseline, 1, 3, 6, and 12 months, every 6 months to 3 years and then annually along with prostate-specific antigen/testosterone. Fisher's exact test compared categorical variables and the Mann-Whitney U test Expanded Prostate Cancer Index Composite (EPIC) domain scores.

RESULTS

From January 2014 to December 2019, a random number generator assigned 195 men: 108 to HDR and 87 to LDR. Median age was 71 years. Risk group was high in 57% and unfavorable intermediate in 43%. Androgen deprivation (used in 74%) began with 3 months neoadjuvant and continued for median 12 months. Baseline EPIC scores were similar for the LDR/HDR cohorts: 89 and 88 respectively for Genito-urinary; 92 and 93 for Gastro-intestinal. EPIC urinary scores decreased at 1 month for HDR but recovered promptly to a steady state by 6 months. LDR scores reached a nadir at 3 months with slow recovery to 18 months, after which urinary QoL was similar for HDR and LDR. Bowel QOL scores fell in both cohorts reaching respective nadirs at 12 months. HDR patients recovered close to baseline and maintained higher scores than LDR patients to 5 years. The decline for LDR patients remained more than the minimum clinically important difference out to 5 years.

CONCLUSIONS

The patient experience for combined EBRT and prostate BT is improved with HDR BT. Urinary QoL improves over time to be equivalent between the 2 modalities after 18 months, but LDR patients report lasting bowel symptoms.

Protocol-based CT-guided brachytherapy for patients with prostate cancer and previous rectal extirpation-a curative approach

OBJECTIVE

There are numerous curative treatment possibilities for prostate cancer. In patients who have undergone rectal extirpation for rectal cancer treatment, curative options are limited due to anatomic changes and previous irradiation of the pelvis. In this analysis, we validate the feasibility of CT-guided transperineal interstitial brachytherapy for this specific scenario.

PATIENTS AND METHODS

We analyzed the treatment procedures and outcomes of 5 patients with metachronic nonmetastatic prostate cancer. Ultrasound-guided brachytherapy was not possible in any of the patients. Of these 5 patients, 3 were treated for prostate cancer using temporary brachytherapy with Ir-192 only, and 2 were treated with external-beam radiation therapy and temporary brachytherapy as a boost. CT-guided brachytherapy was performed in all patients. We analyzed the feasibility, efficacy, treatment-related toxicity, and quality of life (EORTC-30, IEFF, IPSS, and ICIQ questionnaires) of the treatments.

RESULTS

Median follow-up was 35 months. Two out of five patients received boost irradiation (HDR 2 × 9 Gy, PDR 30 Gy). Three out of five patients were treated with PDR brachytherapy in two sessions up to a total dose of 60 Gy. Dosimetric parameters were documented as median values as follows: V100 94.7% (94.5-98.4%), D2bladder 64.3% (50.9-78.3%), D10urethra 131.05% (123.2%-141.2%), and D30urethra 122.45% (116.2%-129.5%). At the time of analysis, no biochemical recurrence had been documented. Furthermore, neither early nor late side effects exceeding CTCAE grade 2 were documented.

CONCLUSION

CT-guided transperineal brachytherapy of the prostate in patients with previous rectal surgery and radiation therapy is safe and represents a possible curative treatment option. Brachytherapy can be considered for patients with metachronic prostate cancer in this specific scenario, albeit preferably in experienced high-volume centers.

Mesenchymal stem cell-derived exosomes for management of prostate cancer: An updated view

Prostate cancer represents the second most prevalent form of cancer found in males, and stands as the fifth primary contributor to cancer-induced mortality on a global scale. Research has shown that transplanted mesenchymal stem cells (MSCs) can migrate by homing to tumor sites in the body. In prostate cancer, researchers have explored the fact that MSC-based therapies (including genetically modified delivery vehicles or vectors) and MSC-derived exosomes are emerging as attractive options to improve the efficacy and safety of traditional cancer therapies. In addition, researchers have reported new insights into the application of extracellular vesicle (EV)-MSC therapy as a novel treatment option that could provide a more effective and targeted approach to prostate cancer treatment. Moreover, the new generation of exosomes, which contain biologically functional molecules as signal transducers between cells, can simultaneously deliver different therapeutic agents and induce an anti-tumor phenotype in immune cells and their recruitment to the tumor site. The results of the current research on the use of MSCs in the treatment of prostate cancer may be helpful to researchers and clinicians working in this field. Nevertheless, it is crucial to emphasize that although dual-role MSCs show promise as a therapeutic modality for managing prostate cancer, further investigation is imperative to comprehensively grasp their safety and effectiveness. Ongoing clinical trials are being conducted to assess the viability of MSCs in the management of prostate cancer. The results of these trials will help determine the viability of this approach. Based on the current literature, engineered MSCs-EV offer great potential for application in targeted tumor therapy.

Penalty weight tuning in high dose rate brachytherapy using multi-objective Bayesian optimization

Objective.Treatment plan optimization in high dose rate brachytherapy often requires manual fine-tuning of penalty weights for each objective, which can be time-consuming and dependent on the planner's experience. To automate this process, this study used a multi-criteria approach called multi-objective Bayesian optimization with q-noisy expected hypervolume improvement as its acquisition function (MOBO-qNEHVI).Approach.The treatment plans of 13 prostate cancer patients were retrospectively imported to a research treatment planning system, RapidBrachyMTPS, where fast mixed integer optimization (FMIO) performs dwell time optimization given a set of penalty weights to deliver 15 Gy to the target volume. MOBO-qNEHVI was used to find patient-specific Pareto optimal penalty weight vectors that yield clinically acceptable dose volume histogram metrics. The relationship between the number of MOBO-qNEHVI iterations and the number of clinically acceptable plans per patient (acceptance rate) was investigated. The performance time was obtained for various parameter configurations.Main results.MOBO-qNEHVI found clinically acceptable treatment plans for all patients. With increasing the number of MOBO-qNEHVI iterations, the acceptance rate grew logarithmically while the performance time grew exponentially. Fixing the penalty weight of the tumour volume to maximum value, adding the target dose as a parameter, initiating MOBO-qNEHVI with 25 parallel sampling of FMIO, and running 6 MOBO-qNEHVI iterations found solutions that delivered 15 Gy to the hottest 95% of the clinical target volume while respecting the dose constraints to the organs at risk. The average acceptance rate for each patient was 89.74% ± 8.11%, and performance time was 66.6 ± 12.6 s. The initiation took 22.47 ± 7.57 s, and each iteration took 7.35 ± 2.45 s to find one Pareto solution.Significance.MOBO-qNEHVI combined with FMIO can automatically explore the trade-offs between treatment plan objectives in a patient specific manner within a minute. This approach can reduce the dependency of plan quality on planner's experience and reduce dose to the organs at risk.

Iodine‑125 seeds combined with carboplatin in the treatment of retroperitoneal metastatic seminoma: A case report and literature review

Testicular seminoma is a relatively rare malignant tumor, with the most common site of recurrence and metastasis being the retroperitoneal lymph nodes. Since seminoma is highly sensitive to radiotherapy and chemotherapy, even if it metastasizes, its cure rate is still >95%. However, the long-term toxicity and side effects of radiotherapy and chemotherapy cannot be ignored. Iodine-125 seeds represent a low-energy radioactive source that kills tumor cells while protecting the surrounding normal tissues, and brachytherapy using iodine-125 seeds has been widely used for the treatment of various malignancies. In addition, carboplatin can be used as an alternative to cisplatin-based combination chemotherapy to reduce the incidence of pulmonary toxicity, neurological damage and renal toxicity. In the present study, a case in which iodine-125 seeds were implanted for the treatment of retroperitoneal metastatic seminoma is reported. The patient was diagnosed with postoperative recurrence of seminoma that metastasized to the retroperitoneal lymph nodes. Since the tumor was large and surrounded blood vessels, surgical intervention and external radiotherapy were not considered. Moreover, considering the potential long-term toxic side effects of standard chemotherapy, a treatment plan for the patient using iodine-125 seed implantation combined with carboplatin (AUC7) therapy was finally formulated. No disease recurrence or toxic reactions occurred during the 3-year follow-up after treatment. The present case therefore demonstrated the antitumor efficacy and reduced toxicity of iodine-125 seeds combined with carboplatin for treating seminoma.

Stereotactic ablative brachytherapy versus percutaneous microwave ablation for early-stage non-small cell lung cancer: a multicenter retrospective study

BACKGROUND

To analyze the efficacy of stereotactic ablative brachytherapy (SABT) and percutaneous microwave ablation (MWA) for the treatment of early-stage non-small cell lung cancer (NSCLC).

METHODS

Patients with early-stage (T1-T2aN0M0) NSCLC who underwent CT-guided SABT or MWA between October 2014 and March 2017 at four medical centers were retrospectively analyzed. Survival, treatment response, and procedure-related complications were assessed.

RESULTS

A total of 83 patients were included in this study. The median follow-up time was 55.2 months (range 7.2-76.8 months). The 1-, 3-, and 5-year overall survival (OS) rates were 96.4%, 82.3%, and 68.4% for the SABT group (n = 28), and 96.4%, 79.7%, and 63.2% for MWA group (n = 55), respectively. The 1-, 3-, and 5-year disease-free survival (DFS) rates were 92.9%, 74.6%, and 54.1% for SABT, and 92.7%, 70.5%, and 50.5% for MWA, respectively. There were no significant differences between SABT and MWA in terms of OS (p = 0.631) or DFS (p = 0.836). The recurrence rate was also similar between the two groups (p = 0.809). No procedure-related deaths occurred. Pneumothorax was the most common adverse event in the two groups, with no significant difference. No radiation pneumonia was found in the SABT group.

CONCLUSIONS

SABT provided similar efficacy to MWA for the treatment of stage I NSCLC. SABT may be a treatment option for unresectable early-stage NSCLC. However, future prospective randomized studies are required to verify these results.

Safety of high-dose rate (HDR) brachytherapy for patients with prostate cancer and history of prior chemoradiation for rectal cancer: A case series

PURPOSE

A history of prior pelvic radiation therapy (RT) for rectal cancer is a relative contraindication for definitive RT for prostate cancer. High-dose-rate (HDR) brachytherapy can significantly limit the dose to surrounding tissues compared to external beam RT. However, there is limited data surrounding its safety in patients with prior pelvic RT.

METHODS AND MATERIALS

A retrospective chart review was performed at the University of California, San Francisco to identify patients diagnosed with prostate cancer with a history of pelvic RT for rectal cancer who were treated with high-dose-rate brachytherapy (HDR-BT) between 2006 and 2022. Inclusion criteria were biopsy-confirmed prostate cancer with no evidence of distant disease on clinical examination or imaging, and at least one post-treatment clinic appointment.

RESULTS

Seven patients were treated with salvage HDR-BT at a median interval of 17.7 years after RT for rectal cancer. HDR-BT doses included 3600 cGy in six fractions (n = 5), 2700 cGy in 2 fractions (n=1), or 2800 cGy in four fractions (n = 1). There was no acute grade ≥2 gastrointestinal toxicity, and 1 patient developed late grade 2 rectal bleeding. Two patients developed acute grade 2 genitourinary toxicity consisting of urinary frequency and urgency, which persisted through long-term follow up. At a median follow up of 29.5 months after HDR brachytherapy, one patient developed regional and distant failure, and another had seminal vesicle recurrence.

CONCLUSIONS

HDR-BT is a safe treatment for patients with prostate cancer who previously received RT for rectal cancer. Further studies are needed to better characterize the long-term toxicity of HDR-RT in this population.

Ultrasmall Gold Nanoparticles Radiolabeled with Iodine-125 as Potential New Radiopharmaceutical

The relatively high linear energy transfer of Auger electrons, which can cause clustered DNA damage and hence efficient cell death, makes Auger emitters excellent candidates for attacking metastasized tumors. Moreover, gammas or positrons are usually emitted along with the Auger electrons, providing the possibility of theragnostic applications. Despite the promising properties of Auger electrons, only a few radiopharmaceuticals employing Auger emitters have been developed so far. This is most likely explained by the short ranges of these electrons, requiring the delivery of the Auger emitters to crucial cell parts such as the cell nucleus. In this work, we combined the Auger emitter 125I and ultrasmall gold nanoparticles to prepare a novel radiopharmaceutical. The 125I labeled gold nanoparticles were shown to accumulate at the cell nucleus, leading to a high tumor-killing efficiency in both 2D and 3D tumor cell models. The results from this work indicate that ultrasmall nanoparticles, which passively accumulate at the cell nucleus, have the potential to be applied in targeted radionuclide therapy. Even better tumor-killing efficiency can be expected if tumor-targeting moieties are conjugated to the nanoparticles.

Review of brachytherapy clinical trials: a cross-sectional analysis of ClinicalTrials.gov

INTRODUCTION

Characterizing the landscape of clinical trials including brachytherapy can provide an overview of the current status and research trends which may guide further areas of investigation.

METHOD

We queried 449,849 clinical trials from the ClinicalTrials.gov registry using brachytherapy-related keywords from 1980 to 2023, yielding 245 multi-arm and 201 single-arm, brachytherapy trials. Multi-arm and single-arm brachytherapy trials were compared using 12 trial protocol elements.

RESULTS

The number of trials including brachytherapy has increased over time, with over 60% of trials registered in 2010 onwards. The majority of clinical trials were Phase 2 or 3, evaluated both safety and efficacy, and were funded by academic sponsors. The most common tumor sites evaluated in brachytherapy clinical trials include prostate, cervix, liver, endometrium, and breast.

CONCLUSION

There remains continued interest in clinical trials including brachytherapy focused on evaluation of novel delivery systems, treatment planning, and new indications. More brachytherapy clinical trials are needed to define the optimal clinical utilization and advance prospective research in this field.

The 17-Gene Genomic Prostate Score Assay Is Prognostic for Biochemical Failure in Men With Localized Prostate Cancer After Radiation Therapy at a Community Cancer Center

Purpose

The objective of this study was to assess the association between the Oncotype DX Genomic Prostate Score (GPS) assay and long-term outcomes in men with localized prostate cancer (PCa) after radiation therapy (RT). We hypothesized that the GPS assay is prognostic for biochemical failure (BCF), along with distant metastasis (DM) and PCa-specific mortality in patients with PCa receiving RT.

Methods and Materials

We retrospectively studied men with localized PCa treated with definitive RT at Georgia Urology from 2010 to 2016. The primary objective was to assess the association between GPS results and time to BCF per the Phoenix criteria; we also assessed time to DM and PCa-specific mortality. We used Cox proportional hazards regression models for all analyses, with clinicopathologic covariates determined a priori for multivariable modeling.

Results

A total of 450 patients (median age, 65 years; 35% Black) met eligibility criteria. There was a strong univariable association between GPS result and time to BCF (hazard ratio [HR] per 20-unit increase = 3.08; 95% confidence interval [CI], 2.11-4.46; P < .001), which persisted after adjusting for clinicopathologic characteristics in multivariable analyses. We also observed this association for time to DM (HR = 5.19; 95% CI, 3.06-8.77; P < .001) and PCa-specific mortality (HR = 13.07; 95% CI, 4.42-49.39; P < .001). Race was not a predictor of time to BCF or DM, and the GPS assay was strongly prognostic for all endpoints in Black and White patients.

Conclusions

In a community-based cohort, the GPS assay was strongly prognostic for time to BCF as well as long-term outcomes in men treated with RT for localized PCa.

Artificial intelligence applications in brachytherapy: A literature review

PURPOSE

Artificial intelligence (AI) has the potential to simplify and optimize various steps of the brachytherapy workflow, and this literature review aims to provide an overview of the work done in this field.

METHODS AND MATERIALS

We conducted a literature search in June 2022 on PubMed, Embase, and Cochrane for papers that proposed AI applications in brachytherapy.

RESULTS

A total of 80 papers satisfied inclusion/exclusion criteria. These papers were categorized as follows: segmentation (24), registration and image processing (6), preplanning (13), dose prediction and treatment planning (11), applicator/catheter/needle reconstruction (16), and quality assurance (10). AI techniques ranged from classical models such as support vector machines and decision tree-based learning to newer techniques such as U-Net and deep reinforcement learning, and were applied to facilitate small steps of a process (e.g., optimizing applicator selection) or even automate the entire step of the workflow (e.g., end-to-end preplanning). Many of these algorithms demonstrated human-level performance and offer significant improvements in speed.

CONCLUSIONS

AI has potential to augment, automate, and/or accelerate many steps of the brachytherapy workflow. We recommend that future studies adhere to standard reporting guidelines. We also stress the importance of using larger sample sizes and reporting results using clinically interpretable measures.

QSM Throughout the Body

Magnetic materials in tissue, such as iron, calcium, or collagen, can be studied using quantitative susceptibility mapping (QSM). To date, QSM has been overwhelmingly applied in the brain, but is increasingly utilized outside the brain. QSM relies on the effect of tissue magnetic susceptibility sources on the MR signal phase obtained with gradient echo sequence. However, in the body, the chemical shift of fat present within the region of interest contributes to the MR signal phase as well. Therefore, correcting for the chemical shift effect by means of water-fat separation is essential for body QSM. By employing techniques to compensate for cardiac and respiratory motion artifacts, body QSM has been applied to study liver iron and fibrosis, heart chamber blood and placenta oxygenation, myocardial hemorrhage, atherosclerotic plaque, cartilage, bone, prostate, breast calcification, and kidney stone.

Evaluation of dose perturbations around iodine-125 seed sources in supplemental external beam prostate radiotherapy

We investigated dose perturbations caused by 125I seeds in patients undergoing supplemental external beam radiotherapy (EBRT) for prostate cancer. We examined two types of nonradioactive seed models: model 6711 and model STM1251. All experiments were performed using a water-equivalent phantom. Radiochromic film was used to measure the dose distributions adjacent to the seeds upstream and downstream of the external beam source. Single and clusters of multiple seeds were placed in slots in a solid water (SW) slab to measure dose perturbations with separate versus dense seed placement at beam energies of 6 or 10 MV. Monte Carlo simulations (MCSs) were also performed to include the theoretical basis against film dosimetry. Distinct patterns of dose enhancement (buildup [BU]) were upstream, and dose reduction (builddown [BD]) were downstream of the radiation source. Model 6711 with lower photon beam energies produced larger dose perturbations of BU and BD than the model STM1251. The results showed the same tendency with different seed placements and beam energies. However, these differences were not observed in the rotational irradiation measurement, which replicated a clinical plan. Dose perturbations around seeds result in dose enhancement and dose reduction with varying impact depending on the photon beam energy and seed type. This has the potential to cancel out these perturbations using multiple beam direction fields.

Comparison of chronic gastrointestinal and genitourinary toxicities between brachytherapy and external beam radiotherapy for patients with prostate cancer: A systematic review and meta-analysis

BACKGROUND

125I BT is an effective radiotherapy for prostate cancer. However, comparison data of GI and GU toxicities between BT, BT + EBRT, and EBRT-alone patient groups is limited.

OBJECTIVE

To define the GI and GU toxicities in prostate cancer to prevent adverse events after treatment.

METHODS

We searched published studies in PubMed, Cochrane, and Embase databases up to December 31, 2022. The endpoints were the RRs of GI and GU toxicities. Pooled data were assessed using a random-effects model.

RESULTS

Fifteen eligible studies were included into this analysis. LDR-BT had significantly lower RRs than LDR-BT + EBRT for acute GI (2.13; 95% CI, 1.22-3.69; P= 0.007) and late GI toxicities (3.96; 95% CI, 1.23-12.70; P= 0.02). Moreover, EBRT had significantly higher RRs than LDR-BT for acute GU (2.32; 95% CI, 1.29-4.15; P= 0.005) and late GU toxicities (2.38; 95% CI, 1.27-4.44; P= 0.007). HDR-BT had significantly higher RRs for acute GU toxicities than LDR-BT alone (0.30; 95% CI, 0.23-0.40; P< 0.00001).

CONCLUSION

The results implied that BT with and without EBRT can result in both GI and GU toxicities in patients with prostate cancer, with LDR-BT leading to a poorer urinary function than EBRT.

Automatic segmentation of prostate and extracapsular structures in MRI to predict needle deflection in percutaneous prostate intervention

PURPOSE

Understanding the three-dimensional anatomy of percutaneous intervention in prostate cancer is essential to avoid complications. Recently, attempts have been made to use machine learning to automate the segmentation of functional structures such as the prostate gland, rectum, and bladder. However, a paucity of material is available to segment extracapsular structures that are known to cause needle deflection during percutaneous interventions. This research aims to explore the feasibility of the automatic segmentation of prostate and extracapsular structures to predict needle deflection.

METHODS

Using pelvic magnetic resonance imagings (MRIs), 3D U-Net was trained and optimized for the prostate and extracapsular structures (bladder, rectum, pubic bone, pelvic diaphragm muscle, bulbospongiosus muscle, bull of the penis, ischiocavernosus muscle, crus of the penis, transverse perineal muscle, obturator internus muscle, and seminal vesicle). The segmentation accuracy was validated by putting intra-procedural MRIs into the 3D U-Net to segment the prostate and extracapsular structures in the image. Then, the segmented structures were used to predict deflected needle path in in-bore MRI-guided biopsy using a model-based approach.

RESULTS

The 3D U-Net yielded Dice scores to parenchymal organs (0.61-0.83), such as prostate, bladder, rectum, bulb of the penis, crus of the penis, but lower in muscle structures (0.03-0.31), except and obturator internus muscle (0.71). The 3D U-Net showed higher Dice scores for functional structures ([Formula: see text]0.001) and complication-related structures ([Formula: see text]0.001). The segmentation of extracapsular anatomies helped to predict the deflected needle path in MRI-guided prostate interventions of the prostate with the accuracy of 0.9 to 4.9 mm.

CONCLUSION

Our segmentation method using 3D U-Net provided an accurate anatomical understanding of the prostate and extracapsular structures. In addition, our method was suitable for segmenting functional and complication-related structures. Finally, 3D images of the prostate and extracapsular structures could simulate the needle pathway to predict needle deflections.

Outcomes following brachytherapy boost for intermediate- and high-risk prostate cancer: A retrospective bicenter study by the SFRO brachytherapy group

INTRODUCTION

Radiotherapy dose escalation improves biochemical control in intermediate- or high-risk prostate cancer. Brachytherapy boost was shown to further improve biochemical control compared to radiotherapy alone in three randomized trials. The SFRO brachytherapy group sought to evaluate the efficacy and toxicity of BT-boost for intermediate and high-risk prostate cancer in real life, and to determine prognostic factors for efficacy and toxicity.

MATERIAL AND METHOD

A retrospective study was conducted, including all patients with intermediate- or high-risk prostate cancer treated with a combination of external beam radiotherapy (EBRT) and high dose-rate brachytherapy boost (HDR-BB), from 2006 until December 2019 at two centers. Patient characteristics, initial disease, treatment and follow-up were collected.

RESULTS

709 patients from two centers were analyzed given a short follow-up in the other centers. Out of those, 277 were intermediate risk (170 favorable and 107 unfavorable) and 432 were high risk. The median EBRT and HDR-BB doses were 46 Gy (35-50) and 14 Gy (10-20). After a median follow-up of 62 months, biochemical control at 5 years was 87.5 % for the overall population, 91 % and 85 % for intermediate- and high-risk cancers, respectively. At 5 years, biochemical and clinical relapse-free survival, metastasis-free survival and local control rates were 83 %, 90 % and 97 % respectively. 5-years overall survival was 94 %. Late grade 2 or higher GU or GI toxicity was found in 36 patients (5 %) and 9 patients (1.3 %).

CONCLUSION

This bicenter analysis shows the efficacy and tolerability of HDR-BB as a complement to external radiotherapy. Further improvements such as combination with new hormonal agents or new brachytherapy-radiotherapy fractionation regimens are warranted to improve further the outcomes and therapeutic ratio.

Feasibility of online adaptive HDR prostate brachytherapy: A novel treatment concept

PURPOSE

The purpose of this study was to determine the feasibility of online adaptive transrectal ultrasound (TRUS)-based high-dose-rate prostate brachytherapy (HDRPBT) through retrospective simulation of source positioning and catheter swap errors on patient treatment plans.

METHOD

Source positioning errors (catheter shifts in 1 mm increments in the cranial/caudal, anterior/posterior, and medial/lateral directions up to ±6 mm) and catheter swap errors (between the most and least heavily weighted) were introduced retrospectively into DICOM treatment plans of 20 patients that previously received TRUS HDRPBT. Dose volume histogram (DVH) indices were monitored as errors were introduced sequentially into individual catheters, simulating potential errors throughout treatment. Whenever DVH indices were outside institution thresholds: prostate V100% <95%, urethra D0.1cc >118% and rectum Dmax >80%, the plan was adapted using remaining catheters (i.e., simulating previous catheters as previously delivered). The final DVH indices were recorded.

RESULTS

Prostate coverage (V100% >95%) could be maintained for source position errors up to 6 mm through online plan adaptation. The source position error at which the urethra D0.1cc and rectum Dmax was able to return to clinically acceptable levels using online adaptation varied between 6 mm to 1 mm, depending on the direction of the source position error and patient anatomy. After introduction of catheter swap errors to patient plans, prostate V100% was recoverable using online adaptation to near original plan characteristics. Urethra D0.1cc and rectum Dmax showed less recoverability.

CONCLUSION

Online adaptive HDRPBT maintains the prostate V100% to clinically acceptable values for majority of directional shifts. However, the current online adaptive method may not correct for source position errors near organs at risk.

Does brachytherapy boost improve survival outcomes in Gleason Grade Group 5 patients treated with external beam radiotherapy and androgen deprivation therapy? A systematic review and meta-analysis

•

Adding a BT boost to external beam radiation can be used to intensify treatment.

•

BT boost improves DMFS but not PCSS or OS in Gleason GG5 prostate cancer.

•

There is no prospective data evaluating BT boost in Gleason GG5 disease.

Background

Localized Gleason Grade Group 5 (GG5) prostate cancer has a poor prognosis and is associated with a higher risk of treatment failure, metastases, and death. Treatment intensification with the addition of a brachytherapy (BT) boost to external beam radiation (EBRT) maximizes local control, which may translate into improved survival outcomes.

Methods

A systematic review and meta-analysis was performed to compare survival outcomes for Gleason GG5 patients treated with androgen deprivation therapy (ADT) and either EBRT or EBRT + BT. The MEDLINE (PubMed), EMBASE and Cochrane databases were searched to identify relevant studies. Survival probabilities for distant metastasis-free survival (DMFS), prostate cancer-specific survival (PCSS), and overall survival (OS) were extracted and pooled to create a summary survival curve for each treatment modality, which were then compared at fixed points in time. An additional analysis was performed among studies directly comparing EBRT and EBRT + BT using a random-effects model.

Results

Eight retrospective studies were selected for inclusion, representing a total of 1393 EBRT patients and 877 EBRT + BT patients. EBRT + BT was associated with higher DMFS starting at 6 years (86.8 % vs 78.8 %; p = 0.018) and extending out to 10 years (81.8 % vs 66.1 %; p < 0.001), with an overall hazard ratio of 0.53 (p = 0.02). There was no difference in PCSS or OS between treatment modalities. Differences in toxicity were not assessed. There was a wide range of heterogeneity between studies.

Conclusion

The addition of BT boost is associated with improved long-term DMFS in Gleason GG5 prostate cancer, but its impact on PCSS and OS remains unclear. These results may be confounded by the heterogeneity across study populations with concern for a risk of bias. Therefore, prospective studies are necessary to further elucidate the survival advantage associated with BT boost, which must ultimately be weighed against the toxicity-related implications of this treatment strategy.

One case of iodine-125 therapy – A new minimally invasive treatment of intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver cancer associated with a poor prognosis. ICC accounts for about 10% of primary liver malignancies but with increasing incidence in recent years. Recently, some studies suggested that minimally interventional therapy can be used in the treatment of ICC. However, there are few references on interventional therapy for the clinical treatment of ICC. Herein we reported a case of a 48-year-old man who suffered from ICC. The patient was diagnosed with ICC by computerized tomography scan and pathological biopsy. The patient was completely cured by minimally interventional therapy with iodine-125 seed implantation. These results provide an important reference for the treatment option of ICC.

Role of Brachytherapy Boost in Clinically Localized Intermediate and High-Risk Prostate Cancer: Lack of Benefit in Patients with Very High-Risk Factors T3b-4 and/or Gleason 9-10

Simple Summary

In general, brachytherapy (BT) improves biochemical control in intermediate-to high-risk prostate cancer. We previously reported that importance of very high-risk factors (VHR: T3b–4 or Gleason score 9–10) and patients with double VHR (VHR-2) showed the worst prognosis among high-risk groups. We explored the role of BT-boost in patients with VHR and compared it to intermediate- and other high-risk groups. We confirmed that BT-boost improved prostate-specific antigen (PSA) control but resulted in equivalent overall survival rates for the intermediate- and high-risk groups, except for the patients with VHR. In the VHR-1 group (single VHR), BT-boost showed superior PSA control to conventional-dose RT (EQD2 ≤ 72 Gy) but not to the dose-escalated radiotherapy group (EQD2 ≥ 74 Gy). In the VHR-2 group, BT-boost did not improve the biochemical control rate of either Conv RT or DeRT. BT-boost showed no benefit over modern DeRT in the patients with VHR.

Abstract

This study examined the role of brachytherapy boost (BT-boost) and external beam radiotherapy (EBRT) in intermediate- to high-risk prostate cancer, especially in patients with very high-risk factors (VHR: T3b–4 or Gleason score 9–10) as patients with double very high-risk factors (VHR-2: T3b–4 and Gleason score 9–10) previously showed worst prognosis in localized prostate cancer. We retrospectively reviewed multi-institutional data of 1961 patients that were administered radiotherapy (1091 BT-boost and 872 EBRT: 593 conventional-dose RT (Conv RT: equivalent to doses of 2 Gy per fraction = EQD2 ≤ 72 Gy) and 216 dose-escalating RT (DeRT = EQD2 ≥ 74 Gy). We found that BT-boost improved PSA control and provided an equivalent overall survival rate in the intermediate- and high-risk groups, except for patients within the VHR factor group. In the VHR-1 group (single VHR), BT-boost showed a superior biochemical control rate to the Conv RT group but not to the DeRT group. In the VHR-2 group, BT-boost did not improve outcomes of either Conv RT or DeRT groups. In conclusion, BT-boost showed no benefit to modern DeRT in the patients with VHR; therefore, they are not good candidates for BT-boost to improve outcome and may be amenable to clinical trials using multimodal intensified systemic treatments.

The Interactive Influence of Institutional Quality and Resource Dependence on Regional Economic Growth: Evidence from China’s Resource-Based Provinces

In China, after experiencing high resource dependence (RD) and extensive development, some regions that once had abundant resource reserves have fallen into a state of long-term economic stagnation. Therefore, an in-depth analysis of the relationship, the influencing mechanisms, and the key influencing factors between natural resources and regional economic development will help to clarify the change in and the development of China’s resource-based regions. This study takes 19 resource-based provinces in China as the research object, and it builds an analysis model that includes the regional economic growth, the RD, the institutional quality (IQ), the technological innovation (TI), and other variables, on the basis of panel data from 2000 to 2019. China’s actual research conclusions. First, there is a substantial negative correlation between RD and economic development; that is, at the current stage of economic development in the sample provinces, the resource-curse (RC) phenomenon exists, and RD has become an obstacle to economic growth. Moreover, through further research, we find that institutional relationships between quality and economic growth are not apparent, but there is a significant positive correlation between the interaction term of the IQ and RD and economic growth. Finally, TI plays an important intermediary function in the relation between RD and economic growth; high-quality TI can significantly reduce the adverse impact of RD on economic growth. The conclusions of this study help enrich the connotation of the “resource curse” theory in terms of emerging economies, and the policy implications have guiding significance for China’s ongoing “regional economic transformation and sustainable development.”

Comparison of toxicities between ultrahypofractionated radiotherapy versus brachytherapy with or without external beam radiotherapy for clinically localized prostate cancer

To compare gastrointestinal (GI) and genitourinary (GU) toxicities in patients with localized prostate cancer treated with ultrahypofractionated radiotherapy (UHF) or brachytherapy [BT; low dose rate, LDR or high dose rate (HDR) with or without external beam radiotherapy (EBRT)]. We compared 253 UHF and 1664 BT ± EBRT groups. The main outcomes were the incidence and severity of acute and late GU and GI toxicities. The secondary endpoint was biochemical control rate. Cumulative late actuarial GU toxicity did not differ for grade ≥ 2 (8.6% at 5-years in UHF and 13.3% in BT ± EBRT, hazard ratio [HR], 0.7066; 95% CI, 0.4093–1.22, p = 0.2127). Actuarial grade ≥ 2 late GI toxicity was higher in UHF (5.8% at 5-years, HR: 3.619; 95% CI, 1.774–7.383, p < 0.001) than in BT ± EBRT (1.1%). In detailed subgroup analyses, the high-dose UHF group (H-UHF) using BED ≥ 226 Gy_1.5, showed higher GI toxicity profiles than the other subgroups (HDR + EBRT, LDR + EBRT, and LDR monotherapy, and L-UHF BED < 226 Gy_1.5) with equivalent GU toxicity to other modalities. With a median follow-up period of 32 months and 75 months, the actuarial biochemical control rates were equivalent between the UHF and BT ± EBRT groups. UHF showed equivalent efficacy, higher GI and equivalent GU accumulated toxicity to BT ± EBRT, and the toxicity of UHF was largely dependent on the UHF schedule.

Implementation of High-Dose-Rate, CT-Based Prostate Brachytherapy in an Academic Teaching Hospital and Residency Training Program

Introduction Prostate brachytherapy provides the most durable local control for prostate adenocarcinoma among all radiation treatment options. However, likely due to decreased trainee familiarity with the technique and resource intensity, it has seen a decline in utilization. Here we outline our experience with starting a high-dose-rate (HDR) prostate brachytherapy program within a residency training program and present our outcome data. Methods Patients were identified and screened using clinical data and volume study for candidacy for brachytherapy implantation. Eligible candidates were implanted and subsequently had radiation planning and delivery in our clinic. Descriptive statistical analysis was performed on our outcomes and dosimetry data and presented in tabular form. Results Seventeen patients were treated for a total of 18 implants (one monotherapy). No implant was aborted. No acute urinary retention requiring catheterization or chronic urethral stricture occurred. Biochemical recurrence-free survival was 94% at a median follow-up of 28.5 months (range 8.2-50 months); the one failure occurred in a very high-risk patient at 37 months following treatment. Dosimetrically, prostate coverage, urethra sparing, and rectum sparing aims were met. Volumetric bladder aims were also met; however, the max point dose to the bladder neck was above the guideline. Conclusion Our department successfully implemented an HDR prostate brachytherapy program. Treatments were effective and there was no grade 3 toxicity to report.

Recommendations on Weight Loss and Healthy Lifestyle in Prostate Cancer Clinical Guidelines: A Systematic Review

Obesity is associated with negative prostate cancer outcomes (e.g., specific mortality, all-cause mortality, biochemical recurrence, etc.), according to the current scientific literature. Nevertheless, recommendations on weight loss and healthy lifestyles are poorly covered by clinicians. We aimed at identifying these recommendations from clinical practice guidelines (CPGs) for prostate cancer. We systematically searched MEDLINE, EMBASE, Web of Science, Scopus, guideline databases and online sources for CPGs updated from January 2015 to August 2021. The searches were independently conducted by two researchers, without language restrictions. A total of 97 prostate cancer guidelines, including 84 (86.6%) CPGs and 13 (13.4%) consensus statements, were included. Recommendations on reaching and maintaining a healthy weight or healthy lifestyles were provided by 7 (7.2%) and 13 (13.4%) documents, respectively. No differences regarding recommendations were found by type of document, year of publication or country. Our results suggest that professional societies and governments should update prostate cancer guidelines to include these recommendations for improving prostate cancer prognosis.

Conventional dose versus dose escalated radiotherapy including high-dose-rate brachytherapy boost for patients with Gleason score 9-10 clinical localized prostate cancer

As several recent researches focus on the importance of Gleason 9-10, we examine the role of radiotherapy dose escalation in those patients. We analyzed 476 patients with Gleason score 9-10 prostate cancer treated with radiotherapy. Of them, 127 patients were treated with conventional-dose external beam radiotherapy (Conv RT) and 349 patients were treated with high-dose radiotherapy (HDRT; 249 patients received high-dose-rate brachytherapy boost + external beam radiotherapy [HDR boost] and 100 patients received intensity-modulated radiotherapy [IMRT]). We compared these treatment groups using multi-institutional retrospective data. The patients had a median follow-up period of 66.3 months. HDRT showed superior biochemical disease-free survival (bDFS) rate (85.2%; HDR boost 84.7% and IMRT 86.6%) to Conv RT (71.1%, p < 0.0001) at 5 years, with a hazard ratio of 0.448. There were borderline difference in prostate cancer-specific mortality (PCSM; 4.3% and 2.75%, p = 0.0581), and distant metastasis-free survival (DMFS; 94.4% and 89.6%, p = 0.0916) rates at 5-years between Conv RT and HDRT group. Dose escalated radiotherapy showed better bDFS, borderline improvement in PCSM, and equivocal outcome in DMFS in with clinically localized Gleason 9-10 prostate cancer.

Patterns of Prostate Cancer Recurrence After Brachytherapy Determined by Prostate-Specific Membrane Antigen-Positron Emission Tomography and Computed Tomography Imaging

PURPOSE

The aim of this study was to characterize the patterns of prostate cancer recurrence after brachytherapy (BT) using 2-(3-[1-carboxy-5-([6-¹⁸F-fluoropyridine-3-carbonyl]-amino)-pentyl]-ureido)-pentanedioic acid ([¹⁸F]DCFPyL) prostate-specific membrane antigen (PSMA) positron emission tomography (PET) and computed tomography (CT) imaging.

METHODS AND MATERIALS

Patients were selected from an ongoing prospective institutional trial investigating the use of [¹⁸F]DCFPyL PSMA PET and CT in recurrent prostate cancer (NCT02899312). This report included patients who underwent BT (either monotherapy or boost) and experienced a biochemical failure (BF) defined by the Phoenix definition (prostate-specific antigen [PSA] > 2 ng/mL above nadir).

RESULTS

Between March 2017 and April 2020, 670 patients underwent [¹⁸F]DCFPyL PSMA PET and CT imaging. Of these 670 patients, 93 were treated with BT; 73 underwent monotherapy, and 20 underwent BT boost (19 low-dose rate and 1 high-dose rate). To report on patterns of recurrence outcomes, 86 patients (median prescan PSA 6.0) with a positive [¹⁸F]DCFPyL PSMA PET and CT scan and true BF were included. The most common location of relapse was local; 62.8% had a component of local failure (defined as prostate and/or seminal vesicles), and 46.5% had isolated local failure only, with no other sites of involvement. Regional failure occurred in 40.7% of patients, and 36.0% had metastatic failure. Isolated local recurrence was seen in 54.3% of monotherapy patients versus only in 12.5% of boost patients. Metastatic failure was seen in 28.6% of monotherapy patients versus 68.8% of the boost patients. Local recurrences (69.0%) were found within the same prostate biopsy sextant involved with the tumor at diagnosis, and 76.0% of patients with seminal vesicle recurrences had prostate-base involvement at diagnosis.

CONCLUSIONS

Contrary to previous evidence, our study suggests that in prostate BT patients with biochemical recurrence, the most common site of failure is local for the patients treated with monotherapy and metastatic for patients treated with a combination of external beam radiation and BT boost.

Prostate cancer brachytherapy: SFRO guidelines 2021

Prostate brachytherapy techniques are described, concerning both permanent seed implant and high dose rate brachytherapy. The following guidelines are presented: brachytherapy indications, implant procedure for permanent low dose rate implants and high dose rate with source projector, as well as dose and dose-constraints objectives, immediate postoperative management, post-treatment evaluation, and long-term follow-up.

Defining Biochemical Cure After Low Dose Rate Prostate Brachytherapy: External Validation of 4-year Prostate-specific Antigen Nadir as a Predictor of 10- and 15-year Disease-free Survival

AIMS

To externally validate a proposed biochemical definition of cure following low dose rate (LDR) brachytherapy for prostate cancer - 4-year post-implant prostate-specific antigen (PSA) ≤0.2 ng/ml - in a UK population, and report the long-term (10- and 15-year) outcomes for patients stratified by National Comprehensive Cancer Network (NCCN) risk groups, through analysis of a large, prospectively collected, single-centre database.

MATERIALS AND METHODS

All patients treated with LDR brachytherapy for prostate cancer at a single UK centre between 2001 and November 2020 (n = 1142) were eligible; 632 patients met the inclusion criteria for the analysis. The primary end point was disease-free survival (DFS), defined as freedom from clinical, radiological or PSA progression requiring androgen deprivation therapy. Four-year PSA was categorised as ≤0.2, >0.2 to ≤0.5, >0.5 to ≤1.0 and >1.0 ng/ml. Kaplan-Meier analysis to 15 years was undertaken for each group, and sensitivity and specificity of 4-year PSA as a surrogate for long-term cure were calculated. Kaplan-Meier analysis to 15 years was repeated, stratifying patients by NCCN risk groups.

RESULTS

The median cohort age was 63 years; the median follow-up was 9.1 years (range 3.5-18.7). In total, 248 patients were available for analysis at year 10, 46 at year 15. Sixty-four patients (10.1%) relapsed during the study period. The 10-year DFS for 4-year PSA categories ≤0.2, >0.2 to ≤0.5, >0.5 to ≤1.0 and >1.0 ng/ml (95% confidence intervals) were 97.5% (95.4-99.6), 89.0% (82.4-96.1), 81.5% (70.5-94.2) and 41.8% (29.7-58.9), respectively. The 10-year DFS results for NCCN low, favourable-intermediate and unfavourable-intermediate risk disease were 93.1% (89.6-96.7), 92.1% (87.6-96.9) and 75.9% (67.8-84.9), respectively.

CONCLUSIONS

Patients with 4-year PSA ≤0.2 ng/ml may be considered cured, and could be discharged to general practitioner follow-up. LDR brachytherapy is an excellent treatment option for patients with low and favourable-intermediate risk prostate cancer, but those with unfavourable-intermediate risk disease should be considered for treatment intensification strategies.

Design of the novel ThermoBrachy applicators enabling simultaneous interstitial hyperthermia and high dose rate brachytherapy

OBJECTIVE

In High Dose Rate Brachytherapy for prostate cancer there is a need for a new way of increasing cancer cell kill in combination with a stable dose to the organs at risk. In this study, we propose a novel ThermoBrachy applicator that offers the unique ability to apply interstitial hyperthermia while simultaneously serving as an afterloading catheter for high dose rate brachytherapy for prostate cancer. This approach achieves a higher thermal enhancement ratio than in sequential application of radiation and hyperthermia and has the potential to decrease the overall treatment time.

METHODS

The new applicator uses the principle of capacitively coupled electrodes. We performed a proof of concept experiment to demostrate the feasibility of the proposed applicator. Moreover, we used electromagnetic and thermal simulations to evaluate the power needs and temperature homogeneity in different tissues. Furthermore we investigated whether dynamic phase and amplitude adaptation can be used to improve longitudinal temperature control.

RESULTS

Simulations demonstrate that the electrodes achieve good temperature homogeneity in a homogenous phantom when following current applicator spacing guidelines. Furthermore, we demonstrate that by dynamic phase and amplitude adaptation provides a great advancement for further adaptability of the heating pattern.

CONCLUSIONS

This newly designed ThermoBrachy applicator has the potential to revise the interest in interstitial thermobrachytherapy, since the simultaneous application of radiation and hyperthermia enables maximum thermal enhancement and at maximum efficiency for patient and organization.

Radioactive Iodine-125 in Tumor Therapy: Advances and Future Directions

Radioactive iodine-125 (I-125) is the most widely used radioactive sealed source for interstitial permanent brachytherapy (BT). BT has the exceptional ability to deliver extremely high doses that external beam radiotherapy (EBRT) could never achieve within treated lesions, with the added benefit that doses drop off rapidly outside the target lesion by minimizing the exposure of uninvolved surrounding normal tissue. Spurred by multiple biological and technological advances, BT application has experienced substantial alteration over the past few decades. The procedure of I-125 radioactive seed implantation evolved from ultrasound guidance to computed tomography guidance. Compellingly, the creative introduction of 3D-printed individual templates, BT treatment planning systems, and artificial intelligence navigator systems remarkably increased the accuracy of I-125 BT and individualized I-125 ablative radiotherapy. Of note, utilizing I-125 to treat carcinoma in hollow cavity organs was enabled by the utility of self-expandable metal stents (SEMSs). Initially, I-125 BT was only used in the treatment of rare tumors. However, an increasing number of clinical trials upheld the efficacy and safety of I-125 BT in almost all tumors. Therefore, this study aims to summarize the recent advances of I-125 BT in cancer therapy, which cover experimental research to clinical investigations, including the development of novel techniques. This review also raises unanswered questions that may prompt future clinical trials and experimental work.

Gantry-Based 5-Fraction Elective Nodal Irradiation in Unfavorable-Risk Prostate Cancer: Outcomes From 2 Prospective Studies Comparing SABR Boost With MR Dose-Painted HDR Brachytherapy Boost

PURPOSE

Guidelines from the American Society of Clinical Oncology and Cancer Care Ontario recommend brachytherapy boost for patients with intermediate-risk or high-risk prostate cancer. SABR is an emerging technique for prostate cancer, but its use in high-risk disease is limited. Efficacy, toxic effects, and quality of life (QoL) were compared in patients treated on 2 prospective protocols that used SABR boost or magnetic resonance-guided high-dose-rate brachytherapy (HDR-BT) boost with 6 to 18 months of androgen deprivation therapy (ADT).

METHODS AND MATERIALS

In SATURN study (study 1), patients received 40 Gy to the prostate and 25 Gy to the pelvis in 5 weekly fractions. In SPARE (study 2), patients received HDR-BT (15 Gy × 1) to the prostate and ≤22.5 Gy to the magnetic resonance imaging nodule, followed by 25 Gy in 5 weekly fractions to the pelvis. All patients received between 6 and 18 months of ADT.

RESULTS

Thirty patients (7% unfavorable intermediate risk and 93% high risk, per National Comprehensive Cancer Network [NCCN] criteria) completed study 1, and 31 patients (3% favorable intermediate risk, 47% unfavorable intermediate risk, and 50% high risk) completed treatment as per study 2. The median follow-up times were 72 and 62 months, respectively. In study 2, 6 patients had biochemical failure, and all 6 developed metastatic disease. Actuarial 5-year biochemical failure was 0% for study 1 and 18.2% for study 2 (P = .005). There was no significant difference in the worst acute or late gastrointestinal or genitourinary toxicity. Grade 3 late genitourinary toxicity was noted in 3% of the patients in study 2 (HDR-BT boost). There was either no significant difference or minimal clinically important change in QoL.

CONCLUSIONS

In the context of 5-fraction pelvic radiation therapy and ADT, there did not appear to be a significant difference in toxicity or QoL between SABR and HDR-BT boost. Although efficacy favored the SABR boost cohort, this should be viewed in the context of limitations and biases associated with comparing 2 sequential phase 2 studies.

Eligibility criteria according to EAU/ESTRO/SIOG guidelines for exclusive iodine-125 brachytherapy for intermediate-risk prostate adenocarcinoma patients: impact on relapse-free survival

Purpose

Iodine-125 (¹²⁵I) brachytherapy (BT) alone for intermediate-risk (IR) prostate adenocarcinoma (PCA) is controversial. The purpose of the study was to investigate potential predictive factors in selected IR-PCA patients treated with BT.

Material and methods

Among 547 patients treated with ¹²⁵I BT between 2003 and 2013, 149 IR-PCA cases were selected according to NCCN classification after an additional exclusion of patients with prostate specific antigen (PSA) > 15 ng/ml and ISUP group 3. A relapse was defined as a biochemical failure, using ASTRO Phoenix definition, or a relapse identified on imaging. Survival curves were estimated with Kaplan-Meier method. Potential prognostic variables including EAU/ESTRO/SIOG guidelines eligibility criteria were analyzed using univariate and Cox’s proportional hazards regression analysis.

Results

Of the 149 IR patients, 112 were classified as favorable, with 69 cases eligible to BT according to EAU/ESTRO/SIOG guidelines, and 37 patients were identified as unfavorable as per NCCN. Androgen deprivation therapy (ADT) was applied in 6 patients only. Percentage of positive biopsy cores were ≤ 33% and ≥ 50% for 119 and 11 patients, respectively. With a median follow-up of 8.5 years, 30 patients experienced a relapse. 10-year overall survival, progression-free survival (PFS), and relapse-free survival (RFS) were 84% (95% CI: 75-90%), 66% (95% CI: 56-75%), and 77% (95% CI: 67-84%), respectively. Failure to meet EAU/ESTRO/SIOG criteria was significantly associated with a lower RFS (p = 0.0267, HR = 2.37 [95% CI: 1.10-5.08%]).

Conclusions

Brachytherapy is an effective treatment for selected IR-PCA cases. Patients who were not eligible according to EAU/ESTRO/SIOG guidelines demonstrated a lower RFS.

Treatment Strategies for High-Risk Localized and Locally Advanced and Oligometastatic Prostate Cancer

Simple Summary

The definitions of locally advanced and oligometastatic prostate cancer are ambiguous, and there are no standard treatments for these. Although multidisciplinary treatment combining systemic and local treatment may be effective, there are many unresolved issues such as the choice of local treatment, use of new endocrine agents and chemotherapy, and selection of optimal patients. The present article discusses the definitions, diagnoses, and treatment of very high-risk prostate cancer and oligometastatic prostate cancer.

Abstract

Despite the significant advances in the treatment of high-risk prostate cancer, patients with very high-risk features such as being locally advanced (clinical stage T3–4 or minimal nodal involvement), having a high Gleason pattern, or with oligometastasis may still have a poor prognosis despite aggressive treatment. Multidisciplinary treatment with both local and systemic therapies is thought to be effective, however, unfortunately, there is still no standard treatment. However, in recent years, local definitive therapy using a combination of radiotherapy and androgen deprivation is being supported by several randomized clinical trials. This study reviews the current literature with a focus on the definition of very high-risk prostate cancer, the role of modern imaging, and its treatment options.

Comparison of Three Groups of Patients Having Low Dose Rate Prostate Brachytherapy: Prostate-Specific Antigen Failure and Overall Survival

Purpose To examine dosimetric and clinical outcomes for Cs-131 radioactive seed implant compared to Pd-103 and I-125.  Background/Significance Cs-131 is a novel isotope with relatively short half-life (9.7 days) that may have clinical advantages in seed implant treatments of prostate cancers. There may be a shorter duration of symptoms and increased PSA control rates. Methods We performed a retrospective study in which clinical and dosimetric outcomes were compared for 186 prostate implants performed over a ten-year time period at three different Ascension hospitals. Isotopes that were used included Cs-131 (n=66; half-life 9.7 days), I-125 (n=60; half-life 60 days), and Pd-103 (n=60; half-life 17 days) Results The implants used standard radiation dosages. These were 145 Gy for I-125 alone or 109 Gy when combined with external beam radiation. In the case of Cs-131 used alone, the dose was 115 Gy or 85 Gy when combined with an external beam. For Pd-103, 125 Gy was used for monotherapy and 90 Gy when combined with an external beam. The Cs-131 dosimetry was found to be similar to I-125 and Pd-103 on a quantitative basis. However, there was better homogeneity, and the delivered activity per seed and the number of seeds employed were greater compared to other isotopes. We compared the corrected total source strengths (i.e. normalized to sample mean values) and were able to demonstrate similar distributions for the three isotopes. Dosimetric analysis also suggested there was superior homogeneity with Cs-131. The median PSA value at 60 months was 0.11 ng/ml. There were only a few PSA failures in the three groups of cases, nonetheless, the Cs-131 had the fewest.  Conclusions One attractive option for men with early-stage prostate cancer is interstitial brachytherapy. The use of the shorter-acting Cs-131 isotope may be expected to have dose-related side effects that resolve more rapidly. This series suggests a trend for improved PSA control outcomes for Cs-131 patients compared with I-125 and Pd-103.

Utilization of brachytherapy in Quebec, Canada

BACKGROUND AND PURPOSE

Despite the excellent clinical outcomes from brachytherapy treatments compared with other modalities and the low associated costs, there have been reports of a decline in utilization of brachytherapy. The aim of this study was to investigate in detail the trend in utilization of brachytherapy in the province of Québec, Canada, from 2011 to 2019.

MATERIALS AND METHODS

All radiotherapy clinics in the province of Quebec, and among these the clinics that provide brachytherapy treatments, were identified. This observational retrospective cohort study involved analysis of data compiled by the Ministère de la Santé et des Services Sociaux du Québec for the period of 2011 to end of 2019 on all brachytherapy procedures performed in the province of Quebec. Time series graphs were used to describe the number of high dose rate (HDR) and low dose rate (LDR) brachytherapy treatments during the studied time period. Statistical analysis was conducted using R statistical software.

RESULTS

Between 2011 and 2019, 12 hospitals in the province of Québec provided radiotherapy treatments, and all of them offered brachytherapy services. The median annual number of brachytherapy sessions was 4413 (range 3930-4829). HDR brachytherapy represented over 90% of all brachytherapy treatments throughout the study period. Significant changes over time were observed in the number of treatments: at least 5% change was seen only for the two most common subtypes of brachytherapy, HDR interstitial and HDR intracavitary, with an increase of 9.6% and a decrease of 9.2%, respectively. The use of other subtypes of brachytherapy (HDR-plesiotherapy, LDR-interstitial, LDR-intracavitary, LDR-eye plaque) was stable between 2011 and 2019, with ≤ 2.5% variation.

CONCLUSION

This study demonstrates an overall steady use of brachytherapy between 2011 and 2019 in Quebec. Brachytherapy offers numerous advantages for the treatment of diverse cancer sites. Although more sophisticated external beam radiotherapy treatments have emerged in the last decades, the precision and cost-effectiveness of brachytherapy remain unbeaten. To ensure the continued use and availability of brachytherapy, governments must put in place policies and regulations to that effect. Training and exposure of future health care professionals to brachytherapy within Quebec and Canada is essential to provide all patients the same access to this life saving modality.

Stereotactic Ablative Brachytherapy: Recent Advances in Optimization of Radiobiological Cancer Therapy

Brachytherapy (BT), a type of focal anti-cancer radiotherapy, delivers a highly focused radiation dose to localized tumors, sparing surrounding normal tissues. Recent technological advances have helped to increase the accuracy of BT and, thus, improve BT-based cancer treatment. Stereotactic ablative brachytherapy (SABT) was designed to improve the ablative effect of radiation, which was achieved via improved image guidance, and calculation of ablative dose, shorter treatment duration, and better organ preservation. Recently collected data characterized SABT as having the potential to cure various early-stage cancers. The method provides higher tumor control rate levels that were previously achievable only by surgical resection. Notably, SABT is suitable for application with unresectable malignancies. However, the pathological assessment of SABT irradiated tumors is limited due to difficulties in specimen acquisition. Prostate, lung, liver, and gynecological cancers are the most commonly reported SABT-treated malignancies. This study will give an overview of SABT, focusing on the advances in SABT optimization, and provide insights on the future benefits of the combined application of SABT with cancer immunotherapies.

Novel Prognostic Index of High-Risk Prostate Cancer Using Simple Summation of Very High-Risk Factors

This study aimed to examine the role of very high-risk (VHR) factors (T3b-4 and Gleason score 9-10) for prognosis of clinically localized high-risk prostate cancer. We reviewed multi-institutional retrospective data of 1413 patients treated with radiotherapy (558 patients treated with external beam radiotherapy (EBRT) and 855 patients treated with brachytherapy (BT) ± EBRT. We introduced an index by simple summation of the number of VHR factors-VHR-0, VHR-1, and VHR-2. With median follow-up of 69.6 months, the 5-year biochemical disease free survival rate (bDFS), prostate cancer-specific mortality (PCSM), and distant metastasis-free survival (DMSF) rates were 59.4%, 7.65%, and 83.2% for the VHR-2 group, respectively; 86.7%, 1.50%, and 95.4% for the VHR-1 group, respectively; and 93.1%, 0.12%, and 98.2% for the VHR-0 group, respectively. The VHR-2 group had significantly worse bDFS, PCSM, and DMSF than the VHR-0 (hazard ratios: 4.55, 9.607, and 7.904, respectively) and VHR-1 (hazard ratios: 1.723, 2.391, and 1.491, respectively) groups. The VHR-2 group could be identified as a super high-risk group compared with other groups, and could be a good candidate for clinical trials using multimodal intensified treatments. Simple summation of the number of VHR factors is an easy and useful predictive index for bDFS, PCSM, and DMSF.

A review of the research progress of interventional medical equipment and methods for prostate cancer

BACKGROUND

Prostate cancer is a common disease in men and has a relatively high mortality rate. However, the interventional medical equipment used for prostate biopsy and brachytherapy has always been a social concern.

METHODS

To understand interventional medical equipment for prostate cancer, the structure of manual, semi-automatic and automatic medical equipment were considered as the mainline, while the corresponding research on these structures were the auxiliary lines. The characteristics and corresponding research status have been discussed.

RESULTS

Interventional medical equipment for prostate cancer with different degrees of automation and its characteristics were determined, and the imaging principles and characteristics of computed tomography, transrectal ultrasound and magnetic resonance imaging have been briefly described.

CONCLUSION

Certain feasible research suggestions have been proposed for future development from the perspective of structure, accuracy and safety. These include flexible and compact robot structures, high-precision image recognition and guidance, accurate dose planning and monitoring, real-time imaging monitoring without delay, high-precision needle insertion strategy, master-slave control, virtual reality and remote control.

PSA outcomes and late toxicity of single-fraction HDR brachytherapy and LDR brachytherapy as monotherapy in localized prostate cancer: A phase 2 randomized pilot study

PURPOSE

To evaluate the PSA outcomes and the late patient's reported health related quality of life (HRQOL) and toxicity after single-fraction High-Dose-Rate brachytherapy (HDRB) and Low-Dose-Rate brachytherapy (LDRB) for prostate cancer.

METHODS

Men with low and favorable intermediate-risk prostate cancer across 3 centres were randomized between monotherapy brachytherapy with either Iodine-125 LDRB or 19 Gy single-fraction HDRB. Biochemical outcomes were evaluated using the Phoenix definition, PSA nadir and absolute PSA value <0.4 ng/mL. Toxicities and HRQOL were recorded at 24 and 36 months.

RESULTS

A total of 31 patients were randomized, 15 in the LDRB arm and 16 patients in the HDRB arm. After a median follow-up of 45(36-53) months, 3 patients in the HDRB arm experienced biochemical failure (p = 0.092). Nineteen Gy single-fraction HDRB was associated with significantly higher PSA nadir compared to LDRB (1.02 ± 0.66vs 0.25 ± 0.39, p < 0.0001). Moreover, a significantly larger proportion of patients in the LDRB group had a PSA <0.4 ng/mL (13/15 vs 2/16, p < 0.0001). For late Genito-Urinary, Gastro-Intestinal, and sexual toxicities at 24 and 36 months, no significant differences were found between the 2 arms. As for HRQOL, the IPSS and EPIC-26 urinary irritative score were significantly better for patients treated with HDRB over the first 36 months post-treatment (p = 0.001 and p = 0.01, respectively), reflecting superior HRQOL.

CONCLUSION

HDRB resulted in superior HRQOL in the irritative urinary domain compared to LDRB. PSA nadir was significantly lower in the LDRB group and a higher proportion of patients in the LDRB group reached PSA <0.4 ng/mL.

Integration of functional imaging in brachytherapy

Functional imaging allows the evaluation of numerous biological properties that could be considered at all steps of the therapeutic management of patients treated with brachytherapy. Indeed, it enables better initial staging of the disease, and some parameters may also be used as predictive biomarkers for treatment response, allowing better selection of patients eligible for brachytherapy. It may also improve the definition of target volumes with the aim of dose escalations by dose-painting. Finally, it could be useful during the follow-up to assess response to treatment. In this review, we report how functional imaging is integrated at the present time during the brachytherapy procedure, and what are its potential future contributions in the main tumour locations where brachytherapy is recommended. Functional imaging has great potential in the contact of brachytherapy, but still, several issues remain to be resolved before integrating it into clinical practice, especially as a biomarker or in dose painting strategies.

Stereotactic pelvic radiotherapy with HDR boost for dose escalation in intermediate and high-risk prostate cancer (SPARE): Efficacy, toxicity and quality of life

BACKGROUND

The ASCO/CCO guidelines recommend brachytherapy (BT) boost for eligible intermediate- (IR) or high-risk (HR) prostate cancer (PCa) patients. We present efficacy, toxicity and quality-of-life (QoL) outcomes in patients treated on a prospective protocol of MRI dose-painted high-dose-rate BT boost (HDR-BT) followed by 5-fraction pelvic radiotherapy (RT) and 6-18 months of androgen deprivation therapy (ADT).

METHODS

In this phase I/II study, IR or HR PCa patients received HDR-BT 15 Gy × 1 to prostate and up to 22.5 Gy to MRI nodule, followed by 25 Gy in 5, weekly fractions to pelvis. Toxicity was assessed using CTCAEv3.0, and QoL was captured using EPIC questionnaire. Biochemical failure (BF; nadir + 2.0), and proportion of patients with PSA < 0.4 ng/ml at 4-years (4yPSARR) were evaluated. A minimally clinically important change (MCIC) was recorded if QoL score decreased >0.5 standard deviation of baseline scores.

RESULTS

Thirty-one patients (NCCN 3.2% favorable IR, 48.4% unfavorable IR and 48.4% HR) completed treatment with a median follow-up of 61 months. Median D90 to MR nodule was 19.0 Gy and median prostate V100% was 96.5%. The actuarial 5-year BF rate was 18.2%, and the 4yPSARR was 71%. One patient died of PCa. Acute grade 2 and 3 toxicities: GU: 50%, 7%, and GI: 3%, none, respectively. Late grade 2 and 3 toxicities were: GU: 23%, 3%, and GI: 7%, none, respectively. Proportion of patients with MCIC was 7.7% for urinary domain and 32.0% for bowel domain.

CONCLUSIONS

This novel treatment protocol incorporating MRI dose-painted HDR-BT boost and 5-fraction pelvic RT with ADT is well tolerated.

Low-/high-dose-rate brachytherapy boost in patients with intermediate-risk prostate cancer treated with radiotherapy: long-term results from a single institution team experience

Purpose

To compare brachytherapy (BT) boost of low-dose-rate (LDR) and high-dose-rate (HDR) techniques in patients diagnosed with intermediate-risk prostate cancer.

Material and methods

Between January 2005 and February 2018, 142 patients (50 LDR and 92 HDR) with intermediate-risk prostate cancer were treated with a BT boost, and retrospectively analyzed. Prescribed dose was 45 Gy with external beam radiotherapy (EBRT) plus 100-108 Gy with LDR-BT, and 60 Gy with EBRT plus one fraction of 10 Gy with HDR-BT. 99% of patients received androgen deprivation therapy (ADT) for 6 months. Primary endpoint was to compare LDR and HDR boosts in terms of biochemical progression-free survival (bPFS). Secondary endpoint, after re-classifying patients into "favorable" and "unfavorable" sub-groups, was to analyze differences with a similar treatment intensity.

Results

Median overall follow-up for the total cohort was 66.5 months (range, 16-185 months). There were no significant differences in bPFS, overall survival, cause specific survival, local failure, lymph node failure, or distant failure when LDR or HDR was employed. bPFS at 90 months was 100% for favorable, and 89% and 85% for unfavorable patients at 60 months and 90 months, respectively (log-rank test, p = 0.017). The crude incidence of genitourinary acute and chronic toxicity grade 3 was 0.7% and 4%, respectively. Twelve patients (8%) had chronic rectal hemorrhage grade 2, in whom argon was applied (4 LDR and 8 HDR).

Conclusions

Combined treatment is an excellent therapeutic option in patients with intermediate-risk prostate carcinoma, with similar results in both LDR and HDR approaches and very low toxicities. Importantly, the current literature has indicated that unfavorable-risk patients belong to a different category, and should be treated as patients with high-risk factors. Therefore, the stratification and identification of both risk groups is extremely relevant.

Radiotherapy for Clinically Localized T3b or T4 Very-High-Risk Prostate Cancer-Role of Dose Escalation Using High-Dose-Rate Brachytherapy Boost or High Dose Intensity Modulated Radiotherapy

Simple Summary

Recently, high-risk prostate cancer was subdivided to a very-high-risk group considered to have the worst prognosis, including clinical stage T3b–T4, primary Gleason pattern 5, or more than four biopsy cores with Gleason score 8–10. Among these, T3b–T4 stage is a special interest in radiotherapy because of their wider target volume outside the prostate. We examined this subgroup and found that dose escalation in radiotherapy both with brachytherapy or intensity modulated radiotherapy (IMRT) improved biochemical free survival rate but not in prostate cancer specific survival rate and overall survival rate.

Abstract

To examine the efficacy of dose escalating radiotherapy into patients with cT3b or T4 localized prostate cancer, we compared Group A (86 conventional dose external beam radiotherapy: EBRT group, treated with 70–72 Gy) and group B (39 high dose EBRT group (HDEBRT group, 74–80 Gy) and 124 high-dose-rate brachytherapy (HDR) + EBRT (HDR boost)) using multi-institutional retrospective data. The actuarial 5-year biochemical disease-free survival (bDFS) rate, prostate cancer specific survival rate (PSS), and overall survival rate (OS) were 75.8%, 96.8%, and 93.5%. Group B showed superior 5-year bDFS rate (81.2%) as compared to the group A (66.5%) (p < 0.0001) with a hazard ratio of 0.397. Equivocal 5-year PSS (98.3% and 94.8% in group B and group A) and OS (both 93.7%) were found between those groups. Accumulated late grade ≥ 2 toxicities in gastrointestinal and genitourinary tracts were similar among those three groups. Therefore, both HDEBRT and HDR boost could be good options for improving the bDFS rate in cT3–T4 localized prostate cancer without affecting PSS and OS.

High-dose-rate brachytherapy with external beam radiotherapy versus low-dose-rate brachytherapy with or without external beam radiotherapy for clinically localized prostate cancer

To compare the outcomes of localized prostate cancer treatment with high-dose-rate brachytherapy (HDR-BT) and low-dose-rate brachytherapy (LDR-BT), we examined 924 patients treated with HDR-BT + external beam radiotherapy (EBRT) and 500 patients treated with LDR-BT ± EBRT using multi-institutional retrospective data. The HDR-BT treated advanced disease with more hormonal therapy than LDR-BT. To reduce background selection bias, we performed inverse probability of treatment weighting (IPTW) analysis using propensity scores and excluded patients with T3b-4 disease/ initial prostate-specific antigen (PSA) levels > 50 ng/ml. The actuarial 5-year biochemical control rates (5y-bNED) were 96.3% and 95.7% in the HDR-BT and LDR-BT groups, respectively. The corresponding values were 100% and 96.5% in the low-risk group; 97.4% and 97.1% in the intermediate-risk group (97.2% and 97% in the higher titer group and 97.5% and 94.6% in the lower titer group, respectively); and 95.7% and 94.9% in the selected high-risk group, respectively. IPTW correction indicated no significant difference among the groups. The 5y-bNED in the HDR-BT + EBRT, LDR-BT + EBRT, and LDR-BT alone groups were 96.3%, 95.5%, and 97%, respectively (P = 0.3011). The corresponding values were 97.4%, 94.7%, and 96.6% (P = 0.1004) in the intermediate-risk group (97.5%, 100%, and 94.5% in the lower titer group [P = 0.122] and 97.2%, 96.2%, and 100% [P = 0.664] in the higher titer group, respectively) and 95.7%, 95.5%, and 100% (P = 0.859) in the high-risk group, respectively. The HDR-BT group showed a lower incidence of acute grade ≥ 2 genitourinary toxicities; the incidence of other early and late grade ≥ 2 toxicities were similar between the HDR-BT and LDR-BT groups. Acute genitourinary toxicity predicted the occurrence of late genitourinary toxicity. EBRT increased the risk of grade ≥ 2 gastrointestinal toxicity. HDR-BT + EBRT is a good alternative to LDR-BT ± EBRT for low-, intermediate-, and selected high-risk patients.