High-dose-rate brachytherapy for large prostate volumes (≥50 cc)—Uncompromised dosimetric coverage and acceptable toxicity

doi:10.1016/j.brachy.2007.10.005

Brachytherapy

Volume 7, Issue 1, January–March 2008, Pages 7-11

https://doi.org/10.1016/j.brachy.2007.10.005 Get rights and content

Abstract

Purpose

The purpose of this study was to review our single-institution experience using high-dose-rate (HDR) brachytherapy in patients with large-volume prostate glands (≥50 cc).

Methods and materials

Fifty-four patients treated with HDR brachytherapy for prostate cancer at the Penrose Cancer Center between 2001 and 2006 were identified as having an ultrasound volume of at least 50 cc at the time of implant (range, 50–97.3 cc; mean, 61.5 cc; median, 57 cc; upper quartile, 83.3–97.3 cc). Neoadjuvant hormones (17 patients) were not routinely recommended unless the initial ultrasound volume suggested pubic arch interference or the patient's Gleason score or prostate specific antigen prompted use. All patients received HDR brachytherapy as a boost before or after conformal external beam radiation therapy to 4500 cGy. Boost brachytherapy doses ranged from 1600 to 1900 cGy, given in two to three fractions.

Results

The median D₉₀ (minimal dose to 90% of the prostate) was 109% of prescription dose (range, 95–115%) and the median V₁₀₀ (volume receiving 100% of the dose) was 96% (range, 90–99%). V₁₅₀ ranged from 10% to 35%, with a median value of 18.3%. Six patients (11%) required temporary placement of a urinary catheter for acute obstructive symptoms after brachytherapy. With a median followup of 1.8 years, there has been a single case of Grade 2 gastrointestinal toxicity and 1 patient has developed a bulbo-urethral stricture requiring dilation. There have been no cases of rectal bleeding.

Conclusions

Large prostate volume is not a contraindication to HDR brachytherapy. Excellent dosimetric coverage can be attained with acceptable acute toxicity.

Section snippets

Purpose

Low-dose-rate (LDR) brachytherapy with permanent radioactive seeds has become a standard treatment for localized prostate cancer over the past decade. Historically, patients with large-volume glands (>50–60 cc) have been considered suboptimal candidates for LDR brachytherapy. It has been shown that prostate volume correlates directly with the ability to perform an adequate permanent seed implant [1], [2], [3], post-treatment urinary symptoms [4], [5], [6], [7], [8], and pubic arch interference

Patient selection

The records of 315 patients treated with HDR brachytherapy for clinically localized prostate cancer at the Penrose Cancer Center between 2001 and 2006 were retrospectively reviewed under institutional review board approval. From the entire cohort of eligible patients, 54 were identified as having a preimplant ultrasound volume of at least 50 cc (range, 50–97.3 cc; mean, 61.5 cc; median, 57 cc; upper quartile, 83.3–97.3 cc). Neoadjuvant hormones (17 of 54 patients) were not routinely recommended

Results

Table 1 summarizes pretreatment clinical characteristics of the 54 eligible patients.

All dosimetric goals were adequately achieved. The median D₉₀ (minimal dose to 90% of the prostate) was 109% of prescription dose (range, 95–115%). The median V₁₀₀ (volume receiving 100% of the prescribed dose) was 96% (range, 90–99). V₁₅₀ ranged from 10% to 35%, with a median value of 18.3%. The median dose to the maximally irradiated 5% of rectum and bladder was 56% and 49% of the implant dose, respectively.

Discussion

Performing permanent LDR prostate brachytherapy on large-volume glands is fraught with difficulties, ranging from inadequate coverage to excessive toxicity. Conventional wisdom previously held that glands >50–60 cc may be better treated with surgery or external beam radiation, though this notion may be challenged with modern LDR techniques. This study supports the notion that HDR brachytherapy may be a reasonable option for patients with large glands.

The primary goal of this study was to show

Conclusions

Large prostate volume is not a contraindication to HDR brachytherapy. Excellent dosimetric coverage can be attained with acceptable acute toxicity.

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Cited by (22)

Does prostate volume has an impact on biochemical failure in patients with localized prostate cancer treated with HDR boost?
2016, Radiotherapy and Oncology
Citation Excerpt :
In this paper, we have presented the results of the largest known study on the impact of prostate volume on clinical outcome and toxicity in prostate cancer patients treated with HDR boost. Our results concur with the smaller studies of Monroe et al. (N=54) and Le et al. (N = 164) and show that HDR boost treatment in patients with lager prostate volume (⩾60 cc) does not increase risk of biochemical failure and acute and late GU and GI toxicities [10,15]. Similarly to the Le et al. study, we compared PSA failure and GU and GI toxicities of the larger glands group with a cohort of patient with smaller glands treated during the same period.
To compare biochemical failure free survival (BFFS) of patients with small and large prostate glands treated with external beam radiation therapy (EBRT) and HDR (high dose rate) brachytherapy boost.
Between 2002 and 2012, 548 patients were treated with EBRT followed by HDR boost. The effect of covariates and prostate volume on biochemical failure was analyzed by survival analysis and Cox regression model.
The median follow-up and age were not different between the two groups. The mean prostate gland volume at the time of CT planning was 48.1 and 76.0 cc in small (<60 cc) and large (⩾ 60 cc) prostate volume, respectively (p < 0.001). When PSA bounces were excluded, there was no significant difference between the two groups with a 5-years BFFS of 95.8% vs 92.3%, p = 0.094. There were no significant differences between the two groups for urinary symptoms (IPSS) as well as acute and late GI toxicities.
This study showed that a HDR brachytherapy boost in large prostate gland cases is feasible at the price of increased PSA bounces. When the benign bounces are excluded, there is no significant difference between the two groups for tumor control and toxicity. Therefore, in our experience, there is no rational precluding the use of HDR boost in patients with a prostate size of 60 cc or more so long as an adequate dosimetry is achievable.
High dose rate brachytherapy for prostate cancer: Standard of care and future direction
2016, Cancer/Radiotherapie
High dose rate brachytherapy is a highly conformal method of radiation dose escalation for prostate cancer and one of several treatment options for men with localised disease. The large doses per fraction exploit the low alpha/beta ratio of prostate cancer cells so that biological radiation dose delivered is substantially greater than that achieved with conventional external beam delivery. This review article presents contemporary data on the rationale for high dose rate brachytherapy including treatment technique and future directions.
La curiethérapie de haut débit de dose est une technique d’irradiation de haute précision autorisant, grâce à une grande conformité des volumes traités, une escalade de dose. Elle constitue désormais un standard de la prise en charge des patients atteints de cancer localisé de la prostate. Les hautes doses délivrées par fraction permettent d’exploiter le rapport alpha/bêta bas de l’adénocarcinome prostatique et d’obtenir des doses biologiques significativement supérieures à ce qui est réalisable avec des techniques d’irradiation externe. Cette mise au point a pour but de faire le point sur les connaissances actuelles du rationnel de la curiethérapie de haut débit de dose dans les cancers de prostate, les techniques disponibles, et perspectives de développement.
Dose-volume analysis and the temporal nature of toxicity with stereotactic body radiation therapy for prostate cancer
2015, Practical Radiation Oncology
The purpose of this study was to evaluate the dose-volume relationships of genitourinary toxicity after stereotactic body radiation therapy (SBRT) monotherapy for prostate cancer.
Fifty-six patients diagnosed with low- to intermediate-risk prostate cancer treated with SBRT alone were reviewed retrospectively. All patients received a total dose of 38 Gy in 4 fractions with a planning target volume expansion of 2 mm. Overall, acute, and late genitourinary toxicity were documented according to the Common Terminology Criteria for Adverse Events (version 4) and International Prostate Symptom Scores (IPSS).
The median age at treatment was 68 years, and the median prostate volume was 45.5 mL, with a median baseline IPSS of 9.95. The median prescription isodose line was 68%. The median clinical follow-up was 35.49 months. Acute grade 1, 2, and 3 genitourinary toxicities occurred in 41.1%, 35.7%, and 0% of patients. All acute genitourinary toxicities resolved except 1 patient with grade 2 toxicity that progressed to grade 3 late toxicity. No dose-volume relationships were associated with acute genitourinary grade 2 + toxicity. Late grade 1, 2, and 3 genitourinary toxicity occurred in 19.6%, 19.6%, and 3.6% of cases, respectively. Of the cases with late toxicities, 16.7% were persistent. Late grade 2 + genitourinary toxicity was associated with prostate volume ≥ 50 mL, lower homogeneity index, and urethral maximum point dose ≥ 47 Gy. The overall risk of any grade 2 + genitourinary toxicity was associated with baseline IPSS > 7, prostate volume ≥ 50 mL, urethral volume receiving 44 Gy, and bladder volume receiving 19 Gy.
SBRT for prostate cancer appears well tolerated, with mostly transient low-grade toxicity. Urethral sparing should be used with a maximum point dose < 47 Gy, volume receiving 120 Gy < 50% of the prostate, and bladder volume receiving 19 Gy < 15 mL in 4 fraction treatments. Patients with prostate volumes ≥ 50 mL should be counseled regarding the increased risk of moderate-grade genitourinary toxicity.
Brachytherapy
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High-dose-rate brachytherapy as monotherapy for prostate cancer
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To review and analyze the published data on high-dose-rate brachytherapy as monotherapy in the treatment of prostate cancer.
A literature search and a systematic review of the high-dose-rate (HDR) brachytherapy (monotherapy) prostate literature were performed on PubMed using “high-dose-rate, brachytherapy, prostate, monotherapy” as search terms. More than 80 articles and abstracts published between 1990 and 2013 were identified. Data tables were generated and summary descriptions created. Commentary and opinion was formulated through discussion and consensus based on the critical review of the literature and the author's combined personal experience and knowledge.
Thirteen articles reported clinical outcome and toxicity with followup ranging from 1.5 to 8.0 years. Results were available for all risk groups. A variety of dose and fractionation schedules were described. Prostate-specific antigen progression–free survival ranged from 79% to 100% and local control from 97% to 100%. The toxicity rates were low. Genitourinary toxicity, mainly frequency/urgency, was 0–16% (Grade 3). Gastrointestinal toxicity was 0–2% (Grade 3). Erectile function preservation was 67–89%. The radiobiological, clinical, and technical features of HDR brachytherapy were reviewed and discussed.
Consistently high local tumor control and low complications rates are reported with HDR monotherapy. It provides reproducible high-quality dosimetry, it has an advantage from a radiobiology perspective, and it has a good radiation safety profile. HDR brachytherapy is a safe and effective local treatment modality for prostate cancer.
ACR Appropriateness Criteria high-dose-rate brachytherapy for prostate cancer
2014, Brachytherapy
High-dose-rate (HDR) brachytherapy plays a potential curative role in the treatment of prostate cancer. An expert panel was convened to review the recent literature and reach a consensus on its appropriate clinical applications.
The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
A summary of HDR brachytherapy's clinical applications and recent literature review was completed. Three clinical variants were developed to address common HDR dose, fractionations, and indications for its use in definitive therapy for primary and local recurrent prostate cancer. The panel reached a consensus on the specific treatment approaches with numerical rating and commentary.
In combining available medical literature and expert opinion, this manuscript may serve as an aid for other practitioners in the appropriate application of HDR brachytherapy for prostate cancer.

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High-dose-rate brachytherapy for large prostate volumes (≥50 cc)—Uncompromised dosimetric coverage and acceptable toxicity

Abstract

Purpose

Methods and materials

Results

Conclusions

Section snippets

Purpose

Patient selection

Results

Discussion

Conclusions

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Urology

Int J Radiat Oncol Biol Phys

J Urol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys