A. Gomez-Iturriaga

Comparison of Health-Related Quality of Life 5 Years After SPIRIT: Surgical Prostatectomy Versus Interstitial Radiation Intervention Trial

PURPOSEnThe American College of Surgeons Oncology Group phase III Surgical Prostatectomy Versus Interstitial Radiation Intervention Trial comparing radical prostatectomy (RP) and brachytherapy (BT) closed after 2 years due to poor accrual. We report health-related quality of life (HRQOL) at a mean of 5.3 years for 168 trial-eligible men who either chose or were randomly assigned to RP or BT following a multidisciplinary educational session.nnnPATIENTS AND METHODSnAfter initial lack of accrual, a multidisciplinary educational session was introduced for eligible patients. In all, 263 men attended 47 sessions. Of those, 34 consented to random assignment, 62 chose RP, and 94 chose BT. Five years later, these 190 men underwent HRQOL evaluation by using the cancer-specific 50-item Expanded Prostate Cancer Index Composite, the Short Form 12 Physical Component Score, and Short Form 12 Mental Component Score. Response rate was 88.4%. The Wilcoxon rank sum test was used to compare summary scores between the two interventions.nnnRESULTSnOf 168 survey responders, 60.7% had BT (9.5% randomly assigned) and 39.3% had RP (9.5% randomly assigned). Median age was 61.4 years for BT and 59.4 for RP (P = .05). Median follow-up was 5.2 years (range, 3.2 to 6.5 years). For BT versus RP, there was no difference in bowel or hormonal domains, but men treated with BT scored better in urinary (91.8 v 88.1; P = .02) and sexual (52.5 v 39.2; P = .001) domains, and in patient satisfaction (93.6 v 76.9; P < .001).nnnCONCLUSIONnAlthough treatment allocation was random in only 19%, all patients received identical information in a multidisciplinary setting before selecting RP, BT, or random assignment. HRQOL evaluated 3.2 to 6.5 years after treatment showed an advantage for BT in urinary and sexual domains and in patient satisfaction.

Dose escalation to dominant intraprostatic lesions with MRI-transrectal ultrasound fusion High-Dose-Rate prostate brachytherapy. Prospective phase II trial

BACKGROUND AND PURPOSEnTo demonstrate the feasibility, safety and effectiveness of dose escalation to intraprostatic lesions with MRI-transrectal ultrasound fusion High-Dose-Rate (HDR) brachytherapy.nnnMATERIALS AND METHODSn15 patients with intermediate-high risk prostate cancer and visible dominant intra-prostatic nodule on mpMRI have been treated. The treatment consisted of combined MRI-TRUS fusion HDR-brachytherapy (1 fraction of 1500cGy) and hypofractionated external beam (3750cGy in 15 fractions). A dose of 1875Gy was delivered to at least 98% of the DIL volume.nnnRESULTSnMedian prostate volume was 23.8cc; median number of needles was 16 (13-18). Dose escalation to DIL was feasible in 14/15 patients (93%) without violating dosimetric constraints and 1 patient presented a minimal deviation of dosimetric restrictions. With a median follow-up of 18months (17-24), none of the patients developed acute urinary retention or grade ⩾3 toxicity. In addition to standard PSA follow-up, response has been assessed by mpMRI at 12months. All patients presented adequate morphological responses on anatomical and functional sequences.nnnCONCLUSIONSnHDR brachytherapy using MRI-transrectal ultrasound fusion for image guidance is a suitable technique for partial prostate dose escalation. Tolerance and toxicity profiles are excellent and results are encouraging in terms of biochemical, morphological and functional response.

The efficacy of hyperbaric oxygen therapy in the treatment of medically refractory soft tissue necrosis after penile brachytherapy

PURPOSEnSoft tissue necrosis is reported in up to 26% of patients undergoing radiotherapy for penile cancer. Management options include local irrigation, wound debridement, antibiotics, anti-inflammatory medication, and analgesics. Refractory lesions may be treated with partial penectomy. Hyperbaric oxygen therapy (HBO) has a well-defined role in the treatment of late radiation toxicities. We present experience with HBO for medically refractory soft tissue necrosis after penile brachytherapy.nnnMETHODS AND MATERIALSnFrom November 2001 to January 2009, 7 men of 43 treated with penile brachytherapy for squamous carcinoma developed refractory soft tissue necrosis and were treated with HBO. All had received a prescribed dose of 60 Gy through interstitial brachytherapy using Paris system guidelines. All had failed conservative medical therapies for soft tissue necrosis.nnnRESULTSnMedian age was 55 years (range, 35-72 years). Comorbidities potentially effecting wound healing included hypertension (2), current smokers (5), former smoker (1) but no diabetes mellitus, or peripheral vascular disease. Median time between completion of brachytherapy and appearance of soft tissue necrosis was 13 months (range, 9-24 months) and the median interval before starting HBO was 7.5 months (range, 3-13 months). The median number of dives per HBO course was 40 (30-53). All 7 experienced an excellent response with healing of the necrosis and resolution of symptoms, although 3 required an additional course, 2 for consolidation of healing, and 1 for a relapse 4 months later. No patient was submitted to penectomy.nnnCONCLUSIONSnHBO should be considered as a treatment option in patients with refractory soft tissue necrosis of the penis after brachytherapy.

Transperineal biopsies of MRI-detected aggressive index lesions in low- and intermediate-risk prostate cancer patients: Implications for treatment decision

PURPOSEnMultiparametric MRI (mpMRI) has a potential role for the identification of aggressive cancer that can be targeted for biopsy. We report the incidence and severity of discordant information between the pathology found on the transrectal ultrasound (TRUS)-guided biopsy and the mpMRI findings in patients with favorable or intermediate-risk prostate cancer referred for brachytherapy.nnnMETHODS AND MATERIALSnFrom March 2014 to September 2015, 10/44 consecutive patients with low- or intermediate-risk prostate cancer referred for brachytherapy presented an aggressive lesion on mpMRI and underwent an MRI-TRUS fusion-guided transperineal biopsy of the index lesion.nnnRESULTSnA median of two intraprostatic lesions were detected by mpMRI for each patient. Three patients had bilateral disease, and seven had unilateral disease on mpMRI. The median number of cores obtained by MRI-TRUS-guided fusion of the index lesion was 3 (range 2-4). As a result of the re-evaluation consequent to additional information becoming available after the transperineal biopsy, upgrading of Gleason score occurred in 8 of the 10 patients, which changed the risk group in 9 patients. These changes resulted in modification of the proposed treatment in 8 patients.nnnCONCLUSIONSnMpMRI-US fusion-targeted biopsy sampling allows detection and characterization of otherwise undetected aggressive disease, often placing men in higher risk groups and altering the treatment approach.