M. Buckstein

Treatment outcomes and morbidity following definitive brachytherapy with or without external beam radiation for the treatment of localized prostate cancer: 20-Year experience at Mount Sinai Medical Center

OBJECTIVES To present our treatment algorithm and 20-year experience in treating prostate cancer with brachytherapy since 1990, with focus on cancer-control outcomes and treatment-related morbidity. METHODS AND MATERIALS We selected patients treated for localized prostate cancer with brachytherapy, combination therapy with external beam radiotherapy, and adjuvant androgen deprivation therapy as prescribed by our Mount Sinai risk stratification and treatment algorithm. Outcomes were analyzed with respect to biochemical failure, distant metastases, prostate cancer-specific survival, and overall survival. Morbidity was assessed with respect to urinary, sexual, and rectal outcomes. RESULTS In total, 2,495 patients met inclusion criteria. The 12-year actuarial freedom from biochemical failure was 83% (low risk: 90%, intermediate risk: 84%, and high risk: 64%); freedom from distant metastasis was 95%; prostate cancer-specific survival was 95%; and overall survival was 70%. On multivariate analysis, significant associations were found between cancer control and risk group, total biologically effective dose, and androgen deprivation therapy. With regard to morbidity, potency was preserved in 61%, and urinary symptoms improved in 35%. The 12-year actuarial freedom from urinary retention events was 90% and from severe rectal bleed was 93%. CONCLUSIONS Brachytherapy, as administered via the Mount Sinai algorithm, remains an efficacious and benign treatment option for patients with localized prostate cancer of all risk groups.

Long-term potency preservation following brachytherapy for prostate cancer: POTENCY PRESERVATION FOLLOWING BRACHYTHERAPY

Study Type – Therapy (case series)

Long-term Outcomes and Toxicity in Patients Treated With Brachytherapy for Prostate Adenocarcinoma Younger Than 60 Years of Age at Treatment With Minimum 10 Years of Follow-up

OBJECTIVE To report the outcomes and late toxicities in younger patients with long-term follow-up treated with brachytherapy with or without external beam radiotherapy for prostate adenocarcinoma. MATERIALS AND METHODS Patients treated with brachytherapy with or without external beam radiotherapy who were aged ≤ 60 years at treatment with ≥ 10 years of follow-up were selected from our database. The outcomes were analyzed regarding biochemical failure, distant metastases, and cause of death. Genitourinary outcomes were assessed using the International Prostate Symptom Score, Radiation Therapy Oncology Group, and Common Terminology Criteria for Adverse Events criteria. Gastrointestinal toxicity was measured using Radiation Therapy Oncology Group scales. Erectile dysfunction was measured using Sexual Health Inventory for Men and the Mount Sinai Erectile Function score. RESULTS A total of 131 patients met the inclusion criteria, with a median age of 57 years at treatment and a median follow-up of 11.5 years. Of the patients in this cohort, 9.9% developed biochemical failure with 1 failure and 1 prostate cancer-related death after 10 years. The International Prostate Symptom Score were statistically unchanged after 10 years. Of 22 cases (17%) of grade 2 or greater genitourinary toxicities, only 6 (4.5%) continued after 10 years. Of 11 cases (8.3%) of grade 2 or greater gastrointestinal events, none persisted past 10 years. A significant decrease occurred in the mean Sexual Health Inventory for Men score from 19.5 to 15.3 (P = .008). Of the potent patients before treatment, 69% remained potent at last follow-up. A total of 4 second malignancies were detected, 2 of which were within the radiation field. CONCLUSION Men <60 years old who underwent brachytherapy for prostate cancer can expect minimal late genitourinary and gastrointestinal toxicity after 10 years and excellent potency preservation.

LONG-TERM POTENCY PRESERVATION FOLLOWING BRACHYTHERAPY FOR PROSTATE CANCER

In this report, investigators from Mount Sinai evaluated factors associated with erectile dysfunction following permanent prostate seed implants with or without external beam radiation therapy. They concluded that the use of external beam radiation therapy increased the risk of erectile dysfunction. Based on a review of the data and the associated conclusions concerning the dose/volume/clinical outcome data for penile bulb for patients treated with external beam radiation therapy, this fi nding should come as no surprise [ 1 ] . Most, but not all, studies fi nd an association between impotence and dosimetric parameters (e.g. threshold doses) and clinical factors (e.g. age). It appears that it is prudent to keep the mean dose for 95% of the penile bulb volume to < 50 Gy. The penile bulb itself is not the critical component of the erectile apparatus, but it appears to be a surrogate for yet to be determined structure(s) critical for erectile function. Patients who are treated with brachytherapy combined with external beam radiation therapy may be at greater risk for exceeding the tolerance suggested, but using image guided intensity modulated radiotherapy it should be possible to cure many of these patients without substantially increasing the risk of erectile dysfunction. Clearly awareness and more research are warranted.

Radiographic extracapsular extension and treatment outcomes in locally advanced oropharyngeal carcinoma

Pathologic extracapsular extension (pECE) in metastatic lymph nodes is associated with poor prognosis for oropharyngeal carcinoma. The prognostic value of radiographic extracapsular extension (rECE) has not been studied.

Radiobiological rationale and clinical implications of hypofractionated radiation therapy.

Recent clinical trials of hypofractionated radiation treatment have provided critical insights into the safety and efficacy of hypofractionation. However, there remains much controversy in the field, both at the level of clinical practice and in our understanding of the underlying radiobiological mechanisms. In this article, we review the clinical literature on hypofractionated radiation treatment for breast, prostate, and other malignancies. We highlight several ongoing clinical trials that compare outcomes of a hypofractionated approach versus those obtained with a conventional approach. Lastly, we outline some of the preclinical and clinical evidence that argue in favor of differential radiobiological mechanisms underlying hypofractionated radiation treatment. Emerging data from the ongoing studies will help to better define and guide the rational use of hypofractionation in future years.

The relative importance of hormonal therapy and biological effective dose in optimizing prostate brachytherapy treatment outcomes

To compare the relative importance of radiation dose escalation vs androgen deprivation therapy (ADT) in the definitive treatment of prostate adenocarcinoma.

Computed tomography and positron emission tomography/ computed tomography surveillance after combined modality treatment of supradiaphragmatic Hodgkin lymphoma: a clinical and economic perspective

Abstract We studied the clinical benefits of radiological imaging, in the follow-up of patients after combined modality treatment for stage I/II classical supradiaphragmatic Hodgkin lymphoma (HL). Imaging data were collected for 78 adults treated during 1996–2008. Median follow-up was 4.6 years. Six of the nine relapses were detected clinically. On average, 31 imaging studies/patient were performed, with an estimated cost of

Tolerability, Toxicity, and Temporal Implications of Transoral Robotic Surgery (TORS) on Adjuvant Radiation Therapy in Carcinoma of the Head and Neck

12 608/patient. Chest computed tomography (CT) scans accounted for 25%, abdominopelvic CT scans 41% and positron emission tomography (PET) or PET/CT scans 22% of this expense. Only one patient recurred infradiaphragmatically. The estimated radiation dose from imaging was 399 mSv and 229 mSv per patient, in relapse and non-relapse groups, respectively. CT scans contributed over 80% of the imaging radiation exposure. The routine use of CT scans in the surveillance of patients with HL after curative treatment adds to healthcare costs and total body radiation exposure with a low yield. History and physical examination remain effective tools for the follow-up of patients.

Prognostic value of radiographic extracapsular extension in locally advanced head and neck squamous cell cancers

Objectives: Overall treatment package time (from surgery to radiotherapy [RT] completion) > 100 days can portend poor outcomes in head and neck cancer. Faster postoperative recovery seen with transoral robotic surgery may decrease treatment duration and toxicity for adjuvant RT and chemoradiation. Methods: We retrospectively reviewed all patients treated with transoral robotic surgery (n = 124) and adjuvant RT and chemoradiation (n = 33) at our institution for head and neck cancer from April 2007 to December 2011 to determine treatment duration, acute toxicity, and long-term percutaneous gastric tube rates. Results: The median overall treatment time was 86 days and from surgery to RT start was 41 days; median RT duration was 44 days. No wound breakdown or infection occurred during or after RT. Two-year actuarial locoregional control, distant metastasis–free survival, and overall survival rates were 93%, 96%, and 97%, respectively. Conclusions: Adjuvant RT after transoral robotic surgery for head and neck cancer can be completed safely and in a timely fashion. Longer follow-up and a larger cohort will be needed to determine if this regimen is more effective than traditional surgery followed by adjuvant RT.