Michael Dattoli

103Pd brachytherapy and external beam irradiation for clinically localized, high-risk prostatic carcinoma

PURPOSE To summarize biochemical failure rates and morbidity of external beam irradiation (EBRT) combined with palladium (103Pd) boost for clinically localized high-risk prostate carcinoma. METHODS AND MATERIALS Seventy-three consecutive patients with stage T2a-T3 prostatic carcinoma were treated from 1991 through 1994. Each patient had at least one of the following risk factors for extracapsular disease extension: Stage T2b or greater (71 patients), Gleason score 7-10 (40 patients), prostate specific antigen (PSA) > 15 (32 patients), or elevated prostatic acid phosphatase (PAP) (17 patients). Patients received 41 Gy EBRT to a limited pelvic field, followed 4 weeks later by a 103Pd boost (prescription dose: 80 Gy). Biochemical failure was defined as a PSA greater than 1.0 ng/ml (normal < 4.0 ng/ml). Patients whose PSA was still decreasing at the last follow-up were censored at that time. Patients whose PSA plateaued at a value greater than 1.0 were scored as failures at the time the PSA first plateaued. RESULTS The overall, actuarial freedom from biochemical failure at 3 years after treatment was 79%. In Cox proportional hazard multivariate analysis, the strongest predictor of failure was elevated acid phosphatase (p = 0.04), followed by PSA (p = 0.17), Stage (p = 0.23), and Gleason score (p = 0.6). Treatment-related morbidity was usually limited to temporary, RTOG Grade 1-2 urinary symptoms. One patient, who had both a transurethral incision of the prostate (TUIP) and a transurethral resection of the prostate (TURP), developed low-volume urinary incontinence. The actuarial potency rate at 3 years after implantation was 77% for 46 patients who were sexually potent prior to implant. CONCLUSION Biochemical freedom from failure rates following combined EBRT and 103Pd brachytherapy for clinically localized, high-risk prostate cancer compare favorably with that reported after conventional dose EBRT alone. Morbidity has been acceptable.

LOW RISK OF URINARY INCONTINENCE FOLLOWING PROSTATE BRACHYTHERAPY IN PATIENTS WITH A PRIOR TRANSURETHRAL PROSTATE RESECTION

PURPOSE To review post implant morbidity in patients with prior transurethral prostate resection (TURP). METHODS AND MATERIALS Nineteen patients with stage T1-T2 prostatic carcinoma and prior TURP were treated with I-125 or Pd-103 implantation from 1991 through 1994. Follow-up ranged from 1 to 6 years (median: 3 years). The time from TURP to implantation ranged from 2 months to 15 years (median: 3 years). RESULTS Only one patient developed mild urinary stress incontinence, 6 months following his I-125 implant. The actuarial freedom from permanent urinary incontinence at 3 years after implantation was 94%. No patient required urethral dilatation for urethral stricture. Eleven patients were sexually potent prior to implantation. At 3 years after treatment, all patients had maintained potency. CONCLUSION In our experience, there has been remarkably little adverse sequelae following I-125 or Pd-103 implantation in patients with a prior history of TURP.

Radiation therapy for intracranial germinoma: The case for limited volume treatment

Although radiation therapy has been universally accepted as the treatment of choice for primary intracranial germinomas, the optimal treatment technique continues to be a matter of controversy. Some authors advocate routine prophylactic craniospinal irradiation for all patients with localized intracranial germinomas whereas others have recommended partial brain fields. A retrospective analysis was performed on all 30 patients with tumors of the pineal and suprasellar regions irradiated at our institution between 1967 and 1987. Definitive histology was obtained in 23 patients. There were 13 germinomas and 10 non-germinomatous germ cell tumors. The 13 patients with biopsy proven germinomas constitute one of the largest modern series and will form the basis of this report. In all 13 patients, the tumor was confined to a single site within either the pineal region (9 patients) or the suprasellar region (4 patients). One patient with a pineal germinoma had CSF cytology positive for malignant cells and this patient was treated with craniospinal irradiation. Twelve patients were treated using partial brain fields encompassing either the tumor plus margin (10 patients) or the entire ventricular system followed by a boost to the primary tumor (2 patients). With the exception of one patient, all patients received a total dose between 4900 and 5500 cGy to the primary (median 5040 cGy). The patient receiving less (3960 cGy) suffered from both local and spine relapse 26 months after diagnosis. The remaining 12 patients were free of disease at 81 months median follow-up time. We suggest that for patients with biopsy proven pineal or suprasellar germinomas, irradiation of partial brain is sufficient and craniospinal irradiation should be administered only to those patients with disease involving more than one intracranial site, demonstrated meningeal seeding, or positive CSF cytology.

Long-term outcomes after treatment with brachytherapy and supplemental conformal radiation for prostate cancer patients having intermediate and high-risk features.

This study summarizes long‐term outcomes from treatment of prostate cancer with increased risk of extracapsular cancer extension (ECE) using brachytherapy‐based treatment.

Analysis of multiple prognostic factors in patients with stage IB cervical cancer: Age as a major determinant

To evaluate the prognostic importance of age in patients with Stage IB cervical cancer we reviewed the results of 131 patients treated between 1974 and 1985. Patients ranged in age from 25 to 87 (mean 48) and were followed for a median of 65 months. One hundred twenty-five patients had complete follow-up information for survival analysis. Patients were divided into two groups; Group A comprising 43 patients less than or equal to age 40 and Group B comprising 88 patients greater than age 40. Both Group A and Group B patients were comparable with respect to all covariables studied. The 5-year actuarial survival for the 125 patients studied was 80%, whereas that for Group A (42 patients) and Group B (83 patients) was 54% and 91%, respectively (p = .0001). The 5-year survival for 100 surgical patients was 79% and that for Group A (36 patients) and Group B (64 patients) was 53% and 90%, respectively (p = .0001). The 5-year survival for 25 patients treated with curative RT was 65% and that for Group A (six patients) and Group B (19 patients) was 42% and 90%, respectively (p = .005). Eighteen patients were treated with adjuvant RT following surgery and their 5-year survival was 69% with three out of nine Group A and nine out of nine Group B patients alive at 65 months (p = .004). In 18 patients with pelvic nodal involvement, the 5-year survival was 48% compared to 84% in patients with negative nodes (p = .007). The difference in survival at 5 years between Group A (nine patients) and Group B (nine patients) with positive nodes was 25% and 75%, respectively. Finally, there was an increase in both local and distant failure in Group A patients. Our data illustrate that age has a profound influence on survival in women with Stage IB cervical cancer independent of potentially confounding variables.

Prognostic role of serum prostatic acid phosphatase for 103Pd-based radiation for prostatic carcinoma

PURPOSE To establish the prognostic role of serum enzymatic prostatic acid phosphatase (PAP) in patients treated with palladium (103Pd) and supplemental external beam irradiation (EBRT) for clinically localized, high-risk prostate carcinoma. METHODS AND MATERIALS One hundred twenty-four consecutive patients with Stage T2a-T3 prostatic carcinoma were treated from 1992 through 1995. Each patient had at least one of the following risk factors for extracapsular disease extension: Stage T2b or greater (100 patients), Gleason score 7-10 (40 patients), pretreatment prostate specific antigen (PSA) >15 ng/ml (32 patients), or elevated serum PAP (25 patients). Patients received 41 Gy conformal EBRT to a limited pelvic field, followed 4 weeks later by a 103Pd boost (prescription dose 80 Gy). Biochemical failure was defined as a PSA greater than 1 ng/ml (normal <4 ng/ml). RESULTS The overall, actuarial freedom from biochemical failure at 4 years after treatment was 79%. In Cox-proportional hazard multivariate analysis, the strongest predictor of failure was elevated pretreatment acid phosphatase (p = 0.02), followed by Gleason score (p = 0.1), and PSA (p = 0.14). CONCLUSION PAP was the strongest predictor of long-term biochemical failure. It may be a more accurate indicator of micrometastatic disease than PSA, and as such, we suggest that it be reconsidered for general use in radiation-treated patients.

A simple method to stabilize the prostate during transperineal prostate brachytherapy

PURPOSE The authors report a simple, remarkably effective method to limit prostatic motion during prostate brachytherapy. METHODS AND MATERIALS Two 18-ga. stainless-steel needles (the same type used for source placement) are inserted transperineally, obliquely into the prostate, using finger and fluoroscopic guidance. These needles are left in place during the implant procedure. In our experience, maximum lateral displacement is decreased from about 1 cm to 0.2 mm, while craniocaudal motion is virtually eliminated. CONCLUSION The method described here is simple to perform and does not require specialized equipment.