Richard Anderson

The morbidity of transperineal template-guided prostate mapping biopsy

To evaluate the effect of transperineal template‐guided prostate mapping biopsy (TTMB) on urinary, bowel and erectile function.

Risk Factors for the Development of Prostate Brachytherapy Related Urethral Strictures

PURPOSEnWe identified clinical, treatment and dosimetric parameters associated with the development of urethral strictures following permanent prostate brachytherapy.nnnMATERIALS AND METHODSnFrom April 1995 through April 2003, 1,186 consecutive patients underwent prostate brachytherapy for clinical stage T1b-T3a NxM0 (2002 American Joint Committee on Cancer) prostate cancer. The treatment plan included supplemental XRT in 625 patients (52.7%) and androgen deprivation therapy in 465 (39.2%). Median followup was 4.3 years. Multiple clinical, treatment and dosimetric parameters were evaluated in univariate and multivariate analyses to identify independent predictors for urethral stricture disease.nnnRESULTSnA total of 29 patients had brachytherapy related urethral strictures. All strictures involved the BM urethra with a 9-year actuarial risk of 3.6% and a median time to development of 2.4 years. The mean radiation dose to the BM urethra was significantly greater in patients with vs without stricture (p = 0.002). On multivariate analysis the BM urethral dose and supplemental XRT predicted urethral stricture. All except 3 patients were successfully treated with urethral dilation or internal optical urethrotomy.nnnCONCLUSIONSnBrachytherapy related urethral stricture disease correlates highly with the radiation dose to the BM urethra. Careful attention to brachytherapy preplanning and intraoperative execution along with the judicious use of supplemental XRT is essential to minimize the incidence of stricture disease.

Erectile function durability following permanent prostate brachytherapy.

PURPOSEnTo evaluate long-term changes in erectile function following prostate brachytherapy.nnnMETHODS AND MATERIALSnThis study included 226 patients with prostate cancer and preimplant erectile function assessed by the International Index of Erectile Function-6 (IIEF-6) who underwent brachytherapy in two prospective randomized trials between February 2001 and January 2003. Median follow-up was 6.4 years. Pre- and postbrachytherapy potency was defined as IIEF-6 > or = 13 without pharmacologic or mechanical support. The relationship among clinical, treatment, and dosimetric parameters and erectile function was examined.nnnRESULTSnThe 7-year actuarial rate of potency preservation was 55.6% with median postimplant IIEF of 22 in potent patients. Potent patients were statistically younger (p = 0.014), had a higher preimplant IIEF (p < 0.001), were less likely to be diabetic (p = 0.002), and were more likely to report nocturnal erections (p = 0.008). Potency preservation in men with baseline IIEF scores of 29-30, 24-28, 18-23, and 13-17 were 75.5% vs. 73.6%, 51.7% vs. 44.8%, 48.0% vs. 40.0%, and 23.5% vs. 23.5% in 2004 vs. 2008. In multivariate Cox regression analysis, preimplant IIEF, hypertension, diabetes, prostate size, and brachytherapy dose to proximal penis strongly predicted for potency preservation. Impact of proximal penile dose was most pronounced for men with IIEF of 18-23 and aged 60-69. A significant minority of men who developed postimplant impotence ultimately regained erectile function.nnnCONCLUSIONnPotency preservation and median IIEF scores following brachytherapy are durable. Thoughtful dose sparing of proximal penile structures and early penile rehabilitation may further improve these results.

Dosimetry of an extracapsular anulus following permanent prostate brachytherapy.

Purpose:Recent studies have suggested that extracapsular brachytherapy treatment margins correlate with biochemical control. It is likely that volumetric geographic dosimetric parameters will be more robust than selected radial measurements. Accordingly, we evaluated extracapsular volumetric dosimetric parameters in low-risk patients. Materials and Methods:A total of 263 low-risk prostate cancer patients randomized to Pd-103 versus I-125 were implanted with a brachytherapy target volume consisting of the prostate with a 5-mm periprostatic margin. The median follow-up was 4.2 years. All patients were implanted at least 3 years prior to analysis. Within 2 hours of implantation, an axial CT was obtained for postimplant dosimetry. A 5-mm three-dimensional periprostatic anulus was constructed around the prostate and evaluated in its entirety and in 90° segments. Prostate and anular dosimetric parameters consisted of V100/V150/V200 and D90. Biochemical progression-free survival (bPFS) was defined as a PSA ≤0.50 ng/mL after nadir. Results:The Pd-103 and I-125 arms were well-matched in terms of clinical, biochemical, and pathologic presentation. Six-year bPFS was 96.8% versus 99.2% for I-125 versus Pd-103 (P = 0.149). The most recent median posttreatment PSA was <0.04 ng/mL for both isotopes. No significant differences in postoperative anular doses were discerned between bPFS and failed patients. Conclusions:A postimplant 5-mm, three-dimensional periprostatic anulus provides substantial information regarding dosimetric coverage. However, with a median follow-up of 4.2 years, such volumetric and geographic parameters have not proven useful in predicting biochemical outcome in low-risk patients.

Prebiopsy PSA Velocity Not Reliable Predictor of Prostate Cancer Diagnosis, Gleason Score, Tumor Location, or Cancer Volume After TTMB

OBJECTIVESnTo evaluate the effect of prostate-specific antigen (PSA) velocity (PSAV) on prostate cancer diagnosis, Gleason score, tumor location, and cancer volume in men undergoing transperineal template-guided mapping biopsy (TTMB). PSAV has been associated with greater Gleason scores and greater prostate cancer-specific mortality.nnnMETHODSnFrom January 2005 through September 2007, 217 patients underwent TTMB. The inclusion criteria included a persistently elevated PSA level and/or diagnosis of atypical small acinar proliferation or high-grade prostatic intraepithelial neoplasia on previous biopsy. The prostate gland was arbitrarily divided into 24 regions, and a median of 58 cores were obtained per patient. The patients were divided into 3 velocity cohorts according to the following changes in PSA level in the year before biopsy: < or =0.0, 0.1-1.9, and > or =2.0 ng/mL. The PSAV was evaluated as a predictor for prostate cancer diagnosis, Gleason score, tumor volume, and cancer location.nnnRESULTSnThe mean patient age was 64.2 years, with a mean prebiopsy PSA level of 8.5 ng/mL. Prostate cancer was diagnosed in 97 patients (44.7%). The study population had undergone an average of 1.8 +/- 1.0 biopsies before TTMB. PSAV did not predict for prostate cancer diagnosis (P = .84), Gleason score (P = .78), the percentage of positive cores (P = .37), or tumor location.nnnCONCLUSIONSnAmong patients with persistently elevated PSA levels despite previously negative biopsy findings, PSAV did not reliably predict for a diagnosis of prostate cancer nor did it correlate with prostate cancer grade, volume, or location using TTMB.

Pathology and Quality of Life Outcomes Following Office-based Transperineal Prostate Biopsy

OBJECTIVEnTo report the incidence of prostate cancer diagnosis and quality of life outcomes following transperineal prostate biopsy.nnnMETHODSnForty-six consecutive patients underwent office-based transperineal prostate biopsy for an elevated prostate-specific antigen and a normal digital rectal examination without prior prostate biopsy. Prior to biopsy, a repeat prostate-specific antigen was obtained to ensure persistent elevation. Silodosin (8u2009mg daily) was initiated the day prior to biopsy and continued for 1 week. A total of 18-20 biopsy cores were obtained per patient. All patients responded to a visual analog scale ranging from 0 to 10 immediately following the completion of both the local anesthesia and the biopsy procedure. In addition, an International Prostate Symptom Score (IPSS), Rectal Function Assessment Score, International Index of Erectile Function, Center for Epidemiologic Studies Depression Scale, and postvoid residual were obtained at baseline and 30 days following biopsy, except IPSS which was also obtained at day 7.nnnRESULTSnThe mean patient age was 63.3 years with a mean prostate volume of 41.8u2009cm(3). The mean visual analog scale was 4.2 for the local anesthesia and 3.0 for the biopsy. Thirty-one patients (67.4%) were diagnosed with prostate cancer, with 18 having a Gleason scoreu2009≥u20097. Compared to baseline, no adverse changes in IPSS, Rectal Function Assessment Score, International Index of Erectile Function, Center for Epidemiologic Studies Depression Scale, or postvoid residual were detected at day 30. No patient required catheterization, developed sepsis, or required hospitalization.nnnCONCLUSIONnOffice-based transperineal prostate biopsy was well tolerated with reasonable treatment-related discomfort, a high rate of prostate cancer diagnosis, and the absence of significant morbidity including sepsis.

Higher percentage of positive biopsy cores and Gleason score are associated with a greater degree of prostate gland shrinkage after neoadjuvant cytoreductive therapy

PURPOSEnTo determine whether adverse pathologic features, including tumor grade and percent positive biopsy (PPB) cores, predict for prostate size reduction after neoadjuvant cytoreductive therapy.nnnMETHODS AND MATERIALSnEighty-two consecutive patients who were diagnosed with prostate cancer by transperineal template-guided mapping biopsy (TTMB) received neoadjuvant cytoreductive therapy. The median number of biopsy cores was 59. Thirty patients received a leutinizing hormone-releasing hormone agonist and bicalutamide, whereas 52 patients received bicalutamide (50mg daily) and dutasteride (0.5mg daily). A transrectal ultrasound volumetric study of the prostate gland and ellipsoid volume determinations of the prostate gland and transition zone (TZ) were obtained immediately before TTMB and at 90 days (±7 days) after the initiation of neoadjuvant medical therapy. Univariate and multivariate regression analyses were performed to identify predictors of prostate gland and TZ volume reduction.nnnRESULTSnAt TTMB, the mean prostate volumetric and ellipsoid volumes were 55.4xa0cm(3) and 49.0xa0cm(3), respectively. After neoadjuvant medical therapy, the mean volumetric and ellipsoid prostate volumes were 30.8xa0cm(3) and 28.5xa0cm(3), respectively. On average, the prostate volume decreased by 43.9% and 41.0% on volumetric and ellipsoid measurements, respectively. The TZ volume decreased from 19.8xa0cm(3) to 10.1xa0cm(3) (mean volume reduction of 47.7%). In multivariate analysis, prostate volume cytoreduction was most closely associated with PPB (p=0.014), TTMB prostate volume (p=0.01), and drug regimen (p=0.001).nnnCONCLUSIONSnThe degree of prostate volume cytoreduction was positively associated with higher Gleason score and PPBs. Greater reductions in prostate volume may be an indicator of more aggressive cancer.