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Brachytherapy is a radiation therapy method in which radionuclide sources are used to deliver a radiation dose at a distance of up to a few centimeters by surface, intracavitary, intraluminal, or interstitial application. This practice parameter refers only to the use of radionuclides for brachytherapy. Brachytherapy alone or combined with external beam therapy plays an important role in the management and treatment of patients with cancer. High-dose-rate (HDR) brachytherapy uses radionuclides such as iridium-192 at dose rates of 20 cGy per minute (12 Gy per hour) or more to a designated target point or volume. High-dose-rate (HDR) brachytherapy is indicated for treating malignant or benign tumors where the treatment volume or targeted points are defined and accessible.

Purpose To evaluate the effect of primary Gleason pattern on biochemical progression-free survival (bPFS), cause-specific survival (CSS), and overall survival (OS) in Gleason 7 prostate cancer patients treated with low-dose-rate (LDR) interstitial brachytherapy with or without supplemental external beam radiation therapy and androgen deprivation therapy. Methods and Materials We retrospectively reviewed the medical records of 932 consecutive patients with biopsy-confirmed Gleason 7 prostate cancer who received LDR interstitial brachytherapy as a component of their definitive treatment regimen. Treatment outcomes were compared between patients with primary Gleason pattern 3 and 4. Results With a median followup of 7.4 years, the 10- and 14-year bPFS, CSS, and OS for the entire Gleason 7 study group were 95.7/95.7%, 98.6/98.6% and 77.2/64.3%, respectively. When biochemical control was evaluated as a function of primary Gleason pattern, the primary pattern 3 had a statistically higher 10- and 14-year bPFS (97.8/97.8% vs. 93.1/93.1%, p = 0.006). The Gleason pattern 3 patients also trended toward a higher 10- and 14-year CSS (99.3/99.3% vs. 96.9/96.9%, p = 0.058). OS was not statistically different between the two Gleason 7 cohorts. Conclusions Gleason 7 prostate cancer patients treated with LDR interstitial brachytherapy have an excellent long-term outcome. There was a small but statistically significant advantage in bPFS and a trend toward improved CSS in patients with a primary Gleason pattern of 3.

Transperineal permanent brachytherapy is a safe and effective treatment option for patients with organ-confined prostate cancer. Careful adherence to established brachytherapy standards has been shown to improve the likelihood of procedural success and reduce the incidence of treatment-related morbidity. A collaborative effort of the American College of Radiology (ACR) and the American Brachytherapy Society (ABS) has produced practice parameters for LDR prostate brachytherapy. These practice parameters define the qualifications and responsibilities of all the involved personnel, including the radiation oncologist, physicist and dosimetrist. Factors with respect to patient selection and appropriate use of supplemental treatment modalities such as external beam radiation and androgen suppression therapy are discussed. Logistics with respect to the brachytherapy implant procedure, the importance of dosimetric guidelines, and attention to radiation safety procedures and documentation are presented. Adherence to these parameters can be part of ensuring quality and safety in a successful prostate brachytherapy program.

Purpose To evaluate outcome in the most unfavorable subset of high-risk prostate cancer patients treated with a combination of supplemental external beam radiation therapy (EBRT) and brachytherapy. Methods and Materials Very high-risk prostate cancer was defined as follows: any Gleason score 10, Gleason score 8–9 with >50% of the biopsy cores positive for malignancy, Gleason score 8–9 with a prostate-specific antigen (PSA) >20 ng/mL, any clinical stage T3, or any PSA >40 ng/mL. One hundred thirty-one patients were identified who met the aforementioned criteria. The median followup was 6.6 years. One hundred twenty (91.6%) patients received supplemental EBRT and 100 (76.4%) received androgen deprivation therapy (median duration, 19.5 months; range, 4–36 months). The median postimplant day 0 D90 (i.e., the minimum percentage of the prescription dose that covers the planning target volume) was 121.9% of prescription dose. Multiple clinical treatment and dosimetric parameters were evaluated for impact on the evaluated survival parameters. Results The median pretreatment PSA and Gleason score were 11.0 ng/mL and 8. One hundred ten (84%) patients had a Gleason score ≥8. At 9 and 12 years, the cause-specific survival, biochemical progression-free survival, and overall survival were 91.0% and 86.5%, 87.3% and 87.3%, and 70.5% and 60.5%, respectively. The most common cause of death was heart disease (22.2%) with deaths from nonprostate cancer (12.7%) and prostate cancer (8.3%) being less likely. Conclusions Permanent interstitial brachytherapy usually with supplemental EBRT and androgen deprivation therapy results in excellent biochemical control and cause-specific survival in the most unfavorable subset of high-risk prostate cancer patients. Death from diseases of the heart was more than twice as likely as death from prostate cancer.

Purpose To determine whether adverse pathologic features, including tumor grade and percent positive biopsy (PPB) cores, predict for prostate size reduction after neoadjuvant cytoreductive therapy. Methods and Materials Eighty-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 (50 mg daily) and dutasteride (0.5 mg 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. Results At TTMB, the mean prostate volumetric and ellipsoid volumes were 55.4 cm3 and 49.0 cm3, respectively. After neoadjuvant medical therapy, the mean volumetric and ellipsoid prostate volumes were 30.8 cm3 and 28.5 cm3, respectively. On average, the prostate volume decreased by 43.9% and 41.0% on volumetric and ellipsoid measurements, respectively. The TZ volume decreased from 19.8 cm3 to 10.1 cm3 (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). Conclusions The 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.

Purpose To determine whether periprostatic treatment margins correlate with biochemical control in prostate brachytherapy patients with optimized intraprostatic dosimetry. Methods and Materials Nineteen biochemically failed brachytherapy patients were matched to 74 dosimetric and clinically equivalent nonfailures. The median followup time for the entire study population was 9.4 years. Eligibility requirements included a Day 0 intraprostatic D 90 of 100% or greater and V 100 of 90% or greater, absence of androgen deprivation therapy, and no evidence of distant metastasis in biochemically failed patients. A 5-mm annulus was constructed around the perimeter of each prostate. D 90 and V 100 at the anterior, posterior, superior, inferior, right lateral, and left lateral aspects of the annulus were evaluated for patients with biochemically controlled and failed disease. Biochemical progression-free survival (bPFS) was defined as a prostate-specific antigen level of 0.40 ng/mL or less after nadir. D 90 and V 100 parameters were compared between the controlled and failed groups using logistic regression. Predictors of biochemical failure were identified using Cox regression. Results No statistically significant differences in prostate-specific antigen level, Gleason score, percent positive biopsies, or intraprostatic dosimetry were observed between the controlled and failed patients. The D 90 and V 100 at the anterior, posterior, superior, inferior, right lateral, and left lateral aspects of the annulus were not statistically different between biochemically controlled and failed groups. Conclusion In this study, there was no relationship observed between annular dosimetry and biochemical control. It is unlikely that further radial dose intensification would have altered treatment outcome in this population of patients with optimized intraprostatic dosimetry.

Purpose Acute prostate brachytherapy-related morbidity is dominated by urinary symptomatology. In this study, we evaluated the effect of severe early brachytherapy-related urinary morbidity on late urinary function. Methods and materials From January 1998 to September 2003, 1029 patients were implanted for clinical stage T1b–T3a (2002 American Joint Committee on Cancer [AJCC] criteria) prostate cancer. Five hundred sixteen (50.1%) received supplemental external beam radiation therapy and 440 (42.8%) received androgen deprivation therapy. Severe acute urinary morbidity (SAUM) was defined as a dysuria frequency score of at least 4 (of 5), a dysuria severity score of at least 8 (of 10), an internation prostate symptom score (IPSS) elevated to at least 30 or 15 above preimplant value for 4 weeks, and/or requirement of a urinary catheter for at least 5 days. Dysuria severity and frequency resolution were defined as a return to within one point of baseline. IPSS resolution was defined as a return to within two points of baseline. Results Of the 1029 patients, 175 met at least one of the criteria for inclusion. Dysuria frequency resolved in 5.0 vs. 1.3 weeks and dysuria severity in 5.7 vs. 1.4 weeks, for patients with and without SAUM. The mean time for IPSS resolution was 13.8 vs. 6.6 weeks, for patients with and without SAUM. The incidence of transurethral resection (2.3% [4/173] vs. 1.5% [13/841]) and bulbomembranous urethral strictures (2.2% [4/175] vs. 1.8% [15/854]) were comparable among patients with and without SAUM. Conclusions Patients experiencing brachytherapy-related SAUM have long-term urinary function and complications comparable to patients who did not develop SAUM.

Purpose To determine whether a previously reported substratification system can be extrapolated to patients with high-risk prostate cancer treated with permanent interstitial brachytherapy. Methods and Materials Four hundred six National Comprehensive Cancer Network patients with high-risk prostate cancer treated with permanent prostate brachytherapy with or without supplemental external beam radiotherapy were stratified into good (prostate-specific antigen >20 or Gleason score ≥8 or ≥T3), intermediate (prostate-specific antigen >20 and ≥T3), and poor (Gleason score ≥8 with ≥1 additional high-risk feature) prognostic cohorts. Because of only 1 patient with intermediate high-risk disease, the analysis was performed on patients in the good and poor cohorts. Biochemical failure (BF), prostate cancer–specific mortality (PCSM), distant metastasis, and overall mortality were assessed as function of prognostic group. Multiple parameters were evaluated for impact on outcome. Results With a median followup time of 7.9 years, 10- and 14-year rates of BF and PCSM for the entire cohort were 7.8% and 3.7%, respectively. The BF rate was significantly greater in the poor prognostic category (16.8% vs. 7.8%, p = 0.041). The poor prognostic category was the strongest predictor of BF in univariate and multivariate analyses. No statistically significant differences in PCSM, distant metastasis, or overall mortality were identified between the good and poor prognostic categories. Conclusions Patients with high-risk prostate cancer treated with a brachytherapy approach have excellent long-term biochemical control and cancer-specific survival. The poor prognostic high-risk category had a higher rate of BF compared with the good prognostic category without a higher rate of PCSM or distant metastasis.

On univariate analysis, BF was associated (p! 0.05) with Gleason 7 and pre-tx PSA; CF with HDR boost, T stage, and pre-tx PSA; and decreased OS with IGRT, age, and Gleason 7. Race, perineural invasion (PNI) and androgen deprivation were not associated with any outcome. Higher PSA nadir (p! 0.001) and PSA nadir at 1 year (p#0.02) were associated with worse BF, CF and OS. On multivariate analysis (MVA), BF was associated (p! 0.05) with Gleason 7 and pre-tx PSA, and a trend for PNI (p 5 0.06); CF with Gleason 7, and pre-tx PSA; and worse OS with Gleason 7 and age, and trend for pre-tx PSA (p 5 0.08). PSA nadir at 1 year greater than 1 ng/mL was associated with worse outcomes when added to all three models (p#0.02). Conclusions: Dose escalated IGRT and HDR boost both yield excellent clinical outcomes. The higher rate CF for HDR boost is likely due to worse pathologic characteristics, while the increased OS is likely due to younger age. When accounted for in the MVA, treatment type was not significant.

volumes and dimensional parameters were normalized on the respective parameters of the HRCTV delineated on MRI at the time of BT (HRCTVREF). All patients were analyzed with respect to stage and the IB2 and advanced cases were also analyzed in respect to tumor response to EBRT (10 out of 16 had a reductionO50% of the initial volume) and pre-BT tumor dimension (5 patients out of 16 had a tumor widthO5 cm at the time of BT). Results:The respectivemedian volumes were 53.5 21cc (HRCTV1), 38.5 18cc (HRCTV2), 34.15 15.5cc (HRCTV3) and 35.3 19.2cc (HRCTVREF). The normalized median value was 1.5 0.57 (HRCTV1), 1.1 0.36 (HRCTV2) and 1 0.19 (HRCTV3). Median widths were 5.46 1.23cm (HRCTV1), 4.93 1.09cm (HRCTV2), 4.84 0.83cm (HRCTV3) and 4,96 0,96cm (HRCTVREF), with a normalized median width value of 1.18 0.17 (HRCTV1), 1.1 0.13 (HRCTV2) and 1.03 0.08 (HRCTV1), respectively. Median heights were 4.7 0.8cm (HRCTV1), 3.7 0.82cm (HRCTV2), 3.25 0.84cm (HRCTV3) and 3.45 1cm (HRCTV4). The normalized height values were 1.17 0.25 (HRCTV1), 1.04 0.16 (HRCTV2) and 0.94 0.08 (HRCTV3). No significant differences were found in respective HR-CTVs thickness. Subgroup analysis results according tumor stage, response to EBRT and pre-BT tumor size is reported in Fig. 1.