Search

One strategy to improve the effectiveness of intravascular brachytherapy (IVBT) is to study its failures. Previous investigations described mostly discrete, focal recurrences, typically at the proximal or distal edges of the irradiated segment after plain angioplasty or bare metal stents. We reviewed failure patterns of 30 unselected drug-eluting stent (DES) patients who had follow-up angiograms for recurrence within their IVBT-treated vessel.Records of 53 unselected IVBT patients treated between 2016 and 2021 were reviewed. Thirty of the 53 patients had at least one subsequent percutaneous intervention (PCI) for in-stent restenosis (ISR) after IVBT. Angiographic findings of those 30 patients with ISR within their previously irradiated vessel are reported here.Of the 30 patients, 21 (70%) developed recurrent ISR within the irradiated segment. Six of the 21 patients who failed within the irradiated segment also experienced ISR proximal or distal to the irradiated segment. Only 15 patients (50%) failed exclusively within the irradiated segment. In nine patients (30%), restenosis occurred proximally and/or distally to the irradiated segment, but not inside of the irradiated segment itself.We have shown here that 50% of failures after coronary IVBT for DES ISR occur exclusively within the irradiated segment. An additional 20% of patients had failure within and outside of the irradiated segment. These percentages suggest that a higher radiation dose might improve the long-term patency rates, a conclusion that should be tempered by the lack of universal follow-up.

In the 1998-2005 heyday of intravascular coronary brachytherapy, a variety of delivery devices were developed and marketed. As the industry shrank, only one device, the Novoste Beta-Cath 3.5F System (Best Vascular, Norcross, GA) remained in commercial production. The 2008 instruction manual, the only official source of technical guidance, lacks recommendations for various common scenarios.The clinical conundrums described here were encountered during regular use of the Novoste system in 81 patients treated from January to December of 2020 in the course of using the Novoste device in accordance with the 2008 manufacturer's instruction manual. Our experience and strategies are reported and critiqued.Ambiguous patient selection factors include vein grafts, multiple affected vessels, large vessels, retreatment, multiple overlapping stents and prior radiation. Procedural ambiguities include vessel size determination, proper prescription dose, very long lesions and eccentric source positioning. Potential procedural mishaps include stuck sources and the risk of contamination.The Novoste intravascular coronary brachytherapy system is the only commercially available brachytherapy delivery catheter, and may remain so for some time. The issues detailed here provide insight and guidance for current users and may prompt research into areas lacking adequate information.

Total body irradiation (TBI) is an integral part of stem cell transplant. However, patients are at risk of treatment-related toxicities, including radiation pneumonitis. While lung dose is one of the most crucial aspects of TBI dosimetry, currently available data are based on point doses. As volumetric dose distribution could be substantially altered by lung block parameters, we used 3D dosimetry in our treatment planning system to estimate volumetric lung dose and measure the impact of various lung block designs.We commissioned a TBI beam model in RayStation that matches the measured tissue-phantom ratio under our clinical TBI setup. Cerrobend blocks were automatically generated in RayStation on thoracic Computed Tomography (CT) scans from three anonymized patients using the lung, clavicle, spine, and diaphragmatic contours. The margin for block edge was varied to 0, 1, or 2 cm from the superior, lateral, and inferior thoracic borders, with a uniform margin 2.5 cm lateral to the vertebral bodies. The lung dose was calculated and compared with a prescription dose of 1200 cGy in six fractions (three with blocks and three without).The point dose at midplane under the block and the average lung dose are at the range of 73%-76% and 80%-88% of prescription dose respectively regardless of the block margins. In contrast, the percent lung volume receiving 10 Gy increased by nearly two-fold, from 31% to 60% over the margins from 0 to 2 cm.The TPS-derived 3D lung dose is substantially different from the nominal dose assumed with HVL lung blocks. Point doses under the block are insufficient to accurately gauge the relationship between dose and pneumonitis, and TBI dosimetry could be highly variable between patients and institutions as more descriptive parameters are not included in protocols. Much progress remains to be made to optimize and standardize technical aspects of TBI, and better dosimetry could provide more precise dosimetric predictors for pneumonitis risk.

BACKGROUND The objective of this study was to define the long-term prognostic significance of prostatic acid phosphatase (PAP) levels in patients with higher risk, early-stage prostate carcinoma. METHODS One hundred sixty-one consecutive patients with Stage T1–T3 prostate carcinoma (according to the 1992 criteria of the American Joint Committee on Cancer) were treated from 1992 through 1996. Each patient had a Gleason score ≥ 7 and/or a prostate specific antigen (PSA) level > 10 ng/mL. The original biopsy slides for 130 of 161 patients were retrieved and rereviewed by a single pathologist (L.T.). Enzymatic PAP measurements were determined using a standard method. Values up to 2.5 Units were considered normal. Patients received 41 grays (Gy) of external beam radiation therapy to a limited pelvic field followed 4 weeks later by a palladium 103 (Pd-103) boost using transrectal ultrasound and fluoroscopic guidance as described previously. The prescribed minimum Pd-103 dose to the prostate was 80 Gy (pre-National Institute of Standards and Technology [NIST]-99). Freedom from biochemical failure was defined as a serum PSA level ≤0.2 ng/mL at last follow-up. RESULTS There was little correlation between pretreatment PSA levels, Gleason scores, and PAP measurements. Thirty-eight patients developed biochemical failure. The overall actuarial freedom from biochemical progression at 10 years is 79%, with 118 patients followed for > 5 years. In a multivariate Cox proportional hazards analysis that considered each factor as a continuous variable, the strongest predictor of failure was PAP (P = 0.0001), followed by Gleason score (P = 0.13), and PSA (P = 0.04). PAP was especially helpful in stratifying patients with pretreatment PSA levels between 4 ng/mL and 20 ng/mL, for whom the prognosis does not different when they are subdivided into PSA categories. When the PAP subgroup analysis was limited to this relatively favorable group, there was a wide range of prognoses. CONCLUSIONS The biochemical cure rate was remarkably high among the 161 patients evaluated. The fact that the PAP was the strongest predictor of long-term biochemical failure in patients with otherwise higher risk features reported here suggests that it may be a more accurate indicator of micrometastatic disease compared with the Gleason score and the PSA level. This report adds to the rationale for reintroducing PAP measurement into general practice. Cancer 2003;97:979–83. © 2003 American Cancer Society. DOI 10.1002/cncr.11154

Sexual function was evaluated in 34 patients with low-risk prostate cancer (PSA ≤ 10, Gleason score ≤ 6, clinical stage T1/T2) undergoing brachytherapy in a phase III prospective randomized trial comparing iodine-125 (125I) to palladium-103 (103Pd). The mean and median International Index of Erectile Function (IIEF) scores for the entire group were 14.2 and 16.5, respectively, and there was no difference between these scores when stratified by isotope. IIEF scores < 6, 6 to 11, and ≥ 12 were recorded in 35% (12/34), 6% (2/34), and 59% (20/34) of patients, respectively. Hematospermia, orgasmalgia (pain at the time of orgasm), and alteration in intensity of orgasm were documented in 26% (9/34), 15% (5/34), and 38% (13/34) of patients, respectively, but these side effects were of limited duration for most patients. There was no relationship between radiation dose to the neurovascular bundles (NVB), which averaged 209% of the prescribed prostate dose, and the development of postbrachytherapy impotence. All four impotent patients who used sildenafil responded favorably. With a median follow-up of 13 months, 65% of patients undergoing prostate brachytherapy maintained sexual function without pharmacologic support. Including sildenafil responses, 76.5% of patients sustained erections sufficient for sexual intercourse. 2001 Wiley-Liss, Inc.

The purpose of this study is to help clarify the use of prostate size as a selection factor for prostate brachytherapy. From 1997 to 1998, 33 patients with a TRUS-based prostate volume greater than 50 cc were treated at the University of Washington by I-125 (144 Gy) or Pd-103 (115 Gy) implantation for prostatic carcinoma. These 33 patients comprised 7% of the total implants performed. Each patient underwent a preimplant TRUS study in the lithotomy position, taking serial axial images of the prostate at 0.5 cm intervals from the base of the gland to the apex. The contours on the preimplant TRUS images were used to calculate the prostate volumes reported here. Only one patient received supplemental external beam irradiation prior to implantation. Twelve patients were treated with neoadjuvant androgen ablation prior to implantation. The prostate volumes quoted here are those taken after hormonal downsizing. Postimplant axial CT images were digitized to calculate the CT-based target coverage. Preimplant urinary obstructive symptoms were quantified by the criteria of the American Urologic Association. Each patient was contacted at the time of this article preparation to update postimplant morbidity information. In all cases, at least 80% of the postimplant volume was covered, despite a median implant-related volume increase of 15%. Five of the 33 patients' postimplant CT scans showed some degree of incomplete target coverage of the anterior/lateral prostate margin. There was no clear association between inadequate anterior/lateral coverage and the degree of interference. Twelve of the 33 patients developed acute postimplant urinary retention, all occurring within 24 hr of implantation. Within this group of 33 patients with a large prostate volume, there was no relationship between the likelihood of acute or chronic urinary retention and preimplant prostate size or obstructive symptoms. Patients who developed postimplant retention lasting more than one week were generally managed by intermittent self-catheterization. By one month, 85% of patients were catheter-free. Based on the data reported here, we are more inclined to accept patients with a large prostate for implantation without insisting on preimplant size reduction. Int. J. Cancer (Radiat. Oncol. Invest.) 90, 199–205 (2000). © 2000 Wiley-Liss, Inc.

Purpose: To determine urinary morbidity in patients who have transurethral resection of the prostate (TURP) after 125 I brachytherapy. Materials and Methods: A total of 109 patients with Stage T1–T2 prostatic carcinoma were treated with 125 I implantation from 1991 through 1995. Ten patients underwent TURP/transurethral incision of the prostate (TUIP) after brachytherapy to relieve urinary obstruction refractory to nonsurgical management. Results: Patients who developed refractory urinary retention had a slightly larger preimplant prostate volume than those who did not (62 vs. 54 ml; p = 0.16). Seven of the 10 patients developed some degree of permanent urinary incontinence following TURP/TUIP. Urinary incontinence was mild in three patients [Late Effects Normal Tissue Radiation Oncology Group (LENT) score = 1] and severe in four additional patients (LENT score = 3). There was no obvious relationship between the degree of incontinence and use of TURP vs. TUIP, amount of tissue resected, or time between brachytherapy and TURP/TUIP. In five patients for whom detailed urethral radiation dose information was available, the doses were higher than generally recommended. Conclusion: Permanent urinary incontinence is common in patients who require a TURP or TUIP after prostate brachytherapy. Its cause is apparently multifactorial and may include the degree of physical damage to the urinary sphincters and the radiation dose to the urethral region.

Purpose: There are minimal data to support the perceived contraindication of radiation therapy in patients with inflammatory bowel disease (IBD). Because of widespread concern about the possibility of radiation-related morbidity in IBD patients, the posttreatment course for 6 patients with a history of IBD who were treated with 125 I prostate implantation for early stage prostate cancer are reported here. Materials and Methods: Six patients with a prior history of IBD and Stage T1c–T2c prostatic carcinoma underwent 125 I prostate brachytherapy from 1991–1996. Three patients had Crohn's disease and three had ulcerative colitis. The treatment plans were designed to treat the preimplant prostatic margin, as defined on planning CT scan, to 150 Gy. No special effort was made to minimize the rectal surface dose. Detailed records were available for all patients, and all patients were interviewed for this report. Follow-up ranged from 1 to 6 years (median: 3.7 years). Results: None of the 6 patients experienced unusual or significant gastrointestinal side effects following implantation. All 6 patients remain free of GI complications. The rectal surface area that received >100 Gy was kept below 10 mm 2 in all patients, in accordance with previously published guidelines. Conclusions: Based on the limited information available, it appears that prostate brachytherapy is safe in patients with a history of IBD.

Purpose: To demonstrate CT-based target coverage achieved by an experienced brachytherapy team, with a documented history of clinical efficacy. These results may serve as a point of reference by which other implant teams could evaluate their technical results. Methods and Materials: Two to 4 h after implantation, a CT scan of the pelvis was obtained, taking 3-mm thick images at 3 mm scan intervals. The outer margins of the rectum and prostate were outlined on each CT section by a single investigator (KW). CT scans from 20 consecutive, unselected patients with stage T1 or T2 prostatic carcinoma who had transperineal 1-125 implants at MSKCC in 1995 were analyzed. The prescribed minimum peripheral prostate dose was 140 Gy, based on a preimplant CT scan of the prostate. Target volumes were determined based on planar reconstruction of the prostate. Results: An average of 84% of the target (range: 76-92%) was covered by the 140 Gy isodose line. An average of 90% of the target (range: 81-96%) was covered by the 120 Gy isodose line. The average minimum target dose was 57 Gy (range: 40-70 Gy). There was a loose correlation between the minimum dose and the degree of target coverage (r = 0.33). Conclusions: Based on CT scanning on the day of the implant, coverage of 80% or more of the target volume by the prescription dose is probably adequate. Accurate evaluation is a complex problem that is made imprecise by difficulty in target identification and by volume changes after the implant.

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 dilation for urethral strictrue. 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 sequele following I-125 or Pd-103 implantation in patients with a prior history of TURP.

Purpose: We report the prostate specific antigen (PSA) based recurrence-free survival rate after 125iodine (sup 125 I) implantation for early stage prostatic carcinoma.Materials and Methods: A total of 197 patients with clinical stage T1 or T2 prostatic carcinoma underwent outpatient 125I seed implantation. Followup was 1 to 7 years (median 3). Pretreatment serum PSA levels were elevated (greater than 4.0 ng./ml.) in 138 patients (70 percent). There were 105 well differentiated (Gleason score 2 to 4), 87 moderately differentiated (Gleason score 5 to 6) and 5 indeterminate tumors. The prescribed minimum prostatic dose was 160 Gy. The total dosage of 125I implanted ranged from 15 to 62 mCi. (median 37). Staging lymph node dissection and seminal vesicle biopsies were not routinely performed.Results: Among 138 patients with an elevated PSA level before implantation and no prior hormonal treatment, the PSA value returned to normal in 98 percent and decreased to less than 1.0 ng./ml. in 82 percent withi...

PURPOSE: To establish dosimetry guidelines to minimize urethral and rectal morbidity following permanent I-125 prostatic brachytherapy. METHODS AND MATERIALS: Dosimetric parameters were correlated with long-term morbidity for 65 patients following transperineal I-125 implantation for Stage T1/T2 prostatic carcinoma. The prescribed minimum prostatic dose was 150 Gy. The median total activity used was 48 mCi (range: 32-77 mCi). Patients were followed for 1-5 years (median follow-up: 2 years). Postimplant computerized tomography (CT)-based dosimetry was performed for 45 patients. Morbidity was evaluated using a modification of the RTOG grading system, with a scale of grade 0-5. RESULTS: The incidence of grades 2 and 3 urinary morbidity was associated with the maximum central urethral dose (p = 0.03), and with the length of urethra that received greater than 400 Gy (p = 0.07). Patients with larger prostates had more long-term urinary morbidity (p = 0.06). Rectal bleeding (RTOG grade 1) or ulceration (RTOG grade 2) was associated with irradiation of the rectal wall to doses in excess of 100 Gy (p = 0.02). There was no relationship between the matched peripheral dose (MPD), mCi/source or total mCi implanted and long-term morbidity. CONCLUSIONS: Postimplant, CT-based dosimetry can predict which patients are at higher risk of radiation-related morbidity. More simplistic parameters including the MPD, total activity implanted, or mCi/source, had no relationship with morbidity. To decrease the risk of long-term morbidity, an effort should be made to keep the central urethral dose below 400 Gy, and the rectal surface dose below 100 Gy. Language: en

PURPOSE To determine the prognostic significance of a normal serum prostate-specific antigen (PSA) level in patients with prostatic cancer with long-term follow-up evaluation after radiotherapy. MATERIALS AND METHODS PSA information was available in 403 patients (38%) who were treated with pelvic lymph node dissection and retropubic radioactive iodine-125 implantation. One hundred eighty-two patients had a normal serum PSA level (< or = 4.0 ng/mL) the first time this test was conducted during the follow-up period, designated PSA-1. RESULTS Among patients with PSA-1 values < or = 1.0 ng/mL, the 5-year PSA relapse-free survival rate was 85% compared with 27%, respectively, among those with PSA values in the higher range of normal (P < .00001). Multivariate analysis demonstrated that only a PSA-1 value greater than 1.0 to < or 4.0 (P < .00001) and grade II/III histology (P = .009) had a negative impact on continued PSA relapse-free survival. The only independent variable identified by a multivariate analysis to affect local relapse-free survival (LRFS) was a PSA-1 value greater than 1.0 to < or = 4.0 ng/mL (P < .004), while high-grade histology (P < .0001) and local failure (P < .001) were the only significant variables to affect distant metastases-free survival (DMFS). CONCLUSION Patients with PSA values < or = 1.0 ng/mL are significantly less likely to have a subsequent relapse after therapy than those with levels greater than 1.0 to < or = 4.0 ng/mL. Continuously maintained PSA levels of < or = 1.0 ng/mL after treatment may serve as an end point for early evaluation of the efficacy of experimental radiotherapy protocols in prostate cancer.

Purpose : To evaluate short-term clinical and chemical disease progression following computed tomography (CT)-based transperineal I-125 prostate implantation. Methods and Materials : Sixty-two patients with clinical Stage T1 or T2 prostatic carcinoma had outpatient, CT-based transperineal I-125 prostate implantation and have been followed for 6–55 months (median: 19 months). Fifty-six patients had an elevated prostate specific antigen (PSA) before implantation (. 4.0 ng/mL). Twenty patients had well-differentiated tumors, 39 were moderately differentiated, 2 were poorly differentiated, and 1 was indeterminate. A total of 32–73 mCi I-125 was implanted (median: 47 mCi). The prescribed minimum prostatic dose was 140–160 Gy, and the actual matched peripheral dose ranged from 109–258 Gy (median: 160 Gy). Lymph node dissection or postimplantation prostatic biopsies were not routinely performed. Results : Of 54 patients with an elevated PSA prior to implantation and no prior hormonal treatment, 96% returned to normal within 24 months of treatment. In 85% of patients, the PSA fell below 2.0 ng/mL and in 74% of patients, the PSA value fell to below 1.0 ng/mL. Seven patients had disease progression, one of whom has an isolated, rising PSA. The actuarial rate of chemical (rising PSA) or clinical failure at 3 years following implantation was 17%. Of 38 patients who were sexually potent prior to implantation, 81% remained potent at 3 years. Five patients developed radiation-induced rectal ulcerations, 11–22 months following implantation. Three patients required a transurethral resection of the prostate for postimplant urinary symptoms. Conclusions : The short-term clinical and chemical freedom-from-progression rates following I-125 implantation are comparable to that achieved with prostatectomy, with high preservation of sexual potency and moderate morbidity.

Purpose: To quantitate the influence of dose inhomogeneity on brachytherapy efficacy. Methods and Materials: A computed tomography-based system of planning, implementation and evaluation was used to generate tumor-specific dose-volume histograms of eight permanent 125 I implants of prostate cancers. The radiobiological effect was then assessed, voxel by voxel, in terms of the biologically effective dose and the associated cell inactivation. The overall cell survival of the entire target volume was then computed. To evaluate the influence of inhomogeneity, the dose-volume histogram was modified in an iterative fashion, with the corresponding surviving fraction calculated after each step. Specifically, the volume in the highest dose bin was combined with that in the next bin to give a new frequency distribution from which cell survival was generated. Tumor control probability (TCP) was also used as an endpoint, using the same iterative procedure. Results: Doses 20–30% higher than D99 (the dose that covered 99% of the target volume) contributed to additional cell inactivation, but still higher doses did not further increase cell kill. With homogeneous irradiation at D 99 as a reference, we defined the inhomogeneity enhancement factor as the ratio of the biologic effective dose of the actual implant to that of the reference dose distribution. The calculated enhancement factors were inversely dependent on tumor potential doubling time (Tp), about 1.2 – 1.3 for a Tp of 30 days, and between 1.3 and 1.7 if Tp=10 days, with higher values for implants with low D99. Dose inhomogeneity enhanced TCP. For implants with high control probabilities, doses significantly higher (> 20%) than the D99 value did not further enhance the tumor control probabilities. In contrast, for implants with relatively low tumor control and D 99 values, the control probability continued to increase with doses significantly higher than D 99 , up to a dose of 2 × D 99 . The underlying reasons were the incorporation of patient "population averaging" in the calculation and the saturation of tumor control dose response at about 120 Gy. Conclusion: Dose heterogeneity in implants increased tumor cell kill and local control probability, although doses > 20% higher than the prescription dose is wasted. The increase the beneficial effect of dose inhomogeneity may be greatest when most needed.

Purpose: To summarize the urinary, rectal, and sexual symptoms occuring during the first 12 months following 125 I prostatic implantation. Methods and Materials: Thirty-one patients with Stage T 1 or T 2 prostatic carcinoma were evaluated for morbidity following computed tomography-guided transperineal 1251 implants from 1988 to 1991. The median total activity used was 47 mCi (range 35–73 mCi). Toxicity was evaluated using a modification of the Radiation Therapy Oncology Group grading system. Results: Nocturia was the most common treatment-related symptom, reported by 80% of patients within 2 months after implantation, and persisted at 12 months in 45% of the patients. Mild dysuria developed in 48% of patients within 2 months of implantation; two patients needed analgesics for their dysuria. Terazosin hydrochloride (2–10 mg qd) provided subjective improvement of urinary symptoms in seven of eight patients in whom it was tried. Rectal urgency, soft stools, and increased frequency of bowel movements was reported by 25% of the patients within 1–2 months after implantation. The incidence of assymptomatic rectal bleeding or ulceration occurring at any time after implantation was 47%, but resolved in all patients with expectant treatment. Self-limited ulceration of the rectal mucosal occurred in 16%, but only one patient developed a prostato-rectal fistula, managed with an ileal conduit. Five of the 18 potent patients experienced discomfort on erection or ejaculation, beginning within several weeks of their implant. The discomfort resolved within 6 months in three of the patients, but persisted for 18 and 24 months in the other two. Conclusion: 125 I implantation, as performed in this series, is generally associated with only mild-moderate genitourinary and rectal symptoms that may persist 6 months or more after implantation. Prostatic carcinoma, Brachytherapy, Morbidity.

Between March 1970 and December 1987, 1,078 patients with adenocarcinoma of the prostate were treated with pelvic lymph node dissection and permanent 125iodine implantation. Before implantation, 257 patients (27%) underwent transurethral resection of the prostate, while 702 (73%) did not and their diagnosis was established by needle biopsy. A total of 119 patients (10%) underwent hormonal therapy before implantation and they were excluded from the present analysis. Clinical stage and pathological grade were similar in both groups. A higher percentage of patients in the transurethral resection group had nodal metastases at implantation. Positive lymph nodes were found in 121 patients (47%) in the transurethral resection group versus 199 (26%) who did not undergo resection (p0.001). The actuarial 5, 10 and 15-year distant metastasis-free survival rates among the patients who underwent transurethral resection of the prostate were 79%, 42% and 16%, respectively, compared to 86%, 52% and 27%, respectively, in the group without transurethral resection (p0.0001). Similarly, the actuarial disease-free and local relapse-free survival rates were significantly inferior in the transurethral resection group. A negative impact of transurethral resection of the prostate could be demonstrated among patients with grade I/II tumors. However, when stratified for nodal status, no difference in outcome in any clinical parameter was noted between the groups with and without transurethral resection of the prostate. Specifically, distant metastasis-free survival among transurethral resection group patients with negative nodes was 78%, 57% and 47% at 5, 10 and 15 years, respectively, compared to 80%, 59% and 47%, respectively, among the patients with negative nodes who did not undergo transurethral resection of the prostate (p = 0.38). Similarly, the differences between the 2 groups among patients with positive lymph nodes were not significant. When stratified by the clinical stage, grade and nodal status, the negative impact of transurethral resection of the prostate could not be demonstrated in any combination. A multivariate analysis failed to demonstrate transurethral resection of the prostate to be an independent variable in predicting the metastatic, local control or disease-free survival outcome. In conclusion, the long-term results in these pathologically staged cases indicate that transurethral resection of the prostate does not impact negatively on the clinical outcome.

Purpose : To determine the long-term impact on function of treatment for primary cerebral gliomas, Karnofsky Performance Status, employment history, and memory function were used to evaluate the status of adults who are alive and disease-free more than 1 year after cranial irradiation. Methods and Materials : Of 30 eligible adult patients, seventeen patients had anaplastic astrocytoma, seven had a glioblastoma, four had low grade astrocytoma, one had a mixed glioma, and one had an anaplastic oligodendroglioma. Sixteen patients received partial brain irradiation only, 12 had whole brain irradiation with a partial brain boost, and two had whole brain irradiation only. The total dose ranged from 54–66 Gy, with a fraction size of 1.7–2.0 Gy. Median follow-up was 3.5 years. Eighty-three percent of patients also received adjuvant chemotherapy. Results : Karnofsky Performance Status generally remained stable after the completion of irradiation. Mean Performance status was 84 at the end of irradiation and was unchanged at the time of last follow-up. The actuarial freedom from performance status decline after irradiation was 93% at 5 years. The performance status increased in two patients, both within several months of completing irradiation. Most patients (68%) returned to work after irradiation. Sixty-two percent remained at work 1 year later, and 58% were working at the time of last follow-up. No patient who did not return to work within 4 months of completing irradiation was able to work at a later date. All working patients were employed in a capacity similar to their pre-morbid position. Only one patient, with an intercurrent lung cancer, eventually developed deficits that limited self care. Conclusions : Contrary to previously published reports, long-term glioma survivors maintained a relatively good performance status in the absence of recurrence and did not experience a progressive decline in neuropsychologic function after completion of cranial irradiation. A patient's functional state at the completion of irradiation is a reliable predictor of long-term functional outcome in the absence of recurrence. Although the number of patients in each subgroup is small and no significant differences could be detected, patients treated with partial brain irradiation had a higher and more stable performance status, better memory function, and superior employment history.

There has recently been a resurgence of interest in iodine-125 (I-125) prostate implantation for early stage carcinoma due to the introduction of transrectal ultrasonography (TRUS) or computerized-tomographic (CT)-based transperineal techniques. The present study details initial tumor response and morbidity of CT-based transperineal prostate implantation. Forty-two patients with clinical stage T1 or T2 prostatic carcinoma had CT-planned transperineal I-125 implantation of the prostate and have been followed for 6–47 months (median: 19 months). Thirty-eight patients had an elevated PSA before implantation (>4.0 ng/ml). A total of 35–73 mCi I-125 was implanted (median: 48 mCi). At 1 year after implantation, 84% of 29 palpable tumors were no longer palpable. Of 38 patients with an elevated prostate specific antigen (PSA) prior to implantation, 98% returned to normal within 12 months of treatment. In 74% of patients, the PSA value fell to below 1.0 ng/ml within 12 months of implantation. Of 25 patients who were sexually potent prior to implantation, 80% remained potent at 3 years. Four patients developed radiation-induced rectal ulcerations 9–19 months following implantation. Of those four patients, one has healed spontaneously, two are improving, and one was diagnosed only 1 month prior to this report. Initial tumor response to I-125 implantation is comparable to that achieved with external beam irradiation, with acceptable morbidity and high preservation of sexual potency. With adjustments in technique, morbidity is expected to be lower in the future. © 1993 Wiley-Liss, Inc.

Treatment planning for malignant astrocytomas has been an area of controversy for the past 30 years. Several key studies have supported widely divergent treatment philosophies. Before the availability of computerized tomography (CT) scanning, whole brain irradiation (WBRT) was necessary to ensure adequate tumor coverage, due to limitations of less-sophisticated imaging studies. Following the introduction of high-quality CT scanning and magnetic resonance imaging (MRI), there was a shift to the use of more-limited radiation fields to treat only the contrast-enhancing tumor plus a margin. Additional impetus for use of smaller treatment fields came from studies implicating WBRT in cerebral dysfunction in long-term survivors.‘~* Recently, the appeal of limited field irradiation has been tempered by biopsy and autopsy studies that suggest wider migration of malignant cells than previously believed?” There have thus emerged two schools of thought. One is that patients should receive limited field irradiation, with the hope of avoiding mental deterioration in the few long-term survivors. The opposite argument is that patients should receive WBRT in order to treat all potential sites of tumor infiltration in all patients. While both points of view have merit, they must be reconciled with the fact that many patients will die of their disease within 1 year of diagnosis, regardless of the radiation fields used. The bulk of retrospective data available do not show a survival advantage to large versus small field irradiation (for review, see reference 5). The first study to systematically analyze radiation planning for high-grade astrocytomas was published by Concannon et al” in 1960. Partial brain irradiation (PBRT) fields were compared with tumor volumes identified at autopsy in 2 1 patients who died shortly after starting treatment. The fields were designed

The study evaluates the effect of the locally recurring tumor on the incidence of metastatic disease in early stage carcinoma of the prostate. The probability of distant metastases was studied in 679 patients with Stage B-C/NO carcinoma of the prostate treated at MSKCC between 1970 and 1985 (median follow-up of 97 months). Patients were staged with pelvic lymph node dissection and treated with retropubic 125I implantation. The actuarial distant metastases free survival (DMFS) for patients at risk at 15 years after initial therapy was 37%. Cox proportional hazard regression analysis of covariates affecting the metastatic outcome showed that local failure, used in the model as a time dependent variable, was the most significant covariate, although stage, grade, and implant volume were also found to be independent variables. The relative risk of metastatic spread subsequent to local failure was 4-fold increased compared to the risk without evidence of local relapse. The 15-year actuarial DMFS in 351 patients with local control was 77% compared to 24% in 328 patients who developed local relapses (p < 0.00001). The relation of distant spread to the local outcome was observed regardless of stage, grade, or implant dose. Even stage BI/NO-Grade I patient with local control showed a 15-year actuarial DMFS of 82%, compared to 22% in patients with local relapse; p < 0.00001). The median local relapse-free survival (LRFS) in the 268 patients with local recurrences who did not receive hormonal therapy before distant metastases were detected was 51 months, compared to a median of 71 months for DMFS in the same patients (p < 0.001), consistent with the possibility that distant dissemination may develop secondary to local failure. Furthermore, distant metastases in patients with local control, apparently already existing as micrometastases before treatment, were detected earlier (median DMFS of 37 months) than in patients with local relapse (median DMFS of 54 months; p = 0.009). These data suggest that the existence and re-growth of local residual disease in localized prostatic carcinoma promotes an enhanced spread of metastatic disease, and that early and complete eradication of the primary tumor is required if a long term cure is to be achieved, although the clinical expression of secondary metastases may not become apparent for 6.5 years or more in one-half of the patients.

Thirty patients treated with surgical resection and brachytherapy for chest wall sarcoma at Memorial Sloan-Kettering Cancer Center from 1980 through 1987 were reviewed. Patients selected to receive adjuvant irradiation were those for whom there was doubt as to the completeness of surgical resection. Overall 5-year survival and locoregional control after brachytherapy were 65% and 54%, respectively. Locoregional control was similar for tumors treated at initial diagnosis (12 patients), at the time of recurrence (13 patients), or for tumors that were metastatic to the chest wall (five patients). Six patients with tumors larger than 10 cm in maximum dimension had a locoregional recurrence rate of 69% versus a recurrence rate of 39% for 18 patients with smaller tumors (p = 0.27). Fifty-four percent of high-grade tumors recurred locoregionally versus 28% of low-grade tumors (p = 0.37). Bone invasion or the presence of positive resection margins was not clearly associated with a higher locoregional failure rate. Only one patient (1/28; 7%) was known to have had recurrence within the irradiated area. Eight patients (8/28; 37%) had recurrence adjacent to the implanted area, and the precise failure site could not be determined for the remaining two patients. Because of the relatively high risk of regional versus in-field recurrence, patients with chest wall sarcoma who receive adjuvant treatment should be treated primarily with external-beam irradiation to allow more generous coverage of the tumor bed. Brachytherapy could be used as a tumor bed "boost" treatment. In patients undergoing resection of recurrent tumor in a previously irradiated site, adjuvant brachytherapy, without external-beam irradiation, should be considered to reduce the risk of extensive soft tissue necrosis.

Prostate brachytherapy is an effective treatment option for early-stage prostate cancer. During a prostate brachytherapy procedure, transrectal ultrasound (TRUS) and fluoroscopy imaging modalities complement each other by providing good visualization of soft tissue and implanted seeds, respectively. Therefore, the registration of these two imaging modalities, which are readily available in the operating room, could facilitate intraoperative dosimetry, thus enabling physicians to implant additional seeds into the underdosed portions of the prostate while the patient is still on the operating table. It is desirable to register TRUS and fluoroscopy images by using the seeds as fiducial markers. Although the locations of all the implanted seeds can be reconstructed from three fluoroscopy images, only a fraction of these seeds can be located in TRUS images. It is challenging to register the TRUS and fluoroscopy images by using the identified seeds, since the correspondence between them is unknown. Furthermore, misdetection of nonseed structures as seeds can lead to the inclusion of spurious points in the data set. We developed a new method called iterative optimal assignment (IOA) to overcome these challenges in TRUS-fluoroscopy registration. By using the Hungarian method in an optimization framework, IOA computes a set of transformation parameters that yield the one-to-one correspondence with minimum cost. We have evaluated our registration method at varying noise levels, seed detection rates, and number of spurious points using data collected from 25 patients. We have found that IOA can perform registration with an average root mean square error of about 0.2 cm even when the seed detection rate is only 10%. We believe that IOA can offer a robust solution to seed-based TRUS-fluoroscopy registration, thus making intraoperative dosimetry possible.

Twenty patients with leukemic (8) or lymphomatous (12) meningitis and cranial nerve palsies were treated with cranial irradiation at Memorial Sloan-Kettering Cancer Center from June 1987 through December 1988. The diagnosis of malignant meningitis was confirmed by malignant or `suspicious' cerebrospinal fluid cytology in 1320 patients. The 6th and 7th cranial nerves were most commonly involved. Multiple nerve involvement was present in 1120 patients, for a total of 42 nerves affected. Treatment consisted of whole brain irradiation to a median dose of 2400 cGy (range: 1000–3000) at 200–300 cGy per fraction. Median survival was 7 months. Forty of 42 nerves improved, for an actuarial response rate of 95% at 3 months. The complete response rate was 44% and was better for patients with lymphoma than for those with leukemia (72% vs 19%, p = 0.04). Delaying initiation of irradiation more than 3 days after the onset of symptoms did not affect the ultimate response rate, but slightly increased the median time to response (9 days vs 14 days, p = 0.1). Radiation therapy is an effective means of reversing cranial nerve dysfunction in leukemia and lymphoma. Higher doses may be needed to increase the rate of complete response.

CT scans of 12 patients who underwent resection of recurrent malignant astrocytoma and who had a radiographically documented second tumor recurrence were studied. Second tumor recurrence was histologically verified in four patients. Eight of 12 second recurrences were no more than 2.0 cm from the contrast-enhancing margin of the first recurrence. The remaining four patients had tumor recurrence within 2.2, 4.6, 5.1 and 6.9 cm of the enhancing margin of the first tumor recurrence. Peritumoral edema at the time of initial recurrence had no relationship to the patterns of second recurrence. It is concluded that patients who undergo reoperation for recurrent malignant astrocytoma are still primarily at risk for local tumor failure, as opposed to diffuse dissemination of disease throughout the brain.

Prostatic acid phosphatase (PAP) emerged as the world's first clinically useful tumor marker in the 1940s and 1950s. With the introduction of the prostate-specific antigen (PSA) test in the 1980s, which performed significantly better than PAP in terms of screening and monitoring response to treatment, PAP fell into disfavor. An increasing number of recent studies have identified PAP as a significant prognostic factor for patients with intermediate- and high-risk prostate cancer. PAP appears to be particularly valuable in predicting distant failure in higher-risk patients for whom high levels of local control are achieved with aggressive initial local treatment. As prostate cancer care becomes increasingly focused on identifying the minority of patients who would benefit from aggressive systemic therapy, a reevaluation of the potential contribution of the prostatic acid phosphatase test seems timely.

Purpose: Despite the occurrence of some rectal complications in most large series of patients treated with radiation, there is surprisingly little information regarding their management. We report here the clinical course of such patients after I-125 brachytherapy, in an effort to help delineate a rational management policy. Methods and Materials: 109 patients with stage T1 to T2 prostatic carcinoma and Gleason score 2 to 7 were treated with I-125 implantation from 1988 through 1995. No external radiation was given. The prescribed minimum radiation dose to the prostate was 140 to 160 Gy. Results: Nineteen of 109 patients (actuarial incidence: 19%) developed persistent, bright red rectal bleeding, from 1 to 28 months following I-125 implantation. Most occurred in the early part of the implant experience. Bleeding resolved in 6 of the 19 patients, from 9 to 48 months from the time of onset. Nine patients were treated with steroid enemas. Laser coagulation was used in three patients, and six patients had no intervention. There was no obvious difference in the resolution rate between groups. There was no obvious difference in the rectal wall radiation for patients who did or did not experience resolution of their bleeding. Conclusion: Persistent, minor radiation-related bleeding after prostate brachytherapy can be a source of consternation to patients. They should be reassured that spontaneous healing is likely to occur eventually in a large portion of patients, and should be cautioned against invasive treatment, unless absolutely necessary. © 1998 Elsevier Science Inc.

To detail the effect of supplemental beam radiation on prostate brachytherapy-related morbidity.The 220 patients reported here were a subgroup randomized on two treatment protocols, with a planned total accrual of 1200. Low-risk patients, with Gleason Grade 2-6, prostate-specific antigen (PSA) 4-10 ng/mL, were randomized to implantation with I-125 (144 Gy, TG-43) vs. Pd-103 (125 Gy, NIST-99). Intermediate-risk patients, with Gleason Grade 7 or higher or PSA of 10-20 ng/mL, were randomized to implantation with Pd-103, delivering 90 vs. 115 Gy (NIST-1999), with 44 vs. 20 Gy external beam irradiation (EBRT), respectively. Beam radiation was delivered with a four-field arrangement, designed to cover the prostate and seminal vesicles with a 2-cm margin (reduced to 1.0 cm posteriorly). Treatment-related morbidity was monitored by mailed questionnaires, using standard American Urologic Association (AUA) and Radiation Therapy Oncology Group criteria at 1, 3, 6, 12 and 24 months. Use of alpha-blockers to relieve obstructive symptoms was not controlled for, but was noted at each follow-up time.AUA score increases were highest at 1 month in the patients treated with higher prescription doses of Pd-103 (125 Gy Pd-103 alone or 115 Gy Pd-103 with 20 Gy EBRT), consistent with prior reports. By 6 months, most Pd-103 patients had returned to baseline, whereas I-125 patient scores were still declining. Patients treated with lower dose Pd-103 combined with EBRT had lesser elevations of their AUA scores at 1 and 6 months, but differences between those receiving 20 vs. 44 Gy beam radiation were inconsistent. At no point did beam radiation significantly affect postimplant AUA scores or urinary morbidity scores. Rectal morbidity scores were remarkably similar between groups, apart from higher scores at 1 month in patients treated with full dose Pd-103. Rectal morbidity consisted primarily of increased frequency and mucous passage. There have been no instances of rectal ulceration or fistula. The addition of beam radiation significantly increased postimplant rectal morbidity scores only at the 1-month time point.The addition of supplemental beam radiation had little effect on morbidity. We do not believe that morbidity per se should influence the decision of whether or not to use supplemental beam radiation.

Local anesthesia for prostate brachytherapy was instituted at the Puget Sound Veterans Hospital in 1999, peforming the procedure in our own department without anesthesia personnel in attendance.The patient is brought into the simulator suite in the radiation oncology department, an i.v. line is started, a cardiac monitor attached, and a urinary catheter is inserted. He is then placed in the lithotomy position, using stirrups attached to the simulator table. A 6-8 cm patch of perineal skin and subcutaneous tissue is anesthetized by local infiltration of 1% lidocaine. The transrectal ultrasound (TRUS) probe is then inserted and positioned to reproduce the planning images. A 3.0 inch 22-gauge spinal needle is used to inject lidocaine up to the prostatic apex, in a pattern around the periphery of the prostate. Once the pelvic floor and prostatic apex are anesthetized, a 7.0-inch, 22-gauge spinal needle is inserted through an 18-gauge 3 inch spinal needle into the peripheral planned needle tracks, monitored by TRUS. As the needles are advanced to the prostatic base, about 1.0 cc of lidocaine solution is injected in the intraprostatic track. A total of 200 to 500 mg of lidocaine is used.As of December 2000, more than 600 patients have received implants under local anesthesia at Seattle, WA. Patients tolerate brachytherapy under local anesthesia surprisingly well. Post-implant CT-defined target coverage has ranged from 80% to 95%, well within published criteria for technical adequacy. Patients' typical implant pain score is 3, on a scale of 0-10. After a series of patient acceptance quality studies, we have abandoned the routine use of sedation, and relied instead on local lidocaine infiltration alone.In addition to a high degree of patient satisfaction, performing implants under local anesthesia allows for phenomenal logistical efficiencies and cost advantages.

The purpose of this study was to test the hypothesis that the shorter half-life of Pd-103 versus I-125 results in a shorter duration of radiation-related symptoms after prostate brachytherapy.As of February 2000, 110 of a planned total of 380 patients with 1997 American Joint Commission clinical stage T1c-T2a prostatic carcinoma (Gleason grade 2-6, prostate-specific antigen, 4-10 ng/mL) had been randomly assigned to implantation with I-125 (144 Gy, TG-43) or Pd-103 (125 Gy, NIST-99). Isotope implantation was performed by standard techniques, using a modified peripheral loading pattern. Treatment-related morbidity was monitored by mailed questionnaires, using standard American Urologic Association (AUA) and Radiation Therapy Oncology Group criteria at 1, 3, 6, 12, and 24 months. Use of alpha-blockers to relieve obstructive symptoms was not controlled for but was noted at each follow-up point. All patients reported here have a minimum 1-year follow-up. Randomization was carried out at a central enrollment office where eligibility criteria were confirmed and the patient assigned by computerized random number generator to one of the two treatment arms. Patients were assigned to 95 blocks of four. Most statistical comparisons shown here are by Student's unpaired t-test at specific follow-up times, as indicated in the figure legends. Additionally, considering the patients' scores change overtime, repeated measures were incorporated in a mixed model assuming an unstructured covariance matrix.Patients in each arm were well matched by preimplant prostate volume, AUA score, and age. The AUA scores peaked at the 1-month point for both isotopes and then gradually declined. The difference was greatest at 6 months, when I-125 patients had a mean AUA score of 16 (+/- 8), compared with 11 (+/- 10) for the Pd-103 patients. By 12 months, mean AUA scores for the Pd-103 patients had decreased to 12 (+/- 9), compared with 13 (+/- 8) for the I-125 patients. At 6 months after implantation, 41% of Pd-103 patients were still taking alpha-blockers, versus 44% of I-125 patients. The differences between isotopes were more marked in patients with a low pretreatment AUA score or smaller preimplant transrectal ultrasonography volume. Results of the mixed model, incorporating repeated measures for each patient, showed that the effect of isotope choice on AUA score depended on time. This effect was further dependent on baseline AUA score, but not on transrectal ultrasonography volume or on age. Urinary and rectal morbidity was generally low, typically grade 1 or 2. There was a trend to greater morbidity with I-125 than with Pd-103, most markedly at the 6-month time point.Patients treated with Pd-103 recovered from their radiation-induced prostatitis sooner than I-125 patients. It appears that patients with minimal pretreatment urinary obstructive symptoms are the most likely to experience implant-related exacerbations of their symptoms and are the most likely to benefit from the more rapid half-life of Pd-103 rather than I-125.

During the last 15 years, a series of substantial technical improvements have occurred in external beam radiation and brachytherapy. The introduction of PSA-based posttreatment monitoring has allowed a reasonable comparison between each radiation modality and prostatectomy. Such comparisons show more similarities than differences. Probably the most exciting finding in regard to curing cancer is that higher-risk patients have a more favorable prognosis than previously recognized using higher doses now achievable with either form of radiation.

Our aim was to document the technical and clinical course of prostate brachytherapy patients with radiographic evidence of median lobe hyperplasia (MLH). Eight patients with MLH were identified during our routine brachytherapy practice, representing 9% of the 87 brachytherapy patients treated during a 6-month period. No effort was made to avoid brachytherapy in patients noted to have MLH on diagnostic work-up. Cystoscopic evaluation was not routinely performed. Postimplant axial computed tomographic (CT) images of the prostate were obtained at 0.5 cm intervals. Preimplant urinary obstructive symptoms were quantified by the criteria of the American Urologic Association (AUA). Each patient was contacted during the writing of this report to update postimplant morbidity information. There was no apparent association between the degree of MLH and preimplant prostate volume or AUA score. Intraoperatively, we were able to visualize MLH by transrectal ultrasound and did not notice any particular difficulty placing sources in the MLH tissue or migration of sources out of the tissue. The prescription isodose covered from 81% to 99% of the postimplant CT-defined target volume, achieving adequate dose to the median lobe tissue in all patients. Two of the eight patients developed acute, postimplant urinary retention. The first patient required intermittent self-catheterization for 3 months and then resumed spontaneous urination. MLH does not appear to be a strong contraindication to prostate brachytherapy, and prophylactic resection of hypertrophic tissue in such patients is probably not warranted. Int. J. Cancer (Radiat. Oncol. Invest.) 90, 152–156 (2000). © 2000 Wiley-Liss, Inc.

To report the 5-year prostate-specific antigen (PSA) relapse-free survival outcome and incidence of long-term morbidity for patients with localized prostate cancer treated with CT-planned permanent I-125 prostate implantation using a transperineal technique (TPI).Between 1989-1996, 248 patients with clinically localized prostate cancer were treated with TPI. The median age was 65 years (range: 45-80 years). The clinical stage was T1c in 143 patients (58%), Stage T2a in 102 (41%), and T2b in 3 (1%). Thirty patients (12%) had Gleason scores6, 158 patients (64%) had Gleason scores of 6, and 60 (24%) had scoresor =7. The median pretreatment PSA was 7 ng/mL (range: 1-58 ng/mL). The median prescribed implant dose was 150 Gy. Patients were characterized as having favorable risk disease if their pretreatment PSA level wasor =10.0 ng/mL and Gleason scoreor = 6; those with one and two adverse prognostic features (PSA10 ng/mL and Gleason score6) were classified as having intermediate and unfavorable risk disease, respectively. PSA relapse was defined according to the American Society of Therapeutic Radiation Oncology Consensus Statement, and toxicity was scored according to the Radiation Therapy Oncology Group morbidity scoring scale. The median follow-up was 48 months (range: 12-126 months).Thirty-eight patients (15%) developed a PSA relapse, and the overall 5-year PSA relapse-free survival (PRFS) rate was 71%. The 5-year PRFS rates for favorable-risk (n = 146), intermediate-risk (n = 85), and unfavorable-risk (n = 17) patients were 88%, 77%, and 38%, respectively (p0.0001). The 5-year PRFS rates among patients treated with a 2-month course of neoadjuvant androgen deprivation (NAAD) prior to TPI compared to patients treated with TPI only were 100% and 77%, respectively (p = 0.03). Multivariate analysis identified pretreatment PSA10 ng/mL and Gleason score6 as independent predictors for biochemical relapse after TPI. The 5-year actuarial likelihood of late Grade 2 urinary toxicity was 41%. The 5-year likelihood of urethral stricture development was 10%, and the median time to stricture development was 18 months. One patient (0. 4%) in the early phase of this clinical experience developed a Grade 4 urethral complication. The actuarial incidence of late Grade 2 rectal bleeding was 9%. One patient (0.4%) developed a Grade 4 rectal complication.Especially for favorable risk disease, the 5-year biochemical outcome with this approach was excellent and appears to be comparable to other therapeutic interventions. Grade 2 urinary symptoms were common in these patients but gradually resolved in most. Improved treatment planning approaches that further constrain the urethral dose without compromising the target volume dose will likely decrease the incidence of Grade 2 and 3 urinary symptoms after TPI.

Purpose: To determine the prognostic significance of pretreatment edema, lesion size and location on morbidity following stereotactic radiosurgery (SRS). Methods and Materials: Forty-seven evaluable patients with 63 lesions were treated on a 6-MV linear accelerator radiosurgery system at Memorial Sloan Kettering Cancer Center. All patients received a 10-mg intravenous bolus of dexamethasone sodium phosphate (Decadron) prior to SRS. Thirteen patients were treated for asymptomatic lesions while 34 were treated because of neurologic symptoms. The median dose delivered was 1800 cGy and the median prescription isodose curve was 85%. Pretreatment edema was measured on a transaxial T2-weighted MR image acquired within 1 month of the SRS. Results: Ten patients experienced morbidity as a result of their treatment. The complication rate was measured by neurologic events following SRS and was not significantly influenced by the extent of peritumoral edema. Lesion size was also unrelated to the development of post-treatment symptoms as assessed by the ease of tapering steroids. The only parameter found to influence post-SRS complications was lesion location. Four of six (66%) patients treated to lesions in the motor cortex suffered post-SRS seizure activity, whereas only 6 of 37 (16%) patients treated to lesions elsewhere in the brain parenchyma experienced seizure activity. Conclusion: The presence of pretreatment edema and lesion size are not predictors of post-SRS complication rates or the ability to taper Decadron. Lesion location is predictive of post-SRS seizure activity.

To evaluate the role of detailed pathologic features in predicting outcome for early-stage prostate cancer treated with I-125 brachytherapy. The pretreatment biopsy slides of 103 patients with T1/T2 and Gleason scores of 4–7 prostatic carcinoma, which was treated by transperineal I-125 implantation, were reviewed retrospectively by a single pathologist (P.B.G.). Biochemical tumor control rates [prostate-specific antigen (PSA) below 1.0] were correlated with pretreatment PSA, Gleason score, the amount of tumor in the biopsy samples, and the presence of perineural invasion.In Cox proportional-hazard, multivariate analysis, the strongest predictors of failure were pretreatment PSA above 10 ng/ml (P = 0.013) and the length of the biopsy specimen replaced by tumor (P = 0.15). The percent of biopsy tissue replaced by tumor (P = 0. 74), perineural invasion (P = 0.78), and Gleason score (P = 0.66) were less predictive of prognosis. It was concluded that pretreatment PSA is the strongest predictor of biochemical failure. Detailed assessment of pathological features on needle biopsy added little prognostic information beyond that of pretreatment PSA alone. Like all other prognostic parameters for prostate cancer, there is considerable overlap in pathologic features between those patients who will or will not be controlled biochemically. Radiat. Oncol. Invest. 6:170–174, 1998. © 1998 Wiley-Liss, Inc.

Purpose:To determine the incidence of postimplant in patients who are not given prophylactic antibiotics (ATBs). Methods and Materials One hundred thirty-one patients had computerized tomography (CT)-planned transperineal 125 I implantation of the prostate from 1988 through 1995. One hundred fourteen of the patients did not receive prophylactic ATBs, 19 of whom required postimplant Foley catheter drainage for 1 day or more for acute urinary retention. Results: The incidence of postimplant febrile episodes within 2 weeks of surgery among the patients who had not received prophylactic ATBs was 2 of 114 (2%). One of the two patients who developed postimplantation febrile episodes was treated successfully with ATBs as an outpatient. The second patient, who had a history of chronic lymphocytic leukemia (CLL) and immune suppression, developed E. coli sepsis and required intravenous antibiotics. Of 17 patients who received prophylactic ATBs, none had a postoperative febrile episode. Conclusion: We continue to refrain from routinely prescribing prophylactic ATBs unless there is some compelling circumstance including rheumatic heart disease, prosthetic devices, immune compromise, or a previous history of prostatitis.

PURPOSE To quantify disease progression and morbidity following computer tomography (CT)-based transperineal iodine 125 prostate implantation. METHODS Ninety-two patients with clinical stage T1 or T2, Gleason score 2 to 7/10, prostatic carcinoma had outpatient, CT-based transperineal 125I prostate implantation and were monitored for 1 to 7 years (median, 3). The prescribed minimum radiation dose was 140 to 160 Gy. Lymph node dissection and postimplantation prostatic biopsies were not routinely performed. RESULTS In 46% of patients, radiation-related urinary symptoms were substantial enough at 1 month following implantation to require medication. Radiation-related urinary symptoms gradually resolved. Two years after implantation, 14% of patients had persistent urinary symptoms of Radiation Therapy Oncology Group (RTOG) > or = grade 2. Eight percent of patients underwent a transurethral resection of the prostate (TURP) within 2 years of implantation. Five patients developed radiation-induced rectal ulcerations. Of 56 patients who were sexually potent preimplantation, 86% retained potency at 3 years. Twenty-five patients had biochemical disease progression. The overall actuarial freedom from biochemical failure rate at 4 years following implantation was 63%. In Cox proportional hazards multivariate analysis, the strongest predictor of failure was prostate-specific antigen (PSA) level less than or greater than 10 ng/mL (P = .005), followed by Gleason score (2 to 4 v 5 to 7, P = .08) and stage (T1 v T2, P = .09). CONCLUSION The 5-year biochemical freedom-from-progression rates following transperineal 125I implantation are comparable with those achieved with prostatectomy. The morbidity has decreased with increased physician experience.

Purpose : To decribe a novel way to assure proper needle positioning within the prostate during transperineal implantation, using the urethra as the primary radiographic landmark. Methods and Materials : Preoperative computerized tomography (CT) images through the prostate are used to plan optimal transperineal needle-seed placement. When performing the procedure, a Foley catheter, with radio-opaque wire is used to visualize the prostatic urethra fluoroscopically in anterior-posterior and lateral projections. Proper needle placement is determined by their position relative to the urethra. Results : Sixty patients have been implanted with this method at Memorial Sloan-Kettering Cancer Center from 1990–1992. Conclusion : The method described here is an improvement over previously described CT-based techniques. It could be used to supplement or replace ultrasound imaging.

The tumor control probabilities (TCPs) for 11 transperineal permanent implants of the prostate with 125I seeds have been computed, based on target-specific volume-dose histogram data. Prostate dose-response of this modality is converted from that of external beam therapy based on biologically effective dose derived from the α β model. The calculated TCPs for these transperineal prostate cases are compared with the results of 679 previous retropubic implants, providing interesting insight about these two techniques. Further refinement and validation of this model await long-term followup results of sufficient number of patients.