INTERSTITIAL HIGH DOSE RATE
(HDR) BRACHYTHERAPY FOR EARLY
STAGE PROSTATE CANCER
Rufus Mark, MD, Robin S. Akins, MD,
Paul Anderson, MD,Thomas Neumann, MD,
Murali Nair, PhD, David White, CMD,
Steve Gurley, CMD
Joe Arrington Cancer Center and
Texas Tech University Medical Center
Lubbock, TX
LOGIC FOR HDR MONOTHERAPY
1. XRT + LDR Implant has yet to prove
superior to LDR Implant alone.
2. HB + LDR Implant has yet to prove
superior to LDR Implant alone.
3. Surgical Pathology EPE data from
Mayo Clinic and Cleveland Clinic
4. HDR Dosimetry covers EPE
LDR IMPLANT +/- XRT
Blasko et al.
“Although the addition of XRT to
Brachtherapy is conceptually appealing
for patients with higher risk prostate
carcinoma, we were unable to
demonstrate a benefit.”
(Radiother Oncol, 2000 ; 57 : 273)
LDR IMPLANT +/- XRT
Author #PTS F/U PSA-DFS
Blasko 634 10 yrs nsd
Grado 490 5 yrs nsd
Merrick 413 5 yrs nsd
Potters 1,504 12 yrs nsd
Stock 1,510 6 yrs nsd
RADIAL EXTENSION OF EXTRA-
PROSTATIC EXTENSION (EPE) IN
PROSTATE CANCER
(MAYO CLINIC)
“Treatment of the prostate with
a 3 - 5 mm margin would encompass
96 - 99% of specimens with EPE.”
(IJROBP, 1998 ; 42 [1] : 132)
(Cancer, 2002 ; 95 [3] : 513)
INTERSTITIAL NEEDLE PLACEMENT
UTS PROSTATE PRE - IMPLANT
UTS PROSTATE POST - IMPLANT
UTS SEMINAL VESICLES
CT - HDR TREATMENT PLAN
MATERIALS & METHODS
- IRB approved Protocol
- 206 pts. with T1 or T2 prostate cancer
- No Gleason Score GS or PSA exclusions
- Median GS : 7 (range : 4 to 10)
- Median PSA : 9.3 (range : 2.7 to 39.8)
RISK GROUPS
GROUP % PTS
LOW 26% (54/206)
INTERMEDIATE 65% (133/206)
HIGH 9% (19/206)
MATERIALS & METHODS
- No pt. Received XRT or HB
- Treatment Volume included Prostate
+ Seminal Vesicles in all cases
- Median Treatment Volume : 84 cm3
(range : 42 cm3 to 196 cm3)
- Urethral Dose 20 55% 4 yrs
JACC 206 4 -10 T1-2 < 40 89% 6.5 yrs
Beaumont 65 <6 T1-2 < 10 97% 3 yrs
Intergroup 132 <6 T1-2 < 10 98% 2.3 yrs
California 117 <6 T1-2 < 10 96% 2.1 yrs
Middlesex 109 4 -10 T1-2 < 40 100% 1.5 yrs
PROSTATE CANCER
PERMANENT LDR (I-125, Pd-103)
IMPLANT RESULTS
PSA
AUTHOR #PTS STAGE DFS F/U
Wallner 92 T1-2 60% 2 yrs
Grimm 126 T1-2 85% 10 yrs
Beyer 465 T1-2 67% 3 yrs
Critz 303 T1-2 79% 5.5 yrs
Blasko 226 T1-2 78% 5.5 yrs
Potters 1,504 T1-2 78% 6 yrs
Stock 1,510 T1-2 76% 6 yrs
? HDR vs. LDR
- No worries re : Seed Supply.
- No worries re : Lost Seeds.
- No worries re : Radiation Exposure.
- No worries re : Seed Migration.
- No worries re : Seed Emboli.
- No worries re : pre-plan matching.
- No worries re : EPE.
- No worries re : SV.
- No worries re : Pubic Arch.
- No worries re : Volume.
COMPLICATIONS
Complication Incidence
Acute Urinary Retention 4.4% (9/206)
Deep Venous Thrombosis 1.9% (4/206)
Urethral Stricture 5.3% (11/206)
Urinary Stress Incontinence 3.9% (8/206)
Rectal Incontinence 0% (0/206)
RTOG Bladder Grade II-IV 3.9% (8/206)
RTOG Rectal Grade I-III 3.4% (7/206)
RTOG Rectal Grade IV 0.5% (1/206)
CONCLUSIONS
1. 6.5 year PSA DFS with HDR Monotherapy
compare favorably to Surgery, XRT, LDR +/-
XRT, and HDR + XRT.
2. Complications with HDR Monotherapy also
compare favorably to Surgery, XRT, LDR +/-
XRT, and HDR + XRT.
3. ? HDR vs. LDR Randomized Trial ?
DIFFERENTIAL CATHETER
LOADING
The needle placement is the same in each plan.
By changing dwell times in the needles, there is
great flexibility in radiation delivery.