- Email: [email protected]
13 The truth on permanent prostate brachytherapy
Invited abstracts / Critical Reviews in Oncology/Hematology 78 S1 (2011) S1−S20
Radical Prostatectomy: Limitations and Complications. Eur Urol. 2010; 57: 735–746. Menon M, Bhandari M, Gupta N, Lane Z, Peabody JO et al Biochemical Recurrence Following Robot-Assisted Radical Prostatectomy: Analysis of 1384 Patients with a Median 5-year Follow-up Eur Urol 58 (2010) 838–846.
13 The truth on permanent prostate brachytherapy J.J. Battermann1 *. 1 University Medical Centre, Utrecht, Netherlands Objectives: The objectives of this paper are to discuss results of permanent prostate brachytherapy according to literature data and own experience with over 2000 patients. Introduction: Although permanent prostate brachytherapy (PPB) is practiced since the beginning of the seventies it is still difficult to convince urologists of the advantages of PPB. In 1983 Holm1 published the first experience with a perineal technique for PPB using ultrasonography guidance in the placing of needles. This technique was adopted by different centres over the world and promising results were published with this technique (Blasko2 , Battermann3 ). In the past twenty years we saw a significant improvement in staging by PSA, in pathology of biopsies using the Gleason score and imaging in ultrasonography and MRI. By now there are several papers with long term experience of 10 and more years (Zelefsky4 , Morris5 , Hinnen6 , Henry7 , Taira8 ). Since the natural history of prostate cancer is slow in the majority of patients, outcome is often stated as biochemical disease free interval (bDFS). PSA decrease is slow after PPB and may take 5 years or more to reach PSA nadir lower than 0.1 ng/ml Grimm9 . Overall survival (OS) may be not a good end point because many men will die of cardiovascular disease and not of prostate cancer (Bittner10 ). Material and Results: In low risk patients (T1c-2c; PSA <10 ng/ml; Gleason sum 7) results are similar after permanent brachytherapy and surgery (Kupelian11 , Potters12 , Sharkey13 , Tward14 , Colberg15 ), although never proven by randomised studies. In other studies it was found that outcome after PPB was related to dose to 90% of the prostate over or under 200Gy (Pi˜n16 ) and implantation technique using stranded or loose seeds (Hinnen17 ). Also for medium risk patients (T1c-2c; Gleason 7; PSA 10−20ng/ml) good results are described by different authors (Ash18 , Datolli19 , Morris5 , Munro20 ). Hinnen6 shows an improvement in outcome for medium risk patients in the past decade compared with earlier experience, but not for low risk patients. However, definitions of intermediate risk cases and selection criteria are different from series to series and the treatment may be combined with external beam radiotherapy (EBRT) (Datolli19 ) and/or androgen deprivation therapy (ADT) (Morris5 , Munro20 ). There are conflicting results in literature concerning the results in Gleason 3+4 and 4+3 for all treatment modalities. Wright21 looked at prostate cancer specific mortality for
S9
Gleason 3+4 and 4+3 after surgery and radiotherapy and found an increased risk of recurrence or progression and specific mortality in those with Gleason 4+3 versus 3+4. Merrick22 described a series of 530 patients with Gleason 3+4 (300) or 4+3 (230). At 10 years primary Gleason score did not impact survival, while death from cardiovascular disease or second malignancies were 9.6 times more common than death from prostate cancer. High risk (T3; Gleason >7; PSA>20 ng/ml) patients have a significant lower cure rate because a substantial number of them will have microscopic metastases. In the treatment of these patients brachytherapy can be used, either alone or in combination with EBRT and/or ADT. Many of these combined treatments are performed successfully using HDR brachytherapy (Martinez23 ). Data in literature show that results after PPB in patients before sixty years of age are at least as good as in older patients (Merrick24 , Shapiro25 , Burri26 ). Shapiro25 found freedom from progression at 10 years after PPB, presenting with low-, intermediate- and high-risk was 91.3%, 80.0% and 70.2% compared to 91.8%, 83.4% and 72.1%, respectively, for men before 60 years versus men of 60 years or older. Interestingly, Merrick27 described high rates of cause-specific and biochemical progression-free survival after PPB in 145 consecutive men over 74 years of age. Overall survival and non-cancer deaths were best predicted by tobacco status. It is well known that radiation may induce cancer, but conflicting data are presented, either showing an increase in secondary primary cancers (SPCs) after EBRT of the prostate (Baxter28 ) or not showing an increase (Bhojani29 ). We recently assessed the risk of SPC s after I-125 prostate brachytherapy compared to prostatectomy in a cohort of 1,888 patients treated with brachytherapy (63%) or prostatectomy (37%). 223 patients were diagnosed with a SPC, 136 (11.5%) in the brachytherapy group and 87 (12.4%) in the prostatectomy group. Patients 60 years had a significant increased risk of bladder cancer. This also was found earlier by Singh30 from the SEER registry in patients after surgery and/or EBRT. Never the less, the Commission on Radiological Protection considers the risk of SPCs after PPB negligible (Cosset31 ). Discussion: Although the outcome of treatment is not substantially different between the established treatment options prostatectomy, EBRT and PPB, still more patients at low risk are treated by surgery. Of course, results of EBRT or brachytherapy cannot be much better than surgery, but in experienced hands toxicity after brachytherapy is much lower than after surgery. Up till now there is no indication that (robot assisted) laparoscopic prostatectomy will ensure a higher cure rate than open surgery, nor will it lower the complication rate (Ficarra32 ). Quality of life six years after PPB was similar to base line, as was presented in a paper from Roeloffzen33 . Malcolm34 compared quality of life after open or robotic prostatectomy, cryoablation or brachytherapy. Brachytherapy was associated with higher urinary function,
S10
Invited abstracts / Critical Reviews in Oncology/Hematology 78 S1 (2011) S1−S20
bother scores and sexual function compared to open and Da Vinci prostatectomy. As well as in surgery also in PPB new developments have resulted in better outcome, both in disease free survival and in toxicity. The introduction of stranded seeds gave us more homogeneity in dose distribution and less seed loss, but comparative studies could not yet show a difference between strands and loose seeds. However, with the use of an after-loading technique with loose seeds not only the dose distribution was better than with strands, but also the biochemical outcome was better (Hinnen17 ). MRI gives the opportunity to better visualise tumour areas in the prostate. This can be used to select patients for focal brachytherapy and hence further reduce side effects as in whole gland implants. For focal therapy only low risk patients with one defined tumour might be candidates. As was proven in a pilot study with patients after previous radiotherapy on the prostate, patients with focal brachytherapy had significant lower complications compared with patients who had been treated on the whole gland (Moman34 ). On the other hand, Isbarn35 studied 243 men with low-risk localized prostate cancer after RP. Despite unilateral stage at biopsy, bilateral or even non-organ-confined cancer was reported in 64% of all patients. The authors state that this alarming finding questions the safety and validity of hemiablative therapy. Conclusion: In this article we show that PPB is at least equal to surgery and therefore should be part of the armamentarium for low- and intermediate-risks prostate cancer patients. Excellent long-term biochemical disease free survival for low- and intermediate risk patients is mentioned in this paper from many series worldwide. Quality of life after PPB is, also after 6 six years, not compromised. Reference(s) [1] Holm HH, N Juul, JF Pedersen, et al. Transperineal 125-Iodine seed implantation in prostatic cancer guided by transrectal ultra-sonography. J Urol 130:283–286, 1983. [2] Blasko JC, H Ragde, RW Luse, et al. Should brachytherapy be considered a therapeutic option in localized prostate cancer? Urol Clin North Am 23:633–650, 1996. [3] Battermann JJ. I-125 implantation for localized prostate cancer: the Utrecht experience. Radiother Oncol 57:269–272, 2000. [4] Zelefsky MJ, DA Kuban, LB Levy, et al. Multi-institutional analysis of long-term outcome for stages T1-T2 prostate cancer treated with permanent seed implantation. Int J Radiat Oncol Biol Phys 67:327–333, 2007. [5] Morris WJ, M Keyes, D Palma, et al. Evaluation of dosimetric parameters and disease response after 125 Iodine transperineal brachytherapy for low- and intermediate-risk prostate cancer. Int J Radiat Oncol Biol Phys 73:1432–1438, 2009. [6] Hinnen KA, JJ Battermann, JGH van Roermond, et al. Long term biochemical and survival outcome of 921 patients treated with I-125 permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys 76:1433–1438, 2010. [7] Henry AM, B Al-Qaisieh, K Gould, et al. Outcomes following iodine-125 monotherapy for localized prostate cancer: the results of Leeds 10-year single-center brachytherapy experience. Int J Radiat Oncol Biol Phys 76:50−56, 2010.
[8] Taira AlV, GS Merrick, RW Galbreath, et al. Natural history of clinically staged low- and intermediate-risk prostate cancer treated with monotherapeutic permanent interstitial brachytherapy. Int J Radiat Oncol Biol Phys 76:349–354, 2010. [9] Grimm PD, JC Blasko, JE Sylvester, et al. 10-Year biochemical (prostate-specific antigen) control of prostate cancer with 125-I brachytherapy. Int J Radiat Oncol Biol Phys 51:31−40, 2001. [10] Bittner N, GS Merrick, R Galbreath, et al. Primary causes of death after permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys 72:433–440, 2008. [11] Kupelian PA, L Potters, D Khuntia, et al. Radical prostatectomy, external beam radiotherapy <72 Gy, external beam radiotherapy 72 Gy, permanent seed implantation, or combined seeds/external beam radiotherapy for stage T1-T2 prostate cancer. Int J Radiat Oncol Biol Phys 58:25−33, 2004. [12] Potters L, Morgenstern C, Calugaru E, et al. 12-year outcomes following permanent prostate brachytherapy in patients with clinically localized prostate cancer. J Urol 173:1562–1566, 2005. [13] Sharkey J, A Canto, Z Solc, et al. Pd103 brachytherapy versus radical prostatectomy in patients with clinically localized prostate cancer: A 12-year experience from a single group practice. Brachytherapy 2005;4:33−44. [14] Tward JD, CM Lee, LM Pappas, et al. Survival of men with clinically localized prostate cancer treated with prostatectomy, brachytherapy, or no definitive treatment: impact of age at diagnosis. Cancer 2006;107:2392–2400. [15] Colberg JW, RH Decker, AM Khan, et al. Surgery versus implant for early prostate cancer: results from a single institution, 1992–2005. Cancer J 13:229–232, 2007. [16] Pi˜na AG-I, J Crook, J Borg, C Ma. Biochemical disease-free rate and toxicity for men treated with iodine-125 prostate brachytherapy with D90 180 Gy. Int J Radiat Oncol Biol Phys 78:422–427, 2010. [17] Hinnen KA, MA Moerland, JJ Battermann, et al. Loose seeds versus stranded seeds in I-125 prostate brachytherapy: differences in clinical outcome. Radiother Oncol 96:30−33, 2010. [18] Ash D, B Al-Qaisieh, D Bottomley, et al. The correlation between D90 and outcome for I-125 seed implant monotherapy for localised prostate cancer. Radiother Oncol 79:185–189, 2006. [19] Datolli M, K Walner, L true, et al. Long-term outcomes after treatment with brachytherapy and supplemental conformal radiation for prostate cancer patients having intermediate and high-risk features. Cancer 110:551–555, 2007. [20] Munro NP, B Al-Qaisieh, P Bownes, et al. Outcomes from Gleason 7, intermediate risk, localized prostate cancer treated with Iodine-125 monotherapy over 10 years. Radiother and Oncol 96:34−37, 2010. [21] Wright JL, CA Salinas, DW Kolb, et al. Prostate cancer specific mortality and Gleason 7 disease differences in prostate cancer outcomes between cases with Gleason 4+3 and 3+4 tumors in a population based cohort. J Urol 182:2702–2707, 2009. [22] Merrick GS, RW Galbreath, Butler WM, et al. Primary Gleason pattern does not impact survival after permanent interstitial brachytherapy for Gleason score 7 prostate cancer. Cancer 110:289–296, 2007.
Invited abstracts / Critical Reviews in Oncology/Hematology 78 S1 (2011) S1−S20
[23] Martinez A, Gonzalez J, Spencer W, et.al. Conformal high dose rate brachytherapy improves biochemical control and cause specific survival in patients with prostate cancer and poor prognostic factors. J Urol 169:974–979, 2003. [24] Merrick GS, KE Wallner, WM Butler, et al. Brachytherapy in men aged < or = 54 years with clinically localized prostate cancer. BJU Int 98:324–328, 2006. [25] Shapiro EY, S Rais-Bahrami, C Morgenstern, et al. Longterm outcomes in younger men following permanent prostate brachytherapy. J Urol 181:1665–1671, 2009. [26] Burri RJ, AY Ho, K Forsythe, et al. Young men have equivalent biochemical outcomes compared with older men after treatment with brachytherapy for prostate cancer. Int J Radiat Oncol Biol Phys 77:1315–1321, 2010. [27] Merrick GS, KE Wallner, RW Galbreath, et al. Prostate brachytherapy in men 75 years of age. Int J Radiat Oncol Biol Phys 72:415–420, 2008. [28] Baxter NN, JE Tepper, SB Durham, et al. Increased risk of rectal cancer after prostate radiation: a population-based study. Gastroenterology 128:819–824, 2005. [29] Bhojani N, U Capitanio, N Suardi, et al. The rate of secondary malignancies after radical prostatectomy versus external beam radiation therapy for localized prostate cancer: a population based study on 17,845 patients. Int J Radiat Oncol Biol Phys 76:342–348, 2010. [30] Singh AK, TL Mashtare, SA McCloskey, et al. Increasing age and treatment modality are predictors for subsequent diagnosis of bladder cancer following prostate cancer diagnosis. Int J Radiat Oncol Biol Phys 78:1086–1094, 2010. [31] Cosset JM, L Pinillos-Ashton, F Mettler. The recommendations of the International Commission on Radiological Protection (ICRP) for high-dose-rate brachytherapy and for permanent prostatic implants. Cancer 8(Suppl 1):S50−55, 2004. [32] Ficarra V, G Novara, W Artibani, et al. Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol 55:1037–1063, 2009. [33] Roeloffzen EMA, IM Lips, MPR van Gellekom, et al. Health-related quality of life up to six years after I-125 brachytherapy for early-stage prostate cancer. Int J Radiat Oncol Biol Phys 76:1054–1060, 2010. [34] Malcolm JB, MD Fabrizio, BB Barone, et al. Quality of life after open or robotic prostatectomy, cryoablation or brachytherapy for localized prostate cancer. J Urol 183:1822– 1829, 2010. [35] Moman MR, CAT van den Berg, AE Boeken Kruger, et al. Focal salvage guided by T2-weighted and dynamic contrastenhanced magnetic resonance imaging for prostate cancer recurrences. Int J Radiat Oncol Biol Phys 76:741–746, 2010. [36] Isban I, PI Karakiewitcz, S Vogel, et al. Unilateral prostate cancer cannot be accurately predicted in low-risk patients. Int J Radiat Oncol Biol Phys 77:784–787, 2010.
14 High-intensity focused ultrasound and cryotherapy F.J. Murat1 *. 1 Val d’Ouest Hospital, Department of Urology, Ecully, France Emerging technologies, such as cryotherapy or more recently High Intensity Focused Ultrasound, have gained acceptance
S11
as minimally invasive therapies for the treatment of localized prostate cancer demonstrating promising oncological results with limited morbidity. Technological advances that are pending, the unique ability of these two therapies of being repeated combined with improvements in imaging technologies with reliable PCa mapping and subsequent safer PCa focal therapy, will undoubtely expand the role of these two treatment modalities in the prostate cancer armamentarium making them even more accurate and effective.
Controversy: Locally advanced prostate cancer 15 Role of radical prostatectomy in locally advanced prostate cancer A. Heidenreich1,2,3,4 *. 1 RWTH University Aachen, Department of Urology, Aachen, 2 RWTH University Aachen, Oncological Urology, Aachen, 3 RWTH University Aachen Pediatric Urology Aachen, 4 RWTH University Aachen Renal Transplantation, Aachen, Germany High-risk localised PCa: cT3a or Gleason score 8−10 or PSA >20: The widespread use of PSA testing has led to a significant migration in stage and grade of PCa, with >90% of men in the current era diagnosed with clinically localised disease. Despite the trends towards lower-risk PCa, 20−35% of patients with newly diagnosed PCa are still classified as high risk, based on either PSA >20 ng/mL, Gleason score >8, or an advanced clinical stage (50). Patients classified with high-risk PCa are at an increased risk of PSA failure, the need for secondary therapy, metastatic progression and death from PCa. Nevertheless, not all high-risk patients have a uniformly poor prognosis after RP. There is no consensus regarding the optimal treatment of men with high-risk PCa. Decisions on whether to elect surgery as local therapy should be based on the best available clinical evidence. Locally advanced PCa: cT3a: Stage T3a cancer is defined as cancer that has perforated the prostate capsule. In the past, locally advanced PCa was seen in about 40% of all clinically diagnosed tumours. This figure is lower today, although its management remains controversial. Surgical treatment of clinical stage T3 PCa has traditionally been discouraged, mainly because patients have an increased risk of positive surgical margins and lymph node metastases and/or distant relapse. Several randomised studies of radiotherapy combined with androgen-deprivation therapy (ADT) versus radiotherapy alone have shown a clear advantage for combination treatment, but no trial has ever proven combined treatment to be superior to RP. Another problem is ‘contamination’ by the additional use of either
Radical Prostatectomy: Limitations and Complications. Eur Urol. 2010; 57: 735–746. Menon M, Bhandari M, Gupta N, Lane Z, Peabody JO et al Biochemical Recurrence Following Robot-Assisted Radical Prostatectomy: Analysis of 1384 Patients with a Median 5-year Follow-up Eur Urol 58 (2010) 838–846.
13 The truth on permanent prostate brachytherapy J.J. Battermann1 *. 1 University Medical Centre, Utrecht, Netherlands Objectives: The objectives of this paper are to discuss results of permanent prostate brachytherapy according to literature data and own experience with over 2000 patients. Introduction: Although permanent prostate brachytherapy (PPB) is practiced since the beginning of the seventies it is still difficult to convince urologists of the advantages of PPB. In 1983 Holm1 published the first experience with a perineal technique for PPB using ultrasonography guidance in the placing of needles. This technique was adopted by different centres over the world and promising results were published with this technique (Blasko2 , Battermann3 ). In the past twenty years we saw a significant improvement in staging by PSA, in pathology of biopsies using the Gleason score and imaging in ultrasonography and MRI. By now there are several papers with long term experience of 10 and more years (Zelefsky4 , Morris5 , Hinnen6 , Henry7 , Taira8 ). Since the natural history of prostate cancer is slow in the majority of patients, outcome is often stated as biochemical disease free interval (bDFS). PSA decrease is slow after PPB and may take 5 years or more to reach PSA nadir lower than 0.1 ng/ml Grimm9 . Overall survival (OS) may be not a good end point because many men will die of cardiovascular disease and not of prostate cancer (Bittner10 ). Material and Results: In low risk patients (T1c-2c; PSA <10 ng/ml; Gleason sum 7) results are similar after permanent brachytherapy and surgery (Kupelian11 , Potters12 , Sharkey13 , Tward14 , Colberg15 ), although never proven by randomised studies. In other studies it was found that outcome after PPB was related to dose to 90% of the prostate over or under 200Gy (Pi˜n16 ) and implantation technique using stranded or loose seeds (Hinnen17 ). Also for medium risk patients (T1c-2c; Gleason 7; PSA 10−20ng/ml) good results are described by different authors (Ash18 , Datolli19 , Morris5 , Munro20 ). Hinnen6 shows an improvement in outcome for medium risk patients in the past decade compared with earlier experience, but not for low risk patients. However, definitions of intermediate risk cases and selection criteria are different from series to series and the treatment may be combined with external beam radiotherapy (EBRT) (Datolli19 ) and/or androgen deprivation therapy (ADT) (Morris5 , Munro20 ). There are conflicting results in literature concerning the results in Gleason 3+4 and 4+3 for all treatment modalities. Wright21 looked at prostate cancer specific mortality for
S9
Gleason 3+4 and 4+3 after surgery and radiotherapy and found an increased risk of recurrence or progression and specific mortality in those with Gleason 4+3 versus 3+4. Merrick22 described a series of 530 patients with Gleason 3+4 (300) or 4+3 (230). At 10 years primary Gleason score did not impact survival, while death from cardiovascular disease or second malignancies were 9.6 times more common than death from prostate cancer. High risk (T3; Gleason >7; PSA>20 ng/ml) patients have a significant lower cure rate because a substantial number of them will have microscopic metastases. In the treatment of these patients brachytherapy can be used, either alone or in combination with EBRT and/or ADT. Many of these combined treatments are performed successfully using HDR brachytherapy (Martinez23 ). Data in literature show that results after PPB in patients before sixty years of age are at least as good as in older patients (Merrick24 , Shapiro25 , Burri26 ). Shapiro25 found freedom from progression at 10 years after PPB, presenting with low-, intermediate- and high-risk was 91.3%, 80.0% and 70.2% compared to 91.8%, 83.4% and 72.1%, respectively, for men before 60 years versus men of 60 years or older. Interestingly, Merrick27 described high rates of cause-specific and biochemical progression-free survival after PPB in 145 consecutive men over 74 years of age. Overall survival and non-cancer deaths were best predicted by tobacco status. It is well known that radiation may induce cancer, but conflicting data are presented, either showing an increase in secondary primary cancers (SPCs) after EBRT of the prostate (Baxter28 ) or not showing an increase (Bhojani29 ). We recently assessed the risk of SPC s after I-125 prostate brachytherapy compared to prostatectomy in a cohort of 1,888 patients treated with brachytherapy (63%) or prostatectomy (37%). 223 patients were diagnosed with a SPC, 136 (11.5%) in the brachytherapy group and 87 (12.4%) in the prostatectomy group. Patients 60 years had a significant increased risk of bladder cancer. This also was found earlier by Singh30 from the SEER registry in patients after surgery and/or EBRT. Never the less, the Commission on Radiological Protection considers the risk of SPCs after PPB negligible (Cosset31 ). Discussion: Although the outcome of treatment is not substantially different between the established treatment options prostatectomy, EBRT and PPB, still more patients at low risk are treated by surgery. Of course, results of EBRT or brachytherapy cannot be much better than surgery, but in experienced hands toxicity after brachytherapy is much lower than after surgery. Up till now there is no indication that (robot assisted) laparoscopic prostatectomy will ensure a higher cure rate than open surgery, nor will it lower the complication rate (Ficarra32 ). Quality of life six years after PPB was similar to base line, as was presented in a paper from Roeloffzen33 . Malcolm34 compared quality of life after open or robotic prostatectomy, cryoablation or brachytherapy. Brachytherapy was associated with higher urinary function,
S10
Invited abstracts / Critical Reviews in Oncology/Hematology 78 S1 (2011) S1−S20
bother scores and sexual function compared to open and Da Vinci prostatectomy. As well as in surgery also in PPB new developments have resulted in better outcome, both in disease free survival and in toxicity. The introduction of stranded seeds gave us more homogeneity in dose distribution and less seed loss, but comparative studies could not yet show a difference between strands and loose seeds. However, with the use of an after-loading technique with loose seeds not only the dose distribution was better than with strands, but also the biochemical outcome was better (Hinnen17 ). MRI gives the opportunity to better visualise tumour areas in the prostate. This can be used to select patients for focal brachytherapy and hence further reduce side effects as in whole gland implants. For focal therapy only low risk patients with one defined tumour might be candidates. As was proven in a pilot study with patients after previous radiotherapy on the prostate, patients with focal brachytherapy had significant lower complications compared with patients who had been treated on the whole gland (Moman34 ). On the other hand, Isbarn35 studied 243 men with low-risk localized prostate cancer after RP. Despite unilateral stage at biopsy, bilateral or even non-organ-confined cancer was reported in 64% of all patients. The authors state that this alarming finding questions the safety and validity of hemiablative therapy. Conclusion: In this article we show that PPB is at least equal to surgery and therefore should be part of the armamentarium for low- and intermediate-risks prostate cancer patients. Excellent long-term biochemical disease free survival for low- and intermediate risk patients is mentioned in this paper from many series worldwide. Quality of life after PPB is, also after 6 six years, not compromised. Reference(s) [1] Holm HH, N Juul, JF Pedersen, et al. Transperineal 125-Iodine seed implantation in prostatic cancer guided by transrectal ultra-sonography. J Urol 130:283–286, 1983. [2] Blasko JC, H Ragde, RW Luse, et al. Should brachytherapy be considered a therapeutic option in localized prostate cancer? Urol Clin North Am 23:633–650, 1996. [3] Battermann JJ. I-125 implantation for localized prostate cancer: the Utrecht experience. Radiother Oncol 57:269–272, 2000. [4] Zelefsky MJ, DA Kuban, LB Levy, et al. Multi-institutional analysis of long-term outcome for stages T1-T2 prostate cancer treated with permanent seed implantation. Int J Radiat Oncol Biol Phys 67:327–333, 2007. [5] Morris WJ, M Keyes, D Palma, et al. Evaluation of dosimetric parameters and disease response after 125 Iodine transperineal brachytherapy for low- and intermediate-risk prostate cancer. Int J Radiat Oncol Biol Phys 73:1432–1438, 2009. [6] Hinnen KA, JJ Battermann, JGH van Roermond, et al. Long term biochemical and survival outcome of 921 patients treated with I-125 permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys 76:1433–1438, 2010. [7] Henry AM, B Al-Qaisieh, K Gould, et al. Outcomes following iodine-125 monotherapy for localized prostate cancer: the results of Leeds 10-year single-center brachytherapy experience. Int J Radiat Oncol Biol Phys 76:50−56, 2010.
[8] Taira AlV, GS Merrick, RW Galbreath, et al. Natural history of clinically staged low- and intermediate-risk prostate cancer treated with monotherapeutic permanent interstitial brachytherapy. Int J Radiat Oncol Biol Phys 76:349–354, 2010. [9] Grimm PD, JC Blasko, JE Sylvester, et al. 10-Year biochemical (prostate-specific antigen) control of prostate cancer with 125-I brachytherapy. Int J Radiat Oncol Biol Phys 51:31−40, 2001. [10] Bittner N, GS Merrick, R Galbreath, et al. Primary causes of death after permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys 72:433–440, 2008. [11] Kupelian PA, L Potters, D Khuntia, et al. Radical prostatectomy, external beam radiotherapy <72 Gy, external beam radiotherapy 72 Gy, permanent seed implantation, or combined seeds/external beam radiotherapy for stage T1-T2 prostate cancer. Int J Radiat Oncol Biol Phys 58:25−33, 2004. [12] Potters L, Morgenstern C, Calugaru E, et al. 12-year outcomes following permanent prostate brachytherapy in patients with clinically localized prostate cancer. J Urol 173:1562–1566, 2005. [13] Sharkey J, A Canto, Z Solc, et al. Pd103 brachytherapy versus radical prostatectomy in patients with clinically localized prostate cancer: A 12-year experience from a single group practice. Brachytherapy 2005;4:33−44. [14] Tward JD, CM Lee, LM Pappas, et al. Survival of men with clinically localized prostate cancer treated with prostatectomy, brachytherapy, or no definitive treatment: impact of age at diagnosis. Cancer 2006;107:2392–2400. [15] Colberg JW, RH Decker, AM Khan, et al. Surgery versus implant for early prostate cancer: results from a single institution, 1992–2005. Cancer J 13:229–232, 2007. [16] Pi˜na AG-I, J Crook, J Borg, C Ma. Biochemical disease-free rate and toxicity for men treated with iodine-125 prostate brachytherapy with D90 180 Gy. Int J Radiat Oncol Biol Phys 78:422–427, 2010. [17] Hinnen KA, MA Moerland, JJ Battermann, et al. Loose seeds versus stranded seeds in I-125 prostate brachytherapy: differences in clinical outcome. Radiother Oncol 96:30−33, 2010. [18] Ash D, B Al-Qaisieh, D Bottomley, et al. The correlation between D90 and outcome for I-125 seed implant monotherapy for localised prostate cancer. Radiother Oncol 79:185–189, 2006. [19] Datolli M, K Walner, L true, et al. Long-term outcomes after treatment with brachytherapy and supplemental conformal radiation for prostate cancer patients having intermediate and high-risk features. Cancer 110:551–555, 2007. [20] Munro NP, B Al-Qaisieh, P Bownes, et al. Outcomes from Gleason 7, intermediate risk, localized prostate cancer treated with Iodine-125 monotherapy over 10 years. Radiother and Oncol 96:34−37, 2010. [21] Wright JL, CA Salinas, DW Kolb, et al. Prostate cancer specific mortality and Gleason 7 disease differences in prostate cancer outcomes between cases with Gleason 4+3 and 3+4 tumors in a population based cohort. J Urol 182:2702–2707, 2009. [22] Merrick GS, RW Galbreath, Butler WM, et al. Primary Gleason pattern does not impact survival after permanent interstitial brachytherapy for Gleason score 7 prostate cancer. Cancer 110:289–296, 2007.
Invited abstracts / Critical Reviews in Oncology/Hematology 78 S1 (2011) S1−S20
[23] Martinez A, Gonzalez J, Spencer W, et.al. Conformal high dose rate brachytherapy improves biochemical control and cause specific survival in patients with prostate cancer and poor prognostic factors. J Urol 169:974–979, 2003. [24] Merrick GS, KE Wallner, WM Butler, et al. Brachytherapy in men aged < or = 54 years with clinically localized prostate cancer. BJU Int 98:324–328, 2006. [25] Shapiro EY, S Rais-Bahrami, C Morgenstern, et al. Longterm outcomes in younger men following permanent prostate brachytherapy. J Urol 181:1665–1671, 2009. [26] Burri RJ, AY Ho, K Forsythe, et al. Young men have equivalent biochemical outcomes compared with older men after treatment with brachytherapy for prostate cancer. Int J Radiat Oncol Biol Phys 77:1315–1321, 2010. [27] Merrick GS, KE Wallner, RW Galbreath, et al. Prostate brachytherapy in men 75 years of age. Int J Radiat Oncol Biol Phys 72:415–420, 2008. [28] Baxter NN, JE Tepper, SB Durham, et al. Increased risk of rectal cancer after prostate radiation: a population-based study. Gastroenterology 128:819–824, 2005. [29] Bhojani N, U Capitanio, N Suardi, et al. The rate of secondary malignancies after radical prostatectomy versus external beam radiation therapy for localized prostate cancer: a population based study on 17,845 patients. Int J Radiat Oncol Biol Phys 76:342–348, 2010. [30] Singh AK, TL Mashtare, SA McCloskey, et al. Increasing age and treatment modality are predictors for subsequent diagnosis of bladder cancer following prostate cancer diagnosis. Int J Radiat Oncol Biol Phys 78:1086–1094, 2010. [31] Cosset JM, L Pinillos-Ashton, F Mettler. The recommendations of the International Commission on Radiological Protection (ICRP) for high-dose-rate brachytherapy and for permanent prostatic implants. Cancer 8(Suppl 1):S50−55, 2004. [32] Ficarra V, G Novara, W Artibani, et al. Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol 55:1037–1063, 2009. [33] Roeloffzen EMA, IM Lips, MPR van Gellekom, et al. Health-related quality of life up to six years after I-125 brachytherapy for early-stage prostate cancer. Int J Radiat Oncol Biol Phys 76:1054–1060, 2010. [34] Malcolm JB, MD Fabrizio, BB Barone, et al. Quality of life after open or robotic prostatectomy, cryoablation or brachytherapy for localized prostate cancer. J Urol 183:1822– 1829, 2010. [35] Moman MR, CAT van den Berg, AE Boeken Kruger, et al. Focal salvage guided by T2-weighted and dynamic contrastenhanced magnetic resonance imaging for prostate cancer recurrences. Int J Radiat Oncol Biol Phys 76:741–746, 2010. [36] Isban I, PI Karakiewitcz, S Vogel, et al. Unilateral prostate cancer cannot be accurately predicted in low-risk patients. Int J Radiat Oncol Biol Phys 77:784–787, 2010.
14 High-intensity focused ultrasound and cryotherapy F.J. Murat1 *. 1 Val d’Ouest Hospital, Department of Urology, Ecully, France Emerging technologies, such as cryotherapy or more recently High Intensity Focused Ultrasound, have gained acceptance
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as minimally invasive therapies for the treatment of localized prostate cancer demonstrating promising oncological results with limited morbidity. Technological advances that are pending, the unique ability of these two therapies of being repeated combined with improvements in imaging technologies with reliable PCa mapping and subsequent safer PCa focal therapy, will undoubtely expand the role of these two treatment modalities in the prostate cancer armamentarium making them even more accurate and effective.
Controversy: Locally advanced prostate cancer 15 Role of radical prostatectomy in locally advanced prostate cancer A. Heidenreich1,2,3,4 *. 1 RWTH University Aachen, Department of Urology, Aachen, 2 RWTH University Aachen, Oncological Urology, Aachen, 3 RWTH University Aachen Pediatric Urology Aachen, 4 RWTH University Aachen Renal Transplantation, Aachen, Germany High-risk localised PCa: cT3a or Gleason score 8−10 or PSA >20: The widespread use of PSA testing has led to a significant migration in stage and grade of PCa, with >90% of men in the current era diagnosed with clinically localised disease. Despite the trends towards lower-risk PCa, 20−35% of patients with newly diagnosed PCa are still classified as high risk, based on either PSA >20 ng/mL, Gleason score >8, or an advanced clinical stage (50). Patients classified with high-risk PCa are at an increased risk of PSA failure, the need for secondary therapy, metastatic progression and death from PCa. Nevertheless, not all high-risk patients have a uniformly poor prognosis after RP. There is no consensus regarding the optimal treatment of men with high-risk PCa. Decisions on whether to elect surgery as local therapy should be based on the best available clinical evidence. Locally advanced PCa: cT3a: Stage T3a cancer is defined as cancer that has perforated the prostate capsule. In the past, locally advanced PCa was seen in about 40% of all clinically diagnosed tumours. This figure is lower today, although its management remains controversial. Surgical treatment of clinical stage T3 PCa has traditionally been discouraged, mainly because patients have an increased risk of positive surgical margins and lymph node metastases and/or distant relapse. Several randomised studies of radiotherapy combined with androgen-deprivation therapy (ADT) versus radiotherapy alone have shown a clear advantage for combination treatment, but no trial has ever proven combined treatment to be superior to RP. Another problem is ‘contamination’ by the additional use of either