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Comparison of outcomes of lung cancer patients treated with surgical resection with 125I lung brachytherapy vs stereotactic hypofractionated radiation therapy for single lung lesions
Oral Presentations / Brachytherapy 8 (2009) 105e180 192
Methods and Materials: An HDR afterloader machine using Ir source for brachytherapy purpose was used. Adding some tubes around an ordinary gastroscope, made the passage of brachytherapy applicators possible. Also, a novel applicator was developed. The main component of the applicator was an endoscope brush wire with a needle at the tip of it. The needle was mounted in order to allow insertion to the desired depth of tumor. Since the applicator was not a common and tested one, some dosimetry tests were done as well. The dosimetry tests were done by means of a well type chamber and some pieces of GAFCHROMICÔ EBT films. The well type chamber provided us a relative result in comparison with standard interstitial applicators, while the films were used for an absolute dosimetry as a function of distance from the applicator surface. In addition, the insertion procedure of the needles and the applicators, via the endoscope, was evaluated in a gastric simulator phantom. Results: Treatment planning of the determined CTV and two OARs (spinal cord and aorta) in the phantom showed 93.6% coverage of CTV while 90% of spinal cord and aorta got about one third of the prescribed dose. The chamber showed a reading between two proprietary applicators that was acceptable. Also, the film experiments on proposed applicator showed correlation coefficient of 99.15% with a standard interstitial applicator which was used in the treatment planning system. Conclusions: This study aimed to ensure the feasibility of a new treatment method for gastric adenocarcinoma using a new applicator. Considering the promising results, not only the procedure is feasible, but also the experiments showed a good agreement between the suggested and the standard applicators. Therefore, it can be used as a new HDR applicator after introducing the correction factors to the treatment planning systems. Although the results were acceptable, clinical trials are inevitable to examine the efficacy of this new treatment modality.
PO56 High-dose-rate brachyhterapy as a boost for carcinoma of the oral tongue Ahmed M. Akl, M.D.,1 Mohamad Elazizi, D.D.S.,1 Raof Mikhail, M.D.,2 Naser Ahmad, M.D.,2 Khaled Shukairy, M.D.2, Steven Marchetta, D.O.,3 Ashraf Heram, D.D.S.1 1Raduiation Oncology, Genesys Hurley Cancer Institute, Flint, MI; 2Hurely Medical Center, Flint, MI; 3ENT, Genesys Medical Center, Grand Blanc, MI. Purpose: To evaluate the outcome of patients with the diagnosis of invasive carcinoma of the oral tongue treated with external beam radiation and highdose-rate (HDR) brachytherapy as a boost. Methods and Materials: Charts from Genesys Hurley Cancer Institute of patients with the diagnosis of invasive carcinoma of the oral tongue treated with external beam radiation and high-dose-rate (HDR) brachytherapy between March 2002 and December 2005 were reviewed (9 patients with squamous cell carcinoma and 1 patient with adenoid cystic carcinoma). There was 1 patient with T1N0M0 and 9 patients with T2N0M0. The patient with T1 was treated with HDR brachytherapy as monotherapy (8 treatments each delivered 50 Gy to the tumor plus at least 2.5 cm margin). Patients with T2N0M0 received external beam radiation to the neck nodes to a total dose of 46 Gy in 23 treatments, or 50.4 Gy in 28 treatments were delivered to the primary and neck nodes. The technique used was parallel right and left lateral to the upper neck nodes and direct anterior to the lower neck nodes. Catheters were inserted in the operating room after patients were prepared with nasal intubation for general anesthesia and neck hyperextended. Needles were inserted through the submental and submandibular area through the floor of the mouth to the upper surface of the tongue. Subsequently, a guide wire was inserted in the needles at the upper surface of the tongue and the needles were pulled from the submental and submandibular area to allow the plastic tube insertion into the tongue. These tubes with a blind end and fixed to a button which were located at the upper surface of the tongue to prevent escape of the tubes. Patients subsequently were admitted to the hospital, then transferred to the Radiation Oncology Department and underwent CT treatment planning and computer-aided dosimetry to ensure adequate coverage of the target volume which would include the
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tumor volume prior to external beam radiation and at least 2.5 cm margin. Patients received HDR treatment twice per day. Dose was given 4 Gy per fraction twice per day for 4-6 fractions depending on the tumor size and the response. The 1 patient with adenoid cystic carcinoma received 4 Gy per fraction for 6 treatments. Results: All patients had complete response. The median followup was 32.7 months (ranging from 8-84 months). Patients with T1 lesions had no evidence of disease at 50 months. One patient with T2, a 19-year-old male, relapsed locally at 12 months post radiation and salvaged with radical surgery to include subtotal glossectomy and hemimandibulectomy. The patient relapsed again locally and expired six months post surgery. Two patients expired with no evidence of disease at 8 and 14 months post radiation treatment. Remaining patients are alive with no evidence of disease at 24, 24, 25, 26, 50, 60 and 84 months. All patients were followed up regularly. All patients developed pain in the tongue post implant for approximately three months post treatment, except for two patients where the pain persisted with 1 patient one year and the other patient 1-1/2 years. All patients regained their taste completely within 4-6 months post treatment. One patient developed infection post implant and was placed on antibiotics for approximately 1 month. All patients tongue function is completely normal with no limitation of movement. Conclusions: High-dose-rate brachytherapy is an effective primary therapy for T1 squamous cell carcinoma of the tongue and as a boost post external beam for T2N0 squamous cell carcinoma of the tongue.
PO57 Comparison of outcomes of lung cancer patients treated with surgical resection with 125I lung brachytherapy vs stereotactic hypofractionated radiation therapy for single lung lesions Bhupesh Parashar, A. Gabriella Wernicke, M.D., Albert Sabbas, Ph.D., Samuel Trichter, Dattatreyudu Nori, M.D.Radiation Oncology, Weill Cornell Medical Center, New York, NY. Purpose: A single lung cancer lesion can be treated with surgical resection (lobectomy or wedge resection) with or without the addition of 125I radiation seeds. Alternatively, inoperable patients may be treated with hypofractionated stereotactic radiation therapy (SRT). The purpose of this study is to evaluate and compare the outcomes of patients with single lung cancer lesions treated at our institute with either surgery plus 125I radiation seeds or SRT. Methods and Materials: We did a retrospective chart review of 150 patients treated at our institution between 1999 and 2008. Of those, 39 patients were found to be eligible for the study. Eighteen patients received a surgical resection and an intraoperative 125I implant (surgery group) for 18 lesions and 20 patients received hypofractionated stereotactic radiation therapy (SRT) to 21 lesions. The study subjects were evaluated for local recurrence (LR) and development of distant metastasis (DM). Chi square test was employed to estimate LR and DM in both cohorts. Results: The median age of patients was 65.5 years (range 36-79 years) and 78 years (range 60-90 years) in surgery and SRT group respectively. In the surgery group there were 16/18 (88.8%) patients with non-small cell lung cancer, 1/18 (5.5%) with small cell carcinoma and 1/18 (5.5%) with high grade sarcoma. In the same group, 5/18 (27.7%) patients underwent lobectomy, 1/18 (5.5%) had a local excision of a mediastinal sarcoma, and 9/18 (50%) underwent a wedge resection. The median number of 125I seeds placed was 21 (range 10-46).The median tumor size was 2.3 cm (range 1.2-6 cm). The median activity of the seeds was 0.529 mCi (range 0.390-0.700 mCi). The median followup was 7 months (range 1-84 months). In the SRT group, 18/20 (90%) patients were non-small cell and 2/20 (10%) patients were metastatic carcinoma, 1 from an endometrial and 1 from parotid adenocarcinoma. The median tumor size in the SRT group was 1.7 cm (range 0.3-4.8 cm) and median followup was 14.5 months (Range 3-72 months). SRT dose to 13/21 (61.9%) lesions was 30 Gy in 3 fractions, 4/21 (19%) lesions was 40 Gy in 4 fractions, 1/21 (4.7%) lesions was 50 Gy in 5 fractions and 3/21 (14.2%) patients was 60 Gy in 4 fractions. The local control in the surgery group was 88.8% vs. 100% in the SRT group (p 5 0.117). Distant failure as the first site of
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failure was observed in 4/18 (22.2%) patients in the surgery group vs. 0/21 (0%) in the SRT group (p 5 0.023). Conclusions: Both surgery plus 125I seed implant and SRT produce high local control rates in patients with single lung cancer lesions. However, in our retrospective study, SRT resulted in fewer local recurrences (statistically non-significant) and fewer distant recurrences (statistically significant) when compared to surgery plus 125I seed implant. Additional studies with larger patient number are needed to verify this difference on local control and to assess overall survival with either modality.
PROSTATE POSTERS Saturday-Tuesday May 30, 2009eJune 2, 2009 PO58 Early mortality after treatment for localized prostate cancer Chandana A. Reddy, M.S.,1 Jay P. Ciezki, M.D.,1 Eric A. Klein, M.D.2 1 Radiation Oncology, Cleveland Clinic, Cleveland, OH; 2Glickman Urological Institute, Cleveland Clinic, Cleveland, OH. Purpose: To identify which patients will benefit from screening and treatment for prostate cancer (CaP). Current guidelines recommend that men >75 years of age not be screened for prostate cancer. This study examines what patient factors are associated with early mortality vs. late mortality after treatment for localized CaP. Methods and Materials: From 1996 to 2005, 4223 patients with low- or intermediate-risk CaP were definitively treated with brachytherapy (PI), radical prostatectomy (RP), or external beam radiotherapy (EBRT) at our institution. The clinical characteristics, treatment information, and outcomes of these men were reviewed. Early mortality was defined as death within five years after treatment. Results: The median followup for all patients was 53 months (range: 0.1144). The median age is 63 years (range: 39-87), with 7% of all patients being >75 years. The majority of patients had no co-morbidities (median Charlson score 5 0, range: 0-7). At the time of this study, 358 patients had died. Fifty-three percent of all deaths had occurred within five years after treatment. The median time to death for patients who died within five years of treatment was 37 months (range: 0.1-60) vs. 84 months (range: 61-131) for patients who died more than five years after treatment. On univariate analysis, factors found to be associated with early mortality were Charlson score as a continuous variable (p 5 0.0024, OR 5 1.36) and as a score of >3 vs. <2 (p 5 0.0012, OR 5 5.06); race (p 5 0.179, OR 5 1.90); and treatment, with EBRT patients dying sooner than PI patients (p 5 0.0331, OR 5 1.687). Age as a continuous variable or as a comparison of !75 years vs. >75 was not associated with early mortality after treatment (p 5 0.445 and p 5 0.451, respectively). On multivariate analyses, only Charlson score as a continuous variable (p 5 0.0022, OR 5 1.38) and as a score of >3 vs <2 (p 5 0.0012, OR 5 5.17) remained significant for predicting early mortality. Conclusions: Charlson score rather than age may be a better way of identifying which men will benefit from screening and treatment for CaP. Patients >75 years of age should not necessarily be prevented from getting therapy or being screened if they have a low co-morbidity burden.
PO59 Previous transurethral resection of the prostate is not a contraindication for interstitial high-dose-rate brachytherapy for prostate cancer Rufus J. Mark, M.D., Paul J. Anderson, M.D., Robin S. Akins, M.D., Murali Nair, Ph.D. Radiation Oncology, Joe Arrington Cancer Center, Lubbock, TX. Purpose: Transrectal ultrasound (TRUS) -guided interstitial implant for prostate cancer using low-dose-rate (LDR) and high-dose-rate (HDR) technique has been reported with results comparing favorably to surgery
and external beam radiation therapy (EBRT). Previous transurethral resection of the prostate (TURP) has been considered a relative contraindication for LDR permanent seed implant because of higher rates of urinary incontinence. There are little data on previous TURP and subsequent incontinence after HDR implant. We report our urinary incontinence results with HDR with or without previous TURP. Methods and Materials: Between 1997 and 2008, 380 patients with T1 and T2 localized prostate underwent TRUS guided interstitial implant. There were no Gleason Score or PSA exclusions. After discussion of treatment options, 109 patients elected HDR Implant þ IMRT and 269 patients underwent HDR monotherapy. No patient received Hormonal Blockade. Median Gleason Score was 7 (range : 4 to 10). Median PSA was 9.8 (0.60 to 39.8). IMRT treatment volume included the prostate þ seminal vesicles þ 2 cm margin. Implant treatment volumes ranged from 41 cm3 to 196 cm3. In patients who received IMRT þ HDR, 4500 cGy in 25 fractions was given via IMRT and 1650 cGy to 2000 cGy in 3 fractions via HDR. Our protocol for HDR alone, has called for two HDR Implants. The treatment volume received 2,250 cGy in 3 fractions prescribed to the 100% Isodose line, given over 24 hours. A 2nd implant was performed 4 weeks later, delivering a further 2,250 cGy in 3 fractions, bringing the final dose to the prostate to 4,500 cGy in 6 fractions. Urethral dose points (12e16) were followed, and limited to <105% of the prescription dose. Care was also taken to limit dose to the bladder sphincter regions. Results: There was no significant difference between the treatment groups with respect to T-Stage, Gleason Score, and PSA. With a median followup of 85 months (range : 6 months to 145 months), urinary stress incontinence has occurred in 3.2% (12/380). Previous TURP was performed in 59 patients. Incontinence has developed in 3.4% (2/59) undergoing previous TURP vs. 3.1% (10/321) in the non-TURP group (p 5 0.58). RTOG late bladder toxicities were: 0% Grade 4, 0% Grade 3, and 3.2% (12/380) Grade 2. Urinary stress incontinence has occurred in 3.3% (9/271), undergoing HDR alone, vs. 2.8% (3/109) treated with HDR + IMRT (p 5 0.53). Conclusions: Urinary stress incontinence after HDR implant occurs in rates comparable to LDR implant. Previous TURP is not a contraindication to HDR implant for prostate cancer.
PO60 145 Gy vs. 160 Gy for a prescription dose: A comparison of dosimetry and acute toxicity in 125I permanent implant for prostate cancer Atsunori Yorozu, M.D.,1 Kazuhito Toya, M.D.,1 Yutaka Shiraishi, M.D.,1 Satoshi Seki, M.D.,1 Shiro Saito, M.D.,2 Michio Kosugi, M.D.2 1Radiology, Tokyo Medical Center, NHO, Tokyo, Japan; 2Urology, Tokyo Medical Center, NHO, Tokyo, Japan. Purpose: To compare the postimpant dosimetry and acute toxicity of a 160 Gy-prescribed group with a 145 Gy-prescribed group in 125I permanent implant with intraoperative real-time planning technique for prostate cancer. Methods and Materials: The permanent seed prostate brachytherapy program at Tokyo Medical Center began in September 2003 and has treated more than 1000 patients. We started intraoperative real-time planning with 145 Gy for a prescribed dose in 2005, then escalated to 160 Gy for prescription in 2006. A cohort of consecutive 199 patients was treated with the 145 Gy-prescribed dose and consecutive 183 patients were treated with the 160 Gy-prescribed dose. All patients were implanted with loose seeds using the interactive US-guided technique described by Stock and Stone. A CT scan was obtained on Day 1 and Day 30 after implantation for postimplant dosimetry. The urethra was identified by Foley catheter on the intraoperative US scan and on the Day 1 CT scan. Urethral dosimetry was compared for the two cohorts using UD5, UD30 and UV150, and rectal dosimetry using RV100 and RD1. All patients were prescribed with tamslosin preventively. Acute morbidity was defined by the CTC-AE ver3.0. Urinary morbidity was defined by urinary retention, maximum increase in IPSS, and prescribed periods of tamslosin. Results: There was no significant difference between the treatment groups with respect to risk group, prostate volume and baseline IPSS. The mean D90 of prostate on the the Day 30 CT scan was 174 Gy for the 145 Gy-prescription group and 191 Gy for the 160 Gy-prescription group.
Methods and Materials: An HDR afterloader machine using Ir source for brachytherapy purpose was used. Adding some tubes around an ordinary gastroscope, made the passage of brachytherapy applicators possible. Also, a novel applicator was developed. The main component of the applicator was an endoscope brush wire with a needle at the tip of it. The needle was mounted in order to allow insertion to the desired depth of tumor. Since the applicator was not a common and tested one, some dosimetry tests were done as well. The dosimetry tests were done by means of a well type chamber and some pieces of GAFCHROMICÔ EBT films. The well type chamber provided us a relative result in comparison with standard interstitial applicators, while the films were used for an absolute dosimetry as a function of distance from the applicator surface. In addition, the insertion procedure of the needles and the applicators, via the endoscope, was evaluated in a gastric simulator phantom. Results: Treatment planning of the determined CTV and two OARs (spinal cord and aorta) in the phantom showed 93.6% coverage of CTV while 90% of spinal cord and aorta got about one third of the prescribed dose. The chamber showed a reading between two proprietary applicators that was acceptable. Also, the film experiments on proposed applicator showed correlation coefficient of 99.15% with a standard interstitial applicator which was used in the treatment planning system. Conclusions: This study aimed to ensure the feasibility of a new treatment method for gastric adenocarcinoma using a new applicator. Considering the promising results, not only the procedure is feasible, but also the experiments showed a good agreement between the suggested and the standard applicators. Therefore, it can be used as a new HDR applicator after introducing the correction factors to the treatment planning systems. Although the results were acceptable, clinical trials are inevitable to examine the efficacy of this new treatment modality.
PO56 High-dose-rate brachyhterapy as a boost for carcinoma of the oral tongue Ahmed M. Akl, M.D.,1 Mohamad Elazizi, D.D.S.,1 Raof Mikhail, M.D.,2 Naser Ahmad, M.D.,2 Khaled Shukairy, M.D.2, Steven Marchetta, D.O.,3 Ashraf Heram, D.D.S.1 1Raduiation Oncology, Genesys Hurley Cancer Institute, Flint, MI; 2Hurely Medical Center, Flint, MI; 3ENT, Genesys Medical Center, Grand Blanc, MI. Purpose: To evaluate the outcome of patients with the diagnosis of invasive carcinoma of the oral tongue treated with external beam radiation and highdose-rate (HDR) brachytherapy as a boost. Methods and Materials: Charts from Genesys Hurley Cancer Institute of patients with the diagnosis of invasive carcinoma of the oral tongue treated with external beam radiation and high-dose-rate (HDR) brachytherapy between March 2002 and December 2005 were reviewed (9 patients with squamous cell carcinoma and 1 patient with adenoid cystic carcinoma). There was 1 patient with T1N0M0 and 9 patients with T2N0M0. The patient with T1 was treated with HDR brachytherapy as monotherapy (8 treatments each delivered 50 Gy to the tumor plus at least 2.5 cm margin). Patients with T2N0M0 received external beam radiation to the neck nodes to a total dose of 46 Gy in 23 treatments, or 50.4 Gy in 28 treatments were delivered to the primary and neck nodes. The technique used was parallel right and left lateral to the upper neck nodes and direct anterior to the lower neck nodes. Catheters were inserted in the operating room after patients were prepared with nasal intubation for general anesthesia and neck hyperextended. Needles were inserted through the submental and submandibular area through the floor of the mouth to the upper surface of the tongue. Subsequently, a guide wire was inserted in the needles at the upper surface of the tongue and the needles were pulled from the submental and submandibular area to allow the plastic tube insertion into the tongue. These tubes with a blind end and fixed to a button which were located at the upper surface of the tongue to prevent escape of the tubes. Patients subsequently were admitted to the hospital, then transferred to the Radiation Oncology Department and underwent CT treatment planning and computer-aided dosimetry to ensure adequate coverage of the target volume which would include the
159
tumor volume prior to external beam radiation and at least 2.5 cm margin. Patients received HDR treatment twice per day. Dose was given 4 Gy per fraction twice per day for 4-6 fractions depending on the tumor size and the response. The 1 patient with adenoid cystic carcinoma received 4 Gy per fraction for 6 treatments. Results: All patients had complete response. The median followup was 32.7 months (ranging from 8-84 months). Patients with T1 lesions had no evidence of disease at 50 months. One patient with T2, a 19-year-old male, relapsed locally at 12 months post radiation and salvaged with radical surgery to include subtotal glossectomy and hemimandibulectomy. The patient relapsed again locally and expired six months post surgery. Two patients expired with no evidence of disease at 8 and 14 months post radiation treatment. Remaining patients are alive with no evidence of disease at 24, 24, 25, 26, 50, 60 and 84 months. All patients were followed up regularly. All patients developed pain in the tongue post implant for approximately three months post treatment, except for two patients where the pain persisted with 1 patient one year and the other patient 1-1/2 years. All patients regained their taste completely within 4-6 months post treatment. One patient developed infection post implant and was placed on antibiotics for approximately 1 month. All patients tongue function is completely normal with no limitation of movement. Conclusions: High-dose-rate brachytherapy is an effective primary therapy for T1 squamous cell carcinoma of the tongue and as a boost post external beam for T2N0 squamous cell carcinoma of the tongue.
PO57 Comparison of outcomes of lung cancer patients treated with surgical resection with 125I lung brachytherapy vs stereotactic hypofractionated radiation therapy for single lung lesions Bhupesh Parashar, A. Gabriella Wernicke, M.D., Albert Sabbas, Ph.D., Samuel Trichter, Dattatreyudu Nori, M.D.Radiation Oncology, Weill Cornell Medical Center, New York, NY. Purpose: A single lung cancer lesion can be treated with surgical resection (lobectomy or wedge resection) with or without the addition of 125I radiation seeds. Alternatively, inoperable patients may be treated with hypofractionated stereotactic radiation therapy (SRT). The purpose of this study is to evaluate and compare the outcomes of patients with single lung cancer lesions treated at our institute with either surgery plus 125I radiation seeds or SRT. Methods and Materials: We did a retrospective chart review of 150 patients treated at our institution between 1999 and 2008. Of those, 39 patients were found to be eligible for the study. Eighteen patients received a surgical resection and an intraoperative 125I implant (surgery group) for 18 lesions and 20 patients received hypofractionated stereotactic radiation therapy (SRT) to 21 lesions. The study subjects were evaluated for local recurrence (LR) and development of distant metastasis (DM). Chi square test was employed to estimate LR and DM in both cohorts. Results: The median age of patients was 65.5 years (range 36-79 years) and 78 years (range 60-90 years) in surgery and SRT group respectively. In the surgery group there were 16/18 (88.8%) patients with non-small cell lung cancer, 1/18 (5.5%) with small cell carcinoma and 1/18 (5.5%) with high grade sarcoma. In the same group, 5/18 (27.7%) patients underwent lobectomy, 1/18 (5.5%) had a local excision of a mediastinal sarcoma, and 9/18 (50%) underwent a wedge resection. The median number of 125I seeds placed was 21 (range 10-46).The median tumor size was 2.3 cm (range 1.2-6 cm). The median activity of the seeds was 0.529 mCi (range 0.390-0.700 mCi). The median followup was 7 months (range 1-84 months). In the SRT group, 18/20 (90%) patients were non-small cell and 2/20 (10%) patients were metastatic carcinoma, 1 from an endometrial and 1 from parotid adenocarcinoma. The median tumor size in the SRT group was 1.7 cm (range 0.3-4.8 cm) and median followup was 14.5 months (Range 3-72 months). SRT dose to 13/21 (61.9%) lesions was 30 Gy in 3 fractions, 4/21 (19%) lesions was 40 Gy in 4 fractions, 1/21 (4.7%) lesions was 50 Gy in 5 fractions and 3/21 (14.2%) patients was 60 Gy in 4 fractions. The local control in the surgery group was 88.8% vs. 100% in the SRT group (p 5 0.117). Distant failure as the first site of
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failure was observed in 4/18 (22.2%) patients in the surgery group vs. 0/21 (0%) in the SRT group (p 5 0.023). Conclusions: Both surgery plus 125I seed implant and SRT produce high local control rates in patients with single lung cancer lesions. However, in our retrospective study, SRT resulted in fewer local recurrences (statistically non-significant) and fewer distant recurrences (statistically significant) when compared to surgery plus 125I seed implant. Additional studies with larger patient number are needed to verify this difference on local control and to assess overall survival with either modality.
PROSTATE POSTERS Saturday-Tuesday May 30, 2009eJune 2, 2009 PO58 Early mortality after treatment for localized prostate cancer Chandana A. Reddy, M.S.,1 Jay P. Ciezki, M.D.,1 Eric A. Klein, M.D.2 1 Radiation Oncology, Cleveland Clinic, Cleveland, OH; 2Glickman Urological Institute, Cleveland Clinic, Cleveland, OH. Purpose: To identify which patients will benefit from screening and treatment for prostate cancer (CaP). Current guidelines recommend that men >75 years of age not be screened for prostate cancer. This study examines what patient factors are associated with early mortality vs. late mortality after treatment for localized CaP. Methods and Materials: From 1996 to 2005, 4223 patients with low- or intermediate-risk CaP were definitively treated with brachytherapy (PI), radical prostatectomy (RP), or external beam radiotherapy (EBRT) at our institution. The clinical characteristics, treatment information, and outcomes of these men were reviewed. Early mortality was defined as death within five years after treatment. Results: The median followup for all patients was 53 months (range: 0.1144). The median age is 63 years (range: 39-87), with 7% of all patients being >75 years. The majority of patients had no co-morbidities (median Charlson score 5 0, range: 0-7). At the time of this study, 358 patients had died. Fifty-three percent of all deaths had occurred within five years after treatment. The median time to death for patients who died within five years of treatment was 37 months (range: 0.1-60) vs. 84 months (range: 61-131) for patients who died more than five years after treatment. On univariate analysis, factors found to be associated with early mortality were Charlson score as a continuous variable (p 5 0.0024, OR 5 1.36) and as a score of >3 vs. <2 (p 5 0.0012, OR 5 5.06); race (p 5 0.179, OR 5 1.90); and treatment, with EBRT patients dying sooner than PI patients (p 5 0.0331, OR 5 1.687). Age as a continuous variable or as a comparison of !75 years vs. >75 was not associated with early mortality after treatment (p 5 0.445 and p 5 0.451, respectively). On multivariate analyses, only Charlson score as a continuous variable (p 5 0.0022, OR 5 1.38) and as a score of >3 vs <2 (p 5 0.0012, OR 5 5.17) remained significant for predicting early mortality. Conclusions: Charlson score rather than age may be a better way of identifying which men will benefit from screening and treatment for CaP. Patients >75 years of age should not necessarily be prevented from getting therapy or being screened if they have a low co-morbidity burden.
PO59 Previous transurethral resection of the prostate is not a contraindication for interstitial high-dose-rate brachytherapy for prostate cancer Rufus J. Mark, M.D., Paul J. Anderson, M.D., Robin S. Akins, M.D., Murali Nair, Ph.D. Radiation Oncology, Joe Arrington Cancer Center, Lubbock, TX. Purpose: Transrectal ultrasound (TRUS) -guided interstitial implant for prostate cancer using low-dose-rate (LDR) and high-dose-rate (HDR) technique has been reported with results comparing favorably to surgery
and external beam radiation therapy (EBRT). Previous transurethral resection of the prostate (TURP) has been considered a relative contraindication for LDR permanent seed implant because of higher rates of urinary incontinence. There are little data on previous TURP and subsequent incontinence after HDR implant. We report our urinary incontinence results with HDR with or without previous TURP. Methods and Materials: Between 1997 and 2008, 380 patients with T1 and T2 localized prostate underwent TRUS guided interstitial implant. There were no Gleason Score or PSA exclusions. After discussion of treatment options, 109 patients elected HDR Implant þ IMRT and 269 patients underwent HDR monotherapy. No patient received Hormonal Blockade. Median Gleason Score was 7 (range : 4 to 10). Median PSA was 9.8 (0.60 to 39.8). IMRT treatment volume included the prostate þ seminal vesicles þ 2 cm margin. Implant treatment volumes ranged from 41 cm3 to 196 cm3. In patients who received IMRT þ HDR, 4500 cGy in 25 fractions was given via IMRT and 1650 cGy to 2000 cGy in 3 fractions via HDR. Our protocol for HDR alone, has called for two HDR Implants. The treatment volume received 2,250 cGy in 3 fractions prescribed to the 100% Isodose line, given over 24 hours. A 2nd implant was performed 4 weeks later, delivering a further 2,250 cGy in 3 fractions, bringing the final dose to the prostate to 4,500 cGy in 6 fractions. Urethral dose points (12e16) were followed, and limited to <105% of the prescription dose. Care was also taken to limit dose to the bladder sphincter regions. Results: There was no significant difference between the treatment groups with respect to T-Stage, Gleason Score, and PSA. With a median followup of 85 months (range : 6 months to 145 months), urinary stress incontinence has occurred in 3.2% (12/380). Previous TURP was performed in 59 patients. Incontinence has developed in 3.4% (2/59) undergoing previous TURP vs. 3.1% (10/321) in the non-TURP group (p 5 0.58). RTOG late bladder toxicities were: 0% Grade 4, 0% Grade 3, and 3.2% (12/380) Grade 2. Urinary stress incontinence has occurred in 3.3% (9/271), undergoing HDR alone, vs. 2.8% (3/109) treated with HDR + IMRT (p 5 0.53). Conclusions: Urinary stress incontinence after HDR implant occurs in rates comparable to LDR implant. Previous TURP is not a contraindication to HDR implant for prostate cancer.
PO60 145 Gy vs. 160 Gy for a prescription dose: A comparison of dosimetry and acute toxicity in 125I permanent implant for prostate cancer Atsunori Yorozu, M.D.,1 Kazuhito Toya, M.D.,1 Yutaka Shiraishi, M.D.,1 Satoshi Seki, M.D.,1 Shiro Saito, M.D.,2 Michio Kosugi, M.D.2 1Radiology, Tokyo Medical Center, NHO, Tokyo, Japan; 2Urology, Tokyo Medical Center, NHO, Tokyo, Japan. Purpose: To compare the postimpant dosimetry and acute toxicity of a 160 Gy-prescribed group with a 145 Gy-prescribed group in 125I permanent implant with intraoperative real-time planning technique for prostate cancer. Methods and Materials: The permanent seed prostate brachytherapy program at Tokyo Medical Center began in September 2003 and has treated more than 1000 patients. We started intraoperative real-time planning with 145 Gy for a prescribed dose in 2005, then escalated to 160 Gy for prescription in 2006. A cohort of consecutive 199 patients was treated with the 145 Gy-prescribed dose and consecutive 183 patients were treated with the 160 Gy-prescribed dose. All patients were implanted with loose seeds using the interactive US-guided technique described by Stock and Stone. A CT scan was obtained on Day 1 and Day 30 after implantation for postimplant dosimetry. The urethra was identified by Foley catheter on the intraoperative US scan and on the Day 1 CT scan. Urethral dosimetry was compared for the two cohorts using UD5, UD30 and UV150, and rectal dosimetry using RV100 and RD1. All patients were prescribed with tamslosin preventively. Acute morbidity was defined by the CTC-AE ver3.0. Urinary morbidity was defined by urinary retention, maximum increase in IPSS, and prescribed periods of tamslosin. Results: There was no significant difference between the treatment groups with respect to risk group, prostate volume and baseline IPSS. The mean D90 of prostate on the the Day 30 CT scan was 174 Gy for the 145 Gy-prescription group and 191 Gy for the 160 Gy-prescription group.