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Interstitial High Dose Rate (HDR) Brachytherapy + IMRT versus HDR Monotherapy for Early Stage Prostate Cancer: A Report of 363 Cases
I. J. Radiation Oncology d Biology d Physics
S290
Volume 72, Number 1, Supplement, 2008
Conclusions: Percentage of positive biopsy cores is associated with biochemical outcome for intermediate-risk prostate cancer patients treated with RT. Patients with $50% PC have the highest risk for biochemical failure, and may be more likely to derive a benefit from ADT in the setting of dose escalated RT. Author Disclosure: S.L. Liauw, None; D. Correa, None; A.B. Jani, None.
2270
Interstitial High Dose Rate (HDR) Brachytherapy + IMRT versus HDR Monotherapy for Early Stage Prostate Cancer: A Report of 363 Cases
T. R. Neumann1, R. Mark1,2, P. Anderson1, M. Nair1, R. Akins3, S. Gurley1, D. White1 1 Joe Arrington Cancer Center, Lubbock, TX, 2Texas Tech University, Lubbock, TX, 3University of Miami, Miami, FL Purpose/Objective(s): Transrectal ultrasound (TRUS) guided interstitial implant for prostate cancer using High Dose Rate (HDR) + External Beam Radiation Therapy (EBRT) technique has been reported with results comparing favorably to surgery, Low Dose Rate (LDR) brachytherapy +/ EBRT, EBRT, and Intensity Modulated Radiation Therapy (IMRT). The role of supplemental EBRT in brachytherapy is controversial. We compare our results of HDR + IMRT vs. HDR monotherapy. Materials/Methods: Between 1997 and 2008, 363 patients with T1 and T2 localized prostate underwent TRUS interstitial implant. There were no Gleason Score or PSA exclusions. After discussion of treatment options, 109 patients elected HDR implant + IMRT and 254 patients underwent HDR monotherapy. No patient received Hormonal Blockade. Median Gleason Score was 7 (range, 4-10). Median PSA was 9.8 (0.60-39.8). The IMRT treatment volume included the prostate + seminal vesicles + 2 cm margin. Implant treatment volumes ranged from 42 cm3 to 196 cm3. In patients who received IMRT + HDR, 4,500 cGy in 25 fractions was given via IMRT and 1,650 cGy to 2,000 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 second 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 (12-16) were followed, and limited to #105% of the prescription dose. Results: There was no significant difference between the treatment groups with respect to T-Stage, Gleason Score, and PSA. With a median follow-up of 90 months (range, 6 months to 146 months), the overall PSA Disease-Free Survival (DFS) was 88.4% (321/ 363). In patients undergoing IMRT + HDR implant, PSA DFS was 87.2% (95/109) vs. 88.9% (226/254) for patients undergoing HDR alone (p = 0.59). The 5-year actuarial survival was 86% for the group receiving IMRT + HDR vs. 89% with HDR monotherapy (log-rank = 0.5). Urethral stricture requiring dilatation has developed in 4.7% (17/363) of patients. Urinary stress incontinence has occurred in 3.6% (13/363). The RTOG late bladder toxicities were: 0% Grade 4, 0% Grade 3, and 3.6% (13/363) Grade 2. The RTOG late rectal toxicities were: 0.3% (1/363) Grade 4, 0% Grade 3, 3.0% (11/363) Grade 2, and 3.6% (13/363) Grade 1. The RTOG late rectal toxicity was higher in patients undergoing HDR + IMRT with 15.6% (17/109) of patients experiencing Grade 2 and 1 symptoms vs. 2.8% (7/254) receiving HDR alone (p \ 0.0001). Conclusions: We observed no significant difference in PSA DFS in patients undergoing HDR monotherapy vs. HDR + IMRT. Complications were similar, though RTOG Grade 1 and 2 late toxicity were higher in patients receiving HDR + IMRT. Author Disclosure: T.R. Neumann, None; R. Mark, None; P. Anderson, None; M. Nair, None; R. Akins, None; S. Gurley, None; D. White, None.
2271
Long-term Outcomes for Patients with Gleason Scores 8-10 Prostate Cancer Treated with Combination Brachytherapy, External Beam Irradiation and Hormonal Therapy
R. G. Stock, J. A. Cesaretti, J. Yeh, N. N. Stone Mount Sinai Medical Center, New York, NY Purpose/Objective(s): Gleason scores of 8-10 prostate cancer has remained a therapeutic challenge due to its associated high local tumor burden as well as its propensity for systemic spread. Long-term outcomes are reported following combined therapy with hormonal therapy, brachytherapy, and external beam irradiation to assess its efficacy in treating this aggressive form of prostate cancer. Materials/Methods: From 1994 to 2005, 177 patients with Gleason scores 8 -10 prostate cancer were treated with 9 months of hormonal therapy in combination with Pd-103 (prescription dose – 100 Gy) prostate brachytherapy and external beam irradiation (median dose – 45 Gy). Biologically effective dose values (BED) were calculated for all treatments from the 1 month CT dosimetry D90 using and a/b ratio of 2. Presenting PSA levels were #10 in 54%, .10-20 in 27%, and .20 in 19%. Gleason scores were 8 in 67% and 9-10 in 33%. Clinical stage was #t1c in 19%, t2a in 10%, t2b in 32%, t2c in 24%, and t3 in 15%. Follow-up ranged from 2 to 11 years (median - 5). Results: The actuarial freedom from biochemical failure rates (FBF) at 10 years for all patients were 78% (ASTRO), 74% Phoenix (PHNX), and 66% (AUA ($0.2 ng/mL). Freedom from distant metastases at 10 years was 76%. In the 33 patients with biochemical failure (PHNX), the rate of developing distant metastases was 49% at 5 years and 78% by 10 years. Prostate cancer-specific and overall survival at 10 years was 92% and 78%, respectively. There was a significant difference in 10-year FBF rates (PHNX) for patients with a Gleason score of 8 (84%) versus those with 9, 10 (58%), p = 0.002. Presenting PSA also had a significant impact with rates of 78% for patients with PSA #20 (PHNX) versus 58% for those with PSA .20 (p = 0.004). Higher BED values were associated with increased biochemical control. Patients with BED \200 (71 patients) had a 10-year FBF rate of 66% versus 78.5% for those with BED $200 (106 patients) (p = 0.02). A total of 31 patients underwent posttreatment biopsy with 97% having negative biopsies. Last testosterone levels ranged from 10 to 826 (median - 288). 64% had levels .200. Conclusions: The 10 year biochemical control rates following prostatectomy for patients with Gleason scores 8-10 are consistently in the 35-40% range. Combined brachytherapy, hormonal therapy, and external beam appear to provide markedly improved biochemical control rates. These outcomes along with the biopsy results and observed dose response highlight the importance of local control in the treatment of high-grade prostate cancer. Patients failing this regimen have a high likelihood of developing clinical metastatic disease and should be treated aggressively following biochemical recurrence. Author Disclosure: R.G. Stock, None; J.A. Cesaretti, BARD, F. Consultant/Advisory Board; J. Yeh, None; N.N. Stone, Prologics, E. Ownership Interest.
S290
Volume 72, Number 1, Supplement, 2008
Conclusions: Percentage of positive biopsy cores is associated with biochemical outcome for intermediate-risk prostate cancer patients treated with RT. Patients with $50% PC have the highest risk for biochemical failure, and may be more likely to derive a benefit from ADT in the setting of dose escalated RT. Author Disclosure: S.L. Liauw, None; D. Correa, None; A.B. Jani, None.
2270
Interstitial High Dose Rate (HDR) Brachytherapy + IMRT versus HDR Monotherapy for Early Stage Prostate Cancer: A Report of 363 Cases
T. R. Neumann1, R. Mark1,2, P. Anderson1, M. Nair1, R. Akins3, S. Gurley1, D. White1 1 Joe Arrington Cancer Center, Lubbock, TX, 2Texas Tech University, Lubbock, TX, 3University of Miami, Miami, FL Purpose/Objective(s): Transrectal ultrasound (TRUS) guided interstitial implant for prostate cancer using High Dose Rate (HDR) + External Beam Radiation Therapy (EBRT) technique has been reported with results comparing favorably to surgery, Low Dose Rate (LDR) brachytherapy +/ EBRT, EBRT, and Intensity Modulated Radiation Therapy (IMRT). The role of supplemental EBRT in brachytherapy is controversial. We compare our results of HDR + IMRT vs. HDR monotherapy. Materials/Methods: Between 1997 and 2008, 363 patients with T1 and T2 localized prostate underwent TRUS interstitial implant. There were no Gleason Score or PSA exclusions. After discussion of treatment options, 109 patients elected HDR implant + IMRT and 254 patients underwent HDR monotherapy. No patient received Hormonal Blockade. Median Gleason Score was 7 (range, 4-10). Median PSA was 9.8 (0.60-39.8). The IMRT treatment volume included the prostate + seminal vesicles + 2 cm margin. Implant treatment volumes ranged from 42 cm3 to 196 cm3. In patients who received IMRT + HDR, 4,500 cGy in 25 fractions was given via IMRT and 1,650 cGy to 2,000 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 second 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 (12-16) were followed, and limited to #105% of the prescription dose. Results: There was no significant difference between the treatment groups with respect to T-Stage, Gleason Score, and PSA. With a median follow-up of 90 months (range, 6 months to 146 months), the overall PSA Disease-Free Survival (DFS) was 88.4% (321/ 363). In patients undergoing IMRT + HDR implant, PSA DFS was 87.2% (95/109) vs. 88.9% (226/254) for patients undergoing HDR alone (p = 0.59). The 5-year actuarial survival was 86% for the group receiving IMRT + HDR vs. 89% with HDR monotherapy (log-rank = 0.5). Urethral stricture requiring dilatation has developed in 4.7% (17/363) of patients. Urinary stress incontinence has occurred in 3.6% (13/363). The RTOG late bladder toxicities were: 0% Grade 4, 0% Grade 3, and 3.6% (13/363) Grade 2. The RTOG late rectal toxicities were: 0.3% (1/363) Grade 4, 0% Grade 3, 3.0% (11/363) Grade 2, and 3.6% (13/363) Grade 1. The RTOG late rectal toxicity was higher in patients undergoing HDR + IMRT with 15.6% (17/109) of patients experiencing Grade 2 and 1 symptoms vs. 2.8% (7/254) receiving HDR alone (p \ 0.0001). Conclusions: We observed no significant difference in PSA DFS in patients undergoing HDR monotherapy vs. HDR + IMRT. Complications were similar, though RTOG Grade 1 and 2 late toxicity were higher in patients receiving HDR + IMRT. Author Disclosure: T.R. Neumann, None; R. Mark, None; P. Anderson, None; M. Nair, None; R. Akins, None; S. Gurley, None; D. White, None.
2271
Long-term Outcomes for Patients with Gleason Scores 8-10 Prostate Cancer Treated with Combination Brachytherapy, External Beam Irradiation and Hormonal Therapy
R. G. Stock, J. A. Cesaretti, J. Yeh, N. N. Stone Mount Sinai Medical Center, New York, NY Purpose/Objective(s): Gleason scores of 8-10 prostate cancer has remained a therapeutic challenge due to its associated high local tumor burden as well as its propensity for systemic spread. Long-term outcomes are reported following combined therapy with hormonal therapy, brachytherapy, and external beam irradiation to assess its efficacy in treating this aggressive form of prostate cancer. Materials/Methods: From 1994 to 2005, 177 patients with Gleason scores 8 -10 prostate cancer were treated with 9 months of hormonal therapy in combination with Pd-103 (prescription dose – 100 Gy) prostate brachytherapy and external beam irradiation (median dose – 45 Gy). Biologically effective dose values (BED) were calculated for all treatments from the 1 month CT dosimetry D90 using and a/b ratio of 2. Presenting PSA levels were #10 in 54%, .10-20 in 27%, and .20 in 19%. Gleason scores were 8 in 67% and 9-10 in 33%. Clinical stage was #t1c in 19%, t2a in 10%, t2b in 32%, t2c in 24%, and t3 in 15%. Follow-up ranged from 2 to 11 years (median - 5). Results: The actuarial freedom from biochemical failure rates (FBF) at 10 years for all patients were 78% (ASTRO), 74% Phoenix (PHNX), and 66% (AUA ($0.2 ng/mL). Freedom from distant metastases at 10 years was 76%. In the 33 patients with biochemical failure (PHNX), the rate of developing distant metastases was 49% at 5 years and 78% by 10 years. Prostate cancer-specific and overall survival at 10 years was 92% and 78%, respectively. There was a significant difference in 10-year FBF rates (PHNX) for patients with a Gleason score of 8 (84%) versus those with 9, 10 (58%), p = 0.002. Presenting PSA also had a significant impact with rates of 78% for patients with PSA #20 (PHNX) versus 58% for those with PSA .20 (p = 0.004). Higher BED values were associated with increased biochemical control. Patients with BED \200 (71 patients) had a 10-year FBF rate of 66% versus 78.5% for those with BED $200 (106 patients) (p = 0.02). A total of 31 patients underwent posttreatment biopsy with 97% having negative biopsies. Last testosterone levels ranged from 10 to 826 (median - 288). 64% had levels .200. Conclusions: The 10 year biochemical control rates following prostatectomy for patients with Gleason scores 8-10 are consistently in the 35-40% range. Combined brachytherapy, hormonal therapy, and external beam appear to provide markedly improved biochemical control rates. These outcomes along with the biopsy results and observed dose response highlight the importance of local control in the treatment of high-grade prostate cancer. Patients failing this regimen have a high likelihood of developing clinical metastatic disease and should be treated aggressively following biochemical recurrence. Author Disclosure: R.G. Stock, None; J.A. Cesaretti, BARD, F. Consultant/Advisory Board; J. Yeh, None; N.N. Stone, Prologics, E. Ownership Interest.