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MP05-04 EFFECTIVENESS OF COMBINATION THERAPY OF EXTERNAL-BEAM RADIATION AND HIGH DOSE-RATE BRACHYTHERAPY FOR HIGH-RISK PROSTATE CARCINOMA
e38
THE JOURNAL OF UROLOGYâ
Vol. 197, No. 4S, Supplement, Friday, May 12, 2017
ART. These results support current clinical trials underway discerning the utility of SRT in men with adverse pathologic features.
Source of Funding: none
MP05-03 CONTINENCE AFTER POST-PROSTATECTOMY INTENSITY MODULATED RADIATION THERAPY Itay Sagy*, Nimrod Barashi, Shay Golan, Scott eggener, Chicago, IL; Stanley Liauw, chicago, IL; Arieh Shalhav, Chicago, IL INTRODUCTION AND OBJECTIVES: Limited data exist regarding urinary continence after post-radical prostatectomy (RP) intensity modulated radiation therapy (IMRT) and whether IMRT influences urinary continence or interfere with the recovery from RP when given early. METHODS: 118 men were treated with curative-intent RT after RP. Forty-three men (36%) received adjuvant RT (13%) and early salvage (23%) within the 1st year from surgery and 75 men (64%) received late salvage RT (>1year from RP). Quality of life measures were prospectively assessed using the Expanded Prostate Cancer Index Composite (EPIC-26) by patients at baseline and at follow-up times. Each group (early and late RT) was compared to a control group from our prospective collected RP cohort that did not had RT based on age at RP, BMI, pre-operative incontinence scores and post-operative incontinence scores and pad usage. The control group included 248 men with a median follow-up time of 44 months. Due to differences in stage of the RP and RT cohorts, it was not possible to control for sparing of the neurovascular bundles. Endpoints are pad usage and incontinence score. RESULTS: With a median follow-up time of 60m, in men treated with IMRT, 29 patients (25%) deteriorated in pad usage, 14 (12%) improved and 75 (63%) were stable. Deterioration in continence was correlated with poor baseline incontinence scores (p<0.001) and with pre-RT number of pad usage per day. Of the patients that scores 100 in the incontinence score, only 3% deteriorated in continence.In the early (<1 year) RT group, mean incontinence score improved from 57 to 72 (p<0.01) and in the late RT group, mean incontinence score deteriorated from 80 to 69 (p<0.001) and was associated with a 13% deterioration in pad-free rates (p<0.05). Comparison to the control group showed a 12% and 5% differences in pad-free status in the late RT group and the early RT group respectively. Comparison of the entire cohort to the control group showed a 10% higher pad free rate in the control group - 74% Vs. 64% (p<0.001) (figure 1) CONCLUSIONS: Late salvage RT caused 12% deterioration in pad-free status. With the limitations of our control group, comparison to the cohort group showed 10% lower pad free rates after post prostatectomy RT. Deterioration in continence is strongly associated with the baseline urinary function.
Source of Funding: none
MP05-04 EFFECTIVENESS OF COMBINATION THERAPY OF EXTERNAL-BEAM RADIATION AND HIGH DOSE-RATE BRACHYTHERAPY FOR HIGH-RISK PROSTATE CARCINOMA Kenjiro Suzuki*, Suguru Shirotake, Koshiro Nishimoto, Soichi Makino, Hideyuki Kondo, Takashi Okabe, Yota Yasumizu, Kiichiro Kodaira, Shingo Kato, Masafumi Oyama, Saitama, Japan INTRODUCTION AND OBJECTIVES: Our institution is a high volume center of radiotherapy for prostate cancer patients (PCaPts). We have performed either neoadjuvant androgen deprivation therapy (NADT), followed by external-beam radiation therapy (total 39 Gray) and high dose-rate brachytherapy (HDR-B, total 18 Gray) (NEH) or radical prostatectomy (RP) on high-risk PCaPts, as defined by prostate specific antigen (PSA) level (>20ng/mL), pathology of biopsy specimen (Gleason score [GS]: 8), and/or clinical staging (T3). No comparative studies have been reported for NEH and RP. In order to determine if NEH is a better therapy than RP, we compared biochemical recurrencefree survival (bRFS, i.e., post therapeutic PSA elevation) and overall survival (OS) between NEH and RP on high-risk PCaPts. METHODS: Between 2007 and 2012, 192 and 167 high-risk PCaPts were treated by NEH and RP, respectively. Biochemical failure (BF) for NEH was defined using Phoenix definition: any PSA increase of >2 ng/mL higher than the PSA nadir value, regardless of the PSA nadir value. Whereas BF for RP was defined as PSA values of >0.2 ng/mL. Of note, PSA of 18 RP-cases (10.8 %) did not decrease to less than 0.2 ng/mL. In these cases, the day of PSA nadir was defined as BF date. Difference between bRFS and OS were calculated using Kaplan-Meier method and log-rank tests. RESULTS: The median follow-up duration was 58.7 months. Age was significantly older in NEH group (median [interquartile range] ¼ 71.9 [67.3-75.3] years) than in RP group (69.0 [64.9-72.3] years, p< 0.001, Mann-Whitney U test [MWU]). Initial PSA was higher in NEH (20.0 [10.1-43.6]) than RP group (15.9 [8.1-24.7] ng/dL, p<0.01, MWU). RP group had a trend of higher GS (72.1%) than NEH group (62.5%, p¼0.07, chi square test). T stage was similar (NEH [66.1 %] vs RP [66.4 %], p¼0.928, chi square test). The 5- and 7-year bRFS rates in NEH group (0.79 and 0.76, respectively) were significantly higher than those in RP group (0.51 and 0.41, respectively, p<0.001 each, Fig. 1A). However, in OS, no significant difference was found (p¼0.838). CONCLUSIONS: We retrospectively compared clinical outcomes of NEH and RP, and found that NEH might be as effective as RP for high-risk PCaPts. Currently, we are preparing prospective randomized case study comparing NEH and RP by adjusting age, GS, PSA, and T stage.
THE JOURNAL OF UROLOGYâ
Vol. 197, No. 4S, Supplement, Friday, May 12, 2017
e39
89.6%, 96.5 vs. 84.4% and 94.9 vs. 75% (p<0.001) and for CSS was 99.6 vs. 97.8%, 96.4 vs. 82.1% and 91.3 vs. 65.7% (p<0.001). CSS by BED < 180 vs 180 Gy2 was 55.6 vs. 76.9% (p¼0.406). In these highrisk patients, prostate cancer death was 40/314 (12.7%) for men with -SVB and 8/21 (38.1%) for +SVB (OR 4.22, 95%CI 1.6-10.8). Cox HR demonstrated GS (p¼0.001, HR 1.9), BED (p¼0.05, HR 0.991) and +SVB (p<0.001, HR 0.125) as significantly associated with CSS. CONCLUSIONS: Men who have pT3b disease have inferior BFFF, FFM and CSS. Advanced stage and high GS are highly associated with a +SVB. Higher radiation dose is associated with improved CSS in the pT3b patients. Taken together these data suggest SVB should be performed in men presenting with high GS and stage when considering combination radiation therapy. When performing PSI, implantation of the SVs will increase dose and improve long-term cause-specific survival. Source of Funding: none
MP05-06 LONG-TERM SURVIVAL IN MEN WITH GLEASON SCORE 9-10 TREATED WITH PROSTATE BRACHYTHERAPY AND EXTERNAL BEAM IRRADIATION Nelson Stone*, Richard Stock, New York, NY Source of Funding: none
MP05-05 LONG-TERM OUTCOMES OF MEN WITH STAGE PT3B PROSTATE CANCER DIAGNOSED BY SEMINAL VESICLE BIOPSY AND TREATED BY BRACHYTHERAPY AND EXTERNAL BEAM IRRADIATION Nelson Stone*, Richard Stock, New York, NY INTRODUCTION AND OBJECTIVES: Men diagnosed after prostatectomy with seminal vesicle invasion often have external beam irradiation (EBRT) as adjuvant treatment. Typically, men treated with radiation do not have assessment or treatment for T3b because it is often not detected. We report our results of seminal vesicle biopsy (SVB) in men with higher risk features planning to undergo permanent seed implant (PSI) followed by EBRT. METHODS: Of 1981 men who treated by PSI and followed 5-22 years (mean 10), 615 (31%) with high risk features had 6 TRUS guided biopsies of the SV (3 from each side). Patients with +SVB underwent laparoscopic pelvic lymph node dissection and those with positive nodes, bone or CT scans were excluded from implantation. 3 months of hormone therapy (NHT) was followed by Pd-103 implant to the prostate (dose 100 Gy) and proximal SV and 2 months later 45 Gy of conformal or image guided EBRT to prostate and SV only. NHT was given a median of 9 months. Within 2 months after treatment CT-based dosimetry was done with radiation doses converted to the biologic effective dose (BED). Biochemical freedom from failure (BFFF) was computed by the Phoenix definition, freedom from metastasis (FFM) in men with BF by absence of a positive bone or CT scan and causespecific survival (CSS) by freedom from death in men with clinical recurrence. Association of risk features to +SVB were compared by chisquare and linear regression (LR). Survival was computed by KaplanMeier estimates with comparisons by log rank and Cox hazard rates (HR). RESULTS: 53/615 (9.4%) had +SVB. Higher stage, Gleason score (GS) and PSA were associated with a positive SVB (p<0.001). LR demonstrated significance for stage (p<0.001) and GS (p¼0.001). BED was higher in patients receiving a SV implant (202. Vs. 179.3 Gy2, p<0.001). BFFF, FFM and CSS was worse for +SVB (all p<0.001). 48/ 53 (90.6%) with +SVB had NCCN3 (high risk) status. BFFF in these men without and with a +SVB was 88.5 vs. 74.9%, 75.3 vs. 62.2% and 70.3 vs 62.2% at 5, 10 and 15 years (p¼0.023). FFM was 99.3 vs.
INTRODUCTION AND OBJECTIVES: Very high grade prostate cancer is associated with poor outcomes. We report on the long-term outcomes of men with Gleason score (GS) 9-10 prostate cancer treated by prostate brachytherapy (PSI) and external beam irradiation (EBRT). METHODS: Of 1981 men who were treated by PSI and followed 5-22 years (mean 10), GS was 6 in 1304 (65.8%), 7 in 466 (23.5%), 8 in 142 (7.2%) and 9-10 in 69 (3.5%). Men with positive bone or CT scans were excluded from implantation. 3 months of hormone therapy (NHT) was followed by Pd-103 implant to the prostate (dose 100 Gy) and 2 months later 45 Gy of conformal or image guided EBRT. NHT was given a median of 9 months. Within 2 months after treatment CT-based dosimetry was done with radiation doses converted to the biologic effective dose (BED). Biochemical freedom from failure (BFFF) was computed by the Phoenix definition, freedom from metastasis (FFM) in men with BF by absence of a positive bone or CT scan and cause-specific survival (CSS) by freedom from death in men with clinical recurrence. Association of risk features to GS 9-10 were compared by chi-square and linear regression (LR). Survival was computed by Kaplan-Meier estimates with comparisons by log rank and Cox hazard rates (HR). RESULTS: Mean age was 65.6 years (median 66, range 39-85); mean PSA was 9.4 ng/ml (median 6.7, range 0.3-300) and mean BED 194.6 Gy (median 200, range 15-299). Median BED for GS9-10 was 199 Gy2. BFFF, FFM and CSS by GS are shown in the table. The mean survival time for the 4 GS groups was: 1) 21.5 years (95%CI 21.2-21.8), 2) 19.2 years (95%CI 18.6-19.7), 3) 18.1 years (95%CI 17.2-19.1) and 4) 13.9 years (95%CI 13.1-14.8, p<0.001). Only clinical stage was associates with CSS with 15-year survival for T2a 100%, T2b-c 40.5% and T3 0% (p¼0.025). Cox HR for CSS was significant for stage (p¼0.055, HR 2.0) and BED (p¼0.081, HR 0.985). CONCLUSIONS: PBI combined with EBRT has excellent 15year survival in men with GS 9-10 and clinical stage T2a. While 68% of men with T3 GS9-10 are alive at 10 years, at 15-year survival was 0. These men should be considered for alternate treatment strategies, possibly with early systemic therapy.
THE JOURNAL OF UROLOGYâ
Vol. 197, No. 4S, Supplement, Friday, May 12, 2017
ART. These results support current clinical trials underway discerning the utility of SRT in men with adverse pathologic features.
Source of Funding: none
MP05-03 CONTINENCE AFTER POST-PROSTATECTOMY INTENSITY MODULATED RADIATION THERAPY Itay Sagy*, Nimrod Barashi, Shay Golan, Scott eggener, Chicago, IL; Stanley Liauw, chicago, IL; Arieh Shalhav, Chicago, IL INTRODUCTION AND OBJECTIVES: Limited data exist regarding urinary continence after post-radical prostatectomy (RP) intensity modulated radiation therapy (IMRT) and whether IMRT influences urinary continence or interfere with the recovery from RP when given early. METHODS: 118 men were treated with curative-intent RT after RP. Forty-three men (36%) received adjuvant RT (13%) and early salvage (23%) within the 1st year from surgery and 75 men (64%) received late salvage RT (>1year from RP). Quality of life measures were prospectively assessed using the Expanded Prostate Cancer Index Composite (EPIC-26) by patients at baseline and at follow-up times. Each group (early and late RT) was compared to a control group from our prospective collected RP cohort that did not had RT based on age at RP, BMI, pre-operative incontinence scores and post-operative incontinence scores and pad usage. The control group included 248 men with a median follow-up time of 44 months. Due to differences in stage of the RP and RT cohorts, it was not possible to control for sparing of the neurovascular bundles. Endpoints are pad usage and incontinence score. RESULTS: With a median follow-up time of 60m, in men treated with IMRT, 29 patients (25%) deteriorated in pad usage, 14 (12%) improved and 75 (63%) were stable. Deterioration in continence was correlated with poor baseline incontinence scores (p<0.001) and with pre-RT number of pad usage per day. Of the patients that scores 100 in the incontinence score, only 3% deteriorated in continence.In the early (<1 year) RT group, mean incontinence score improved from 57 to 72 (p<0.01) and in the late RT group, mean incontinence score deteriorated from 80 to 69 (p<0.001) and was associated with a 13% deterioration in pad-free rates (p<0.05). Comparison to the control group showed a 12% and 5% differences in pad-free status in the late RT group and the early RT group respectively. Comparison of the entire cohort to the control group showed a 10% higher pad free rate in the control group - 74% Vs. 64% (p<0.001) (figure 1) CONCLUSIONS: Late salvage RT caused 12% deterioration in pad-free status. With the limitations of our control group, comparison to the cohort group showed 10% lower pad free rates after post prostatectomy RT. Deterioration in continence is strongly associated with the baseline urinary function.
Source of Funding: none
MP05-04 EFFECTIVENESS OF COMBINATION THERAPY OF EXTERNAL-BEAM RADIATION AND HIGH DOSE-RATE BRACHYTHERAPY FOR HIGH-RISK PROSTATE CARCINOMA Kenjiro Suzuki*, Suguru Shirotake, Koshiro Nishimoto, Soichi Makino, Hideyuki Kondo, Takashi Okabe, Yota Yasumizu, Kiichiro Kodaira, Shingo Kato, Masafumi Oyama, Saitama, Japan INTRODUCTION AND OBJECTIVES: Our institution is a high volume center of radiotherapy for prostate cancer patients (PCaPts). We have performed either neoadjuvant androgen deprivation therapy (NADT), followed by external-beam radiation therapy (total 39 Gray) and high dose-rate brachytherapy (HDR-B, total 18 Gray) (NEH) or radical prostatectomy (RP) on high-risk PCaPts, as defined by prostate specific antigen (PSA) level (>20ng/mL), pathology of biopsy specimen (Gleason score [GS]: 8), and/or clinical staging (T3). No comparative studies have been reported for NEH and RP. In order to determine if NEH is a better therapy than RP, we compared biochemical recurrencefree survival (bRFS, i.e., post therapeutic PSA elevation) and overall survival (OS) between NEH and RP on high-risk PCaPts. METHODS: Between 2007 and 2012, 192 and 167 high-risk PCaPts were treated by NEH and RP, respectively. Biochemical failure (BF) for NEH was defined using Phoenix definition: any PSA increase of >2 ng/mL higher than the PSA nadir value, regardless of the PSA nadir value. Whereas BF for RP was defined as PSA values of >0.2 ng/mL. Of note, PSA of 18 RP-cases (10.8 %) did not decrease to less than 0.2 ng/mL. In these cases, the day of PSA nadir was defined as BF date. Difference between bRFS and OS were calculated using Kaplan-Meier method and log-rank tests. RESULTS: The median follow-up duration was 58.7 months. Age was significantly older in NEH group (median [interquartile range] ¼ 71.9 [67.3-75.3] years) than in RP group (69.0 [64.9-72.3] years, p< 0.001, Mann-Whitney U test [MWU]). Initial PSA was higher in NEH (20.0 [10.1-43.6]) than RP group (15.9 [8.1-24.7] ng/dL, p<0.01, MWU). RP group had a trend of higher GS (72.1%) than NEH group (62.5%, p¼0.07, chi square test). T stage was similar (NEH [66.1 %] vs RP [66.4 %], p¼0.928, chi square test). The 5- and 7-year bRFS rates in NEH group (0.79 and 0.76, respectively) were significantly higher than those in RP group (0.51 and 0.41, respectively, p<0.001 each, Fig. 1A). However, in OS, no significant difference was found (p¼0.838). CONCLUSIONS: We retrospectively compared clinical outcomes of NEH and RP, and found that NEH might be as effective as RP for high-risk PCaPts. Currently, we are preparing prospective randomized case study comparing NEH and RP by adjusting age, GS, PSA, and T stage.
THE JOURNAL OF UROLOGYâ
Vol. 197, No. 4S, Supplement, Friday, May 12, 2017
e39
89.6%, 96.5 vs. 84.4% and 94.9 vs. 75% (p<0.001) and for CSS was 99.6 vs. 97.8%, 96.4 vs. 82.1% and 91.3 vs. 65.7% (p<0.001). CSS by BED < 180 vs 180 Gy2 was 55.6 vs. 76.9% (p¼0.406). In these highrisk patients, prostate cancer death was 40/314 (12.7%) for men with -SVB and 8/21 (38.1%) for +SVB (OR 4.22, 95%CI 1.6-10.8). Cox HR demonstrated GS (p¼0.001, HR 1.9), BED (p¼0.05, HR 0.991) and +SVB (p<0.001, HR 0.125) as significantly associated with CSS. CONCLUSIONS: Men who have pT3b disease have inferior BFFF, FFM and CSS. Advanced stage and high GS are highly associated with a +SVB. Higher radiation dose is associated with improved CSS in the pT3b patients. Taken together these data suggest SVB should be performed in men presenting with high GS and stage when considering combination radiation therapy. When performing PSI, implantation of the SVs will increase dose and improve long-term cause-specific survival. Source of Funding: none
MP05-06 LONG-TERM SURVIVAL IN MEN WITH GLEASON SCORE 9-10 TREATED WITH PROSTATE BRACHYTHERAPY AND EXTERNAL BEAM IRRADIATION Nelson Stone*, Richard Stock, New York, NY Source of Funding: none
MP05-05 LONG-TERM OUTCOMES OF MEN WITH STAGE PT3B PROSTATE CANCER DIAGNOSED BY SEMINAL VESICLE BIOPSY AND TREATED BY BRACHYTHERAPY AND EXTERNAL BEAM IRRADIATION Nelson Stone*, Richard Stock, New York, NY INTRODUCTION AND OBJECTIVES: Men diagnosed after prostatectomy with seminal vesicle invasion often have external beam irradiation (EBRT) as adjuvant treatment. Typically, men treated with radiation do not have assessment or treatment for T3b because it is often not detected. We report our results of seminal vesicle biopsy (SVB) in men with higher risk features planning to undergo permanent seed implant (PSI) followed by EBRT. METHODS: Of 1981 men who treated by PSI and followed 5-22 years (mean 10), 615 (31%) with high risk features had 6 TRUS guided biopsies of the SV (3 from each side). Patients with +SVB underwent laparoscopic pelvic lymph node dissection and those with positive nodes, bone or CT scans were excluded from implantation. 3 months of hormone therapy (NHT) was followed by Pd-103 implant to the prostate (dose 100 Gy) and proximal SV and 2 months later 45 Gy of conformal or image guided EBRT to prostate and SV only. NHT was given a median of 9 months. Within 2 months after treatment CT-based dosimetry was done with radiation doses converted to the biologic effective dose (BED). Biochemical freedom from failure (BFFF) was computed by the Phoenix definition, freedom from metastasis (FFM) in men with BF by absence of a positive bone or CT scan and causespecific survival (CSS) by freedom from death in men with clinical recurrence. Association of risk features to +SVB were compared by chisquare and linear regression (LR). Survival was computed by KaplanMeier estimates with comparisons by log rank and Cox hazard rates (HR). RESULTS: 53/615 (9.4%) had +SVB. Higher stage, Gleason score (GS) and PSA were associated with a positive SVB (p<0.001). LR demonstrated significance for stage (p<0.001) and GS (p¼0.001). BED was higher in patients receiving a SV implant (202. Vs. 179.3 Gy2, p<0.001). BFFF, FFM and CSS was worse for +SVB (all p<0.001). 48/ 53 (90.6%) with +SVB had NCCN3 (high risk) status. BFFF in these men without and with a +SVB was 88.5 vs. 74.9%, 75.3 vs. 62.2% and 70.3 vs 62.2% at 5, 10 and 15 years (p¼0.023). FFM was 99.3 vs.
INTRODUCTION AND OBJECTIVES: Very high grade prostate cancer is associated with poor outcomes. We report on the long-term outcomes of men with Gleason score (GS) 9-10 prostate cancer treated by prostate brachytherapy (PSI) and external beam irradiation (EBRT). METHODS: Of 1981 men who were treated by PSI and followed 5-22 years (mean 10), GS was 6 in 1304 (65.8%), 7 in 466 (23.5%), 8 in 142 (7.2%) and 9-10 in 69 (3.5%). Men with positive bone or CT scans were excluded from implantation. 3 months of hormone therapy (NHT) was followed by Pd-103 implant to the prostate (dose 100 Gy) and 2 months later 45 Gy of conformal or image guided EBRT. NHT was given a median of 9 months. Within 2 months after treatment CT-based dosimetry was done with radiation doses converted to the biologic effective dose (BED). Biochemical freedom from failure (BFFF) was computed by the Phoenix definition, freedom from metastasis (FFM) in men with BF by absence of a positive bone or CT scan and cause-specific survival (CSS) by freedom from death in men with clinical recurrence. Association of risk features to GS 9-10 were compared by chi-square and linear regression (LR). Survival was computed by Kaplan-Meier estimates with comparisons by log rank and Cox hazard rates (HR). RESULTS: Mean age was 65.6 years (median 66, range 39-85); mean PSA was 9.4 ng/ml (median 6.7, range 0.3-300) and mean BED 194.6 Gy (median 200, range 15-299). Median BED for GS9-10 was 199 Gy2. BFFF, FFM and CSS by GS are shown in the table. The mean survival time for the 4 GS groups was: 1) 21.5 years (95%CI 21.2-21.8), 2) 19.2 years (95%CI 18.6-19.7), 3) 18.1 years (95%CI 17.2-19.1) and 4) 13.9 years (95%CI 13.1-14.8, p<0.001). Only clinical stage was associates with CSS with 15-year survival for T2a 100%, T2b-c 40.5% and T3 0% (p¼0.025). Cox HR for CSS was significant for stage (p¼0.055, HR 2.0) and BED (p¼0.081, HR 0.985). CONCLUSIONS: PBI combined with EBRT has excellent 15year survival in men with GS 9-10 and clinical stage T2a. While 68% of men with T3 GS9-10 are alive at 10 years, at 15-year survival was 0. These men should be considered for alternate treatment strategies, possibly with early systemic therapy.