- Email: [email protected]
Percentage of Positive Biopsy Cores is a Strong Predictor of Clinical Outcome and Overall Survival in Prostate Cancer
Proceedings of the 51st Annual ASTRO Meeting bladder wall to rectum; (b) inferior edge of pubic symphysis to urethra; (c) vesico- urethral anastomosis to anterior rectum; (d) width and depth of the funnel-shaped lower bladder deformity; (e) vesico-urethral anastomosis to pubococcygeal line; (f) length of urethra (membranous and total); (g) superior and inferior separation of the levator ani in the coronal plane; and (h) pubic symphysis to rectum in the axial plane. We used t-tests to examine mean differences in each of the parameters between RARP and OP, and ANCOVA to examine mean differences controlling for length of follow-up MRI post surgery (in days) as a covariate. Results: MRI images on 15 post-RARP patients were compared to those on 10 post-OP patients. The groups were balanced with regard to prostate size (p = 0.69) and body-mass index (p = 0.91), however, the length of time from surgery to MRI was significantly different (p \ 0.01), as RARP is relatively nascent in its experience as compared to OP. Of the measurements, we found that the levator separation is significantly greater in the post-RARP group (p \ 0.01). Similarly, the post-RARP group had a greater mean resection defect measurement (p = 0.01). This suggests that the size of trigonal musculature defect seems more pronounced after RARP. The total urethral length was longer in the RARP group (p = 0.03), as was the distance of the vesico-urethral anastamosis to pubococcygeal line after adjusting for follow-up length (p = 0.042). The vesico-rectal distance was variable depending on the location along the rectal wall but trended toward larger separation in the post-RARP group (p = 0.06). Conclusions: As RARP continues to become a more widespread surgical option for the management of localized prostate cancer, XRT field design may need to be adjusted to prevent unnecessary toxicity to surrounding normal structures, particularly in the posterior and inferior dimensions. Further study is warranted, mainly to correlate the treatment approach with post treatment side effects. Author Disclosure: A.E. Hirsch, None; M.J. Janicek, None; K. Mui, None; R.J. Lee, None; D.S. Wang, None; R.K. Babayan, None; A.C. Zumwalt, None; A. Ozonoff, None; A.L. Zietman, None.
2263
Dose-volume Analysis of Predictors for Chronic Rectal Toxicity following Treatment of Prostate Cancer with Adaptive Image-guided Radiotherapy (IGRT)
D. Y. Lee, S. D. McGrath, D. Yan, J. Liang, J. Dilworth, M. I. Ghilezan, D. S. Brabbins, F. A. Vicini, A. A. Martinez, L. L. Kestin William Beaumont Hospital, Royal Oak, MI Purpose/Objective(s): We analyzed our experience treating prostate cancer with CT-based offline adaptive IGRT +/-intensitymodulated radiotherapy (IMRT) to identify factors associated with chronic rectal toxicity. Materials/Methods: From 1998-2006, 844 patients with T1-T3N0M0 prostate cancer were prospectively treated with adaptive IGRT via 3D-CRT (n = 509, 60%) or IMRT (n = 335, 40%) to a median dose of 75.6 Gy (range: 63.0-79.2 Gy, minimum dose to confidence limited-planning target volume (cl-PTV)) in 1.8-Gy fractions (median isocenter dose=79.7 Gy). A patient-specific cl-PTV was constructed based on 5 CT scans by applying an adaptive process to assure target accuracy and minimize PTV margin. For each case, the rectal solid was contoured from the SI joints or rectosigmoid junction (whichever was lower) to the anal verge or ischial tuberosities (whichever was higher) for a median vol. of 82.7 cc. The rectal wall was defined based on the rectal solid using a 3-mm wall thickness (median=26.6 cc). Toxicity was quantified using NCI CTC v3. Multiple dose-volume histogram (DVH) endpoints were evaluated for association with chronic rectal toxicity. Median follow-up was 3.0 yrs (0.1-7.6). Results: Chronic grade$2 (CG2T) and $3 (CG3T) GI toxicity was 21% and 3% for all patients, respectively, at a median interval of 0.9 and 1.0 yrs. 152 patients experienced CG2T (17% rectal bleeding, 5% proctitis, 3% rectal incontinence, 2% diarrhea, 2% rectal pain). 20 patients experienced CG3T (2% rectal bleeding, 0.6% proctitis, 0.4% incontinence). Rectal wall (RW) and solid (RS) relative V20-80 were significantly associated with CG2T both as continuous variables (t-test & regression) and when divided into subgroups. CG2T was 15%, 23% and 44% for RW V70\25%, 25-40%, and .40% (p \ 0.01). RW and RS relative V30-80 were associated with CG3T (t-test & regression) with $V50 most closely associated with toxicity. CG3T was 0.9%, 3.5% and 8.2% for the RW V70 as above (p\ 0.01). 3-year CG2T and CG3T was reduced from 28.8% and 4% with 3D-CRT to 8% and 0.8% with IMRT (p \ 0.01, p = 0.045). IMRT was superior to 3D-CRT across multiple prescription and isocenter dose subgroups. Stratification by isocenter doses \78 Gy, 78 - 82 Gy, and.82Gy revealed less CG2T with IMRT (21% v. 1% (p \ 0.01), 18% v. 3% (p \ 0.01), 20 vs. 3%, (p = 0.08)). Use of IMRT reduced CG3T as well (5% v. 0% (p = 0.02), 1.4% v. 0.4% (p = 0.3), 4% v. 0% (p = 0.2)). Conclusions: While a very broad range of DVH parameters predicted for chronic grade$2 and $3 rectal toxicity, toxicity was highly dependent on rectal wall or solid relative V50 to V80 with V70 appearing optimal. When treating patients with adaptive IGRT, the addition of IMRT significantly reduces chronic rectal toxicity. Author Disclosure: D.Y. Lee, None; S.D. McGrath, None; D. Yan, None; J. Liang, None; J. Dilworth, None; M.I. Ghilezan, None; D.S. Brabbins, None; F.A. Vicini, None; A.A. Martinez, None; L.L. Kestin, None.
2264
Percentage of Positive Biopsy Cores is a Strong Predictor of Clinical Outcome and Overall Survival in Prostate Cancer
L. L. Kestin, F. Vicini, H. Ye, S. McGrath, M. Ghilezan, A. Martinez William Beaumont Hospital, Royal Oak, MI Purpose/Objective(s): To assess the prognostic value of percentage of positive biopsy cores (PPC) and perineural invasion (PNI) in predicting clinical outcome following radiotherapy (RT) for prostate cancer. Materials/Methods: 866 patients with clinical stage T1-T3 N0 M0 prostate cancer and $ 4 biopsy cores sampled and complete biopsy core data available were treated with either adaptive image-guided RT (median 75.6 Gy, n = 321), low-dose EBRT (median 66.6 Gy, n = 304), EBRT and high dose rate brachytherapy boost (n = 213), or brachytherapy alone (n = 28) at William Beaumont Hospital (1991-2007). 191 patients (22%) also received neoadjuvant androgen deprivation. Biochemical failure (BF) was scored according to the Phoenix definition. Clinical failure (CF) was defined as any locoregional recurrence (LRR) or distant metastasis (DM). Median follow-up = 5.7 years. Results: Mean cores sampled=7.4, mean cores positive=2.6, and mean PPC=38%. 15% had PNI. On univariate Cox regression, higher PPC was associated with BF, CF, LRR, DM, cause-specific survival (CSS), and overall survival as a continuous variable. On
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multivariate Cox regression, PPC, Gleason score, pre-treatment PSA, and low-dose EBRT were associated with BF (p \ 0.01). PPC and Gleason score were the only factors associated with DM and CSS (p \ 0.01). Gleason score, PNI, low-dose EBRT, and younger age were associated with LRR (p \ 0.03). PPC, low-dose EBRT, and older age were associated with overall survival (p \ 0.02). When grouping PPC as #33%, 34-66%, & $67%, 6-year CF was 3%, 8%, & 22% (p \ 0.01). When grouping PPC as \25%, 25-49%, 50-74%, & $75%, 6-year CF was 2%, 7%, 9%, & 23% (p \ 0.01). When grouping PPC as \20%, 20-39%, 4059%, 60-79%, & $80%, 6-year CF was 3%, 6%, 7%, 18%, & 24% (p \ 0.01). Combining #66% vs $67% PPC with NCCN risk group stratification demonstrated added prognostic value for intermediate- (6-year CF: 4% vs 13%) and high-risk (6-year CF: 10% vs 36%, p \ 0.01) groups. When only examining high-dose RT, PPC remained significant. Bilateral involvement and high unilateral PPC did not add to the prognostic value of overall PPC. 6-year CF was 6% for no PNI vs 20% with PNI (p \ 0.01). On univariate analysis, PNI was associated with BF, CF, and LRR, but only LRR on multivariate analysis. Conclusions: PPC is independently associated with BF, CF, and survival and should be considered for risk group stratification in prostate cancer. In this dataset, only Gleason score appeared to be more closely associated with clinical outcome than PPC. Author Disclosure: L.L. Kestin, None; F. Vicini, None; H. Ye, None; S. McGrath, None; M. Ghilezan, None; A. Martinez, None.
2265
Is Low-dose Rate Interstitial Brachytherapy for Patients with Large Prostates (.60cc) Safe and Effective?
H. V. Patone, D. Shasha, M. Orlanzino, D. Vongtama, J. Rineer, N. Shah, L. B. Harrison Beth Israel Medical Center, New York, NY Purpose/Objective(s): The purpose of this study was to review the dosimetry and efficacy of our single physician, single-institution experience using low-dose-rate (LDR) brachytherapy in patients with large volume prostate glands (.60cc). Materials/Methods: Out of a total of 925 consecutive patients treated with LDR interstitial brachytherapy implants for prostate cancer at Beth Israel Medical Center between 1998 and 2008, 87 patients were identified as having a pre-implant ultrasound volume of more than 60cc (mean, 72.4cc; median, 68.6cc; range, 60.2-117.0cc). Sixty-eight patients received LDR brachytherapy as a boost (108Gy) before or after conformal external beam radiation therapy, and the remaining 21 patients received LDR brachytherapy alone (144Gy). Sixty-seven percent of patients received neoadjuvant, concurrent, and adjuvant androgen deprivation therapy. Post-implant dosimetry was obtained on the day of implant for all patients, with a single implanting physician performing all contours. Results: The median D90 (minimal dose to 90% of the prostate) was 105% of prescription dose (range, 75-135%), the median V100 (volume receiving 100% of the dose) was 91% (range, 69-100%) and the median V150 was 48% (range, 19-79%). The median volume of rectum receiving 100% of the prescription dose was 0.53cc. The median V150 for the urethra (volume receiving 150% of the dose) was 17%. Long-term follow-up data (minimum 1 year follow-up) was available for 59 out of the 87 patients. With a median follow-up of 5.0 years, there have been no biochemical failures. Four patients (5%) required temporary placement of a urinary catheter for acute obstructive symptoms, with one patient (who had multiple sclerosis) developing a fistula requiring permanent suprapubic catheterization. There have been no cases of acute or long-term Grade 2 gastrointestinal toxicity. Conclusions: We present one of the largest series evaluating efficacy and toxicity outcomes after LDR brachytherapy performed in patients with prostatomegaly. Our findings demonstrate that large prostate volume is not a contraindication to LDR brachytherapy. Furthermore, excellent dosimetric coverage is routinely achievable without incurring significant acute and long-term toxicity. Author Disclosure: H.V. Patone, None; D. Shasha, None; M. Orlanzino, None; D. Vongtama, None; J. Rineer, None; N. Shah, None; L.B. Harrison, None.
2266
Prostatic Duct Adenocarcinoma: Clinical Characteristics, Treatment Options and Outcomes: A Rare Cancer Network Study
S. Igdem1, D. Spiegel2, J. Efstathiou2, A. Zietman2, R. Miller3, P. Poortmans4, D. Unsal5 Istanbul Bilim University, Istanbul, Turkey, 2Massachusetts General Hospital, Harvard Medical School, Boston, MA, 3Mayo Clinic, Rochester, MN, 4Dr Bernard Verbeeten Institute, Tilburg, Netherlands, 5Gazi University, Ankara, Turkey 1
Purpose/Objective(s): Prostatic duct adenocarcinoma (PDA) is a rare variant of prostate cancer representing about 1% of all prostate cancer cases. To evaluate the characteristics, treatment options, and outcomes for PDA we initiated a Rare Cancer Network (RCN) study. Materials/Methods: A retrospective review was performed in the 5 member institutions of the RCN which showed interest to this project. Thirty-one patients were identified who were treated for PDA between 1980-2007 and had a minimum follow-up of 1 year. Their median age at presentation was 69 (range, 52-82 years). Seventy percent of the patients had T2c or higher stage disease. Excluding the patients from pre-PSA era the initial PSA level ranged from 0.5-49 ng/ml. Fifteen patients had pure PDA, the remaining 16 mixed acinar/ductal carcinoma with a median Gleason score of 7. Fourteen patients were diagnosed with TRUS guided biopsy, 4 with transurethral resection, 1 with cystoscopy, 1 using both modalities, and the remaining 11 after prostatectomy. Five cases were located in the urethra, 1 in the urethra and prostate, 27 in the prostate. Sixteen patients underwent radical prostatectomy, 7 of whom received adjuvant or salvage radiation, 14 were definitively treated with radiotherapy +/- androgen deprivation to a median prostatic dose of 66Gy, and 1 patient was treated with total androgen deprivation alone. Endpoints examined were time to biochemical failure, local failure, metastatic disease, and death. Results: Of the 15 patients with pure ductal carcinoma median PSA was 8ng/ml compared 7.5ng/ml for those with mixed ductal/acinar tumors. Overall 5 patients developed locoregional recurrence, and 4 distant metastases. Of the 14 patients managed with radiotherapy, 8 remain alive without disease after a median follow up of 36 months (range, 12-132 months). Only one patient died of prostate cancer, and 3 of other causes in this group. Of the 15 who underwent radical prostatectomy 12 were alive without disease and only 1 patient died of disease at a median follow up of 31 months (range, 12-143 months). The patient treated with androgen deprivation alone developed bone metastases, but remains alive after 22 months of follow
2263
Dose-volume Analysis of Predictors for Chronic Rectal Toxicity following Treatment of Prostate Cancer with Adaptive Image-guided Radiotherapy (IGRT)
D. Y. Lee, S. D. McGrath, D. Yan, J. Liang, J. Dilworth, M. I. Ghilezan, D. S. Brabbins, F. A. Vicini, A. A. Martinez, L. L. Kestin William Beaumont Hospital, Royal Oak, MI Purpose/Objective(s): We analyzed our experience treating prostate cancer with CT-based offline adaptive IGRT +/-intensitymodulated radiotherapy (IMRT) to identify factors associated with chronic rectal toxicity. Materials/Methods: From 1998-2006, 844 patients with T1-T3N0M0 prostate cancer were prospectively treated with adaptive IGRT via 3D-CRT (n = 509, 60%) or IMRT (n = 335, 40%) to a median dose of 75.6 Gy (range: 63.0-79.2 Gy, minimum dose to confidence limited-planning target volume (cl-PTV)) in 1.8-Gy fractions (median isocenter dose=79.7 Gy). A patient-specific cl-PTV was constructed based on 5 CT scans by applying an adaptive process to assure target accuracy and minimize PTV margin. For each case, the rectal solid was contoured from the SI joints or rectosigmoid junction (whichever was lower) to the anal verge or ischial tuberosities (whichever was higher) for a median vol. of 82.7 cc. The rectal wall was defined based on the rectal solid using a 3-mm wall thickness (median=26.6 cc). Toxicity was quantified using NCI CTC v3. Multiple dose-volume histogram (DVH) endpoints were evaluated for association with chronic rectal toxicity. Median follow-up was 3.0 yrs (0.1-7.6). Results: Chronic grade$2 (CG2T) and $3 (CG3T) GI toxicity was 21% and 3% for all patients, respectively, at a median interval of 0.9 and 1.0 yrs. 152 patients experienced CG2T (17% rectal bleeding, 5% proctitis, 3% rectal incontinence, 2% diarrhea, 2% rectal pain). 20 patients experienced CG3T (2% rectal bleeding, 0.6% proctitis, 0.4% incontinence). Rectal wall (RW) and solid (RS) relative V20-80 were significantly associated with CG2T both as continuous variables (t-test & regression) and when divided into subgroups. CG2T was 15%, 23% and 44% for RW V70\25%, 25-40%, and .40% (p \ 0.01). RW and RS relative V30-80 were associated with CG3T (t-test & regression) with $V50 most closely associated with toxicity. CG3T was 0.9%, 3.5% and 8.2% for the RW V70 as above (p\ 0.01). 3-year CG2T and CG3T was reduced from 28.8% and 4% with 3D-CRT to 8% and 0.8% with IMRT (p \ 0.01, p = 0.045). IMRT was superior to 3D-CRT across multiple prescription and isocenter dose subgroups. Stratification by isocenter doses \78 Gy, 78 - 82 Gy, and.82Gy revealed less CG2T with IMRT (21% v. 1% (p \ 0.01), 18% v. 3% (p \ 0.01), 20 vs. 3%, (p = 0.08)). Use of IMRT reduced CG3T as well (5% v. 0% (p = 0.02), 1.4% v. 0.4% (p = 0.3), 4% v. 0% (p = 0.2)). Conclusions: While a very broad range of DVH parameters predicted for chronic grade$2 and $3 rectal toxicity, toxicity was highly dependent on rectal wall or solid relative V50 to V80 with V70 appearing optimal. When treating patients with adaptive IGRT, the addition of IMRT significantly reduces chronic rectal toxicity. Author Disclosure: D.Y. Lee, None; S.D. McGrath, None; D. Yan, None; J. Liang, None; J. Dilworth, None; M.I. Ghilezan, None; D.S. Brabbins, None; F.A. Vicini, None; A.A. Martinez, None; L.L. Kestin, None.
2264
Percentage of Positive Biopsy Cores is a Strong Predictor of Clinical Outcome and Overall Survival in Prostate Cancer
L. L. Kestin, F. Vicini, H. Ye, S. McGrath, M. Ghilezan, A. Martinez William Beaumont Hospital, Royal Oak, MI Purpose/Objective(s): To assess the prognostic value of percentage of positive biopsy cores (PPC) and perineural invasion (PNI) in predicting clinical outcome following radiotherapy (RT) for prostate cancer. Materials/Methods: 866 patients with clinical stage T1-T3 N0 M0 prostate cancer and $ 4 biopsy cores sampled and complete biopsy core data available were treated with either adaptive image-guided RT (median 75.6 Gy, n = 321), low-dose EBRT (median 66.6 Gy, n = 304), EBRT and high dose rate brachytherapy boost (n = 213), or brachytherapy alone (n = 28) at William Beaumont Hospital (1991-2007). 191 patients (22%) also received neoadjuvant androgen deprivation. Biochemical failure (BF) was scored according to the Phoenix definition. Clinical failure (CF) was defined as any locoregional recurrence (LRR) or distant metastasis (DM). Median follow-up = 5.7 years. Results: Mean cores sampled=7.4, mean cores positive=2.6, and mean PPC=38%. 15% had PNI. On univariate Cox regression, higher PPC was associated with BF, CF, LRR, DM, cause-specific survival (CSS), and overall survival as a continuous variable. On
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multivariate Cox regression, PPC, Gleason score, pre-treatment PSA, and low-dose EBRT were associated with BF (p \ 0.01). PPC and Gleason score were the only factors associated with DM and CSS (p \ 0.01). Gleason score, PNI, low-dose EBRT, and younger age were associated with LRR (p \ 0.03). PPC, low-dose EBRT, and older age were associated with overall survival (p \ 0.02). When grouping PPC as #33%, 34-66%, & $67%, 6-year CF was 3%, 8%, & 22% (p \ 0.01). When grouping PPC as \25%, 25-49%, 50-74%, & $75%, 6-year CF was 2%, 7%, 9%, & 23% (p \ 0.01). When grouping PPC as \20%, 20-39%, 4059%, 60-79%, & $80%, 6-year CF was 3%, 6%, 7%, 18%, & 24% (p \ 0.01). Combining #66% vs $67% PPC with NCCN risk group stratification demonstrated added prognostic value for intermediate- (6-year CF: 4% vs 13%) and high-risk (6-year CF: 10% vs 36%, p \ 0.01) groups. When only examining high-dose RT, PPC remained significant. Bilateral involvement and high unilateral PPC did not add to the prognostic value of overall PPC. 6-year CF was 6% for no PNI vs 20% with PNI (p \ 0.01). On univariate analysis, PNI was associated with BF, CF, and LRR, but only LRR on multivariate analysis. Conclusions: PPC is independently associated with BF, CF, and survival and should be considered for risk group stratification in prostate cancer. In this dataset, only Gleason score appeared to be more closely associated with clinical outcome than PPC. Author Disclosure: L.L. Kestin, None; F. Vicini, None; H. Ye, None; S. McGrath, None; M. Ghilezan, None; A. Martinez, None.
2265
Is Low-dose Rate Interstitial Brachytherapy for Patients with Large Prostates (.60cc) Safe and Effective?
H. V. Patone, D. Shasha, M. Orlanzino, D. Vongtama, J. Rineer, N. Shah, L. B. Harrison Beth Israel Medical Center, New York, NY Purpose/Objective(s): The purpose of this study was to review the dosimetry and efficacy of our single physician, single-institution experience using low-dose-rate (LDR) brachytherapy in patients with large volume prostate glands (.60cc). Materials/Methods: Out of a total of 925 consecutive patients treated with LDR interstitial brachytherapy implants for prostate cancer at Beth Israel Medical Center between 1998 and 2008, 87 patients were identified as having a pre-implant ultrasound volume of more than 60cc (mean, 72.4cc; median, 68.6cc; range, 60.2-117.0cc). Sixty-eight patients received LDR brachytherapy as a boost (108Gy) before or after conformal external beam radiation therapy, and the remaining 21 patients received LDR brachytherapy alone (144Gy). Sixty-seven percent of patients received neoadjuvant, concurrent, and adjuvant androgen deprivation therapy. Post-implant dosimetry was obtained on the day of implant for all patients, with a single implanting physician performing all contours. Results: The median D90 (minimal dose to 90% of the prostate) was 105% of prescription dose (range, 75-135%), the median V100 (volume receiving 100% of the dose) was 91% (range, 69-100%) and the median V150 was 48% (range, 19-79%). The median volume of rectum receiving 100% of the prescription dose was 0.53cc. The median V150 for the urethra (volume receiving 150% of the dose) was 17%. Long-term follow-up data (minimum 1 year follow-up) was available for 59 out of the 87 patients. With a median follow-up of 5.0 years, there have been no biochemical failures. Four patients (5%) required temporary placement of a urinary catheter for acute obstructive symptoms, with one patient (who had multiple sclerosis) developing a fistula requiring permanent suprapubic catheterization. There have been no cases of acute or long-term Grade 2 gastrointestinal toxicity. Conclusions: We present one of the largest series evaluating efficacy and toxicity outcomes after LDR brachytherapy performed in patients with prostatomegaly. Our findings demonstrate that large prostate volume is not a contraindication to LDR brachytherapy. Furthermore, excellent dosimetric coverage is routinely achievable without incurring significant acute and long-term toxicity. Author Disclosure: H.V. Patone, None; D. Shasha, None; M. Orlanzino, None; D. Vongtama, None; J. Rineer, None; N. Shah, None; L.B. Harrison, None.
2266
Prostatic Duct Adenocarcinoma: Clinical Characteristics, Treatment Options and Outcomes: A Rare Cancer Network Study
S. Igdem1, D. Spiegel2, J. Efstathiou2, A. Zietman2, R. Miller3, P. Poortmans4, D. Unsal5 Istanbul Bilim University, Istanbul, Turkey, 2Massachusetts General Hospital, Harvard Medical School, Boston, MA, 3Mayo Clinic, Rochester, MN, 4Dr Bernard Verbeeten Institute, Tilburg, Netherlands, 5Gazi University, Ankara, Turkey 1
Purpose/Objective(s): Prostatic duct adenocarcinoma (PDA) is a rare variant of prostate cancer representing about 1% of all prostate cancer cases. To evaluate the characteristics, treatment options, and outcomes for PDA we initiated a Rare Cancer Network (RCN) study. Materials/Methods: A retrospective review was performed in the 5 member institutions of the RCN which showed interest to this project. Thirty-one patients were identified who were treated for PDA between 1980-2007 and had a minimum follow-up of 1 year. Their median age at presentation was 69 (range, 52-82 years). Seventy percent of the patients had T2c or higher stage disease. Excluding the patients from pre-PSA era the initial PSA level ranged from 0.5-49 ng/ml. Fifteen patients had pure PDA, the remaining 16 mixed acinar/ductal carcinoma with a median Gleason score of 7. Fourteen patients were diagnosed with TRUS guided biopsy, 4 with transurethral resection, 1 with cystoscopy, 1 using both modalities, and the remaining 11 after prostatectomy. Five cases were located in the urethra, 1 in the urethra and prostate, 27 in the prostate. Sixteen patients underwent radical prostatectomy, 7 of whom received adjuvant or salvage radiation, 14 were definitively treated with radiotherapy +/- androgen deprivation to a median prostatic dose of 66Gy, and 1 patient was treated with total androgen deprivation alone. Endpoints examined were time to biochemical failure, local failure, metastatic disease, and death. Results: Of the 15 patients with pure ductal carcinoma median PSA was 8ng/ml compared 7.5ng/ml for those with mixed ductal/acinar tumors. Overall 5 patients developed locoregional recurrence, and 4 distant metastases. Of the 14 patients managed with radiotherapy, 8 remain alive without disease after a median follow up of 36 months (range, 12-132 months). Only one patient died of prostate cancer, and 3 of other causes in this group. Of the 15 who underwent radical prostatectomy 12 were alive without disease and only 1 patient died of disease at a median follow up of 31 months (range, 12-143 months). The patient treated with androgen deprivation alone developed bone metastases, but remains alive after 22 months of follow