Abstract
The optimal treatment of patients with localized prostate cancer remains controversial. Significant clinical data are available, however, demonstrating that patients treated with radiation therapy (RT) have a significantly better outcome as the dose to the gland is increased. What remains debatable, however, is how to best deliver these higher doses of RT without significantly increasing normal tissue toxicities. Conformal high dose rate brachytherapy (C-HDR BT) represents an alternative means of precise dose delivery that offers similar tumoricidal effects as three-dimensional (3D) conformal external beam radiotherapy (EBRT) or permanent interstitial prostate seed implants with potential additional advantages. Since C-HDR BT consists of temporarily placing afterloading needles or catheters directly into the prostate gland under real-time ultrasound guidance, a steep dose gradient between the prostate and adjacent normal tissues can be generated that is minimally affected by organ motion and edema or treatment setup uncertainties. The ability to control the amount of time the single HDR radioactive source "dwells" at each position along the length of each brachytherapy catheter further enhances the conformity of the dose. In addition, recent radiobiological data on prostate cancer treatment suggest that C-HDR BT should produce tumor control and late normal tissue side effects that are at least as good as achieved with conventional fractionation, with the additional possibility that acute side effects might be reduced. Published data from several groups performing C-HDR BT as boosts in patients with locally advanced disease have supported these assumptions. Combined with the physical advantages discussed above, C-HDR BT should provide similar tumor control as 3D conformal EBRT with the added advantages of reduced treatment times, less acute toxicity, and no additional technological requirements to account and correct for treatment setup uncertainties and organ motion. Due to the success of C-HDR BT as boost treatment in locally advanced disease, this form of radiation treatment has recently been applied to low-risk prostate cancer patients as an alternative brachytherapy technique to permanent interstitial seed implantation. Advantages in this setting include an improved ability to define and deliver the prescribed dose, a significantly shortened treatment schedule compared to 3D conformal EBRT, and the fact that patients are not radioactive after implantation.
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Bolla M, Collette L, Blank L, Warde P, Dubois JB, Mirimanoff RO, Storme G, Bernier J, Kuten A, Sternberg C, Mattelaer J, Lopez TJ, Pfeffer JR, Lino CC, Zurlo A, Pierart M (2002) Long-term results with immediate androgen suppression and external irradiation in patients with locally advanced prostate cancer (an EORTC study): a phase III randomised trial. Lancet 360:103–106
Bolla M, Gonzalez D, Warde P, Dubois JB, Mirimanoff RO, Storme G, Bernier J, Kuten A, Sternberg C, Gil T, Collette L, Pierart M (1997) Improved survival in patients with locally advanced prostate cancer treated with radiotherapy and goserelin. N Engl J Med 337:295–300
Borghede G, Hedelin H, Holmang S, Johansson KA, Aldenborg F, Pettersson S, Sernbo G, Wallgren A, Mercke C (1997) Combined treatment with temporary short-term high dose rate iridium-192 brachytherapy and external beam radiotherapy for irradiation of localized prostatic carcinoma. Radiother Oncol 44:237–244
Borghede G, Hedelin H, Holmang S, Johansson KA, Sernbo G, Mercke C (1997) Irradiation of localized prostatic carcinoma with a combination of high dose rate iridium-192 brachytherapy and external beam radiotherapy with three target definitions and dose levels inside the prostate gland. Radiother Oncol 44:245–250
Brenner DJ, Martinez AA, Edmundson GK, Mitchell C, Thames HD, Armour EP (2002) Direct evidence that prostate tumors show high sensitivity to fractionation (low alpha/beta ratio), similar to late-responding normal tissue. Int J Radiat Oncol Biol Phys 52:6–13
Curran MJ, Healey GA, Bihrle W, III, Goodman N, Roth RA (2000) Treatment of high-grade low-stage prostate cancer by high-dose-rate brachytherapy. J Endourol 14:351–356
D'Souza WD, Thames HD (2001) Is the alpha/beta ratio for prostate cancer low? Int J Radiat Oncol Biol Phys 51:1–3
Deger S, Boehmer D, Turk I, Roigas J, Wernecke KD, Wiegel T, Hinkelbein W, Dinges S, Budach V, Loening SA (2002) High dose rate brachytherapy of localized prostate cancer. Eur Urol 41:420–426
Deger S, Dinges S, Roigas J, Schnorr D, Turk I, Budach V, Hinkelbein W, Loening SA (1997) High-dose rate iridium192 afterloading therapy in combination with external beam irradiation for localized prostate cancer. Tech Urol 3:190–194
Demanes DJ, Rodriguez RR, Altieri GA (2000) High dose rate prostate brachytherapy: the California Endocurietherapy (CET) method. Radiother Oncol 57:289–296
Duchesne GM, Peters LJ (1999) What is the alpha/beta ratio for prostate cancer? Rationale for hypofractionated high-dose-rate brachytherapy. Int J Radiat Oncol Biol Phys 44:747–748
Edmundson GK, Yan D, Martinez AA (1995) Intraoperative optimization of needle placement and dwell times for conformal prostate brachytherapy. Int J Radiat Oncol Biol Phys 33:1257–1263
Fiveash JB, Hanks G, Roach M, Wang S, Vigneault E, McLaughlin PW, Sandler HM (2000) 3D conformal radiation therapy (3DCRT) for high grade prostate cancer: a multi-institutional review. Int J Radiat Oncol Biol Phys 47:335–342
Forman JD, Porter AT (1997) The experience with neutron irradiation in locally advanced adenocarcinoma of the prostate. Semin Urol Oncol 15:239–243
Fowler J, Chappell R, Ritter M (2001) Is alpha/beta for prostate tumors really low? Int J Radiat Oncol Biol Phys 50:1021–1031
Fowler JF, Chappell RJ, Ritter MA (2002) The prospects for new treatments for prostate cancer. Int J Radiat Oncol Biol Phys 52:3–5
Fukunaga-Johnson N, Sandler HM, McLaughlin PW, Strawderman MS, Grijalva KH, Kish KE, Lichter AS (1997) Results of 3D conformal radiotherapy in the treatment of localized prostate cancer. Int J Radiat Oncol Biol Phys 38:311–317
Galalae RM, Kovacs G, Schultze J, Loch T, Rzehak P, Wilhelm R, Bertermann H, Buschbeck B, Kohr P, Kimmig B (2002) Long-term outcome after elective irradiation of the pelvic lymphatics and local dose escalation using high-dose-rate brachytherapy for locally advanced prostate cancer. Int J Radiat Oncol Biol Phys 52:81–90
Gerber GS, Thisted RA, Chodak GW, Schroder FH, Frohmuller HG, Scardino PT, Paulson DF, Middleton AW, Jr., Rukstalis DB, Smith JA, Jr., Ohori M, Theiss M, Schellhammer PF (1997) Results of radical prostatectomy in men with locally advanced prostate cancer: multi-institutional pooled analysis. Eur Urol 32:385–390
Han M, Partin AW, Pound CR, Epstein JI, Walsh PC (2001) Long-term biochemical disease-free and cancer-specific survival following anatomic radical retropubic prostatectomy. The 15-year Johns Hopkins experience. Urol Clin North Am 28:555–565
Hanks GE (2000) Conformal radiotherapy for prostate cancer. Ann Med 32:57–63
Hanks GE, Hanlon AL, Pinover WH, Horwitz EM, Price RA, Schultheiss T (2000) Dose selection for prostate cancer patients based on dose comparison and dose response studies. Int J Radiat Oncol Biol Phys 46:823–832
Hanks GE, Hanlon AL, Pinover WH, Horwitz EM, Schultheiss TE (1999) Survival advantage for prostate cancer patients treated with high-dose three-dimensional conformal radiotherapy. Cancer J Sci Am 5:152–158
Hanks GE, Hanlon AL, Schultheiss TE, Pinover WH, Movsas B, Epstein BE, Hunt MA (1998) Dose escalation with 3D conformal treatment: five year outcomes, treatment optimization, and future directions. Int J Radiat Oncol Biol Phys 41:501–510
Kestin LL, Martinez AA, Stromberg JS, Edmundson GK, Gustafson GS, Brabbins DS, Chen PY, Vicini FA (2000) Matched-pair analysis of conformal high-dose-rate brachytherapy boost versus external-beam radiation therapy alone for locally advanced prostate cancer. J Clin Oncol 18:2869–2880
Kini VR, Edmundson GK, Vicini FA, Jaffray DA, Gustafson G, Martinez AA (1999) Use of three-dimensional radiation therapy planning tools and intraoperative ultrasound to evaluate high dose rate prostate brachytherapy implants. Int J Radiat Oncol Biol Phys 43:571–578
Lattanzi J, McNeeley S, Donnelly S, Palacio E, Hanlon A, Schultheiss TE, Hanks GE (2000) Ultrasound-based stereotactic guidance in prostate cancer-quantification of organ motion and set-up errors in external beam radiation therapy. Comput Aided Surg 5:289–295
Martinez A, Gonzalez J, Spencer W, Gustafson G, Kestin L, Kearney D, Vicini FA (2003) Conformal high dose rate brachytherapy improves biochemical control and cause specific survival in patients with prostate cancer and poor prognostic factors. J Urol 169:974–979
Martinez AA, Gustafson G, Gonzalez J, Armour E, Mitchell C, Edmundson G, Spencer W, Stromberg J, Huang R, Vicini F (2002) Dose escalation using conformal high-dose-rate brachytherapy improves outcome in unfavorable prostate cancer. Int J Radiat Oncol Biol Phys 53:316–327
Martinez AA, Kestin LL, Stromberg JS, Gonzalez JA, Wallace M, Gustafson GS, Edmundson GK, Spencer W, Vicini FA (2000) Interim report of image-guided conformal high-dose-rate brachytherapy for patients with unfavorable prostate cancer: the William Beaumont phase II dose-escalating trial. Int J Radiat Oncol Biol Phys 47:343–352
Martinez AA, Pataki I, Edmundson G, Sebastian E, Brabbins D, Gustafson G (2001) Phase II prospective study of the use of conformal high-dose-rate brachytherapy as monotherapy for the treatment of favorable stage prostate cancer: a feasibility report. Int J Radiat Oncol Biol Phys 49:61–69
Mate TP, Gottesman JE, Hatton J, Gribble M, Van Hollebeke L (1998) High dose-rate afterloading 192Iridium prostate brachytherapy: feasibility report. Int J Radiat Oncol Biol Phys 41:525–533
Michalski JM, Purdy JA, Winter K, Roach M, III, Vijayakumar S, Sandler HM, Markoe AM, Ritter MA, Russell KJ, Sailer S, Harms WB, Perez CA, Wilder RB, Hanks GE, Cox JD (2000) Preliminary report of toxicity following 3D radiation therapy for prostate cancer on 3DOG/RTOG 9406. Int J Radiat Oncol Biol Phys 46:391–402
Nag S, Gupta N (2000) A simple method of obtaining equivalent doses for use in HDR brachytherapy. Int J Radiat Oncol Biol Phys 46:507–513
Oefelein MG, Smith ND, Grayhack JT, Schaeffer AJ, McVary KT (1997) Long-term results of radical retropubic prostatectomy in men with high grade carcinoma of the prostate. J Urol 158:1460–1465
Paul R, Hofmann R, Schwarzer JU, Stepan R, Feldmann HJ, Kneschaurek P, Molls M, Hartung R (1997) Iridium 192 high-dose-rate brachytherapy—a useful alternative therapy for localized prostate cancer? World J Urol 15:252–256
Pellizzon AC, Nadalin W, Salvajoli JV, Fogaroli RC, Novaes PE, Maia MA, Ferrigno R (2003) Results of high dose rate afterloading brachytherapy boost to conventional external beam radiation therapy for initial and locally advanced prostate cancer. Radiother Oncol 66:167–172
Pilepich MV, Caplan R, Byhardt RW, Lawton CA, Gallagher MJ, Mesic JB, Hanks GE, Coughlin CT, Porter A, Shipley WU, Grignon D (1997) Phase III trial of androgen suppression using goserelin in unfavorable-prognosis carcinoma of the prostate treated with definitive radiotherapy: report of Radiation Therapy Oncology Group Protocol 85-31. J Clin Oncol 15:1013–1021
Pollack A, Zagars GK, Smith LG, Lee JJ, von Eschenbach AC, Antolak JA, Starkschall G, Rosen I (2000) Preliminary results of a randomized radiotherapy dose-escalation study comparing 70 Gy with 78 Gy for prostate cancer. J Clin Oncol 18:3904–3911
Pollack A, Zagars GK, Starkschall G, Antolak JA, Lee JJ, Huang E, von Eschenbach AC, Kuban DA, Rosen I (2002) Prostate cancer radiation dose response: results of the M. D. Anderson phase III randomized trial. Int J Radiat Oncol Biol Phys 53:1097–1105
Ragde H, Elgamal AA, Snow PB, Brandt J, Bartolucci AA, Nadir BS, Korb LJ (1998) Ten-year disease free survival after transperineal sonography-guided iodine-125 brachytherapy with or without 45-gray external beam irradiation in the treatment of patients with clinically localized, low to high Gleason grade prostate carcinoma [see comments]. Cancer 83:989–1001
Stromberg JS, Martinez AA, Horwitz EM, Gustafson GS, Gonzalez JA, Spencer WF, Brabbins DS, Dmuchowski CF, Hollander JB, Vicini FA (1997) Conformal high dose rate iridium-192 boost brachytherapy in locally advanced prostate cancer: superior prostate-specific antigen response compared with external beam treatment. Cancer J Sci Am 3:346–352
Syed AM, Puthawala A, Sharma A, Gamie S, Londrc A, Cherlow JM, Damore SJ, Nazmy N, Sheikh KM, Ko SJ (2001) High-dose-rate brachytherapy in the treatment of carcinoma of the prostate. Cancer Control 8:511–521
Vicini FA, Abner A, Baglan KL, Kestin LL, Martinez AA (2001) Defining a dose-response relationship with radiotherapy for prostate cancer: is more really better? Int J Radiat Oncol Biol Phys 51:1200–1208
Vicini FA, Kestin LL, Martinez AA (2000) Use of conformal high-dose rate brachytherapy for management of patients with prostate cancer: optimizing dose escalation. Tech Urol 6:135–145
Yan D, Lockman D (2001) Organ/patient geometric variation in external beam radiotherapy and its effects. Med Phys 28:593–602
Yan D, Xu B, Lockman D, Kota K, Brabbins DS, Wong J, Martinez AA (2001) The influence of interpatient and intrapatient rectum variation on external beam treatment of prostate cancer. Int J Radiat Oncol Biol Phys 51:1111–1119
Yoshioka Y, Nose T, Yoshida K, Inoue T, Yamazaki H, Tanaka E, Shiomi H, Imai A, Nakamura S, Shimamoto S, Inoue T (2000) High-dose-rate interstitial brachytherapy as a monotherapy for localized prostate cancer: treatment description and preliminary results of a phase I/II clinical trial. Int J Radiat Oncol Biol Phys 48:675–681
Yoshioka Y, Nose T, Yoshida K, Oh RJ, Yamada Y, Tanaka E, Yamazaki H, Inoue T, Inoue T (2003) High-dose-rate brachytherapy as monotherapy for localized prostate cancer: a retrospective analysis with special focus on tolerance and chronic toxicity. Int J Radiat Oncol Biol Phys 56:213–220
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Vicini, F., Vargas, C., Gustafson, G. et al. High dose rate brachytherapy in the treatment of prostate cancer. World J Urol 21, 220–228 (2003). https://doi.org/10.1007/s00345-003-0358-8
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DOI: https://doi.org/10.1007/s00345-003-0358-8