Three-dimensional computed tomography-guided monotherapeutic pararectal brachytherapy of prostate cancer with seminal vesicle invasion.

PURPOSE: To treat patients with prostate cancer and seminal vesicle invasion with monotherapeutic three dimensional computed tomography (3-DCT)-guided posterior pararectal brachytherapy. METHODS AND MATERIALS: Three hundred and sixty two patients with clinical stage T1 a,b or T2 a,b of prostate cancer were referred for 3-DCT-guided brachytherapy. Each underwent ftirther staging with 3-D CT-guided pararectal biopsy of the seminal vesicles under local anesthesia during the pre-treatment CT-planning. Forty-three patients (12%) were upstaged to T3 cNoMo disease. In the set of 43 patients, Eight had Gleason's score< or =6, 24 Gleason's score=7, and 11 patients > or =8. Initial PSA was <10 ng/ml in 14 patients, 10-20 ng/ml in 11 patients, and >20 in 18 patients. Of the 43 patients, 37 patients were treated monotherapeutically with 3-D CT-guided brachytherapy. No patients received hormone therapy after the implant. The prescribed dosage to the seminal vesicles and prostate is 120 Gy with Pd-103 seeds and 144 Gy with 1-125 seeds. RESULTS: The prescribed dosage was achieved in all 37 patient's throughout the seminal vesicles whose range of target radiation extended 5-10 mm outside the target in the adjacent fat as calculated with post-implant CT-dosimetry with Varian Brachy Vision or MMS software. Prostate Specific Antigen (PSA) outcome data were available in 34 patients treated with monotherapy and follow up ranged from 12-56 months (median, 24 months). Decreased PSA levels were stratified into six groups based on the presenting Gleason's score and initial PSA. In the first group (with Gleason's score< or =6 and initial PSA <20 ng/ml), PSA levels decreased to less than 0.5 ng/ml in all seven patients (100%) after brachytherapy. In the second group (with Gleason's=7 and initial PSA<20 ng/ml), PSA levels decreased to less than 1 ng/ml in 11 of 13 patients (85%); additionally PSA levels decreased to less than 0.5 ng/ml in ten patients (77% in this group). In the third group (with Gleason's score=7 and initial PSA> 20 ng/ml), PSA decreased to less than 0.5 ng/ml in four out of eight patients (50%). All of the patients in the fourth group (with Gleason's score> or =8 and initial PSA<20 ng/ml) decreased their PSA levels to less than 0.5 ng/ml in three of three patients. PSA decreased less than 0.5 ng/ml in two out of three patients (67% in the last group with Gleason's score> or =8 and initial PSA> 20 ng/ml). There were no patients with Gleason's score of 1-6 and greater than 20 ng/ml initial PSA. Patients, irrespective of the Gleason's score and PSA, had an overall response of decreased PSA (less than 1 ng/ml) of 79%. CONCLUSION: 3-D CT-guided brachytherapy delivers adequate dosage to the seminal vesicles. Clinical and biochemical results are encouraging in patients with low initial PSA levels regardless of their Gleason's scores, but longer-term data in a greater number of patients is necessary.

A three-dimensional stereotactic device for computed tomography-guided invasive diagnostic and therapeutic procedures.

RATIONALE AND OBJECTIVES: A three-dimensional stereotactic technique is presented as an improvement in precision needle placement for percutaneous diagnostic and therapeutic procedures. METHODS: This method uses transaxial computed tomography (CT) imaging for the selection of the optimal target path, and it employs a three-dimensional stereotactic device designed to match precisely the CT parameters in a three-dimensional space. RESULTS: In selected cases, we reached targets as small as 1 to 2 cm while avoiding vital structures. CONCLUSIONS: In our hands, in selected cases, this has been a simple, safe, and accurate technique for improvement of percutaneous diagnostic and therapeutic procedures under CT guidance.

Stereotactic percutaneous lumbar discectomy.

Sixty-nine patients with documented and contained disc herniations underwent percutaneous discectomy. The procedure was carried out with a new stereotactic device mounted on the floor and positioned over the computed tomographic scanner. In each instance, this device provided accurate insertion of the needle and localization of the aspiration probe (Nucleotome) within the appropriate area of the disc. Aspiration of the herniated nucleus pulposus was accomplished in every patient, and no complications were encountered.

High- and low-risk prostate cancer treated with 3D CT-guided brachytherapy: 1-to 5-year follow-up.

PURPOSE: To provide a preliminary report of 301 patients treated for prostate carcinoma with three-dimensional CT-guided transischiorectal stereotactic brachytherapy using either iodine-125 or palladium-103 seeds as monotherapy. PATIENTS AND METHODS: Patients with clinical stage T1, T(2ab), or T(3ab) disease with prostate volumes 23 to 180 cm3 and serum prostate specific antigen (PSA) concentrations of 0.9 to 143 ng/mL had seeds placed 10 mm apart under CT guidance. No androgen blockade was used postoperatively, but 47% of the patients had hormonal therapy preoperatively. RESULTS: At 12 to 63 months (median 26 months) of follow-up, PSA concentrations had decreased to <2 ng/mL in 90% of the patients and to <1 ng/mL in 83%. Four patients underwent transurethral resection or incision at least 12 months after implantation; none became incontinent. Three patients had rectal ulceration that lasted for several months. CONCLUSIONS: Computed tomography-guided transischiorectal brachytherapy allows accurate placement of radionuclide seeds in prostate glands of all sizes. The early results, as judged by serum PSA, are encouraging.

Stereotactic lumbar microdiscectomy.

Stereotaxis eliminates the risk of trial and error in fluoroscopic guidance. This technique appears ideal in the hands of those who do not have extensive experience with guidance of the instruments under fluoroscopic control. The procedure is atraumatic and almost free of complications, but acceptance of the stereotactic technique will be greater if a special CT suite is designed not only for stereotactic microdiscetomies but also for other percutaneous diagnostic and therapeutic procedures.

Three-dimensional stereotactic posterior ischiorectal space computerized tomography guided brachytherapy of prostate cancer: a preliminary report.

PURPOSE: A 3-dimensional (D) stereotactic posterior ischiorectal space computerized tomography (CT) guided approach is presented for brachytherapy of localized prostate adenocarcinoma. MATERIALS AND METHODS: During the last 2 years 130 patients 49 to 90 years old (median age 71) with clinical stage A, B or C adenocarcinoma have been treated by this method. The initial prostate specific antigen profile was range 0.9 to 143 ng./ml., mean, 16.25 and median 13.0. Range of initial prostatic volume was 30 to 156 cm.3, with a (median 62 and mean 65). Of the patients 15% had signs and symptoms of urinary obstruction, that is with residual urine greater than 100 cc and significant nocturia and frequency. Transurethral resection of the prostate defects were present in 20% of the patients. Volume and treatment planning is performed by CT. Placement of the after loading needles is accomplished with a 3-D stereotactic system mounted on a CT table. The prescribed dose is 12,000 cGy. for 103Palladium seeds and 16,000 for 125I. The dosage is achieved by spacing the after loading needles 10 mm. apart with the seeds averaging 10 mm. apart from center to center. RESULTS: Prostate specific antigen levels decreased to less than 2 ng./ml. in 95% of the patients including those at high risk 6 to 24 months after the procedure. Except for treatment related transient symptoms of urethritis and proctitis, there have been no complications. No patients had incontinence, acute infection, hemorrhage or radiation damage to the rectum. No patients required post-implant transurethral resection of the prostate. There was significant clinical improvement in patients with obstructive uropathy. CONCLUSIONS: The 3-D stereotactic CT guided posterior ischiorectal space approach for brachytherapy is not limited by prostate size, transurethral prostatic resection defects or public arch interference, and it allows for needle verification and correction if necessary. Initial clinical and biochemical results in patients treated with this method are promising.

Prostatourethral-rectal fistula after prostate brachytherapy.

BACKGROUND: Brachytherapy (BT) has seen increased utilization as a potentially curative treatment for patients with localized initial or recurrent prostate carcinoma. This modality can be delivered by palladium 103 (Pd(103)) or iodine 125 (I(125)) implant with or without external beam radiotherapy (EBRT). Prostatourethral-rectal fistula (PRF) is a serious complication of this approach, and its incidence, clinical presentation, and risk factors for occurrence have not been documented thoroughly. Thus, the authors sought to determine these factors in a large series of patients who were treated at two institutions. METHODS: Seven hundred sixty-five patients received outpatient BT using a computed tomography (CT)-guided or transrectal ultrasound (TRUS)-guided technique between July 1994 and June 1999 using either Pd(103) or I(125) implants. Of the 754 patients with follow-up, 640 patients received BT monotherapy, 69 patients received BT monotherapy as a boost after EBRT, and 45 patients received BT as salvage therapy after locally recurrent prostate carcinoma that was treated initially with BT (20 patients), EBRT (20 patients), surgery plus EBRT (3 patients), surgery and high dose rate radiotherapy (HDR) (1 patient), or EBRT plus HDR (1 patient). CT dosimetry of the TRUS-guided implants was carried out in all patients 1-7 days postprocedure. Patient follow-up and clinical status were compiled in a data base. RESULTS: Seven PRFs developed in 754 patients (1%) between 9 months and 12 months after treatment. One PRF (0.2%) occurred in patients who were treated with BT monotherapy. PRFs occurred in patients who were treated with combination therapy (2 of 69 patients; 2.9%) and in patients who underwent salvage BT (4 of 45 patients; 8.8%) patients. All six patients who developed fistulas in the context of combination BT/EBRT or salvage BT had biopsy of an anterior rectal lesion overlying the prostate noted on physical examination during routine follow-up. Gastrointestinal endoscopic evaluation alone was not associated with any PRF. Five of the seven PRFs resolved with either surgical repair (3 patients) or conservative management (2 patients). CONCLUSIONS: There is a low incidence of PRF formation after BT monotherapy. Because all patients who developed PRF did so subsequent to prior rectal biopsies, the authors currently are discouraging such practices strongly if the rectal lesion is consistent with radiation-induced effects.