Treatment outcomes with permanent brachytherapy in high-risk prostate cancer patients stratified into prognostic categories.

PURPOSE: To determine whether a previously reported substratification system can be extrapolated to patients with high-risk prostate cancer treated with permanent interstitial brachytherapy. METHODS AND MATERIALS: Four hundred six National Comprehensive Cancer Network patients with high-risk prostate cancer treated with permanent prostate brachytherapy with or without supplemental external beam radiotherapy were stratified into good (prostate-specific antigen >20 or Gleason score ≥8 or ≥T3), intermediate (prostate-specific antigen >20 and ≥T3), and poor (Gleason score ≥8 with ≥1 additional high-risk feature) prognostic cohorts. Because of only 1 patient with intermediate high-risk disease, the analysis was performed on patients in the good and poor cohorts. Biochemical failure (BF), prostate cancer-specific mortality (PCSM), distant metastasis, and overall mortality were assessed as function of prognostic group. Multiple parameters were evaluated for impact on outcome. RESULTS: With a median followup time of 7.9 years, 10- and 14-year rates of BF and PCSM for the entire cohort were 7.8% and 3.7%, respectively. The BF rate was significantly greater in the poor prognostic category (16.8% vs. 7.8%, p = 0.041). The poor prognostic category was the strongest predictor of BF in univariate and multivariate analyses. No statistically significant differences in PCSM, distant metastasis, or overall mortality were identified between the good and poor prognostic categories. CONCLUSIONS: Patients with high-risk prostate cancer treated with a brachytherapy approach have excellent long-term biochemical control and cancer-specific survival. The poor prognostic high-risk category had a higher rate of BF compared with the good prognostic category without a higher rate of PCSM or distant metastasis.

Performance of transperineal template-guided mapping biopsy in detecting prostate cancer in the initial and repeat biopsy setting.

Transrectal ultrasound (TRUS) biopsy can miss 20-30% of clinically significant cancers. We evaluate an alternative approach-transperineal template-guided mapping biopsy (TTMB) in the initial and repeat biopsy setting. From January 2005 through September 2008, 373 consecutive men underwent TTMB (294 men with > or =1 prior negative biopsy and 79 men as the initial biopsy). The location of each positive biopsy core, number of positive cores, and percent involvement of each core was recorded. Cancer detection rate for the initial biopsy was 75.9%. For men with 1, 2, and > or =3 prior negative biopsies detection rates were 55.5%, 41.7%, and 34.4%, respectively. In all, 55.5% of the cancers identified were Gleason > or =7. The majority of the cancers were multifocal. There was no significant change in the number of positive cores or Gleason score as the number of prior biopsies increased. The anterior and apical aspects of the prostate were among the most common cancer locations. TTMB provides a high rate of cancer detection as initial and repeat biopsy. TTMB was particularly effective at diagnosing anterior and apical cancer. TTMB may have particular application for men considering active surveillance, with prior negative TRUS biopsies, and those considering subtotal gland or other minimally invasive treatments.

Does hormonal manipulation in conjunction with permanent interstitial brachytherapy, with or without supplemental external beam irradiation, improve the biochemical outcome for men with intermediate or high-risk prostate cancer?

OBJECTIVE: To determine whether hormonal manipulation improves the biochemical outcome for men with intermediate or high-risk prostate cancer and undergoing permanent brachytherapy with or without supplemental external beam radiation therapy. PATIENTS AND METHODS: From April 1995 to August 2000, 350 patients with intermediate-risk (225 men; a Gleason score of >or= 7 or a prostate specific antigen, PSA, level of >or= 10 ng/mL or clinical stage >or= T2b) or high-risk features (125 men; two or three of a Gleason score of >or= 7 or PSA >or= 10 ng/mL or clinical stage >or= T2b) underwent transperineal ultrasonography-guided permanent brachytherapy. No patient underwent pathological lymph node staging. Of these patients, 293 received supplemental external beam radiation therapy (EBRT), 141 received hormonal manipulation, with 82 having hormonal therapy for 4 months) regimens, supplemental EBRT, isotope and dosimetric variables. RESULTS: For intermediate-risk patients, the 6-year actuarial BDF survival rates were 98%, 96% and 100% for hormone naïve, cytoreductive and adjuvant treatment, respectively (P = 0.693); for high-risk patients the respective values were 79%, 94% and 92% (P = 0.046). When stratified by pretreatment PSA, hormonal manipulation improved the outcome for patients with a PSA of >or= 10 ng/mL (P = 0.019), but not for those with < 10 ng/mL (P = 0.661). Hormonal status was not statistically significant in predicting biochemical outcome when stratified by Gleason score. The follow-up in hormone-naïve patients was significantly longer than that in hormonally manipulated patients, at 55 (20) vs 43 (15) months (P < 0.001). In a multivariate analysis only the Gleason score predicted failure in intermediate-risk patients, while pretreatment PSA, the use of hormonal manipulation and Gleason score predicted the outcome in high-risk patients (P = 0.035). For both hormone-naïve and hormonally manipulated BDF patients, the median PSA level after implantation was < 0.1 ng/mL. CONCLUSION: In patients treated by permanent prostate brachytherapy, hormonal manipulation improved the biochemical outcome for those at high-risk and those with an initial PSA of >or= 10 ng/mL, but not for those with intermediate-risk features. The use of hormonal therapy for> 4 months conferred no additional biochemical advantage over short-course regimens. Because the follow-up in hormone-naïve patients was longer than that for those receiving hormonal manipulation, additional follow-up will be mandatory to confirm the durability of these findings.

Perineural invasion is not predictive of biochemical outcome following prostate brachytherapy.

PURPOSE: The purpose of this article is to evaluate whether the presence of perineural invasion (PNI) in the biopsy specimen is predictive of 5-year biochemical disease-free outcome after prostate brachytherapy. MATERIALS AND METHODS: Four hundred twenty-five patients underwent transperineal ultrasound-guided prostate brachytherapy using either 103Pd or 125I for clinical T1b/T3a NXMO (1997 American Joint Committee on Cancer) adenocarcinoma of the prostate gland from April 1995 to October 1999. No patient was lost to follow-up, and no patient underwent pathological lymph node staging. Two hundred twenty-one patients were implanted with 103Pd, and 204 patients were implanted with 125I. Of this cohort, 190 patients were implanted without supplemental beam radiation, and 235 received moderate-dose external-beam radiation therapy followed by a prostate brachytherapy boost. One hundred sixty-three patients received hormonal manipulation in conjunction with the brachytherapy implant (86 of these patients received moderate-dose external-beam radiation therapy before brachytherapy), and 262 patients were hormone naïve. Perineural invasion, defined as carcinoma tracking along or around a nerve within the perineural space, was identified in 105 patients (24.7% of the population). The median patient age was 68 years (range, 48-81 years). The mean follow-up was 37.1 +/- 15.2 months, and the median follow-up was 35.4 months (range, 6-74 months). Follow-up was calculated from the date of implantation. Biochemical disease-free survival was defined by the American Society of Therapeutic Radiation and Oncology (ASTRO) consensus definition. RESULTS: When Kaplan-Meier survival analysis was performed, the presence of PNI did not predict failure. When PNI was entered into a Cox regression analysis with evaluated clinical predictors of failure (age, clinical T stage, pretreatment prostate-specific antigen level, and Gleason score) or treatment parameters (use of neoadjuvant hormonal therapy, supplemental external-beam radiation therapy, and choice of isotope), PNI did not add to the predictive strength of these variables. The median disease-free prostate-specific antigen level was 0.1 ng/mL for the entire cohort. CONCLUSIONS: Our results indicate that actuarial 5-year biochemical outcomes with a prostate brachytherapy approach that utilizes generous periprostatic margins is not dependent on the presence of PNI. In addition, PNI should not be used as an independent prognosticator in determining the need for combined-modality therapy in patients undergoing prostate brachytherapy.