Intensity modulated radiotherapy (IMRT) or conformational radiotherapy (3D-CRT) with conventional fractionation for prostate cancer: Is there any clinical difference?

ABSTRACT Purpose: To compare the treatment outcomes of a cohort of prostate cancer patients treated with conventional schedule using IMRT or 3DRT technique. Materials and Methods: Between 2010-2017, 485 men with localized prostate cancer were treated with conventional radiotherapy schedule with a total dose ≥74Gy using IMRT (231) or 3DCRT (254). Late gastrointestinal (GI) and genitourinary (GU) toxicity were retrospectively evaluated according to modified RTOG criteria. The biochemical control was defined by the Phoenix criteria (nadir + 2ng/mL). The comparison between the groups included biochemical recurrence free survival (bRFS), overall survival (OS) and late toxicity. Results: With a median follow-up of 51 months (IMRT=49 and 3DRT=51 months), the maximal late GU for >=grade- 2 during the entire period of follow-up was 13.1% in the IMRT and 15.4% in the 3DRT (p=0.85). The maximal late GI ≥ grade- 2 in the IMRT was 10% and in the 3DRT 24% (p=0.0001). The 5-year bRFS for all risk groups with IMRT and 3D-CRT was 87.5% vs. 87.2% (p=0.415). Considering the risk-groups no significant difference for low-, intermediate- and high-risk groups between IMRT (low-95.3%, intermediate-86.2% and high-73%) and 3D-CRT (low-96.4%, intermediate-88.2% and high-76.6%, p=0.448) was observed. No significant differences for OS and DMFS were observed comparing treatment groups. Conclusion: IMRT reduces significantly the risk of late GI severe complication compared with 3D-CRT using conventional fractionation with a total dose ≥74Gy without any differences for bRFS and OS.

Salvage radiotherapy for biochemical recurrence after radical prostatectomy: does the outcome depend on the prostate cancer characteristics?

ABSTRACT Objective: To build a model to evaluate the impact of salvage radiotherapy (SRT) in men with PSA rise or persistent PSA after undergoing radical prostatectomy (RP). Materials and Methods: The study included 107 node-negative patients treated with SRT after RP at a single institution. Patients received SRT for either prostate-specific antigen (PSA) rising, or PSA persistence after RP. All patients received local radiation to the prostate / seminal vesicle bed. The primary measured outcome was the biochemical recurrence (BCR) free survival. Multivariable Cox regression analysis was used to develop a risk-stratification group to identify predictive factors associated with the probability of BCR at 5yr. Results: At a median follow-up of 52 months, the BCR free survival rate and overall survival in 5 years was 73% and 94%, respectively. At multivariable analysis, pre-SRT PSA level > 0.35ng / mL (p = 0.023), negative margins (p = 0.038), and seminal vesicles invasion (p = 0.001) were significantly associated with BCR free survival. Three risk groups using regression analysis for SRT administration was built. Low-, intermediate- and the high-risk groups had a BCR free survival in 5-years of 96%, 84%, and 44% (p = 0.0001), respectively. Conclusions: We developed a risk group stratification to show the impact of SRT based on prostate cancer characteristics. SRT showed to be extremely beneficial for patients with low- and intermediate-risk tumors. Moreover, the risk-group built could identify patients classified as high-risk who might benefit from more aggressive treatment for SRT.

Análise de custo-efetividade da técnica de IMRT para o tratamento do câncer de próstata localizado / Cost-effectiveness analysis of the IMRT technique for the treatment of localized prostate cancer

De acordo com os dados do Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA), foram esperados, no Brasil, 61.200 novos casos de câncer de próstata para o ano de 2016. Estabelecido o diagnóstico, as opções terapêuticas são consideradas e se baseiam no estadiamento, dosagem do antígeno prostático específico (PSA) e escore histológico de Gleason. Segundo as diretrizes diagnósticas e terapêuticas do adenocarcinoma de próstata publicadas (2015), a técnica de radioterapia de intensidade modulada (IMRT) apresenta benefício no controle da doença e a menor probabilidade de toxicidade. Este trabalho teve como objetivo analisar a custo-efetividade da técnica de IMRT, na perspectiva do SUS, para o tratamento do câncer de próstata localizado, comparada com a técnica conformacional (3DRT). Foi construído um modelo de Markov e, uma coorte hipotética de homens de 65 a 70 anos foi acompanhada por 10 anos. A medida de desfecho clínico foram os anos de vida ajustados para qualidade (QALY). Os custos levantados se basearam nos valores da tabela APAC para um tratamento na dose de 74 a 76 Gy. Análise de sensibilidade probabilística baseada em simulação de Monte Carlo a fim de construir um limiar de aceitabilidade para incorporação da tecnologia em questão foi desenvolvida. O uso da tecnologia IMRT proporcionou um incremento de 0,79 QALY, mas não se mostrou custo-efetiva em relação aos pacientes que receberam radioterapia pela 3DRT. A IMRT apresentou uma razão de custoefetividade incremental de R$10.580,98/QALY. Ao considerar um limiar de aceitabilidade de três vezes o produto interno bruto (PIB) per capita, segundo recomendação da Organização Mundial de Saúde (2011), estimado em R$ 86.628,00/QALY, para 2016, o cenario para a incorporaçao dessa tecnologia se apresenta favoravel. A probabilidade do IMRT ser custo-efetiva foi de 72,5% para limiares de aceitabilidade de R$15.000,00

According to data from the Coordination of Prevention and Surveillance of the National Cancer Institute José Alencar Gomes da Silva (NCI) 61,200 new cases of prostate cancer were expected in Brazil in 2016. Once the diagnosis is established, the therapeutic options are considered according to risk groups described by D'Amico (1998), which are based on staging, prostate-specific antigen (PSA) and Gleason score. For localized prostate tumors, and for all risk groups, radiotherapy is indicated. According to the diagnostic and therapeutic guideline of prostate adenocarcinoma published in October 2015, the intensity modulated radiotherapy (IMRT) technique has a benefit in controlling the disease and the lower probability of toxicity. According to this premise, this study aimed to analyze the costeffectiveness of the IMRT technique, from the perspective of SUS, for the treatment of localized prostate cancer, compared with three-dimensional technique (3DRT). A mathematical model based on Markov models was constructed and a hypothetical cohort of men aged 65 to 70 years was followed up for 10 years. A probabilistic sensitivity analysis was performed based on Monte Carlo simulation to construct a threshold of acceptability for incorporation of the technology in question. As a result of the study, the use of IMRT technology provided a 0.79-year increase in quality-adjusted life years (QALY), but was not cost-effective compared to patients who received radiotherapy using the 3DRT. The IMRT presented an incremental cost-effectiveness ratio of R $ 10,580.98 / QALY. Based on a threshold of three times the per capita GDP, according to the WHO recommendation (2011), calculated at R $ 86,628.00 / QALY for 2016, the scenario for the incorporation of this technology is favorable. If a threshold of acceptability of R $ 28,876 is considered equivalent to a GDP per capita, the probability of IMRT being cost-effective is 72%

Long term outcome and side effects in patients receiving low-dose I125 brachytherapy: a retrospective analysis

ABSTRACT Objectives: To retrospectively evaluate the disease free survival (DFS), disease specific survival (DSS),overall survival (OS) and side effects in patients who received low-dose rate (LDR) brachytherapy with I125 stranded seeds. Materials and methods: Between july 2003 and august 2012, 274 patients with organ confined prostate cancer were treated with permanent I125 brachytherapy. The median follow-up, age and pretreatment prostate specific antigen (iPSA) was 84 months (12-120), 67 years (50-83) and 7.8 ng/mL (1.14-38), respectively. Median Gleason score was 6 (3-9). 219 patients (80%) had stage cT1c, 42 patients (15.3%) had stage cT2a, 3 (1.1%) had stage cT2b and 3 (1.1%) had stage cT2c. The median D90 was 154.3 Gy (102.7-190.2). Results: DSS was 98.5%.OS was 93.5%. 13 patients (4.7%) developed systemic disease, 7 patients (2.55%) had local progression. In 139 low risk patients, the 5 year biochemical freedom from failure rate (BFFF) was 85% and 9 patients (6.4%) developed clinical progression. In the intermediate risk group, the 5 year BFFF rate was 70% and 5 patients (7.1%) developed clinical progression. Median nPSA in patients with biochemical relapse was 1.58 ng/mL (0.21 – 10.46), median nPSA in patients in remission was 0.51 ng/mL (0.01 – 8.5). Patients attaining a low PSA nadir had a significant higher BFFF (p<0.05). Median D90 in patients with biochemical relapse was 87.2 Gy (51 – 143,1). Patients receiving a high D90 had a significant higher BFFF (p<0.05). Conclusion: In a well selected patient population, LDR brachytherapy offers excellent outcomes. Reaching a low PSA nadir and attaining high D90 values are significant predictors for a higher DFS.

Low-dose-rate brachytherapy for patients with transurethral resection before implantation in prostate cancer. Long-term results

ABSTRACT We analyzed the long-term oncologic outcome for patients with prostate cancer and transurethral resection who were treated using low-dose-rate (LDR) prostate brachytherapy. Methods and Materials: From January 2001 to December 2005, 57 consecutive patients were treated with clinically localized prostate cancer. No patients received external beam radiation. All of them underwent LDR prostate brachytherapy. Biochemical failure was defined according to the "Phoenix consensus". Patients were stratified as low and intermediate risk based on The Memorial Sloan Kettering group definition. Results: The median follow-up time for these 57 patients was 104 months. The overall survival according to Kaplan-Meier estimates was 88% (±6%) at 5 years and 77% (±6%) at 12 years. The 5 and 10 years for failure in tumour-free survival (TFS) was 96% and respectively (±2%), whereas for biochemical control was 94% and respectively (±3%) at 5 and 10 years, 98% (±1%) of patients being free of local recurrence. A patient reported incontinence after treatment (1.7%). The chronic genitourinary complains grade I were 7% and grade II, 10%. At six months 94% of patients reported no change in bowel function.Conclusions: The excellent long-term results and low morbidity presented, as well as the many advantages of prostate brachytherapy over other treatments, demonstrates that brachytherapy is an effective treatment for patients with transurethral resection and clinical organ-confined prostate cancer

Adjuvant radiotherapy versus observation alone, after radical prostatectomy in high risk prostate cancer / Radioterapia adjuvante versus vigilância após prostatectomia radical em câncer de próstata de alto risco

SummaryObjectives:the authors compared biochemical and clinical outcomes of patients with resected high-risk prostate cancer, managed with adjuvant radiotherapy or observation alone.Methods:patients treated with radical prostatectomy (RP) between January 1995 and December 2005 at the authors’ department were evaluated. Patients with pT3, with or without positive surgical margins (PSM), were included for analysis. Demographic, clinical, pathologic and follow-up data were recorded. Comparison was made between adjuvant radiotherapy group (AR) and observation alone group (OA). Primary end-point was biochemical progression-free survival.Results:out of 739 patients treated with RP, 49 presented with pT3 with or without PSM. 39 received adjuvant radiotherapy and 10 were observed. Median follow- up was 6.2 years for AR and 7.3 years for OA. Biochemical progression occurred in 12.8%, in AR, and 70%, in OA (p=0.0008). Five-year biochemical progression-free survival was 87.1% in AR and 30% in OA (HR 0.12, 95% CI 0.03- 0.48 – p<0.0001). Rescue androgen deprivation therapy was needed in 2.6%, in AR, and 30%, in OA (p=0.023).Conclusions:adjuvant radiotherapy after radical prostatectomy in high-risk prostate cancer provided better biochemical outcomes. Whether this translates into better clinical progression, it is still unknown.

ResumoObjetivo:comparar resultados clínicos e bioquímicos de pacientes com câncer de próstata de alto risco submetidos à prostatectomia radical, tratados com radioterapia adjuvante (RA) ou vigilância.Métodos:foram avaliados os pacientes tratados com prostatectomia radical, entre janeiro de 1995 e dezembro de 2005. Pacientes que apresentaram pT3, com ou sem margens cirúrgicas positivas, foram incluídos para análise. Foram registrados dados demográficos, clínicos, patológicos e de seguimento. Foram comparados os resultados entre o grupo que recebeu RA e o grupo em vigilância. O desfecho principal avaliado foi a sobrevida livre de progressão bioquímica.Resultados:entre os 739 pacientes tratados com prostatectomia radical, 49 apresentaram tumores pT3, com ou sem margens cirúrgicas positivas. Trinta e nove receberam RA e 10 foram submetidos à vigilância. O seguimento médio foi de 6,2 anos para a RA e de 7,3 anos para a vigilância. Houve progressão bioquímica em 12,8% dos pacientes no grupo RA e em 70%, no grupo da vigilância (p=0,0008). A sobrevida livre de progressão bioquímica em 5 anos foi de 87,1% na RA e 30% na vigilância (HR 0,12, IC95% 0,03-0,48 - p<0,0001). Terapia hormonal de resgate foi necessária em 2,6% dos pacientes na RA e em 30% na vigilância (p=0,023).Conclusões:a radioterapia adjuvante após prostatectomia radical em pacientes com câncer de próstata de alto risco ofereceu melhores resultados bioquímicos. Ainda não está claro se isso se traduz em uma evolução clínica melhor.

Dosimetric Coverage of the Prostate, Normal Tissue Sparing, and Acute Toxicity with High-Dose-Rate Brachytherapy for Large Prostate Volumes

To evaluate dosimetric coverage of the prostate, normal tissue sparing, and acute toxicity with HDR brachytherapy for large prostate volumes.

A Novel Approach for the Treatment of Radiation-Induced Hemorrhagic Cystitis with the GreenLight™ XPS Laser

The treatment of pelvic malignancies with radiotherapy can develop severe sequelae, especially radiation-induced hemorrhagic cystitis. It is a progressive disease that can lead to the need for blood transfusion, hospitalizations, and surgical interventions. This tends to affect the quality of life of these patients, and management can at times be difficult. We have evaluated the GreenLight Xcelerated Performance System (XPS) with TruCoag, although primarily used for management of benign prostatic hypertrophy (BPH), for the treatment of radiation-induced hemorrhagic cystitis.

Liposomal topical capsaicin in post-herpetic neuralgia: a safety pilot study / Capsaicina lipossomal tópica na neuralgia pós-herpética: um estudo piloto de segurança

Topical treatments have gained popularity for general use as an adjunct to systemic drugs in neuropathic pain, but their use produces variable clinical results and local adverse events. Objective To evaluate the safety and analgesic effect of a formulation of liposomal capsaicin (LC) (0.025%) in patients with post herpetic neuralgia (PHN). Method Patients who remained symptomatic after first-and second-line treatment were randomized to receive LC for six weeks in a placebo-controlled, crossover design study. Clinical assessment was performed at baseline, in the second, fourth and sixth week of treatment. Results Thirteen patients completed both treatment periods. Visual Analog Scale (VAS) was significantly decreased after the end of the study (p = 0.008), however the effect of treatment was not significant (p = 0.076). There was no difference on global impression of change and other pain characteristics. LC was safe and well tolerated. However, at the concentration used, its analgesic effects were marginal and not significant. .

Os tratamentos tópicos ganharam popularidade para uso geral como um adjuvante de medicamentos sistêmicos na dor neuropática, mas seu uso produz resultados clínicos variáveis e eventos adversos locais. Objetivo Avaliar o efeito de segurança e analgesia de uma formulação de capsaicina lipossomal (LC) (0,025%) em pacientes com neuralgia pós-herpética. Método Os pacientes que permaneceram sintomáticos após tratamento de primeira e de segunda linha foram randomizados para receber LC durante seis semanas em um estudo cruzado controlado por placebo. A avaliação clínica foi realizada no início do estudo, na segunda, quarta e sexta semana de tratamento. Resultados Treze pacientes completaram dois períodos de tratamento. Escala Visual Analógica diminuiu significativamente após o final do estudo (p = 0,008), no entanto, o efeito do tratamento não era significativo (p = 0,076). Não houve diferença na impressão global de mudança e de outras características da dor. LC foi segura e bem tolerada. No entanto, para a concentração utilizada, os seus efeitos analgésicos foram marginais e não significativos. .

Responsabilidad sanitaria en odontólogos: Casuística de casos evaluados en el Servicio Médico Legal de Chile / Professional liability claims against dentists

Background: The frequency and features of malpractice lawsuits against dentists in Chile are not well known. Aim: To determine the magnitude and frequency of professional liability claims against dentists. Material and Methods: A retrospective analysis of the Medical Liability Unit of the Legal Medical Service of Chile database. This public organization deals with most professional liability claims in Chile. Results: Between 2007 and 2012, 3,990 expert opinions about liability of health care professionals were requested. Odontology was the fifth specialty most commonly sued and dentists, the second most frequently sued professionals. Sixty nine percent of cases originated in private clinics, which is coincident with a higher frequency of dentists working in private practice. Most petitioners were adult women and most claims originated from surgical interventions and infections. In 35% of claims against dentists, a violation of Lex Artis was confirmed, compared with 9% of all expert opinions that generated in the unit. Conclusions: Claims against dentists are more common than previously thought and these professionals should adopt preventive measures to avoid them.

Quality of life after high-dose-rate brachytherapy monotherapy for prostate cancer

Purpose There is little information in the literature on health-related quality of life (HRQOL) changes due to high-dose-rate (HDR) brachytherapy monotherapy for prostate cancer. Materials and Methods We conducted a prospective study of HRQOL changes due to HDR brachytherapy monotherapy for low risk or favorable intermediate risk prostate cancer. Sixty-four of 84 (76%) patients who were treated between February 2011 and April 2013 completed 50 questions comprising the Expanded Prostate Cancer Index Composite (EPIC) before treatment and 6 and/or 12 months after treatment. Results Six months after treatment, there was a significant decrease (p<0.05) in EPIC urinary, bowel, and sexual scores, including urinary overall, urinary function, urinary bother, urinary irritative, bowel overall, bowel bother, sexual overall, and sexual bother scores. By one year after treatment, EPIC urinary, bowel, and sexual scores had increased and only the bowel overall and bowel bother scores remained significantly below baseline values. Conclusions HDR brachytherapy monotherapy is well-tolerated in patients with low and favorable intermediate risk prostate cancer. EPIC urinary and sexual domain scores returned to close to baseline 12 months after HDR brachytherapy. .

External beam radiation therapy and a low-dose-rate brachytherapy boost without or with androgen deprivation therapy for prostate cancer

Purpose To assess outcomes with external beam radiation therapy (EBRT) and a low-dose-rate (LDR) brachytherapy boost without or with androgen deprivation therapy (ADT) for prostate cancer. Materials and Methods From January 2001 through August 2011, 120 intermediate-risk or high-risk prostate cancer patients were treated with EBRT to a total dose of 4,500 cGy in 25 daily fractions and a palladium-103 LDR brachytherapy boost of 10,000 cGy (n = 90) or an iodine-125 LDR brachytherapy boost of 11,000 cGy (n = 30). ADT, consisting of a gonadotropin-releasing hormone agonist ± an anti-androgen, was administered to 29/92 (32%) intermediate-risk patients for a median duration of 4 months and 26/28 (93%) high-risk patients for a median duration of 28 months. Results Median follow-up was 5.2 years (range, 1.1-12.8 years). There was no statistically-significant difference in biochemical disease-free survival (bDFS), distant metastasis-free survival (DMFS), or overall survival (OS) without or with ADT. Also, there was no statistically-significant difference in bDFS, DMFS, or OS with a palladium-103 vs. an iodine-125 LDR brachytherapy boost. Conclusions There was no statistically-significant difference in outcomes with the addition of ADT, though the power of the current study was limited. The Radiation Therapy Oncology Group 0815 and 0924 phase III trials, which have accrual targets of more than 1,500 men, will help to clarify the role ADT in locally-advanced prostate cancer patients treated with EBRT and a brachytherapy boost. Palladium-103 and iodine-125 provide similar bDFS, DMFS, and OS. .

Change in the risk stratification of prostate cancer after Slide Review by a uropathologist: the experience of a reference center for the treatment of prostate cancer

Introduction Brachytherapy is an option for treating low-risk prostate cancer (PC). Biochemical control of low-risk disease can reach 95%. The practice advocated is that a review of prostate biopsies should be mandatory before choosing the best treatment for patients with PC. Our objective was to evaluate the change in PC risk after review of a prostate biopsy by an experienced uropathologist at a reference hospital. Materials and Methods Between December 2003 and August 2012, 182 men were referred to our institution for brachytherapy to treat PC. Their slides were reviewed by the same uropathologist. Results and Discussion Classification risk disagreement occurred in 71 (39%) cases, including one in which no tumor was observed. The main cause of risk change was related to the Gleason score (GS), with 57 (81.4%) cases upgraded to GS 7 or 8. Tumor volume was also compared, although only the number of fragments was reported in most original reports. The concordance of the number of cores affected by tumor was 43.9%, and in 49% of the cases, the number was decreased by the uropathologist. Perineural invasion (PNI) was reported in one quarter of original reports, and the agreement was 58%. Conclusion Slide review by an uropathologist remains essential at reference radiotherapy centers for the treatment of PC. The change in PC risk evaluation is mainly due to the GS, but tumor volume and PNI, which are important for the characterization of tumor aggressiveness, are also misinterpreted and could drive a change in the therapy choice. .

Surgical Management of a Locally Advanced Symptomatic Recurrence of Penile Sarcoma Secondary to Prostate Brachytherapy

Background The surgical management of patients with symptomatic metastatic or locally advanced recurrences involving the penis remains poorly characterized. The aim of the present abstract and video is to detail our experience in the surgical management of a specific patient with a locally advanced symptomatic recurrence of penile sarcoma secondary to prostate cancer treated with primary brachytherapy. Materials and Methods A 70 year old male patient initially treated for localized prostate cancer with interstitial brachytherapy at an outside facility developed an unfortunate secondary malignancy consisting of a locally advanced penile sarcoma involving as well the prostate and base of the bladder. Despite our best efforts to control his pain, he developed a very symptomatic local recurrence with a secondary penile abscess and purulent periurethral drainage. At this time, it was felt a surgical resection consisting of a total penectomy, urethrectomy, cystoprostatectomy, and ileal conduit urinary diversion would be the best option for local cancer control in this particular patient. Results The patient underwent the surgical resection without any complications as illustrated in this surgical video, with a jejunal intestinal mass identified at the time of surgery which was resected with a primary bowel anastomosis performed. The patient was discharged from hospital uneventfully with his symptomatic local recurrence being successfully managed and the patient no longer requiring oral narcotics for pain control. The pathological report confirmed a locally advanced sarcoma involving the penile, prostate, and bladder which was resected with negative surgical margins and the jejunal mass was confirmed to represent a small bowel sarcoma metastatic site. Conclusion As highlighted in the present video, the treatment of a symptomatic sarcoma local recurrence contiguously involving the penis can be successfully managed provided the patient ...

Tratamiento del cáncer de próstata con radioterapia por modulación de intensidad, primera experiencia en Chile / Intensity modulated radiotherapy treatment for prostate cancer, first experience in Chile

Background: Intensity modulated radiotherapy (IMRT) is an important step forward in cancer treatment. Aim: To report the first experience in Chile with IMRT for prostate cancer and compare the results obtained with different doses. Patients and Methods: From January 1997 through June 2008, 156 patients with a mean age of 70 years, were treated with radiotherapy and 121 with IMRT. Patients were staged according to American Commission on Cancer Staging. Their biochemical relapse risk was classified according to the MD Anderson classification. Patients were routinely checked during and after therapy to evaluate side effects and relapse. Results: Median follow up was 46 months (4-120). Overall five years survival was 85%. Biochemical relapse free five years survival for low, intermediate and high risk patients was 100, 82 and 70%, respectively. Biochemical relapse free survival for patients receiving radiotherapy doses over 76 Gy was 83%, compared to 30% for those receiving lower doses (p < 0.05). Urinary and gastrointestinal acute toxicity was low in 80% and 90% of patients respectively. Late toxicity developed in less than 3% of patients. Conclusions: IMRTforprostate cancer is readily available and safe in Chile. Biochemical disease free survival improved with higher doses with low toxicity rates.

Outcomes following negative prostate biopsy for patients with persistent disease after radiotherapy for prostate cancer

Purpose: When faced with biochemical recurrence after definitive radiotherapy for prostate cancer, clinicians must determine whether the recurrence is local or systemic. Post radiotherapy prostate biopsies to detect persistent local disease are difficult to interpret histopathologically and are subject to sampling error. Our study examines outcomes for patients with a negative prostate biopsy performed for rising prostate-specific antigen (PSA) levels after prostate radiation. Materials and methods: We performed a retrospective review of 238 prostate cancer patients with a negative biopsy following definitive radiotherapy. Seventy-five of these patients had biochemical recurrence at the time of biopsy. A negative biopsy was defined as the absence of prostate cancer without radiation-treatment effect in the specimen. Results: Patients underwent biopsy at a mean of 41 months after the completion of radiation. They had a mean PSA of 6. Patients were followed for an average of 63 months. Thirty-two patients (43 percent) developed metastasis, and 11 (15 percent) died of prostate cancer despite a negative post-radiation biopsy. Five of nine patients (56 percent) with sequential biopsies had a positive second biopsy. Conclusions: Patients with PSA recurrence and a negative post-radiation biopsy have a high chance of persistent local disease, progression, and death from prostate cancer. Furthermore, an initial negative biopsy does not rule-out local recurrence. Patients with biochemical recurrence after radiotherapy for prostate cancer need to be evaluated earlier for local recurrence.

Radioactive seed migration after prostate brachytherapy with Iodine-125 using loose seeds versus stranded seeds

Objectives: To assess the incidence and clinical parameters that could influence migration of seeds in localized prostate cancer patients treated by stranded versus loose sources by Iodine-125 brachytherapy. Material and Methods: 100 patients were treated from January/1998 until December/2006. Age, PSA, clinical stage, Gleason, prostate volume, number of seeds, activity of radioactive seeds, and dosimetric parameters, such as V100, V150 and D90 were evaluated. Results: Mean follow-up was 79 months (18 - 120. CI 95 percent: 72 - 85). Overall, 6 of 100 patients experienced seed migration. Seed migration was found in 4/50 (8 percent) patients using loose seeds and in 2/50 (4 percent) treated by stranded seeds. Mean value dosimetric parameters for stranded seeds were greater than those for loose seeds (V100( percent): 88.7/82, D90(Gy): 149.2/140.3, D90( percent): 104.2/93.8, V150 ( percent): 53.8/47, respectively). No significant difference in migration of seeds was detected between loose and stranded seeds considering age (p = 0.33), PSA (p = 0.391), prostate volume (p = 0.397), activity of radioactive seeds (p = 0.109), number of seeds (p = 0.338), V100 (p = 0.332), although significant differences were measured in the values of D90( percent and Gy) (p = 0.022 and 0.011) and V150 (p = 0.023). Conclusions: Seed migration after brachytherapy might occur and it does affect post-implant dosimetry.

Critical analysis of salvage radical prostatectomy in the management of radioresistant prostate cancer

Purpose: To critically evaluate salvage radical prostatectomy (SRP) in the treatment of patients with recurrent prostate cancer (PCa). Materials and Methods: From January 2005 to June 2007, we assessed patients with recurrent localized PCa. Recurrence was suspected when there were three or more successive increases in prostate specific antigen (PSA) after nadir. After the routine imagery examinations, and once localized PCa was confirmed, patients were offered SRP. Following surgery, we evaluated bleeding, rectal injury, urinary incontinence or obstruction and impotence. PSA values were measured at 1, 3, 6, months and thereafter twice a year. Results: Forty-two patients underwent SRP. The average age was 61 years. Following radiotherapy , the mean PSA nadir was 1.5 ng/mL (0.57-5.5). The mean prostate specific antigen doubling time (PSA-DT) was 14 months (6-20). Prior to SRP, the mean PSA was 5.7 ng/mL (2.9-18). The pathologic staging was pT2a: 13 percent; pT2b: 34 percent; pT2c: 27 percent; pT3a: 13 percent; and pT3b: 13 percent. Bleeding > 600 mL occurred in 14 percent of the cases; urethral stenosis in 50 percent; and urinary incontinence (two or more pads/day) in 72 percent. The mean follow-up post-SRP ranged from 6 to 30 months. The PSA level rose in 9, of which 6 had PSA-DT < 10 months. Conclusions: SRP is a feasible method in the management of localized radioresistant PCa. PSA-DT has shown to be important for the selection and SRP should not be performed if PSA-DT > 10 months. Due to its increased morbidity, SRP should be only offered to the patients who are more concerned about survival rather than quality of life.

Prostatectomía radical laparoscópica de rescate post radioterapia externa: reporte de un caso y revisión de la literatura / Salvage laparoscopic radical prostatectomy after failed radiotherapy: a case report and review of the literature

Objetivo: Reportar un caso de prostatectomía radical laparoscópica de rescate (PRLR) indicada por una falla local post radioterapia, y realizar una revisión de la técnica quirúrgica y sus resultados. Métodos/Resultados: Varón de 68 años de edad, con antecedentes de cáncer prostático incidental (pT1b) manejado con radioterapia externa, que presenta recidiva bioquímica al quinto año post-irradiado. Tras estudio se realiza PRLR sin incidentes. Estudio patológico demuestra un adenocarcinoma Score Gleason 7, estadío pT2. Evoluciona continente a las 3 semanas de postoperado. La Prostatectomía Radical de Rescate es la única alternativa curativa y con resultado oncológico demostrado a largo plazo. Su morbilidad cada vez es menor, pero se mantiene con mayores tasas de incontinencia y estrechez de anastomosis con respecto a la Prostatectomía Radical realizada como tratamiento primario. La vía laparoscópica ha demostrado ser efectiva, sin agregar morbilidad a la técnica. Conclusiones: la PRLR es una alternativa de tratamiento en los pacientes con falla local post radioterapia, que no aumenta la morbilidad con respecto a la cirugía abierta.

Objective: report a case of salvage laparoscopic radical prostatectomy (SLRP) after radiation failure, and review the literature about the surgical technique and his results. Method/Results: 68 old, with history of incidental prostate cancer (pT1B), treated with external beam radiation, who presented a local failure after 5 years. Metastatic disease was ruled out preoperatively by bone scintigraphy, and computed tomography. SLRP was done, without complications. Histologic analysis revealed prostate cancer score Gleason 7, pT2. The patient was continent at three weeks. Currently, Salvage Radical Prostatectomy represents the only curative treatment option for these patients, with long term oncologic results. His morbidity has decreased, but still shows more incontinence and anastomotic stricture, compared to radical prostatectomy de novo. SRLP has been shown to be effective, and with no mayor complications. Conclusions: SLRP is safe surgical technique to treat a local failure after radiationtherapy, without increase in morbidity compared with open surgery.

Updated results of high-dose rate brachytherapy and external beam radiotherapy for locally and locally advanced prostate cancer using the RTOG-ASTRO phoenix definition

PURPOSE: To evaluate the prognostic factors for patients with local or locally advanced prostate cancer treated with external beam radiotherapy (RT) and high dose rate brachytherapy (HDR) according to the RTOG-ASTRO Phoenix Consensus Conference. MATERIALS AND METHODS: The charts of 209 patients treated between 1997 and 2005 with localized RT and HDR as a boost at the Department of Radiation Oncology, AC Camargo Hospital, Sao Paulo, Brazil were reviewed. Clinical and treatment parameters i.e.: patient's age, Gleason score, clinical stage, initial PSA (iPSA), risk group (RG) for biochemical failure, doses of RT and HDR were evaluated. Median age and median follow-up time were 68 and 5.3 years, respectively. Median RT and HDR doses were 45 Gy and 20 Gy. RESULTS: Disease specific survival (DSS) at 3.3 year was 94.2 percent. Regarding RG, for the LR (low risk), IR (intermediate risk) and HR (high risk), the DSS rates at 3.3 years were 91.5 percent, 90.2 percent and 88.5 percent, respectively. On univariate analysis prognostic factors related to DSS were RG (p = 0.040), Gleason score ¡Ü 6 ng/mL (p = 0.002), total dose of HDR ¡Ý 20 Gy (p < 0.001) On multivariate analysis the only statistical significant predictive factor for biochemical control (bNED) was the RG, p < 0.001 (CI - 1.147-3.561). CONCLUSIONS: Although the radiation dose administered to the prostate is an important factor related to bNED, this could not be established with statistical significance in this group of patients. To date , in our own experience, HDR associated to RT could be considered a successful approach in the treatment of prostate cancer.