Reconstruction of shear wave speed in tissue-mimicking phantoms from aliased pulse-echo imaging of high-frequency wavefields.

Quantitative elasticity estimation in medical and industrial applications may benefit from advancements in reconstruction of shear wave speed with enhanced resolution. Here, shear wave speed is reconstructed from pulse-echo ultrasound imaging of elastic waves induced by high-frequency (>400 Hz), time-harmonic mechanical excitation. Particle displacement in shear wavefields is mapped from measured interframe phase differences with compensation for timing of multiple scan lines, then processed by spatial Fourier analysis to estimate the predominant wave speed and analyzed by algebraic wavefield inversion to reconstruct wave speed maps. Reconstructions of shear wave speed from simulated wavefields illustrate the accuracy and spatial resolution available with both methods, as functions of signal-to-noise ratio and sizes of windows used for Fourier analysis or wavefield smoothing. The methods are applied to shear wavefields with frequencies up to six times the Nyquist rate, thus extending the frequency range measurable by a given imaging system. Wave speed measurements in tissue-mimicking phantoms are compared with supersonic shear imaging and mechanical tensile testing, demonstrating feasibility of the wavefield measurement and wave speed reconstruction methods employed.

Multiple back fractures as a result of the first seizure.

Non-traumatic fractures due to seizures are an overlooked diagnostic group. It is well known that patients with generalized tonic-clonic seizures have an increased trauma risk. However, the cause of fracture is rarely due to the violent forces of muscle contractions. Usually, the primary patient examination focuses on the aetiology of the seizure, which sometimes delays the diagnosis of fractures. This is a case report of a 19-year-old woman who sustained three compression fractures of the thoracic spine due to a generalized tonic-clonic seizure, and a discussion of the diagnostic challenges in such a rare case.

Atypical presentation of Lemierre's syndrome caused by penicillin-susceptible Staphylococcus aureus in a patient with chronic stomatitis and COVID-19.

A healthy man in his late 20s was admitted to the emergency department due to a flare-up in his severe chronic stomatitis, along with flu-like symptoms. CXR showed multiple bilateral consolidations and subsequent CT revealed thrombosis of the left facial and internal jugular vein, together with septic embolism in both lungs. Blood cultures showed penicillin-susceptible Staphylococcus aureus The patient was diagnosed with Lemierre's syndrome, despite atypical bacteria and clinical presentation. During hospitalisation, he developed pulmonary empyema as a complication and was admitted for 4 weeks. During hospitalisation and after discharge, the patient was examined for multiple rheumatic, immunological and dermatological diseases, but no underlying cause for Lemierre's syndrome has been found. We present this case due to the rarity of its nature, with atypical clinical presentation and pathogen for Lemierre's syndrome, but with classic radiological findings.

Outcomes after prostate brachytherapy are even better than predicted.

BACKGROUND: During the first 3 years after prostate cancer treatment with radiation therapy, benign prostate-specific antigen (PSA) bounces are difficult for clinicians to distinguish from a biochemical recurrence, which can result in unnecessary interventions and erroneous predictions of outcomes. The objective of this study was to evaluate a commonly used PSA failure definition in a multinational, multi-institutional study after monotherapy with prostate brachytherapy. METHODS: Participants were selected from 2919 men who underwent permanent prostate brachytherapy at the University Medical Center Utrecht, Princess Margaret Hospital, or Seattle Prostate Institute between 1998 and 2006. Inclusion required not having received androgen-deprivation therapy and having at least 30 months of follow-up. Failure was defined as any post-treatment use of hormone therapy, clinical relapse, or prostogram-defined biochemical (PSA) failure. Cases in which the nomogram predicted biochemical failure were evaluated at each institution to verify biochemical status over time and the actual clinical outcome at 5 years. RESULTS: The median follow-up for the 1816 patients was 5.2 years. Concordance between the prostogram-predicted and actual outcomes, as measured by the Harrell c statistic, was 0.655 (95% confidence interval [CI], 0.536-0.774; P = .010) for the Princess Margaret group, 0.493 (95% CI, 0.259-0.648; P = .955) for the Seattle group, and 0.696 (95% CI, 0.648-0.744, P < .001) for the Utrecht group. The overall mean difference in biochemical recurrence-free survival at 5 years between actual outcomes and prostogram-defined outcomes was 9.2% (95% CI, 7.7%-10.6%). The total numbers of prostogram-defined and actual biochemical failures were 312 and 157, respectively (P = .001). CONCLUSIONS: The widely used prostogram could not adequately distinguish a benign PSA bounce from a biochemical recurrence after prostate brachytherapy and could not be used to counsel patients about their predicted outcomes after treatment. The authors conclude that, to avoid unnecessary active interventions after treatment, clinicians should monitor PSA levels for at least 3 years and provide reassurance to patients that a PSA rise during this time is common and may not indicate a treatment failure.

Report of a consensus meeting on focal low dose rate brachytherapy for prostate cancer.

What's known on the subject? and What does the study add? Whole gland brachytherapy has been used to successfully treat prostate cancer but the protocol for focal therapy has not previously been established. The consensus findings provide guidance on patient selection for focal brachytherapy as well as recommendations for conducting therapy and patient follow-up. Low dose rate prostate brachytherapy is an effective treatment for localized prostate cancer. Recently, it has been considered for use in a focused manner whereby treatment is targeted only to areas of prostate cancer. The objective of focal brachytherapy is to provide effective cancer control for low-risk disease but with reduced genitourinary and rectal side-effects in a cost-effective way. We report on the outputs of a consensus meeting of international experts in brachytherapy and focal therapy convened to consider the feasibility and potential development of focal brachytherapy. A number of factors were considered for focal brachytherapy including optimal patient selection, disease characterization and localization, treatment protocols and outcome measures. The consensus meeting also addressed the design of a clinical trial that would assess the oncological outcomes and side-effect profiles resulting from focal brachytherapy.

Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group.

What's known on the subject? and What does the study add? Very few comparative studies to date evaluate the results of treatment options for prostate cancer using the most sensitive measurement tools. PSA has been identified as the most sensitive tool for measuring treatment effectiveness. To date, comprehensive unbiased reviews of all the current literature are limited for prostate cancer. This is the first large scale comprehensive review of the literature comparing risk stratified patients by treatment option and with long-term follow-up. The results of the studies are weighted, respecting the impact of larger studies on overall results. The study identified a lack of uniformity in reporting results amongst institutions and centres. A large number of studies have been conducted on the primary therapy of prostate cancer but very few randomized controlled trials have been conducted. The comparison of outcomes from individual studies involving surgery (radical prostatectomy or robotic radical prostatectomy), external beam radiation (EBRT) (conformal, intensity modulated radiotherapy, protons), brachytherapy, cryotherapy or high intensity focused ultrasound remains problematic due to the non-uniformity of reporting results and the use of varied disease outcome endpoints. Technical advances in these treatments have also made long-term comparisons difficult. The Prostate Cancer Results Study Group was formed to evaluate the comparative effectiveness of prostate cancer treatments. This international group conducted a comprehensive literature review to identify all studies involving treatment of localized prostate cancer published during 2000-2010. Over 18,000 papers were identified and a further selection was made based on the following key criteria: minimum/median follow-up of 5 years; stratification into low-, intermediate- and high-risk groups; clinical and pathological staging; accepted standard definitions for prostate-specific antigen failure; minimum patient number of 100 in each risk group (50 for high-risk group). A statistical analysis (standard deviational ellipse) of the study outcomes suggested that, in terms of biochemical-free progression, brachytherapy provides superior outcome in patients with low-risk disease. For intermediate-risk disease, the combination of EBRT and brachytherapy appears equivalent to brachytherapy alone. For high-risk patients, combination therapies involving EBRT and brachytherapy plus or minus androgen deprivation therapy appear superior to more localized treatments such as seed implant alone, surgery alone or EBRT. It is anticipated that the study will assist physicians and patients in selecting treatment for men with newly diagnosed prostate cancer.

Intra- and Interobserver Variability of Shear Wave Elastography in Rectal Cancer.

BACKGROUND: Endorectal ultrasound (ERUS) is an important tool when evaluating complex rectal adenomas and rectal cancer, and the accuracy is improved by adding elastography measurements. A high interobserver agreement is imperative in clinical practice. Therefore, the aim of this study was to evaluate interobserver agreement assessed on real-time images. Additionally, we investigated the intra- and interobserver agreement between experienced and inexperienced observers. MATERIALS AND METHODS: We prospectively included patients referred to an ERUS at the Department of Radiology with a complex rectal polyp or suspected rectal malignancy. Two operators independently scanned each patient in turn. Furthermore, four observers assessed previously obtained images using three different methods for placing the region of interest (ROI). Three months later, the four observers reassessed the images to assess intraobserver variability. RESULTS: A total of 19 patients were included for live assessment. Agreement of tumor classification was substantial for T stage (kappa: 0.86) and fair for N stage (kappa: 0.73), with an absolute agreement for T and N stages of 84% and 89%, respectively. Agreement of SWE was good for Emean (ICC 0.94, 95% CI 0.86-0.98) and fair for Emax (ICC 0.85, 95% CI 0.66-0.94). Intra- and interobserver agreement between inexperienced and experienced observers showed good to excellent agreement with all ROI methods. CONCLUSION: Interobserver agreement is high in SWE when performed in a clinical setting. We found the best agreement using the mean value of several ROIs. Intra- and interobserver agreement was high regardless of operator experience.

Ultrasound and contrast enhanced CT imaging of a colon mesentery leiomyosarcoma.

Primary leiomyosarcoma of the colon mesentery is an extremely rare neoplasm, and only a small number of cases have been reported. We describe a case of leiomyosarcoma originating in the colonic mesentery, in a 68-year-old woman. Ultrasound showed a heterogeneous mass with varying vascularization in the left fossa. Central areas of the mass were hypoechoic, without detectable vascularization. Contrast enhanced computed tomography (CECT) of chest and abdomen showed a contrast enhanced tumour, with central non-enhanced areas. The tumour was radically resected and histopathology showed primary leiomyosarcoma. Two years after primary surgery, follow-up CECT revealed a local recurrence, which was re-resected. Subsequent follow-up CECT since have shown no sign of recurrence.

Intra- and Interobserver Variability in Magnetic Resonance Imaging Measurements in Rectal Cancer Patients.

Colorectal cancer is the second most common cancer in Europe, and accurate lymph node staging in rectal cancer patients is essential for the selection of their treatment. MRI lymph node staging is complex, and few studies have been published regarding its reproducibility. This study assesses the inter- and intraobserver variability in lymph node size, apparent diffusion coefficient (ADC) measurements, and morphological characterization among inexperienced and experienced radiologists. Four radiologists with different levels of experience in MRI rectal cancer staging analyzed 36 MRI scans of 36 patients with rectal adenocarcinoma. Inter- and intraobserver variation was calculated using interclass correlation coefficients and Cohens-kappa statistics, respectively. Inter- and intraobserver agreement for the length and width measurements was good to excellent, and for that of ADC it was fair to good. Interobserver agreement for the assessment of irregular border was moderate, heterogeneous signal was fair, round shape was fair to moderate, and extramesorectal lymph node location was moderate to almost perfect. Intraobserver agreement for the assessment of irregular border was fair to substantial, heterogeneous signal was fair to moderate, round shape was fair to moderate, and extramesorectal lymph node location was substantial to almost perfect. Our data indicate that subjective variables such as morphological characteristics are less reproducible than numerical variables, regardless of the level of experience of the observers.

Phlegmasia cerulea dolens in a patient treated with carboplatin.

Phlegmasia cerulea dolens (PCD) is a rare, fulminant, potentially lethal and often debilitating presentation of deep venous thrombosis (DVT). Mortality and amputations rates are high. We present a rare case of bilateral PCD in the lower extremities. A 67-year-old woman presented with newly diagnosed squamous cell cancer of unknown primary origin with lymph node metastases to the neck. The patient started curatively intended treatment, consisting of removal of one lymph node on the neck, radiotherapy with concomitant carboplatin and nimorazol. The patient developed bilateral DVT in the legs. Despite treatment with low-molecular-weight heparins, the patient developed thrombosis in the inferior vena cava and lungs. Due to developing painful discolouration and necrosis on the legs, the patient underwent acute and extensive surgery. PCD is a severe and potentially lethal form of DVT. There are several known risk factors for developing DVT, including active cancer and the use of chemotherapy.

Permanent prostate brachytherapy preplanned technique: The modern Seattle method step-by-step and dosimetric outcomes.

PURPOSE: To describe, step-by-step, the current Seattle preplan technique, and report the dosimetric outcomes on 1,131 consecutively such treated prostate brachytherapy patients. METHODS AND MATERIALS: One thousand one hundred thirty one patients with prostate cancer were treated with iodine-125 ((125)I), palladium-103 ((103)Pd), or cesium-131 ((131)Cs) using a preplanned template-guided transrectal ultrasound-guided approach between January 2005 and August 2007. Day one computed tomography (CT) scans were taken for postimplantation dose-volume histogram evaluations. Postoperative prostate contours were drawn by one author (DN) on CT images taken on postoperative day one. RESULTS: The volume of prostate receiving 100% of prescription dose (V(100)) and percent dose to 90% of the prostate (%D(90)) were 95% and 106% for 558 monotherapy (125)I implants, 91% and 102% for 327 (103)Pd implants, and 97% and 111.5% for 13 (131)Cs implants, respectively. The median V(100) and percent D(90) were 91% and 101% for five boost (125)I implants, 92% and 104% for 228 boost (103)Pd implants. The median rectal volume receiving 100% of prescription dose (RV(100)) for (125)I, (103)Pd, and (131)Cs monotherapy implants were 0.3, 0.13, and 0.38cc, and for (125)I and (103)Pd boost implants were 0.16 and 0.13cc, respectively. No patient received an RV(100) of >0.92cc. CONCLUSIONS: Modern preplanned template and ultrasound-guided prostate brachytherapy can consistently result in excellent prostate dosimetry and rectal sparing.

Analysis of the Pro-Qura Database: rectal dose, implant quality, and brachytherapist's experience.

PURPOSE: This study analyzed rectal dosimetry outcomes of Pro-Qura proctored implants to assess the achievability of proposed rectal dose constraints in the setting of standardized pre- and postimplant dosimetry in community-based brachytherapy programs. METHODS AND MATERIALS: From August 2005 to July 2007, 713 postimplant CT scans were evaluated from 26 brachytherapists actively participating in Pro-Qura. Postimplant dosimetry was performed in a standardized fashion. The entirety of the rectal wall was contoured and evaluated for dose. Rectal dose was defined in terms of the volume of the rectum receiving 100% of the prescription dose (R(100)). Criteria for implant adequacy for both (103)Pd and (125)I included a prostate the percentage of the prostate volume covered by the prescription dose (V(100))>80%, a prostate the maximum dose covering 90% of the prostate volume (D(90)) of 90-140%, and an R(100)<1.0cm(3) for early (Day 0-7) dosimetry and <1.3cm(3) for late (Day 20-45) dosimetry. RESULTS: Mean prostatic volume was 35.1cm(3). The mean time from implant to CT scan was 29.9 days (range, 0-45 days). The respective mean overall prostate V(100) and D(90) were 89% and 101%, respectively, and remained consistent for sequence groups 1 through 6. Overall, the mean R(100) was 0.97+/-1.04cm(3). The R(100) was 1.15cm(3) for sequence Group 1 and with each subsequent sequence group decreased with a nadir of 0.83cm(3) in sequence Group 6 (p=0.22). Rectal dosimetry was deemed inadequate in 39% of Group 1 implants but only 22% in Group 6 (p=0.016). The reduced rectal doses did not impact prostate gland coverage. CONCLUSIONS: Using standardized dosimetry, R(100) improved with increasing brachytherapist's experience, reaching a plateau after approximately 20 patients.

15-Year biochemical relapse free survival in clinical Stage T1-T3 prostate cancer following combined external beam radiotherapy and brachytherapy; Seattle experience.

PURPOSE: Long-term biochemical relapse-free survival (BRFS) rates in patients with clinical Stages T1-T3 prostate cancer continue to be scrutinized after treatment with external beam radiation therapy and brachytherapy. METHODS AND MATERIALS: We report 15-year BRFS rates on 223 patients with clinically localized prostate cancer that were consecutively treated with I(125) or Pd (103) brachytherapy after 45-Gy neoadjuvant EBRT. Multivariate regression analysis was used to create a pretreatment clinical prognostic risk model using a modified American Society for Therapeutic Radiology and Oncology consensus definition (two consecutive serum prostate-specific antigen rises) as the outcome. Gleason scoring was performed by the pathologists at a community hospital. Time to biochemical failure was calculated and compared by using Kaplan-Meier plots. RESULTS: Fifteen-year BRFS for the entire treatment group was 74%. BRFS using the Memorial Sloan-Kettering risk cohort analysis (95% confidence interval): low risk, 88%, intermediate risk 80%, and high risk 53%. Grouping by the risk classification described by D'Amico, the BRFS was: low risk 85.8%, intermediate risk 80.3%, and high risk 67.8% (p = 0.002). CONCLUSIONS: I(125) or Pd(103) brachytherapy combined with supplemental EBRT results in excellent 15-year biochemical control. Different risk group classification schemes lead to different BRFS results in the high-risk group cohorts.

Initial analysis of Pro-Qura: a multi-institutional database of prostate brachytherapy dosimetry.

PURPOSE: The study aimed to analyze the Pro-Qura database in terms of patient implant sequence number for each institution to determine evidence for a dosimetric learning curve. METHODS AND MATERIALS: In the Pro-Qura database, 2833 of a total of 4614 postplans from 57 brachytherapists were analyzed for evidence of a dosimetric learning curve. The median time between implant and postimplant CT scan was 30 days. I-125 was used in 2123 patients (1687 monotherapy and 536 boost) and Pd-103 in 710 patients (367 monotherapy and 343 boost). Preimplant prostate volume was 35.3 and 32.9 cm3 in the I-125 and Pd-103 cohorts, respectively. The mean I-125 seed activity was 0.32 and 0.26 mCi for monotherapy and boost, whereas for Pd-103 the mean seed activity was 1.59 and 1.27 mCi, respectively. Postimplant dosimetry was performed in a standardized fashion by overlaying the preimplant ultrasound and the postimplant CT scan. Criteria for implant adequacy included a D90 >90% and a V100 >80% for both isotopes. An adequate V150 was defined as <60% for I-125 and <75% for Pd-103. RESULTS: The mean V100 and D90 were 88.9% and 101.9% of prescription dose, respectively. When analyzed in terms of patient sequence number for each institution, the mean V100 for the first 10 patients was 87.4% and increased to 88.6% for patients 11-20 (p = 0.036). Similarly, the mean D90 for the first 10 patients was 98.9%, whereas for the second cohort of 10 patients the mean D90 increased to 102.2% (p = 0.001). In terms of mean V100 and D90, there was minimal further change for subsequent 10 patient institutional groupings of patient sequence numbers. For the first 10 cases, 27.2% were deemed "too cool" (V100 <80% and/or D90 <90%). Approximately 16% of all implants were deemed "too hot" (D90 >140% or V150 >60% for I-125 or >75% for Pd-103). CONCLUSIONS: Although a learning curve exists for prostate brachytherapy, high-quality brachytherapy is achievable in approximately 75-80% of patients treated at community centers.

Interstitial implant alone or in combination with external beam radiation therapy for intermediate-risk prostate cancer: a survey of practice patterns in the United States.

PURPOSE: This study is aimed at understanding and defining the current patterns of care with respect to prostate brachytherapy for patients with intermediate-risk localized disease in the combined academic and community setting. METHODS AND MATERIALS: A nomogram-based survey was developed at the Seattle Prostate Institute defining the accepted criteria for intermediate-risk prostate cancer. Patients were defined as having intermediate-risk prostate cancer if they met one of the following criteria: prostate-specific antigen (PSA) >10 ng/dL, Gleason score (GS) > or = 7, or cT2b or cT2c disease. Additional potential predictive factors including perineural invasion (PNI), GS 3+4 vs. 4+3, and high-volume disease were included. RESULTS: In the absence of PNI, all of those surveyed would perform monotherapy for intermediate-risk patients, GS 7 (3+4) or PSA 10-20, with cT1c and <30% cores +. Up to 80% would perform monotherapy for patients with cT1c, GS 7 (4+3), and <30% cores +. Eighty to 90% of physicians would perform an implant alone with cT2a and either a PSA of 10-20 or GS of 7 (3+4) and <30% cores +. Fifty to 60% of those surveyed stated that they would treat a patient with cT2b disease, GS 7 (3+4), or PSA 11-20, with less than two-thirds of the biopsy cores positive in the absence of PNI. CONCLUSIONS: This Patterns of Care (POC) study reveals that certain subsets of intermediate-risk localized prostate cancer patients are considered appropriate candidates for an interstitial implant alone.

Second malignancies after prostate brachytherapy: incidence of bladder and colorectal cancers in patients with 15 years of potential follow-up.

PURPOSE: To report the incidence of second bladder and colorectal cancers after prostate brachytherapy. METHODS AND MATERIALS: This review included 125 patients treated with I-125 brachytherapy alone, and 223 patients who received supplemental external beam radiation therapy. Median follow-up was 10.5 years. Patients were followed for the development of lower genitourinary and colorectal cancers. Second malignancies arising five years after radiation therapy were defined as being potentially associated with treatment; observed rates were then compared with age-matched expected rates according to Surveillance, Epidemiology, and End Results data. RESULTS: Five years out of treatment, there were 15 patients with a second solid tumor, including bladder cancer (n = 11), colorectal cancer (n = 3), and prostatic urethra cancer (n = 1). The incidence of second malignancy was no different in patients treated with brachytherapy alone (1.6%) vs. those receiving external beam radiotherapy (5.8%, p = 0.0623). There were more observed bladder cancers compared with those expected (relative risk, 2.34, 95% confidence interval 0.96-3.72; absolute excess risk 35 cancers per 10,000 patients). Relative risk did not significantly change over increasing follow-up intervals up to 20 years after treatment. CONCLUSIONS: There may be an increased but small risk of developing a second malignancy after radiation therapy for prostate cancer. This outcome could be related to radiation carcinogenesis, but more vigilant screening and thorough workup as a result of radiation side effects and predisposing conditions (e.g., genetic and environmental factors) in many of the patients found to have second malignancies likely contributed to the higher number of observed malignancies than expected.

Variability of prostate brachytherapy pre-implant dosimetry: a multi-institutional analysis.

PURPOSE: To conduct a multi-institutional comparison of prostate brachytherapy pre-implant dosimetry of Pd-103 and I-125. METHODS AND MATERIALS: Eight experienced brachytherapists submitted Pd-103 and I-125 monotherapeutic and boost pre-implant dosimetry plans for central review. All 32 plans were calculated using the same transrectal ultrasound volumetric study. Seeds of any strength were acceptable, but were restricted to Theraseed Model 200 (Theragenics Inc., Buford, GA) and Oncura Oncoseed Model 6711 (Oncura, Plymouth Meeting, PA). The dosimetric analysis included evaluation of target volume, target to prostate ratio, target length, number of needles, seed activity, number of seeds, total activity, total activity divided by treatment planning volume, the use of extracapsular seeds, and average treatment margins (defined as the perpendicular distance between the prostate capsule and the 100% isodose line). Prostate coverage was defined in terms of V(100)/V(150)/V(200)/V(300) and D(100)/D(90)/D(50), whereas urethral dosimetry consisted of UV(100)/UV(150)/UV(200) and UD(90)/UD(50). RESULTS: The mean planning target volume to prostate volume ratio varied dramatically (mean 1.29, range 0.99-1.76) with the target length ranging from 3.5 to 4.5 cm. Although the prostate V(100) was >95% in all cases, the V(150) ranged from 29.9% to 92.1% and the V(200) from 6.72% to 52.5%. The urethral V(100) was 100% in all cases with six of the eight brachytherapists limiting the UV(150) to <3%. However, the median urethral dose varied by up to 50%. Treatment margins also varied significantly (average 3.98 mm, range 0.32-7.68 mm). All brachytherapists used extracapsular seeds with five implanting >25% of the seeds in extracapsular locations (range 6.4-58.2%). In addition, significant variability existed in the number of needles, number of seeds, and seed strength. CONCLUSIONS: This study highlights the substantial variability that exists regarding target volume, seed strength, dose homogeneity, treatment margins, and extracapsular seed placement, although prostate brachytherapy prescription doses are uniform. The standardization of pre-implant dosimetry is essential for meaningful multi-institutional comparisons of biochemical outcomes and morbidity.

Brachytherapy for carcinoma of the prostate: techniques, patient selection, and clinical outcomes.

Brachytherapy for prostate carcinoma has developed as either low dose rate permanent implants or high dose rate afterloading. Both approaches offer unsurpassed dose escalation and, particularly with permanent implants, the convenience of a single outpatient treatment. These therapies have now entered the mainstream of treatment options and are in the refinement phase of development. Techniques of implantation, treatment planning approaches, innovative fractionation schemes, and appropriate patient selection are the subject of current investigation. Treatment results are available beyond 10 years and appear equivalent or superior to other modalities. Although short term morbidity can be significant with brachytherapy, most current series report low long-term urinary and rectal complications. Meaningful quality of life studies and randomized cooperative group trials are now underway and should help define the role of brachytherapy in the near future.