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Brachytherapy vs Surgery An Unresolved Dilemma

Brachytherapy vs Surgery An Unresolved Dilemma. Rick Popert, Peter Acher, Netty Nichol, Stephen Morris & Ron Beaney Departments of Urology & Oncology Guy’s & St Thomas’ NHS Foundation Trust. Brachytherapy.

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Brachytherapy vs Surgery An Unresolved Dilemma

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  1. Brachytherapy vs SurgeryAn Unresolved Dilemma Rick Popert, Peter Acher, Netty Nichol, Stephen Morris & Ron Beaney Departments of Urology & Oncology Guy’s & St Thomas’ NHS Foundation Trust

  2. Brachytherapy • Delivering radioactivity by positioning sources directly into or in close proximity to a tumour. • Open retropubic. • Transperineal.

  3. Rationale for Prostate Brachytherapy Grimm & Blasko, Seattle 1985 Surgical & EBRT Outcomes Sub Optimal Some success with retropubic implants Development of TRUS guidance Achieve higher radiation dose than EBRT Lower morbidity Convenient outpatient treatment

  4. TRUS Guided Brachytherapy circa 1985 John Blasko Seattle • Monoplane imaging • Poor quality images • Crude stabilizing devices • No prior experience • No planning systems • No CT based dosimetry

  5. Prostate Brachytherapy • 5–10 year data showed excellent outcomes • 15 yr data available on first 123 patients • All low risk, low volume disease, Gleason <6 • All aged over 70yrs at time of treatment • Treated with I-125 • Overall survival follow actuarial predictions • Disease specific survival in 96%

  6. 125I Monotherapy – 15 Year Overall Survival 42% Ave. survival of 70 yo male n=76

  7. n = 97 n = 26 PSA 0.1

  8. PSA Based Results of Brachytherapy(ASTRO Definition)10 – 14 Years 1. ASTRO, 2004

  9. Comparative Cohort Study • Total 1866 consecutive cases, Treated 1992 to 1998 • Clinical Stage T1-T2 • Facility: • Cleveland Clinic Foundation: • 1225 cases (94 PI, 348 EBRT, 783 RP) • Memorial Sloan Kettering @ Mercy Medical Center: • 641 cases (641 PI) • All patients treated with monotherapy • Radical prostatectomy • External beam radiation (min dose 70 Gy) • Permanent Implant

  10. Cleveland Clinic/MSKCC Treatment Comparisons 77%–83% 1 .8 .6 .4 .2 0 (mono) PI Seeds Alone vs Seeds+EB vs EB <72 Gy vs EB >72 Gy vs RP EB>72 Gy COMB RP 51% bNED EB<72 Gy 1,866 patients Follow-up 56 months 0 12 24 36 48 60 72 84 Time (months) *Kupelian PA, et al.. IJROBP 58: 25-33: 2004.

  11. 1 .8 .6 .4 .2 0 0 12 24 36 48 60 72 84 Biochemical relapse free survival: Treatment modality EBRT RP PI Biochemical relapse free survival 5yr 7 yr RP 83% 79% PI 82% 74% EBRT 77% 77% p=0.82 Time (months)

  12. EBRT 1 RP PI .8 .6 Biochemical relapse free survival .4 .2 p=0.82 0 84 0 12 24 36 48 60 72 Time (months) Biochemical Relapse-Free Survival: Favourable Tumours: (T1/T2A, biopsy GS <6, and iPSA <10)

  13. 1 .8 RP .6 EBRT Biochemical relapse free survival PI .4 .2 p=0.15 0 84 0 12 24 36 48 60 72 Time (months) Biochemical relapse free survival: Unfavourable Tumours: (T2B or biopsy GS >7 or iPSA >10)

  14. Extraprostatic Extension* • 105 prostatectomies* • Gleason 6.3 (range 3-9) • PSA 8.6 (range 0.3-98) *Davis et al. Cancer 85(12) 1999

  15. Radial Distance of Extraprostatic Extension* *Davis et al. Cancer 85(12) 1999

  16. Brachytherapy Margins 100% isodose Extraprostatic disease, 3 mm + margins critical to success, Particularly with monotherapy U Margin: 3-6 mm

  17. Goals of Dosimetry • D90 > 90% of prescription dose (145Gy) • D90 = dose to 90% of the prostate • Brachytherapy equivalent of “Negative Margins” • Document ‘that’ patient’s implant • Predictor of the patient’s response • Evaluate effectiveness of technique • Develop an understanding of the process and what makes a ‘good’ implant

  18. Importance of Implant Dosimetry* D90 > 90% n = 503 D90 < 90% n = 216 *Potters et al Urology 62 (6) 2003

  19. Disease Selection Criteria PSA < 15 Gleason Score < 7 (3+4) T2a disease or less Patient Selection Minimal urinary symptoms Smallish prostate (<45 cc) Max Flow >15ml/sec Minimal residual urine Relative Contraindications Severe lower urinary tract symptoms (IPSS > 12) Large prostate > 50 ml Previous Prostate Surgery Absolute Contraindications Previous pelvic radiation Urinary retention Locally advanced disease Prostate Brachytherapy

  20. Cost Effective Less time off work Continence unaffected Mild LUTS in 70% Moderate LUTS in 30% Preservation of potency Preservation of ejaculation but may be reduced Fertility preserved Expensive 6 to 12 weeks recovery 50% immediate continence 75% by 3 months 97% by 1 year Potency never the same True ejaculation does not occur Infertile – require IVF Brachytherapy Surgery

  21. Recommendations • Brachytherapy for “low risk” Carcinoma • Provides an opportunity for long term cure - ? at any age • It is a MONOTHERAPY and avoids hormones • Patients want treatment for observational uncertainty • Patients concerned about continence and potency • Brachytherapy for “intermediate risk” Ca P • Unsuitable for RRP (Age & Co Morbidity) • Preferential Loading • Not recommended in the young 40 – 60s (but ? Salvage) • Patient Preference • Careful Counselling • Evaluation / Treatment of LUTS

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