Comparing radical prostatectomy and brachytherapy for localized prostate cancer

Radical prostatectomy and ultrasound-guided transperineal brachytherapy are both commonly used for the treatment of localized prostate cancer. No randomized trials are available to compare these modalities. Therefore, the physician must rely on institutional reports of results to determine which therapy is most effective. While some investigators have concluded that both therapies are effective, others have concluded that radical prostatectomy should remain the gold standard for the treatment of this disease. This article reviews the major series available for both treatments and discusses the major controversies involved in making these comparisons. The data indicate that for low-risk disease, both treatments are effective, controlling disease in over 80% of the cases, with no evidence to support the use of one treatment over the other. Similarly, for intermediate-risk disease, the conclusion that one treatment is superior to the other cannot be drawn. Brachytherapy should be performed in conjunction with external-beam radiation therapy in this group of patients. For patients with high-risk disease, neither treatment consistently achieves biochemical control rates above 50%. Although radical prostatectomy and/or brachytherapy may play a role in the care of high-risk patients in the future, external-beam radiation therapy in combination with androgen deprivation has the best track record to date.     

Isotope selection for patients undergoing prostate brachytherapy.

PURPOSE: Ultrasound-guided transperineal interstitial permanent prostate brachytherapy (TIPPB) is generally performed with either 103Pd or 125I. The use of 125I for low Gleason score tumors and 103Pd for higher Gleason scores has been suggested based on isotope dose rate and cell doubling time observed in in vitro studies. While many centers follow these isotope selection criteria, other centers have elected to use only a single isotope, regardless of Gleason score. No clinical data have been published comparing these isotopes. This study was undertaken to compare outcomes between 125I and 103Pd in a matched pair analysis for patients undergoing prostate brachytherapy. METHODS AND MATERIALS: Six hundred forty-eight consecutively treated patients with clinically confined prostate cancer underwent TIPPB between June 1992 and February 1997. Five hundred thirty-two patients underwent TIPPB alone, whereas 116 received pelvic external beam irradiation and TIPPB. Ninety-three patients received androgen deprivation therapy prior to TIPPB. The prescribed doses for TIPPB were 160 Gy for 125I (pre-TG43) and 120 Gy for 103Pd. Patients treated with combination therapy received 41.4 or 45 Gy (1.8 Gy/fraction) external beam irradiation followed by a 3- to 5-week break and then received either a 120-Gy 125I or a 90-Gy 103Pd implant. Until November 1994, all patients underwent an 125I implant after which the isotope selection was based on either Gleason score (Gleason score 2-5:125I; Gleason 5-8:103Pd) or isotope availability. A matched pair analysis was performed to assess any difference between isotopes. Two hundred twenty-two patients were matched according to Gleason score, prostate-specific antigen (PSA), and stage. PSA relapse-free survival (PSA-RFS) was calculated based on the American Society for Therapeutic Radiology and Oncology (ASTRO) Consensus Group definition of failure. Kaplan-Meier actuarial survival curves were compared to assess differences in pretreatment PSA and Gleason score. RESULTS: Univariate analysis of the 648 patients identified Gleason score, pretreatment PSA value, and stage as significant factors to predict PSA-RFS, but failed to identify isotope selection as significant. To address the significance of isotope selection further, the matched pair groupings were performed. The minimum follow-up for all 222 matched patients is 24 months with a median follow-up of 42 months (24-82). The actuarial PSA-RFS at 5 years for all 222 patients is 86.5%. One hundred eleven of the 222 matched patients received a 103Pd implant with an 87.1% 5-year PSA-RFS. The remaining 111 patients underwent a 125I implant with an 85.9% 5-year PSA-RFS (p = n.s.). Analysis of Gleason score subgroups 2-4, 5-6, and 7-9 failed to show any significant difference in PSA-RFS comparing isotopes. Pretreatment PSA subgroups of < or = 10 or > 10 ng/ml also failed to show any significant difference in PSA-RFS survival comparing isotopes. Analysis of postimplant dosimetry using dose delivered to 90% of the prostate volume (D90) did not identify any difference between the isotope groups. CONCLUSIONS: This matched pair analysis failed to demonstrate a difference for 125I and 103Pd in PSA-RFS for patients undergoing TIPPB. In addition, there were no observed advantages for either 125I or 103Pd in either the low or high Gleason score groups. This data indicates that the role of isotope selection for patients undergoing TIPPB requires further clarification.     

Prostate brachytherapy for localized prostate cancer

Opinion statement After skin cancer, prostate cancer (CaP) is the most common cancer diagnosed in men. As a result of screening with prostate-specific antigen, CaP is being caught earlier than it was in the past. This has led to an increase in cure rates across all treatment modalities. There are no firm, reproducible data that demonstrate the superiority of one modality over another. The expectations for cure should be approximately 90% for low-risk patients and approximately 80% for intermediate-risk patients, regardless of treatment modality. The toxicity of available treatment modalities discriminates among them. All modalities have acute toxicity of similar severity; however, prostate brachytherapy (PI) has the least amount of long-term toxicity when compared with external beam radiotherapy and radical prostatectomy. Therefore, a patient who is confronted with the diagnosis of CaP is counseled to choose among the modalities based on the toxicity rather than the efficacy of the treatment options available. Adopting this evidence-based algorithm has led to the increased application of PI.     

Potency after permanent prostate brachytherapy for localized prostate cancer

The evaluation of potency preservation after treatment of localized prostate cancer with transperineal permanent prostate brachytherapy (PPB) and the efficacy of sildenafil were studied.

This study comprised 482 patients who were able to maintain an erection suitable for intercourse before treatment from a cohort of 1166 patients with clinically localized prostate cancer treated with PPB. All patients have been followed prospectively, and actuarial analysis was performed to assess potency preservation over time. Patients treated with sildenafil were evaluated as to its efficacy.

The median follow-up of this cohort was 34 months (6–92), with a median age of 68 years (47–80). Potency was preserved in 311 of the 482 patients, with a 5-year actuarial potency rate of 52.7%. The 5-year actuarial potency rate for patients treated with PPB as monotherapy was 76%, and, for those treated with combination external beam radiotherapy (EBT) + PPB, 56% (p = 0.08). Patients treated with neoadjuvant androgen deprivation (NAAD) + PPB had a 5-year potency rate of 52%, whereas those with combination EBT + PPB + NAAD had a potency rate of 29% (p = 0.13). Cox regression analysis identified that pretreatment use of NAAD and patient age predicted for impotence (p = 0.0001 and 0.04, respectively). Of 84 patients treated with sildenafil, 52 had a successful outcome (62%). The response to sildenafil was significantly better in those patients not treated with NAAD (p = 0.04).

The actuarial potency rates at 5 years for patients treated with PPB are lower than generally acknowledged, except for those patients treated with PPB as monotherapy. Patients who received sildenafil exhibited improved potency in a majority of cases.     

A prospective quality-of-life study in men with clinically localized prostate carcinoma treated with radical prostatectomy, external beam radiotherapy, or interstitial brachytherapy

PURPOSE: To prospectively assess the health-related quality of life (HRQOL) and changes in HRQOL during the first year after 3 different treatments for clinically localized prostate cancer. METHODS AND MATERIALS: Ninety men with T1-T2 adenocarcinoma of the prostate were treated with curative intent between May 1998 and June 1999 and completed a quality-of-life Functional Assessment of Cancer Therapy-Prostate (FACT-P) questionnaire before treatment (T0) and 1 month (T1), 3 months (T3), and 12 months (T12) after treatment. Forty-four men were treated with permanent source interstitial brachytherapy (IB), 23 received external beam radiotherapy (EBRT), and 23 men were treated with radical prostatectomy (RP). The mean age of the entire study population was 65.9 years (median 67, range 42-79). The mean pretreatment prostate-specific antigen level of the entire study population was 6.81 ng/mL (median 6.25, range 1.33-19.6). The Gleason score was 相似文献   

Radical prostatectomy for localized prostate cancer.

A retrospective analysis of 70 patients, undergoing a radical prostatectomy in 1989 and 1990 is reported. The value of computed tomography (CT) scanning in preoperative lymph node staging should be reconsidered. Evaluation of the resection margins is of utmost importance as is the distinction between capsular invasion, penetration and transgression. The etiology of local failure and its treatment are discussed.     

Biochemical outcome after radical prostatectomy or external beam radiation therapy for patients with clinically localized prostate carcinoma in the prostate specific antigen era

BACKGROUND: To the authors' knowledge, consensus is lacking regarding the relative long-term efficacy of radical prostatectomy (RP) versus conventional-dose external beam radiation therapy (RT) in the treatment of patients with clinically localized prostate carcinoma. METHODS: A retrospective cohort study of 2635 men treated with RP (n = 2254) or conventional-dose RT (n = 381) between 1988-2000 was performed. The primary endpoint was prostate specific antigen (PSA) survival stratified by treatment received and high-risk, intermediate-risk, or low-risk group based on the serum PSA level, biopsy Gleason score, 1992 American Joint Commission on Cancer clinical tumor category, and percent positive prostate biopsies. RESULTS: Estimates of 8-year PSA survival (95% confidence interval [95% CI]) for low-risk patients (T1c,T2a, a PSA level < or = 10 ng/mL, and a Gleason score < or = 6) were 88% (95% CI, 85, 90) versus 78% (95% CI, 72, 83) for RP versus patients treated with RT, respectively. Eight-year estimates of PSA survival also favored RP for intermediate-risk patients (T2b or Gleason score 7 or a PSA level > 10 and < or = 20 ng/mL) with < 34% positive prostate biopsies, being 79% (95% CI, 73, 85) versus 65% (95% CI, 58, 72), respectively. Estimates of PSA survival in high-risk (T2c or PSA level > 20 ng/mL or Gleason score > or = 8) and intermediate-risk patients with at least 34% positive prostate biopsies initially favored RT, but were not significantly different after 8 years. CONCLUSIONS: Intermediate-risk and low-risk patients with a low biopsy tumor volume who were treated with RP appeared to fare significantly better compared with patients who were treated using conventional-dose RT. Intermediate-risk and high-risk patients with a high biopsy tumor volume who were treated with RP or RT had long-term estimates of PSA survival that were not found to be significantly different.     

The association of treatment-related symptoms with quality-of-life outcomes for localized prostate carcinoma patients

BACKGROUND: Most studies of treatment outcomes in men with localized prostate carcinoma have emphasized sexual, urinary, and bowel symptoms with the assumption that they have an impact on quality of life. However, very few studies have directly examined and compared the impact of these symptoms on overall and cancer specific quality of life. METHODS: The authors examined 783 incident cases of localized prostate carcinoma, diagnosed from 1993 to 1998, and 1928 age-matched healthy controls from the Health Professionals Follow-Up Study cohort. Information on frequency of ejaculation and urinary symptoms were collected before cancer diagnosis. After cancer diagnosis, the authors mailed a questionnaire including the Medical Outcomes Study Short Form-36 Health Status Survey (SF-36), the Cancer Rehabilitation Evaluation System-Short Form (CARES-SF), and the University of California at Los Angeles Prostate Cancer Index in 1998. RESULTS: Cases had slightly lower scores on most of the SF-36 scales and reported much more bother from sexual, urinary, and bowel symptoms compared with healthy controls. Among prostate carcinoma patients, bowel symptoms had the greatest negative impact on quality of life, followed by sexual and urinary symptoms. As expected, treatment-related symptoms were associated with the physical domains of quality of life, but psychosocial domains were just as strongly affected. CONCLUSIONS: Patients and health care providers need to consider the potential mental quality-of-life impacts associated with prostate carcinoma treatment symptoms when making treatment decisions. Even after patients have completed cancer treatment, significant health impairments may remain. Health care providers should continue to address the mental and physical well-being of prostate carcinoma patients in follow-up care.     

Late rectal complications after prostate brachytherapy for localized prostate cancer

This review of the literature on late rectal complications after prostate brachytherapy indicated that it is a highly effective treatment modality for patients with clinically localized prostate cancer but can cause chronic radiation proctitis. The most common manifestation of chronic radiation proctitis was anterior rectal wall bleeding, which often occurred within the first 2 years after brachytherapy. It is interesting to note that the rates of late rectal morbidity appear to have declined over time, which may reflect improvements in implantation techniques and imaging. Rectal biopsy as part of the workup to evaluate rectal bleeding can lead to rectal fistula and the need for colostomy, a rare but major complication. The authors recommend 1) screening colonoscopy before brachytherapy for patients who have not had a screening colonoscopy within the preceding 3 years to rule out colorectal malignancies and, thus, facilitate conservative management should rectal bleeding occur; 2) lifestyle modifications during treatment to limit exposure of the rectum to radiation; and 3) conservative management for rectal bleeding that occurs within 2 years after brachytherapy. Cancer 2009. © 2009 American Cancer Society.     

Neoadjuvant docetaxel before radical prostatectomy in patients with high-risk localized prostate cancer.

PURPOSE: To determine the clinical, pathologic, and molecular effects of neoadjuvant docetaxel chemotherapy in high-risk localized prostate cancer. EXPERIMENTAL DESIGN: Patients with biopsy Gleason scores of 8 to 10, serum prostate-specific antigen levels >20 ng/mL, and/or clinical stage T3 disease received weekly docetaxel (36 mg/m2) for 6 months, followed by radical prostatectomy, and were monitored with weekly visits, serum prostate-specific antigen measurements, and endorectal magnetic resonance imaging (MRI). Frozen tumor specimens were collected for microarray analysis. RESULTS: The 19 patients enrolled received 82% of the planned chemotherapy. Toxicity was mild to moderate; fatigue and taste disturbance were common. Prostate-specific antigen declines of >50% were seen in 11 of 19 patients (58%; 95% confidence interval, 33-80%) and endorectal MRI showed maximum tumor volume reduction of at least 25% in 13 of 19 patients (68%; 95% confidence interval, 47-85%) and at least 50% in 4 patients (21%; 95% confidence interval, 6-46%). Sixteen patients completed chemotherapy and had radical prostatectomy; none achieved pathologic complete response. Microarray analysis identified coordinate up-regulation of genes involved in androgen metabolism associated with docetaxel therapy. Specifically, RNA expression for genes that decrease cellular levels of bioactive androgens was coordinately increased in response to chemotherapy. CONCLUSIONS: Neoadjuvant docetaxel administered for 6 months before radical prostatectomy is feasible, well tolerated, and often results in prostate-specific antigen declines of >50% and decreased tumor volume on endorectal MRI. No pathologic complete responses were observed. Altered androgen metabolism may partially account for the noted declines in prostate-specific antigen and be a mechanism for chemotherapy resistance.     

Radiotherapy for localized prostate carcinoma

We reviewed the radiation therapy treatment experience for localized prostate carcinoma at the Joint Center for Radiation Therapy from 1968-1978 (N = 229 patients, median follow-up of 5 years). Actuarial 5 (and 8) year survival rates for clinical Stage A (N = 25), B (N = 85), and C (N = 88) disease were 96% (82), 77% (63), and 61% (38). The corresponding 5 (and 8) year relapse-free survivals were 84% (67), 68% (61), and 53% (36). Actuarial rates of clinical local failure at 5 (and 8) years were 0%, (0), 12% (20), and 15% (30) for Stage A, B, and C respectively. There was a suggestion of a decrease in the force of local and overall recurrence after 8 years, although further follow-up will be necessary for confirmation. Among 42 patients who underwent pelvic lymphadenectomy followed by irradiation, lymph node status appeared to be a strong predictor of distant failure (9% (3/32) failures for node (-) patients compared to 70% (7/10) for node (+) patients). Twenty-nine patients received radiotherapy after radical prostatectomy for clinically palpable (Stage B and C) tumor. Only one of 16 patients treated post-operatively because of microscopic or gross residual disease has developed recurrence. By contrast, only 2 of 13 patients irradiated because of clinical local tumor recurrence remain alive and free of disease. We conclude that radiation therapy can provide effective long-term local control of prostate carcinoma, but that the ultimate radiocurability of the disease is not yet known.     

Palladium-103 brachytherapy for prostate carcinoma

PURPOSE: A report of biochemical outcomes for patients treated with palladium-103 (Pd-103) brachytherapy over a fixed time interval. METHODS AND MATERIALS: Two hundred thirty patients with clinical stage T1-T2 prostate cancer were treated with Pd-103 brachytherapy and followed with prostate-specific antigen (PSA) determinations. Kaplan-Meier estimates of biochemical failure on the basis of two consecutive elevations of PSA were utilized. Multivariate risk groups were constructed. Aggregate PSA response by time interval was assessed. RESULTS: The overall biochemical control rate achieved at 9 years was 83.5%. Failures were local 3.0%; distant 6.1%; PSA progression only 4.3%. Significant risk factors contributing to failure were serum PSA greater than 10 ng/ml and Gleason sum of 7 or greater. Five-year biochemical control for those exhibiting neither risk factor was 94%; one risk factor, 82%; both risk factors, 65%. When all 1354 PSA determinations obtained for this cohort were considered, the patients with a proportion of PSAs < or = 0.5 ng/ml continued to increase until at least 48 months post-therapy. These data conformed to a median PSA half-life of 96.2 days. CONCLUSIONS: Prostate brachytherapy with Pd-103 achieves a high rate of biochemical and clinical control in patients with clinically organ-confined disease. PSA response following brachytherapy with low-dose-rate isotopes is protracted.     

Recursive partitioning for prognostic grouping of patients with clinically localized prostate carcinoma

BACKGROUND: Patients treated with radical prostatectomy for clinically localized prostate carcinoma present considerable heterogeneity in terms of disease free survival outcome. Multiple studies have attempted to create prognostic groupings of these patients in the perioperative phase, using information available regarding several clinicopathologic variables. Such groupings allow physicians to make early yet prudent decisions regarding adjuvant combination therapies. The current study presents results from a statistical analysis that enables the natural identification of such prognostic groups. METHODS: Examination of consecutive radical prostatectomy specimens was performed between January 1991 and December 1995 at Wayne State University, Harper Hospital, Detroit, Michigan. Disease free survival in a cohort of 485 of these men was analyzed using recursive partitioning and amalgamation technique. Clinicopathologic parameters evaluated included age, race, preoperative prostate specific antigen (PSA) level, clinical and pathologic stage, and Gleason grade of the fine-needle biopsy as well as the radical prostatectomy specimen. RESULTS: A binary decision tree representation was generated for classifying patients based on the clinicopathologic variables mentioned earlier. The worst prognosis was for patients with either advanced stage and a PSA level > 24.1 ng/mL or advanced stage, a PSA level 相似文献   

Prediction of PSA bounce after permanent prostate brachytherapy for localized prostate cancer

Background  

We aimed to calculate the frequency and features of the development of a prostate-specific antigen (PSA) bounce after prostate brachytherapy alone, to correlate the bounce with clinical and dosimetric factors and to identify factors that predict PSA bounce.