Neoadjuvant chemoradiation followed by interstitial prostate brachytherapy for synchronous prostate and rectal cancer

PurposeTo describe outcomes with the use of neoadjuvant pelvic chemoradiation followed by prostate interstitial brachytherapy for the treatment of synchronous prostate and rectal cancers.Methods and MaterialsAn Internal Review Board approved retrospective review was undertaken of 4 patients with synchronous prostate and rectal cancer treated between 2006 and 2008. Patients underwent pelvic chemoradiation followed by prostate brachytherapy, then low anterior resection of the rectum with diverting loop ileostomy and adjuvant chemotherapy. Follow-up evaluation included imaging and laboratory analysis of cancer markers in addition to routine interval history and physical examination.ResultsAt 38-62 months postdiagnosis (24-53 months post-treatment), 6 of 8 cancers remained without evidence of relapse. One patient had rising carcinoembryonic antigen levels but no clinically evident rectal cancer relapse; another developed bony metastasis of his high-risk prostate cancer. Three patients experienced grade 1-2 treatment-related toxicity; one patient had grade 3 gastrointestinal toxicity from radiation and surgery, which precluded his receiving adjuvant chemotherapy and ileostomy reversal.ConclusionsChemoradiation followed by prostate brachytherapy, surgery, and adjuvant chemotherapy may be utilized to manage patients with synchronous prostate and rectal cancers.     

Combination external beam radiation and brachytherapy boost with androgen deprivation for treatment of intermediate-risk prostate cancer: long-term results of CALGB 99809

BACKGROUND:

Combined transperineal prostate brachytherapy and external beam radiation therapy (EBRT) is widely used for treatment of prostate cancer. Long‐term efficacy and toxicity results of a multicenter phase 2 trial assessing combination of EBRT and transperineal prostate brachytherapy boost with androgen deprivation therapy (ADT) for intermediate‐risk prostate cancer are presented.

METHODS:

Intermediate‐risk patients per Memorial Sloan‐Kettering Cancer Center/National Comprehensive Cancer Network criteria received 6 months of ADT, and 45 grays (Gy) EBRT to the prostate and seminal vesicles, followed by transperineal prostate brachytherapy with I¹²⁵ (100 Gy) or Pd¹⁰³ (90 Gy). Toxicity was graded using the National Cancer Institute Common Toxicity Criteria version 2 and Radiation Therapy Oncology Group late radiation morbidity scoring systems. Disease‐free survival (DFS) was defined as time from enrollment to progression (biochemical, local, distant, or prostate cancer death). In addition to the protocol definition of biochemical failure (3 consecutive prostate‐specific antigen rises >1.0 ng/mL after 18 months from treatment start), the 1997 American Society for Therapeutic Radiology and Oncology (ASTRO) consensus and Phoenix definitions were also assessed in defining DFS. The Kaplan‐Meier method was used to estimate DFS and overall survival.

RESULTS:

Sixty‐one of 63 enrolled patients were eligible. Median follow‐up was 73 months. Late grade 2 and 3 toxicity, excluding sexual dysfunction, occurred in 20% and 3% of patients. Six‐year DFS applying the protocol definition, 1997 ASTRO consensus, and Phoenix definitions was 87.1%, 75.1%, and 84.9%. Six deaths occurred; only 1 was attributed to prostate cancer. Six‐year overall survival was 96.1%.

CONCLUSIONS:

In a cooperative setting, combination of EBRT and transperineal prostate brachytherapy boost plus ADT resulted in excellent DFS with acceptable late toxicity for patients with intermediate‐risk prostate cancer. Cancer 2011;. © 2011 American Cancer Society.     

Incidence and clinical course of hemorrhagic radiation proctitis after iodine-125 prostate brachytherapy

PURPOSE: Hemorrhagic radiation proctitis (HRP) is a potential complication of prostate brachytherapy. We sought to determine the incidence and clinical course of hemorrhagic radiation proctitis after iodine-125 (125I) prostate brachytherapy. PATIENTS AND METHODS: Between 1995 and 2003, 221 consecutive patients were treated at the Barrett Cancer Center with permanent 125I seed implantation for presumed localized adenocarcinoma of the prostate. No patients received EBRT. All cases of HRP were confirmed by colonoscopy. Median follow-up was 52 months. All patients were evaluated for HRP using a 5-grade rectal bleeding scale developed by the Radiation Therapeutic Oncology Group. RESULTS: Thirty-three patients experienced grade>or=1 toxicity at some point after treatment. Twenty patients developed grade 2 toxicity, 9 developed grade 3, and 2 developed grade 4. The median time to onset of symptoms of HRP was 14 months. The incidence of HRP had a bimodal temporal onset, with a peak seen at 4 months and a second larger peak at 16 months. Peak toxicity occurred at 18 months after the onset of rectal bleeding, after which there was a sharp decline in toxicity. CONCLUSION: This study demonstrates tolerable rectal morbidity after transperineal prostate brachytherapy of the prostate. Hemorrhagic radiation proctitis occurring after brachytherapy for prostate cancer is usually self-limiting and frequently resolves without treatment or with minor medical treatment. Patients develop HRP soon after treatment or after a delay in treatment. Symptoms appear to peak 18 months after the onset of HRP.     

Serial changes of international prostate symptom score following I-125 prostate brachytherapy

Background This study was conducted to assess serial changes in the International Prostate Symptom Score (IPSS) within the first 12 months after iodine-125 (I-125) prostate brachytherapy. Methods Between September 2003 and June 2004, a group of 103 patients with localized prostate cancer was treated with I-125 prostate brachytherapy, either alone (monotherapy; 60 patients) or in combination with external-beam radiotherapy (combined therapy; 43 patients). The IPSS was obtained at preimplant, and at 1, 6, and 12 months after treatment. The minimum IPSS follow-up for this study was 12 months. Dosimetry was based on computed tomography (CT) scan 1 month postimplant. Clinical, treatment-related, and dosimetric factors were assessed for correlations with the maximum IPSS increase (the peak IPSS minus the preimplant IPSS). Results The median preimplant IPSS was 7.0, with a median peak of 16 at 1 month. The IPSS returned to baseline in 42 patients (40.8%) and it returned to within 3 points of the baseline in 64 (62.1%) at 1-year follow-up. On univariate and multivariate analyses, the maximum IPSS increase was best predicted by lower preimplant IPSS, in both the monotherapy and combined therapy groups. Conclusion In our series, IPSS after prostate brachytherapy peaked at 1 month and gradually returned to approximately baseline at 12 months.     

Urinary and rectal complications of contemporary permanent transperineal brachytherapy for prostate carcinoma with or without external beam radiation therapy

BACKGROUND: Prostate brachytherapy is increasingly used to treat prostate carcinoma, alone or combined (combination therapy) with external beam radiation therapy (EBRT). This report cites the frequency and nature of urinary and rectal complications requiring unplanned interventions after contemporary brachytherapy with or without EBRT. METHODS: A total of 177 consecutive patients underwent either brachytherapy (100 patients [56.5%]) or combination therapy (77 patients [43.5%]) for clinical T1-2 prostate carcinoma between July 1998 and July 2000. All the patients were analyzed with regard to disease characteristics, treatment details, and complications requiring unplanned interventions in up to 48 months of follow-up. RESULTS: Catheter drainage for urinary retention was required for a median of 55 days (range, 3-330 days) in 36 patients (20%), including 24% after brachytherapy and 16% after combination therapy. Transurethral resection of the prostate (TURP) was performed at a median of 12 months (range, 8-18 months) after implantation in 5% of patients after brachytherapy and 14.5% of patients after combination therapy (P = 0.029). Colonoscopy with or without fulguration for rectal bleeding was performed in 37 of 158 patients (97 in the brachytherapy group and 61 in the combination therapy group) (23.4%) at a median of 17 months (range, 4-45 months), including 15 patients (15.5%) after brachytherapy and 22 patients (36%) after combination therapy (P = 0.002). Combination therapy resulted in fecal diversion in 6.6% of patients (P = 0.021), urinary diversion in 3.2% of patients (P = 0.148), and clean intermittent self-catheterization for recurrent stricture after multiple TURPs in 4.9% of patients (P = 0.055), none of which occurred after brachytherapy. Overall, 20.6% of patients underwent TURP or colonoscopy after brachytherapy, whereas 44.2% underwent those or more extensive unplanned procedures after combination therapy (P = 0.001). CONCLUSIONS: Complications requiring unplanned procedures may occur after brachytherapy, and may be increased significantly after brachytherapy combined with EBRT. These data reinforce the concept that quality assurance and technique are important in prostate brachytherapy, but, even when these are in place, complications can occur, especially when EBRT is added to brachytherapy.     

Gastrointestinal toxicity of transperineal interstitial prostate brachytherapy

PURPOSE: To characterize the severity and time course of rectal toxicity following transperineal prostate brachytherapy using prospectively recorded data, and to determine factors associated with toxicity. METHODS AND MATERIALS: One hundred thirty-four patients with prostate cancer treated with transperineal brachytherapy from 1997 to 1999 had rectal toxicity data available for analysis. Patients with Gleason score (GS) > 6, prostate-specific antigen (PSA) > 6, or stage > T2a were treated initially with external beam radiation therapy followed by brachytherapy boost; patients with none of these features were treated with brachytherapy alone. Both iodine-125 and palladium-103 sources were used, and loaded according to a modified Quimby distribution. At each follow-up, toxicity was recorded according to a modified RTOG gastrointestinal scale. RESULTS: Thirty-nine percent of patients experienced gastrointestinal toxicity, mostly Grade 1. Median duration of symptoms was 6 months. Two patients experienced Grade 3 toxicity, both of whom had minimal symptoms until their 12-month follow-up. There was no Grade 4 or 5 toxicity. The addition of external beam radiation therapy (p = 0.003), higher clinical stage (p = 0.006), and Caucasian race (p = 0.01) were associated with increased incidence of toxicity. CONCLUSION: Most patients with rectal toxicity have very mild symptoms. There is a small risk of severe late toxicity. External beam radiation, higher stage, and race are associated with toxicity.     

Radiation pneumonitis caused by a migrated brachytherapy seed lodged in the lung

We report a case of radiation pneumonitis caused by a migrated seed lodged in the lung after prostate brachytherapy. A 71-year-old man underwent transperineal interstitial permanent prostate brachytherapy for localized prostate cancer. On the day after brachytherapy, a routine postimplant chest X-ray revealed migration of one seed to the lower lobe of the left lung. After 1 month, pulmonary opacities were observed in the left lower lobe but not near the seed. He was diagnosed with bacterial pneumonia, and antibiotic therapy was commenced. Two months after brachytherapy, the patient's symptoms, laboratory data and pulmonary opacities improved; however, an abnormal shadow (consolidation) developed around the migrated seed. Lung consolidation disappeared almost completely 12 months after brachytherapy without any medical treatment. The abnormal shadow probably represented radiation pneumonitis. To the best of our knowledge, this is the first report of radiation pneumonitis caused by a migrated brachytherapy seed in the lung.     

Late rectal function after prostate brachytherapy

PURPOSE: Using a patient-administered quality of life instrument, to evaluate the effect of permanent prostate brachytherapy on late rectal function. METHODS AND MATERIALS: One hundred eighty-nine prostate brachytherapy patients were mailed the Rectal Function Assessment Score (R-FAS), with a prestamped return envelope. The R-FAS consists of nine questions and a scoring range of 0-27, with higher scores indicative of poorer bowel function. One hundred eighty-seven (98.4%) surveys were returned. The median follow-up was 66.3 months (range 54-92 months). Clinical, treatment, and dosimetric parameters evaluated for bowel dysfunction included patient age, diabetes, hypertension, tobacco consumption, clinical T-stage, elapsed time since implant, prostate ultrasound volume, planning target volume, hormonal status, supplemental external beam radiation therapy (EBRT), isotope, average, median and maximum rectal doses, total implanted seed strength, values of the minimum dose received by 90% of the prostate gland (D(90)), and the percent prostate volume receiving 100%, 150%, and 200% of the minimum prescribed dose (V(100/150/200)). RESULTS: The R-FAS score for the evaluated cohort was 3.92, which represented a slight improvement from the 1999 survey score of 4.15 (p = 0.29). Of the evaluated clinical, treatment, and dosimetric parameters, the number of preimplant bowel movements, a history of tobacco consumption, and the median rectal dose correlated with the R-FAS. Although lower rectal doses were noted with Pd-103, isotope did not predict for bowel function. Only 12% (23/187) of patients reported their bowel function to be worse after implantation. Patient perception of overall rectal quality of life was inversely related to the use of supplemental EBRT (p = 0.007). CONCLUSION: Minor bowel changes are noted following prostate brachytherapy. The vast majority of patients did not report any deterioration in bowel function. In addition, the R-FAS continue to improve with time.     

Rectal function following prostate brachytherapy

PURPOSE: Quality of life following therapeutic intervention for carcinoma of the prostate gland has not been well documented. In particular, a paucity of data has been published regarding bowel function following prostate brachytherapy. This study evaluated late bowel function in 209 consecutive prostate brachytherapy patients via a one-time questionnaire administered 16-55 months postimplant. MATERIALS AND METHODS: Two hundred nineteen consecutive patients underwent permanent prostate brachytherapy from April 1995 through February 1998 using either (125)I or (103)Pd for clinical T1c-T3a carcinoma of the prostate gland. Of the 219 patients, 7 had expired. Of the remaining 212 patients (median follow-up, 28 months), each patient was mailed a self-administered questionnaire (10 questions) with a prestamped return envelope; 209 (98.6%) surveys were returned. Clinical parameters evaluated for bowel dysfunction included patient age, diabetes, hypertension, history of tobacco consumption, clinical T-stage, elapsed time since implant, and prostate ultrasound volume. Treatment parameters included utilization of neoadjuvant hormonal manipulation, utilization of moderate dose external beam radiation therapy prior to implantation, choice of isotope ((125)I vs. (103)Pd), rectal dose (average, median and maximum doses), total implanted seed strength, values of the minimum dose received by 90% of the prostate gland (D(90)), and the percent prostate volume receiving 100%, 150%, and 200% of the prescribed minimum peripheral dose (V(100), V(150) and V(200), respectively). Because detailed baseline bowel function was not available for these patients, a cross-sectional survey was performed in which 30 newly diagnosed prostate cancer patients of comparable demographics served as controls. RESULTS: The total rectal function scores for the brachytherapy and control patients were 4.3 and 1.6, respectively, out of a total 27 points (p < 0.001). Of the evaluated clinical parameters, only the preimplant number of bowel movements per day were correlated with the total survey score (p < 0.01). None of the treatment parameters were significantly correlated with the total survey score. Despite the fact that implantation with (103)Pd resulted in lower radiation doses to the rectum, the choice of isotope was not predictive of bowel function scores. A trend toward increased rectal scores was noted for older patients, and a nonsignificant improvement in rectal survey scores was noted with elapsed time from implantation. Only 19.2% (40/208) of the treatment group reported a worsening of bowel function following implantation. Patient perception of overall rectal quality of life, however, was inversely related to the utilization of external beam radiation therapy (p = 0.034). CONCLUSION: To date, no severe changes in late bowel function have been noted following prostate brachytherapy. Although the survey scores indicate bowel function is worse after an implant, the minor changes are not significant enough to bother most individuals. Less than 20% of patients reported that their bowel function was worse following prostate brachytherapy.     

American Society for Radiation Oncology (ASTRO) and American College of Radiology (ACR) practice guideline for the transperineal permanent brachytherapy of prostate cancer

Transperineal permanent prostate brachytherapy is a safe and efficacious treatment option for patients with organ-confined prostate cancer. Careful adherence to established brachytherapy standards has been shown to improve the likelihood of procedural success and reduce the incidence of treatment-related morbidity. A collaborative effort of the American College of Radiology (ACR) and American Society for Therapeutic Radiation Oncology (ASTRO) has produced a practice guideline for permanent prostate brachytherapy. The guideline defines the qualifications and responsibilities of all the involved personnel, including the radiation oncologist, physicist and dosimetrist. Factors with respect to patient selection and appropriate use of supplemental treatment modalities such as external beam radiation and androgen suppression therapy are discussed. Logistics with respect to the brachytherapy implant procedure, the importance of dosimetric parameters, and attention to radiation safety procedures and documentation are presented. Adherence to these practice guidelines can be part of ensuring quality and safety in a successful prostate brachytherapy program.     

A phase I/II study of external beam radiation, brachytherapy, and concurrent chemotherapy for patients with localized carcinoma of the esophagus (Radiation Therapy Oncology Group Study 9207): final report

BACKGROUND: A multiinstitutional, prospective study of the Radiation Therapy Oncology Group (RTOG) was designed to determine the feasibility and toxicity of chemotherapy, external beam radiation, and esophageal brachytherapy (EB) in a potentially curable group of patients with adenocarcinoma or squamous cell carcinoma of the esophagus. A preliminary analysis indicated a 17% 1-year actuarial risk of treatment-related fistulas. A final analysis of this study was considered important to determine the median survival time, local control, and late toxicity associated with this treatment regimen. METHODS: Planned treatment was 50 grays (Gy) of external beam radiation (25 fractions given over 5 weeks) followed 2 weeks later by EB (either high-dose-rate 5 Gy during Weeks 8, 9, and 10, for a total of 15 Gy, or low-dose-rate 20 Gy during Week 8). Chemotherapy was given during Weeks 1, 5, 8, and 11, with cisplatin 75 mg/m(2) and 5-fluorouracil 1000 mg/m(2)/24 hours in a 96-hour infusion. RESULTS: Of the 49 eligible patients, 45 (92%) had squamous histology and 4 (6%) had adenocarcinoma. Forty-seven patients (96%) completed external beam radiation plus at least 2 courses of chemotherapy, whereas 34 patients (69%) were able to complete external beam radiation, EB, and at least 2 courses of chemotherapy. The estimated survival rate at 12 months was 49%, with an estimated median survival of 11 months. Life-threatening toxicity or treatment-related death occurred in 12 (24%) and 5 (10%) cases, respectively. Treatment-related esophageal fistulas occurred in 6 cases (12% overall, 14% of patients starting EB) at 0.5-6.2 months from the first day of brachytherapy, leading to death in 3 cases. CONCLUSIONS: In this study, severe toxicity, including treatment-related fistulas, occurred within 7 months of brachytherapy. Based on the 12% incidence of fistulas, the authors continue to urge caution in employing EB, particularly when used in conjunction with chemotherapy.     

High dose brachytherapy (real time) in patients with intermediate-or high-risk prostate cancer: technical description and preliminary experience

INTRODUCTION. It has been well documented that the outcome of prostate cancer treatment depends on the dose administered. Hence, techniques have been developed that allow high-dose administration without increasing the complications, e.g. external radiotherapy combined with high-dose radiation (HDR) brachytherapy. In this article we analyse the technique and protocol of real-time HDR brachytherapy together with the preliminary results that support its use. Materials and methods. Between June 1998 and December 2004, 100 patients with adenoma of the prostate were treated with 46 Gy of external irradiation to the pelvis and 2 HDR brachytherapy fractions (each of 1150 cGy) at the end of weeks 1 and 3 of a 5-week radiotherapy course. The 1997 American Joint Commission on Cancer (AJCC) system was used to establish disease stage. Patients with intermediate-risk (PSA 10-20 ng/ml or Gleason = 7 or T2c) and high-risk (two intermediate risk factors or PSA > 20 ng/ml or Gleason > 7 or > T2c) without metastases were eligible for the brachytherapy. Biochemical failure was defined according to the American Society for Therapeutic Radiology and Oncology (ASTRO) consensus panel statement. SPSS statistical package was used to quantify survival (Kaplan-Meier method). Toxicity was scored according to RTOG guidelines. RESULTS. The mean age of patients was 67 years (range 49-78). Clinical stage was T2a in 22% of the patients, 26% T2b and 52% T3. Initial PSA was = 10 ng/ml in 22% of the patients and > 10 ng/ml in 78%. Median follow-up was 28 months (range: 12-79). The 5-year overall survival and actuarial biochemical control were 99% and 87% respectively. No chronic severe complications were noted. CONCLUSIONS. The good results of local control, disease-free survival and few complications that the external radiotherapy combined with HDR brachytherapy have shown suggest that the method should be considered as first-choice in the treatment of prostate tumours of high- and intermediate-risk.     

Combined intensity-modulated radiation therapy and brachytherapy in the treatment of cervical cancer

PURPOSE: This treatment planning study compared pseudo-step-wedge intensity modulation (PSWIM), intensity-modulated radiation therapy (IMRT), and conventional external irradiation, all combined with brachytherapy, for treatment of patients with cervical cancer. METHODS AND MATERIALS: This was a prospective study of 10 patients treated with PSWIM delivering 50.4 Gy to the pelvic lymph nodes and 20 Gy to the cervical tumor. This treatment was compared with a conventional treatment plan with a four-field box to 45 Gy and to an IMRT plan delivering 45 Gy. In each case, brachytherapy was prescribed to a total Point A low-dose-rate equivalent dose of 85 Gy. Total doses to Points A, Point P, the bladder point, and the rectal point were calculated. Acute toxicity and treatment response were prospectively recorded. RESULTS: The mean PSWIM total low-dose-rate equivalent dose to Points A and P (97.3 Gy and 65.1 Gy, respectively) was significantly higher, the mean rectal dose was the same, and the mean bladder dose was higher than with IMRT or four-field box. No acute toxicity of greater Grade 2, as defined by the than Radiation Therapy Oncology Group, was experienced. The positron emission tomography-based treatment response compared favorably with our institutional experience. CONCLUSIONS: Use of PSWIM and brachytherapy delivers significantly more dose to the tumor and lymph nodes than do competing techniques. Rectal doses are comparable. Maximum bladder point doses are higher. Toxicity and tumor response are acceptable.     

Intraoperative brachytherapy alone for incomplete resected recurrent rectal cancer.

In order to determine the impact of intraoperative brachytherapy alone in patients with recurrent rectal cancer who, due to prior pelvic radiation therapy, were ineligible to receive further external beam pelvic radiation, we retrospectively reviewed the records of 36 patients with recurrent rectal cancer who had gross residual disease remaining in the pelvis following biopsy alone or subtotal resection. The median follow-up was 24 months (6-81 months). The median survival was 27 months and the 4 year actuarial survival was 25%. There was a suggestion of lower survival in patients who underwent biopsy alone compared with those who underwent a subtotal resection (21% vs. 34%). The local failure (LF) rate was 22% as the only site of failure and 44% as a component of failure. There was a lower but non-significant LF rate in patients who underwent subtotal resection vs. biopsy alone (33% vs. 66%) and those with an 125I implant volume of less than 40 cm3 vs. greater than or equal to 40 cm3 (39% vs. 100%). Four patients (11%) developed treatment-related severe complications (without evidence of LF). Our data suggest that, although it is not clear that intraoperative brachytherapy impacts on the ultimate survival rate in this group of patients, it does offer reasonable local control with acceptable morbidity. Since local control, in and of itself is an important endpoint in the treatment of rectal cancer, we continue to recommend brachytherapy as part of an overall aggressive approach in patients who are unable to receive pelvic radiation therapy.     

Rectal morbidity following I-125 prostate brachytherapy in relation to dosimetry

BACKGROUND: To investigate rectal morbidity after I-125 prostate brachytherapy and to analyze predictive factors of rectal morbidity. METHODS: A group of 227 consecutive patients with localized prostate cancer were treated with I-125 prostate brachytherapy with or without external beam radiotherapy (EBRT) between September 2003 and January 2005. Rectal morbidity (diarrhea, bleeding and pain) was evaluated using the Radiation Therapy Oncology Group (RTOG) criteria. Dosimetry was based on computerized tomography (CT) scan 1 month post-implant. The clinical, treatment-related and dosimetric factors were evaluated for the risk of grade 2 rectal morbidity. Rectal dosimetric factors included the rectal volume that received >100% and 150% of the prescribed dose, and the maximal rectal dose which was defined as the sum of the minimal dose received by 1% of the rectum volume and the prescribed dose of EBRT. RESULTS: Grade 2 rectal bleeding occurred in 10 (4.4%): for nine patients within the first year and for one patient between the first and second year. Grade 2 diarrhea occurred in one patient (0.4%) within the first year. No patient reported grade 2 pain. In the univariate analysis with grade 2 rectal bleeding, there were significant correlations with number of seeds, supplemental EBRT, and all of the rectal dosimetric parameters. On subsequent multivariate analysis, the only significant factor was the maximal rectal dose (P < 0.001). Rectal dose > 160 Gy was correlated to grade 2 rectal morbidity. All the patients with rectal dose > 160 Gy received EBRT. CONCLUSIONS: Manifestations of rectal morbidity are acceptable events after I-125 prostate brachytherapy. Rectal dose-volume histogram for the brachytherapy is a predictive method for assessing the risk of developing grade 2 rectal bleeding. Delivery of the rectal dose should not exceed 160 Gy in order to avoid rectal complications.     

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.     

Emerging role of intensity-modulated radiation therapy in anorectal cancer

Although radiation therapy has an established role to play in the management of rectal and anal tumors, there are often treatment-related morbidities that negatively impact on patients. There is a long-standing interest in radiation oncology on maximizing treatment efficacy while minimizing treatment-related toxicities, which can be pronounced in the treatment of pelvic malignancies. Intensity-modulated radiation therapy is a recently introduced technology that has the potential to increase the efficacy:toxicity ratio. It has been implemented in the treatment of prostate and head and neck tumors with success. This article reviews the rationale for its use in treating anorectal tumors and discusses early clinical data supporting its continued investigation.     

Rectal bleeding after high-dose-rate brachytherapy combined with hypofractionated external-beam radiotherapy for localized prostate cancer: impact of rectal dose in high-dose-rate brachytherapy on occurrence of grade 2 or worse rectal bleeding

PURPOSE: To evaluate the incidence of Grade 2 or worse rectal bleeding after high-dose-rate (HDR) brachytherapy combined with hypofractionated external-beam radiotherapy (EBRT), with special emphasis on the relationship between the incidence of rectal bleeding and the rectal dose from HDR brachytherapy. METHODS AND MATERIALS: The records of 100 patients who were treated by HDR brachytherapy combined with EBRT for > or =12 months were analyzed. The fractionation schema for HDR brachytherapy was prospectively changed, and the total radiation dose for EBRT was fixed at 51 Gy. The distribution of the fractionation schema used in the patients was as follows: 5 Gy x 5 in 13 patients; 7 Gy x 3 in 19 patients; and 9 Gy x 2 in 68 patients. RESULTS: Ten patients (10%) developed Grade 2 or worse rectal bleeding. Regarding the correlation with dosimetric factors, no significant differences were found in the average percentage of the entire rectal volume receiving 30%, 50%, 80%, and 90% of the prescribed radiation dose from EBRT between those with bleeding and those without. The average percentage of the entire rectal volume receiving 10%, 30%, 50%, 80%, and 90% of the prescribed radiation dose from HDR brachytherapy in those who developed rectal bleeding was 77.9%, 28.6%, 9.0%, 1.5%, and 0.3%, respectively, and was 69.2%, 22.2%, 6.6%, 0.9%, and 0.4%, respectively, in those without bleeding. The differences in the percentages of the entire rectal volume receiving 10%, 30%, and 50% between those with and without bleeding were statistically significant. CONCLUSIONS: The rectal dose from HDR brachytherapy for patients with prostate cancer may have a significant impact on the incidence of Grade 2 or worse rectal bleeding.     

A second transient prostate-specific antigen elevation after external-beam radiation therapy and fractionated magnetic resonance imaging-guided high-dose rate brachytherapy boost

A 63-year-old man with a T1c adenocarcinoma of the prostate, Gleason score of 7 (4+3), and a pretreatment prostate-specific antigen (PSA) level of 9.5 ng/mL was treated with external-beam radiation therapy (45 Gy) and 2 magnetic resonance imaging-guided high-dose rate brachytherapy boosts (10 Gy each.) The patient also received neoadjuvant, concurrent, and adjuvant hormonal treatment with leuprolide for 7 months total. Without any further intervention the patient had 2 separate and prolonged PSA increases and decreases 12-35 months after therapy. His PSA nadir was <0.2 ng/mL and rose slowly over several months to 4.2 ng/mL, resolved, and then rose 2.3 ng/mL before again slowly resolving. After prostate irradiation, many patients experience a transient rise in serum PSA levels and a subsequent decline without any treatment. This is known as a PSA "bounce" or "bump." Some patients experience a second transient rise in PSA levels after irradiation. To our knowledge, this case report is the first documentation of a second PSA bump in a patient treated with external-beam radiation therapy and high-dose rate boost therapy and provides context to address concerns and therapeutic decisions confronting physicians and patients.