Identification of pubic arch interference in prostate brachytherapy: simplifying the transrectal ultrasound technique

PURPOSE: We report a simplified technique allowing identification of pubic arch interference (PAI) using transrectal ultrasound (TRUS). METHODS AND MATERIALS: Fifty consecutive brachytherapy patients implanted using a two-stage technique were studied. The pubic arch was outlined using a marker pen on the ultrasound monitor screen during the dose planning ultrasound. Where pubic arch interference (PAI) was identified attempted needle passage was used to confirm PAI (n = 3). RESULTS: Mean time to perform PAI assessment was 90 s. Three of 50 patients had PAI, which was confirmed by attempted needle passage. No patients required modification to the implant plan during the implant procedure. CONCLUSIONS: TRUS reliably identifies PAI. This simple technique may be used with any TRUS scanner and avoids the need for CT scanning or specific software to identify PAI. Our low incidence of PAI may be related to lower prostate volumes at implantation due to patient selection, neoadjuvant androgen deprivation, or improved patient positioning.     

Real-time US versus CT determination of pubic arch interference for brachytherapy

PURPOSE: Part 1, to determine whether transrectal ultrasonography (US) enables accurate determination of pubic arch interference (PAI) for prostate brachytherapy (PBT); part 2, to compare the accuracy of transrectal US with that of computed tomography (CT) for PAI determination; and part 3, to determine the cost savings of PAI determination with transrectal US versus that with CT. MATERIALS AND METHODS: Part 1: The pubic arch was identified intraoperatively with transrectal US and compared with attempted needle passage (14 patients). Part 2: Planning CT with the patient supine was compared with planning transrectal US with patients in the dorsal lithotomy position (nine patients). Part 3: Cost savings were calculated for PAI determination with transrectal US versus that with CT (32 patients per group). RESULTS: Part 1: Transrectal US accurately showed the pubic arch relative to the prostate. Part 2: CT resulted in PAI overestimation by 11.8 mm. Part 3: Cost savings with transrectal US were $1,465 per patient. CONCLUSION: Transrectal US PAI determination is easily performed, intraoperatively useful, and accurate. CT can result in PAI overestimation. Reducing direct CT costs and the indirect costs of unnecessary hormonal therapy for false-positive PAI will reduce expense and improve patient care. Transrectal US should replace CT for PAI determination.     

Factors associated with late local failure and its influence on survival in men undergoing prostate brachytherapy

BACKGROUND AND PURPOSETo determine the factors associated with a positive post-treatment prostate biopsy (PB) and the effects of local failure on biochemical control and cause-specific survival (CSS) in men receiving prostate brachytherapy.METHODS AND MATERIALSOf 545 men with post-implant PB, 484 were routine (median 24 months) while 61 (median 55 months) were for cause. 114 had a repeat PB for rising PSA. Initial mean PSA was 10.5 ng/ml (±13.9) while 244 (44.8%), 202 (37.1%) and 99 (18.2%) had low, intermediate or high-risk disease. Treatments were implant only in 287 (52.7%), and implant with androgen deprivation therapy (ADT) ± external beam in 258. Radiation doses were converted to the biologically equivalent dose (BED). Final biopsy results were the last biopsy performed on that patient. Associations for the first and final biopsies with PSA, clinical stage (CS), Gleason grade group, time on hormone therapy (ADT) and BED were determined by ANOVA, chi-square and binary linear regression. Freedom from Phoenix failure (FFPF) and cause-specific survival were estimated by Kaplan Meier method and Cox proportions hazards.RESULTSAfter a median of 11.4 years the first and final biopsy were positive in 10.8% and 8.8%, respectively. Significant linear regression associations with first positive PB were ADT (p = 0.005), CS (p = 0.044) and BED (p = 0.030) while only BED (p < 0.001) was significant for the final PB. Positive biopsy occurred in 21/112 (18.8%), 16/230 (7.0%) and 3/182 (1.6%) for BED ≤150, >150–200 and >200 Gy (p < 0.001), and in 29/261 (11.1%) for BED (median) ≤185 Gy vs. 5/263 (1.9%) for > 185 Gy (OR 4.2, p < 0.001). 15-year FFPF was 75.6 vs. 17.5% and cause-specific survival was 94.2 vs. 75.5% for negative vs. positive biopsy.CONCLUSIONSHigher radiation doses are associated with 1.9% late local failure following prostate brachytherapy. A negative post-implant PB is associated with superior FFPF and decreased prostate cancer mortality.     

Dosimetric effect of interfractional needle displacement in prostate high-dose-rate brachytherapy

PurposeTo quantify the dosimetric deviations that would arise from delivering subsequent prostate high-dose-rate fractions with only needle readjustment and no replanning after the first fraction.Methods and MaterialsPatients were treated with either two implant sessions (two 9.5-Gy fractions per session) separated by 2–4 weeks or with one implant session and external beam radiotherapy. After needle placement, needle positions were adjusted under CT guidance, after which dosimetric planning was performed before each fraction. To evaluate the consequence of not replanning before the second fraction, we analyzed the dosimetric parameters of 45 consecutive implants (26 patients). Needles with optimized dwell positions from the first fraction were transferred to the needle positions in the second fraction. Needle displacement between fractions was assessed as well as changes in plan metrics.ResultsAfter adjustment, the mean interfractional needle displacement was 3.5 mm. If replanned, the probability of planning target volume D_90% ≥95% is 100%, prostate V_100% ≥95% is 87%, and urethra V₁₁₅% ≤10% is 78%. If treated without replanning, the probability of planning target volume D_90% ≥95% is 82%, prostate V_100% ≥95% is 53%, and urethra V_115% ≤10% is 69%. Even for implants with minimal needle displacement (<3 mm) and minimal prostate volume change (<3 cc), the dosimetric consequence of not replanning the second fraction would result in 46% of cases with a prostate V_100% <95%.ConclusionThe dosimetric consequences of not replanning the second fraction for prostate high-dose-rate implants results in significantly inferior plan metrics.     

Prostate gland motion and deformation caused by needle placement during brachytherapy

PURPOSE: To determine the extent of edge and gland position changes caused by needle insertion in patients undergoing prostate brachytherapy. METHODS AND MATERIALS: Nineteen patients with T1-T3 prostate cancer were implanted with the real-time method by using a two-phase peripheral loading technique. Serial contours of the prostate at 5-mm intervals were acquired by the dose-planning system. All of the peripheral needles were then placed and spaced 5-10 mm apart by using the largest transverse ultrasound image as the reference plane. The position of the probe was relocated at the zero plane, and the difference between the preneedle and postneedle zero plane was recorded as the difference in the z axis. Axial ultrasound images were again acquired. The second set of captured images, which matched in number the first set, was contoured over the previously contoured preneedle images. Prostate gland deformation and displacement were determined by comparing the preneedle contoured image with the images captured after needle placement. Deformation was determined by calculating the differences between the edges of the gland as measured at the major axis of the gland (x and y planes). Displacement was determined by measuring the differences between the center positions of the two contoured structures. Deformation and displacement were determined on each acquired 5-mm image. Differences were compared by student's t test. RESULTS: The mean preneedle prostate volume was 47 ml (range, 21.5-68.7 ml), compared with 48.1 ml (range, 19.4-80.3 ml; p = 0.228) after peripheral needle placement. A median of 16 (range, 12-19) peripheral needles were placed. The median change in the base position of the prostate was 1.5 cm (range of 0 to 3.0 cm; p = 0.0034). The mean x and y deformation was 6.8 mm (median, 7.9 mm; range, 4.3-8.1 mm) and 3.6 mm (median, 3.3 mm; range, 1.0-5.5 mm), respectively. The greatest deformation for any individual slice for x was 21.6 mm and for y was 15.3 mm. The mean number of slices that were found with a >2-, 5-, and 10-mm deformation in the x axis was 7 (range, 3-10), 4 (range, 1-3), and 1 (range, 0-4), respectively. Similar deformation in the y axis was found in 6 (range, 3-10), 2.5 (range, 0-6), and 0.3 (range, 0-2) slices. The mean x and y displacement was 1.9 mm (median, 1.8 mm; range, 0.3-6.6 mm) and 2.8 mm (median, 1.9 mm; range, 2-5.8 mm). The greatest displacement for any individual slice for x was 7 mm and for y was 10 mm. The mean number of slices with a displacement >2, 5, and 10 mm in the x axis was 5 (range, 1-10), 0.8 (range, 0-5), and 0, respectively. Similar displacement in the y axis was found in 5 (range, 0-9), 1.7 (range, 0-7), and 0 slices, respectively. CONCLUSIONS: Placing most needles in the periphery results in a minimal prostate volume increase, suggesting little need to overplan the implant when this method is used. However, significant edge and gland position changes caused by the needle insertion did occur. These changes may explain some of the difficulty in reproducing the preplan and should be taken into consideration for all types of prostate brachytherapy planning.     

Intraprostatic calcification and biochemical recurrence in men treated with cesium-131 prostate brachytherapy

PURPOSEBaseline intraprostatic calcification (IC) has been shown to be associated with a higher rate of biochemical recurrence (BCR) in men treated with iodine-125 prostate brachytherapy (PB). We evaluated this association in a cohort of men treated with cesium-131 PB.METHODS AND MATERIALSWe retrospectively reviewed the charts of all low- and intermediate-risk prostate cancer patients treated with cesium-131 PB +/- external beam radiotherapy (EBRT) at our institution from 2/2011 to 7/2018. Patients with < 24 months of follow up or those who received androgen deprivation therapy were excluded. Baseline IC status (defined as one or more ICs ≥ 5 mm) was determined on post-PB CT scans. Cox analysis was used to assess predictors of BCR and Kaplan–Meier survival curves were calculated.RESULTSTwo hundred and sixteen low- and intermediate-risk prostate cancer patients treated with cesium-131 PB +/- EBRT were included. Median follow up was 56.9 months (range 24.1–111.4). Overall, 76 (35.2%) patients had baseline IC and 140 (64.8%) did not. Baseline disease characteristics did not differ significantly between groups. On univariate Cox analysis, only risk group (p = 0.047) and initial PSA (p = 0.016) were significant predictors of BCR, whereas baseline IC was not (p = 0.11). The 5-year BCR-free survival in patients with versus without baseline IC was 97.7% versus 93.8% (p = 0.405), respectively.CONCLUSIONSIn a cohort of low- and intermediate-risk prostate cancer patients treated with cesium-131 PB, the rate of BCR in men with baseline IC was low and baseline IC was not associated with a higher risk of BCR.     

Prognostic importance of tobacco use in men receiving definitive prostate brachytherapy

PurposeSeveral prominent publications have identified an overall association between tobacco use and an increased risk of disease recurrence and disease-specific mortality in prostate cancer patients. The authors explored whether tobacco use adversely impacts treatment outcomes in men treated with permanent interstitial brachytherapy.Methods and MaterialsFrom April 1995 to August 2008, 2057 patients underwent brachytherapy by a single brachytherapist. Median follow-up was 7.5 years. The role of tobacco use as a prognostic factor for biochemical progression-free survival, cause-specific survival, and overall survival was investigated. Differences in survival between smokers and nonsmokers were compared using Kaplan–Meier curves and log-rank tests.ResultsCurrent smokers presented with a lower body mass index (p < 0.001), smaller prostate size (p = 0.003), younger age (p < 0.001), higher prostate-specific antigen level (p = 0.002), a trend toward higher percentage biopsy core involvement (p = 0.08), higher incidence of perineural invasion (p = 0.015), and higher risk disease (p < 0.001) than former or nonsmokers. There was no difference in biochemical progression-free survival (p = 0.30) or cause-specific survival (p = 0.72) at 10 years for smokers compared with nonsmokers. On univariate and multivariate analysis, tobacco use was an adverse risk factor for overall survival (p < 0.001). There was no association between smoking and any prostate cancer-specific outcome.ConclusionsSmokers treated with brachytherapy have excellent outcomes and are at no higher risk of treatment failure than men who are nonsmokers.     

Permanent prostate brachytherapy is safe in men with severe baseline lower urinary tract symptoms

PurposeTo evaluate the long-term urinary outcomes of men with severe pretreatment lower urinary tract symptoms (LUTS) treated with permanent prostate brachytherapy (PPB) ± external beam radiation therapy for localized prostate cancer.Methods and materialsA total of 105 men with International Prostate Symptom Score (IPSS) 20–35 before PPB were categorized by IPSS change at last followup: (1) worse = IPSS rise >3; (2) no change = IPSS change within three points of baseline; (3) improved = IPSS fall by >3 points. We then evaluated patients who worsened vs. those who did not (no change or improved) with respect to incontinence outcomes, LUTS medication usage, and predictors of symptom worsening.ResultsMean followup was 80.3 ± 55.8 months. Mean age was 66.3 ± 7.1 years; mean pretreatment IPSS was 23.6 ± 3.0. Overall mean improvement in IPSS was 7.6 ± 9.3. Specifically, 14.3% (15/105) worsened, 21.9% (23/105) had no significant change, and 63.8% (67/105) improved. There were no patient- or treatment-related factors significantly associated with long-term worsening of urinary symptoms. No men required anticholinergic therapy at last followup, whereas 7% (8/105) were using an alpha blocker. Only 2.9% (3/105) of men were using at least one pad daily at last followup. Alternatively, only 7.7% (8/105) reported subjective incontinence.ConclusionsPPB is an acceptable option in the setting of severe baseline LUTS in appropriately selected and counseled patients when performed by a skilled practitioner.     

改良前列腺容积算法提高经直肠超声对近距离放疗病人前列腺体积估算的准确率

目的 评价传统经直肠超声对前列腺体积测量方式的准确性,探讨根据面积法以前列腺形态为基础而计算出的更精确的前列腺体积测量方式是否适合大多数前列腺。方法 本回顾性研究获得审查委员会同意,无需知情同意。共有138例接受前列腺近距离放疗的连续病人被纳入研究。     

Transperineal mapping biopsy improves selection of brachytherapy boost for men with localized prostate cancer

PURPOSETo determine if transperineal mapping biopsy (TPMB) can improve the selection of brachytherapy alone (BT) or brachytherapy boost (BTB) in men with localized prostate cancer.Methods and MaterialsTwo hundred and eighteen men underwent TPMB with a mean of 48.6 cores retrieved. Comparisons were made between prebiopsy risk features and biopsy results to treatment choice with associations tested with ANOVA (bootstrap), χ² test (Pearson), and linear regression. Survival estimates were tested by the Kaplan–Meier method with comparisons by log rank.ResultsMean age, prostate specific antigen (PSA), prostate specific antigen density (PSAD), and prostate volume were 67.2 years, 8.1 ng/mL, 0.19, and 50.3 cc, respectively. 105 (48.2%) biopsies were positive for Gleason Group (GG) 1: 34 (32.4%), 2: 21 (20%), 3: 31 (29.5%), 4: 7 (6.7%), and 5: 12 (11.4%). The mean number of positive cores (PCs) was 7.3 (median 6, range 1–37). Men with six or more PCs had higher PSA (11.3 vs. 6.0 ng/mL, p = 0.025) and PSAD (0.34 vs. 0.13, p = 0.013). Overall brachytherapy was used in 74 (70.5%) as either monotherapy or boost therapy. Men with BTB had higher PSA (9.7 vs. 6.7 ng/mL, p = 0.029), PSAD (0.27 vs. 0.16, p = 0.007), GG (3.3 vs. 1.8, p < 0.001), more bilateral disease (75.9% vs. 55.6%, odds ratio 3.9, p = 0.008), and PCs (10.9 vs. 4.4, p < 0.001). On linear regression, only GG (p = 0.008) and PCs (p = 0.044) were associated with BTB. Biochemical-free failure at 5 years was 92.7%.ConclusionsTPMB improves the selection of patients for BTB. Men with more PCs are more likely to have BTB. Restricting the need for BTB to those with greater volume prostate cancer may reduce radiation side effects.     

Real-time Doppler ultrasound to identify vessels and guide needle placement for gynecologic interstitial brachytherapy

PurposeDoppler ultrasound (US) gives real-time information regarding anatomy and blood vessel location to guide needle placement for gynecologic interstitial (IS) brachytherapy (BT). We retrospectively assessed Doppler US images for vessel quantity, size, and distribution in cervical cancer patients undergoing high-dose-rate BT at our institution.Methods and MaterialsEleven consecutive patients undergoing IS high-dose-rate BT implants for cervical cancer between 2015 and 2017 were included. Transrectal Doppler US was used for real-time image guidance. US images were retrospectively evaluated. Vessel quantity, size, and distribution at superior and inferior levels of the cervix were recorded. Correlation of vessel quantity with tumor size and International Federation of Gynecology and Obstetrics stage was evaluated.ResultsAverage vessel quantity was 4.2 in the inferior cervix and 3.8 in the superior cervix (range 1–11). Median vessel diameter was 2 mm in the inferior cervix and 2 mm in the superior cervix (range 1–6 mm). The most common location was posterolateral (3:00–5:00 and 7:00–9:00), outer third (78% of vessels inferiorly, 64% of vessels superiorly). Vessel quantity was correlated to initial tumor size superiorly (p = 0.04, paired t-test) but not inferiorly (p = 0.31, paired t-test). There was no correlation between vessel quantity and International Federation of Gynecology and Obstetrics stage (p > 0.05, analysis of variance). Doppler US was successfully used to guide needle placement away from visualized blood vessels with no incidents of hemorrhage in these patients.ConclusionsDoppler US is a useful tool to guide needle placement for IS BT for cervical cancer. Vessel quantity varied with increased vessel quantity seen higher in the cervix for larger tumors. Vessels were most commonly distributed in the outer third of the posterolateral cervix.     

The use of supplemental external beam radiotherapy in men with low-risk prostate cancer undergoing brachytherapy before and after the 1999 American Brachytherapy Society Guideline statement

PurposeIn 1999, the American Brachytherapy Society (ABS) recommended brachy-monotherapy for men with low-risk prostate cancer because of the potential for increased toxicity with combined external beam radiotherapy (EBRT) and brachytherapy without the proof of increased efficacy. We investigated the patterns of care in the community in this patient population before and after the reporting of the ABS guideline.Methods and MaterialsThe study cohort consisted of 4943 men (median age, 69.0 years) with low-risk prostate cancer treated with brachytherapy with or without supplemental EBRT from 1991 to 2007 across 21 community radiation oncology centers. Multivariable logistic regression analysis was performed to determine if there was a significant association between the year of brachytherapy, prostate-specific antigen level, clinical tumor (T) category, patient's age, and the use of supplemental EBRT.ResultsSupplemental EBRT was used in 647 men (13%). The EBRT use initially increased until 2001 and then decreased yielding a significant association (adjusted odds ratio [AOR], 0.92; p < 0.001) between the EBRT use and the year of brachytherapy using a quadratic formulation. Specifically, EBRT use peaked at 24.6% in 2001 and subsequently declined to 3.3% by 2007. Men with clinical category T2a as compared with T1c disease (AOR, 1.43; p < 0.001) were more likely to receive combined modality therapy.ConclusionsThe use of supplemental EBRT in men with low-risk prostate cancer treated with brachytherapy has decreased since 2001. This change in practice patterns suggests gradual adoption of the 1999 ABS practice guidelines.     

Recovery of serum testosterone following neoadjuvant and adjuvant androgen deprivation therapy in men treated with prostate brachytherapy

AIM: To investigate the time course of testosterone (T) recovery after cessation of androgen deprivation therapy (ADT) in patients treated with brachytherapy.METHODS: One-hundred and seventy-four patients treated between June 1999 and February 2009 were studied. Patients were divided into a short-term usage group (≤ 12 mo, n = 91) and a long-term usage group (≥ 36 mo, n = 83) according to the duration of gonadotropin-releasing hormone agonist therapy. Median follow-up was 29 mo in the short-term group and was 60 mo in the long-term group.RESULTS: Cumulative incidence rates of T recovery to normal and supracastrate levels at 24 mo after cessation were 28.8% and 74.6%, respectively, in the long-term usage group, whereas these values were 96.4% and 98.8% in the short-term usage group. T recovery to normal and supracastrate levels occurred significantly more rapidly in the short-term than in the long-term usage group (P < 0.001 and P < 0.001, respectively). Five years after cessation, 22.6% of patients maintained a castrate T level in the long-term usage group. On multivariate analysis, lower T levels (< 10 ng/dL) at cessation of ADT was significantly associated with prolonged T recovery to supracastrate levels in the long-term usage group (P = 0.002).CONCLUSION: Lower T levels at cessation of ADT were associated with prolonged T recovery in the long-term usage group. Five years after cessation of long-term ADT, approximately one-fifth of patients still had castrate T levels. When determining the therapeutic effect, especially biochemical control, we should consider this delay in T recovery.     

External radiotherapy and permanent prostate brachytherapy in patients with localized prostate cancer

We examined the difference in prostate-specific antigen (PSA)-freedom from recurrence (FFR) in patients with localized prostate cancer treated with permanent prostate brachytherapy (PPB) alone or external radiotherapy combined with PPB (RT-PPB). A total of 1476 patients with prostate cancer (T1/T2) were treated with PPB by following the American Brachytherapy Society criteria. Patient self-selection and preference allowed for an overlap of treatment methodologies and risk factors. Monotherapy consisted of 125I or 103Pd. RT-PPB consisted of RT followed by PPB. PSA-FFR was based on a published modification of the American Society for Therapeutic Radiology and Oncology definition. Cox regression analysis was performed to assess the role of Gleason sum, pretreatment PSA value, clinical stage, RT-PPB, the addition of hormones, and the minimum dose covering 90% of the prostate volume (D90 dose). Monotherapy was used for 1016 patients (79%), and RT-PPB was used for 281 patients (21%), with an overall 6-year PSA-FFR of 83.2% (median follow-up of 34.7 months; range, 6-91 months). Multivariate Cox regression analysis to predict PSA-FFR identified the following highly significant variables: pretreatment PSA value, Gleason sum, and the addition of hormones. When the D90% (D90 dose relative to the prescribed dose) was included as a variable, Cox regression identified only the following significant variables: D90%, pretreatment PSA, and Gleason sum. Cox regression failed to identify an improvement in PSA-FFR with RT-PPB or the addition of hormones. Although these conclusions question the role for RT-PPB, only a comparative trial will be able to answer this question definitively.     

MRI-based sector analysis enhances prostate palladium-103 brachytherapy quality assurance in a phase II prospective trial of men with intermediate-risk localized prostate cancer

PurposePalladium-103 (¹⁰³Pd) may be superior to other isotopes in brachytherapy for localized intermediate-risk prostate cancer because of its relatively short half-life, higher initial dose rate, and greater dose heterogeneity within the target volume; these properties also underscore the need for accurate target delineation and postimplant quality assurance. We assessed the use of prostate sector analysis based on MRI for quality assurance after ¹⁰³Pd monotherapy.Methods and MaterialsFifty men with intermediate-risk prostate cancer underwent ¹⁰³Pd monotherapy in a prospective phase II trial at MD Anderson Cancer Center. Dosimetric analyses on day 30 after the implant were done using both CT and fused CT/MRI scans. Dosimetric variables were assessed for the entire prostate and for each of three or six sectors. Volumes and dosimetric variables were compared with paired t tests.ResultsPostimplant dosimetric variables for the entire prostate were significantly different on CT vs. CT/MRI (p = 0.019 for V₁₀₀ and p < 0.01 for D₉₀). Prostate volumes were smaller on the CT/MRI scans (p < 0.00001). The base sector contributed the greatest difference, with doses based on CT/MRI lower than those based on CT (p < 0.01 for V₁₀₀ and D₉₀). To date, these lower base doses have not affected biochemical outcomes for patients with disease in prostate base biopsy samples.ConclusionsCT/MRI is more precise than CT for prostate volume delineation and dosimetric quality assessment and thus provides superior heterogeneity control assessment after ¹⁰³Pd monotherapy implants.     

Interstitial hyperthermia of the prostate in combination with brachytherapy

Objective

A retrospective study to evaluate the feasibility and toxicity of interstitial hyperthermia (IHT) combined with high-dose-rate (HDR) brachytherapy as the initial treatment for low- and intermediate-risk prostate cancer, and as a salvage therapy in previously irradiated patients with local recurrence.

Patients and methods

Between 18 December 2008 and 5 September 2012, 73  prostate cancer patients were treated with interstitial HDR brachytherapy of the prostate combined with IHT. In 54 patients this was the initial therapy for prostate cancer, while the other 19 were treated for local recurrence after previously undergoing external beam radiotherapy (EBRT). Toxicity for the organs of the genitourinary system and rectum was assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) v. 4.03 within 3 months after treatment.

Results

Median follow-up was 15 months (range 3–46). The combination of HDR brachytherapy and IHT was well tolerated. The toxicity profile was similar to that of HDR brachytherapy when not combined with hyperthermia. The most common minor complications were urinary frequency (grade 1: 37?%; grade 2: 22?%), nocturia (three times per night: 29?%; four- or more times per night: 20?%) and transient weakening of the urine stream (grade 1: 36?%; grade 2: 11?%). No early rectal complications were observed in the patient group and the severity of genitourinary toxicity was only grade 1–2.

Conclusion

Early tolerance of IHT in combination with HDR brachytherapy is good. Further prospective clinical studies should focus on the effects of combining IHT with HDR brachytherapy and the influence of this adjuvant therapy on biochemical disease-free survival, local control and overall survival.