Magnetic resonance spectroscopic imaging-guided brachytherapy for localized prostate cancer

Abstract

Purpose: Prostate brachytherapy (PB) entails the placement of radioactive sources throughout the entire prostate gland to treat localized cancer. Typically, the target volume in PB encompasses the entire prostate gland because of the inability to localize the cancer and the multifocal nature of this malignancy. However, because of the unique biochemical nature of the prostate gland, recent advances in magnetic resonance spectroscopic imaging (MRSI) of the prostate have allowed precise delineation of the cancer location within the prostate gland. This report reveals our initial experience of MRSI-guided PB. Methods: An MRSI study was obtained in 15 favorable-risk (prostate-specific antigen level ≤10 ng/mL, Gleason score ≤6, and clinical Stage ≤T2a) patients before their scheduled PB. The results of this study were used to internally map 7 × 7 × 9-mm volumes of prostate tissue to assign cancerous areas a higher dose of radiation. Such tumor-bearing areas had a low citrate/(choline+creatine) ratio consistent with cancer. On the basis of the anatomic MRI and MRSI correlation, three-dimensional coordinates were assigned to the locations of MRSI-defined cancer. The entire target volume was treated to 145 Gy using 125I. Abnormal citrate regions, termed the biologic tumor volume, were prescribed a dose of 130% of the target volume dose (188 Gy) to dose escalate in the abnormal citrate regions while respecting the normal radiation tolerances of the surrounding areas. Three-dimensional treatment planning was used to perform the implant. Results: Of the 15 prostate cancer patients evaluated, all had successful three-dimensional MRSI acquisition before their scheduled PB procedure. In 14 of the 15 patients planned with MRSI, the data were successfully incorporated into their treatment planning and were used to increase the radiation dose prescription to 130% in the MRSI-defined volumes. In 1 patient, MRSI revealed significant multifocal disease that made focal boosts impractical. Postimplant dosimetry confirmed a median V100 of 95% (range 89–98%) in the 15 evaluated patients for the prescription dose of 145 Gy to the target volume. Furthermore, the median BTV100 for the abnormal citrate region was 90% (range 80–100%) as determined by postimplant dosimetry. Urethral and rectal dose-volume histograms were within normal limits. Morbidity was comparable with that for conventionally treated patients. Conclusion: MRSI offers a promising new approach for the delivery of ionizing radiation in PB. Although this series was small and with a short follow-up, MRSI-guided implants are feasible and warrant further investigation as a means of improving the therapeutic ratio in PB.