Iridium-192 Implantation Research Articles

Use of Iridium-192 wires in treating peri-ocular sarcoids in horses

ABSTRACT:Iridium-192 (192Ir) implants can be used to treat peri-ocular sarcoids when more conventional therapies are not possible or previously have been unsuccessful. Although an effective treatment, it does have health and safety implications for veterinary personnel, owing to potential radiation exposure.

Comparison of iridium implant boost versus electron boost as a component of breast conservation treatment for early-stage breast carcinoma.

Abstract Abstract #5144 Background: Breast conservation treatment includes lumpectomy followed by definitive radiation therapy, with radiation delivered to the whole breast followed by tumor bed boost. Currently, the boost is typically delivered by electron beams, but was previously delivered by iridium-192 implants. With re-emergence of implant radiotherapy techniques in current practice, long-term outcomes of both boost techniques are important.
 Methods: From 1977 to 1983, 141 patients with early-stage breast cancer were treated with iridium-192 boost after whole breast radiation. These patients were matched 1:1 to 141 patients who received electron boost from 1980 to 1990. Most implant patients were treated before widespread electron availability. Matching criteria included age at diagnosis, final pathologic margin status, pathologic tumor stage, and pathologic nodal stage. All patients had AJCC Stage I or II invasive breast carcinoma, had surgical excision of the primary tumor, and underwent definitive radiation to at least 60 grays. Chemotherapy was administered to 30 implant patients and 41 electron patients (p=0.014), and hormonal treatment to 3 implant patients and 12 electron patients (p=0.032). These systemic treatment variations were expected due to treatment era differences. Median follow-up was 16.7 years for implant patients (range 0.7-28.5) and 12.6 years for electron patients (range 1.4-25.4) (p<0.001).
 Results: Electron boost patients were more likely to have excellent/good cosmesis versus fair/poor cosmesis than implant boost patients. At 1-year follow-up, this was significant (p=0.014). This trend continued, with odds ratio of having excellent/good cosmesis versus fair/poor cosmesis in implant patients compared to electron patients being 0.29 after 5 years (95% CI 0.027-1.38, p=0.114) and 0.24 after 10 years (95% CI 0.005-1.93, p=0.266).
 Incidence of all complications evaluated did not differ between the two groups (all p≥0.07). Incidence of breast fibrosis was 3% per year in implant patients and 4% per year in electron patients (p=0.17). In total, breast fibrosis developed in 41% of implant patients and 16% of electron patients. Incidence of infection was 14% per year in the implant group and 6% per year in the electron group (p=0.09). In total, infection developed in 7% of implant patients and 9% of electron patients. Incidence of rib fracture was 2% per year in both groups (p=0.8). Incidence of cardiopulmonary complications was 4% per year in implant patients and 3% per year in electron patients (p=0.7). Incidence of non-cardiac vascular complications was 4% per year in both groups (p=0.1). Incidence of neuropathy was 4% per year in implant patients and 1% per year in electron patients (p=0.07).
 Conclusions: Patients treated with electron boost were more likely than those treated with implant boost to have excellent/good cosmesis, though this observation did not reach statistical significance at 5- and 10-year follow-up. Complication rates did not differ significantly between the groups with long-term follow-up. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5144.

Iridium-192 implantation for T1 and T2a carcinoma of the tongue and floor of mouth: retrospective study of the results of treatment at the Royal Berkshire Hospital.

Carcinomas of the tongue and floor of mouth are relatively rare tumours, which may be treated using several modalities. We reviewed the results of iridium wire implants performed at the Royal Berkshire Hospital between 1994 and 2000. 24 patients had iridium wire implants as primary treatment for tongue and floor of mouth cancers. Four patients were treated after excision biopsy with close or involved margins. One patient was treated for a recurrence after surgery. The median age at treatment was 61 years. There were 18 men and 11 women. 21 patients had tumours of the tongue and eight of the floor of mouth. 13 had T1 tumours and 11 had T2a tumours. The median follow up was 42 months. The primary tumour was controlled in 22 of the 29 patients by the implant alone. Of the seven patients with local recurrence four were successfully salvaged with surgery. The acturarial 2 year survival rates were: overall survival 81%, disease specific survival 91%, local recurrence free survival 85% and nodal relapse free survival 76%. The recorded complication rate was low, one patient developing radionecrosis of the mandible at 7 years post implant. We believe these results show that brachytherapy remains a treatment option for patients with early tongue carcinoma with a high rate of local control and low toxicity.

Treatment of a recurrent ocular squamous cell carcinoma in a horse with Iridium-192 implantation

A 7-year-old Selle français gelding was presented for a recurrent conjunctival tumour on the left eye. A previous histologic analysis revealed a conjunctival squamous cell carcinoma. As it was the third recurrence after surgical excision in a 1½-year period, we decided to perform interstitial radiotherapy combined with the surgical excision. Two Iridium-192 pins were implanted in the subcutaneous fascia of the lower eyelid over the tumor site and were removed 3 days later. No postoperative adverse reactions were observed. Twelve months postoperatively, there were no signs of local recurrence. Surgical excision combined with Iridium-192 therapy appeared to be an effective treatment in this case.

Quality assurance in interstitial iridium-192 implants for breast cancer

We evaluate an easy and low cost method to decrea-sed errors in interstitial brachytherapy for breast cancer to avoid cutaneous sequelae: a simple X-ray after loading Ir-192 wires.Between January-1997 and January-1999, 575 interstitial implants of iridium-192 were performed in 572 women with breast tumors after conservative treatment. Implants evaluated were 556 (97%). Simple radiograph was made after loading iridium-192 wires into the needles to confirm the accurate positioning of radiactives sources.None errors were detected in 506 (91%) X-rays films. The errors consisted in: 33/556 (5.9%) implants with wrong position of source into the needle, 14/556 (2.5%) with wrong active or inactive length, and 3/556 (0.5%) with order confused in the implant.Systematic radiographs to check the loading of iridium-192 in interstitial brachytherapy for breast cancer represent an easy method as control of quality assurance. Correction of minimal errors was possible in all cases and it could determine a reduction of cutaneous sequelae.

The impact of gap duration on local control in anal canal carcinoma treated by split-course radiotherapy and concomitant chemotherapy

Purpose: To investigate the potential benefit of reducing the intersequence gap in patients with anal cancer treated with split-course chemoradiotherapy. Methods: The study group consisted of 90 patients with anal squamous carcinoma treated between 1981 and 1998, using concomitant chemotherapy (CT) and radiation (RT). Median age was 65 years (range 41–87). RT was delivered in a split course, with a median gap of 37.5 days (range 4–97) between sequences. First (pelvic) sequence delivered a median dose of 40 Gy (range 36–50.4), using AP/PA megavoltage photon beams. Boost treatment (median dose 20 Gy, range 13–26) consisted of either Iridium-192 implantation (49 patients) or external beam RT (41 patients). CT consisted of 1–2 cycles of a 5-day continuous infusion of 5-fluorouracil and bolus mitomycin C, usually administered during the first week of each RT course. Median follow-up was 76.2 months. Univariate and multivariate analyses were performed to determine the factors associated with locoregional control (LRC). Results: Five-year actuarial LRC was 72.5%. Factors associated with poorer LRC (univariate) were: age ≤ 65, male gender, and gap > 37.5 days. Number of CT cycles (1 vs. 2 or more), boost technique (brachytherapy vs. external), and T-stage were not significantly associated with LRC. In multivariate analysis, only age ( p = 0.01), and gap ( p = 0.02) retained their significance. In patients older than 65 years, LRC was 92.3% and 75% for shorter and longer gaps, respectively. In younger patients, the corresponding values for LRC were 73.7% and 50%. Conclusion: In anal cancers, split-course RT with > 50 Gy dose delivery is difficult to avoid because of acute toxicity. The present analysis suggests that shortening the gap contributes to optimizing LRC. Gaps longer than 5 weeks correlated with poorer LRC, with especially unsatisfactory results observed in younger patients.

Attitudes and treatment outcome of breast conservation therapy for stage I & II breast cancer using peroperative iridium-192 implant boost to the tumour bed.

Breast conservation therapy for early breast cancer is an established but grossly under-utilized treatment option in India for various reasons. Breast conservation therapy was offered to 200 suitable breast cancer patients between June 1993 and June 1998. Fifty-one patients (25%) opted for breast conservation and the remaining preferred mastectomy. In patients agreeing to conservation therapy, surgery was performed first along with peroperative implantation of iridium-192 to deliver a boost. Whole breast irradiation of 45 Gy was delivered 3-4 weeks after the boost. Cosmesis was assessed at the end of 6 months from completion of therapy. The main reason for refusal of breast conservation therapy was fear of recurrence in the remaining breast (60%). There were no locoregional failures in our study at a median follow up of 42 months; one patient experienced a systemic relapse. Cosmesis was good to excellent in 80% of patients. Breast conservation therapy using peroperative iridium-192 implant provides excellent locoregional disease control and cosmesis. The results of our study indicate that patient preference for mastectomy is an important reason for the under-utilization of breast conservation therapy in India.

Iridium-192 Implantation for Node-Negative Carcinoma of the Penis: The Cookridge Hospital Experience

Carcinoma of the penis is a rare tumour of the male urogenital tract, which may be treated by using several modalities. We present a single-centre experience of iridium-192 implantation. From 1980 to 1997, 31 patients with node-negative penile cancer were treated with an iridium-192 implant to the penis. A retrospective analysis of the case notes was made. Survival curves were estimated by the Kaplan–Meier method. The median age at treatment was 61.5 years. Twenty-seven patients presented with Jackson Stage I disease and four with Stage II disease. They were treated with an iridium-192 implant to the penis after biopsy (n = 25) or tumour excision (n = 6), with a ‘watch and wait’ policy for inguinal nodes. Four patients did not complete their implantation treatment and had additional external beam radiotherapy. The median follow-up was 61.5 months. The primary tumour was controlled in 25 of 31 patients (80.6%) by the implant. In all but one patient with primary relapse, surgical salvage was successful, although one patient died of septicaemia 3 weeks after surgery. Nodes were the initial site of relapse in seven patients, with associated relapse in the primary in one. The actuarial 5-year survival rates were as follows: overall survival 69.0%, disease-specific survival (corrected for intercurrent deaths) 85.4%, relapse-free survival 57.8% and local relapse-free survival 75.6%. One patient underwent amputation for necrosis and 11 of 25 patients (44%) who achieved penile conservation required dilatation for urethral stenosis.In conclusion, iridium-192 implantation is a successful method of treatment for penile cancer in terms of local control, with preservation of function in the majority of patients. In those who do relapse at the primary site, surgical salvage is usually possible.

Iridium-192 Implantation for Node-Negative Carcinoma of the Penis: The Cookridge Hospital Experience

Iridium-192 Implantation for Node-Negative Carcinoma of the Penis: The Cookridge Hospital Experience

Interstitial Iridium-192 Implantation for Recurrent and/or Locally Advanced Head and Neck Cancer

We report our experience with the use of interstitial iridium-192 implantation in the management of patients with recurrent and locally advanced squamous cell carcinoma of the head and neck. Between June 1992 and July 1998 this technique was employed in the management of two groups of patients: (1) a primary group, comprising 42 patients who had presented for the first time with advanced head and neck disease, and had therefore not undergone any previous treatment; and (2) a salvage group of 16 patients with recurrent disease previously treated with external beam radiotherapy (four received therapy to the neck, one to the cheek, eight to the tongue and three to the floor of the mouth). The follow-up in each group was short, ranging from 3 to 56 months. The overall response in the primary group was 38/42 (90%). A complete response was achieved in 35/42 (83%). In the salvage group, the overall response was 13/16 (81%); 4/16 (25%) showed a complete response and 9/16 (56%) a partial response. The estimated percentage surviving at 1 year for patients with primary disease is 70% (95% confidence interval (CI) 54–86). For those receiving salvage therapy the estimated percentage surviving at 1 year is 45% (95% CI 19–71).

Interstitial iridium-192 implantation combined with external radiotherapy in anal cancer: Ten years experience

Purpose : To report our experience in the use of interstitial iridium-192 implantation combined with external radiotherapy in anal cancer. Methods and Matarials : From 1984 to 1994, 79 patients with anal cancer were treated with radical intent using radiotherapy (plus chemotherapy) at Beatson Oncology Centere, Glasgow, Scotland. The mean and median age at presetantion were 68 and 70 years, respectively (range 34–85) with a male-to-female ratio of 0.39. The histologic distribution was as follows: 48 squamous, 16 basaloid, 14 adenocarcinoma, and 1 basal cell carcinoma. The T stages were: 8 T1, 40 T2, 26 T3, and 5 T4 lesions. Twelve (15%) patients had nodal involvement at presentation. All patients underwent interstitial implantation using iridium-192 as part of the initial treatment. Seventy-six patients were treated with external radiotherapy followed by implant with a mean delay of 37 days after the end of radiotherapy. Twelve patients also received chemotherapy with 5-fluorouracil and mitomycin-C concurrently with external radiotherapy. Follow-up ranged from 6 to 123 months, and with median of 37 months. Results : Seventy-nine patients were analyzed to assess local control, survival, and complications. A complete response rate of 91% (72 of 79) was achieved after planned radiation treatment. At the end of external radiotherapy, 29% (22 of 76) had achieved complete response, 58% (7 of 12) with chemotherapy and 23% (15 of 64) without it. Local control was achieved in 62 of 79 (78%) patients and 8 of 17 (47%) local failures were salvage by abdominoperineal resection. Five patients developed inguinal node failure; four of these were salvaged. Overall, 10% of all patients developed distant metastasis as the first site of failure and 25% failed at any site after salvage therapy. Time to unsalvageable relapse was significantly different on comparing T stage ( p = 0.005) and histology ( p = 0.029) of tumor. Major requiring surgical intervention were seen in six (7.5%) patients. Anal function preservation with local control was possible in 56 of 79 (71%) patients. Conclusion : We report excellent results with radiotherapy in T1 and T2 lesions. The role of chemoradiotherapy as radical treatment of anal cancer should be defined in the context of locally andvanced tumors.

2036 Interstitial iridium-192 implantation combined with external radiotherapy in anal cancer: Ten years experience

2036 Interstitial iridium-192 implantation combined with external radiotherapy in anal cancer: Ten years experience

Interstitial hyperthermia and iridium-192 treatment alone vs. interstitial iridium-192 treatment/hyperthermia and low dose cisplatinum infusion in the treatment of locally advanced head and neck malignancies

Purpose : To determine whether the addition of low dose platinum infusional chemotherapy adds to the effectiveness of interstitial hyperthermia/iridium-192 management of locally advanced head and neck malignancies. Methods and Materials : From 1987 to 1993, 36 patients with locally advanced head and neck malignancies were treated locally with interstitial hyperthermia and iridium-192 as part of all of their management. Twenty-two of the above-mentioned patients also received low dose infusional cisplatinum chemotherapy at 20 mg/M 2 per day during the time of the implant. No patient received greater than 100 mg/M 2 total dose. Implant times ranges from 38.5 to 134h and total doses delivered with the radiation implants ranges from 15 to 39.9 Gy. Average implant volume was 50 cc. Twenty-three patients received external beam irradiation supplementation in a dose range from 25.2 to 64 Gy. Results : Median follow-up for the entire group was 8, months with 7 months for the chemotherapy group vs. 12 months for the no-chemotherapy group. Freedom from relapse rates for the chemotherapy group vs. the no-chemotherapy group were 70% at 41 months vs. 63% at 60 months, p = not significant ( p = NS). Overall survival by Life Table Analysis was 28% for the chemotherapy group at 41 months vs. 31% for the no-chemotherapy group at 60 months ( p = NS). Complete response (CR) rates were 93% for the chemotherapy group vs. 86% for the no-chemotherapy group. Seven patients in the chemotherapy group had recurrent disease and four patients in the no-chemotherapy group were being treated for recurrent disease. Complication rates were similar in both group, with two patients in the chemotherapy arm requiring hyperbaric oxygen treatments and one patient in the no-chemotherapy arm requiring hyperbaric oxygen treatments (for soft tissue necrosis). Conclusions : It appears that low dose platinum infusional chemotherapy can be added safely to patients receiving interstitial iridium-192 implants along with interstitial hyperthermia for head and neck malignancies. Although there appears to be a trend toward better freedom from relapse by adding chemotherapy, a larger trial and longer follow-up will be necessary to prove statistical significance. Further research in these areas is recommended in the form of a randomized prospective study.

Perioperative implantation of iridium-192 as the boost technique for stage I and II breast cancer: results of a 10-year study of 655 patients.

To assess the efficacy of perioperative implantation of iridium-192 for stage I and II breast cancer. The authors retrospectively reviewed findings from 655 patients with stage I and II cancer treated with conservative surgery and Ir-192 implantation between 1982 and 1992. Hollow plastic tubes were placed in the tumor bed as a single- or double-plane implant at lumpectomy. Ribbons with Ir-192 seeds were inserted into the tubes 4-6 hours later. The Ir-192 was left in place for approximately 50 hours. External-beam irradiation was given to the whole breast 10-14 days later. Follow-up ranged from 2 to 146 months. The local control at 10 years for stage I and II disease was 93% and 87%, respectively. The 10-year actuarial survival rate was 92% +/- 1 for stage I disease and 72% +/- 4 for stage II disease. The rate of survival with no evidence of disease for stage I and II disease combined was 82% +/- 1 at 5 years and 75% +/- 3 at 10 years. Perioperative implantation produced excellent local control equal to that with electron-beam therapy.

Radiotherapy of Stage I and II carcinomas of the mobile tongue and/or floor of the mouth

From 1977 to 1990, 94 evaluable patients were treated with iridium-192 implantation in the Centre Claudius Regaud for a Stage I (52 patients) or a Stage 11(42 patients) squamous cell carcinoma of the mobile tongue and/or the floor of the mouth. Interstitial brachytherapy was associated with external irradiation in 68 patients (group 1; mean dose, 48 Gy for external irradiation, 26 Gy for brachytherapy) or was exclusive in 26 patients (group 2; mean dose, 66 Gy). The mean follow-up was 44 months. Eleven acute complications were noted during or immediately after the implant (1 lethal myocardial infarction, 6 hematomas of the tongue which spontaneously resolved, 3 local sepsis). The mean duration of the mucositis was 9 weeks (from 4 to 20 weeks). Ten patients (17%) experienced a late complication (8 in group 1, 2 in group 2): 3 bone necroses requiring hemimandibulectomy (1 post-operative death), 1 tongue necrosis treated by a transoral mucosal excision, 6 bone expositions which recovered after medical treatment. Local control rates for T1 and T2 tumors were 75% (39/52) and 51% (21/41), respectively. Sixteen patients (17%) presented a nodal relapse which was associated in 6 cases with a concomitant local relapse. The local control rate of T1 tumors was 64% (23/36) in group 1 versus 100% (16/16) in group 2 ( p < 0.01). For T2 tumors, these figures were 45% ( 14 31 ) and 70% ( 7 10 ), respectively ( p > 0.3). The influence of 13 parameters on the local control was studied in analysis. In the one model analysis, a cox regression tumor size was significantly predictive of actuarial local recurrence ( p < 0.001). The therapeutic modality was close to the significance level ( p = 0.06). The other variables (age, sex, anatomic site, macroscopic aspect of the tumor, pathologic differentiation, technique of implant, intersource spacing and dose rate) had no significant influence. This retrospective study suggests that exclusive brachytherapy is the best modality in terms of local control and functional results.

Influence of dose-rate and dose per fraction on clinical outcome of breast cancer treated by external beam irradiation plus iridium-192 implants: Analysis of 289 cases

Purpose : To study the influence of Iridium 192 implant dose-rate and dose per fraction of external irradiation on clinical outcome, the results in 289 patients with early breast cancer were analyzed retrospectively. Methods and Materials : From 1980 to 1990, 118 T, and 171 T 2 lesions of breast were treated definitively by radiotherapy, following conservative surgery. External irradiation dose of 45 Gy was delivered either with 2.5 Gy or 1.8 Gy per fraction to the entire target volume, plus boost to the primary tumor. Boost dose of 15 to 30 Gy was given to the primary tumor either with iridium-192 implants or electrons. The implant dose-rate varied between 20 cGy/hr to 160 cGy/hr. Result : The minimum follow-up was of 12 months and maximum of 11 years (median: 56 months). Out of 273 tumors boosted with implants, the 270 patients were divided into five groups according to dose-rate as, groups 1 (20–29 cGy/hr, n = 17), group 2 (30–49 cGy/hr, n = 144), group 3 (50–69 cGy/hr, n = 69), group 4 (70–99 cGy/hr, n = 27) and group 5 (100–160 cGy/hr, n = 13). The local failure rate was significantly increased in the group of patients treated with implant dose-rate < 30 cGy/hr ( p < 0.05). While the incidence of late normal tissue complications and poor cosmetic outcome was significantly higher in the group of patients treated with implant dose-rate > 100 cGy/hr ( p < 0.05). Conclusion : The present analysis indicate that the implant dose-rate should be maintained between 30–70 cGy/hr to maximize local control and reduce the late normal tissue injury. Also the increase in dose per fraction of external irradiation white not influencing local control rate was crucial for incidence of late complications and cosmetic outcome.

Surgical Resection Followed by Brachytherapy for Malignancies Involving the Base of the Skull

Between January 1990 and July 1991, 14 patients were referred to the University of Pittsburgh for cranial base surgery following diagnosis of end-stage primary or recurrent neoplasms of the base of the skull. The treatment approach consisted of resection of the tumor along with placement of afterloading nylon catheters for iridium-192 implantation in areas where remaining tumor was believed to be present. A median dose of 3600 cGy (range, 2500 to 6000) was delivered to the tumor bed 1 to 14 days following surgery. with a median follow-up of 9 months, three patients remain alive without disease at 18, 19 and 36 months, and two are alive with disease at 5 and 31 months. Six patients died of disease at 3, 3, 3, 7, 16, and 17 months and three patients died of intercurrent disease at 1, 5, and 11 months. Cranial base surgery followed by brachytherapy appears to be a viable alternative in patients who otherwise have exhausted other methods of treatment. Careful attention to preoperative evaluation, surgery, and postoperative recovery should be given in order to prevent major complications.

Temporary iridium-192 implant in the management of carcinoma of the prostate

The controversy about the treatment of carcinoma of the prostate has increased in the last decade, with most urologists favoring radical prostatectomy rather than primary irradiation. Several reports of persistent tumors in 50% to 90% of patients after external irradiation and permanent iodine-125 implantation of the prostate have been disturbing. From July 1977 to December 1985, 200 patients with adenocarcinoma of the prostate were treated by combining bilateral pelvic lymphadenectomy and temporary interstitial iridium-192 implantation of the prostate, followed by external irradiation. Seventy-four (36%) patients underwent biopsies of the prostate 4 months to 2 years after completion of the irradiation. Only 12 (16%) patients had persistent tumors. Complications were minimized subsequently by dose modifications.

Factors influencing cosmetic outcome and complication risk after conservative surgery and radiotherapy for early-stage breast carcinoma.

The study was undertaken to assess the relationship among cosmesis and complications to factors related to disease presentation, surgical and radiotherapeutic technique, and adjuvant systemic therapy in conservative treatment for early-stage breast carcinoma. Between 1982 and 1988, 234 women with stage I/II breast carcinoma were treated with conservation therapy by a highly standardized protocol of limited excision and radiotherapy. Radiation boost and/or reexcision were determined by careful quantitation of the normal tissue margin around the primary tumor. Boosts to 20 Gy were preferentially performed with interstitial iridium-192 (192Ir) implants. Axillary node dissections were performed in all patients aged less than 70 years. Adjuvant therapy consisted of cyclophosphamide, methotrexate, (doxorubicin), and fluorouracil (CM[A]F) six to eight times for node-positive premenopausal women and tamoxifen for node-positive or -negative postmenopausal women. Median follow-up was 50 months (range, 20 to 80 months). Cosmesis was graded by defined criteria, and complications were individually scored. Factors found to impact cosmesis adversely were palpable tumors (P = .046), volume of breast tissue resected (P = .027), reexcision of the tumor bed (P = .01), number of radiation fields (P = .03), radiation boost (P = .01), and chest wall separation (P = .01). There was a trend toward worse cosmesis (P = .062) in patients receiving tamoxifen. Cosmesis was not adversely affected by interstitial implant in spite of a higher prescribed dose. Factors influencing complication risk were axillary node dissection (P = .02), number of lymph nodes harvested (P = .05), and chemotherapy (P = .03). Optimal cosmesis and minimal complication risk require careful attention to the technical details of surgery and radiotherapy. The impact of systemic therapies needs to be more thoroughly examined.

Conservative management of prostate cancer

This report relates the experiences of several urologic centers in treating stages A, B, and C prostate cancer. The goal of these various treatments is to improve the quality of the treatment while preserving urethral, bladder, bowel, erectile function, and bone narrow. The procedures discussed include a review of techniques used as Stanford University by Malcolm Bagshaw, M. D., to improve external beam irradiation; iridium-192 implants for stage C carcinoma and permanent implants for stages A and B with iodine-125 and palladium-103 using trans-rectal ultrasound guidance by Drs. Bagshaw and Brosman; the role of laser therapy by Dr. Lennart Anderson; the results of histologic sectioning of radical prostatectomy specimens in determining candidates for nerve-sparing procedures by Dr. Fuad Freiha; and data supporting the use of neoadjuvant androgen ablation therapy and radical prostatectomy for patients with stage C disease by Dr. William Fair. The treatment programs for patients with stage C disease emphasize the need for multimodal therapy, while localized disease is still thought to be manageable by monotherapy. Complication rates for all forms of therapy have been decreasing, and the ability to offer more and safer options to patients with this disease should improve both quality of care and quality of life.