Permanent Prostate Research Articles

Long-term outcomes of a prospective randomized trial of 131Cs/125I permanent prostate brachytherapy

PurposeIodine-125 (125I) is the most commonly used isotope for prostate brachytherapy (BT). Cesium-131 (131Cs) has a higher dose rate and shorter dose delivery time resulting in decreased duration of acute urinary morbidity. Long-term data suggest excellent oncologic outcomes; it is not known how outcomes compare. A prospective randomized trial comparing the two isotopes was initiated. Materials and MethodsPatients with low- or intermediate-risk disease were treated with a BT in a single outpatient facility. Prescription dose was 144 Gy for 125I and 115 Gy for 131Cs. Androgen deprivation or supplemental EBRT was not allowed. The primary study objective was comparison of the mean EPIC Urinary Domain Score. Secondary objective was biochemical relapse-free survival (BRFS) comparison. Time-to-event for all outcomes of interest was measured from implant date. ResultsOne hundred forty men were enrolled; 81.4% were low-risk and 18.6% were intermediate-risk. The median followup was 97 months. Urinary and sexual health-related quality of life did not differ between isotopes at any recorded time point. At 2 months after implantation, bowel health-related quality of life was worse with 125I; however, this difference was lost at subsequent time points. The 9-year BRFS was 87.2% and 84.0% for the 125I and 131Cs group, respectively (p = 0.897). There was no statistically significant difference in BRFS based on initial T stage, PSA, or Gleason score. ConclusionsShort- and long-term urinary, sexual, and bowel quality of life, as well as long-term biochemical control were comparable between 125I and 131Cs. This report therefore supports the continued use of 131Cs as an effective and comparable alternative isotope.

Relationship between radiation doses and erectile function deterioration in patients with localized prostate cancer treated with permanent prostate brachytherapy.

To investigate the relationship between radiation doses in prostate brachytherapy and deterioration of erectile function in patients with localized prostate cancer. A longitudinal survey study was carried out among 261 prostate cancer patients who received prostate brachytherapy. A total of 48 patients were potent at baseline and they did not receive any supplemental therapy preoperatively. Dosimetry parameters of the whole prostate gland, prostate apex, urethra and rectum were collected using the VariSeed 8.0 treatment planning system (Varian Medical Systems, Palo Alto, CA, USA). We carried out a logistic regression analysis to clarify the relationship between radiation doses and erectile function deterioration, which was assessed using the International Index of Erectile Function-15 questionnaire. The median patient age was 66years (range 53-70years) with a median follow-up time of 44months (36-71months). The mean total International Index of Erectile Function-15 score decreased from 49.9 at baseline to 34.7 after 12months (P<0.001), but gradually plateaued within 36months. Erectile function deterioration was noted in 32 (66.7%) patients 36months after prostate brachytherapy. In an analysis of risk factors for erectile function deterioration after prostate brachytherapy, age ≥70years (P=0.029), prostate V100 ≥95% (P=0.024), apex V100 ≥95% (P=0.024), apex V150 ≥70% (P=0.009) and apex D90 ≥150Gy (P=0.011) correlated with erectile function deterioration. A multivariate analysis identified an age of ≥70years (odds ratio 7.91, P=0.024) and apex V150 ≥70% (odds ratio 7.75, P=0.007) as independent risk factors for erectile function deterioration after prostate brachytherapy. An excessive radiation dose, particularly to the prostate apex area, and an advanced age might have a negative impact on the preservation of potency after prostate brachytherapy.

Time to achieve a prostate-specific antigen nadir of ≤0.2 ng/mL and related factors after permanent prostate brachytherapy

PurposeThe purpose of this study was to identify the time to achieve a prostate-specific antigen (PSA) nadir of ≤0.2 ng/mL and the related factors to achieve this goal. Materials and MethodsWe retrospectively reviewed 2218 Japanese prostate cancer patients who received 125I brachytherapy with or without external beam radiotherapy between 2003 and 2013 at one institution. Among them, patients followed up for ≥72 months and without luteinizing hormone–releasing hormone (LH-RH) agonist/antagonist were included (total of 1089 patients). The time to a PSA nadir of ≤0.2 ng/mL (months) was defined as the time between the date of implantation and the first time the lowest PSA value reached ≤0.2 ng/mL. Biochemical recurrence (BCR) was determined using the Phoenix definition. Multivariate linear regression analysis was performed to detect the related factors to achieve this nadir. ResultsWe assigned 409, 592, and 88 patients to the low-, intermediate-risk, and high-risk groups, respectively. The median followup time was 9.5 years. The median time to achieve a PSA nadir of ≤0.2 ng/mL was 44.0 (95% confidence interval: 42.3–45.7) months. The percentage of patients that achieved the nadir was 89.1%. BCR was noted in 107 (9.8%) patients. In the multivariate analysis of patients without BCR, younger age, larger prostate volume at implantation, higher initial PSA level, and monotherapy were significantly associated with longer time to achieve the PSA nadir. ConclusionThe median time to achieve a PSA nadir of ≤0.2 ng/mL was 44.0 months. Some patients, however, may require a lengthy period of time to do so.

A deep learning method for real-time intraoperative US image segmentation in prostate brachytherapy.

This paper addresses the detection of the clinical target volume (CTV) in transrectal ultrasound (TRUS) image-guided intraoperative for permanent prostate brachytherapy. Developing a robust and automatic method to detect the CTV on intraoperative TRUS images is clinically important to have faster and reproducible interventions that can benefit both the clinical workflow and patient health. We present a multi-task deep learning method for an automatic prostate CTV boundary detection in intraoperative TRUS images by leveraging both the low-level and high-level (prior shape) information. Our method includes a channel-wise feature calibration strategy for low-level feature extraction and learning-based prior knowledge modeling for prostate CTV shape reconstruction. It employs CTV shape reconstruction from automatically sampled boundary surface coordinates (pseudo-landmarks) to detect the low-contrast and noisy regions across the prostate boundary, while being less biased from shadowing, inherent speckles, and artifact signals from the needle and implanted radioactive seeds. The proposed method was evaluated on a clinical database of 145 patients who underwent permanent prostate brachytherapy under TRUS guidance. Our method achieved a mean accuracy of [Formula: see text] and a mean surface distance error of [Formula: see text]. Extensive ablation and comparison studies show that our method outperformed previous deep learning-based methods by more than 7% for the Dice similarity coefficient and 6.9 mm reduced 3D Hausdorff distance error. Our study demonstrates the potential of shape model-based deep learning methods for an efficient and accurate CTV segmentation in an ultrasound-guided intervention. Moreover, learning both low-level features and prior shape knowledge with channel-wise feature calibration can significantly improve the performance of deep learning methods in medical image segmentation.

Prostate brachytherapy intraoperative dosimetry using a combination of radiographic seed localization with a C-arm and deformed ultrasound prostate contours

PurposeThe purpose of the study was to assess the feasibility of performing intraoperative dosimetry for permanent prostate brachytherapy by combining transrectal ultrasound (TRUS) and fluoroscopy/cone beam CT [CBCT] images and accounting for the effect of prostate deformation. Methods and Materials13 patients underwent TRUS and multiview two-dimensional fluoroscopic imaging partway through the implant, as well as repeat fluoroscopic imaging with the TRUS probe inserted and retracted, and finally three-dimensional CBCT imaging at the end of the implant. The locations of all the implanted seeds were obtained from the fluoroscopy/CBCT images and were registered to prostate contours delineated on the TRUS images based on a common subset of seeds identified on both image sets. Prostate contours were also deformed, using a finite-element model, to take into account the effect of the TRUS probe pressure. Prostate dosimetry parameters were obtained for fluoroscopic and CBCT-dosimetry approaches and compared with the standard-of-care Day-0 postimplant CT dosimetry. ResultsHigh linear correlation (R2 > 0.8) was observed in the measured values of prostate D90%, V100%, and V150%, between the two intraoperative dosimetry approaches. The prostate D90% and V100% obtained from intraoperative dosimetry methods were in agreement with the postimplant CT dosimetry. Only the prostate V150% was on average 4.1% (p-value <0.05) higher in the CBCT-dosimetry approach and 6.7% (p-value <0.05) higher in postimplant CT dosimetry compared with the fluoroscopic dosimetry approach. Deformation of the prostate by the ultrasound probe appeared to have a minimal effect on prostate dosimetry. ConclusionsThe results of this study have shown that both of the proposed dosimetric evaluation approaches have potential for real-time intraoperative dosimetry.

109 - Response of leukocyte to iodine-125 permanent prostate seed implantation predict PSA failure in patients with localized prostate cancer

109 - Response of leukocyte to iodine-125 permanent prostate seed implantation predict PSA failure in patients with localized prostate cancer

Isotope selection and PSA failure in prostate seed implant: Experience with CS-131 in a community hospital system.

375 Background: A recent large single institutional study reported excellent long-term biochemical control and survival for Cs-131 prostate implant. This isotope has short half-life (9.7 days) with clinical advantages including shorter duration of symptoms. We previously showed Cs-131 dosimetry to be quantitatively similar to I-125 with improved homogeneity (mean percent V150 36% for I-125 versus 27% for Cs-131 (p &lt; 0.0001). Our objective was to evaluate PSA failure rates and dosimetric outcomes in a multi-institutional community based setting. Methods: Within an IRB approved retrospective study, we compared outcomes for three groups of permanent prostate implant patients treated at Ascension Macomb Oakland, Ascension Saint John, and Ascension Providence Rochester Hospitals over a 10 year time interval. The comparison groups included isotopes Cs-131 (n = 66; t1/2 9.7 days), I-125 (n = 60; t1/2 60 days), and Pd-103 (n = 60; t1/2 17 days). Kaplan Meier estimates of PSA failure used the nadir plus 2 (Phoenix) definition. Results: Standard permanent implant doses employed were 145 Gy for I-125 monotherapy or 109 Gy for combination therapy. The dose for Cs-131 was 115 Gy for monotherapy and 85 Gy for combination therapy. For Pd-103, the doses employed were 125 Gy and 90 Gy for mono- and combination therapy, respectively. Median age at diagnosis was Cs-131; 69 (range 49-80), I-125; 71 (49-78), and Pd-103; 70 (60-82). Mean pretreatment PSA values were Cs-131 5.73 ng/ml, I-125 6.62 ng/ml, and for Pd-103 8.87 ng/ml. Median PSA follow up was 30 months and the median PSA value at 60 months was 0.11 ng/ml. There was excellent PSA control for all three groups of cases (p = NS), however with fewer failures using Cs-131. Conclusions: Permanent interstitial brachytherapy continues to be an attractive option for treatment early stage prostate cancer. Only a few large single institutional studies have examined PSA failure rates or dosimetric aspects of shorter half-life Cs-131 seed implants. This series confirms wide applicability of Cs-131 permanent prostate seed implant in the community hospital setting.

Toxicity in patients treated with permanent prostate brachytherapy using intraoperatively built custom-linked seeds versus loose seeds.

PurposeLow-dose-rate brachytherapy (BT) with permanent iodine-125 radioactive seeds is a highly effective treatment option for low- and favorable intermediate-risk prostate cancer. However, optimal implantation is not always achieved due to edema or seeds loss. One way to improve seed placement is the use of stranded seeds called “intraoperatively built custom-linked seeds (IBCLS)” in an opposition to loose seeds (LS). To date, there are few data comparing toxicity rates between these two techniques. The aim of this study was to compare dosimetric parameters and toxicity rates at 2 years between both procedures in a matched-paired population.Material and methodsPatients were considered for BT according to European guidelines. Among 548 patients treated at our institution, 105 patients in the loose seeds cohort were individually matched to 105 patients in the IBCLS group according to age, prostate volume, pre-operative international prostate symptom score (IPSS), clinical stage, and Gleason score. Erectile function was scored using the five-item international index of erectile function (IIEF-5) score. A multivariable linear mixed-effects model was applied to examine the association between total and individual scores (repeated measures) and covariates.ResultsOverall, 61 (29%) patients presented with a favorable intermediate-risk prostate cancer. There were no significant changes in IPSS over time (p = 0.57). During follow-up, the IIEF-5 was similar in the two groups, except at one month, where it was lower in the IBCLS group (10.9 vs. 6.9, p = 0.029). Also, there was no difference in grade ≥ 2 rectal toxicity. At 1 month, D90Gy, V150%, and V100% were higher in the LS group compared to the IBCLS group.ConclusionsLow-dose-rate prostate brachytherapy using IBCLS is a safe technique, with comparable toxicity profiles at 2 years compared to LS brachytherapy.

The development of high quality training program for real tine trans rectal ultrasound low dose rate (LDR) prostate brachytherapy

Although ultrasound forms a critical component of transrectal ultrasound image guided brachytherapy for prostate cancer, ultrasound training is not required as part of radiation oncology training programs, nor does any objective competency measure exist to independently assess clinical performance [ [1] Davis B.J. et al. American Brachytherapy Society consensus guidelines for transrectal ultrasound-guided permanent prostate brachytherapy. Brachytherapy. 2012; Abstract Full Text Full Text PDF Scopus (360) Google Scholar ]. Physical simulation training and objective clinical competency testing can provide a structured approach to training [ [2] McGaghie W.C. et al. A critical review of simulation-based medical education research: 2003–2009. Med. Educ. 2010; Google Scholar ], but only if suitably challenging training devices are available which replicate the complex anatomy of the male pelvis and prostate. This study describes the iterative process in the development of a range of training devices which simulate both the anthropomorphic and sonographic characteristics of the different presentations of patient specific prostate cancer. The design of the clinical features involved selection of patient cases and then rapid prototyping the different anatomical features and inverse casting these features in tissue mimicking materials (TMM). Novel TMMs were developed that had the sonographic appearance of the prostate and overlying tissues, as well as having the relevant mechanical compliance to give the training devices required haptic feedback. These devices will be used in the development of a training programme and will complement the learner’s development of the specific skills required for the procedure. The use of training strategies such as gamification allows trainees to track their own performance over time as well as relative to their peers; thereby, providing a structured and competitive approach to learning. The 3D prototyped clinical features in these devices provided a more clinically-relevant representation of the procedure, thus providing a more efficacious training opportunity.

188 DNA Repair Genes Polymorphisms, Tumour Control and Treatment Toxicity in Prostate Cancer Patients Treated with Permanent Implant Prostate Brachytherapy

188 DNA Repair Genes Polymorphisms, Tumour Control and Treatment Toxicity in Prostate Cancer Patients Treated with Permanent Implant Prostate Brachytherapy

Salvage High Dose Rate Brachytherapy for Recurrent Prostate Cancer after Definitive Radiation

PURPOSE Salvage high-dose-rate brachytherapy (sHDRBT) for locally recurrent prostate cancer after definitive radiation is associated with biochemical control in approximately half of patients at 3-5 years. Given potential toxicity, patient selection is critical. We present our institutional experience with sHDRBT and validate a recursive partitioning machines model for biochemical control. MATERIALS AND METHODS We performed a retrospective analysis of 129 patients who underwent whole-gland sHDRBT between 1998-2016. We evaluated clinical factors associated with biochemical control as well as toxicity. RESULTS At diagnosis the median PSA was 7.77 ng/mL. Majority of patients had T1-2 (73%) and Gleason 6-7 (82%) disease. 71% received external beam RT alone, while 22% received permanent prostate implants. The median disease free interval (DFI) was 56 months, and median pre-salvage PSA was 4.95ng/mL. At sHDRBT, 46% had T3 disease and 51% had Gleason 8-10 disease. At a median of 68 months following sHDRBT, 3 and 5-year disease free survival were 85% (95% CI 79-91%) and 71% (95% CI 62-79%), respectively. Median PSA nadir was 0.18 ng/mL, achieved a median of 10 months after sHDRBT. Patients with ≥35%+ cores and a DFI <4.1 years had worse biochemical control (19% vs. 50%, p = 0.02). Local failure (with or without regional/distant failure) was seen in 11% of patients (14/129). 14 patients (11%) developed acute urinary obstruction requiring Foley placement and 19 patients (15%) developed strictures requiring dilation. CONCLUSIONS sHDRBT is a reasonable option for patients with locally recurrent prostate cancer following definitive RT. Those with <35%+ cores or an initial DFI of ≥4.1 years may be more likely to achieve long-term disease control following sHDRBT.

Patient-reported outcomes after open radical prostatectomy, laparoscopic radical prostatectomy and permanent prostate brachytherapy.

To assess patient-reported outcomes after open radical prostatectomy, laparoscopic radical prostatectomy and permanent prostate brachytherapy. patient-reported outcomes were evaluated using Expanded Prostate Cancer Index Composite scores at baseline and 1, 3, 6, 12 and 36months after treatment, respectively, using differences from baseline scores. Urinary function was the same in the three groups at baseline, but worse after surgery than after permanent prostate brachytherapy until 12months, and similar after open radical prostatectomy and permanent prostate brachytherapy and better than after laparoscopic radical prostatectomy at 36months. Urinary bother was significantly worse at 1month after surgery, but better after open radical prostatectomy than after permanent prostate brachytherapy and laparoscopic radical prostatectomy at 3months, after which symptoms improved gradually in all groups. Obstructive/irritative symptoms were worse after permanent prostate brachytherapy than after open radical prostatectomy at 36months, and worse after laparoscopic radical prostatectomy until 6months. Urinary incontinence was worse after surgery, particularly after 1 month. This symptom returned to the baseline level at 12months after open radical prostatectomy, but recovery after laparoscopic radical prostatectomy was slower. Bowel function after permanent prostate brachytherapy was significantly worse than after surgery at 1 month and this continued until 6months. Bowel bother was slightly worse at 3 and 6months after permanent prostate brachytherapy compared to these time points after surgery. Urinary function and bother were worst after laparoscopic radical prostatectomy, especially in the early postoperative phase, whereas urinary obstructive/irritative symptom, bowel function and bother were worse after permanent prostate brachytherapy. These findings are useful and informative for the treatment of patients with prostate cancer.

The association of intraprostatic calcifications and dosimetry parameters with biochemical control after permanent prostate implant

PurposeThe objective of this study was to evaluate the impact of intraprostatic calcifications (IC) on long-term tumor control in patients treated with permanent implant prostate brachytherapy (PIPB). Materials and MethodsData from 609 I-125 patients treated with PIPB were retrospectively reviewed. The presence of IC was determined by reviewing postimplant CT images. Doses delivered were determined using the Monte Carlo (model-based) calculations and the TG43 approach. Biochemical relapses at 7 and 10 years were determined according to Phoenix definition. Long-term biochemical relapse-free survival (bRFS) was determined using Kaplan–Meier estimates with log rank test. Cox proportional hazard models were used for analysis of predictor factors of biochemical recurrence. ResultsIC were observed for 11.1% of patients. Clinical stage, PSA, Gleason score, D'Amico risk group, and ADT use were comparable between IC and no IC groups. The 7- and 10-year bRFS for the entire cohort were 94.1% and 90.6%, respectively. The bRFS at 7 years was 90.5% (with IC) vs. 94.5% (without IC) (p = 0.198); the corresponding values at 10 years were 78.8% vs. 91.8% (p = 0.046). On Cox model, only prostatic calcifications were a significant risk factor for biochemical relapse (HR: 2.30, IC 95%: 1.05–5.00, p = 0.037; and HR: 3.94; IC 95%: 1.00–15.38; p = 0.049 for univariate and multivariate analysis, respectively). ConclusionThe presence of IC in patients treated with PIPB decreases V100 and D90 for postimplant Monte Carlo dosimetry (compared with TG43); correspondingly, IC are associated with a lower 10-y bRFS. Model-based dose calculations are critical to evaluate potential cold spots due to calcifications.

Deformable registration of x ray and MRI for postimplant dosimetry in low dose rate prostate brachytherapy.

Dosimetric assessment following permanent prostate brachytherapy (PPB) commonly involves seed localization using CT and prostate delineation using coregistered MRI. However, pelvic CT leads to additional imaging dose and requires significant resources to acquire and process both CT and MRI. In this study, we propose an automatic postimplant dosimetry approach that retains MRI for soft-tissue contouring, but eliminates the need for CT and reduces imaging dose while overcoming the inconsistent appearance of seeds on MRI with three projection x rays acquired using a mobile C-arm. Implanted seeds are reconstructed using x rays by solving a combinatorial optimization problem and deformably registered to MRI. Candidate seeds are located in MR images using local hypointensity identification. X ray-based seeds are registered to these candidate seeds in three steps: (a) rigid registration using a stochastic evolutionary optimizer, (b) affine registration using an iterative closest point optimizer, and (c) deformable registration using a local feature point search and nonrigid coherent point drift. The algorithm was evaluated using 20 PPB patients with x rays acquired immediately postimplant and T2-weighted MR images acquired the next day at 1.5T with mean 0.8×0.8×3.0mm voxel dimensions. Target registration error (TRE) was computed based on the distance from algorithm results to manually identified seed locations using coregistered CT acquired the same day as the MRI. Dosimetric accuracy was determined by comparing prostate D90 determined using the algorithm and the ground truth CT-based seed locations. The mean±standard deviation TREs across 20 patients including 1774 seeds were 2.23±0.52mm (rigid), 1.99±0.49mm (rigid+affine), and 1.76±0.43mm (rigid+affine+deformable). The corresponding mean±standard deviation D90 errors were 5.8±4.8%, 3.4±3.4%, and 2.3±1.9%, respectively. The mean computation time of the registration algorithm was 6.1s. The registration algorithm accuracy and computation time are sufficient for clinical PPB postimplant dosimetry.

Interobserver variability of 3.0-tesla and 1.5-tesla magnetic resonance imaging/computed tomography fusion image-based post-implant dosimetry of prostate brachytherapy.

This study aimed to compare the interobserver variabilities in magnetic resonance imaging (MRI)/computed tomography (CT) fusion image–based post-implant dosimetry of permanent prostate brachytherapy (PPB) between 1.5-T and 3.0-T MRI. The study included 60 patients. Of these patients, 30 underwent 1.5-T MRI and CT 30 days after seed implantation (1.5-T group), and 30 underwent 3.0-T MRI and CT 30 days after seed implantation (3.0-T group). All patients received PPB alone. Two radiation oncologists performed MRI/CT fusion image–based post-implant dosimetry, and the interobserver variabilities of dose–volume histogram (DVH) parameters [dose (Gy) received by 90% of the prostate volume (prostate D90)], percentage of the prostate volume receiving at least the full prescribed dose (prostate V100), percentage of the prostate volume receiving at least 150% of the prescribed dose (prostate V150), dose (Gy) received by 5% of the urethral volume (urethral D5) and the urethral volume receiving at least 150% of the prescribed dose (urethral V150)] were retrospectively estimated using the paired Student’s t test and Pearson’s correlation coefficient. The Pearson’s correlation coefficients of all DVH parameters were higher in the 3.0-T group than in the 1.5-T group (1.5-T vs 3.0-T: prostate D90, 0.65 vs 0.93; prostate V100, 0.62 vs 0.82; prostate V150, 0.97 vs 0.98; urethral D5, 0.92 vs 0.93; and urethral V150, 0.88 vs 0.93). In the paired Student’s t test, no significant differences were observed in any of the DVH parameters between the two radiation oncologists in the 3.0-T group (0.068 ≤ P ≤ 0.842); however, significant differences were observed in prostate D90 (P = 0.004), prostate V100 (P = 0.011) and prostate V150 (P = 0.002) between the oncologists in the 1.5-T group. The interobserver variability of DVH parameters in the MRI/CT fusion image–based post-implant dosimetry analysis of brachytherapy was lower with 3.0-T MRI than with 1.5-T MRI.

Longer Preoperative Membranous Urethral Length is Associated with GU Toxicity after Permanent Prostate Brachytherapy

Longer Preoperative Membranous Urethral Length is Associated with GU Toxicity after Permanent Prostate Brachytherapy

Long Term Results from a Prospective Randomized Trial of 131Cs vs 125I Permanent Prostate Brachytherapy

Prostate cancer represents the leading cause of cancer in men, with an estimated incidence of 180,890 cases in 2016. Long-term outcomes reveal equivalent biochemical outcomes with brachytherapy (BT) compared to radical prostatectomy and external beam radiotherapy (EBRT). Iodine-125 (125I) represents the most commonly used isotope for prostate BT. Cesium-131 (131Cs) was introduced as an alternative isotope in 2004. Its higher dose rate and shorter dose delivery time has demonstrated a shorter duration of acute urinary morbidity. Long term data suggest excellent oncologic outcomes with use of 131Cs, yet there is a gap in knowledge about how outcomes between 131Cs and 125I compare. Our institution initiated a prospective randomized trial comparing the two isotopes and report out biochemical outcomes and comparisons.

Dosimetric Analysis of Permanent Prostate Monotherapy with Prostate Rectal Spacer

Dosimetric Analysis of Permanent Prostate Monotherapy with Prostate Rectal Spacer

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.

Reducing seed migration to near zero with stranded-seed implants: Comparison of seed migration rates to the chest in 1000 permanent prostate brachytherapy patients undergoing implants with loose or stranded seeds

PurposePulmonary seed emboli to the chest may occur after permanent prostate brachytherapy (PPB). The purpose of this study is to analyze factors associated with seed migration to the chest in a large series of PPB patients from a single institution undergoing implant with either loose seeds (LS), mixed loose and stranded seeds (MS), or exclusively stranded seeds in an absorbable vicryl suture (VS). Methods and MaterialsBetween May 1998 and July 2015, a total of 1000 consecutive PPB patients with postoperative diagnostic chest x-rays at 4 months after implant were analyzed for seed migration. Patients were grouped based on seed implant technique: LS = 391 (39.1%), MS = 43 (4.3%), or VS = 566 (56.6%). Univariate and multivariate analysis were performed using Cox proportional hazards regression models to determine predictors of seed migration. ResultsOverall, 18.8% of patients experienced seed migration to the chest. The incidence of seed migration per patient was 45.5%, 11.6%, and 0.9% (p < 0.0001), for patients receiving LS, MS, or VS PPB, respectively. The right and left lower lobes were the most frequent sites of pulmonary seed migration. On multivariable analysis, planimetry volume (p = 0.0002; HR = 0.7 per 10 cc [0.6–0.8]), number of seeds implanted (p < 0.0001, HR = 2.4 per 25 seeds [1.7–3.4]), LS implant (p < 0.0001, HR = 15.9 [5.9–42.1]), and MS implant (p = 0.001, HR = 7.9 [2.3–28.1]) were associated with seed migration to the chest. ConclusionsIn this large series, significantly higher rates of seed migration to the chest are observed in implants using any LS with observed hazard ratios of 15.9 and 7.9 for LS and MS respectively, as compared with implants using solely stranded seeds.