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Protocol-based image-guided salvage brachytherapy

Early results in patients with local failure of prostate cancer after radiation therapy

Protokollbasierte bildgesteuerte Salvage-Brachytherapie

Frühe Ergebnisse von Prostatakrebspatienten mit lokalem Rückfall nach Strahlentherapie

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Abstract

Purpose

To assess the overall clinical outcome of protocol-based image-guided salvage pulsed-dose-rate brachytherapy for locally recurrent prostate cancer after radiotherapy failure particularly regarding feasibility and side effects.

Patients and methods

Eighteen consecutive patients with locally recurrent prostate cancer (median age, 69 years) were treated during 2005–2011 with interstitial PDR brachytherapy (PDR-BT) as salvage brachytherapy after radiotherapy failure. The treatment schedule was PDR-BT two times with 30 Gy (pulse dose 0.6 Gy/h, 24 h per day) corresponding to a total dose of 60 Gy. Dose volume adaptation was performed with the aim of optimal coverage of the whole prostate (V100 > 95 %) simultaneously respecting the protocol-based dose volume constraints for the urethra (D0.1 cc < 130 %) and the rectum (D2 cc < 50–60 %) taking into account the previous radiation therapy. Local relapse after radiotherapy (external beam irradiation, brachytherapy with J-125 seeds or combination) was confirmed mostly via choline-PET and increased PSA levels. The primary endpoint was treatment-related late toxicities—particularly proctitis, anal incontinence, cystitis, urinary incontinence, urinary frequency/urgency, and urinary retention according to the Common Toxicity Criteria. The secondary endpoint was PSA-recurrence-free survival.

Results

We registered urinary toxicities only. Grade 2 and grade 3 toxicities were observed in up to 11.1 % (2/18) and 16.7 % (3/18) of patients, respectively. The most frequent late-event grade 3 toxicity was urinary retention in 17 % (3/18) of patients. No late gastrointestinal side effects occurred. The biochemical PSA-recurrence-free survival probability at 3 years was 57.1 %. The overall survival at 3 years was 88.9 %; 22 % (4/18) of patients developed metastases. The median follow-up time for all patients after salvage BT was 21 months (range, 8–77 months).

Conclusion

Salvage PDR-brachytherapy of the prostate following local failure after radiation therapy is a treatment option with a low rate of genitourinary side effects and no late gastrointestinal side effects. The treatment efficacy in the first 3 years is promising.

Zusammenfassung

Ziel der Arbeit

Ziel der Arbeit ist die Beurteilung des klinischen Gesamtergebnisses der protokollbasierten bildgestützten Salvage-PDR-Brachytherapie bei lokal rezidiviertem Prostatakarzinom nach durchgeführter Radiotherapie mit Hauptaugenmerk auf die Durchführbarkeit und die Nebenwirkungen.

Patienten und Methoden

Insgesamt 18 Patienten (medianes Alter 69 Jahre) mit lokal rezidiviertem Prostatakarzinom nach bereits durchgeführter Strahlentherapie wurden im Zeitraum von 2005–2011 mittels interstitieller PDR-Brachytherapie (PDR-BT) in Form einer Salvage-Brachytherapie behandelt. Das Behandlungsschema bestand aus PDR-BT mit 2-mal 30 Gy (Einzelpulsdosis 0,6 Gy/h, 24 h pro Tag) bis zu einer Gesamtreferenzdosis von 60 Gy. Das Bestrahlungsvolumen wurde mit dem Ziel einer optimalen Volumenabdeckung der gesamten Prostata (V100 > 95 %) bei gleichzeitiger Einhaltung der Dosis-Volumen-Restriktionen für die Urethra (D0,1 cc < 130 %) und für das Rektum (D2 cc < 50–60 %) unter Beachtung der bereits vorangegangenen Strahlentherapie durchgeführt. Das Lokalrezidiv nach Strahlentherapie (perkutane Strahlentherapie, Brachytherapie mit Jod-125-Seeds oder Kombinationstherapie) wurde meist mittels Cholin-PET-CT und steigendem PSA-Wert gesichert. Der primäre Endpunkt war die behandlungsassoziierte Spättoxizität – im besonderen Proktitis, Stuhlinkontinenz, Zystitis, Harninkontinenz, Harndrang und Harnverhalt – gemäß der „Common Toxicity Criteria“. Sekundärer Endpunkt war das PSA-rezidivfreie Überleben.

Ergebnisse

Wir verzeichneten nur Toxizitäten bezüglich des Harntrakts. Grad-2- und Grad-3-Toxizitäten wurden bei 11,1 % (2/18) bzw. bei 16,7 % (3/18) der Patienten beobachtet. Die häufigste Grad-3-Spättoxizität war Harnverhalt bei 3 der 18 Patienten (17 %). Es traten keine gastrointestinalen Spättoxizitäten auf. Die Wahrscheinlichkeit für das biochemische PSA-rezidivfreie Überleben nach 3 Jahren betrug 57,1 %. Das Gesamtüberleben nach 3 Jahren betrug 88,9 %. Metastasen entwickelten 22 % (4/18) der Patienten. Die mediane Nachbeobachtungszeit für alle Patienten nach Salvage-BT lag bei 21 Monaten (Spannweite 8–77 Monate).

Schlussfolgerung

Die Salvage-PDR-Brachytherapie des Prostatakarzinomrezidivs nach bereits durchgeführter Strahlentherapie ist eine Behandlungsoption mit einer niedrigen Rate an urogenitalen Nebenwirkungen und ohne gastrointestinalen Spätnebenwirkungen. Die Behandlungseffektivität für die ersten 3 Jahre ist vielversprechend.

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On behalf of all authors, the corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Department of Radiation Oncology, University Hospital Erlangen, Universitätsstr. 27, 91054, Erlangen, Germany

    G. Lahmer MD, M. Lotter, S. Kreppner, R. Fietkau &  V. Strnad MD

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  1. G. Lahmer MD
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  2. M. Lotter
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  3. S. Kreppner
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  4. R. Fietkau
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  5. V. Strnad MD
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Correspondence to V. Strnad MD.

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Lahmer, G., Lotter, M., Kreppner, S. et al. Protocol-based image-guided salvage brachytherapy. Strahlenther Onkol 189, 668–674 (2013). https://doi.org/10.1007/s00066-013-0373-7

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