Successful launching the prostate HDR brachytherapy program in a community hospital setting – a case report and review of the literature - March 2012
The radiation oncology department at Camden-Clark Memorial Hospital (CCMC) launched a successful prostate-HDR program that will benefit a selected group of patients. Low-risk prostate cancer patients even with history of TURP or enlarged prostate gland may be candidates for high dose rate brachytherapy (HDR). A phase-III randomized trial reported in 2012 showed 31% reduction in the risk of local recurrence (p=0.01) with EBRT+HDR boost compared to EBRT alone for intermediate- and high risk patients (1). Low morbidly and high rates of biochemical control have been reported even for high-risk prostate cancer by the 2012 American Brachytherapy Society (2). HDR salvage maybe feasible after biochemical failure (3,4,5). In this report we present a prostate-HDR case, we review the procedure and we discuss the prostate-HDR literature.
Prostate HDR starts with placement of 15-20 plastic catheters in the prostate gland with US guidance under general anesthesia by the urologist (Figure 1). The positions of the catheters are verified by CT simulation. The radiation oncologist develops a 3-dimensional radiation treatment plan with the help of expert radiation physicist (Figure 2). Then the first HDR treatment is delivered in 15 minutes with the Nucletron remote after-loading system. Six hours later the second HDR fraction is delivered, then the catheters are removed and the patient is discharged home. The procedure is repeated in a similar manner in one-two weeks to complete the required radiation treatment.
Figure 1. Template with HDR-needles in place. Figure 2. Prostate-HDR radiation treatment plan
Each radiation fraction is optimized with CT-simulation and 3D inverse treatment planning protocol to allow maximal sparing of the rectum, bladder and urethra. HDR is “intensity modulated” and “Robotic” treatment delivery, since the Nucletron HDR system will automatically “after-load” the catheters that are placed in the prostate gland. With the HDR temporary implant there is no radiation source left in the patient, no radiation exposure of medical personnel performing the procedure, no post-treatment radiation exposure of family members and there is no source migration - contrary to LDR permanent seed implants. Morbidity is low with HDR and the excellent clinical outcome compares favorably to other treatment modalities.
The patient is a 66 year old male with elevated PSA of 5.8 ng/ml. He underwent prostate biopsy showing a Gleason score 6 adenocarcinoma present bilaterally. His past medical history and present physical exam did not indicate any condition that could limit his life expectancy to less than 10 years, therefore management with prostatectomy, radiation therapy and hormonal therapy was discussed with the patient and he elected radiation therapy. His US volume study showed a 65 ml enlarged prostate gland, therefore he was not candidate for LDR seed implant.
Since he lives more than an hour drive from the radiation oncology office, he declined the 8.5 week long daily EBRT and elected the equally effective HDR brachytherapy. We followed the treatment schedule adapted from Dr.Mantinez, William Beaumont Hospital (6), and delivered 9.5Gyx2 fractions 6 hours apart, and repeated the same outpatient procedure two weeks later. He had uneventful temporary catheter placements and radiation treatments and when he returned for routine follow up visits, he denied dysuria or bowel side effects. He had unchanged moderate erectile dysfunction. He was able to carry on his usual daily activities in-between the two procedures and after the second outpatient procedure.
EBRT of prostate cancer, a non-invasive alternative to prostatectomy, requires on average 43 daily radiation treatments over 8.5 weeks. This presents a significant problem for those patients who live far from radiation oncology centers, especially in West Virginia. Lost wages and productivity is a significant social health problem for other patients. It is possible to treat localized prostate cancer with a single outpatient procedure depositing radiation seeds permanently into the prostate gland - referred to as low dose rate brachytherapy (LDR). Patients with history of TURP or enlarged prostate gland are generally not treated with LDR seed implant in fear of higher complication rates. Such patients maybe candidates high dose rate brachytherapy (HDR).
Equal local control and survival results were reported with prostate HDR from different institutions as compared to other treatment modalities. Low risk prostate cancer patients can be treated with HDR monotherapy and do not require EBRT; intermediate risk patients are better treated with 5 weeks of EBRT and HDR boost; selected high risk patients have also been successfully treated with a combination of EBRT+HDR boost.
Thousands of prostate cancer patients were successfully treated with HDR in different centers. Dr. Demanes, reported on 1932 cases treated with excellent result over the past 19 years at CET @ UCLA at the 2010 ABS Meeting. A cohort of 1577 patients treated with EBRT and HDR boost had excellent 82% biochemical control and 93% cause specific survival at 10 year follow up as reported by Dr. Martinez (7).
Dr. Prada reported 79% biochemical control at 10 years for a cohort of 294 high-risk prostate cancer patients treated with EBRT+HDR boost (8). A phase-III randomized trial reported in 2012 showed 31% reduction in the risk of local recurrence (p=0.01) with EBRT+HDR boost compared to EBRT alone for intermediate- and high-risk patients, without difference in severe late urinary and rectal morbidity (1). HDR salvage after biochemical failure was also found to be feasible (3,4,5).
Low morbidity and high rates of biochemical control have been reported even for high risk prostate cancer in the 2012 American Brachytherapy Society consensus guidelines for prostate-HDR (2).
The 10+ year follow up data that is available on thousands of patients treated with prostate HDR in different centers shows considerable success in controlling prostate cancer compared to conventional radiation treatments. Though the dose distribution of Cyberknife has been compared to prostate HDR brachytherapy by Dr. Fuller (9), there is no long term local control or survival data published at the time of this writing using the emerging radiosurgical alternatives to compare outcome with prostate HDR that has a long 10+ year safety and efficacy record documented in the medical literature.
Prostate HDR is a complex treatment and requires close cooperation of the urologist, radiation oncologist, expert physicist and the team of dedicated therapists and nurses to deliver a curative high dose radiation treatment to the prostate gland with sub-millimeter accuracy.
We launched a successful prostate HDR program at CCMC in 2011 for the benefit of selected patients. We follow the American Brachytherapy Society Prostate HDR Task Group guidelines (2,10). Our highly trained staff delivers cancer treatment in a supportive environment thus helping our patients to cope with their cancer.
1. Hoskin PJ, Rojas AM, Bownes PJ, Lowe GJ, Ostler PJ, Bryant L. Randomised trial of external beam radiotherapy alone or combined with high-dose-rate brachytherapy boost for localised prostate cancer. Radiotherapy Oncology. 2012 Feb 16; [Epub ahead of print, PMID: 22341794].
2. American Brachytherapy Society consensus guidelines for prostate-HDR. Brachytherapy. 2012 Jan-Feb; 11(1):20-32.
3. Lee B, Shinohara K, Weinberg V, Gottschalk AR, Pouliot J, Roach M 3rd, Hsu IC. Feasibility of high-dose-rate brachytherapy salvage for local prostate cancer recurrence after radiotherapy: the University of California-San Francisco experience. Int J Radiat Oncol Biol Phys. 2007 Mar 15; 67(4):1106-12.
4. Tharp M, Hardacre M, Bennett R, Jones WT, Stuhldreher D, Vaught J. Prostate high-dose-rate brachytherapy as salvage treatment of local failure after previous external or permanent seed irradiation for prostate cancer. Brachytherapy. 2008 Jul-Sep; 7(3):231-6.
5. Jo Y, Fujii T, Hara R, Yokoyama T, Miyaji Y, Yoden E, Hiratsuka J, Nagai A. Salvage high-dose-rate brachytherapy for local prostate cancer recurrence after radiotherapy - preliminary results. BJU Int. 2012 Mar; 109(6):835-9.
6. Grills IS, Martinez AA, et al. High dose rate brachytherapy as prostate cancer monotherapy reduces toxicity compared to low dose rate palladium seeds. J Urol. 2004; 171(3):1098-104.
7. Ghilezan M, Gallae R, Demanes J, et al. 10-year Results in 1577 Intermediate/High Risk Prostate Cancer Patients Treated With External Beam RT (EBRT) and Hypofractionated High Dose Rate (HDR) Brachytherapy Boost. Int J Radiat Oncol Biol Phys. 2007; Volume 69, Issue 3, Supplement, Pages S83-S84.
8. Prada PJ, González H, Fernández J, Jiménez I, Iglesias A, Romo I. Biochemical outcome after high-dose-rate intensity modulated brachytherapy with external beam radiotherapy: 12 years of experience. BJU Int. 2011 Oct 7; doi: 10.1111/j.1464-410X.2011.10632.x. [Epub ahead of print, PMID: 21981583].
9. Fuller DB, Naitoh J, Lee C, Hardy S, Jin H. Virtual HDR CyberKnife treatment for localized prostatic carcinoma: dosimetry comparison with HDR brachytherapy and preliminary clinical observations. Int J Radiat Oncol Biol Phys. 2008 Apr 1;70(5):1588-97.
10. Hsu IC, Yamada Y, Vigneault E, Pouliot J. American Brachytherapy Society Prostate High Dose Rate Task Group guidelines, 2008 August, www.americanbrachytherapy.org/guidelines/HDRTaskGroup.pdf
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