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Title: The influence of isotope and prostate volume on urinary morbidity after prostate brachytherapy

Abstract

Purpose: To evaluate the influence of isotope and prostate size on International Prostate Symptom Score (IPSS) normalization, catheter dependency, and the need for surgical intervention secondary to bladder outlet obstruction after prostate brachytherapy. Methods and Materials: Between January 1998 and June 2003, 976 consecutive patients underwent brachytherapy for clinical stage T1b-T3a (2002 American Joint Committee on Cancer) prostate cancer. Seven hundred eighty-nine (80.8%) were implanted with {sup 103}Pd and 187 (19.2%) with {sup 125}I. The median follow-up was 41.2 months. Patients were stratified into size cohorts {<=}25 cm{sup 3}, 25.1-35 cm{sup 3}, 35.1-45 cm{sup 3}, and >45 cm{sup 3}. Four hundred eighteen patients (42.8%) received androgen deprivation therapy (ADT). Four hundred eighty-six patients (49.7%) received supplemental external-beam radiation therapy (XRT). In all patients, an alpha blocker was initiated before implantation and continued at least until the IPSS returned to baseline. IPSS resolution was defined as a return to within one point of baseline. The median number of IPSS determinations per patient was 21. Clinical, treatment, and dosimetric parameters evaluated included patient age, pretreatment PSA, Gleason score, clinical T stage, percent positive biopsies, preimplant IPSS, ultrasound volume, planning volume, isotope, V{sub 100/150/20}, D{sub 9}, urethral dose (average and maximum), supplemental XRT,more » ADT, and the duration of ADT ({<=}6 months vs. >6 months). Catheter dependency and the need for postsurgical intervention were also evaluated. Results: For both isotopes and all prostate size cohorts, IPSS peaked 1 month after implantation and returned to baseline at a mean of 1.9 months. Stratification of prostate size cohorts by isotope demonstrated no significant differences in prolonged catheter dependency ({>=}5 days), IPSS resolution, or postimplant surgical intervention. In Cox regression analysis, IPSS normalization was best predicted by preimplant IPSS, XRT, and any need for a catheter after brachytherapy. Catheter dependency correlated with prostate size and ADT, whereas the need for surgical intervention was most closely related to any catheter dependency, maximum urethral dose, ADT, and maximum IPSS increase. Conclusions: Regardless of prostate size, isotope did not impact IPSS resolution, catheter dependency, or the need for postbrachytherapy surgical intervention. Although prostate size did predict for short-term (<5 days) catheter dependency, it did not influence IPSS resolution or the need for surgical intervention.« less

Authors:
 [1];  [2];  [1];  [3];  [1];  [1];  [4];  [5]
  1. Schiffler Cancer Center and Department of Physics, Wheeling Jesuit University, Wheeling, WV (United States)
  2. Schiffler Cancer Center and Department of Physics, Wheeling Jesuit University, Wheeling, WV (United States). E-mail: gmerrick@wheelinghospital.com
  3. Puget Sound Healthcare CorporationGroup Health Cooperative and University of Washington, Seattle, WA (United States)
  4. (United States)
  5. Department of Pathology, Wheeling Hospital, Wheeling, WV (United States)
Publication Date:
OSTI Identifier:
20788277
Resource Type:
Journal Article
Resource Relation:
Journal Name: International Journal of Radiation Oncology, Biology and Physics; Journal Volume: 64; Journal Issue: 1; Other Information: DOI: 10.1016/j.ijrobp.2005.06.035; PII: S0360-3016(05)02218-2; Copyright (c) 2006 Elsevier Science B.V., Amsterdam, The Netherlands, All rights reserved; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; ANDROGENS; BIOPSY; BLADDER; BRACHYTHERAPY; CARCINOMAS; DISEASE INCIDENCE; IODINE 125; PALLADIUM 103; PATIENTS; PROSTATE; REGRESSION ANALYSIS; SURGERY; SYMPTOMS

Citation Formats

Niehaus, Angela, Merrick, Gregory S., Butler, Wayne M., Wallner, Kent E., Allen, Zachariah A., Galbreath, Robert W., Department of Physical Education and Sport Science, Ohio University, Eastern Campus, St. Clairsville, OH, and Adamovich, Edward. The influence of isotope and prostate volume on urinary morbidity after prostate brachytherapy. United States: N. p., 2006. Web. doi:10.1016/J.IJROBP.2005.0.
Niehaus, Angela, Merrick, Gregory S., Butler, Wayne M., Wallner, Kent E., Allen, Zachariah A., Galbreath, Robert W., Department of Physical Education and Sport Science, Ohio University, Eastern Campus, St. Clairsville, OH, & Adamovich, Edward. The influence of isotope and prostate volume on urinary morbidity after prostate brachytherapy. United States. doi:10.1016/J.IJROBP.2005.0.
Niehaus, Angela, Merrick, Gregory S., Butler, Wayne M., Wallner, Kent E., Allen, Zachariah A., Galbreath, Robert W., Department of Physical Education and Sport Science, Ohio University, Eastern Campus, St. Clairsville, OH, and Adamovich, Edward. Sun . "The influence of isotope and prostate volume on urinary morbidity after prostate brachytherapy". United States. doi:10.1016/J.IJROBP.2005.0.
@article{osti_20788277,
title = {The influence of isotope and prostate volume on urinary morbidity after prostate brachytherapy},
author = {Niehaus, Angela and Merrick, Gregory S. and Butler, Wayne M. and Wallner, Kent E. and Allen, Zachariah A. and Galbreath, Robert W. and Department of Physical Education and Sport Science, Ohio University, Eastern Campus, St. Clairsville, OH and Adamovich, Edward},
abstractNote = {Purpose: To evaluate the influence of isotope and prostate size on International Prostate Symptom Score (IPSS) normalization, catheter dependency, and the need for surgical intervention secondary to bladder outlet obstruction after prostate brachytherapy. Methods and Materials: Between January 1998 and June 2003, 976 consecutive patients underwent brachytherapy for clinical stage T1b-T3a (2002 American Joint Committee on Cancer) prostate cancer. Seven hundred eighty-nine (80.8%) were implanted with {sup 103}Pd and 187 (19.2%) with {sup 125}I. The median follow-up was 41.2 months. Patients were stratified into size cohorts {<=}25 cm{sup 3}, 25.1-35 cm{sup 3}, 35.1-45 cm{sup 3}, and >45 cm{sup 3}. Four hundred eighteen patients (42.8%) received androgen deprivation therapy (ADT). Four hundred eighty-six patients (49.7%) received supplemental external-beam radiation therapy (XRT). In all patients, an alpha blocker was initiated before implantation and continued at least until the IPSS returned to baseline. IPSS resolution was defined as a return to within one point of baseline. The median number of IPSS determinations per patient was 21. Clinical, treatment, and dosimetric parameters evaluated included patient age, pretreatment PSA, Gleason score, clinical T stage, percent positive biopsies, preimplant IPSS, ultrasound volume, planning volume, isotope, V{sub 100/150/20}, D{sub 9}, urethral dose (average and maximum), supplemental XRT, ADT, and the duration of ADT ({<=}6 months vs. >6 months). Catheter dependency and the need for postsurgical intervention were also evaluated. Results: For both isotopes and all prostate size cohorts, IPSS peaked 1 month after implantation and returned to baseline at a mean of 1.9 months. Stratification of prostate size cohorts by isotope demonstrated no significant differences in prolonged catheter dependency ({>=}5 days), IPSS resolution, or postimplant surgical intervention. In Cox regression analysis, IPSS normalization was best predicted by preimplant IPSS, XRT, and any need for a catheter after brachytherapy. Catheter dependency correlated with prostate size and ADT, whereas the need for surgical intervention was most closely related to any catheter dependency, maximum urethral dose, ADT, and maximum IPSS increase. Conclusions: Regardless of prostate size, isotope did not impact IPSS resolution, catheter dependency, or the need for postbrachytherapy surgical intervention. Although prostate size did predict for short-term (<5 days) catheter dependency, it did not influence IPSS resolution or the need for surgical intervention.},
doi = {10.1016/J.IJROBP.2005.0},
journal = {International Journal of Radiation Oncology, Biology and Physics},
number = 1,
volume = 64,
place = {United States},
year = {Sun Jan 01 00:00:00 EST 2006},
month = {Sun Jan 01 00:00:00 EST 2006}
}
  • Purpose: To assess the influence of dose on the risk of acute urinary retention (AUR) after iodine-125 prostate brachytherapy. Methods and Materials: Between January 2005 and December 2008, 714 consecutive patients with localized prostate cancer were treated with iodine-125 prostate brachytherapy at our department. All patients completed four imaging studies: magnetic resonance imaging before and 4 weeks after treatment and intraoperative three-dimensional transrectal ultrasonography before and after implantation. The development of AUR was prospectively recorded. The evaluated treatment and dosimetric parameters included prostate volume, number of needles and seeds used, intra- and postoperative prostate edema, percentage of prostate volume receivingmore » 100%, 150%, and 200% of the prescribed dose to the prostate, minimal dose received by 90% of the prostate volume, and percentage of the urethra receiving 100%, 150%, and 200% of the prescribed dose. Logistic regression analysis was used to examine which factors were associated with AUR. Results: Of the 714 patients, 57 (8.0%) developed AUR. On univariate analysis, the following treatment and dosimetric factors were significantly associated with AUR: International Prostate Symptom Score (odds ratio [OR], 2.07, per 10-point increase), preimplant prostate volume (OR, 1.06), postimplant prostate volume (OR, 1.04), number of needles used (OR, 1.09), and number of seeds used (OR, 1.03). On multivariate analysis, the only independent predictive factors for AUR were pretreatment prostate volume (OR, 1.05) and International Prostate Symptom Score (OR, 1.76, per 10-point increase). Patients with a pretreatment prostate volume >35 cm{sup 3} had a 10.4% risk of developing AUR compared with 5.4% for those with a prostate volume of {<=}35 cm{sup 3}. No association was found between any of the dosimetric parameters and the development of AUR. Conclusion: The radiation dose, within the range studied, did not influence the risk of AUR after iodine-125 prostate brachytherapy. Prostate volume and International Prostate Symptom Score were the most important predictors of AUR.« less
  • Purpose: To evaluate the relationship between urinary morbidity after prostate brachytherapy and urethral doses calculated at the base, midprostate, apex, and urogenital diaphragm. Methods and Materials: From February 1998 through July 2002, 186 consecutive patients without a prior history of a transurethral resection underwent monotherapeutic brachytherapy (no supplemental external beam radiation therapy or androgen deprivation therapy) with urethral-sparing techniques (average urethral dose 100%-140% minimum peripheral dose) for clinical T1c-T2b (2002 AJCC) prostate cancer. The median follow-up was 45.5 months. Urinary morbidity was defined by time to International Prostate Symptom Score (IPSS) resolution, maximum increase in IPSS, catheter dependency, and themore » need for postimplant surgical intervention. An alpha blocker was initiated approximately 2 weeks before implantation and continued at least until the IPSS returned to baseline. Evaluated parameters included overall urethral dose (average and maximum), doses to the base, midprostate, apex, and urogenital diaphragm, patient age, clinical T stage, preimplant IPSS, ultrasound volume, isotope, and D90 and V100/150/200. Results: Of the 186 patients, 176 (94.6%) had the urinary catheter permanently removed on the day of implantation with only 1 patient requiring a urinary catheter >5 days. No patient had a urethral stricture and only 2 patients (1.1%) required a postbrachytherapy transurethral resection of the prostate (TURP). For the entire cohort, IPSS on average peaked 2 weeks after implantation with a mean and median time to IPSS resolution of 14 and 3 weeks, respectively. For the entire cohort, only isotope predicted for IPSS resolution, while neither overall average prostatic urethra nor segmental urethral dose predicted for IPSS resolution. The maximum postimplant IPSS increase was best predicted by preimplant IPSS and the maximum apical urethral dose. Conclusions: With the routine use of prophylactic alpha blockers and strict adherence to urethral-sparing techniques, detailed urethral dosimetry did not substantially improve the ability to predict urinary morbidity. Neither the average dose to the prostatic urethra nor urethral doses stratified into base, midprostate, apex, or urogenital diaphragm segments predicted for IPSS normalization. Radiation doses of 100%-140% minimum peripheral dose are well tolerated by all segments of the prostatic urethra with resultant tumorcidal doses to foci of periurethral cancer.« less
  • Purpose: Cesium-131 is a newer radioisotope being used in prostate brachytherapy (PB). This study was conducted to determine the predictors of urinary morbidity with Cs-131 PB. Methods and Materials: A cohort of 159 patients underwent PB with Cs-131 at our institution and were followed by using Expanded Prostate Cancer Index Composite (EPIC) surveys to determine urinary morbidity over time. EPIC scores were obtained preoperatively and postoperatively at 2 and 4 weeks, and 3 and 6 months. Different factors were evaluated to determine their individual effect on urinary morbidity, including patient characteristics, disease characteristics, treatment, and dosimetry. Multivariate analysis of covariancemore » was carried out to identify baseline determinants affecting urinary morbidity. Factors contributing to the need for postoperative catheterization were also studied and reported. Results: At 2 weeks, patient age, dose to 90% of the organ (D90), bladder neck maximum dose (D{sub max}), and external beam radiation therapy (EBRT) predicted for worse function. At 4 weeks, age and EBRT continued to predict for worse function. At the 3-month mark, better preoperative urinary function, preoperative alpha blockers, bladder neck D{sub max}, and EBRT predicted for worse urinary morbidity. At 6 months, better preoperative urinary function, preoperative alpha blockers, bladder neck D{sub max}, and EBRT were predictive of increased urinary problems. High bladder neck D{sub max} and poor preoperative urinary function predicted for the need for catheterization. Conclusions: The use of EBRT plus Cs-131 PB predicts for worse urinary toxicity at all time points studied. Patients should be cautioned about this. Age was a consistent predictor of worsened morbidity immediately following Cs-131 PB, while bladder D{sub max} was the only consistent dosimetric predictor. Paradoxically, patients with better preoperative urinary function had worse urinary morbidity at 3 and 6 months, consistent with recently published literature.« less
  • Objective: To determine whether late genitourinary toxicity, biochemical control of prostate cancer, and dosimetric parameters in patients with large prostate glands is different from those variables in men with smaller glands after treatment with high-dose-rate brachytherapy alone (HDR-BT). Methods: From November 2003 to July 2009, 164 patients with locally advanced prostate carcinoma were sequentially enrolled and treated with 34 or 36 Gy in 4 fractions and 31.5 Gy in 3 fractions of {sup 192}Ir HDR-BT alone. The median follow-up time was 71 months. Gland size was not considered in the selection criteria for this study. Estimates of freedom from biochemicalmore » relapse (FFbR) and late morbidity, stratified by median clinical target volume (CTV), were obtained, and differences were compared. Results: The median CTV volume was 60 cc (range, 15-208 cc). Dose–volume parameters D90 and V100 (ie, minimum dose to 90% of the prostate volume and volume receiving 100% of the prescribed isodose) achieved in patients with glands ≥60 cc were not significantly different from those with glands <60 cc (P≥.2). Nonetheless, biochemical control in patients with larger CTV was significantly higher (91% vs 78% at 6 years; P=.004). In univariate and multivariate analysis, CTV was a significant predictor for risk of biochemical relapse. This was not at the expense of an increase in either moderate (P=.6) or severe (P=.3) late genitourinary toxicity. The use of hormonal therapy was 17% lower in the large gland group (P=.01). Conclusions: Prostate gland size does not affect dosimetric parameters in HDR-BT assessed by D90 and V100. In patients with larger glands, a significantly higher biochemical control of disease was observed, with no difference in late toxicity. This improvement cannot be attributed to differences in dosimetry. Gland size should not be considered in the selection of patients for HDR-BT.« less
  • Purpose: To assess the influence of dose in different prostate regions, and the influence of anatomic variation on the risk of acute urinary retention (AUR) after I-125 prostate brachytherapy. Methods and Materials: In this case-control study, dosimetry and anatomy were compared between 50 patients with AUR (cases) and 50 patients without AUR (controls). Cases and controls were randomly selected from our database. The following structures were delineated on magnetic resonance imaging: prostate, urethra, peripheral zone, transitional zone, apex, base, midprostate, lower sphincter, and bladder neck. The dosimetric parameters analyzed were D{sub 10}, D{sub 50}, D{sub 90}, V{sub 100}, V{sub 150},more » and V{sub 200}. The anatomic parameters analyzed were prostate protrusion into the bladder, bladder overlap, urethra angle, and urethra-bladder angle. The delineator was blinded to the patient's AUR status. Logistic regression analysis was used to investigate the association of these factors with AUR. Results: The dose delivered to different regions of the prostate was not significantly associated with the risk of AUR. Only dose to the bladder neck was significantly associated with AUR (odds ratio 1.13 per 10 Gy; 95% CI 1.02;1.26; p = 0.023). Mean bladder neck D{sub 90} was 65 Gy in AUR cases vs. 56 Gy in controls (p = 0.016), and mean bladder neck D{sub 10} was 128 Gy vs. 107 Gy, respectively (p = 0.018). Furthermore, on univariate analysis, a larger extent of both bladder overlap and of prostate protrusion were associated with a higher risk of AUR (odds ratio 1.16; 95% CI 1.04-1.28; p = 0.005, and odds ratio 1.83; 95% CI 1.37-2.45; p < 0.001, respectively). The mean extent of prostate protrusion was 3.5 mm in AUR cases vs. 1.0 mm in controls (p < 0.001). Odds ratios did not change substantially after adjustment for potential confounders. On multivariate analysis, the extent of prostate protrusion seemed to be a stronger risk factor for AUR than bladder overlap. Conclusion: The risk of AUR is not associated with dose delivered to different regions of the prostate. However, a higher dose to the bladder neck and a larger extent of prostate protrusion into the bladder are risk factors for the development of AUR after I-125 prostate brachytherapy.« less