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Doctors Present Prostate Brachytherapy Program in Barcelona, Spain

The Evansville Cancer Center’s prostate program, better known as the Tri-State Prostate Center, began delivering care in 1999. This is a cooperative program utilizing the skills of Dr. W. Fisher, Dr. K. Foertsch, Dr. T. Gadient, Dr. P. Gilson, Dr. A. Korba, Dr. S. Lamb, Dr. A. Razek, Dr. B. Romick, Dr. B. Samm, Dr. P. Siami, Dr. S. Shah, and Arnold Sorensen.

In 2002, the treatment protocol that combined external beam radiotherapy with high dose rate brachytherapy became the modality of choice for localized prostate cancer. This multimodality protocol reduces the acute rectal and bladder symptomology.

A presentation, ‘Prostate HDR Brachytherapy: An Outpatient Approach’, outlining the results of the treatment was presented at a joint meeting in Barcelona, Spain of the American Brachytherapy Society (ABS), European Society for Therapeutic Radiology & Oncology (ESTRO), Groupe Europee de Curietherape (GEC), and Groupe Latino Americano de Curieterapia (GLAC).

The abstract for the presentation follows. You may also download a full-color presentation poster here in PDF format.

PROSTATE HDR BRACHYTHERAPY: An Outpatient Approach

W. Fisher; D. Foertsch; T. Gadient; P. Gilson; A. Korba; A. Razek; B. Romick; W. Samm; S. Shah; P. Siami; B. Smith; A. Sorensen - Tri-State Prostate Cancer Center/Evansville Cancer Center
ABSTRACT

We have developed an outpatient, multiple insertion procedure for prostate HDR brachytherapy which is safe, efficacious, and team based. This is in contrast to the typical single insertion/multiple fraction procedure requiring patient hospitalization. The team includes urologists, radiation oncologists, physicists, anesthesiologists and nursing staff. All patients must have localized (T1,2N0) disease and be fully informed of alternative approaches including surgery. The TRUS guided placement of needle applicators is performed under spinal anesthesia. Two fractions (2 weeks apart) are delivered 4 weeks after completion of external beam therapy (4500- 5040 cGy) using either 3D conformal or IMRT. CT based isodose planning is carried out using ABACUS algorithm with 1000 cGy to encompass at least 90% of CTV (capsule + 0-2mm margin), 1200 cGy to the peripherial zones with localized hot spots receiving 1500 cGy or more. The dose to the rectum and urethra is maintained to be less than 1000 cGy and 1200 cGy respectively. One hundred forty-five patients were treated between January 2001 and December 2003. The acute side effects to the bladder and rectum were significantly reduced when compared to a group of 326 patients treated between 1999- 2003 with LDR brachytherapy (1-125 and Pd-103 seeds). Our experience demonstrates that HDR brachytherapy can be performed effectively as an outpatient procedure with minimal side effects.
INTRODUCTION

High Dose Rate Brachytherapy for treating localized prostate cancer tumors utilizing transrectal ultrasound (TRUS) and Ir-192 based HDR remote afterloaders is becoming more and more popular. This technique was first introduced at Kiel University(1), Kiel, Germany in 1986 as a combination therapy consisting of conventional external beam radiation therapy (EBRT) and two HDR Ir-192 fractions delivered 2 weeks apart. Since then, a number of institutions including Seattle, Washington(2) and Royal Oak, Michigan(3) have used HDR Brachytherapy for the treatment of the prostate cancer. In most of the institutions in U.S.A., prostate HDR brachytherapy is performed by delivering multiple fractions with a single insertion requiring hospitalization of the patient. At Evansville Cancer Center/Tri-State Prostate Cancer Center, prostate HDR brachytherapy is performed on an outpatient basis with two procedures two weeks apart in combination with EBRT with doses of 4500 cGy or 5040 cGy using IMRT. Before the initiation of IMRT in September, 2003 the external beam treatment was delivered using conformal external beam radiation with a 4 field box technique. A team consisting of radiation oncologist, urologist, physicist, nursing and anesthesia personnel are always present during the procedure.
METHODS & MATERIALS

Flexible interstitial afterloading catheters are placed in the prostate gland through the transperineal route using transrectal ultrasound. A template with 0.5 cm grid is used to direct the needles. The patient is placed in lithotomy position under spinal anesthesia. The ultrasound probe is inserted in the rectum. The probe is attached to the stabilizer along with the template. The stabilization device is then moved to a midglandular region of the prostate and adjusted to ensure that the prostate is covered by the grid positions with the row 2 (Siemens type grid nomenclature) a little above the inferior (rectal) border of the gland and prostate centered to the midline (column G Siemens type grid nomenclature) of the template. Plastic catheters (with stainless steel inserters in the catheters to provide rigidity) are placed under ultrasound guidance. Before inserting the catheter, a guide channel is made using a sharp stainless steel pathfinder (trocar). The catheters are placed as per preplan in a modified peripheral loading pattern to control the dose to the urethra and rectum. Every effort is made to see that the tips of all the catheters are just beyond the base plane (0.0 plane). On average 12-14 catheters are inserted. After the placement of catheters, the template is removed from the stepper unit and sutured to the perineum. The catheters are secured via template locking mechanism to ensure that they do not slide. After suturing the template, the patient’s legs are placed on a MICK leg support “ramp”. Velcro straps are used to avoid any motion of the legs during the rest of the procedure. Cystoscopy is performed to insure that no needles are too close or passing through urethra. Dye is then injected into the bladder. The patient is then transferred to the CT scanner room.

An initial scout CT scan is performed to verify that, preferably, all the catheters have tips passing just beyond the base (0.0) plane. If need be, the catheters are pushed further to adjust them to the desired depth. Dye in the bladder is utilized to visualize the bladder. Once the urologist and radiation oncologist are satisfied with the placement, the metallic inserters are removed from the catheters. The catheters are secured to the template and marked to check any possible sliding of the catheters during the patient transfer from the CT table. CT scan is performed with 5.00 mm slice thickness. The Scan usually includes a few slices before the base plane (showing part of the bladder) and a couple of slices beyond the apex.

CT scans are transferred to ABACUS treatment planning computer via Diacom. The isodose plan is generated using an optimization program. The optimization plan, invariably, does not provide a satisfactory isodose plan and dwell times. The calculated dwell times are edited and manipulated manually to obtain a satisfactory plan. The final plan is developed so that the dose about the periphery (1-3 mm around prostate gland) of the prostate is 1000 cGy. Rectal dose is maintained to be <1000 cGy. The dose to the urethra should not exceed 1200 cGy (usually between 1000 and 1200 cGy). The dose to the lateral regions of the prostate is 1200 cGy with inside non-contiguous areas to receive up to 1500 cGy dose.

After the approval of the isodose plan by the radiation oncologist the patient is brought to the HDR remote afterloader treatment room and treated as per isodose plan. After completion of the treatment, the catheters are removed and the patient is brought to the recovery area. Once the patient has urinated and there are no observable after effects of anesthesia, he is allowed to go home.
GENITOURINARY & GASTROINTESTINAL RADIATION TOXICITY

The data for 130 patients (out of 145 treated) was reviewed with the following results:

- on the Urinary Symptom Score (scale 1-35) 95 (73%) patients reported normalcy; 26 (20%) mild; 8 (6.2%) moderate and 1 (0.8%) reported low severe toxicity.

- only two patients (1.5%) had reported episodes of rectal bleeding and saw GI specialist but did not need any further intervention. One patient reported frequent fecal urgency.
CONCLUSION

Our experience demonstrates that patients tolerate two applications well. Prostate HDR brachytherapy can be effectively performed as an ‘outpatient’ procedure. Due to the increased precision of dose to target volumes and decreased patient morbidity, several participating urologists choose to no longer perform LDR brachytherapy. Long term follow up of the patients is required for definitive conclusions.
REFERENCES

1) Kovacs G, Wirth B, Bertermann R, et. al Prostate preservation by combined external beam and HDR brachytherapy at node negative prostate cancer patients - an intermediate analysis after 10 years experience. Int. J. Radiat. Oncol. BioI. Phys. 1996; 36: 198.

2) Mate TP, Gottesman JE, Hatton J, et. al. High Dose Rate Afterloading Iridium - 192 Prostate Brachytherapy: Feasibility Report. Int. J. Radiat. Oncol. BioI. Phys. 1998; 41: 525-533.

3) Stromberg J., Martinez A., Gonzalez J. et. al. Ultrasound-guided high dose rate conformal brachytherapy boost in prostate cancer: Treatment description and preliminary results of a Phase I/II clinical trial. Int. J. Radiat. Oncol. BioI. Phys. 1995; 33: 161-171.



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