Focal salvage therapy for local prostate cancer recurrences after primary radiotherapy : a comprehensive review

BACKGROUND/AIM: Patients with locally recurrent prostate cancer after primary radiotherapy can be eligible for salvage treatment. Whole-gland salvage techniques carry a high risk of toxicity. A focal salvage approach might reduce the risk of adverse events while maintaining cancer control in carefully selected patients. The aim of this review was to evaluate current literature to assess whether focal salvage leads to a comparable or favourable recurrence rate and less toxicity compared to whole-gland salvage. METHODS: A literature search was performed using PubMed, Embase and the Cochrane Library. A total of 3015 articles were screened and assessed for quality. Eight papers [on focal cryoablation (n = 3), brachytherapy (n = 3) and high-intensity focused ultrasound (n = 2)] were used to report outcomes. RESULTS: One-, 2-, 3- and 5-year biochemical disease-free survival (BDFS) ranges for focal salvage are, respectively, 69-100, 49-100, 50-91 and 46.5-54.5 %. Severe genitourinary, gastrointestinal and sexual function toxicity rates are 0-33.3 %. One study directly compares focal to whole-gland salvage cryotherapy, showing 5-year BDFS of, respectively, 54.4 and 86.5 % with lower toxicity rates for focal salvage patients. CONCLUSION: Provisional data suggest that BDFS rates of focal salvage are in line with those of whole-gland approaches. There is evidence that focal salvage could decrease severe toxicity and preserve erectile function

MRI-geleide brachytherapie bij prostaatkankerrecidief

The number of patients treated for prostate cancer by radiotherapy treatment has increased substantially over recent decades. However, after both external radiotherapy and brachytherapy, a subset of patients still develops recurrent disease during follow-up. In many patients these recurrences are often limited to one localisation in the prostate. In the past, on diagnosis of a recurrence, palliative hormonal treatment was started. Medical imaging by means of a CT scan was not adequate for delineating the recurrent lesion or for excluding metastases. In case where radiotherapy was considered the best treatment for the recurrence, this often resulted in serious adverse effects. Due to improvements in both imaging and radiotherapy techniques, it is now possible to target the local recurrent lesion only. In recurring prostate cancer this technique is known as focal salvage

MRI-geleide brachytherapie bij prostaatkankerrecidief

The number of patients treated for prostate cancer by radiotherapy treatment has increased substantially over recent decades. However, after both external radiotherapy and brachytherapy, a subset of patients still develops recurrent disease during follow-up. In many patients these recurrences are often limited to one localisation in the prostate. In the past, on diagnosis of a recurrence, palliative hormonal treatment was started. Medical imaging by means of a CT scan was not adequate for delineating the recurrent lesion or for excluding metastases. In case where radiotherapy was considered the best treatment for the recurrence, this often resulted in serious adverse effects. Due to improvements in both imaging and radiotherapy techniques, it is now possible to target the local recurrent lesion only. In recurring prostate cancer this technique is known as focal salvage

MRI artifact simulation for clinically relevant MRI sequences for guidance of prostate HDR brachytherapy

For the purpose of magnetic resonance imaging (MRI) guidance of prostate high-dose-rate (HDR) brachytherapy, this paper presents a study on the potential of clinically relevant MRI sequences to facilitate tracking or localization of brachytherapy devices (HDR source/titanium needle), and which could simultaneously be used to visualize the anatomy. The tracking or localization involves simulation of the MRI artifact in combination with a template matching algorithm. Simulations of the MRI artifacts induced by an HDR brachytherapy source and a titanium needle were implemented for four types of sequences: spoiled gradient echo, spin echo, balanced steady-state free precession (bSSFP) and bSSFP with spectral attenuated inversion recovery (SPAIR) fat suppression. A phantom study was conducted in which mentioned sequences (in 2D) as well as the volumetric MRI sequences of the current clinical scan protocol were applied to obtain the induced MRI artifacts for an HDR source and a titanium needle. Localization of the objects was performed by a phase correlation based template matching algorithm. The simulated images demonstrated high correspondences with the acquired MR images, and allowed localization of the objects. A comparison between the object positions obtained for all applied MRI sequences showed deviations (from the average position) of 0.2-0.3 mm, proving that all MRI sequences were suitable for localization of the objects, irrespective of their 2D or volumetric nature. This study demonstrated that the MRI artifact induced by an HDR source or a titanium needle could be simulated for the four investigated types of MRI sequences (spoiled gradient echo, spin echo, bSSFP and bSSFP-SPAIR), valuable for real-time object localization in clinical practice. This leads to more flexibility in the choice of MRI sequences for guidance of HDR brachytherapy, as they are suitable for both object localization and anatomy visualization

Risicopercepties van mannen met gelokaliseerde prostaatkanker

OBJECTIVE: To assess the accuracy of patients' perceptions of the risks associated with localised prostate cancer treatments (radical prostatectomy [RP], radiotherapy [RT], and active surveillance [AS]), and to identify correlates of misperceptions. PATIENTS AND METHODS: We used baseline data (questionnaires completed after treatment information was provided but before treatment) of 426 patients with newly diagnosed localised prostate cancer who participated (87% response rate) in a prospective, longitudinal, multicentre study. Patients' pretreatment perceptions of differences in adverse outcomes of treatments were compared to those based on the literature. We used univariate and multivariate linear regression to identify correlates of misperceptions. RESULTS: About two-thirds (68%, n = 211) of the patients did not understand that the risk of disease recurrence is comparable between RP and RT. More than half of the patients did not comprehend that RP patients are at greater risk of urinary incontinence (65%, n = 202) and erectile dysfunction (61%, n = 190), and less at risk of bowel problems (53%, n = 211) compared to RT patients. Many patients overestimated the risk of requiring definitive treatment following AS (45%, n = 157) and did not understand that mortality rates following AS, RP, and RT are comparable (80%, n = 333). Consulting a radiotherapist or a clinical nurse specialist was positively associated with, and emotional distress was negatively associated with, better understanding of the risks (P < 0.05), although effect sizes were small. CONCLUSION: Prior to choosing treatment, most patients with prostate cancer poorly understood the differences in treatment risks. Greater efforts should be made to better understand why these misperceptions occur and, most importantly, how they can be corrected

Risicopercepties van mannen met gelokaliseerde prostaatkanker

OBJECTIVE: To assess the accuracy of patients' perceptions of the risks associated with localised prostate cancer treatments (radical prostatectomy [RP], radiotherapy [RT], and active surveillance [AS]), and to identify correlates of misperceptions. PATIENTS AND METHODS: We used baseline data (questionnaires completed after treatment information was provided but before treatment) of 426 patients with newly diagnosed localised prostate cancer who participated (87% response rate) in a prospective, longitudinal, multicentre study. Patients' pretreatment perceptions of differences in adverse outcomes of treatments were compared to those based on the literature. We used univariate and multivariate linear regression to identify correlates of misperceptions. RESULTS: About two-thirds (68%, n = 211) of the patients did not understand that the risk of disease recurrence is comparable between RP and RT. More than half of the patients did not comprehend that RP patients are at greater risk of urinary incontinence (65%, n = 202) and erectile dysfunction (61%, n = 190), and less at risk of bowel problems (53%, n = 211) compared to RT patients. Many patients overestimated the risk of requiring definitive treatment following AS (45%, n = 157) and did not understand that mortality rates following AS, RP, and RT are comparable (80%, n = 333). Consulting a radiotherapist or a clinical nurse specialist was positively associated with, and emotional distress was negatively associated with, better understanding of the risks (P < 0.05), although effect sizes were small. CONCLUSION: Prior to choosing treatment, most patients with prostate cancer poorly understood the differences in treatment risks. Greater efforts should be made to better understand why these misperceptions occur and, most importantly, how they can be corrected

Adaptive cone-beam CT planning improves long-term biochemical disease-free survival for 125I prostate brachytherapy

Purpose: Determining the independent effect of additional intraoperative adaptive C-arm cone-beam CT (CBCT) planning vs. transrectal ultrasound (TRUS)-guided interactive planning alone in 125I brachytherapy for prostate cancer (PCa) on biochemical disease-free survival (BDFS). Methods and materials: T1/T2-stage PCa patients receiving TRUS-guided brachytherapy from 2000 to 2014 were analyzed. From October 2006, patients received additional intraoperative adaptive CBCT planning for dosimetric evaluation and subsequent remedial seed placement in underdosed areas. Patients were stratified according to the National Comprehensive Cancer Network (NCCN) risk classification. Kaplan-Meier analysis was used to estimate BDFS (primary outcome), overall survival, and PCa-specific survival (secondary outcomes). Cox regression was used to assess the relation between CBCT use and biochemical failure (BF) and overall mortality. Results: In all, 1623 patients were included. Median followup was 99 months (interquartile range 70-115) for TRUS patients (n = 613) and 51 months (interquartile range 29-70) for CBCT patients (n = 1010). BF occurred 203 times and 206 patients died, 26 from PCa. For TRUS and CBCT patients, 7-year BDFS was 87.2% vs. 93.5% (log rank: p = 0.04) for low, 75.9% vs. 88.5% (p <0.001) for intermediate, and 57.1% vs. 85.0% for high-risk patients (p <0.001). For TRUS and CBCT patients, 7-year PCa-specific survival was 96.0% vs. 100% (p <0.0001). After Cox regression, CBCT patients had lower hazard of BF: hazard ratio (HR) 0.25 (95% confidence interval [CI]: 0.18-0.33; p <0.0001). Corrected for confounders, CBCT remained a predictor of BF: HR 0.51 (95% CI: 0.31-0.86; p = 0.01) but not for overall mortality: HR 0.66 (95% CI: 0.40-1.07; p = 0.09). Conclusions: Additional intraoperative adaptive CBCT planning in 125I prostate brachytherapy leads to a significant increase in BDFS in all NCCN risk groups

Early health economic analysis of 1.5 T MRI-guided radiotherapy for localized prostate cancer:Decision analytic modelling

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