A comprehensive review of CT-based dosimetry parameters and biochemical control in patients treated with permanent prostate brachytherapy.
OBJECTIVE
The American Brachytherapy Society recommends that postprostate implant dosimetry be performed on all patients undergoing transperineal interstitial permanent prostate brachytherapy (TIPPB) utilizing CT scan clinical target volume reconstructions. This study was undertaken to assess the recommended dosimetry parameters from a large cohort of patients undergoing TIPPB that would predict for PSA relapse-free survival (PSA-RFS).


METHODS
Seven hundred nineteen consecutive patients with clinical stage T1/T2 adenocarcinoma of the prostate underwent TIPPB using either I-125 or Pd-103. Postimplant dosimetry was performed at 2 to 3 weeks with CT scan 3-dimensional reconstructions obtained on all patients. The D90 and D100 doses (defined as the minimum dose covering 90% and 100% of the prostate volume, respectively) and the V100 (defined as the percent of the prostate receiving 100% of the prescribed dose) were obtained for each patient. Regression analysis was performed on the D90 dose, D100 dose, and V100 to test for cutoff points that would predict for PSA-RFS, defined by a modification of the American Society for Therapeutic Radiology and Oncology consensus panel statement. A cutoff value was found and was subjected to subset analysis to assess for its robustness. Treatment-related factors were tested for their ability to achieve dosimetry at or above the cutoff dose.


RESULTS
The median follow-up from this cohort is 30 months (7-71 months) with a 48-month PSA-RFS of 89.5%. A D90 dose-response cutoff value > or =90% of the prescribed dose was identified. Prostate implants with a D90 dose <90% of the prescribed dose had an 80.4% 4-year PSA-RFS, while those with a D90 dose > or =90% of the prescribed dose had a 92.4% 4-year PSA-RFS (p = 0.001). No cutoff value was found for the V100 and D100 dose that predicted for PSA-RFS. Using the cutoff value, the D90 dose at 90% of the prescribed dose, a difference in 4-year PSA-RFS survival was identified for patients treated with I-125 (p = 0.04), Pd-103 (p = 0.01), TIPPB as monotherapy (p = 0.001), the addition of hormone therapy (p = 0.005), and TIPPB without hormone therapy (p = 0.001). The D90 dose was not significant for the group of patients treated with external beam radiotherapy and TIPPB (p = 0.15). The only significant finding from Cox regression analysis to predict for a poor D90 dose (<90% of the prescribed dose) was a CT/TRUS volume ratio >1.5 (p = 0.02).


CONCLUSIONS
The American Brachytherapy Society recommends that postimplant CT-based dosimetry be performed for all patients treated with TIPPB. This prospective study identified that the D90 dose > or =90% of the prescribed dose can be used as a factor for predicting PSA-RFS in patients treated with brachytherapy. A dose-response using the D90 dose was observed for several typical clinical treatment variations used in the practice of TIPPB. Using the D90 dose appears to be a satisfactory parameter for predicting outcome in patients treated with TIPPB.
Potters
L
L
Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center at Mercy Medical Center, Rockville Centre, New York 11570, USA. PottersL@mskcc.org
Cao
Y
Y
Calugaru
E
E
Torre
T
T
Fearn
P
P
Wang
X H
XH
D000230:Adenocarcinoma / Q000097:blood / Q000532:radiotherapy*; D001918:Brachytherapy / Q000379:methods*; D015331:Cohort Studies; D018572:Disease-Free Survival; D004307:Dose-Response Relationship, Radiation; D006801:Humans; D007457:Iodine Radioisotopes / Q000627:therapeutic use; D008297:Male; D010165:Palladium / Q000627:therapeutic use; D011446:Prospective Studies; D017430:Prostate-Specific Antigen / Q000097:blood; D011471:Prostatic Neoplasms / Q000097:blood / Q000532:radiotherapy*; D011868:Radioisotopes / Q000627:therapeutic use; D014057:Tomography, X-Ray Computed
D007457:Iodine Radioisotopes; D011868:Radioisotopes; D010165:Palladium; D017430:Prostate-Specific Antigen