title: Fractionated perineal high-dose-rate temporary brachytherapy combined with external beam radiation in the treatment of localized prostate cancer: is lymph node sampling necessary?
abstract: OBJECTIVE
  To study the influence of imaging based nodal staging and local dose escalation by a high-dose-rate brachytherapy (HDR-BT) boost in the treatment of locally confined prostate cancer in terms of prostate specific antigen (PSA) recurrence-free survival (biochemical non-evidence of disease (bNED)), treatment toxicity and prognostic variables.
  
  
  METHODS
  The prospectively recorded files of 144 men aged in a median of 68 years with a mean follow-up of 8 years (60-171 months) receiving curatively intended, transrectal ultrasound guided high-dose-rate 192-iridium-brachytherapy (HDR-BT) combined with external beam radiation therapy (EBRT) for locally confined prostate cancer were analyzed. T-stages were defined by digital rectal investigation and transrectal sonography (TRUS), nodal staging was performed with computed tomography(CT)/magnetic resonance imaging (MRI) (UICC/AJCR 1992). Twenty-nine patients (20.1%) had T1b-T2a tumors, and 115 patients had T2b-T3 tumors. Median initial PSA (iPSA) was 12.15 ng x mL(-1) (mean 25.61 ng x mL(-1)). The total planned dose applied by external beam radiation was 50 Gy in the pelvis, and 40 Gy in the prostate by in-field-dose modification by individual compensators. The perineal, TRUS guided HDR-BT was delivered in two fractions of 15 Gy each. The target of BT boost was the peripheral zone of the prostate.
  
  
  RESULTS
  The overall survival was 71.5% and that of the disease free survival 82.6%. Freedom from distant metastases in T3 stage was 91.3%, whereas for G3 lesions, it was 88.23%. The bNED rate was 72.9%. Regarding treatment related late toxicity according to the EORTC/RTOG score, we observed grade 1, 2, 3 proctitis in 9.72%, 6.94%, 4.10% as well as grade 1, 2, 3 cystitis in 12.5%, 4.16%, 2.08%, respectively. Grade 4 and 5 proctitis or cystitis were not registered.
  
  
  CONCLUSIONS
  The minimum 5-year and mean 8-year results confirm that local dose escalation by TRUS guided perineal HDR-BT and complementary external beam radiation of the pelvic lymphatics has curative potential in men with locally confined high-risk prostate cancer, although surgical staging results in the literature suggest a high probabilityof microscopic nodal involvements at the level of 25.61 ng x mL(-1) mean PSA. The influence of additional short-term (< 6 months) hormonal ablation on the treatment results could not be stated.
authors.affiliation: Interdisciplinary Brachytherapy Centre and Department of Radiation Therapy (Radiooncology), University Hospital, Christian-Albrechts-University, Arnold-Heller street 9, 24105, Kiel, Germany. kovacs@onco.uni-kiel.de <kovacs@onco.uni-kiel.de>
authors.forename: György
authors.initials: G
authors.lastname: Kovács
authors.forename: Razvan
authors.initials: R
authors.lastname: Galalae
mesh_terms: D000368:Aged; D001918:Brachytherapy; D018572:Disease-Free Survival; D006801:Humans; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010502:Perineum; D011379:Prognosis; D011446:Prospective Studies; D017430:Prostate-Specific Antigen / Q000032:analysis; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000473:pathology* / Q000532:radiotherapy* / Q000601:surgery
chemical_list: D017430:Prostate-Specific Antigen