Focal low-dose rate brachytherapy for the treatment of prostate cancer

Figures & data

Table 1 Summary of partial and focal therapy modalities reported

Study	Patients	Patient risk group	Median follow-up	Modality	Sexual and continence toxicity outcome	Outcomes	Notes
Muto et al^Citation18	70 (29 focal therapy; 41 whole-gland therapy)	T1c–T2N0M0 (no exclusion based on PSA or Gleason score)	34 months	HIFU (focal and whole-gland)	Potency not reported; 94% continent (all patients)	2-year bDFS, 83.3% (low risk); 53.6% (intermediate risk)	Focal versus whole-gland: decreased indwelling catheter period, frequency of urinary stricture, and UTI
El Fegoun et al^Citation19	12	PSA ≤ 10 ng/mL, ≤T2a, Gleason score ≤7 (3 + 4)	10 years	HIFU (hemiprostate)	Potency not assessed 100% continent	10-year OS, 83%; CSS, 100%; DFS, 38%	2 UTI; 1 retention
Ahmed et al^Citation83	42	PSA ≤ 15 ng/mL, Gleason score ≤4 + 3, stage ≤T2	12 months	HIFU	89% potency 100% continent	6 months histological free, 77%; clinically free, 92%
Ahmed et al^Citation84	20	PSA ≤ 15 ng/mL, Gleason score ≤4 + 3, ≤cT2bN0M0	12 months	HIFU	95% potency; 95% continent	Histologically free, 89%
Lambert et al^Citation21	25	Gleason score 6 or 7 (3 + 4), confined to one lobe in one or two contiguous biopsy cores	28 months	Cryotherapy	71 % potency; 100% continent	88% bDFS
Onik et al^Citation22	55	Confined to one side; included low to high risk	3.6 years	Cryotherapy	85% potency; 100% continent (1 patient with previous TRUS had incontinence)	95% bDFS; 100% DSS (disease-specific survival)
Bahn et al^Citation20	73	PSA ≤ 20, Gleason score ≤7, clinical stage T1–T2b; clinically unilateral	3.7 years	Cryotherapy	86% potency; 100% continent	Histologically free, 75%
Nguyen et al^Citation9	318	PSA < 15 ng/mL, Gleason score <7(3+4)	5.1 years	LDR brachytherapy peripheral zone	–	5-year failure-free survival, 95.6%; 8-year failure-free survival, 90.0%	Using proposed nadir +2 and PSA velocity >0.75 ng/mL per year as recurrence criteria
Kamrava et al^Citation10	10	–		HDR brachytherapy (hemigland versus whole-gland comparison)	–	–	Reduction in the D2cc was 64.1% to 53.1% for the rectum, 67.5% to 55.9% for the bladder, and 95.2% to 69.3% for the urethra
Miralbell et al^Citation11	50	Included low to high risk	63 months	EBRT whole-gland with focal boost 5–7 Gy/2 fractions after EBRT 64–64.4 Gy	5-year probability grade ≥2 late urinary toxicity free-survival, 82.2%	5 year bDFS, 98%; DSS, 100%	5-year probably late low Gl toxicity-free survival, 72.2%
Schick et al^Citation13	77	Included low to high risk	62 and 67.6 months (unilateral and bilateral groups)	HDR brachytherapy focal boost, 12–16 Gy (unilateral versus bilateral) after EBRT, 64–64.4 Gy	5-year grade ≥3 late urinary toxicity, 10% and 8.8% (unilateral versus bilateral); grade 4 urinary toxicity, 0% versus 8.8% (unilateral versus bilateral)	5 year bDFS, 79.7% and 70.5% (unilateral versus bilateral)	5 year grade ≥2 late rectal toxicity-free survival, 84.4% and 90.6% (unilateral versus bilateral)
Aluwini et al^Citation12	50	PSA ≤ 20, Gleason score ≤7(3+4), clinical stages Tlc–T3a	24 months	SBRT 38 Gy/4 fractions with focal 11 Gy boost per fraction to visible MRI lesion	2 year grade 2 and 3 toxicity was 10% and 6%	2 year biochemical control 100%	Grade 2 gastrointestinal toxicity was 3%

Abbreviations: bDFS, biochemical disease-free survival; CSS, cancer-specific survival; DFS, disease-free survival; EBRT, external beam radiotherapy; Gl, gastrointestinal; HDR, high dose rate; HIFU, high-intensity focused ultrasound; OS, overall survival; PSA, prostate-specific antigen; SBRT, stereotactic body radiation therapy; TRUS, transrectal ultrasound; UTI, urinary tract infection; MRI, magnetic resonance imaging; LDR, low dose rate.

Table 2 Multidisciplinary international consensus group proposal selection

Life expectancy >10 years

PSA ≤15 ng/mL

Multiparametric (T1 W/T2 W score, diffusion-weighting, dynamic contrast enhancement ± spectroscopy)

Magnetic resonance imaging prior to biopsy

Bilateral template-guided prostate mapping biopsy with 5 mm sampling frame

Unilateral disease; lesion size ≤0.5 mL (approximately equates to maximum cancer length of 10 mm) with or without clinically insignificant disease on the contralateral side (cancer core length ≤3 mm)

Gleason score of index lesion 6–7 (3 + 4)

Tumor stage ≤T2b

Prostate size ≤60 mL

Abbreviation: PSA, prostate-specific antigen.

Table 3 Phase II hemigland protocol inclusion criteria

Men ≥21 years of age with a life expectancy estimated to be >10 years

Diagnosis of adenocarcinoma of the prostate confirmed by MSKCC or participating site pathology review

ECOG performance status^Citation85 of 0 or 1

Prostate cancer clinical stage T1c–T2a

PSA <10 ng/mL (this will be the PSA level prompting the prostate biopsy)

MRI evidence of one-sided disease performed within 3 months of registration

Prostate size <60 cm^3 at time of treatment; if the prostate is larger, hormonal therapy is allowed to achieve the required size

Abbreviations: ECOG, Eastern Cooperative Oncology Group; MRI, magnetic resonance imaging; MSKCC, Memorial Sloan-Kettering Cancer Center; PSA, prostate-specific antigen.

Table 4 Phase II hemigland protocol exclusion criteria

Medically unfit for anesthesia

Evidence or suspicion of extracapsular extension on MRI

IPSS score >18

Unable to receive MRI

Prior radiotherapy for the current disease

Abbreviations: IPSS, International Prostate Symptom Score; MRI, magnetic resonance imaging.

Figure 1 Hemigland brachytherapy implant.

Note: Computed tomography (contours of the prostate in red, target in yellow, rectum in blue. 100%, 150%, and 200% isodose lines in green, yellow, and red). The green triangles and circles indicate seed positions.

Figure 2 Representative image of a focal brachytherapy implant.

Notes: Contours of the prostate in red, urethra in green, and rectum in blue. The 100%, 150%, and 200% isodose lines are in green, yellow, and red. The green triangles and circles indicate seed positions.

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