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Prostate Cancer (continued)

Treatment results

Like any procedure, proper patient selection achieves the best results. As the maximum dose from each seed is reached only a few millimeters from its source, organ confined disease will best respond as any focus of cancer beyond the gland's capsule will likely not receive an adequate radiation dose. As a result, patients with low stage disease will respond more favorably than those with more advanced cancer. Although not a fool proof system, these patients can be selected based on their prostate specific antigen (PSA) level and tissue grade, or Gleason score.

Prostate volume also plays a role but this is only for technical considerations of needle and seed placement and can often be manipulated with preoperative hormone therapy. In general, patients with a PSA level less than 10 and a Gleason score of 6 or less will have the best results as they are most likely to have low stage organ confined disease. Other patients can be treated however they risk a higher rate of tumor recurrence and are best approached with multi-modality therapy.

Blasko et. al. reviewed their results for interstitial seed therapy for prostate cancer and provides one of the largest series of brachytherapy for prostate cancer. 98 percent of their prostate cancer patients (T1 or T2) treated with I123 had a normalization of their PSA at one year. 93 percent maintained disease free status (based on PSA failure) at 5 years based on their actuarial data.1 Although not part of their study, in their discussion they compared their results with the prostatectomy series of Lange et. al. (J Urol, 141:873, 1989) and felt that both provided similar survival.

Other studies have found higher PSA failure rates of 76 percent but appear to have included some more advanced tumors.2-3 Blasko's group also looked at post-treatment biopsies and found that 80 percent remained negative at one year with 17 percent indeterminate and 3 percent positive.4 The significance of a positive biopsy remains controversial however as it does not necessarily correlate with a rising PSA and some of the indeterminate biopsies can later become negative. This may well be the result of the difficulty in the pathological interpretation of a radiated prostate as the morphology can appear distorted after radiation.

This uncertainty of post radiation prostate biopsies makes PSA follow up a more objective measure of disease recurrence. Side effects from interstitial brachytherapy appear to be short lived and localized. Urinary related symptoms such as dysuria and retention are the most common with up to 46 percent at one month but resolving to 14 percent at two years in most series. Impotence is seen in 5 to 10 percent of patients at one year post treatment and generally higher in those with more aggressive lesions. Rectal complications are seen in 5 to 9 percent and incontinence in 1 to 3 percent.

As mentioned above, incontinence is uncommon and is usually only seen in individuals who have had a prior transurethral resection of the prostate (TURP). Superficial urethral necrosis is also a complication seen primarily in patients with a prior TURP. It is felt to be related to seed placement and both can be avoided with peripheral loading of the seeds thus sparing the urethra. If an individual requires a TURP, this is best performed after seed placement and also after sufficient time as to allow the seeds to deliver their full dose to the prostate. Peripheral loading of the seeds can decrease the rate of incontinence associated with TURP and also avoid the problem of superficial urethral necrosis.

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