Gelblum D Y, Potters L, Ashley R, Waldbaum R, Wang X H, Leibel S
Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center at Mercy Medical Center, Rockville Centre, NY 11570, USA.
Int J Radiat Oncol Biol Phys. 1999 Aug 1;45(1):59-67. doi: 10.1016/s0360-3016(99)00176-5.
To assess the urinary morbidity experienced by patients undergoing ultrasound-guided, permanent transperineal seed implantation for adenocarcinoma of the prostate.
Between September 1992 and September 1997, 693 consecutive patients presented with a diagnosis of clinically localized adenocarcinoma of the prostate, and were treated with ultrasound-guided transperineal interstitial permanent brachytherapy (TPIPB). Ninety-three patients are excluded from this review, having received neoadjuvant antiandrogen therapy. TPIPB was performed with 125I in 165 patients and with 103Pd in 435 patients. Patients treated with implant alone received 160 Gy with 125I (pre TG43) or 120 Gy with 103Pd. One hundred two patients received preimplant, pelvic external beam radiation (XRT) to a dose of either 41.4 or 45 Gy because of high-risk features including PSA > or = 10 and/or Gleason score > or = 7. Combined modality patients received 120 Gy and 90 Gy, respectively for 125I or 103Pd. All patients underwent postimplant cystoscopy and placement of an indwelling Foley catheter for 24-48 h. Follow-up was at 5 weeks after implant, every 3 months for the first 2 years, and then every 6 months for subsequent years. Patients completed AUA urinary symptom scoring questionnaires at initial consultation and at each follow-up visit. Urinary toxicity was classified by the RTOG toxicity scale with the following adaptations; grade 1 urinary toxicity was symptomatic nocturia or frequency requiring none or minimal medical intervention such as phenazopyridine; grade 2 urinary toxicity was early obstructive symptomatology requiring alpha-blocker therapy; and grade 3 toxicity was considered that requiring indwelling catheters or posttreatment transurethral resection of the prostate for symptom relief. Log-rank analysis and Chi-square testing was performed to assess AUA score, prostate size, isotope selection, and the addition of XRT as possible prognosticators of postimplant urinary toxicity. The prostate volume receiving 150% of the prescribed dose (V150) was studied in patients to assess its correlation with urinary toxicity.
Median follow-up was 37 months (range 6-68). Within the first 60 days, 37.3% of the patients reported grade 1 urinary toxicity, 41% had grade 2, and 2.2% had grade 3 urinary toxicity. By 6 months, 21.4% still reported grade 1 urinary toxicity, whereas 12.8% and 3% complained of grade 2 and 3 urinary difficulties, respectively. Patients with a preimplant AUA score < or = 7 had significantly less grade II toxicity at 60 days compared to those with an AUA score of >7 (32% vs. 59.2%, respectively, p = 0.001). Similarly, prostatic volumes < or = 35 cc had a significantly lower incidence of grade II urinary toxicity (p = 0.001). There was no difference in toxicity regarding the isotope used (p = 0.138 at 60 days, p = 0.45 at 6 months) or the addition of preimplant XRT (p = 0.069 at 60 days, p = 0.84 at 6 months). Twenty-eight patients (4.7%) underwent TURP after 3 isotope half-lives for protracted obstructive symptoms. Five of these men (17%) developed stress incontinence following TURP, but all patients experienced relief of their obstructive symptoms without morbidity at last follow-up. The percent of the prostate receiving 150% of the prescribed dose (V150) did not predict urinary toxicity.
TPIPB is well tolerated but associated with mild to moderate urinary morbidity. Pretreatment prostatic volume and AUA scoring were shown to significantly predict for grade 2 toxicity while the use of preimplant, pelvic XRT and isotope selection did not. Patients undergoing TURP for protracted symptoms following TPIPB did well with a 17% risk of developing stress incontinence. V150 did not help identify patients at risk for urinary morbidity. As transperineal prostate implantation is used more frequently the associated toxicities and the definition of possible pretreatment prognostic factors is necessary to
评估接受超声引导下经会阴永久性前列腺癌粒子植入术患者的泌尿系统并发症。
1992年9月至1997年9月，693例连续诊断为临床局限性前列腺腺癌的患者接受了超声引导下经会阴间质永久性近距离放射治疗（TPIPB）。93例接受新辅助抗雄激素治疗的患者被排除在本研究之外。165例患者采用125I进行TPIPB，435例患者采用103Pd。单纯植入治疗的患者接受160 Gy的125I（TG43之前）或120 Gy的103Pd。102例因包括PSA≥10和/或Gleason评分≥7等高风险特征，在植入前接受盆腔外照射（XRT），剂量为41.4或45 Gy。联合治疗的患者分别接受120 Gy和90 Gy的125I或103Pd。所有患者植入后均接受膀胱镜检查，并留置Foley导尿管24 - 48小时。随访在植入后5周进行，前2年每3个月随访一次，随后每年每6个月随访一次患者在初次咨询和每次随访时完成美国泌尿外科学会（AUA）泌尿系统症状评分问卷。泌尿系统毒性按照放射肿瘤学组（RTOG）毒性量表进行分类，并作如下调整；1级泌尿系统毒性为有症状的夜尿症或尿频，无需或仅需极少的药物干预，如使用非那吡啶；2级泌尿系统毒性为早期梗阻症状，需要α受体阻滞剂治疗；3级毒性被认为需要留置导尿管或治疗后经尿道前列腺切除术以缓解症状。进行对数秩分析和卡方检验，以评估AUA评分、前列腺大小、同位素选择以及是否添加XRT作为植入后泌尿系统毒性的可能预后指标。研究患者接受150%处方剂量的前列腺体积（V150），以评估其与泌尿系统毒性的相关性。
中位随访时间为37个月（范围6 - 68个月）。在最初60天内，37.3%的患者报告有1级泌尿系统毒性，41%有2级，2.2%有3级泌尿系统毒性。到6个月时，21.4%的患者仍报告有1级泌尿系统毒性，而分别有12.8%和3%的患者抱怨有2级和3级排尿困难。植入前AUA评分≤7的患者在60天时2级毒性明显低于AUA评分>7的患者（分别为32%和59.2%，p = 0.001）。同样，前列腺体积≤35 cc的患者2级泌尿系统毒性发生率显著较低（p = 0.001）。所用同位素（60天时p = 0.138，6个月时p = 0.45）或植入前添加XRT（60天时p = 0.069，6个月时p = 0.84）对毒性无差异。28例患者（4.7%）在3个同位素半衰期后因持续性梗阻症状接受了经尿道前列腺切除术（TURP）。其中5例男性（17%）在TURP后出现压力性尿失禁，但所有患者在最后随访时梗阻症状均得到缓解且无并发症。接受150%处方剂量的前列腺百分比（V150）不能预测泌尿系统毒性。
TPIPB耐受性良好，但伴有轻至中度泌尿系统并发症。治疗前前列腺体积和AUA评分被证明可显著预测2级毒性，而植入前盆腔XRT的使用和同位素选择则不能。TPIPB后因持续性症状接受TURP的患者情况良好，发生压力性尿失禁的风险为17%。V150无助于识别有泌尿系统并发症风险的患者。随着经会阴前列腺植入术的更频繁使用，相关毒性以及可能的治疗前预后因素的定义对于……是必要的
