Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands.
Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands.
Int J Radiat Oncol Biol Phys. 2019 Aug 1;104(5):1045-1053. doi: 10.1016/j.ijrobp.2019.03.032. Epub 2019 Mar 27.
For the treatment of localized prostate cancer, focal therapy has the potential to cure with fewer side effects than traditional whole-gland treatments. We report an update on toxicity, quality of life (QoL), and tumor control in our magnetic resonance imaging (MRI)-guided ultrafocal high-dose-rate brachytherapy cohort.
Disease status was evaluated by systematic biopsies and 3T multiparametric MRI. The brachytherapy implant procedure under fused transrectal ultrasound/MRI guidance was followed by a 1.5 T MRI for contour adjustments and catheter position verification. A single dose of 19 Gy was delivered to the tumor with a margin of 5 mm. Genitourinary (GU) toxicity, gastrointestinal (GI) toxicity, and erectile dysfunction (ED) were graded with the Common Terminology Criteria for Adverse Events version 4.0. QoL was measured with RAND-36, European Organisation for Research and Treatment of Cancer QLQ-C30 and PR25. International Prostate Symptom Scores and International Index of Erectile Function scores were obtained. Prostate-specific antigen level was monitored, with biochemical recurrence defined as nadir + 2 ng/mL (Phoenix).
Thirty patients with National Comprehensive Cancer Network low- (13%) to intermediate-risk (87%) prostate cancer were treated between May 2013 and April 2016. Median follow-up was 4 years. Median age was 71 years (interquartile range, 68-73) and median initial prostate-specific antigen level was 7.3 ng/mL (5.2-8.1). Maximum Gleason score was 4 + 3 = 7 (in 2 patients). All tumors were radiologic (MRI) stage T2. No grade >2 GU or >1 GI toxicity occurred. International Prostate Symptom Scores only deteriorated temporarily. Mild pretreatment ED deteriorated to moderate/severe ED in 50% of patients. Long-term clinically relevant QoL deterioration was seen in sexual activity and tiredness, whereas emotional and cognitive functioning improved. At 4 years, biochemical disease-free survival was 70% (95% confidence interval, 52%-93%), metastases-free survival was 93% (85%-100%), and overall survival was 100%. Of intraprostatic recurrences, 7 of 9 were out of field.
Ultrafocal high-dose-rate brachytherapy conveys minimal GU or GI toxicity and has a marginal effect on QoL. An early decline in erectile function was seen. Tumor control outcomes are poor (biochemical disease-free survival of 70% [52%-93%] at 4 years), most likely as a result of poor patient selection.
对于局限性前列腺癌的治疗，与传统的全腺体治疗相比，局灶性治疗具有更少的副作用和治愈的潜力。我们报告了我们在磁共振成像（MRI）引导的超局灶高剂量率近距离治疗队列中，在毒性、生活质量（QoL）和肿瘤控制方面的最新进展。
通过系统活检和 3T 多参数 MRI 评估疾病状况。在经直肠超声/MRI 融合引导下进行近距离治疗植入手术后，进行 1.5T MRI 以调整轮廓和验证导管位置。肿瘤给予 19Gy 的单次剂量，边缘为 5mm。采用通用不良事件术语标准 4.0 对泌尿生殖系统（GU）毒性、胃肠道（GI）毒性和勃起功能障碍（ED）进行分级。采用 RAND-36、欧洲癌症研究和治疗组织 EORTC QLQ-C30 和 PR25 测量 QoL。获得国际前列腺症状评分和国际勃起功能指数评分。监测前列腺特异性抗原水平，生化复发定义为最低点+2ng/mL（凤凰）。
2013 年 5 月至 2016 年 4 月期间，30 例符合国家综合癌症网络低危（13%）至中危（87%）前列腺癌标准的患者接受了治疗。中位随访时间为 4 年。中位年龄为 71 岁（四分位间距，68-73），中位初始前列腺特异性抗原水平为 7.3ng/mL（5.2-8.1）。最大 Gleason 评分为 4+3=7（2 例）。所有肿瘤均为影像学（MRI）T2 期。无>2 级 GU 或>1 级 GI 毒性。国际前列腺症状评分仅暂时恶化。50%的患者轻度预处理 ED 恶化至中度/重度 ED。长期临床相关 QoL 恶化发生在性行为和疲劳方面，而情绪和认知功能得到改善。4 年时，生化无病生存率为 70%（95%置信区间，52%-93%），无转移生存率为 93%（85%-100%），总生存率为 100%。9 例局部复发中有 7 例位于野内。
超局灶高剂量率近距离治疗导致最小的 GU 或 GI 毒性，对 QoL 仅有轻微影响。早期勃起功能下降。肿瘤控制结果较差（4 年时生化无病生存率为 70%[52%-93%]），这很可能是由于患者选择不佳所致。
