Localized prostate cancer with intermediate- or high-risk features treated with combined external beam radiotherapy and iodine-125 seed brachytherapy



      The aim of the study is to compare the results of the combined external beam radiotherapy (EBRT) with iodine-125 seed brachytherapy vs. brachytherapy alone for prostate cancer treatment in patients with intermediate and high risk of disease recurrence.

      Methods and Materials

      Ninety-six patients were treated from January 1998 to December 2006. Twenty-four patients received combined treatment and 72 patients received brachytherapy alone. Patients were classified into intermediate or high risk of recurrence according to the D’Amico’s classification. The prescribed dose for brachytherapy was 145 Gy as monotherapy and 110 Gy for combined treatment. The dose of EBRT was 45 Gy over 5 weeks, with 1.8 Gy daily fractions. Results were analyzed based on Phoenix definition of biochemical recurrence, that is, nadir plus 2 ng/mL.


      Biochemical control was achieved by 96% (23 of 24) of patients receiving combined treatment and by 72% (52 of 72) in the group treated by brachytherapy alone (p<0.015). The addition of EBRT resulted in a 94% biochemical disease-free survival at 5 years; and in brachytherapy alone group, the rate was 54% (p<0.011). Mean followup was 96 months (24–132 months; confidence interval 95%: 90–102).


      This study shows that in patients with localized prostate cancer, with intermediate and high risk of biochemical recurrence, the addition of EBRT can confer a significant biochemical control advantage when added to brachytherapy.


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      1. National Cancer institute / Brasil. Estimative 2010: Incidence of cancer in Brasil. Rio de Janeiro, Brasil. Available at: Accessed August 04, 2010.

        • Jani A.B.
        • Feinstein J.M.
        • Pasciak R.
        • et al.
        Role of external beam radiotherapy with low-dose-rate brachytherapy in treatment of prostate cancer.
        Urology. 2006; 67: 1007-1011
        • Potters L.
        • Morgenstern C.
        • Calugaru E.
        • et al.
        12-Year outcomes following permanent prostate brachytherapy in patients with clinically localized prostate cancer.
        J Urol. 2005; 173: 1562-1566
        • Hoskin P.J.
        • Venselaar J.
        • on behalf of the BRAPHYQS and PROBATE groups of GEC ESTRO
        Prostate brachytherapy in Europe: Growth, practice and guidelines.
        Radiother Oncol. 2007; 83: 1-2
        • Nickers P.
        • Thissen B.
        • Jansen N.
        • et al.
        192Ir or 125I prostate brachytherapy as a boost to external beam radiotherapy in locally advanced prostate cancer: A dosimetric point of view.
        Radiother Oncol. 2006; 78: 47-52
        • Blasko J.C.
        • Grimm P.D.
        • Sylvester J.E.
        • et al.
        The role of external beam radiotherapy with I-125/Pd-103 brachytherapy for prostate carcinoma.
        Radiother Oncol. 2000; 57: 273-278
        • Merrick G.S.
        • Butler W.M.
        • Wallner K.E.
        • et al.
        Impact of supplemental external beam radiotherapy on biochemical outcome after permanent prostate brachytherapy.
        Int J Radiat Oncol Biol Phys. 2005; 61: 32-43
        • D’Amico A.V.
        • Whittington R.
        • Malkowicz S.B.
        • et al.
        Biochemical outcome after radical prostatectomy, external beam radiation therapy or interstitial radiation therapy for clinically localized prostate cancer.
        JAMA. 1998; 280: 969-974
        • Joniau S.
        • Poppel H.V.
        Localized prostate cancer: Can we better define who is at risk of unfavourable outcome?.
        BJU Int. 2008; 101: 5-10
        • Bratt O.
        The urologist’s guide to low dose-rate interstitial brachytherapy with permanent seed implants for localized prostate cancer.
        BJU Int. 2006; 99: 497-501
        • Soto D.E.
        • McLaughlin P.W.
        Combined permanent implant and external-beam radiation therapy for prostate cancer.
        Semin Radiat Oncol. 2008; 18: 23-34
        • Nag S.
        • Beyer D.
        • Friedland J.
        • et al.
        American Brachytherapy Society (ABS) recommedations for transperineal permanent brachytherapy of prostate cancer.
        Int J Radiat Oncol Biol Phys. 1999; 44: 789-799
        • Sylvester J.E.
        • Grimm P.D.
        • Blasko J.C.
        • et al.
        15-year biochemical free survival in clinical stage T1–T3 prostate cancer following combined external beam radiotherapy and brachytherapy: Seattle Experience.
        Int J Radiat Oncol Biol Phys. 2007; 67: 57-64
        • Yu Y.
        • Anderson L.L.
        • Li Z.
        • et al.
        Permanent prostate seed implant brachytherapy: Report of the American Association of Physicists in Medicine Task Group No 64.
        Med Phys. 1999; 26: 2054-2076
        • Salembier C.
        • Lavagnini P.
        • Nickers P.
        • et al.
        Tumour and target volumes in permanent prostate brachytherapy: A supplement to the ESTRO/EAU/EORTC recommendations on prostate brachytherapy.
        Radiother Oncol. 2007; 83: 3-10
        • Merrick G.S.
        • Grimm P.D.
        • Sylvester J.E.
        • et al.
        Initial analysis of Pro-Qura: A multi-institutional database of prostate brachytherapy dosimetry.
        Brachytherapy. 2007; 6: 9-15
        • Roach III, M.
        • Hanks G.
        • Thames Jr., H.
        • et al.
        Defining biochemical failure following radiotherapy with or without hormonal therapy in men with clinically localized prostate cancer: Recommendations of the RTOG-ASTRO Phoenix consensus conference.
        Int J Radiat Oncol Biol Phys. 2006; 64: 965-974
        • Stone N.N.
        • Potters L.
        • Davis B.J.
        • et al.
        Multicenter analysis of effect of high biologic effective dose on biochemical failure and survival outcomes in patients with Gleason score 7-10 prostate cancer treated with permanent prostate brachytherapy.
        Int J Radiat Oncol Biol Phys. 2009; 73: 341-346
        • Potters L.
        • Fearn P.
        • Kattan M.W.
        External radiotherapy and permanent prostate brachytherapy in patients with localized prostate cancer.
        Brachytherapy. 2002; 1: 36-41
        • Franca C.A.S.
        • Vieira S.L.
        • Bernabé A.J.S.
        • et al.
        The seven-years preliminary results of brachytherapy with iodine-125 seeds for localized prostate cancer treated at a Brazilian single-center.
        Int Braz J Urol. 2007; 33: 752-763
        • Khaksar S.J.
        • Laing R.W.
        • Henderson A.
        • et al.
        Biochemical prostate-specific antigen relapse-free survival and toxicity after 125I low-dose-rate prostate brachytherapy.
        BJU Int. 2006; 98: 1210-1215
        • Critz F.A.
        • Levinson K.
        10-year disease-free survival rates after simultaneous irradiation for prostate cancer with a focus on calculation methodology.
        J Urol. 2004; 172: 2232-2238
        • Merrick G.S.
        • Butler W.M.
        • Wallner K.E.
        • et al.
        Temporal effect of neoadjuvant androgen deprivation therapy on PSA kinetics following permanent prostate brachytherapy with or without supplemental external beam radiation.
        Brachytherapy. 2004; 3: 141-146
        • Sylvester J.E.
        • Blasko J.C.
        • Grimm P.D.
        • et al.
        Ten-year biochemical relapse-free survival after external beam radiation and brachytherapy for localized prostate cancer: The Seattle experience.
        Int J Radiat Oncol Biol Phys. 2003; 57: 944-952
        • Zelefsky M.J.
        • Kuban D.A.
        • Levy L.B.
        • et al.
        Multi-institutional analysis of long-term outcome for stages T1–T2 prostate cancer treated with permanent seed implantation.
        Int J Radiat Oncol Biol Phys. 2007; 67: 327-333
        • Ray M.E.
        • Thames H.D.
        • Levy L.B.
        • et al.
        PSA nadir predicts biochemical and distant failures after external beam radiotherapy for prostate cancer: A multi-institutional analysis.
        Int J Radiat Oncol Biol Phys. 2006; 64: 1140-1150
        • Pollack A.
        • Hanlon A.L.
        • Horwitz E.M.
        • et al.
        Prostate cancer radiotherapy dose response: An update of the fox chase experience.
        J Urol. 2004; 171: 1132-1136

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