Prostate Cancer
Brachytherapy in the Treatment of Localised Prostate Cancer – A Review of Minimally Invasive Treatment
Thierry A Flam Professor of Urology, Department of Urology, Hôpital Cochin and Institut Curie, Paris
Abstract
Among the radiotherapy treatments for prostate cancer (PCa), ultrasound-guided low-dose-rate (LDR) transperineal brachytherapy is an option that is capable of delivering highly concentrated doses of radiation to the prostate gland. This technique involves the precise insertion of seeds containing a radioisotope into the prostate gland to apply radiation doses to the tumour while sparing the surrounding healthy tissue. LDR brachytherapy is a safe and efficient technique that is typically applied to patients with low-risk PCa. It has become a mainstream treatment option for a wider population of men diagnosed with PCa, due to the excellent long-term treatment outcomes that have been seen in low- and intermediate-risk patients. The use of LDR brachytherapy is now increasing due to its reliability, reproducibility and the increasing number of tumours being detected at the early stage of localised PCa. Newer surgical techniques in PCa have not improved clinical outcomes and this has contributed to the consideration of brachytherapy, which is a truly minimally invasive technique with excellent clinical outcomes.
Keywords Brachytherapy, low dose rate, prostate cancer, quality of life, radiation therapy, seeds, iodine-125
Disclosure: The author has no conflicts of interest to declare. Received: 25 July 2011 Accepted: 22 November 2011 Citation: European Urological Review, 2011;6(2):74–83 Correspondence: Thierry A Flam, Department of Urology, Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, 75679 Paris Cedex 14, France. E:
thierry.flam@cch.aphp.fr
Support: The publication of this article was funded by Eckert & Ziegler BEBIG. The views and opinions expressed are those of the author and not necessarily those of Eckert & Ziegler BEBIG.
Prostate cancer (PCa) is recognised as one of the major medical problems facing the male population, with a higher incidence among Europeans and populations of European origin compared with other world regions such as Africa and Asia. Within Europe, studies for the years up to 2005 report the incidence of PCa to vary from 10–15 cases/year/100,000 of the population in Serbia to 90–95 cases/100,000 in Sweden, compared with 0–5 reported cases/year/100,000 in Northern Africa and China.1,2
Across other countries in Europe the incidence of PCa also varies; in Spain it has been reported to be in the range 35–39.9 cases/year/100,000, compared with 50–54.9 in the UK, 55–59.9 in France and 60–64.9 in Germany.2
Mortality in PCa is declining at different rates;
across Western Europe this is occurring at -0.8 % to -3.1 %/year, but in Eastern Europe it is increasing at rates of 3–9.6 %/year.1–3
According
to Cancer Research UK, PCa constitutes approximately 24 % of all male cancers4 the UK.5
resulting in 12 % of all male cancer-related deaths in
There are currently a range of treatment options, among which radiotherapy and radical prostatectomy (RP) are the standard approaches. If treated appropriately, patients with localised PCa have a good chance of being disease-free for at least 15 years.6
The current management of localised PCa relies upon four main options: RP, external-beam radiation therapy (EBRT), brachytherapy (BT) and active surveillance (AS). The limited number of randomised controlled comparative clinical trials is reflected in an absence of level 1 clinical evidence for any of these options. Consequently, treatment
74
Ultrasound-guided low-dose-rate (LDR) BT typically employs seeds of iodine-125 (125I) or palladium-103 (103Pd) encapsulated in titanium shells implanted permanently into the prostate. The appearance of LDR BT seeds and an applicator system are shown in Figure 1. In the case of high-dose-rate (HDR) BT, a single radioactive iridium-192 (192Ir) or cobalt-60 (60Co) source is temporarily introduced into the prostate via transperineal sheaths. HDR BT is a parallel technique to LDR BT but is more often used to deliver a boost radiation dose to the prostate in combination with EBRT for the treatment of high-risk localised PCa. HDR BT may also be used in monotherapy protocols but
© TOUCH BRIEFINGS 2011
choice tends to be based on physician experience or patient preference and the perception of potential side effects.
Some urologists consider RP to be the standard option for the treatment of patients with localised cancer and a life expectancy greater than 10 years. However, this procedure carries a significant risk of side effects, including erectile dysfunction, urinary incontinence and surgical complications. The likelihood and impact of these side effects has led to an increasing interest in alternative treatments with potential for decreased morbidity and equivalent disease-free survival. Robot-assisted RP has recently become a predominant surgical method. This treatment, however, has not significantly improved cancer outcome, continence, erectile function preservation and patient satisfaction, compared with traditional surgical techniques for prostatectomy.7–9
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76