0022-534 7 /90/1443-0704$02.00/0 THE JOURNAL OF UROLOGY Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
125
Vol. 144, September Printed in U.S.A.
IODINE REIMPLANTATION FOR LOCALLY PROGRESSIVE PROSTATIC CARCINOMA
KENT E. WALLNER,* DATTATREYUDU NORI, MICHAEL J. MORSE, PRAMOD C. SOGANI, WILLET F. WHITMORE AND ZVI FUKS From the Department of Radiation Oncology and Urology Service, Memorial Sloan-Kettering Cancer Center, New York, New York
ABSTRACT
We treated 13 patients with a second 125iodine implant for local recurrence of prostatic carcinoma. All patients had biopsy proved palpable recurrence without evidence of distant metastases. Full doses of irradiation were used (median matched peripheral dose 170 Gy.). Six patients had complete regression of palpable recurrence, 2 had partial regression, 2 had no apparent response and 3 were unevaluable for local response. Actuarial freedom from local disease progression at 5 years was 51 %. Despite a relatively high rate of local disease control the actuarial rate of distant metastases reached 100% at 6 years after reimplantation. There were 2 severe rectal complications and 4 instances of mild to moderate urinary incontinence among the 13 patients. Local regression of recurrent prostatic carcinoma may be achieved with 125iodine reimplantation but most patients still had distant metastases. (J. Ural., 144: 704-706, 1990) Some investigators have found that 125 iodine (1 25 I) implantation is an effective treatment for early stage prostatic carcinoma. Local control has ranged from 71 to 90%. 1 • 2 However, a substantial minority of patients will have locally recurrent disease. In the absence of distant metastases potentially effective salvage therapy includes prostatectomy, external beam irradiation, reimplantation with 1251 or hormonal manipulation. We describe the experience at our institution using 1251 reimplantation in 13 patients who had clinical local recurrence after initial treatment with 1251. METHODS
We treated 13 patients from May 1978 through June 1988 with a second 1251 implant of the prostate for clinical local recurrence. Local recurrence is defined by progressive abnormality of the prostate by digital rectal examination and/or increasing obstructive symptoms. Most patients treated for local tumor progression during that period were treated with hormonal ablation. There were no formal selection criteria for salvage therapy with reimplantation. Patients were chosen at the discretion of the urologist, medical oncologist or radiation oncologist. Reasons for selecting salvage therapy with reimplantation included patient desire to maintain potency, medical contraindications to hormonal therapy and inadequate placement of 1251 seeds at the initial implantation. All patients had been treated with 125! implantation from 1 to 7 years (median 3 years) previously. External beam irradiation was not used. Staging lymphadenectomy had been performed at the initial implantation and 4 of the 13 patients had positive lymph nodes. Five patients underwent the initial implant elsewhere and 8 underwent treatment at our institution. Three patients had had a clinical complete regression after the initial implant, 6 had partial regression and 2 had no regression, and in 2 the response to initial implantation was undetermined. Of 7 patients with stage B disease at presentation 1 had complete regression after the initial implantation, 3 had partial regression, 2 had no regression and the response was not known in 1. The patient with stage C disease at initial presentation had a partial regression after the initial implantation. Of 4 patients with stage Dl disease 1 had a complete regression of palpable tumor in the prostate, 2 had partial regression and the Accepted for publication March 28, 1990. *Requests for reprints: Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, New York 10021. 704
response in 1 was unknown. In all cases there was palpable tumor recurrence or progression by rectal examination before reimplantation. Needle biopsy in all patients confirmed the presence of malignancy. At reimplantation 5 patients had local disease believed to extend outside the prostatic capsule and 8 had disease that was believed to be confined within the capsule. One tumor was well differentiated, 5 were moderately well differentiated, 4 were poorly differentiated and 3 were ungraded. No patient had metastatic disease by bone scan or chest x-ray at the second implantation; 3 had elevated acid phosphatase values. Patient age at reimplantation ranged from 42 to 69 years (median age 61 years). Of the 13 patients 3 were treated via a retropubic approach, 3 via an open perineal approach and 7 by transperineal implantation with fluoroscopic or computerized tomographic (CT) guidance. The matched peripheral dose for the initial implants ranged from 65 to 193 Gy. (median 160 Gy.) and that for reimplantation ranged from 88 to 292 Gy. (median 170 Gy.). No patient received hormonal therapy in conjunction with reimplantation. All 10 patients who had distant metastases after reimplantation received hormonal therapy when they had metastatic disease. Patients were followed at 3 to 6-month intervals by rectal examination, acid phosphatase determinations and bone scan for periods ranging from 1 to 8 years (median 3 years). Biopsies were not performed after reimplantation. Clinical local progression was judged by progressive enlargement of the gland or tumor by rectal examination. Survival and freedom from progression were calculated by the method of Kaplan and Meier. RESULTS
Of the patients 6 had complete regression of palpable tumor after reimplantation, 2 had partial regression, 2 had no regression and 3 could not be adequately assessed for local tumor response by available records. Five of the 13 patients eventually had local disease progression after reimplantation (fig. 1). Freedom from local progression at 5 years was 51 %. Of the 6 patients with complete regression of palpable tumor only 1 had subsequent local progression, compared to 2 of 7 with stage B disease at initial diagnosis and 2 of 4 with stage Dl disease at initial implantation. The only patient with stage C disease had no tumor progression after reimplantation. Local progression was assessed relative to the volume of
705
REIMPLANTATION FOR LOCALLY PROGRESSIVE PROSTATIC CARCINOMA ~
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125
Vol. 144, September Printed in U.S.A.
IODINE REIMPLANTATION FOR LOCALLY PROGRESSIVE PROSTATIC CARCINOMA
KENT E. WALLNER,* DATTATREYUDU NORI, MICHAEL J. MORSE, PRAMOD C. SOGANI, WILLET F. WHITMORE AND ZVI FUKS From the Department of Radiation Oncology and Urology Service, Memorial Sloan-Kettering Cancer Center, New York, New York
ABSTRACT
We treated 13 patients with a second 125iodine implant for local recurrence of prostatic carcinoma. All patients had biopsy proved palpable recurrence without evidence of distant metastases. Full doses of irradiation were used (median matched peripheral dose 170 Gy.). Six patients had complete regression of palpable recurrence, 2 had partial regression, 2 had no apparent response and 3 were unevaluable for local response. Actuarial freedom from local disease progression at 5 years was 51 %. Despite a relatively high rate of local disease control the actuarial rate of distant metastases reached 100% at 6 years after reimplantation. There were 2 severe rectal complications and 4 instances of mild to moderate urinary incontinence among the 13 patients. Local regression of recurrent prostatic carcinoma may be achieved with 125iodine reimplantation but most patients still had distant metastases. (J. Ural., 144: 704-706, 1990) Some investigators have found that 125 iodine (1 25 I) implantation is an effective treatment for early stage prostatic carcinoma. Local control has ranged from 71 to 90%. 1 • 2 However, a substantial minority of patients will have locally recurrent disease. In the absence of distant metastases potentially effective salvage therapy includes prostatectomy, external beam irradiation, reimplantation with 1251 or hormonal manipulation. We describe the experience at our institution using 1251 reimplantation in 13 patients who had clinical local recurrence after initial treatment with 1251. METHODS
We treated 13 patients from May 1978 through June 1988 with a second 1251 implant of the prostate for clinical local recurrence. Local recurrence is defined by progressive abnormality of the prostate by digital rectal examination and/or increasing obstructive symptoms. Most patients treated for local tumor progression during that period were treated with hormonal ablation. There were no formal selection criteria for salvage therapy with reimplantation. Patients were chosen at the discretion of the urologist, medical oncologist or radiation oncologist. Reasons for selecting salvage therapy with reimplantation included patient desire to maintain potency, medical contraindications to hormonal therapy and inadequate placement of 1251 seeds at the initial implantation. All patients had been treated with 125! implantation from 1 to 7 years (median 3 years) previously. External beam irradiation was not used. Staging lymphadenectomy had been performed at the initial implantation and 4 of the 13 patients had positive lymph nodes. Five patients underwent the initial implant elsewhere and 8 underwent treatment at our institution. Three patients had had a clinical complete regression after the initial implant, 6 had partial regression and 2 had no regression, and in 2 the response to initial implantation was undetermined. Of 7 patients with stage B disease at presentation 1 had complete regression after the initial implantation, 3 had partial regression, 2 had no regression and the response was not known in 1. The patient with stage C disease at initial presentation had a partial regression after the initial implantation. Of 4 patients with stage Dl disease 1 had a complete regression of palpable tumor in the prostate, 2 had partial regression and the Accepted for publication March 28, 1990. *Requests for reprints: Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, New York 10021. 704
response in 1 was unknown. In all cases there was palpable tumor recurrence or progression by rectal examination before reimplantation. Needle biopsy in all patients confirmed the presence of malignancy. At reimplantation 5 patients had local disease believed to extend outside the prostatic capsule and 8 had disease that was believed to be confined within the capsule. One tumor was well differentiated, 5 were moderately well differentiated, 4 were poorly differentiated and 3 were ungraded. No patient had metastatic disease by bone scan or chest x-ray at the second implantation; 3 had elevated acid phosphatase values. Patient age at reimplantation ranged from 42 to 69 years (median age 61 years). Of the 13 patients 3 were treated via a retropubic approach, 3 via an open perineal approach and 7 by transperineal implantation with fluoroscopic or computerized tomographic (CT) guidance. The matched peripheral dose for the initial implants ranged from 65 to 193 Gy. (median 160 Gy.) and that for reimplantation ranged from 88 to 292 Gy. (median 170 Gy.). No patient received hormonal therapy in conjunction with reimplantation. All 10 patients who had distant metastases after reimplantation received hormonal therapy when they had metastatic disease. Patients were followed at 3 to 6-month intervals by rectal examination, acid phosphatase determinations and bone scan for periods ranging from 1 to 8 years (median 3 years). Biopsies were not performed after reimplantation. Clinical local progression was judged by progressive enlargement of the gland or tumor by rectal examination. Survival and freedom from progression were calculated by the method of Kaplan and Meier. RESULTS
Of the patients 6 had complete regression of palpable tumor after reimplantation, 2 had partial regression, 2 had no regression and 3 could not be adequately assessed for local tumor response by available records. Five of the 13 patients eventually had local disease progression after reimplantation (fig. 1). Freedom from local progression at 5 years was 51 %. Of the 6 patients with complete regression of palpable tumor only 1 had subsequent local progression, compared to 2 of 7 with stage B disease at initial diagnosis and 2 of 4 with stage Dl disease at initial implantation. The only patient with stage C disease had no tumor progression after reimplantation. Local progression was assessed relative to the volume of
705
REIMPLANTATION FOR LOCALLY PROGRESSIVE PROSTATIC CARCINOMA ~
100 -~
C:
> > lb.
80
:ll (1)
UJ
60
C 0
40
-
40
(2)
"=
0
20
n
13 patients
20
0
13 patients
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ll. 12
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72
84
96
Months after reimplantation
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