American College of Radiology Appropriateness Criteria(®)--locally advanced (high-risk) prostate cancer.

The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. This review focuses on locally advanced prostate cancer and the evidence for treatment outcomes, both toxicity and efficacy, across the three major treatment modalities of external beam radiotherapy, brachytherapy and surgery. Only data that could pass contemporary quality metrics were used to form this report. This body of literature suffers from an absence of trials prospectively comparing therapies for efficacy and a lack of long-term prospective comparisons of toxicity. Upon review of these data, the authors concluded that there are several acceptable methods for the treatment of locally advanced prostate cancer that is highly dependent of the patient's clinical (both prostate cancer-specific and comorbidity-specific) parameters at diagnosis.

Calculated dosimetric parameters of the IoGold 125I source model 3631-A.

Basic dosimetric parameters as recommended by the AAPM Task Group No. 43 (TG-43) have been determined for recently available IoGold 125I brachytherapy seeds. Monte Carlo methods (MCNP) were used in the calculation of these parameters in water, and results compared with soon to be published experimental parameters also for 125I IoGold seeds as well with parameters for model 6702 and 6711 125I seeds. These parameters were the radial dose function, anisotropy factor and constant, and the dose rate constant. Using MCNP, values for the radial dose function at 0.5, 2.0, and 5.0 cm were 1.053, 0.877, and 0.443, respectively. The anisotropy factor was 0.975, 0.946, 0.945, and 0.952 at 0.5, 1.0, 2.0, and 5.0 cm, respectively, with an anisotropy constant of 0.95. The IoGold dose rate constant was determined by excluding the low energy titanium characteristic x rays produced in the IoGold titanium capsule. Using this post TG-43 revised NIST air kerma methodology, the IoGold dose rate constant was 0.96 cGy h-1 U-1. These calculatively determined parameters for IoGold seeds were compared with those determined experimentally for IoGold seeds, and also compared with parameters determined for model 6702 and 6711 seeds as presented in TG-43.

Quality of life after permanent prostate implant.

Quality of life is one of several endpoints commonly studied in prostate cancer treatment. It refers to how well an individual is functioning in life and his total sense of well being. There is increasing recognition that cancer therapy impacts significantly on the patient's ability to pursue relational, occupational and social interests. Fifty-one patients with clinically localized prostate cancer who had undergone transperineal permanent prostate implantation were evaluated. All patients were clinically staged as T1c or T2a and received an implant alone with Iodine 125 or Palladium 103 as definitive treatment. Six months after implant, data was collected using the European Organization for Research and Treatment of Cancer (EORTC) genitourinary group questionnaire and supplemental questions. Urinary symptoms such as nocturia, hesitancy, frequency, and dysuria were the most pronounced in the first few months after the implant and then decreased in most of patients; 40% noticed that they urinated more frequently and 17% had mild dysuria. All patients denied hematuria and none reported incontinence. Few patients reported any psychological distress or disruption in social or family life; none reported disruption in economic status or viability. All fifty-one patients said that they would have an implant again as definitive treatment. Seventy-nine percent reported an excellent quality of life post-implant. While survival is clearly a central goal of treatment for prostate cancer, the nature of this malignancy compels clinical attention to the quality of the patient's life after treatment. Sexual quality and function are maintained in the majority of patients and there is minimal interruption of their social and economic function.

Breath ethane generation during clinical total body irradiation as a marker of oxygen-free-radical-mediated lipid peroxidation: a case study.

Total body irradiation (TBI) is used therapeutically for treatment of leukemias and other malignancies of the hemopoietic system. Ionizing radiation produces oxygen free radicals that contribute to cytotoxicity. Breath collected from one patient undergoing therapeutic TBI showed measurable changes in levels of ethane during treatment. Breath ethane is a marker of lipid peroxidation of n-3 fatty acids. The TBI treatment involved 4 days of irradiation. The largest changes in breath ethane occurred on Day 2. The increased levels of breath ethane on Day 2 were correlated to clinical manifestations of toxicity. The correlation of the onset of gastrointestinal side effects with higher levels of breath ethane suggests that breath ethane may be a clinically useful measure of the toxicity of various TBI fractionation treatment protocols currently in use at different medical centers. The levels of breath ethane on the other days of treatment were lower, suggesting that the oxidative-antioxidative balance of the patient may be important in protection against free radical mediated injury. These results for a single patient suggest that breath ethane may be a promising approach to elucidate the role of antioxidants in clinical TBI and should be extended for verification to a larger volunteer patient population.

Treatment-related symptoms during the first year following transperineal 125I prostate implantation.

PURPOSE: To summarize the urinary, rectal, and sexual symptoms occurring during the first 12 months following 125I prostatic implantation. METHODS AND MATERIALS: Thirty-one patients with Stage T1 or T2 prostatic carcinoma were evaluated for morbidity following computed tomography-guided transperineal 125I implants from 1988 to 1991. The median total activity used was 47 mCi (range 35-73 mCi). Toxicity was evaluated using a modification of the Radiation Therapy Oncology Group grading system. RESULTS: Nocturia was the most common treatment-related symptom, reported by 80% of patients within 2 months after implantation, and persisted at 12 months in 45% of the patients. Mild dysuria developed in 48% of patients within 2 months of implantation; two patients needed analgesics for their dysuria. Terazosin hydrochloride (2-10 mg qd) provided subjective improvement of urinary symptoms in seven of eight patients in whom it was tried. Rectal urgency, soft stools, and increased frequency of bowel movements was reported by 25% of the patients within 1-2 months after implantation. The incidence of asymptomatic rectal bleeding or ulceration occurring at any time after implantation was 47%, but resolved in all patients with expectant treatment. Self-limited ulceration of the rectal mucosal occurred in 16%, but only one patient developed a prostato-rectal fistula, managed with an ileal conduit. Five of the 18 potent patients experienced discomfort on erection or ejaculation, beginning within several weeks of their implant. The discomfort resolved within 6 months in three of the patients, but persisted for 18 and 24 months in the other two. CONCLUSION: 125I implantation, as performed in this series, is generally associated with only mild-moderate genitourinary and rectal symptoms that may persist 6 months or more after implantation. Prostatic carcinoma, Brachytherapy, Morbidity.

High-dose rate brachytherapy for carcinoma of the cervix.

Increasingly popular in Europe and Asia as the intracavitary component for cervical cancer radiotherapy, high-dose rate brachytherapy demonstrates certain advantages over historical low-dose rate treatments. High-dose rate intracavitary treatment improves radiation safety, lessens treatment times, allows for outpatient treatment regimens, and has improved packing and retraction techniques, which can decrease rectal and bladder doses. Although retrospective studies of high-dose rate treatment show survival rates comparable with those of historical low-dose rate intracavitary treatment, there have been few randomized, prospective studies to support the use of high-dose rate techniques. Low- and high-dose rate comparisons are further complicated by the lack of standardized fractionation schemes and dose prescriptions for high-dose rate treatment. Recent data showing decreased local control in advanced cervical cancer with the prolonged overall treatment time of low-dose rate treatment suggest the practical advantage of outpatient high-dose rate intracavitary brachytherapy, which uses fractionated regimens and shortens overall treatment times. Although high-dose rate treatment has not been shown to improve survival compared with low-dose rate treatment, its practical advantages may account for its increasing use.

Short-term morbidity from CT-planned transperineal I-125 prostate implants.

PURPOSE: To summarize short-term morbidity and tumor response following transperineal CT-guided I-125 prostate implantation. METHODS AND MATERIALS: Twenty-one patients were treated with CT-based transperineal I-125 prostate implantation between June, 1988 and May, 1990. An average of 75 I-125 seeds were placed, with an average activity of .62 mCi/seed. Symptoms were quantified after interviewing each patient in detail. RESULTS: Nearly all patients developed substantial dysuria, nocturia and frequency from 2-24 weeks following implantation. Urinary symptoms usually resolved within 4-6 months of implantation. The one year actuarial potency rate among 18 patients who were potent prior to implantation was 94%. By 6 months after implantation, 14/17 patients (82%) with Stage B tumors had complete regression of palpable disease. Of 17 patients with Stage A or B tumors who presented with an elevated PSA, 76% returned to the normal range within 6 months of implantation. CONCLUSION: CT-guided transperineal prostate implants entail moderate, temporary urinary and rectral morbidity. Short-term tumor responses are encouraging.

An improved method for computerized tomography-planned transperineal 125iodine prostate implants.

Transperineal 125iodine implants of the prostate can be performed with ultrasound guidance, a simple technique that has met with widespread acceptance. However, ultrasound does not allow good visualization of the pubic bones in relation to the pelvic outlet, and the pubic bones may interfere with needle placement in the anterior peripheral aspect of the prostate. Adequate irradiation of the entire periphery of the prostate is important to assure tumor control, since most tumors are multicentric and may involve the anterior aspect of the prostate. A computerized tomography-based treatment planning procedure that allows for angulation of transperineal needles to avoid the pubic bones and still reaches the most peripheral aspects of the gland is described. The technique also allows for the use of transrectal ultrasound and fluoroscopy to verify correct needle placement in the prostate at the procedure. Early treatment results, based on prostate specific antigen and regression of palpable tumors, are encouraging.

Peritoneal dialysis-associated tuberculous peritonitis in an intravenous drug user with acquired immunodeficiency syndrome.

A rare case of tuberculous peritonitis in a continuous ambulatory peritoneal dialysis (CAPD) patient who has multiple risk factors for extrapulmonary disease due to Mycobacterium tuberculosis is presented. This patient' acute course was atypical with a predominance of neutrophils and low levels of protein in the peritoneal fluid. Obtaining the diagnosis of tuberculous peritonitis by acid-fast smear was also unusual, probably facilitated by centrifugation of large amounts of fluid. The patient was successfully treated without catheter removal. Tuberculosis should be considered in patients with culture-negative CAPD peritonitis.