Long-term oncological and functional follow-up in low-dose-rate brachytherapy for prostate cancer: results from the prospective nationwide Swiss registry.

OBJECTIVE: To evaluate the long-term oncological, functional and toxicity outcomes of low-dose-rate brachytherapy (LDR-BT) in relation to risk factors and radiation dose in a prospective multicentre cohort. PATIENTS AND METHODS: Data of patients from 12 Swiss centres undergoing LDR-BT from September 2004 to March 2018 were prospectively collected. Patients with a follow-up of ≥3 months were analysed. Functional and oncological outcomes were assessed at ~6 weeks, 6 and 12 months after implantation and annually thereafter. LDR-BT was performed with 125 I seeds. Dosimetry was done 6 weeks after implantation based on the European Society for Radiotherapy and Oncology recommendations. The Kaplan-Meier method was used for biochemical recurrence-free survival (BRFS). A prostate-specific antigen (PSA) rise above the PSA nadir + 2 was defined as biochemical failure. Functional outcomes were assessed by urodynamic measurement parameters and questionnaires. RESULTS: Of 1580 patients in the database, 1291 (81.7%) were evaluable for therapy outcome. The median (range) follow-up was 37.1 (3.0-141.6) months. Better BRFS was found for Gleason score ≤3+4 (P = 0.03, log-rank test) and initial PSA level of <10 ng/mL (P < 0.001). D'Amico Risk groups were significantly associated with BRFS (P < 0.001), with a hazard ratio of 2.38 for intermediate- and high-risk patients vs low-risk patients. The radiation dose covering 90% of the prostate volume (D90) after 6 weeks was significantly lower in patients with recurrence. Functional outcomes returned close to baseline levels after 2-3 years. A major limitation of these findings is a substantial loss to follow-up. CONCLUSION: Our results are in line with other studies showing that LDR-BT is associated with good oncological outcomes together with good functional results.

PSA bounce after ¹²5I-brachytherapy for prostate cancer as a favorable prognosticator.

BACKGROUND: Permanent low-dose-rate brachytherapy (BT) with iodine 125 is an established curative treatment for localized prostate cancer. After treatment, prostate-specific antigen (PSA) kinetics may show a transient rise (PSA bounce). Our aim was to investigate the association of PSA bounce with biochemical control. PATIENTS AND METHODS: Patients treated with BT in Switzerland were registered in a prospective database. Only patients with a follow-up of at least 2 years were included in our analysis. Clinical follow-up and PSA measurements were assessed after 1.5, 3, 6, and 12 months, and annually thereafter. If PSA increased, additional follow-up visits were scheduled. Cases of PSA bounce were defined as a rise of at least 0.2 ng/ml above the initial PSA nadir with a subsequent decline to or below the initial nadir without treatment. Biochemical failure was defined as a rise to nadir + 2 ng/ml. RESULTS: Between March 2001 and November 2010, 713 patients with prostate cancer undergoing BT with at least 2 years of follow-up were registered. Median follow-up time was 41 months. Biochemical failure occurred in 28 patients (3.9 %). PSA bounce occurred in 173 (24.3 %) patients; only three (1.7 %) patients with PSA bounce developed biochemical failure, in contrast to 25 (4.6 %) patients without previous bounce (p < 0.05). The median time to bounce was 12 months, the median time to biochemical failure was 30 months. The median bounce increase was 0.78 ng/ml. Twenty-eight patients with bounce (16.5 %) had a transient PSA rise of + 2 ng/ml above the nadir. CONCLUSION: In most cases, an early increase in PSA after BT indicates PSA bounce and is associated with a lower risk of biochemical failure.

High-resolution diffusion tensor imaging of prostate cancer using a reduced FOV technique.

OBJECTIVE: Diffusion tensor imaging (DTI) offers the promise of improved tumor localization in prostate cancer but the technique suffers from susceptibility-induced artifacts that limit the achievable resolution. The present work employs a reduced field-of-view technique that enables high-resolution DTI of the prostate at 3T. Feasibility of the approach is demonstrated in a clinical study including 26 patients and 14 controls. MATERIALS AND METHODS: Reduced field-of-view acquisition was established by non-coplanar application of the excitation and the refocusing pulse in conjunction with outer volume suppression. Accuracy for cancer detection of apparent diffusion coefficient (ADC) mapping and T2-weighted imaging was calculated and compared with reference to the findings of trans-rectal ultrasound-guided octant biopsy. Mean ADCs and fractional anisotropy (FA) values in the patients with positive and negative biopsies were compared to each other and to the controls. RESULTS: Fine anatomical details were successfully depicted on the ADC maps with sub-millimeter resolution. Accuracy for prostate cancer detection was 73.5% for ADC maps and 71% for T2-weighted images, respectively. Cohen's kappa (κ=0.48) indicated moderate agreement of the two methods. The mean ADCs were significantly lower, the FA values higher, in the patients with positive biopsy than in the patients with negative biopsy and the controls. Monte Carlo simulations showed that the FA values, but not the ADCs, were slightly overestimated. Bootstrap analysis revealed that the ADC, but not the FA value, is a highly repeatable marker. CONCLUSION: In conclusion, the present work introduces a new approach for high-resolution DTI of the prostate enabling a more accurate detection of focal tumors especially useful in screening populations or as a potential navigator for image-guided biopsy.

Exposure of treating physician to radiation during prostate brachytherapy using iodine-125 seeds: dose measurements on both hands with thermoluminescence dosimeters.

BACKGROUND AND PURPOSE: Only sparse reports have been made about radiation exposure of the treating physician during prostate seed implantation. Therefore, thermoluminescence dosimeter (TLD) measurements on the index fingers and the backs of both hands were conducted. MATERIAL AND METHODS: Stranded iodine-125 seeds with a mean apparent activity of 27.4 MBq per seed were used. During application, the treating physician manipulated the loaded needle with the index fingers, partially under fluoroscopic control. Four physicians with varying experience treated 24 patients. The radiation exposure was determined with TLD-100 chips attached to the index fingertips and the backs of hands. Radiation exposure was correlated with the physician's experience. RESULTS: The average brachytherapy duration by the most experienced physician was 19.2 min (standard deviation sigma = 1.2 min; novices: 34.8 min [sigma = 10.2 min]). The mean activity was 1,703 MBq (sigma = 123 MBq), applied with 16.3 needles (sigma = 2.5 needles; novices: 1,469 MBq [sigma = 229 MBq]; 16.8 needles [sigma = 2.3 needles]). The exposure of the finger of the "active hand" and the back of the hand amounted to 1.31 mSv (sigma = 0.54 mSv) and 0.61 mSv (sigma = 0.23 mSv), respectively (novices: 2.07 mSv [sigma = 0.86 mSv] and 1.05 mSv [sigma = 0.53 mSv]). CONCLUSION: If no other radiation exposure needs to be considered, an experienced physician can perform about 400 applications per year without exceeding the limit of 500 mSv/year; for novices, the corresponding figure is about 200.

Intermittent ureteral herniation--rare cause of flank pain.

Ureteral herniation is rare and difficult to diagnose, especially when intermittent, and ureterocystoneostomy using the psoas hitch or boari flap techniques have so far been used as therapeutic options. We describe ureterolysis in two cases as a successful alternative approach.

Update on screening for prostate cancer with prostate-specific antigen.

Serum prostate-specific antigen (PSA) determination in conjunction with digital rectal examination (DRE) is recommended by the majority of clinical guidelines for early detection(opportunistic screening) of prostate cancer provided the patient is well informed and has a life-expectancy of at least 10 years. The major disadvantage of PSA is its lack of specificity. Various static and dynamic concepts have been developed to improve the diagnostic performance of PSA of which free/total PSA ratio and PSA doubling time seem to be the most promising. Apart from early detection, population screening(mass screening) is a distinct topic. The effect of the latter one with regard to reduction of prostate cancer specific mortality and quality of life issues is not yet clear. Several national and international prospective trials are currently being conducted to answer these important questions but results will only be available in a few years.

CCL19/CCL21-triggered signal transduction and migration of dendritic cells requires prostaglandin E2.

The control of dendritic cell (DC) migration is pivotal for the initiation of cellular immune responses. When activated with inflammatory stimuli, the chemokine receptor CCR7 is up-regulated on DCs. Activated DCs home to lymphoid organs, where the CCR7 ligands CCL19 and CCL21 are expressed. We previously found that human monocyte-derived DCs (MoDCs) exclusively migrated to CCL19 and CCL21 when matured in the presence of prostaglandin (PG) E2. Because PGE2 did not alter CCR7 cell surface expression, we examined whether PGE2 may exert its effect by coupling CCR7 to signal transduction modules. Indeed, stimulation with CCR7 ligands led to enhanced phosphatidylinositol-3-kinase-mediated phosphorylation of protein kinase B when MoDCs were matured in the presence of PGE2. Moreover, CCL19/CCL21-induced intracellular calcium mobilization in MoDCs occurred only when PGE2 was present during maturation. MoDC migration to CCL19 and CCL21 was dependent on phospholipase C and intracellular calcium flux but not on phosphatidylinositol-3 kinase. Hence, our data provide insight into CCL19/CCL21-triggered signal transduction pathways and identify a novel function for PGE2 in controlling the migration of mature MoDCs by facilitating CCR7 signal transduction.

Problems with prostate-specific antigen screening: a critical review.

The effect of population screening with regard to reduction of prostate cancer specific mortality and quality of life issues is not yet clear. Several national and international prospective studies are currently being conducted to answer these important questions. They include the trials in the Federal State of Tyrol, Austria and in the Quebec City area, Canada, as well as the Prostate, Lung, Colorectal and Ovarian (PLCO) trial in the United States and the European Randomized Study of Screening for Prostate Cancer (ERSPC). In the meantime, individual case finding (opportunistic screening) is recommended for men with a life-expectancy of at least 10 years.

Factors of fragment retention after extracorporeal shockwave lithotripsy (ESWL) / Fatores para a retençäo de fragmentos após litotripsia extracorpórea por ondas de choque (LECO)

Objetivo: A retençäo de fragmento é um problema comum após a suficiente desintegraçäo de cálculo no trato urinário. Neste trabalho nós revisamos e discutimos os fatores que impedem a excreçäo de fragmentos após LECO. Material e métodos: Nós revisamos a literatura médica utilizando o Knowledge Finder e o MEDLINE. Resultados: Sabe-se que fatores relacionados ao próprio cálculo, anatomia renal, fatores metabólicos, fatores näo associados ao tratamento e fatores näo relacionados aos pacientes influenciam o resultado e a passagem natural de fragmentos após LECO. Conclusöes: A LECO é o tratamento de escolha para a maioria dos casos de cálculo no trato urinário. Fatores particularmente adversos para a desintegraçäo do cálculo säo o peso elevado do cálculo, a localizaçäo do cálculo no pólo inferior, e o impedimento anatômico da passagem devido à anatomia desfavorável, estenoses ou má-formaçöes.