Laparoscopic pelvic lymph node dissection combined with real-time interactive transrectal ultrasound guided transperineal radioactive seed implantation of the prostate.

Laparoscopic pelvic lymph node dissection with real-time interactive transrectal ultrasound guided transperineal radioactive seed implantation is a new method of treatment for localized carcinoma of the prostate. A total of 58 patients with clinically confined prostate cancer and negative seminal vesicle biopsies underwent staging laparoscopic pelvic lymph node dissection immediately followed by prostate implantation: 50 had 125iodine and 8 had 103palladium implants. Mean operating time was 226 minutes (range 120 to 475), mean blood loss was 57 cc (range 5 to 400) and average hospital stay was 2.2 days (range 0.5 to 8). At a mean followup of 12 months (range 6 to 24), complications included proctitis in 1.7% of the cases, dysuria in 24%, nocturia in 21% and outlet obstruction in 17%. Erectile function remained unchanged. Prostate volume decreased to 58.9% of the pretreatment value by 12 months and to 44.3% by 24 months. Mean prostate specific antigen level was 18.4 +/- 26.3 ng./ml. before treatment, 3.4 +/- 3.9 ng./ml. at 6 months, 2.3 +/- 2.3 ng./ml. at 12 months and 4.9 +/- 6.0 ng./ml. at 24 months (1.2 +/- 1.0 ng./ml. for patients with no evidence of disease). Of the patients 15.8% had local failure at 18 to 24 months as determined by positive transrectal ultrasound guided biopsy. Five of 58 patients (8.6%) had persistently elevated prostate specific antigen levels, only 1 of whom had a positive biopsy. Laparoscopic pelvic lymph node dissection with transrectal ultrasound guided implantation is a safe and promising mode of therapy for patients with localized prostate cancer.

A modified technique allowing interactive ultrasound-guided three-dimensional transperineal prostate implantation.

PURPOSE: Ultrasound-guided transperineal prostate implantation is a new technique for performing permanent isotope implants of the prostate. The details of the technique are presented to demonstrate its ability to place radioactive seeds three-dimensionally within the prostate gland to achieve uniform dose distribution without the need for complicated preplanning. METHODS AND MATERIALS: An accurate measurement of the prostate volume is made using biplanar transrectal ultrasound. The total activity to be implanted is derived from a look-up table based on prostate volume. The basic plan is to implant 60-70% of the total activity in the periphery of the gland and the remaining activity in the interior of the gland. The ultrasound transducer provides visualization of the prostate through transverse, longitudinal and oblique cuts and allows for accurate placement of implant needles, approximately 1 cm apart. In addition, these needles can be moved through the prostate under constant visualization, thus allowing for precise seed placement. RESULTS: The setup of the transrectal ultrasound device as well as prostate volume measurements are performed in 10 to 15 min. The actual placement of the needles and seed implantation takes 1 to 1.5 h to perform. Postimplantation dosimetric evaluation is performed using orthogonal x-ray films and 3 mm thick CT slices taken at 3 mm intervals. This evaluation has confirmed accurate seed placement within the prostate gland. CONCLUSION: Interactive ultrasound guided transperineal prostate implantation is a fast and accurate method of performing permanent radioactive isotope prostate implants.

Simultaneous interstitial radiotherapy with regional or free-flap reconstruction, following salvage surgery of recurrent head and neck carcinoma. Analysis of complications.

OBJECTIVE: Reports on complications following brachytherapy offer conflicting views on the benefit of locoregional flap coverage of the implanted tumor bed. This study reviews complications following pedicled and free-flap coverage of brachytherapy sources after salvage surgery for recurrent head and neck carcinoma. DESIGN: Retrospective chart review. SETTING: Academic tertiary referral center. PARTICIPANTS: Fifteen patients with advanced, radiorecurrent carcinomas of the head and neck, treated between 1988 and 1992. INTERVENTION: All patients underwent surgical resection and implantation of the tumor bed with iridium 192 after-loading catheters (13 patients) or iodine 125 seeds (two patients). The average dose of interstitial radiotherapy supplied was 50.24 +/- 45.19 Gy (mean +/- SD). Coverage of the implanted tumor bed was achieved with regional myocutaneous flaps in 10 patients and microvascular free flaps in five patients. OUTCOME MEASURE: All wound and healing complications were identified. Patients were followed up for a minimum of 3 months. RESULTS: No significant complications were encountered. No flap, pedicled or free, demonstrated any degree of necrosis. Four minor complications developed in the group of patients who underwent reconstruction with pedicled myocutaneous flaps. One orocutaneous fistula developed in a patient in whom a radial forearm was used to reconstruct a posterior pharyngeal wall defect. CONCLUSIONS: An expectation of increased postoperative morbidity should not interfere with the decision to proceed with multimodality salvage therapy of patients with advanced, recurrent head and neck tumors. The advantages of free tissue transfer in the reconstruction of head and neck defects are not compromised when the flaps are simultaneously utilized to provide coverage for brachytherapy sites.

Radiation therapy in regionally advanced bladder cancer.

In conclusion, for patients undergoing bladder preservation, conventional external radiation therapy can no longer be recommended as a curative single modality. The usefulness of prognostic indicators, such as radiation responsiveness and tumor morphology, will have to be evaluated in light of newer treatment regimens. Patients should receive external radiation only if other therapies such as hyperfractionation, brachytherapy, intraoperative electrons, or combined chemotherapy and radiation therapy are unavailable or unable to be tolerated. Patients undergoing a planned cystectomy should receive preoperative radiation therapy until such time as neoadjuvant chemotherapy has been proved more or equally effective.

Combined modality therapy of extrahepatic biliary system cancer.

From January 1985 to December 1988, 10 patients with local/regional extrahepatic biliary system cancer (gallbladder: 2, Klatskin: 4, common bile duct: 4) underwent combined modality therapy. Laparotomy and biopsy or subtotal resection were performed in six patients and endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiogram, and biliary drainage in four patients. Patients initially received 5000 cGy to the tumor bed and primary nodal area. Eight received an additional 1500 cGy boost to the tumor bed. Chemotherapy (5-FU/mitomycin-C) was delivered at the beginning of each radiation treatment course. Four patients received an additional 1-4 cycles of maintenance chemotherapy and six received a boost with brachytherapy. The mean survival was 32 months and the median survival was 16 months. Five patients are currently NED at 16, 17, 17, 48, and 52 months. The overall 3-year actuarial survival was 50%. The cumulative incidence of failure as a component of failure was local/regional: 50%, abdominal: 40%, and distant: 10%. Of the five patients who developed failure, all developed a component of local/regional failure. Our data show that this approach is feasible and offers similar results to those reported in the literature. However, further follow-up will be needed to determine if this combined modality approach offers improved local control and survival rates compared with surgery or biliary bypass/drainage alone.

Iridium-192 implants for primary breast cancer: experience with placement at the time of wide local excision.

An Ir-192 boost is a technique frequently used to deliver an additional dose of radiation therapy to the tumor bed following breast conserving surgery and combined with external beam radiation therapy to the entire breast for patients with early breast cancer. Traditionally these catheters are placed following completion of 4500-5000 cGy, as a separate procedure. This paper described a Pilot Study identifying placement of the catheters at the time of primary wide local excision, or re-excision in 52 patients. The key to the success of this technique is the achievement of complete hemostasis in the primary cavity, the presence of the radiation oncologist during the surgical procedure itself, and closure of the wound prior to placement of the catheters. Details of the technique, and preliminary patient results are presented.