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Patient Information For High Dose Rate Hdr Prostate Brachytherapy

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Patient Information For High Dose Rate Hdr Prostate Brachytherapy

Prostate Brachytherapy Assessment Clinic.

Assessment of your eligibility is usually undertaken at the clinic and discussed between various professionals who include the radiation oncologist, urologist, radiation therapists and physicists. It is important to note that not all men with prostate cancer are suitable for brachytherapy. Currently we have eligibility criteria at the Prostate Cancer Institute in determining those patients most suitable for this procedure. This is based on a number of clinical, pathological and technical factors.

HDR brachytherapy is a form of internal radiation therapy, which is used in combination with external beam radiotherapy. At this point in time HDR brachytherapy is always used in combination with external beam radiotherapy and is not used alone, unlike seed brachytherapy.

The internal radiation (brachytherapy) is delivered through the use of some small plastic catheters, which are directly inserted into the prostate gland. These plastic catheters act as a conduit allowing a radiation source to be directly placed within the target, that is the prostate cancer and the prostate gland.

A number of radiation treatments can then be delivered through these catheters.

Once the radiation treatment has been delivered the catheters are easily pulled out and no radioactive material is left within the prostate gland.

A computer-controlled machine called a Remote After-loader pushes a radioactive iridium source, which is located on the end of a wire into each of the catheters. The radioactive iridium source is then positioned at a number of "dwell" positions to deliver the radiation dose within the prostate.

These positions are determined with the aid of a planning computer allowing optimal dosage to the prostate. The treatment can also be tailored and the various "dwell" positions of the radioactive seed can be altered on the computer to give the best dose distribution within the prostate to minimise the dose to the urethra.

The ability of dose to be modified after the plastic catheters are placed within the prostate is one of the major advantages of HDR brachytherapy.

HDR brachytherapy involves a treatment program, which usually comprises of three separate therapies.

•  Short/long term hormonal therapy
•  High dose rate (HDR) temporary brachytherapy and
•  Moderate dose external beam radiation.

This treatment approach aims at optimising cancer control within various regions.

The hormonal therapy acts systemically as well as acting as a radio- sensitiser enhancing the effects of the radiation within the prostate and prostate cancer.

External beam radiation is used to treat potential prostate cancer that has a spread beyond the capsule of the prostate and in the surrounding tissues and lymph glands. The HDR component of the treatment aims at maximising the dose of the radiation to where the highest likelihood of a cancer is i.e. within the prostate.  

Eligibility criteria

  1. Histological-proven prostate adenocarcinoma

  2. Intermediate risk patients

  3. High risk patient may only have one high risk feature present

    1. i.e. PSA =20 ng/mL or Gleason ³ 8 or Stage T3a

  4. No evidence of nodal (N0) or distant metastases (M0) on

    1. Physical exam

    2. Chest x-ray

    3. CT pelvis

    4. Bone Scan

  5. Pre-intervention PSA must be < 30.

•  No history of TURP (Trans-Urethral Resection of the Prostate)
•  No use of anticoagulants (except aspirin) or history of bleeding disorders
•  No hip replacements
•  Suitable for general or spinal anaesthesia
•  Life expectancy of over 5 years
•  Available for follow-up at the Prostate Cancer Institute.

Implant Procedure

This procedure involves the insertion of 18 plastic catheters into the prostate (these are hollow plastic needles). These are placed using an anaesthetic and under the guidance of a rectal ultrasound and X-ray imaging. After the treatment has been completed these plastic catheters are removed.

Once the plastic catheters are placed you will be transferred to a CT scan where imaging of the prostate and catheters is undertaken and computer planning allowing accurate calculation of the dose to be delivered and adjustment of the radioactive source positions within the prostate will be determined.

Once the plan has been completed, the radioactive iridium source, which is housed in the after- loader, is delivered to the prostate. Two separate treatments are then delivered, separated by at least 6 hours. Each of the treatments takes approximately 1-2 hours to deliver. In total you will be in hospital for 2½ days. Typically the needle placement is performed in the morning.

A CT scan is performed by lunchtime and the planning is undertaken in the afternoon and the first treatment of HDR is delivered late in the afternoon of the first day. The following day the second treatment is delivered in the morning. Once the treatment has been delivered the catheters can be removed and patient discharged the following morning. During the 2½ days you would remain in a hospital bed and would not be able to move significantly, in particular sitting up or walking would not be possible.

A urinary catheter would be inserted at the initial anaesthetic and removed at the end of the brachytherapy treatment.

Approximately 2-3 weeks after the completion of the HDR brachytherapy a course of external beam radiation treatment to a moderate dose (46Gy in 23 separate treatment sessions) would be delivered over 4-5 weeks. Each session is given as an outpatient and usually only takes 20-30 minutes

The extent of the radiation field is determined primarily by the potential risk that the surround lymph glands within the pelvis may contain cancer.

Some patients who have higher risk disease may continue on with further hormonal therapy.

Typically hormone treatment is commenced 3-6 months prior to any radiation therapy and is then ceased.

However in higher risk patients' hormone therapy may continue on for a prolonged period of time. This will be discussed by your radiation oncologist/urologist.

Possible Side Effects

Slight bleeding and bruising and tenderness between the legs are common.

Burning on urination, urinating more frequently, pain or feeling unable to pass urine freely is sometimes side effects. This usually is a limited side effect and uncommonly a urinary catheter may need to be used to alleviate symptoms.

Typically this is related to swelling of the prostate causing blockage of the normal urinary outflow.

Rectal discomfort is uncommon with respect to the HDR component of the treatment. Towards the end of the external beam radiation treatment some patients may experience temporary diarrhoea.

Long-term complications from the external beam radiotherapy at such moderate doses are uncommon. Incontinence is rare.

The risk of developing impotency is thought to be approximately 30-40%. This is similar to other forms of radiation or brachytherapy, however long term results are not yet available.

If impotency occurs it can usually be helped with the use of Viagra or other drugs or methods.

Radiation Safety
Unlike permanent radioactive seed brachytherapy, HDR is only a temporary implant. After the procedure has been performed and the plastic needle catheters have been removed there will be no radioactivity within your body.

You will not be radioactive. Your urine or other body fluids will not be radioactive. During the course of the three treatments given over 24-36 hours there will be periods of time when visitors will not be allowed to enter your hospital room. This will probably be for 1-2 hours at a time. This will happen 3 times during your hospital admission. Visitors will be directed to leave your room at the time of each internal radiation treatment.

Figure 1: A linear accelerator (LINAC), used for external beam radiation treatments.

Brachytherapy has found a renewed application in the treatment of prostate cancer with the use of modern computer and ultrasound technology. This is an exciting development in the treatment of many prostate cancers as it provides the ability to escalate doses of radiation to the prostate in an accurate and safe manner. It should now be considered an alternative treatment option for many patients with prostate cancer.

The full range of prostate brachytherapy services are now offered at the Prostate Cancer Institute together with conventional external beam radiotherapy treatment. Permanent Prostate Seed Brachytherapy and Temporary Prostate Brachytherapy Implantation (HDR) are now part of a comprehensive program available at the Centre.

The Prostate Cancer Institute as formed a capable multidisciplinary team to deliver a high quality brachytherapy service to prostate cancer patients. Experience has been shown to be a critical factor in determining the quality of prostate seed implantation.

As a result Dr Joseph Bucci has recently completed a 12-month overseas fellowship at he British Columbia Cancer Agency in Vancouver and attained formal accreditation from the Agency. Other members of the team have also spent extended periods at the Agency obtaining supervision and formal training in the procedure.

The British Columbia Cancer Agency in Vancouver boasts the largest prostate brachytherapy program in Canada and has already completed over 1000 prostate brachytherapy implants with excellent results. The Prostate Cancer Institute is the first and only public program to offer a fully funded prostate seed brachytherapy service to patients in NSW. This is currently a pilot program but we hope to gain formal recurrent funding. We also offer a private seed brachytherapy service to those with private medical insurance.

The Prostate Cancer Institute Brachytherapy team includes Dr Joseph Bucci and Dr Yaw Chin (Radiation Oncologists), Dr David Malouf (Urologist), Ese Enari, Robert Chambers and Rashmi Gupta (Physicists), Annette Brazell, Kristine Schreiber, Scott Carpenter and Melissa Mc Curly (Radiation therapists), Pauline Thomson (Nursing).

Enquiries to Dr Joseph Bucci (MBBS. FRACP., FRANZCR) Staff Specialist - Radiation Oncologist Cancer Care Centre St.George Hospital, Short St.,Kogarah NSW 2217. Ph +61 2 9113 3831 Fax +61 2 9113 3958 or Dr David Malouf (MBBS. FRACS) Urological Surgeon Ph +61 2 9587 4888.

Questions to ask your radiation oncologist