Patient Selection for Prostate Brachytherapy
Patient Selection for Prostate Brachytherapy
US Oncology Review 2005
Published: October 2008
Published: October 2008
Introduction
Although the majority of permanent prostate brachytherapy studies have demonstrated biochemical control rates and morbidity profiles that compare favorably with radical prostatectomy (RP) and external beam radiation therapy (XRT),1,2 it has become increasingly apparent that efficacy and morbidity are highly dependent on implant quality.1-3 Sophisticated dosimetric analyses have demonstrated that cure rates and brachytherapy-related morbidity are related to specific source placement patterns and the subsequent dose gradients produced.1,2,4
In addition, the need for supplemental XRT or androgen deprivation therapy (ADT) to optimize biochemical outcome is increasingly in doubt.5,6 With high quality brachytherapy, the vast majority of patients can be successfully managed without such supplemental therapies.5
With the emergence of brachytherapy as a mainstream treatment for clinically localized prostate cancer, a rapidly expanding body of literature regarding patient selection and treatment approach has been reported.1,2,7-11 Although not all patients are acceptable candidates for brachytherapy, a reliable set of pre-treatment criteria for predicting outcome has not been formulated. Fortunately, evidence- based factors are rapidly accumulating. The elucidation and widespread adoption of evidence- supported planning philosophies, intra-operative techniques, and medical management should further improve outcomes.
Prostate Size
Although no clear relationship exists between prostate size and a greater incidence of urinary morbidity,12-15 large prostate size remains a relative contraindication to brachytherapy due to technical concerns and the perception that large prostate size increases the risk for acute and prolonged urinary morbidity.16,17 In fact, patients with large prostate glands can be implanted with acceptable morbidity.12-15 In a study using the patient- administered Expanded Prostate Cancer Index Composite (EPIC), long-term urinary function did not correlate with prostate size.14 In the other extreme, favorable dosimetry with minimal urinary morbidity has been reported for patients with small glands (<20cm3).6,14,18
Transition Zone
Unlike overall prostate size, transition zone volume has consistently correlated with brachytherapy- related urinary morbidity (see Figure 1).19-21 Investigators at Harvard University reported that transition zone volume was the most important predictor of acute urinary retention following brachytherapy.19 In patients receiving neoadjuvant ADT for cytoreduction, International Prostate Symptom Score (I-PSS) normalization, prolonged catheter dependency, and the need for post- brachytherapy transurethral resection (TURP) were best predicted by the per cent decrease in transition zone volume.21 In particular, prolonged urinary morbidity was unlikely in patients with greater than a 30% decrease in transition zone volume.21 The currently available data suggest that the transition zone may have a greater predictive power for prediction of significant urinary dysfunction than any other single parameter.
Pubic Arch Interference
Pubic arch interference (the obstruction of anterior needle placement insertion by a narrow pubic arch) has long been considered a relative contraindication to brachytherapy. Surprisingly, prostate volume has proven to be a poor predictor of pubic arch interference.22 With use of the extended lithotomy position and/or veering needles around the arch, almost all patients can be successfully implanted with favorable post-implant dosimetry regardless of the degree of pubic arch interference.22,23
References:
1. Merrick G S,Wallner K E and Butler W M, “Permanent interstitial brachytherapy for the management of carcinoma of the prostate gland”, J. Urol. (2003), 169: pp. 1,643–1,652.
2. Merrick G S,Wallner K E and Butler W M,“Minimizing prostate brachytherapy-related morbidity”, Urology (2003), 62: pp. 786–792.
3. Stock R G, Stone N N,Tabert A, et al,. “A dose-response study for I-125 prostate implants”, Int. J. Radiat. Oncol. Biol. Phys. (1998), 41: pp. 101–108.
4. Merrick G S,Wallner K E and Butler W M, “Patient selection for prostate brachytherapy: more myth than fact”, Oncology (Huntingt.) (2004), 18: pp. 445–452.
5. Merrick G S, Butler W M,Wallner K E, et al., “The impact of supplemental external beam radiation and /or androgen deprivation therapy on biochemical outcome following permanent prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2004), in press.
6. Merrick G S and Butler W M,“Prostate brachytherapy:The role of supplemental external beam radiotherapy”, In: Klein E A (ed), Current Clinical Urology: Management of Prostate Cancer, Second Edition, 2004, Humana Press, Inc.,Totowa, NJ.
7. Nag S, Beyer D, Friedland J, et al., “American Brachytherapy Society (ABS) recommendations for transperineal permanent brachytherapy of prostate cancer”, Int. J. Radiat. Oncol. Biol. Phys. (1999), 44: pp. 789–799.
8. D’Amico A V,Whittington R, Malkowicz S B, et al., “Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer”, JAMA (1998), 280: pp. 969–974.
9. Hakenberg O W,Wirth M P, Hermann T, et al., “Recommendations for the treatment of localized prostate cancer by permanent interstitial brachytherapy”, Urol. Int. (2003), 70: pp. 15–20.
10. Blasko J C, Mate T, Sylvester J E, et al., “Brachytherapy for carcinoma of the prostate:Techniques, patient selection, and clinical outcomes”, Semin. Radiat. Oncol. (2002), 12: pp. 81–94.
11. Crook J, Lukka H, Klotz L, et al.,“Systematic overview of the evidence for brachytherapy in clinically localized prostate cancer”, CMAJ (2001), 164: pp. 975–981.
12. Merrick G S, Butler W M, Lief J H, et al.,“Temporal resolution of urinary morbidity following prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2000), 47: pp. 121–128.
13. Stone N N and Stock R G,“Prostate brachytherapy in patients with prostate volumes >50cm3 : Dosimetric analysis of implant quality”, Int. J. Radiat. Oncol. Biol. Phys. (2000), 46: pp. 1,199–1,204.
14. Merrick G S, Butler W M,Wallner K E, et al.,“Long-term urinary quality of life following permanent prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2003), 56: pp. 454–461.
15. Sherertz T,Wallner K,Wang H, et al., “Long-term urinary function after transperineal brachytherapy for patients with large prostate glands”, Int. J. Radiat. Oncol. Biol. Phys. (2001), 51: pp. 1,241–1,245.
16. Ash D, Flynn A, Battermann J, et al., E”STRO/EAU/EORTC recommendations on permanent seed implantation for localized prostate cancer”, Radiother. Oncol. (2000), 57: pp. 315–321.
17. Pedley I D,“Transperineal interstitial permanent prostate brachytherapy for carcinoma of the prostate”, Surg. Oncol. (2002), 11: pp. 25–34.
18. Merrick G S, Butler W M, Dorsey A T, et al., “The effect of prostate size and isotope selection on dosimetric quality following permanent seed implantation”, Tech. Urol. (2001), 7: pp. 233–240.
19. Thomas M D, Cormack R,Tempany C M, et al., “Identifying the predictors of acute urinary retention following magnetic resonance-guided prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2000), 47: pp. 905–908.
20. Merrick G S, Butler W M, Galbreath R W, et al.,“The relationship between the transition zone index of the prostate gland and urinary morbidity after brachytherapy”, Urology (2001), 57: pp. 524–529.
21. Hinerman-Mulroy A, Merrick G S, Butler W M, et al., “Androgen deprivation-induced changes in prostate anatomy predict urinary morbidity following permanent interstitial brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2004), 59: pp. 1,367–1,382.
22. Bellon J,Wallner K, Ellis W, et al., “Use of pelvic CT scanning to evaluate pubic arch interference of transperineal prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (1999), 43: pp. 579–581.
23. Wallner K E, Blasko J C, Dattoli M J (eds),“Prostate Brachytherapy Made Complicated”, Seattle, SmartMedicine Press, 2001.
24. Wallner K E, Smathers S, Sutlief S, et al., “Prostate brachytherapy in patients with median lobe hyperplasia”, Int. J. Cancer (2000), 90: pp. 199–205.
25. Terk M D, Stock R G and Stone N N, “Identification of patients at increased risk for prolonged urinary retention following radioactive seed implantation of the prostate”, J. Urol. (1998), 160: pp. 1,379–1,382.
26. Landis P,Wallner K, Locke J, et al.,“Late urinary function after prostate brachytherapy”, Brachytherapy (2002), 1: pp. 21–26.
27. Gelblum D Y, Potters L, Ashley R, et al., “Urinary morbidity following ultrasound-guided transperineal prostate seed implantation”, Int. J. Radiat. Oncol. Biol. Phys. (1999), 45: pp. 59–67.
28. Bucci J, Morris W J, Keyes M, et al., “Predictive factors of urinary retention following prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2002), 53: pp. 91–98.
29. Han B H, Demel K C,Wallner K, et al.,“Patient reported complications after prostate brachytherapy”, J. Urol. (2001), 166: pp. 953–957.
30. Merrick G S, Butler W M,Wallner K E, et al., “Prophylactic versus therapeutic alpha blockers following permanent prostate brachytherapy”, Urology (2002), 60: pp. 650–655.
31. Gray G,Wallner K, Roof J, et al., “Cystourethroscopic findings before and after prostate brachytherapy”, Tech. Urol. (2000), 6: pp. 109–111.
32. Wallner K, Lee H,Waserman S, et al.,“Low risk of urinary incontinence following prostate brachytherapy in patients with a prior TURP”, IInt. J. Radiat. Oncol. Biol. Phys. (1997), 37: pp. 565–569.
33. Stone N N, Ratnow E R and Stock R G, “Prior transurethral resection does not increase morbidity following real-time ultrasound-guided prostate seed implantation”, Tech. Urol. (2000), 6: pp. 123–127.
34. Merrick G S, Butler W M,Wallner K E, et al.,“Effect of transurethral resection on urinary quality of life after permanent prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2004), 58: pp. 81–88.
35. Stone N N and Stock R G,“Complications following permanent prostate brachytherapy”, Eur.Urol. (2002), 41: pp. 427–433.
36. Hughes S,Wallner K, Merrick G, et al., “Pre-existing histologic evidence of prostatitis is unrelated to post-implant urinary morbidity”, Radiat. Oncol. Investig. (2002), 96 (suppl): pp. 79–82.
37. Carter H B, Epstein J I and Partin A W, “Influence of age and prostate-specific antigen on the chance of curable prostate cancer among men with nonpalpable disease”, Urology (1999), 53: pp. 126–130.
38. Herold D M, Hanlon A L, Movsas B, et al., “Age-related prostate cancer metastases”, Urology (1998), 51: pp. 985–990.
39. Smith C V, Bauer J J, Connelly R R, et al., “Prostate cancer in men age 50 years or younger: a review of the Department of Defense Center for Prostate Disease Research multicenter prostate cancer database”, J. Urol. (2000), 164: pp. 1,964–1,967.
40. Merrick G S, Butler W M,Wallner K E et al., “Permanent interstitial brachytherapy in younger patients with clinically organconfined prostate cancer”, Urology (2004), 64: pp. 754–759.
41. Merrick G S, Butler W M,Wallner K E et al., “The influence of body mass index (BMI) on biochemical outcome following permanent prostate brachytherapy”, Urology (2004), in press.
42. Merrick G S, Butler W M,Wallner K E, et al., “Permanent prostate brachytherapy induced morbidity in patients with grade II and III obesity”, Urology (2002), 60: pp. 104–108.
43. Merrick G S, Butler W M,Wallner K E, et al., “The effect of cigarette smoking on biochemical outcome following permanent prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2004), 58: pp. 1,056–1,062.
44. Merrick G S, Butler W M,Wallner K E, et al.,“Late rectal function after prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2003), 57: pp. 42–48.
45. Grann A and Wallner K, “Prostate brachytherapy in patients with inflammatory bowel disease”, Int. J. Radiat. Oncol. Biol. Phys. (1998), 40: pp. 135–138.
46. Merrick G S, Butler W M,Wallner K E, et al., “Prognostic significance of percent positive biopsies in clinically organ-confined prostate cancer treated with permanent prostate brachytherapy with or without supplemental external beam radiation”, Cancer J. (2004), 10: pp. 54–60.
47. Merrick G S, Butler W M, Galbreath R W, et al.,“Perineural invasion is not predictive of biochemical outcome following prostate brachytherapy”, Cancer J. (2001), 7: pp. 404–412.
48. Blasko J C, Grimm P D, Sylvester J E, et al.,“Palladium-103 brachytherapy for prostate carcinoma”, Int. J. Radiat. Oncol. Biol. Phys. (2000), 46: pp. 839–850.
49. Merrick G S, Butler W M, Galbreath R W, et al., “Does hormonal manipulation in conjunction with permanent interstitial brachytherapy, with or without supplemental external beam irradiation, improve the biochemical outcome for me with intermediate or high-risk prostate cancer?”, Br. J. Urol. (2003), 91: pp. 23–29.
50. Dattoli M,Wallner K,True L, et al., “Long term outcomes after treatment with external beam radiation therapy and palladium 103 for patients with higher risk prostate carcinoma: Influence of prostatic acid phosphatase”, Cancer (2003), 97: pp. 979–983.
51. Davis B J, Pisansky T M,Wilson T M, et al.,“The radial distance of extraprostatic extension of prostate carcinoma. Implications for prostate brachytherapy”, Cancer (1999), 85: pp. 2,630–2,637.
52. Merrick G S, Butler W M, Wallner K E, et al., “Extracapsular radiation dose distribution after permanent prostate brachytherapy”, Am. J. Clin. Oncol. (2003), 26: pp. 178–189.
53. Han M, Piantadosi S, Zahurak M L, et al., “Serum acid phosphatase level and biochemical recurrence following radical prostatectomy for men with clinically localized prostate cancer”, Urology (2001), 57: pp. 707–711.
54. Cha C M, Potters L,Ashley R, et al.,“Isotope selection for patients undergoing prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (1999), 45: pp. 391–395.
55. Wallner K, Merrick G,True L, et al.,“I-125 versus Pd-103 for low risk prostate cancer: Morbidity outcomes from a prospective randomized multicenter trial”, Cancer J. Sci.Am. (2002), 8: pp. 67–73.
56. Wallner K, Merrick G,True L et al., “I-125 versus Pd-103 for low risk prostate cancer: Preliminary PSA outcomes from a prospective randomized multicenter trial”, Int. J. Radiat. Oncol. Biol. Phys. (2003), 57: pp. 1,297–1,303.
57. Barker J,Wallner K and Merrick G,“Hematuria after prostate brachytherapy”, Urology (2003), 61: pp. 408–411.
58. Merrick G S, “Prostate Brachytherapy:The shrinking role of hormonal therapy”, Brachytherapy (2003), 2: pp. 2–4.
59. Potters L,Torre T, Ashley R, et al., “Examining the role of neoadjuvant androgen deprivation in patients undergoing prostate brachytherapy”, J. Clin. Oncol. (2000), 18: pp. 1,187–1,192.
2. Merrick G S,Wallner K E and Butler W M,“Minimizing prostate brachytherapy-related morbidity”, Urology (2003), 62: pp. 786–792.
3. Stock R G, Stone N N,Tabert A, et al,. “A dose-response study for I-125 prostate implants”, Int. J. Radiat. Oncol. Biol. Phys. (1998), 41: pp. 101–108.
4. Merrick G S,Wallner K E and Butler W M, “Patient selection for prostate brachytherapy: more myth than fact”, Oncology (Huntingt.) (2004), 18: pp. 445–452.
5. Merrick G S, Butler W M,Wallner K E, et al., “The impact of supplemental external beam radiation and /or androgen deprivation therapy on biochemical outcome following permanent prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2004), in press.
6. Merrick G S and Butler W M,“Prostate brachytherapy:The role of supplemental external beam radiotherapy”, In: Klein E A (ed), Current Clinical Urology: Management of Prostate Cancer, Second Edition, 2004, Humana Press, Inc.,Totowa, NJ.
7. Nag S, Beyer D, Friedland J, et al., “American Brachytherapy Society (ABS) recommendations for transperineal permanent brachytherapy of prostate cancer”, Int. J. Radiat. Oncol. Biol. Phys. (1999), 44: pp. 789–799.
8. D’Amico A V,Whittington R, Malkowicz S B, et al., “Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer”, JAMA (1998), 280: pp. 969–974.
9. Hakenberg O W,Wirth M P, Hermann T, et al., “Recommendations for the treatment of localized prostate cancer by permanent interstitial brachytherapy”, Urol. Int. (2003), 70: pp. 15–20.
10. Blasko J C, Mate T, Sylvester J E, et al., “Brachytherapy for carcinoma of the prostate:Techniques, patient selection, and clinical outcomes”, Semin. Radiat. Oncol. (2002), 12: pp. 81–94.
11. Crook J, Lukka H, Klotz L, et al.,“Systematic overview of the evidence for brachytherapy in clinically localized prostate cancer”, CMAJ (2001), 164: pp. 975–981.
12. Merrick G S, Butler W M, Lief J H, et al.,“Temporal resolution of urinary morbidity following prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2000), 47: pp. 121–128.
13. Stone N N and Stock R G,“Prostate brachytherapy in patients with prostate volumes >50cm3 : Dosimetric analysis of implant quality”, Int. J. Radiat. Oncol. Biol. Phys. (2000), 46: pp. 1,199–1,204.
14. Merrick G S, Butler W M,Wallner K E, et al.,“Long-term urinary quality of life following permanent prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2003), 56: pp. 454–461.
15. Sherertz T,Wallner K,Wang H, et al., “Long-term urinary function after transperineal brachytherapy for patients with large prostate glands”, Int. J. Radiat. Oncol. Biol. Phys. (2001), 51: pp. 1,241–1,245.
16. Ash D, Flynn A, Battermann J, et al., E”STRO/EAU/EORTC recommendations on permanent seed implantation for localized prostate cancer”, Radiother. Oncol. (2000), 57: pp. 315–321.
17. Pedley I D,“Transperineal interstitial permanent prostate brachytherapy for carcinoma of the prostate”, Surg. Oncol. (2002), 11: pp. 25–34.
18. Merrick G S, Butler W M, Dorsey A T, et al., “The effect of prostate size and isotope selection on dosimetric quality following permanent seed implantation”, Tech. Urol. (2001), 7: pp. 233–240.
19. Thomas M D, Cormack R,Tempany C M, et al., “Identifying the predictors of acute urinary retention following magnetic resonance-guided prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2000), 47: pp. 905–908.
20. Merrick G S, Butler W M, Galbreath R W, et al.,“The relationship between the transition zone index of the prostate gland and urinary morbidity after brachytherapy”, Urology (2001), 57: pp. 524–529.
21. Hinerman-Mulroy A, Merrick G S, Butler W M, et al., “Androgen deprivation-induced changes in prostate anatomy predict urinary morbidity following permanent interstitial brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2004), 59: pp. 1,367–1,382.
22. Bellon J,Wallner K, Ellis W, et al., “Use of pelvic CT scanning to evaluate pubic arch interference of transperineal prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (1999), 43: pp. 579–581.
23. Wallner K E, Blasko J C, Dattoli M J (eds),“Prostate Brachytherapy Made Complicated”, Seattle, SmartMedicine Press, 2001.
24. Wallner K E, Smathers S, Sutlief S, et al., “Prostate brachytherapy in patients with median lobe hyperplasia”, Int. J. Cancer (2000), 90: pp. 199–205.
25. Terk M D, Stock R G and Stone N N, “Identification of patients at increased risk for prolonged urinary retention following radioactive seed implantation of the prostate”, J. Urol. (1998), 160: pp. 1,379–1,382.
26. Landis P,Wallner K, Locke J, et al.,“Late urinary function after prostate brachytherapy”, Brachytherapy (2002), 1: pp. 21–26.
27. Gelblum D Y, Potters L, Ashley R, et al., “Urinary morbidity following ultrasound-guided transperineal prostate seed implantation”, Int. J. Radiat. Oncol. Biol. Phys. (1999), 45: pp. 59–67.
28. Bucci J, Morris W J, Keyes M, et al., “Predictive factors of urinary retention following prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2002), 53: pp. 91–98.
29. Han B H, Demel K C,Wallner K, et al.,“Patient reported complications after prostate brachytherapy”, J. Urol. (2001), 166: pp. 953–957.
30. Merrick G S, Butler W M,Wallner K E, et al., “Prophylactic versus therapeutic alpha blockers following permanent prostate brachytherapy”, Urology (2002), 60: pp. 650–655.
31. Gray G,Wallner K, Roof J, et al., “Cystourethroscopic findings before and after prostate brachytherapy”, Tech. Urol. (2000), 6: pp. 109–111.
32. Wallner K, Lee H,Waserman S, et al.,“Low risk of urinary incontinence following prostate brachytherapy in patients with a prior TURP”, IInt. J. Radiat. Oncol. Biol. Phys. (1997), 37: pp. 565–569.
33. Stone N N, Ratnow E R and Stock R G, “Prior transurethral resection does not increase morbidity following real-time ultrasound-guided prostate seed implantation”, Tech. Urol. (2000), 6: pp. 123–127.
34. Merrick G S, Butler W M,Wallner K E, et al.,“Effect of transurethral resection on urinary quality of life after permanent prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2004), 58: pp. 81–88.
35. Stone N N and Stock R G,“Complications following permanent prostate brachytherapy”, Eur.Urol. (2002), 41: pp. 427–433.
36. Hughes S,Wallner K, Merrick G, et al., “Pre-existing histologic evidence of prostatitis is unrelated to post-implant urinary morbidity”, Radiat. Oncol. Investig. (2002), 96 (suppl): pp. 79–82.
37. Carter H B, Epstein J I and Partin A W, “Influence of age and prostate-specific antigen on the chance of curable prostate cancer among men with nonpalpable disease”, Urology (1999), 53: pp. 126–130.
38. Herold D M, Hanlon A L, Movsas B, et al., “Age-related prostate cancer metastases”, Urology (1998), 51: pp. 985–990.
39. Smith C V, Bauer J J, Connelly R R, et al., “Prostate cancer in men age 50 years or younger: a review of the Department of Defense Center for Prostate Disease Research multicenter prostate cancer database”, J. Urol. (2000), 164: pp. 1,964–1,967.
40. Merrick G S, Butler W M,Wallner K E et al., “Permanent interstitial brachytherapy in younger patients with clinically organconfined prostate cancer”, Urology (2004), 64: pp. 754–759.
41. Merrick G S, Butler W M,Wallner K E et al., “The influence of body mass index (BMI) on biochemical outcome following permanent prostate brachytherapy”, Urology (2004), in press.
42. Merrick G S, Butler W M,Wallner K E, et al., “Permanent prostate brachytherapy induced morbidity in patients with grade II and III obesity”, Urology (2002), 60: pp. 104–108.
43. Merrick G S, Butler W M,Wallner K E, et al., “The effect of cigarette smoking on biochemical outcome following permanent prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2004), 58: pp. 1,056–1,062.
44. Merrick G S, Butler W M,Wallner K E, et al.,“Late rectal function after prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (2003), 57: pp. 42–48.
45. Grann A and Wallner K, “Prostate brachytherapy in patients with inflammatory bowel disease”, Int. J. Radiat. Oncol. Biol. Phys. (1998), 40: pp. 135–138.
46. Merrick G S, Butler W M,Wallner K E, et al., “Prognostic significance of percent positive biopsies in clinically organ-confined prostate cancer treated with permanent prostate brachytherapy with or without supplemental external beam radiation”, Cancer J. (2004), 10: pp. 54–60.
47. Merrick G S, Butler W M, Galbreath R W, et al.,“Perineural invasion is not predictive of biochemical outcome following prostate brachytherapy”, Cancer J. (2001), 7: pp. 404–412.
48. Blasko J C, Grimm P D, Sylvester J E, et al.,“Palladium-103 brachytherapy for prostate carcinoma”, Int. J. Radiat. Oncol. Biol. Phys. (2000), 46: pp. 839–850.
49. Merrick G S, Butler W M, Galbreath R W, et al., “Does hormonal manipulation in conjunction with permanent interstitial brachytherapy, with or without supplemental external beam irradiation, improve the biochemical outcome for me with intermediate or high-risk prostate cancer?”, Br. J. Urol. (2003), 91: pp. 23–29.
50. Dattoli M,Wallner K,True L, et al., “Long term outcomes after treatment with external beam radiation therapy and palladium 103 for patients with higher risk prostate carcinoma: Influence of prostatic acid phosphatase”, Cancer (2003), 97: pp. 979–983.
51. Davis B J, Pisansky T M,Wilson T M, et al.,“The radial distance of extraprostatic extension of prostate carcinoma. Implications for prostate brachytherapy”, Cancer (1999), 85: pp. 2,630–2,637.
52. Merrick G S, Butler W M, Wallner K E, et al., “Extracapsular radiation dose distribution after permanent prostate brachytherapy”, Am. J. Clin. Oncol. (2003), 26: pp. 178–189.
53. Han M, Piantadosi S, Zahurak M L, et al., “Serum acid phosphatase level and biochemical recurrence following radical prostatectomy for men with clinically localized prostate cancer”, Urology (2001), 57: pp. 707–711.
54. Cha C M, Potters L,Ashley R, et al.,“Isotope selection for patients undergoing prostate brachytherapy”, Int. J. Radiat. Oncol. Biol. Phys. (1999), 45: pp. 391–395.
55. Wallner K, Merrick G,True L, et al.,“I-125 versus Pd-103 for low risk prostate cancer: Morbidity outcomes from a prospective randomized multicenter trial”, Cancer J. Sci.Am. (2002), 8: pp. 67–73.
56. Wallner K, Merrick G,True L et al., “I-125 versus Pd-103 for low risk prostate cancer: Preliminary PSA outcomes from a prospective randomized multicenter trial”, Int. J. Radiat. Oncol. Biol. Phys. (2003), 57: pp. 1,297–1,303.
57. Barker J,Wallner K and Merrick G,“Hematuria after prostate brachytherapy”, Urology (2003), 61: pp. 408–411.
58. Merrick G S, “Prostate Brachytherapy:The shrinking role of hormonal therapy”, Brachytherapy (2003), 2: pp. 2–4.
59. Potters L,Torre T, Ashley R, et al., “Examining the role of neoadjuvant androgen deprivation in patients undergoing prostate brachytherapy”, J. Clin. Oncol. (2000), 18: pp. 1,187–1,192.
