Brachytherapy Treatment

The treatment of prostate cancer (cancer of the male prostate gland) in men with the help of permanent brachytherapy (monotherapy) with iodine 125 seeds (= interstitial radiotherapy)

The urologists Dr. R. Djamali-Leonhard and Dr. F. Meisse team have been performing brachytherapy with their team in Munich since 2002.

Dr. R. Djamali-Leonhard (head physician) and Dr. F. Meisse (senior physician) head the Institute for Surgical Brachytherapy for Prostate Cancer at the Urological Clinic Munich Planegg (www.ukmp.de) and are holders of the required expertise in radiation protection according to the guideline Radiation Protection in Medicine (Radiation Protection Ordinance - StrlSchV) for permanent LDR brachytherapy of the prostate (A1 2.2.2.3).

With approximately 150 treatments per year and over 2000 treatments in total, the department is one of the major treatment centers for brachytherapy with seeds in Germany and Europe.

If you have any questions about brachytherapy, please contact:

djamali-leonhard@ukmp.de

PDF-Infoflyer - Description of Brachytherapy


Literature

Method assessment by the Joint Federal Committee (G-BA) according to § 91 SGB V 9/2020: Brachytherapy for low-risk prostate cancer becomes a treatment alternative also for outpatients

Nature Video (30 October 2019): Brachytherapy's fight for survival, researchers hope to revive an unfashionable treatment for prostate cancer

Prostate Cancer Guidelines der European Association of Urology 2017

Long-term oncological outcomes and toxicity in 597 men ≤60 years of age at time of low dose rate brachytherapy for localised prostate cancer

2021 Updated Interdisciplinary Guideline of Quality S3 for Early Detection, Diagnosis and Therapy of the Different Stages of Prostate Cancer of the German Society of Urology (DGU), Guideline Program Oncology of the AWMW, German Cancer Society e.V. and German Cancer Aid e.V. (PDF abridged version)

ASTRO 2016: Intermediate-Risk Prostate Cancer May Be Well Controlled With Brachytherapy Alone)

The Management of Localized Prostate Cancer, Patient Guide - American Urological Association

NCCN Guidelines for Patients with Prostate Cancer 2019 (National Comprehensive Cancer Network)

AUA/ASTRO/SUO Guidelines (2017) Clinically Localized Prostate Cancer (American Urological Association / American Society for Radiation Oncology / Society of Urologic Oncology)

Health technology assessment report (HTA report) of the National Association of Statutory Health Insurance Physicians and the German Medical Association for the review of evidence-based treatment methods 12/2005

Djamali-Leonhard: Permanent interstitial brachytherapy

Djamali-Leonhard: LDR-Brachytherapy in localized prostate carcinoma - A "must have" in the urological armamentarium, Uro-News 4/2004

Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treated by radical therapy. Results from the Prostate Cancer Results Study Group (Comparative analysis - Results from the Prostate Cancer Results Study Group, P. Grimm et al, BJUI 2012; 109, Supplement 1, 22-29).


Foreword

Prostate carcinoma (PCA) is the most frequent tumor disease in men at an advanced age and the third most frequent cause of cancer-related death in men with an increasing tendency. Optimized and regular preventive examinations by urologists have led in recent years to an increasing early detection of cancer in patients with organ-confined tumor stages, so that suitable therapeutic procedures with good chances of cure are currently available for prostate cancer. In particular, significant positive developments have taken place in radiotherapy.

National and international guidelines clearly define five possible treatment options for localized prostate cancer, depending on the patient's age, state of health, tumor size, and tumor extension: 1. controlled waiting, 2. Radical surgery, 3. External radiation, 4. Interstitial radiation therapy with seeds = LDR brachytherapy as a single therapy (monotherapy) and 5. In selected cases with a so-called high-risk cancer, the combination therapy of external radiation (EBRT) and subsequent brachytherapy boost.

Surgical removal (radical surgery) is still recommended for the vast majority of men in Germany with localized prostate cancer. The loss of the ability to hold urine (incontinence) is one of the problems that patients with prostate cancer fear most after surgical treatment. This makes it all the more important to fully inform patients in advance about the side effects, risks and prospects of success of the various treatment options.

Brachytherapy with seeds is the ideal form of radiotherapy from a radiotherapeutic point of view, as it fulfills all the prerequisites and requirements of modern, effective and highly precise radiotherapy and preserves urinary continence.


Principle of brachytherapy treatment (seed implantation)

After ultrasound-assisted, computer-assisted 3-dimensional dose planning,  small radiation bodies (seeds) with the size of a grain of rice and enriched with radioactive iodine are placed steril in the prostate with millimeter precision via the patient's perineum using special hollow needles under ultrasound guidance. These titanium-enclosed radiators are linked with fine tissue threads (so-called strands), so a migration is largely prevented.

As a result of the short distance between the radiation source and the cancer cell, the cancer cells are damaged and destroyed.

In contrast to external radiation (e.g. 3D conformal external radiation, proton radiation), in low dose brachytherapy the ionizing X-rays do not have to penetrate other organs (skin, intestine, etc.), since the radiation is delivered directly from the center of the diseased prostate and in the Indexläsion of the cancer.

Due to this advantage, combined with a steep dose decrease at the prostate borders, neighboring healthy organs (rectum, urinary bladder) are irradiated only with the dose that these organs usually tolerate well.

The permanent LDR brachytherapy with seeds performed in our institution must be distinguished from the so-called HDR afterloading therapy, in which short-term radiation sources with a high dose are placed in the prostate in 4 to 6 sessions under anesthesia. This procedure is usually combined with additional external radiation.

We do not perform this procedure due to the multiple anesthesia required and the, in our opinion, more tumor-biologically unfavorable radiation dose (high dose in a short time).


When is brachytherapy useful?

LDR brachytherapy is an excellent guideline treatment option for all risk groups of localized prostate cancer.

Brachytherapy with seeds can be performed as monotherapy in patients with a low risk profile (PSA < 10 ng/ml and Gleason Score 6) and favourable intermediate risk profile (Gleason Score 7a and PSA < 10 or Gleason Score 6 and PSA 10 - 20 ng/ml).
For patients with an unfavourable intermediate and high risk profile (PSA > 20 or Gleason Score 7b, 8, 9,10), brachytherapy can also be performed as a combination therapy as a so-called "brachyboost" with dose-reduced external beam radiation.

The prostate volume should be < 60 cc. If the prostate volume is > 60 cc, short-term drug therapy to reduce the volume is possible and recommended.

Chronic or acute inflammatory diseases of the rectum should not exist. Prior irradiation of the rectum or pelvis should not be present.

(Inclusion criteria according to the European and American Societies of Urology and the American Brachytherapy society, ABS and NCCN guidelines, Estro/EAU/EORTC/ASTRO guidelines).


Results

Brachytherapy as monotherapy alone:

The long-term results of permanent brachytherapy alone as a single monotherapy for low-risk tumors and tumors in the favorable intermediate-risk group are excellent, with a PSA progression-free cure rate of over 94% and a 10-year cancer-specific survival rate of 99%, and at least equivalent to invasive radical surgery.

If cancer cells survive or recur in the prostate after brachytherapy (< 2% probability), radical surgery can still be performed at our center without significantly increasing the risk of permanent urinary incontinence compared to primary radical surgery.

The histologically confirmed local recurrence rate after brachytherapy in case of a PSA rise is just under 2% in our patient collective (for comparison: after radical prostatectomy 17-40% of all patients with clinically localized prostate carcinoma have a PSA recurrence after 10 years, 2-21.5% of operated patients with clinically localized prostate carcinoma have a local recurrence after radical op within 3-15 years).

Combination therapy: external beam radiation and brachyboost for high risk Cancer:

For patients with unfavorable intermediate (Gleason 7b) and high risk (Gleason 8-10, PSA > 20ng(ml) ) localized prostate cancer, the 2017 published, multicenter prospective randomized Ascende RT study of 398 men demonstrated highly significant superiority for PSA-free survival of a combination of external beam radiation (EBRT) followed by LDR brachytherapy boost, each with reduced radiation dose and a total of 12 months of androgen suppression, compared with external beam radiation (EBRT) alone with androgen suppression.

(PSA-free survival at 9 years of 83.3% in the combination therapy group vs. 62.4% in the external beam radiation alone group (stratified by surgical scale, PSA > 0.2 ng/ml: PSA-free survival at 9 years 82.2% in the combination group vs. 31.5% in the EBRT group).)

Focal salvage brachytherapy in case of disease recurrence after external radiotherapy:

If there is a relapse of the disease (= local recurrence) in the prostate after external percutaneous radiotherapy of the prostate or brachytherapy, in individual cases the renewed tumour growth can be stopped with another focal salvage brachytherapy, in which only a few seeds are placed specifically into the affected area of the recurrent tumour.

The prerequisite for this is, that the renewed tumor localization and local tumor extension can be visualized by modern imaging (PSMA-PET-MR) and the recurrent tumor is confirmed by a biopsy.

If there are no significant long-term side effects from the initial irradiation and the location of the recurrent tumor is favorable, targeted image-guided selective brachytherapy of this single focus (= ultrafocal salvage brachytherapy) can then be considered.


FFocal salvage brachytherapy: imaging with scheme, radiation planning and x-ray image after targeted implantation of the seeds.

Literature: Salvage brachytherapy for recurrent prostate cancer after definitiveradiation therapy: A comparison of low-dose-rate and high-dose-rate brachytherapy and the importance of prostate-specific antigen doubling time Marisa A. Kollmeier, Michael J. Zelefskyet al: Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NYM.A. Kollmeier et al. / Brachytherapy - (2017)


Timetable and implementation of brachytherapy

If local cancer growth in the prostate is detected, the patient will be informed about the benefits and risks of the treatment by the treating urologist, radiotherapist and anesthesiologist about 14 days before the start of therapy as part of the pre-diagnosis.

At this time, the urologist determines the size and location of the prostate in order to determine the number of "seeds" necessary for brachytherapy.

On the day of treatment, the patient is positioned under anesthesia in the so-called lithotomy position (supine position with legs bent upward at the hips).

At the beginning of the treatment, a catheter is inserted into the urinary bladder (for visualization of the urethra) and the patient is administered an antibiotic and painkillers to prevent infection or pain.

Using special computer software (dose planning system), the urologist, radiation therapist and radiation physicist jointly determine the number and dose distribution of the radiactive sources (seeds) to be placed and their 3D positioning coordinates in the organ (dosimetry) on the basis of a sonographically determined 3-dimensional model of the prostate.

Each seed can thus be placed and deposited at the intended location in the prostate under X-ray and ultrasound control within the prostate via hollow needles inserted into the organ with millimeter precision. The targeted positions of the seeds are permanently and dynamically compared with the actual placement location in the ultrasound image and dose planning system. Shifts in the radiation plan can be corrected even more accurately. The precision of the brachytherapy increases, which leads to an optimization of the treatment (simultaneous dynamic online dosimetry).

Optionally, the intraoperative radiation plan and placement of the seeds can be optimized by a previously performed multiparametric magnetic resonance imaging (MRI) or a PSMA-PET-MR of the prostate. Through these modern imaging techniques, tumor localization and local tumor extension can be well visualized, so that these tumor foci in the prostate can be irradiated selectively and with a selectively higher focal dose (boost) even more intensively, with a simultaneous radiation dose reduction in the remaining prostate tissue (= focused brachytherapy).

In the case of a single, very small tumor focus with low aggressiveness, a targeted selective therapy of only this single focus (= ultrafocal therapy) or only of the affected side lobe of the prostate (= focal therapy) can also be considered after a case-by-case decision.


3-D reconstruction of carcinoma lesions in the prostate for targeted focused irradiation with seeds.

This targeted focused therapy can further reduce potential side effects.

The catheter is removed again before the end of treatment.

Before discharge, each patient is given an information sheet by the urologist for radiation protection in the case of radiation sources in the body and an "implantation card" prescribed in accordance with the Radiation Protection Ordinance.

The position of the seeds is checked on a computer tomogram (CT) 4 to 6 weeks after the brachytherapy treatment (quality control) in order to be able to calculate the actually applied radiation dose on the basis of these results.


Side effects

Typical temporary side effects are increased urinary urgency and possible difficult bladder emptying for about 3 to 12 months.

Short- and long-term radiation-related side effects - and consequences of the intestinal tract are rare compared to external beam irradiation.

Therapy-related long-term urinary incontinence occurs in less than 0.2% of treated patients.

Potency is also preserved in the long term in approximately 80 %.

An increased risk of radiation-induced secondary tumors in the rectum or urinary bladder has not been observed for LDR-Brachytherapy to date due to the minimal radiation dose in healthy tissues, in contrast to external radiation therapy.


Follow-up care

After treatment, the patient remains in regular urological follow-up, during which, in addition to the clinical examination, specific questions are asked about changes in sexual function, defecation behavior, or urinary complaints.


What to do in case of local recurrence?

If the cancer in the prostate recurs after brachytherapy ("relapse" = local recurrence), it is often possible to reapply seeds in this area in the case of small foci. ( reaplication of seeds or focal salvage brachytherapy)

Radical surgery is also still an option and can be carried out good. 

 

The advantages of LDR brachytherapy (permanent seed implantation) are:

  • One-time therapy (monotherapy)

  • Can be performed on an outpatient or short-stay basis

  • Risk of permanent radiation-induced urinary incontinence less than 0.2%.

  • Long-term preservation of potency in more than 80%.

  • Immediate fitness and ability to work 1-2 days after treatment

  • Achievement of a high radiation dose in the organ exposed to cancer the cancer  Indexläsion

  • less stress for the patient's organism during and after the treatment

  • low risk for rectum and urinary bladder compared to external radiation due to low dose in healthy organs

  • no radiation risk for the social environment of the treated person, due to the short range of the radiators in the range of millimeters

  • favorable radiobiological situation with slow and continuous irradiation of cancer cells and possibility of repair and regeneration of co-irradiated benign cells;

  • additional selective irradiation of the known cancer foci in the prostate, with the possibility of increasing ("boost") the focal dose in these areas (= focused brachytherapy of prostate carcinoma).

 

If you have any questions, please do not hesitate to contact us.