Patient selection

Contraindications to brachytherapy include metastatic disease (including lymph node involvement), gross seminal vesicle involvement because that radioactive seeds are unlikely to be capable of sterilizing more than the most proximal 1 cm of seminal vesicle tissue, or large T3 disease that cannot be adequately implanted because of geometrical impediments to adequate tumor mass implantation (an unusual presentation).

Large prostate size can be often contraindication to brachytherapy because that the anterior and lateral portion of the gland may be inadequately covered because of pubic arch interference of needle placement. When a patient has a prostate > 60 cc, and pubic arch interference is a concern, a short course of ADT will reduce prostate volume by an average of approximately 30% in 3-4 months [38, 39]

Patients with a high International Prostate Symptom Score (IPSS) for urinary irritative and obstructive symptoms are at increased risk of developing postimplant urinary retention [40-43]. Terk et al. [44] and Gutman et al. [45] reported that patients with IPSS had a high risk of urinary retention.

Patients with prior pelvic radiotherapy may be at increased risk of developing late GI or GU toxicity. In such patients, the dose delivered to the prostate, rectum, and bladder should be considered.

In patients with prior TURP, a large TURP defect may disturb implantation of seed throughout the entire gland, resulting in unacceptable dosimetry.

Early-stage prostate cancer with T < or = 2a, initial PSA < or = 10ng/ml, and GS < or = 6 is suitable for brachytherapy without supplemental EBRT. Meanwhile, the generally accepted policy has been to add EBRT for the prostate cancer with T > 2a, initial PSA > 10ng/ml, or GS > 6. However, patients with intermediate-risk disease (T = 2b, GS = 7, or PSA > 10 and < or = 20 ng/ml) represent a heterogeneous patient population some of whom may benefit from monotherapy. Some investigators reported their experiences to perform monotherapy for patients with intermediate- and high-risk disease [46 - 51].

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