In this week’s Case Record of the Massachusetts General Hospital is a 65-year-old man was seen because of hematuria and a tumor in the urethra, 10 years after brachytherapy for prostate cancer. Cystoscopy with biopsy revealed adenocarcinoma of the prostatic urethra. Colonoscopic findings were normal. A procedure was performed.
It is generally considered that surgery in all its forms (open prostatectomy, laparoscopic prostatectomy, robot-assisted radical prostatectomy) and radiation in all its forms (conformal external-beam radiation therapy, using either intensity-modulated radiation treatment or protons, and brachytherapy) are similarly effective for cancer control.
• How is PSA density used in the diagnosis of prostate cancer?
The PSA density (the serum PSA level divided by the volume of the prostate) can help to determine whether the elevated PSA level can be explained by the presence of increased normal prostatic tissue or is attributable to the cancer.
• What are the most typical adverse effects associated with the treatment of prostate cancer?
With surgery, incontinence and impotence are the main side effects. With radiation, impotence occurs with about the same frequency as with surgery, whereas incontinence is very uncommon. With radiation, bleeding from the rectum or bladder or both may occur and may persist for years.
Morning Report Questions
Q. What factors have led to brachytherapy coming back into favor?
A. PSA testing allows for the detection of cancers at an earlier stage, as in this patient, when cure is feasible with local treatment. Second, improvements in ultrasound technology and the transrectal probe allow better visualization of the prostate and permit transperineal source insertion under accurate image-guidance
Q. Which patients are most suitable for brachytherapy?
A. A patient with a small cancer in a small prostate gland and no baseline urinary dysfunction will do very well with seed-implant brachytherapy.