MINIMALLY INVASIVE URO-ONCOLOGICAL TREATMENTS ON THE AMBULATORY SETTING PROSTATE BRACHYTHERAPY I125 Luís Campos Pinheiro

PROSTATE BRACHYTHERAPY IS A MATURE TECHNIQUE WELL ESTABLISHED AS A STANDARD LOCALISED PROSTATE CANCER TREATMENT At least 14 Lisbon Centers: British Hospital (2 teams) Hospital da Luz Clínica da Reboleira Hospital S. Luís (2 teams) Hospital das Descobertas Clínica Europa (2 teams) Hospital da Cruz Vermelha Hospital Particular de Lisboa IPO Hospital Sta Maria Hospital de S. José

PROSTATE BRACHYTHERAPY IS A MATURE TECHNIQUE WELL ESTABLISHED AS A STANDARD LOCALISED PROSTATE CANCER TREATMENT BRITISH HOSPITAL SINCE SEPTEMBER 2000 865 brachytherapy patients

PROSTATE BRACHYTHERAPY IS OPERATOR DEPENDENT WHICH IS CLEARLY LINKED TO SURGICAL EXPERIENCE When performed by an experienced, high volume team the likelihood of inadequate implant (D90 less than 140) is less than 5% British Hospital: 4/865 = 0.46%

PROSTATE BRACHYTHERAPY: Low risk T1-T2 achieves low PSA Nadir and durable long term control The 10 to 15 years biochemical survival is consistently in the 85% to 95% range No evidence of late failures after 10 years % Years Stone (Mount Sinai) 88 12 Potters (NY Prostate Institute) 89 Sylvester (Seattle Prostate Institute) 86 15 Taira (University of Washington) 99

PROSTATE BRACHYTHERAPY FOR INTERMEDIATE AND HIGH RISK PCA THE PERFECT DOSE ESCALATION BED over 180 Gy is associated with positive biopsy rates of 3% Intermediate Risk (%) High Risk(%) Years Stone (Mount Sinai) 79 67 12 Potters (NY Prostate Institute) 78 63 Sylvester (Seattle Prostate Institute) 80 62 15 Taira (University of Washington) 97 91

5-year bFFF for Gleason 8-10 by BED Gleason 8-10, PSA > 20 ng/ml 85.7% BED > 220 220 Gy (86%) 71.6% BED 200-220 < 220 Gy (61%) 24.4% BED < 200 Very high doses: BED > 220 Gy I-125 (130 Gy) plus EBRT (45 Gy)

BRITISH HOSPITAL SERIES LISBON SERIES BRITISH HOSPITAL SERIES Between September 2000 and November 2006 52 high risk prostate cancer patients Iodine 125 prostate brchytherapy (110Gy) EBRT (45 Gy) 2 months after Hormonal therapy 3M plus 6M (LHRH analogue) 31/52 pt (59%) High Risk definition: Gleason Score 8 to 10; PSA above 20 ng/ml; T2c – T3 2 of (Gleason Score 7; PSA between 10 to 20; T2b)

BRITISH HOSPITAL SERIES Dosimetric CT (1 month post brachytherapy): Mean D90 of 121.9 Gy (Range 95 Gy to 162 Gy) Biological Equivalent Dose of 211,58 Gy (Range 183 to 256,5 Gy)

BRITISH HOSPITAL SERIES The Actuarial Overall Freedom from PSA failure was 84.7% at 7 years

PROSTATE BRACHYTHERAPY IS AN ORGAN FUNCTION-SPARING TREATMENT Long term erectile dysfunction and urinary incontinence are significantly lower after brachytherapy compared to surgery

CONCLUSIONS Prostate brachytherapy as evolved from a novel, minimally invasive treatment modality indicated only for the low risk prostate cancer To a standard highly efficacy, low morbidity treatment to localized and locally advanced prostate cancer