Marieke van Son

28 CHAPTER 2 Interventions EBRT Radiation was administered using intensity modulated radiotherapy (IMRT) or volumet- ric modulated arc radiotherapy (VMAT). Until 2013, the indicated protocol for patients with low-risk disease (stage T1-2b, ISUP 1) was 70Gy in 35 fractions. After 2013, this protocol was changed to 60Gy in 20 fractions. For patients with a Roach seminal vesicle score 23 >15%, the seminal vesicles were included into the clinical target volume (CTV). Up to 2016, intermediate-risk patients (ISUP 2-3) received 74Gy in 37 fractions, with the base of the seminal vesicles included in the CTV. From 2016 onwards, this was changed to 72Gy in 32 fractions. All protocols included a margin of 5mm (0mm posteriorly) to the CTV for the planning target volume (PTV). Neo-adjuvant short-course (usually 3-6 months) ADT was prescribed for all EBRT patients unless contra-indicated. LRP Surgery was performed as a standardised laparoscopic procedure without pelvic lymph node dissection, using unilateral or bilateral nerve sparing at the discretion of the operating surgeon. If, for any reason, surgery had to be delayed, patients received neo-adjuvant short-course (usually ≤3 months) ADT as a bridging strategy. In case of post-operative adverse pathologic findings (positive surgical margins, upstaging to pT3-4), patients received adjuvant radiotherapy to the prostate bed (66Gy in 33 frac- tions) only if they had concomitant PSA progression. FT Focal HIFU (Sonablate, Sonacare) was offered to patients with peripheral or posterior tumours or those anteriorly based in which the anterior-posterior height was ≤3.5cm. Focal cryotherapy (SeedNet or Visual ICE cryotherapy device, Boston Scientific) was the preferred technique in anterior tumours, larger prostates with an anterior-posterior distance of >3.5cm or those with prostatic calcifications. Focal HDR-brachytherapy (1x19Gy) was performed without restrictions regarding tumour location or prostate size. Detailed descriptions of treatment procedures can be found in previous reports 13,14,24 . Salvage or repeat therapy following focal therapy was advised after histological confir- mation of recurrent or residual disease. All focal patients had regular PSA monitoring, with an MRI performed in the case of two consecutive PSA rises with no identifiable benign cause. If a lesion of PI-RADS 3 or above was identified the patient underwent biopsy. Data collection ISUP grade and maximum cancer core length (MCCL) were determined from either TRUS-guided systematic sampling (LRP patients until 2016, EBRT and focal HDR-brachytherapy patients), MRI-targeted biopsies with peripheral zone sampling (focal HIFU/cryotherapy) or MRI-targeted biopsies with contralateral sampling (LRP