Marieke van Son

44 CHAPTER 3 ABSTRACT Introduction For the treatment of localised prostate cancer, focal therapy has the potential to cure with less side-effects than traditional whole-gland treatments. We report an update of toxicity, quality of life (QoL) and tumour control of our MRI-guided ultrafocal high- dose-rate (HDR) brachytherapy cohort. Materials and methods Disease status was evaluated by systematic biopsies and 3T multiparametric MRI. The brachytherapy implant procedure under fused transrectal ultrasound/MRI guidance was followed by 1.5T MRI for contour adjustments and catheter position verification. In a single dose, 19Gy was delivered to the tumour with a margin of 5 mm. Genitourinary (GU) toxicity, gastro-intestinal (GI) toxicity and erectile dysfunction (ED) were graded with the CTCAE 4.0. QoL was measured with RAND-36, EORTC QLQ-C30 and EORTC QLQ-PR25. IPSS and IIEF scores were obtained. PSA was monitored, with biochemical recurrence defined as nadir+2ng/ml (Phoenix). Results Thirty patients with NCCN low(13%) to intermediate(87%) risk prostate cancer were treated between May 2013 and April 2016. Median follow-up was 4 years. Median age was 71 years (interquartile range 68-73), median iPSA 7.3 ng/ml (5.2-8.1). Maximum Gleason score was 4+3=7 (in 2 patients). All tumours were radiological (MRI) stage T2. No grade >2 GU or >1 GI toxicity occurred. IPSS only deteriorated temporarily. Pre-treat- ment IIEF mild ED deteriorated to moderate/severe ED in 50% of patients.. Long-term clinically relevant QoL deterioration was seen in sexual activity and tiredness, while emotional and cognitive functioning improved. At 4 years, biochemical disease-free survival (BDFS) was 70% (95% CI 52-93%), metastases-free survival 93% (85-100%) and overall survival 100%. Of intraprostatic recurrences, 7/9 were out-of-field. Conclusion Ultrafocal HDR-brachytherapy conveys minimal GU/GI toxicity and has a marginal effect on QoL. An early decline in erectile function was seen. Tumour control outcomes are poor (BDFS 70% [52-93%] at 4 years), most likely as a result of poor patient selection.