Neoadjuvant androgen suppression and permanent radioactive seed implantation in the treatment of stage T-1-T-2 prostate cancer

Neoadjuvant androgen suppression (NAS) and brachytherapy have emerging role s in the treatment of prostate cancer. Although NAS has been used with exte rnal-beam irradiation and radical prostatectomy, there is little informatio n on its use with brachytherapy. We describe our experience with NAS and pe rmanent radioactive seed implantation to assess the impact on prostate volu me and prostate specific antigen (PSA) changes, biopsy results, and morbidi ty. Neoadjuvant androgen suppression was given prior to radioisotope implan tation in 76 patients with prostate volumes >50 cm(3) (N = 13), or Gleason score greater than or equal to 7, PSA >10 ng/mL, or stage T-2c disease (N = 63). Hormonal therapy was accomplished with 3 months of leuprolide and flu tamide prior to and 2 months after seed implantation. All patients received Pd-103 seeds to a dose of 115 Gy. Presenting PSA values ranged from 4.0 to 57.0 ng/mL (median 11 ng/mL; mean 14.4 ng/mL). Gleason scores were 2-4 in 16 patients (21%), 5-6 in 28 patients (37%), and 7 or greater in 32 patient s (42%). The clinical stage was T-1b in 1 patient, T-1c in 15 patients (20% ), T-2a in 16 patients (21%), T-2b in 25 patients (33%), and T-2c in 19 pat ients (25%). Prostate volume measurements were taken using transrectal ultr asonography prior to administration of NAS for 61 patients and ranged from 17.2 to 118.3 cm3 (median 45.5 cm(3); mean 50.16 cm(3)). Follow-up ranged f rom 12 to 65 (median 20) months. The median change in prostate volume after NAS and prior to implantation was a decrease to 60% of the baseline volume . After this decrease in volume, prostate volumes remained stable throughou t the follow-up period and after cessation of NAS. The actuarial freedom fr om biochemical failure at 4 years (PSA less than or equal to 1 ng/mL) was 7 8%. Pretreatment prognostic factors, PSA, stage, and Gleason score had no s ignificant effect on the likelihood of biochemical failure. Negative 2-year post-treatment prostate biopsies were obtained in 23 of 24 patients (96%). The actuarial preservation of sexual potency at 2 years was 54%. There wer e no cases of late bladder or rectal complications. Urinary retention neces sitating Foley catheterization occurred in 12% and led to transurethral res ection of the prostate in 7%. When given prior to Pd-103 brachytherapy, NAS can help reduce prostate volume, and the combined therapy results in relat ively high biochemical control rates and negative post-treatment biopsy res ults in a group of patients with high-risk features. Although the therapy i s associated with low morbidity, it is also associated with a lower preserv ation of sexual potency than seed implants alone.