Neoadjuvant hormonal therapy improves the outcomes of patients undergoing radioactive seed implantation for localized prostate cancer

Neoadjuvant hormonal therapy (NHT) has been extensively studied in patients undergoing radical prostatectomy and external-beam irradiation for prostat e cancer. While there are a few reports in the literature on its use in men undergoing brachytherapy, little information exists about its beneficial e ffects in such patients. In this report? we describe the effects of NHT on prostate volume (PV) prior to seed implantation and on the prostate specifi c antigen (PSA) and postimplant biopsy outcomes of patients who presented w ith high-risk features. Hormone therapy (leuprolide and flutamide 750 mg/da y) was given to 145 patients for 3 months prior to and for 3 months after p ermanent iodine-125 (160 Gy) or palladium-103 (115 Gy) seed implantation. O f these, 28 (19%) received NHT because of a preimplant PV >50 cc, and 117 p atients received NHT because they had a PSA >10 ng/mL, Gleason score greate r than or equal to 7, or clinical stage greater than or equal to T-2b All p atients underwent implantation using the real-time intraoperative method, a nd no patients received external-beam irradiation. Of the 145 patients trea ted, 67 (46%) had a PSA >10 ng/mL (range 1.9-57 ng/mL; mean 12.2 ng/mL), 50 (35%) had Gleason score greater than or equal to 7, and 80 (55%) had stage greater than or equal to T-2b disease. Prostate volume was measured in 106 patients prior to NHT and 3 months later immediately prior to the seed imp lant. The mean PV was 50.4 cc (range 17-150 cc), whereas the mean PV after NHT was 31 cc (range 11.7-73.7 cc). The mean PV reduction was 35% (range 2% -62%). Volume reduction was compared in those patients who presented with a PV <40 cc (N = 51) and those with a PV greater than or equal to 40 cc (N = 56). The mean reduction for the smaller glands was 29% (range 2%-54%) comp ared with 41% (range 7%-62%) for the larger glands (P < 0.05). Patients wer e followed for a minimum of 1 year (range 1.0-6.4; mean 2.2 years). The 1-y ear actuarial rate of freedom from PSA failure (PS >1.0 ng/mL with two cons ecutive elevations) was 85%. There was no difference in rates of freedom fr om PSA failure for those with initial Gleason 2-4 (96%), 5-6 (78%), 7 (80%) , or 8-9 (83%; P = 0.5). Control rates were 85% for patients with PSA less than or equal to 10 ng/mL, 82% for patients with PSA 10 to 20 ng/mL, and 88 % for patients with PSA >20 ng/mL (P = 0.8). There was a trend to decreased control rates with higher-stage disease (98% for T-1-T-2a v 68% for T-2c), but these differences were likewise not significant (P = 0.12). The contro l rates for the 28 low-risk patients with enlarged prostate glands were com pared with those of the 117 with high-risk features and were not different (100% v 82%; P = 0.1). There were 62 patients who agreed to eight-core pros tate biopsies 2 years after implantation, and 60 (97%) were negative for tu mor. This trial shows that NHT can reduce PV an average of 35% prior to see d implantation with the greatest reduction found in patients with larger pr ostates (41%). Hormonal therapy also appears to improve biochemical (PSA) c ontrol and local control (prostate biopsy) in patients with high-risk disea se, yielding results similar to those in men with low-risk prostate cancer.