Prostate Brachytherapy – LDR

Prostate Cancer Epidemiology

There will be 164,690 new cases (19% of all cancers in males) and 29,430 prostate cancer death in the US in 2018(1)


Prostate Cancer Treatment Options

Treatment options in general include active surveillance, radical prostatectomy with or without adjuvant and salvage radiation, prostate brachytherapy with or without adjuvant EBRT and or ADT.  Updated guidelines for patient selection, workup, treatment, post implant dosimetry, and follow-up are provided in ABS guidelines for LDR and HDR(2).


Prostate Brachytherapy - Indications

Prostate brachytherapy (PB) is a standard treatment option of patients with organ confined prostate cancer. Excellent long-term results have been published for all risk groups(3). Low Dose Rate (LDR) Monotherapy is appropriate for low and low-tier intermediate risk prostate cancer.  For most men with high-tier intermediate risk cancer, brachytherapy boost with Low Dose Rate (LDR) or High Dose Rate (HDR) brachytherapy, in combination with External Beam Radiation Therapy (EBRT) with or without Androgen Deprivation Therapy (ADT) for 9-12 months is appropriate. LDR or HDR brachytherapy boost in combination with EBRT and ADT (12-36 months) is appropriate for high risk disease.  HDR monotherapy is still evolving and early results are encouraging.  Based on 3 RTC showing superior PSA outcomes with EBRT and Brachytherapy boost vs EBRT alone(4)(5),(6)  2017 ASCO/ CCO prostate brachytherapy guideline recommends patients be offered prostate brachytherapy if eligible, establishing prostate brachytherapy as a standard of care in prostate cancer in all risk groups(7).


Prostate Brachytherapy – Contraindications(2)

As per ABS guidelines, absolute contraindications for LDR include:

  • Limited life expectancy
  • Unacceptable operative risks
  • Distant metastases
  • Absence of rectum such that TRUS guidance is precluded
  • Large TURP defects, which preclude seed placement and acceptable radiation dosimetry
  • Ataxia telangiectasia


Prostate Brachytherapy – Relative Contraindication

  • High IPSS (>15-20)
  • History of prior pelvic radiotherapy
  • TURP
  • Large median lobe
  • Gland size>60 cm3 at time of implantation
  • Inflammatory bowel disease
  • Gross seminal vesicle involvement


Use of ADT and Brachytherapy

There are significant uncertainties regarding the role of androgen deprivation therapy (ADT) with brachytherapy. Existing evidence shows no benefit of adding ADT to PB in low-risk and favorable IR patients. Unfavourable IR, favourable HR patients and those with suboptimal dosimetry may have up to 15% improvement in PSA PFS, with uncertain impact on Cause Specific and Overall Survival(8).


Expected Outcomes

Long term outcomes will dependent on treatment given and risk group stratification. They may vary between institutions.  In general, long term outcomes in all risk groups are very favourable PSA progression free survival with long 10 year follow up, suggesting ablative effects of brachytherapy.  Low and low- tier intermediate risk patients, have 85-95% long term PSA RFS, Intermediate risk 70-95%, and 85-90% in combination with EBRT (either LDR or HDR boost). Patients with high risk disease have up to 50% chance of PSA control, addition of EBRT increase PSARFS to 60-70% and addition of both, EBRT and ADT, up to 85%(3).  


Standard Doses

125I – Monotherapy 140-160Gy
125I – Boost 108-110Gy

103Pd – Monotherapy 110-125Gy
103Pd – 90-100Gy

131Cs – Monotherapy 100-115Gy
131Cs – Boost 70-80Gy


Side effects

Moderate irritative ad obstructive urinary symptoms are expected in 50% of the patients. Median time for IPSS to return to baseline is 12 months. Ten years after PB, the majority of patients (>90%) will have very little or no urinary symptoms. Worse toxicity is seen with larger prostate volume, and worse baseline urinary function. Incidence of acute urinary retention is < 5-10%, and is more likely in patients with worse baseline urinary function, significant median lobes, and those with larger prostate size. Incidence of TURP (transurethral resection of the prostate) and urethral strictures requiring dilatation is <1-2% with monotherapy(9). Incontinence develops in 40% and 15% of those who undergo TURP and urethral dilatation for stricture respectively. Mild self-limiting rectal irritation affects 20%-30% of patients in the first 1-2 years after the implant. Rectal bleeding is reported in 2-7% of patients. Grade 4 rectal fistula is rare (0.5%).  5 year Erectile function (EF) after brachytherapy depends on pre-treatment function, comorbidity and age.  EF preservation rate at 5 years for ages <55, 56-59, 60-64, 65-69, and > 70,  is about 80%, 75%, 60%, 40%, and 25%, respectively. 50 % of EF decline is related to aging(10).   EBRT and LDR boost have more long term GU and GI toxicity than PB alone (RTOG 0232 (late grade > 2:  53% vs 37%, late grade >3: 12% vs 7%). Likewise, EBRT and LDR boost have more late long term GU and GI toxicity than EBRT alone with cumulative incidence of grade 3 GU toxicity of 18% vs 5.2% and grade 3 GI toxicity of 8.0%  vs. 3.2%. (11)


Training requirements

Formal training in LDR brachytherapy is available in several institutions ion the US Canada and Europe. In Addition, ABS is making hands on workshops available for residents and junior staff on annual bases (link here).

The fundamental aspects of training include proficiency in:

  • Understating indications and contraindications for LDR brachytherapy
  • Patient and side effect management
  • US volume study
  • US prostate anatomy and contouring
  • OR implant procedure
  • CT and MR post implant contouring
  • Dosimetry interpretation
  • Basic concepts of LDR physic and radiobiology
  • Quality Assurance procedure



(1) Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin 2017 Jan;67(1):7-30.

(2) Davis BJ, Horwitz EM, Lee WR, Crook JM, Stock RG, Merrick GS, et al. American Brachytherapy Society consensus guidelines for transrectal ultrasound-guided permanent prostate brachytherapy. Brachytherapy 2012 Jan-Feb;11(1):6-19.

(3) Grimm PD, Billiet I, Bostwick DG, Dicker A. P., Frank SJ, Immerzeel J, et al. Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group. BJU Int 2012;109(supp 1):22-29.

(4) Morris WJ, Tyldesley S, Rodda S, Halperin R, Pai H, McKenzie M, et al. Androgen Suppression Combined with Elective Nodal and Dose Escalated Radiation Therapy (the ASCENDE-RT Trial): An Analysis of Survival Endpoints for a Randomized Trial Comparing a Low-Dose-Rate Brachytherapy Boost to a Dose-Escalated External Beam Boost for High- and Intermediate-risk Prostate Cancer. Int J Radiat Oncol Biol Phys 2016 Nov 24.

(5) Hoskin PJ, Rojas AM, Bownes PJ, Lowe GJ, Ostler PJ, Bryant L. Randomised trial of external beam radiotherapy alone or combined with high-dose-rate brachytherapy boost for localised prostate cancer. Radiother Oncol 2012 May;103(2):217-222.

(6) Sathya JR, Davis IR, Julian JA, Guo Q, Daya D, Dayes IS, et al. Randomized trial comparing iridium implant plus external-beam radiation therapy with external-beam radiation therapy alone in node-negative locally advanced cancer of the prostate. J Clin Oncol 2005 Feb 20;23(6):1192-1199.

(7) Chin J, Rumble RB, Kollmeier M, Heath E, Efstathiou J, Dorff T, et al. Brachytherapy for Patients With Prostate Cancer: American Society of Clinical Oncology/Cancer Care Ontario Joint Guideline Update. J Clin Oncol 2017 May 20;35(15):1737-1743.

(8) Keyes M, Merrick G, Frank SJ, Grimm P, Zelefsky MJ. American Brachytherapy Society Task Group Report: Use of androgen deprivation therapy with prostate brachytherapy-A systematic literature review. Brachytherapy 2017 Jan 16.

(9) Keyes M, Miller S, Pickles T, Halperin R, Kwan W, Lapointe V, et al. Late urinary side effects 10 years after low-dose-rate prostate brachytherapy: population-based results from a multiphysician practice treating with a standardized protocol and uniform dosimetric goals. Int J Radiat Oncol Biol Phys 2014 Nov 1;90(3):570-578.

(10) Keyes M, Pickles T, Crook J, McKenzie M, Cheung A, Spadinger I, et al. Effect of aging and long-term erectile function after iodine-125 prostate brachytherapy. Brachytherapy 2015 May-Jun;14(3):334-341.

(11) Rodda S, Tyldesley S, Morris WJ, Keyes M, Halperin R, Pai H, et al. ASCENDE-RT: An Analysis of Treatment-Related Morbidity for a Randomized Trial Comparing a Low-Dose-Rate Brachytherapy Boost with a Dose-Escalated External Beam Boost for High- and Intermediate-Risk Prostate Cancer. Int J Radiat Oncol Biol Phys 2017 Jan 6.


Long Term Brachytherapy Results

Crook J, Borg J, Evans A, et al. 10-year experience with I-125 prostate brachytherapy at the princess margaret hospital: results for 1,100 patients. Int J Radiat Oncol Biol Phys. 2011;80(5):1323-9.

Frank SJ, Levy LB, van Vulpen M, et al. Outcomes after prostate brachytherapy are even better than predicted. Cancer. 2011 Jul 12. [Epub ahead of print]

Stone NN, Stone MM, Rosenstein BS, et al. Influence of pretreatment and treatment factors on intermediate to long-term outcome after prostate brachytherapy. J Urol. 2011; 185(2):495-500.

Lawton CA, Hunt D, Lee WR, et al. Long-Term Results of a Phase II Trial of Ultrasound-Guided Radioactive Implantation of the Prostate for Definitive Management of Localized Adenocarcinoma of the Prostate (RTOG 98-05). Int J Radiat Oncol Biol Phys. 2011 Apr 4. [Epub ahead of print]

Taira AV, Merrick GS, Butler WM, et al. Long-term outcome for clinically localized prostate cancer treated with permanent interstitial brachytherapy. Int J Radiat Oncol Biol Phys. 2011;79(5):1336-42.

Fang LC, Merrick GS, Butler WM, et al. High-Risk Prostate Cancer with Gleason Score 8-10 and PSA Level ≤15 ng/ mL Treated With Permanent Interstitial Brachytherapy. Int J Radiat Oncol Biol Phys. 2010 Oct 5. [Epub ahead of print]

Bittner N, Merrick GS, Wallner KE, et al. Whole-pelvis radiotherapy in combination with interstitial brachytherapy: does coverage of the pelvic lymph nodes improve treatment outcome in high-risk prostate cancer? Int J Radiat Oncol Biol Phys. 2010;76(4):1078-84.

Sylvester JE, Grimm PD, Wong J, et al. Fifteen-Year Biochemical Relapse-Free Survival, Cause-Specific Survival, and Overall Survival following I(125) Prostate Brachytherapy in Clinically Localized Prostate Cancer: Seattle Experience. Int J Radiat Oncol Biol Phys. 2010 Sep 21. [Epub ahead of print]

Dattoli M, Wallner K, True L, et al. Long-term outcomes for patients with prostate cancer having intermediate and high-risk disease, treated with combination external beam irradiation and brachytherapy. J Oncol. 2010; Epub 2010 Aug 18.

Stock RG, Cesaretti JA, Hall SJ, et al. Outcomes for patients with high-grade prostate cancer treated with a combination of brachytherapy, external beam radiotherapy and hormonal therapy. BJU Int. 2009; 104(11):1631-6.

Stone NN, Potters L, Davis BJ, et al. Multicenter analysis of effect of high biologic effective dose on biochemical failure and survival outcomes in patients with Gleason score 7-10 prostate cancer treated with permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys. 2009; 73(2):341-6.

Bittner N, Merrick GS, Wallner KE, et al. Interstitial brachytherapy should be standard of care for treatment of high-risk prostate cancer. Oncology (Williston Park). 2008;22(9):995-1004

Zelefsky MJ, Kuban DA, Levy LB, et al. Multi-institutional analysis of long-term outcome for stages T1-T2 prostate cancer treated with permanent seed implantation. Int J Radiat Oncol Biol Phys. 2007;67(2):327-33.

Sylvester JE, Grimm PD, Blasko JC, et al. 15-Year biochemical relapse free survival in clinical Stage T1-T3 prostate cancer following combined external beam radiotherapy and brachytherapy; Seattle experience. Int J Radiat Oncol Biol Phys. 2007;67(1):57-64.

Sharkey J, Cantor A, Solc Z, et al. 103Pd brachytherapy versus radical prostatectomy in patients with clinically localized prostate cancer: a 12-year experience from a single group practice. Brachytherapy. 2005; 4(1):34-44.

Potters L, Morgenstern C, Calugaru E, et al. 12-year outcomes following permanent prostate brachytherapy in patients with clinically localized prostate cancer. J Urol. 2005;173(5):1562-6.

Critz FA, Levinson K. 10-year disease-free survival rates after simultaneous irradiation for prostate cancer with a focus on calculation methodology. J Urol. 2004 Dec;172(6 Pt 1):2232-8.

Merrick GS, Butler WM, Wallner KE, et al. Permanent interstitial brachytherapy for clinically organ-confined high-grade prostate cancer with a pretreatment PSA < 20 ng/mL. Am J Clin Oncol. 2004;27(6):611-5.

Grimm PD, Blasko JC, Sylvester JE, et al. 10-year biochemical (prostate-specific antigen) control of prostate cancer with 125I brachytherapy. Int J Radiat Oncol Biol Phys 2001; 51(1):31-40


Radical Prostatectomy

Eggener SE, Scardino PT, Walsh PC, et al. Predicting 15-year prostate cancer specific mortality after radical prostatectomy. J Urol. 2011 Mar;185(3):869-75.

Zhang M S Y, Glass A, Bennett N, et al. Long-term outcomes after radical prostatectomy performed in a community-based health maintenance organization. Cancer. 2004;100(2):300-7.

Melman A, Boczko J, Figueroa J, et al. Critical Surgical Techniques for Radical Perineal Prostatectomy. J Urol. 2004;171(2):786-790.

Han M, Partin AW, Zahurak M, et al. Biochemical (prostate specific antigen) recurrence probability following radical prostatectomy for clinically localized prostate cancer. J Urol. 2003;169(2):517-23.

Salomon L, Levrel O, de la Taille A, et al, Radical prostatectomy by the retropubic, perineal and laparoscopic approach: 12 years of experience in one center. Eur Urol. 2002;42(2):104-10

Roehl KA, Han M, Ramos CG, et al. Cancer progression and survival rates following anatomical radical retropubic prostatectomy in 3,478 consecutive patients: long-term results. J Urol. 2004;172(3):910-4.

Hull GW, Rabbani F, Abbas F, et al. Cancer control with radical prostatectomy alone in 1,000 consecutive patients. J Urol. 2002;167(2 Pt 1):528-34

Han M, Partin AW, Pound CR, et al. Long-term biochemical disease-free and cancer-specific survival following anatomic radical retropubic prostatectomy. The 15-year Johns Hopkins experience. Urol Clin North Am 2001; 28(3):555-65

Amling CL, Blute ML, Zinke H, et al. Long-Term Hazard of Progression After Radical Prostatectomy for Clinically Localized Prostate Cancer: Continued Risk of Biochemical Failure After 5 Years. J Urol. 2000;164:101-105.



Miller DC, Murtagh DS, Suh RS, et al. Regional Collaboration to Improve Radiographic Staging Practices Among Men With Early Stage Prostate Cancer. J Urol. 2011 Jul 23. [Epub ahead of print]

Choi WW, Williams SB, Gu X, et al. Overuse of imaging for staging low risk prostate cancer. J Urol. 2011 May;185(5):1645-9.

Dusing RW, Drisko JA, Grado GG, et al. Prostate Imaging Modalities that Can Be Used for Complementary and Alternative Medicine Clinical Studies. Urol Clin North Am. 2011;38(3):343-57.

Burdick MJ, Reddy CA, Ulchaker J, et al. Comparison of biochemical relapse-free survival between primary Gleason score 3 and primary Gleason score 4 for biopsy Gleason score 7 prostate cancer. Int J Radiat Oncol Biol Phys. 2009 Apr 1;73(5):1439-45.

Frank SJ, Grimm PD, Sylvester JE, et al. Interstitial implant alone or in combination with external beam radiation therapy for intermediate-risk prostate cancer: a survey of practice patterns in the United States. Brachytherapy. 2007;6(1):2-8.

Potters L, Purrazzella R, Brustein S, et al. The prognostic significance of Gleason Grade in patients treated with permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys. 2003;56(3):749-54.

D'Amico AV, Renshaw AA, Cote K Impact of the percentage of positive prostate cores on prostate cancer-specific mortality for patients with low or favorable intermediate-risk disease. J Clin Oncol 2004 Sep 15;22(18):3726-32.

Gancarczyk KJ, Wu H, McLeod DG, et al. Using the percentage of biopsy cores positive for cancer, pretreatment PSA, and highest biopsy Gleason sum to predict pathologic stage after radical prostatectomy: the Center for Prostate Disease Research nomograms. Urology. 2003;61(3):589-95.

Khan MA, Partin AW, Mangold LA, et al. Probability of biochemical recurrence by analysis of pathologic stage, Gleason score, and margin status for localized prostate cancer. Urology. 2003;62(5):866-71.

Gancarczyk KJ, Wu H, McLeod DG, Kane C, et al. Using the percentage of biopsy cores positive for cancer, pretreatment PSA, and highest biopsy Gleason sum to predict pathologic stage after radical prostatectomy: the Center for Prostate Disease Research nomograms. Urology. 2003;61(3):589-95

Partin AW, Mangold LA, Lamm DM, et al. Contemporary update of prostate cancer staging nomograms (Partin Tables) for the new millennium. Urology 2001;58(6):843-8.

Kattan MW, Potters L, Blasko JC, et al. Pretreatment nomogram for predicting freedom from recurrence after permanent prostate brachytherapy in prostate cancer. Urology 2001; 58(3):393-9.

Chan TY, Partin AW, Walsh PC, et al. Prognostic significance of Gleason score 3+4 versus Gleason score 4+3 tumor at radical prostatectomy. Urology 2000;56(5):823-7.


Salvage Brachytherapy

Traudt K, Ciezki J, Klein EA. Low-dose-rate brachytherapy as salvage treatment of local prostate cancer recurrence after radical prostatectomy. Urology. 2011 Jun;77(6):1416-9.

Burri RJ, Stone NN, Unger P, et al. Long-term outcome and toxicity of salvage brachytherapy for local failure after initial radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys. 2010;77(5):1338-44.

Pisters LL, Leibovici D, Blute M, et al. Locally recurrent prostate cancer after initial radiation therapy: a comparison of salvage radical prostatectomy versus cryotherapy. J Urol. 2009 Aug;182(2):517-25.

Beyer DC. Brachytherapy for recurrent prostate cancer after radiation therapy. Semin Radiat Oncol 2003;13(2):158-65.

Grado GL, Collins JM, Kriegshauser JS, et al. Salvage Brachytherapy for Localized Prostate Cancer after Radiotherapy Failure. Urology 1999;53:2-10.

Grado,GL. Benefits of Brachytherapy as Salvage Treatment for Radiorecurrent Localized Prostate Cancer. Urology 1999;54:204-207.


Source Selection

Herbert C, Morris WJ, Hamm J, et al. The effect of loose vs. stranded seeds on biochemical no evidence of disease in patients with carcinoma of the prostate treated with iodine-125 brachytherapy. Brachytherapy. 2011 Mar 11. [Epub ahead of print]

Merrick GS, Sylvester J, Grimm P, et al. Postimplant rectal dosimetry is not dependent on 103Pd or 125I seed activity. Brachytherapy. 2011 Jan-Feb;10(1):35-43.

Hinnen KA, Moerland MA, Battermann JJ, et al. Loose seeds versus stranded seeds in I-125 prostate brachytherapy: differences in clinical outcome. Radiother Oncol. 2010 Jul;96(1):30-3.

Aronowitz JN, Crook JM, Michalski JM, et al. Inter-institutional variation of implant activity for permanent prostate brachytherapy. Brachytherapy. 2008 Oct-Dec;7(4):297-300.

Wallner K, Merrick G, True L, et al. 125I versus 103Pd for low-risk prostate cancer: preliminary PSA outcomes from a prospective randomized multicenter trial. Int J Radiat Oncol Biol Phys. 2003;57(5):1297-303.

Butler WM, Merrick GS, Dorsey AT, et al. Isotope Choice and the Effect of Edema on Prostate Brachytherapy Dosimetry. Med. Phys. 2000; 27:1067-1075

Maguire PD, Waterman FM, Dicker AP. Can the Cost of Permanent Prostate Implants be Reduced? An Argument for Peripheral Loading With Higher Strength Seeds. Tech. Urol. 2000;6: 85-88.

Beyer DC, Puente F, Rogers KL, et al. Prostate brachytherapy: comparison of dose distribution with different 125I source designs. Radiology. 2001;221(3):623-7.

Cha CM, Potters L, Ashley R, et al. Isotope Selection for Patients Undergoing Prostate Brachytherapy. Int J Radiat Oncol Biol Phys. 1999;45:391-395.


Reviews and Guidelines

Bowes D, Crook J. A critical analysis of the long-term impact of brachytherapy for prostate cancer: a review of the recent literature. Curr Opin Urol. 2011 May; 21(3):219-24.

Frank SJ, Arterbery VE, Hsu IC, et al. American College of Radiology Appropriateness Criteria Permanent Source Brachytherapy for Prostate Cancer. Brachytherapy. 2011 Apr 16. [Epub ahead of print]

Rosenthal SA, Bittner NH, Beyer DC, et al. American Society for Radiation Oncology (ASTRO) and American College of Radiology (ACR) practice guideline for the transperineal permanent brachytherapy of prostate cancer. Int J Radiat Oncol Biol Phys. 2011;79(2):335-41

Crook J. The role of brachytherapy in the definitive management of prostate cancer. Cancer Radiother. 2011;15(3):230-7.

Stock RG, Stone NN. Current topics in the treatment of prostate cancer with low-dose-rate brachytherapy. Urol Clin N Am 2010;37: pp 83-96

Potters L, Roach M 3rd, Davis BJ, et al. Postoperative nomogram predicting the 9-year probability of prostate cancer recurrence after permanent prostate brachytherapy using radiation dose as a prognostic variable. Int J Radiat Oncol Biol Phys. 2010;76(4):1061-5.

Vigneri P, Herati AS, Potters L. The second decade of prostate brachytherapy: evidence and cost based outcomes. Urol Oncol. 2010;28(1):86-90.

Lawton CA, Michalski J, El-Naqa I, et al. RTOG GU Radiation oncology specialists reach consensus on pelvic lymph node volumes for high-risk prostate cancer. Int J Radiat Oncol Biol Phys. 2009;74(2):383-7.

Keyes M, Miller S, Moravan V, et al. Predictive factors for acute and late urinary toxicity after permanent prostate brachytherapy: long-term outcome in 712 consecutive patients. Int J Radiat Oncol Biol Phys. 2009;73(4):1023-32.

Liauw SL, Sylvester JE, Morris CG, et al. Second malignancies after prostate brachytherapy: incidence of bladder and colorectal cancers in patients with 15 years of potential follow-up. Int J Radiat Oncol Biol Phys. 2006 Nov 1;66(3):669-73.

Nag S, Beyer D, Friedland J, Grimm P, Nath R. American Brachytherapy Society (ABS) Recommendations for Transperineal Permant Brachytherapy of Prostate Cancer. Int. J. Rad. Onc. Bio. Phys. 1999;44:789-799.


Comparison Papers

Coen JJ, Zietman AL, Rossi CJ, et al. Comparison of High-Dose Proton Radiotherapy and Brachytherapy in Localized Prostate Cancer: A Case-Matched Analysis. Int J Radiat Oncol Biol Phys. 2011 Apr 4. [Epub ahead of print]

Zelefsky MJ, Yamada Y, Pei X et al. Comparison of tumor control and toxicity outcomes of high-dose intensity-modulated radiotherapy and brachytherapy for patients with favorable risk prostate cancer. Urology. 2011 Apr;77(4):986-90.

Pickles T, Morris WJ, Kattan MW, et al. Comparative 5-year outcomes of brachytherapy and surgery for prostate cancer. Brachytherapy. 2011 Jan-Feb;10(1):9-14.

Crook JM, Gomez-Iturriaga A, et al. Comparison of health-related quality of life 5 years after SPIRIT: Surgical Prostatectomy Versus Interstitial Radiation Intervention Trial. J Clin Oncol. 2011 Feb 1;29(4):362-8.

Vassil AD, Murphy ES, Reddy CA, et al. Five year biochemical recurrence free survival for intermediate risk prostate cancer after radical prostatectomy, external beam radiation therapy or permanent seed implantation. Urology. 2010;76(5):1251-7.

Deutsch I, Zelefsky MJ, Zhang Z, et al. Comparison of PSA relapse-free survival in patients treated with ultra-high-dose IMRT versus combination HDR brachytherapy and IMRT. Brachytherapy. 2010;9(4):313-8.

Jabbari S, Weinberg VK, Shinohara K, et al. Equivalent biochemical control and improved prostate-specific antigen nadir after permanent prostate seed implant brachytherapy versus high-dose three-dimensional conformal radiotherapy and high-dose conformal proton beam radiotherapy boost. Int J Radiat Oncol Biol Phys. 2010;76(1):36-42.

Pickles T, Keyes M, Morris WJ. Brachytherapy or conformal external radiotherapy for prostate cancer: a single-institution matched-pair analysis. Int J Radiat Oncol Biol Phys. 2010;76(1):43-9.

Ciezki JP, Klein EA. Brachytherapy or surgery? A composite view. Oncology (Williston Park). 2009;23(11):960-4.

Shanahan TG, Mueller PW, Roszhart DA, et al. Image Guided I125 prostate brachytherapy with hybrid interactive mick technique in the community setting: how does it compare? Technol Cancer Res Treat. 2004 Apr;3(2):209-16

Quaranta BP, Marks LB, Anscher MS. Comparing radical prostatectomy and brachytherapy for localized prostate cancer. Oncology 2004;18(10):1289-302

Kupelian PA, Potters L, Khuntia D, et al. Radical prostatectomy, external beam radiotherapy <72 Gy, external beam radiotherapy >/=72 Gy, permanent seed implantation, or combined seeds/external beam radiotherapy for stage T1-T2 prostate cancer. Int J Radiat Oncol Biol Phys. 2004;58(1):25-33.

Shanahan TG, Nanavati, PJ, Mueller PW, et al. A comparison of permanent prostate brachytherapy techniques: pre-plan verses hybrid interactive planning with postimplant analysis. Int J Radiat Oncol Biol Phys 2002; 53(2): 490-496.

Merrick GS, Butler WM, et al. Is brachytherapy comparable with radical prostatectomy and external-beam radiation for clinically localized prostate cancer? Tech Urol 2001; 7(1):12-19

Brachman DG, Thomas T, Hilbe J et al. Failure-free survival following brachytherapy alone or external beam irradiation alone for T1-2 prostate tumors in 2222 patients: results from a single practice. Int J Radiat Oncol Biol Phys 2000;48:111-117.

D'Amico AV, Whittington R, Malkowicz SB, et al. Biochemical Outcome after Radical Prostatectomy, External Beam Therapy, or Insterstitial Radiation Therapy for Clinically Localized Prostate Cancer. JAMA 1998;280:969-974


Hormone Use

Moyad MA, Roach M 3rd. Promoting wellness for patients on androgen deprivation therapy: why using numerous drugs for drug side effects should not be first-line treatment. Urol Clin North Am. 2011;38(3):303-12.

Valicenti RK, Bae K, Michalski J, et al. Does hormone therapy reduce disease recurrence in prostate cancer patients receiving dose-escalated radiation therapy? An analysis of Radiation Therapy Oncology Group 94-06. Int J Radiat Oncol Biol Phys. 2011;79(5):1323-9.

Bolla M, Van Tienhoven G, Warde P, et al. External irradiation with or without long-term androgen suppression for prostate cancer with high metastatic risk: 10-year results of an EORTC randomised study. Lancet Oncol. 2010;11(11):1066-73.

Fang LC, Merrick GS, Wallner KE. Androgen deprivation therapy: a survival benefit or detriment in men with high-risk prostate cancer? Oncology (Williston Park). 2010 Aug;24(9):790-6, 798.

Alexander A, Crook J, Jones S, et al. Is biochemical response more important than duration of neoadjuvant hormone therapy before radiotherapy for clinically localized prostate cancer? An analysis of the 3- versus 8-month randomized trial. Int J Radiat Oncol Biol Phys. 2010; 76(1):23-30.

Stock RG, Cesaretti JA, Hall SJ, et al. Outcomes for patients with high-grade prostate cancer treated with a combination of brachytherapy, external beam radiotherapy and hormonal therapy. BJU Int. 2009; 104(11):1631-6.

Horwitz EM, Bae K, Hanks GE, et al. Ten-year follow-up of radiation therapy oncology group protocol 92-02: a phase III trial of the duration of elective androgen deprivation in locally advanced prostate cancer. J Clin Oncol. 2008; 26(15):2497-504.

Lawton CA, Bae K, Pilepich M, et al. Long-term treatment sequelae after external beam irradiation with or without hormonal manipulation for adenocarcinoma of the prostate: analysis of radiation therapy oncology group studies 85-31, 86-10, and 92-02. Int J Radiat Oncol Biol Phys. 2008;70(2):437-41.

Roach M 3rd, Bae K, Speight J, et al. Short-term neoadjuvant androgen deprivation therapy and external-beam radiotherapy for locally advanced prostate cancer: long-term results of RTOG 8610. J Clin Oncol. 2008;26(4):585-91.

Merrick GS, Butler WM, Wallner KE, et al. Impact of supplemental external beam radiotherapy and/or androgen deprivation therapy on biochemical outcome after permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys. 2005;61(1):32-43

Lawton CA, Winter K, Grignon D, et al. Androgen suppression plus radiation versus radiation alone for patients with stage D1/pathologic node-positive adenocarcinoma of the prostate: updated results based on national prospective randomized trial Radiation Therapy Oncology Group 85-31. J Clin Oncol. 2005;23(4):800-7.

Ciezki JP, Klein EA, Angermeier K, et al. A retrospective comparison of androgen deprivation (AD) vs. no AD among low-risk and intermediate-risk prostate cancer patients treated with brachytherapy, external beam radiotherapy, or radical prostatectomy. Int J Radiat Oncol Biol Phys. 2004;60(5):1347-50.

Roach M 3rd, DeSilvio M, Lawton C, et al. Phase III trial comparing whole-pelvic versus prostate-only radiotherapy and neoadjuvant versus adjuvant combined androgen suppression: Radiation Therapy Oncology Group 9413. J Clin Oncol. 2003;21(10):1904-11.

Pilepich MV, Winter K, Lawton CA, et al. Androgen suppression adjuvant to definitive radiotherapy in prostate carcinoma-long-term results of phase III RTOG 85-31. Int J Radiat Oncol Biol Phys. 2005;61(5):1285-90

D'Amico AV, Manola J, Loffredo M, et al. 6-month androgen suppression plus radiation therapy vs radiation therapy alone for patients with clinically localized prostate cancer: a randomized controlled trial. JAMA. 2004;292(7):821-7.

Merrick GS, Butler WM, Galbreath RW. Does hormonal manipulation in conjunction with permanent interstitial brachytherapy, with or without supplemental external beam irradiation, improve the biochemical outcome for men with intermediate or high-risk prostate cancer? BJU Int. 2003;91(1):23-9.

Roach M, Jiandong JL, Pilepich MV, et al: Predicting Long-Term Survival and the need for Hormonal Therapy: A Meta-analysis of RTOG Prostate Cancer Trials. Int J Radiat Oncol Biol Phys 2000;47:617-627.


PSA Bounce

Hinnen KA, Monninkhof EM, Battermann JJ, et al. Prostate Specific Antigen Bounce Is Related to Overall Survival in Prostate Brachytherapy. Int J Radiat Oncol Biol Phys. 2011 Feb 5. [Epub ahead of print]

Taira AV, Merrick GS, Galbreath RW, et al. Serum Testosterone Kinetic s After Brachytherapy for Clinically Localized Prostate Cancer. Int J Radiat Oncol Biol Phys. 2011 Apr 6. [Epub ahead of print]

Caloglu M, Ciezki JP, Reddy CA, et al. PSA bounce and biochemical failure after brachytherapy for prostate cancer: a study of 820 patients with a minimum of 3 years of follow-up. Int J Radiat Oncol Biol Phys. 2011 Jul 1;80(3):735-41.

Kirilova A, Damyanovich A, Crook J, et al. 3D MR-spectroscopic imaging assessment of metabolic activity in the prostate during the PSA "bounce" following 125iodine brachytherapy. Int J Radiat Oncol Biol Phys. 2011 Feb 1; 79(2):371-8.

Thompson A, Keyes M, Pickles T, et al. Evaluating the Phoenix definition of biochemical failure after (125)I prostate brachytherapy: Can PSA kinetics distinguish PSA failures from PSA bounces? Int J Radiat Oncol Biol Phys. 2010 Oct 1;78(2):415-21.

McGrath SD, Antonucci JV, Fitch DL, et al. PSA bounce after prostate brachytherapy with or without neoadjuvant androgen deprivation. Brachytherapy. 2010;9(2):137-44.

Kuban DA, Levy LB, Potters L, et al. Comparison of biochemical failure definitions for permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys. 2006 Aug 1;65(5):1487-93.

Critz FA, Williams WH, Levinson AK, et al. Prostate specific antigen bounce after simultaneous irradiation for prostate cancer: the relationship to patient age. Urol. 2003;170(5):1864-7.

Stock RG, Stone NN, Cesaretti JA. Prostate-specific antigen bounce after prostate seed implantation for localized prostate cancer: descriptions and implications. Int J Radiat Oncol Biol Phys. 2003;56(2):448-53.

Reed D, Wallner K, Merrick G. Clinical correlates to PSA spikes and positive repeat biopsies after prostate brachytherapy. Urology. 2003 Oct;62(4):683-8.

Cavanagh W, Blasko JC, Grimm PD, et al. Transient Elevation of Serum PSA Following I125/Pd103 Brachytherapy for Localized Prostate Cancer. Semin. Urol. Oncol. 2000;18:160-165.

Critz FA, Williams WH, Levinson AK, et al. Prostate specific antigen bounce after simultaneous irradiation for prostate cancer: the relationship to patient age. J Urol. 2003;170(5):1864-7.

Merrick GS, Butler WM, Wallner KE, et al. Prostate-specific antigen (PSA) velocity and benign prostate hypertrophy predict for PSA spikes following prostate brachytherapy. Brachytherapy. 2003;2(3):181-8.


Quality of Implant Matters

Chen ZJ, Roberts K, Decker R, et al. The impact of prostate edema on cell survival and tumor control after permanent interstitial brachytherapy for early stage prostate cancers. Phys Med Biol. 2011;56(15):4895-912.

Keyes M, Spadinger I, Liu M, et al. Rectal toxicity and rectal dosimetry in low-dose-rate iodine-125 permanent prostate implants: A long-term study in 1006 patients. Brachytherapy. 2011 Jul 13. [Epub ahead of print]

Spadinger I, Morris WJ, Keyes M, et al. Quadrant dosimetry as a predictor of biochemical relapse in 125I prostate brachytherapy. Brachytherapy. 2011;10(2):87-97.

Herstein A, Wallner K, Merrick G, et al. There is a wide range of predictive dosimetric factors for I-125 and pd-103 prostate brachytherapy. Am J Clin Oncol. 2008;31(1):6-10.

Wallner K, Merrick G, Sutlief S, et al. High-dose regions versus likelihood of cure after prostate brachytherapy. Int J Radiat Oncol Biol Phys. 2005; 62(1):170-4.

Potters L, Huang D, Calugaru E, et al. Importance of implant dosimetry for patients undergoing prostate brachytherapy. Urology 2003;62(6):1073-7.

Potters L, Cao Y, Calugaru E, et al. A comprehensive review of CT-based dosimetry parameters and biochemical control in patients treated with permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys 2001; 50(3):605-614

Stock RG, Stone NN, Lo YC, et al. Post implant dosimetry for I125 prostate implants: definitions and factors affecting outcome. Int J Radiat Oncol Biol Phys 2000; 48(3): 899-906

Stock, RG, Stone NN, Tabert A, et al. A dose response study for I125 prostate implants. Int J Radiat Oncol Biol Phys 1998; 41(1): 101-108


Patient's Age

Hinnen KA, Roeloffzen EM, Battermann JJ, et al. Survival after prostate brachytherapy in patients aged 60 years and younger. BJU Int. 2011; 107(12):1906-11.

Burri RJ, Ho AY, Forsythe K, et al Young men have equivalent biochemical outcomes compared with older men after treatment with brachytherapy for prostate cancer. Int J Radiat Oncol Biol Phys. 2010; 77(5):1315-21.

Gómez-Iturriaga Piña A, Crook J, et al. Median 5 year follow-up of 125iodine brachytherapy as monotherapy in men aged <or=55 years with favorable prostate cancer. Urology. 2010;75(6):1412-6.

Merrick GS, Wallner KE, Galbreath RW, et al. Biochemical and functional outcomes following brachytherapy with or without supplemental therapies in men < or = 50 years of age with clinically organ-confined prostate cancer. Am J Clin Oncol. 2008 Dec;31(6):539-44

Merrick GS, Wallner KE, Galbreath RW, et al. Prostate brachytherapy in men > or =75 years of age. Int J Radiat Oncol Biol Phys. 2008;72(2):415-20.


History of Prostate Brachytherapy

Aronowitz JN. Whitmore, Henschke, and Hilaris: The re-orientation of prostate brachytherapy (1970-1987). Brachytherapy, in press.

Aronowitz JN, Grimard L, Robison R. Precedence for prostate brachytherapy. Brachytherapy 2011;10:201-207

Aronowitz JN. "Benign essential" prostate cancer? Am J Clin Oncol 2009; 32:224-5

Aronowitz JN. The "Golden Age" of prostate brachytherapy: a cautionary tale. Brachytherapy 2008; 7:55-9.

Aronowitz JN. Donald Lawrence and the 'k-capture' revolution. Brachytherapy 2007; 9(4):373-381.

Aronowitz JN. Dawn of prostate brachytherapy: 1915-1930. Int J Radiat Oncol Biol Phys 2002;54(3):712-8

Aronowitz JN. Benjamin Barringer: originator of the transperineal prostate implant. Urology 2002; 60(4):731-4.

Aronowitz JN. Buried emanation; the development of seeds for permanent implantation. Brachytherapy 2002; 1(3):167-78.


Seed Implant Safety

Dauer, L.T.a , Kollmeier, M.A.b , Williamson, M.J.a , et al. Less-restrictive, patient-specific radiation safety precautions can be safely prescribed after permanent seed implantation Brachytherapy 2010; 9 (2), pp. 101-111.

Kaulich, T.W.a , Bamberg, M.b. Radiation protection of persons living close to patients with radioactive implants. Strahlentherapie und Onkologie, 2010;186 (2), pp. 107-112.

Cattani, F.a , Vavassori, A.b , Polo, A.b, et al. Radiation exposure after permanent prostate brachytherapy. Radiotherapy and Oncology 2006; 79 (1), pp. 65-69.

Michalski J, Mutic S, Eichling J, et al. Radiation exposure to family and household members after prostate brachytherapy. Int. J. Rad. Oncol. Biol. Phys. 2003;(3) pp.764–768, 2003