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Prostate Brachytherapy – Field Review Draft 09/30/2019

NOT FOR PUBLICATION, QUOTATION, OR CITATION

PRACTICE PARAMETER 1 Prostate Brachytherapy

The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists, and clinical medical

physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve

radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists, radiation

oncologists, medical physicists, and persons practicing in allied professional fields.

The American College of Radiology will periodically define new practice parameters and technical standards for radiologic practice to help advance the

science of radiology and to improve the quality of service to patients throughout the United States. Existing practice parameters and technical standards will

be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.

Each practice parameter and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has

been subjected to extensive review and approval. The practice parameters and technical standards recognize that the safe and effective use of diagnostic and

therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice

parameter and technical standard by those entities not providing these services is not authorized.

Revised 2015 (CSC/BOC)*

ACR–ABS–ASTRO PRACTICE PARAMETER FOR TRANSPERINEAL

PERMANENT BRACHYTHERAPY OF PROSTATE CANCER

PREAMBLE

This document is an educational tool designed to assist practitioners in providing appropriate radiation oncology

care for patients. Practice Parameters and Technical Standards are not inflexible rules or requirements of practice

and are not intended, nor should they be used, to establish a legal standard of care1. For these reasons and those set

forth below, the American College of Radiology and our collaborating medical specialty societies caution against

the use of these documents in litigation in which the clinical decisions of a practitioner are called into question.

The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the

practitioner in light of all the circumstances presented. Thus, an approach that differs from the guidance in this

document, standing alone, does not necessarily imply that the approach was below the standard of care. To the

contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in this

document when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition

of the patient, limitations of available resources, or advances in knowledge or technology subsequent to publication

of this document. However, a practitioner who employs an approach substantially different from the guidance in

this document is advised to document in the patient record information sufficient to explain the approach taken.

The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis,

alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to always

reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it

should be recognized that adherence to the guidance in this document will not ensure an accurate diagnosis or a

successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action

based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical

care. The sole purpose of this document is to assist practitioners in achieving this objective.

1 Iowa Medical Society and Iowa Society of Anesthesiologists v. Iowa Board of Nursing 831 N.W.2d 826 (Iowa 2013) Iowa Supreme Court refuses to find

that the ACR Technical Standard for Management of the Use of Radiation in Fluoroscopic Procedures (Revised 2008) sets a national standard for who may

perform fluoroscopic procedures in light of the standard’s stated purpose that ACR standards are educational tools and not intended to establish a legal standard

of care. See also, Stanley v. McCarver, 63 P.3d 1076 (Ariz. App. 2003) where in a concurring opinion the Court stated that “published standards or guidelines

of specialty medical organizations are useful in determining the duty owed or the standard of care applicable in a given situation” even though ACR standards

themselves do not establish the standard of care.




I. INTRODUCTION 1

2

This practice parameter was revised collaboratively by the American College of Radiology (ACR) and the American 3

Brachytherapy Society (ABS), and the American Society for Radiation Oncology (ASTRO). 4

5

Radical prostatectomy, external beam radiotherapy, and permanent prostate brachytherapy all represent well-6

established options for the treatment of prostate cancer[1-4]. There are emerging data to suggest that cryoablation 7

and high-intensity focused ultrasound (HIFU) may also be effective as primary therapy for organ-confined prostate 8

cancer, though neither represent the current standard of care [5,6]. Active surveillance can and should be considered 9

in appropriately selected patients with low-risk disease [5]. [7] 10

11

Patients with clinically localized prostate cancer can be treated with radical prostatectomy, external beam 12

radiotherapy, or prostate brachytherapy. The patient requires an understanding of the risks and benefits of each 13

option in order to make an informed decision. It is suggested that all patients with localized prostate cancer have a 14

radiation oncology consultation in order to receive information to make an informed decision on treatment. 15

16

Patients with clinically localized prostate cancer can be treated with radical prostatectomy, external beam 17

radiotherapy, or prostate brachytherapy. The patient requires an understanding of the risks and benefits of 18

each option in order to make an informed decision. It is recommended that patients with localized prostate 19

cancer consult with both a radiation oncologist and urologist in order to achieve this aim. 20

21

A literature search was performed and reviewed to identify published articles regarding practice parameters and 22

technical standards in brachytherapy of prostate cancer. Review of the recent scientific literature regarding 23

permanent transperineal prostate seed implantation reveals significant variation in patient selection, brachytherapy 24

techniques, and medical physics and dosimetric conventions. Despite this range of different procedural practices, 25

interstitial low-dose-rate (LDR) brachytherapy has consistently been shown to be an effective component in the 26

treatment of all prostate cancer risk strata, either as monotherapy or as part of a multimodality regiment regimen 27

[3,6-10]. 28

29

II. QUALIFICATIONS AND RESPONSIBILITIES OF PERSONNEL 30

31

A. Radiation Oncologist 32

33

1. Certification in radiology by the American Board of Radiology to a physician who confines focuses his/her 34

their professional practice to radiation oncology, or certification in Radiation Oncology or Therapeutic 35

Radiology by the American Board of Radiology, the American Osteopathic Board of Radiology, the Royal 36

College of Physicians and Surgeons of Canada, or the Collège des Médecins du Québec may be considered 37

proof of adequate qualification. 38

or 39

2. Satisfactory completion of a residency program in radiation oncology approved by the Accreditation 40

Council for Graduate Medical Education (ACGME), the Royal College of Physicians and Surgeons of 41

Canada (RCPSC), the Collège des Médecins du Québec, or the American Osteopathic Association (AOA). 42

43

3. The radiation oncologist should have formal training in prostate brachytherapy. If this training was not 44

obtained during an ACGME-approved residency or fellowship program the radiation oncologist should 45

comply with the following requirements: 46

a. Appropriate training in transrectal ultrasound (TRUS), computed tomography (CT), or magnetic 47

resonance imaging (MRI) guided prostate brachytherapy. 48




b. Additional training by participating through participation in hands-on workshops on the subject or 49

under the supervision of a qualified proctoring physician through proctored cases with a minimum 50

of five cases required. The proctoring physician should be an experienced prostate brachytherapist with 51

the proficiency to perform the mechanics of the implant procedure and critically assess the dosimetric 52

quality of the implant. He/she The radiation oncologist should have delineated hospital privileges for 53

performing this procedure. These workshops must provide the radiation oncologist with personal 54

supervised experience with seed placement and implant evaluation. 55

56

B. Qualified Medical Physicist 57

58

For the qualifications of the Qualified Medical Physicist, see the ACR–AAPM Technical Standard for the 59

Performance of High-Dose-Rate Brachytherapy Physics or the ACR–AAPM Technical Standard for the 60

Performance of Low-Dose-Rate Brachytherapy Physics [11,12]. 61

62

C. Radiation Therapist 63

64

The radiation therapist must fulfill state licensing requirements and be certified in radiation therapy by American 65

Registry of Radiologic Technologists (ARRT). 66

67

D. Dosimetrist 68

69

Certification by the Medical Dosimetrist Certification Board is recommended. 70

71

E. Patient Support Staff 72

73

Individuals involved in the nursing care of patients should have education or experience in the care of radiation 74

therapy patients. 75

76

III. PATIENT SELECTION CRITERIA 77

78

Candidates for treatment with prostate seed implant alone, as monotherapy, include those for whom there is a 79

significant likelihood that their prostate cancer could be encompassed by the dose distribution from permanent 80

prostate seed implant alone. Patients with a significant risk of disease outside of the implant volume may benefit 81

from the addition of external beam irradiation and/or androgen deprivation therapy (ADT). Specific treatment 82

schemas are evolving, as there are conflicting data regarding the efficacy of combined therapies relative to 83

monotherapy. Consequently, it is suggested that each facility establish and follow its own practice parameters. 84

Ongoing clinical trials will help to better define indications. 85

86

A number of different risk stratification systems exist. The majority of these systems divide prostate cancer patients 87

into low-risk, intermediate-risk, and high-risk groups according to pretreatment prostate-specific antigen (PSA) 88

level, Gleason score, and clinical stage [13,14]. The volume of cancer on the prostate biopsy specimen also has 89

been shown to affect biochemical outcome and may prove to be useful in further subdividing the established risk 90

categories [15,16]. The National Comprehensive Cancer Network (NCCN) risk criteria are perhaps the most 91

commonly cited and represent the standard for most modern clinical trials [17]. Given the heterogeneity that exists 92

within each of the risk groups, some risk classification systems are now sub-stratifying the classic risk groups 93

to very low, low, favorable intermediate, unfavorable intermediate, high, and very high risk. Monotherapy is 94

sufficient treatment for low-risk prostate cancer patients. Assuming good implant quality, there are emerging data 95

showing that intermediate-risk patients with favorable characteristics may also be adequately treated with 96

monotherapy [18-25]. although this remains an area of active investigation [21] Focal (partial gland) 97

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brachytherapy is also being evaluated in the low and favorable intermediate risk prostate cancer population, 98

but at the present time is considered experimental and should only be performed by a highly capable 99

brachytherapist in the setting of a clinical trial [22]. At the present time, most high-risk brachytherapy protocols 100

include supplemental external beam with or without androgen suppression [18,26]. This treatment regimen has 101

produced outcomes which compare favorably with both Retrospective studies have reported favorable outcomes 102

comparing brachytherapy with radical prostatectomy and external beam radiation therapy alone in the high-103

risk population [6,7,9,10,27]. Randomized controlled data demonstrate superior biochemical control when 104

dose escalation is achieved with brachytherapy boost compared with external beam therapy alone [2], though 105

with the addition of a brachytherapy boost is associated with a higher incidence of acute and late 106

genitourinary toxicity [28]. 107

108

External beam treatment volume and the role of androgen suppression are areas of controversy. Extrapolation from 109

external beam radiation therapy data suggests that there may be a potential role for androgen suppression in patients 110

with factors that place them at high risk of metastasis [29-31]. However, the role and duration of androgen 111

suppression therapy in intermediate-risk and high-risk patients treated with brachytherapy have not been established 112

[32]. 113

114

When supplemental external beam radiation therapy is used, the optimal treatment volume has not been established. 115

Some investigators advocate the treatment of a whole-pelvic field in higher-risk patients. Other investigators believe 116

an involved field around the prostate and immediately adjacent structures is appropriate [33-35]. 117

118

Androgen suppression should not be routinely given for low-risk patients. It could can be given to certain patients with 119

large glands if required for volume reduction for in those utilizing a technique that requires prostate downsizing [36]. 120

121

The following are potential exclusion criteria for permanent seed brachytherapy: 122

123

1. Life expectancy of less than 10 years in the setting of low-risk prostate cancer 124

2. Unacceptable operative risk 125

3. Poor anatomy which, in the opinion of the radiation oncologist, could lead to a suboptimal implant (eg, 126

large or poorly healed transurethral resection of the prostate (TURP) defect, large median lobe, large gland 127

size, pubic arch interference, and inability to achieve the dorsal lithotomy position. 128

4. Pathologically positive lymph nodes High-volume lymph node involvement 129

5. Significant obstructive uropathy 130

6. Stage IV disease with high-volume metastatic disease Distant metastases 131

132

Modern prostate brachytherapy series demonstrate excellent biochemical and functional outcomes in 133

patients under the age of 50 [37-39]. Young age should not be considered a contraindication to prostate 134

brachytherapy. 135

136

IV. SPECIFICATIONS OF THE PROCEDURE 137

138

A. Implant Treatment Planning 139

Dosimetric planning should be performed in all patients prior to or during seed implantation. TRUS, CT scanning, 140

or MRI should be used to aid in the treatment planning process [40-47]. 141

142

B. Intraoperative Procedure 143

144

A transperineal approach under transrectal ultrasound guidance is recommended for seed implantation. Ideally, the 145

full definition of the prostate in both longitudinal and transverse planes should be available. Typically, a probe 146

with frequency range of 5.0 to 12.0 MHz probe is used for the TRUS. It is recommended to use a high-resolution 147




biplanar ultrasound probe with axial and sagittal capability and dedicated prostate brachytherapy software, which 148

displays perineal template, coordinates. 149

150

There are several acceptable methods for seed insertion. These include, but are not limited to, the following: 151

152

1. Using a preloaded needle technique 153

a. The preloaded technique is performed based on a preplan and can be used in conjunction with 154

intraoperative planning. 155

b. Needles can be placed one at a time, all at once, by row, or based on peripheral and central locations. 156

c. Seeds can be “stranded,” “linked,” or “loose” within each needle [48]. 157

158

2. Using a free-seed technique 159

a. A Mick applicator or similar device is used to load the seeds into the prostate. 160

b. Free-seed loading can be based on a preplan or an intraoperative plan. 161

c. Needles can be placed one at a time, all at once, by row, or based on peripheral and central locations. 162

163

There are some studies showing that injection of an absorbable hydrogel spacer can be used to reduce rectal 164

dose in patients undergoing LDRbrachytherapy [49]. The hydrogel can be placed in the space between the 165

posterior prostate and anterior rectal under ultrasound guidance. Further studies are needed to determine 166

whether hydrogel placement reduces rectal toxicity in the setting of permanent prostate brachytherapy. 167

168

For dose calculations, the AAPM Task Group No. 43 Report (TG-43) [50,51] and its successors should be adopted. 169

The precise radiation dose necessary for eradicating prostate cancer by brachytherapy is not absolutely defined. 170

Based on available data the following recommendations are made for dose prescriptions: for patients with low-risk 171

or favorable disease treated by monotherapy, the prescription dose ranges from 110 to 125 Gy for palladium-103 172

and 140 to 160 Gy for iodine-125 [52-54]. In recent years there has been experience with cesium-131, and if that 173

isotope is used, reference to current literature is advised. The currently recommended dose is 115 Gy if cesium-131 is 174

used as monotherapy. Doses of approximately 85 Gy are being investigated when combined with external beam 175

radiation therapy [55]. With external beam plus brachytherapy the recommended external beam dose to the prostate 176

and periprostatic area is in the range of 20 to 50.4 Gy [19]. Implant technique has been shown to vary 177

substantially among different institutions in terms of seed strength, dose homogeneity, and extracapsular 178

seed placement/margins [56]. With this being the case, dosimetric parameters such D90 (the minimum dose 179

received by 90% of the target volume) and V100 (the percentage of the target volume receiving 100% of the 180

prescription dose) should be reported in conjunction with prescribed dose to provide a meaningful 181

assessment of implant quality. 182

183

Whole-pelvic irradiation may be used in those cases at high risk for pelvic node metastases. The palladium-103 184

prescription boost dose is in the range of 80 to 110 Gy, and for iodine-125 the prescription boost dose is 100 to 110 185

Gy [33,38,42,43,57]. When brachytherapy is used in conjunction with external beam radiation, it is recommended 186

that the treating clinician consider the biologically effective dose (BED) that results from the combination of these 187

two modalities. Several formulas have been proposed to account for the different dose-fractionation schemas that 188

exist for the external beam component of treatment and also the various isotopes that can be used in the 189

brachytherapy implant [54,58,59]. Given the known correlation between BED and treatment outcome, every effort 190

should be made to attain a BED threshold that will maximize cure while minimizing treatment-related morbidity. 191

192

There are no recommendations regarding the selection of radionuclide. regarding the choice of one radionuclide 193

over another. One randomized trial examined differences between the two isotopes (palladium-103, iodine-125) 194

and noted no significant differences in long-term morbidity or PSA-based cancer control [60]. Experience with 195

cesium-131 is less established compared with the other two isotopes, but 5-year biochemical control rates are 196




favorable and a recently published phase II study demonstrated similar quality of life outcomes between 197

patients treated with palladium-103, iodine-125, and cesium-131[61,62]. 198

199

C. Postimplant Procedures 200

201

Cystoscopy may can be performed after the procedure. Cystoscopy allows for removal of blood clots and misplaced 202

seeds in the bladder and/or urethra. Patients should be advised that there is a risk of seed migration to the lungs or 203

other organs, particularly if loose seeds are employed. Urinary anesthetics, antispasmodics, analgesics, perineal 204

ice packs, and stool softeners may be added in symptomatic patients. Consideration should be given to the 205

prophylactic use of alpha blockers before and after the procedure [63]. 206

207

V. DOCUMENTATION 208

209

Reporting and communication should be in accordance with the ACR–ASTRO Practice Parameter for 210

Communication: Radiation Oncology [64]. 211

212

VI. POSTIMPLANT DOSIMETRY 213

214

Postimplant dosimetry is mandatory. This information expresses the actual dose delivered and identifies variance 215

from the original treatment plan. Although useful for seed counting, plain radiographs alone are not adequate for 216

dosimetric analysis. We recommend the use of image-based planning such as CT or MRI to evaluate the relationship 217

of the seeds and the prostate, bladder, and rectum Postimplant dosimetry assessment is mandatory for each 218

patient. The intent is not merely documentation of seeds and evaluation for a medical event; CT and/or MRI 219

based post implant dosimetry assessment evaluates the quality of the implant. Postimplant dosimetry 220

expresses the actual dose delivered and identifies variance from the original treatment plan. Because quality 221

is correlated with outcome and morbidity, postimplant dosimetry is an objective tool for self-assessment and 222

improvement. Plain radiographs alone are not adequate for dosimetric analysis. We recommend the use of 223

image-based planning such as CT and/or MRI to be completed within 60 days of the brachytherapy 224

procedure to evaluate the relationship of the seeds and the prostate, bladder, and rectum [65-70]. 225

226

The optimal timing for obtaining the postimplant CT and/or MRI is not known. Implant dosimetry will vary in a 227

predictable fashion depending on when the imaging evaluation is performed. Imaging obtained within 24 hours of 228

the implant procedure will result in lower calculated doses to the prostate and anterior rectal wall, whereas day 30 229

imaging will predict higher doses to these respective structures [68,71-73]. Some studies suggest an interval of 2 to 230

6 weeks postimplant (AAPM TG-64 and TG-137 Reports) [74,75]. Others have argued that dosimetric evaluation 231

should be performed within 24 hours of implant because this allows for immediate correction of dose deficiency 232

and allows for implant assessment at the time of maximal prostatic edema [76,77]. Regardless of convention, it is 233

preferred that the timing of postimplant image acquisition be kept consistent within each practice. The TRUS 234

volume study can be fused with the postimplant CT or MRI for the purposes of postimplant dosimetry [78]. 235

236

Significant intraobserver variability in the contouring of prostate volumes and normal structures can be noted on 237

postimplant CT scans, and this should be considered before drawing specific inferences regarding dosimetric 238

parameters [79,80]. 239

The following parameters should be reported: 240

241

1. The prescribed (intended) dose 242

243

2. The D90, defined as the minimum dose received by 90% of the target volume as delineated on the 244

postimplant CT and the V100, defined as the percentage of the target volume delineated on the postimplant 245

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CT receiving 100% of the prescribed dose [81-83]. A D90 of at least 90% of the prescription dose and a 246

V100 that corresponds to at least 90% of the contoured prostate are recommended as the current standard 247

of care, but this should be balanced with respect to the morbidity of the adjacent normal tissue doses 248

[53,54,84-88]. Reporting of the V150 and V200 (ie, the percentage of prostate volume receiving 150% and 249

200% of prescribed dose, respectively) should also be considered [83]. 250

251

3. Doses to organs at risk, (OAR) including rectum and prostatic urethra [89-91]. The dose to the rectum is 252

commonly reported as the RV100 and RV150, the volumes in cubic centimeters of the rectal wall receiving 253

100% and 150% of the prescribed dose, respectively. The dose to the urethra is often reported as UrV150, 254

which is the volume in cubic centimeters of the urethra receiving 150% of the prescribed dose [92]. A 255

peripheral loading pattern is recommended to avoid extreme central doses to the urethra. The 256

performance of post-procedure urethral dosimetry is favored if imaging and postimplant timing 257

readily permit it. Dose to the penile bulb may be reported, but there are conflicting results regarding the 258

clinical utility of this practice parameter [93,94]. 259

260

VII. RADIATION SAFETY AND PHYSICS QUALITY CONTROL 261

262

A. TRUS Imaging System 263

264

The report of the AAPM Ultrasound Task Group 128 [95] for acceptance testing and quality assurance and the 265

ACR–AAPM Technical Standard for Diagnostic Medical Physics Performance Monitoring of Real Time 266

Ultrasound Equipment [96] provide guidance for ultrasound imaging units. Physicists and physicians should pay 267

attention to spatial resolution, grayscale contrast, geometric accuracy, and distance measurement. The 268

correspondence between the electronic grid pattern on the ultrasound image and the template grid pattern should be 269

verified prior to the procedure as part of the ultrasound QA. 270

271

B. Computerized Planning System 272

273

The computerized planning system should be commissioned by the Qualified Medical Physicist prior to clinical 274

use. The AAPM TG-40 Report [97] should be followed. In addition, dose-rate calculations from planning systems 275

should be compared to the AAPM TG-43 Report [50,51]. The Qualified Medical Physicist and/or radiation 276

oncologist should also be familiar with the AAPM TG-64 Report [75]. 277

278

C. Brachytherapy Source Calibrations 279

280

The recommendations set forth by the AAPM TG-40 [97], TG-56 [98], and TG-64 [75] reports and the 281

recommendations of AAPM Low Energy Brachytherapy Source Calibration Working Group [99] should be 282

followed for calibrating brachytherapy sources. 283

D. Implantation Procedure 284

285

The radiation oncologist will verify the position of the prostate gland relative to the template coordinates. The total 286

number of seeds implanted should be verified at the end of the implant procedure. At the completion of the implant, 287

a radiation survey of the patient and the room should be conducted with an appropriately calibrated survey 288

instrument. Patient survey measurements should be performed at the surface of the patient and at 1 meter from the 289

patient. The room survey should include the vicinity of the implanted area, the floor, the waste fluids/materials, 290

linens, and all applicators. Prior to the release of the patient, the Qualified Medical Physicist, or an appropriately 291

trained member of the physics staff, and/or the radiation oncologist or radiation safety staff should review the 292

postimplantation survey results to confirm that all pertinent federal and state regulations regarding the release of 293

patients with radioactive sources have been followed. The brachytherapy team must follow the new 10CFR 294

Part35 applicable to the permanent implant brachytherapy. 295

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296

E. Postimplant Radiation Safety Considerations 297

298

Patients should be provided with written descriptions of the radiation protection guidelines, including but not limited 299

to, discussion of potential limitations of patient contact with minors and pregnant women. This description must be in 300

compliance with state and federal regulations. The radiation oncologist, the Qualified Medical Physicist, and the 301

radiation safety officer should define the postimplant radiation safety guidelines for patients treated with permanent 302

seed implantation. 303

304

VIII. FOLLOW-UP 305

306

Follow-up of definitively treated cancer patients is part of radiation oncology practice, as noted in the ACR–ASTRO 307

Practice Parameter for Radiation Oncology [100]. Postoperative follow-up should consist of sufficient visits within 308

the first 3 months to assure patient safety and comfort and to minimize acute complications associated with the 309

radiation therapy procedure. The frequency and sequence of subsequent visits may vary among the radiation 310

oncologist, urologist, and other physicians involved in the care of the patient. The radiation oncologist should make 311

an effort to obtain long-term follow-up on patient status. 312

313

The best definition of biochemical PSA failure has yet to be determined for brachytherapy patients [101]. The 314

current ASTRO Phoenix PSA failure definition is most commonly used [102]. PSA failure can also be defined 315

according to an absolute threshold (ie, PSA exceeding a certain level), but when using such a definition, adequate 316

time should be allowed for the PSA to reach its nadir. One benefit to a threshold definition of biochemical failure 317

is that it better facilitates comparison of treatment outcome with prostatectomy [103]. Consideration should 318

be given to the PSA bounce or spike phenomenon in cases of spurious PSA elevation following implantation[104-319

106]. Although most spikes occur at 18 to 30 months, they can occur much later. Other clinical laboratory and 320

radiologic studies may be performed when clinically indicated. If there is concern regarding recurrence, other 321

treatment options can be considered. 322

323

IX. SUMMARY 324

325

Transperineal prostate brachytherapy is an effective modality for treating prostate cancer. It’s safe and effective 326

execution is a complex process that requires coordination between the radiation oncologist and other health 327

professionals. Appropriate patient selection criteria and quality assurance procedures are important for a successful 328

program. 329

330

ACKNOWLEDGEMENTS 331

332

This practice parameter was revised according to the process described under the heading The Process for 333

Developing ACR Practice Parameters and Technical Standards on the ACR website (https://www.acr.org/Clinical-334

Resources/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters – Radiation 335

Oncology of the ACR Commission on Radiation Oncology in collaboration with the ABS. 336

337

Collaborative Committee – members represent their societies in the initial and final revision of this practice

parameter

ACR ASTRO

Nathan H.J. Bittner, MD, MS, Chair Brian Davis, MD, PhD, FABS

Gregory S. Merrick, MD, FACR Martin King, MD

https://www.acr.org/-/media/ACR/Files/Practice-Parameters/RadOnc.pdf?la=en


https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards

https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards




Collaborative Committee – members represent their societies in the initial and final revision of this practice

parameter

Peter Orio, DO, MS Colleen A F Lawton MD, FACR, FASTRO

Zoubir Ouhib, MS, FACR, FABS, FAAPM

ABS

Brett Cox, MD

Peter Rossi, MD

Tim Showalter, MD, MPH

338

339

Committee on Practice Parameters – Radiation Oncology

(ACR Committee responsible for sponsoring the draft through the process)

Naomi R. Schechter, MD, Chair Join Y. Luh, MD

Nathan H. J. Bittner, MD, MS Matthew Poggi, MD

Samuel T. Chao, MD Helen A. Shih, MD

Neil B. Desai, MD Paul E. Wallner, DO, FACR

Beth A Erickson-Wittmann, MD Kristina L. Woodhouse, MD

Matthew Harkenrider, MD Ying Xiao, PhD

Mark Hurwitz, MD Sue S. Yom, MD, PhD 340

William Small, Jr, MD, FACR, Chair of the Commission on Radiation Oncology 341

342

REFERENCES 343

344

1. Bill-Axelson A, Holmberg L, Ruutu M, et al. Radical prostatectomy versus watchful waiting in early prostate 345

cancer. N Engl J Med. 2011;364(18):1708-1717. 346

2. Morris WJ, Tyldesley S, Rodda S, et al. Androgen Suppression Combined with Elective Nodal and 347

Dose Escalated Radiation Therapy (the ASCENDE-RT Trial): An Analysis of Survival Endpoints for 348

a Randomized Trial Comparing a Low-Dose-Rate Brachytherapy Boost to a Dose-Escalated External 349

Beam Boost for High- and Intermediate-risk Prostate Cancer. Int J Radiat Oncol Biol Phys. 350

2017;98(2):275-285. 351

3. Spratt DE, Zumsteg ZS, Ghadjar P, et al. Comparison of high-dose (86.4 Gy) IMRT vs combined 352

brachytherapy plus IMRT for intermediate-risk prostate cancer. BJU Int. 2014;114(3):360-367. 353

4. Sylvester JE, Grimm PD, Blasko JC, et al. 15-Year biochemical relapse free survival in clinical Stage T1-T3 354

prostate cancer following combined external beam radiotherapy and brachytherapy; Seattle experience. Int J 355

Radiat Oncol Biol Phys. 2007;67(1):57-64. 356

5. Klotz L, Vesprini D, Sethukavalan P, et al. Long-term follow-up of a large active surveillance cohort 357

of patients with prostate cancer. J Clin Oncol. 2015;33(3):272-277. 358

6. Bittner N, Merrick GS, Galbreath RW, Butler WM, Adamovich E. Treatment outcomes with 359

permanent brachytherapy in high-risk prostate cancer patients stratified into prognostic categories. 360

Brachytherapy. 2015;14(6):766-772. 361

7. Kishan AU, Cook RR, Ciezki JP, et al. Radical Prostatectomy, External Beam Radiotherapy, or 362

External Beam Radiotherapy With Brachytherapy Boost and Disease Progression and Mortality in 363

Patients With Gleason Score 9-10 Prostate Cancer. JAMA. 2018;319(9):896-905. 364

8. Stock RG, Cahlon O, Cesaretti JA, Kollmeier MA, Stone NN. Combined modality treatment in the 365

management of high-risk prostate cancer. Int J Radiat Oncol Biol Phys. 2004;59(5):1352-1359. 366




9. Taira AV, Merrick GS, Butler WM, et al. Time to failure after definitive therapy for prostate cancer: 367

implications for importance of aggressive local treatment. J Contemp Brachytherapy. 2013;5(4):215-221. 368

10. Zelefsky MJ, Yamada Y, Pei X, et al. Comparison of tumor control and toxicity outcomes of high-dose 369

intensity-modulated radiotherapy and brachytherapy for patients with favorable risk prostate cancer. Urology. 370

2011;77(4):986-990. 371

11. American College of Radiology. ACR–AAPM technical standard for the performance of high-dose-372

rate brachytherapy physics. 2015; Available at: https://www.acr.org/-/media/ACR/Files/Practice-373

Parameters/HDR-BrachyTS.pdf?la=en. Accessed June 26, 2019. 374

12. American College of Radiology. ACR–AAPM technical standard for the performance of low-dose-rate 375

brachytherapy physics. 2015; Available at: https://www.acr.org/-/media/ACR/Files/Practice-376

Parameters/LDR-BrachyTS.pdf?la=en. Accessed June 26, 2019. 377

13. Beyer DC, Thomas T, Hilbe J, Swenson V. Relative influence of Gleason score and pretreatment PSA in 378

predicting survival following brachytherapy for prostate cancer. Brachytherapy. 2003;2(2):77-84. 379

14. D'Amico AV, Whittington R, Malkowicz SB, et al. Pretreatment nomogram for prostate-specific antigen 380

recurrence after radical prostatectomy or external-beam radiation therapy for clinically localized prostate 381

cancer. J Clin Oncol. 1999;17(1):168-172. 382

15. D'Amico AV, Schultz D, Silver B, et al. The clinical utility of the percent of positive prostate biopsies in 383

predicting biochemical outcome following external-beam radiation therapy for patients with clinically 384

localized prostate cancer. Int J Radiat Oncol Biol Phys. 2001;49(3):679-684. 385

16. Merrick GS, Butler WM, Galbreath RW, Lief JH, Adamovich E. Relationship between percent positive 386

biopsies and biochemical outcome after permanent interstitial brachytherapy for clinically organ-confined 387

carcinoma of the prostate gland. Int J Radiat Oncol Biol Phys. 2002;52(3):664-673. 388

17. National Comprehensive Cancer Network. Available at: 389

https://www.nccn.org/store/login/login.aspx?ReturnURL=http://www.nccn.org/professionals/physician_gls/390

pdf/prostate.pdf. Accessed March 10, 2014. 391

18. Marshall RA, Buckstein M, Stone NN, Stock R. Treatment outcomes and morbidity following definitive 392

brachytherapy with or without external beam radiation for the treatment of localized prostate cancer: 20-year 393

experience at Mount Sinai Medical Center. Urol Oncol. 2014;32(1):38 e31-37. 394

19. Merrick GS, Wallner KE, Butler WM, et al. 20 Gy versus 44 Gy of supplemental external beam 395

radiotherapy with palladium-103 for patients with greater risk disease: results of a prospective 396

randomized trial. Int J Radiat Oncol Biol Phys. 2012;82(3):e449-455. 397

20. Merrick GS, Wallner KE, Galbreath RW, et al. Is supplemental external beam radiation therapy 398

necessary for patients with higher risk prostate cancer treated with 103Pd? Results of two prospective 399

randomized trials. Brachytherapy. 2015;14(5):677-685. 400

21. Prestidge BR, Winter K, Sanda MG, et al. Initial report of NRG Oncology/RTOG 0232: A phase 3 401

study comparing combined external beam radiation and transperineal interstitial permanent 402

brachytherapy with brachytherapy alone for select patients with intermediate-risk prostatic 403

carcinoma. Int J Radiat Oncol Biol Phys. 2016;96(2):S4. 404

22. SS M, IT S, SE S. Focal application of low-dose-rate brachytherapy for prostate cancer: A pilot study. 405

J Contemp Brachytherapy. 2017;9(3):197-208. 406

23. Stone NN, Potters L, Davis BJ, et al. Multicenter analysis of effect of high biologic effective dose on 407

biochemical failure and survival outcomes in patients with Gleason score 7-10 prostate cancer treated with 408

permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys. 2009;73(2):341-346. 409

24. Cosset JM, Flam T, Thiounn N, et al. Selecting patients for exclusive permanent implant prostate 410

brachytherapy: the experience of the Paris Institut Curie/Cochin Hospital/Necker Hospital group on 809 411

patients. Int J Radiat Oncol Biol Phys. 2008;71(4):1042-1048. 412

25. Frank SJ, Grimm PD, Sylvester JE, et al. Interstitial implant alone or in combination with external beam 413

radiation therapy for intermediate-risk prostate cancer: a survey of practice patterns in the United States. 414

Brachytherapy. 2007;6(1):2-8. 415





https://www.nccn.org/store/login/login.aspx?ReturnURL=http://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf

https://www.nccn.org/store/login/login.aspx?ReturnURL=http://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf




26. Liss AL, Abu-Isa EI, Jawad MS, et al. Combination therapy improves prostate cancer survival for 416

patients with potentially lethal prostate cancer: The impact of Gleason pattern 5. Brachytherapy. 417

2015;14(4):502-510. 418

27. Ciezki JP, Weller M, Reddy CA, et al. A Comparison Between Low-Dose-Rate Brachytherapy With or 419

Without Androgen Deprivation, External Beam Radiation Therapy With or Without Androgen Deprivation, 420

and Radical Prostatectomy With or Without Adjuvant or Salvage Radiation Therapy for High-Risk Prostate 421

Cancer. Int J Radiat Oncol Biol Phys. 2017;97(5):962-975. 422

28. Rodda S, Tyldesley S, Morris WJ, et al. ASCENDE-RT: An Analysis of Treatment-Related Morbidity for a 423

Randomized Trial Comparing a Low-Dose-Rate Brachytherapy Boost with a Dose-Escalated External Beam 424

Boost for High- and Intermediate-Risk Prostate Cancer. Int J Radiat Oncol Biol Phys. 2017;98(2):286-295. 425

29. Bolla M, Collette L, Blank L, et al. Long-term results with immediate androgen suppression and external 426

irradiation in patients with locally advanced prostate cancer (an EORTC study): a phase III randomised trial. 427

Lancet. 2002;360(9327):103-106. 428

30. Bolla M, Descotes JL, Artignan X, Fourneret P. Adjuvant treatment to radiation: combined hormone therapy 429

and external radiotherapy for locally advanced prostate cancer. BJU Int. 2007;100 Suppl 2:44-47. 430

31. Horwitz EM, Bae K, Hanks GE, et al. Ten-year follow-up of radiation therapy oncology group protocol 92-431

02: a phase III trial of the duration of elective androgen deprivation in locally advanced prostate cancer. J 432

Clin Oncol. 2008;26(15):2497-2504. 433

32. Keyes M, Merrick G, Frank SJ, Grimm P, Zelefsky MJ. American Brachytherapy Society Task Group Report: 434

Use of androgen deprivation therapy with prostate brachytherapy-A systematic literature review. 435

Brachytherapy. 2017;16(2):245-265. 436

33. Bittner N, Merrick GS, Wallner KE, Butler WM, Galbreath R, Adamovich E. Whole-pelvis radiotherapy in 437

combination with interstitial brachytherapy: does coverage of the pelvic lymph nodes improve treatment 438

outcome in high-risk prostate cancer? Int J Radiat Oncol Biol Phys. 2010;76(4):1078-1084. 439

34. Lawton CA, DeSilvio M, Roach M, 3rd, et al. An update of the phase III trial comparing whole pelvic to 440

prostate only radiotherapy and neoadjuvant to adjuvant total androgen suppression: updated analysis of 441

RTOG 94-13, with emphasis on unexpected hormone/radiation interactions. Int J Radiat Oncol Biol Phys. 442

2007;69(3):646-655. 443

35. Roach M, 3rd, DeSilvio M, Lawton C, et al. Phase III trial comparing whole-pelvic versus prostate-only 444

radiotherapy and neoadjuvant versus adjuvant combined androgen suppression: Radiation Therapy Oncology 445

Group 9413. J Clin Oncol. 2003;21(10):1904-1911. 446

36. Merrick GS, Butler WM, Wallner KE, et al. Androgen deprivation therapy does not impact cause-specific or 447

overall survival in high-risk prostate cancer managed with brachytherapy and supplemental external beam. 448

Int J Radiat Oncol Biol Phys. 2007;68(1):34-40. 449

37. Langley SEM, Soares R, Uribe J, et al. Long-term oncological outcomes and toxicity in 597 men aged 450

</=60 years at time of low-dose-rate brachytherapy for localised prostate cancer. BJU Int. 451

2018;121(1):38-45. 452

38. Merrick GS, Wallner KE, Galbreath RW, et al. Biochemical and functional outcomes following 453

brachytherapy with or without supplemental therapies in men < or = 50 years of age with clinically 454

organ-confined prostate cancer. Am J Clin Oncol. 2008;31(6):539-544. 455

39. Winoker JS, Omidele OO, Stock RG, Stone NN. Long-term oncological and functional outcomes 456

support use of low-dose-rate brachytherapy with or without external beam radiation in young men 457

(</=60 years) with localized prostate cancer. Brachytherapy. 2019;18(2):192-197. 458

40. Hastak SM, Gammelgaard J, Holm HH. Transrectal ultrasonic volume determination of the prostate--a 459

preoperative and postoperative study. J Urol. 1982;127(6):1115-1118. 460

41. Holm HH, Juul N, Pedersen JF, Hansen H, Stroyer I. Transperineal 125iodine seed implantation in prostatic 461

cancer guided by transrectal ultrasonography. J Urol. 1983;130(2):283-286. 462

42. Narayana V, Roberson PL, Pu AT, Sandler H, Winfield RH, McLaughlin PW. Impact of differences in 463

ultrasound and computed tomography volumes on treatment planning of permanent prostate implants. Int J 464





43. Narayana V, Roberson PL, Winfield RJ, McLaughlin PW. Impact of ultrasound and computed tomography 466

prostate volume registration on evaluation of permanent prostate implants. Int J Radiat Oncol Biol Phys. 467

1997;39(2):341-346. 468

44. Nath R, Meigooni AS, Melillo A. Some treatment planning considerations for 103Pd and 125I permanent 469

interstitial implants. Int J Radiat Oncol Biol Phys. 1992;22(5):1131-1138. 470

45. Roy JN, Wallner KE, Chiu-Tsao ST, Anderson LL, Ling CC. CT-based optimized planning for transperineal 471

prostate implant with customized template. Int J Radiat Oncol Biol Phys. 1991;21(2):483-489. 472

46. Stock RG, Stone NN, Wesson MF, DeWyngaert JK. A modified technique allowing interactive ultrasound-473

guided three-dimensional transperineal prostate implantation. Int J Radiat Oncol Biol Phys. 1995;32(1):219-474

225. 475

47. Venkatesan AM, Stafford RJ, Duran C, Soni PD, Berlin A, McLaughlin PW. Prostate magnetic 476

resonance imaging for brachytherapists: Anatomy and technique. Brachytherapy. 2017;16(4):679-687. 477

48. Merrell KW, Davis BJ, Goulet CC, et al. Reducing seed migration to near zero with stranded-seed 478

implants: Comparison of seed migration rates to the chest in 1000 permanent prostate brachytherapy 479

patients undergoing implants with loose or stranded seeds. Brachytherapy. 2019;18(3):306-312. 480

49. Taggar AS, Charas T, Cohen GN, et al. Placement of an absorbable rectal hydrogel spacer in patients 481

undergoing low-dose-rate brachytherapy with palladium-103. Brachytherapy. 2018;17(2):251-258. 482

50. Rivard MJ, Butler WM, DeWerd LA, et al. Supplement to the 2004 update of the AAPM Task Group No. 43 483

Report. Med Phys. 2007;34(6):2187-2205. 484

51. Rivard MJ, Coursey BM, DeWerd LA, et al. Update of AAPM Task Group No. 43 Report: A revised AAPM 485

protocol for brachytherapy dose calculations. Med Phys. 2004;31(3):633-674. 486

52. Beyer D, Nath R, Butler W, et al. American brachytherapy society recommendations for clinical 487

implementation of NIST-1999 standards for (103)palladium brachytherapy. The clinical research committee 488

of the American Brachytherapy Society. Int J Radiat Oncol Biol Phys. 2000;47(2):273-275. 489

53. Stock RG, Stone NN, Tabert A, Iannuzzi C, DeWyngaert JK. A dose-response study for I-125 prostate 490

implants. Int J Radiat Oncol Biol Phys. 1998;41(1):101-108. 491

54. Stone NN, Potters L, Davis BJ, et al. Customized dose prescription for permanent prostate brachytherapy: 492

insights from a multicenter analysis of dosimetry outcomes. Int J Radiat Oncol Biol Phys. 2007;69(5):1472-493

1477. 494

55. Bice WS, Prestidge BR, Kurtzman SM, et al. Recommendations for permanent prostate brachytherapy with 495

(131)Cs: a consensus report from the Cesium Advisory Group. Brachytherapy. 2008;7(4):290-296. 496

56. Merrick GS, Butler WM, Wallner KE, et al. Variability of prostate brachytherapy pre-implant 497

dosimetry: a multi-institutional analysis. Brachytherapy. 2005;4(4):241-251. 498

57. SJ F, JC P, CJ K. Do younger men have better biochemical outcomes after radical prostatectomy? 499

Urology. 2004;63(3):518-522. 500

58. Butler WM, Stewart RR, Merrick GS. Evaluation of radiobiologic biochemical control in a large permanent 501

prostate brachytherapy population from a single institution using AAPM TG-137 parameters. Brachytherapy. 502

2011;10(1):16-28. 503

59. Stock RG, Stone NN, Cesaretti JA, Rosenstein BS. Biologically effective dose values for prostate 504

brachytherapy: effects on PSA failure and posttreatment biopsy results. Int J Radiat Oncol Biol Phys. 505

2006;64(2):527-533. 506

60. Wallner K, Merrick G, True L, Cavanagh W, Simpson C, Butler W. I-125 versus Pd-103 for low-risk prostate 507

cancer: morbidity outcomes from a prospective randomized multicenter trial. Cancer J. 2002;8(1):67-73. 508

61. Benoit RM, Smith RP, Beriwal S. Five year prostate-specific antigen outcomes after caesium prostate 509

brachytherapy. Clin Oncol (R Coll Radiol). 2014;26(12):776-780. 510

62. Blanchard P, Pugh TJ, Swanson DA, et al. Patient-reported health-related quality of life for men 511

treated with low-dose-rate prostate brachytherapy as monotherapy with 125-iodine, 103-palladium, or 512

131-cesium: Results of a prospective phase II study. Brachytherapy. 2018;17(2):265-276. 513

63. Merrick GS, Butler WM, Wallner KE, Lief JH, Galbreath RW. Prophylactic versus therapeutic alpha-514

blockers after permanent prostate brachytherapy. Urology. 2002;60(4):650-655. 515




64. American College of Radiology. ACR–ASTRO practice parameter for communication: radiation 516

oncology. 2019; Availabile at: https://www.acr.org/-/media/ACR/Files/Practice-517

Parameters/Communication-RO.pdf?la=en. Accessed June 26, 2019. 518

65. Dubois DF, Prestidge BR, Hotchkiss LA, Bice WS, Jr., Prete JJ. Source localization following permanent 519

transperineal prostate interstitial brachytherapy using magnetic resonance imaging. Int J Radiat Oncol Biol 520

Phys. 1997;39(5):1037-1041. 521

66. Moerland MA, Wijrdeman HK, Beersma R, Bakker CJ, Battermann JJ. Evaluation of permanent I-125 522

prostate implants using radiography and magnetic resonance imaging. Int J Radiat Oncol Biol Phys. 523

1997;37(4):927-933. 524

67. Frank SJ, Mourtada F, Crook J, Menard C. Use of magnetic resonance imaging in low-dose-rate and 525

high-dose-rate prostate brachytherapy from diagnosis to treatment assessment: Defining the 526

knowledge gaps, technical challenges, and barriers to implementation. Brachytherapy. 2017;16(4):672-527

678. 528

68. Prestidge BR, Bice WS, Kiefer EJ, Prete JJ. Timing of computed tomography-based postimplant assessment 529

following permanent transperineal prostate brachytherapy. Int J Radiat Oncol Biol Phys. 1998;40(5):1111-530

1115. 531

69. Yue N, Dicker AP, Nath R, Waterman FM. The impact of edema on planning 125I and 103Pd prostate 532

implants. Med Phys. 1999;26(5):763-767. 533

70. Davis BJ, Bresnahan JF, Stafford SL, Karon BL, King BF, Wilson TM. Prostate brachytherapy seed migration 534

to a coronary artery found during angiography. J Urol. 2002;168(3):1103. 535

71. Orio PF, 3rd, Merrick GS, Grimm P, et al. Effects of the time interval between prostate brachytherapy and 536

postimplant dosimetric evaluation in community practice: analysis of the Pro-Qura database. Am J Clin 537

Oncol. 2008;31(6):523-531. 538

72. Taussky D, Yeung I, Williams T, et al. Rectal-wall dose dependence on postplan timing after permanent-seed 539

prostate brachytherapy. Int J Radiat Oncol Biol Phys. 2006;65(2):358-363. 540

73. Waterman FM, Yue N, Reisinger S, Dicker A, Corn BW. Effect of edema on the post-implant dosimetry of 541

an I-125 prostate implant: a case study. Int J Radiat Oncol Biol Phys. 1997;38(2):335-339. 542

74. Nath R, Bice WS, Butler WM, et al. AAPM recommendations on dose prescription and reporting methods 543

for permanent interstitial brachytherapy for prostate cancer: report of Task Group 137. Med Phys. 544

2009;36(11):5310-5322. 545

75. Yu Y, Anderson LL, Li Z, et al. Permanent prostate seed implant brachytherapy: report of the American 546

Association of Physicists in Medicine Task Group No. 64. Med Phys. 1999;26(10):2054-2076. 547

76. Merrick GS, Butler WM, Dorsey AT, Walbert HL. Influence of timing on the dosimetric analysis of 548

transperineal ultrasound-guided, prostatic conformal brachytherapy. Radiat Oncol Investig. 1998;6(4):182-549

190. 550

77. Willins J, Wallner K. Time-dependent changes in CT-based dosimetry of I-125 prostate brachytherapy. 551

Radiat Oncol Investig. 1998;6(4):157-160. 552

78. Roberson PL, McLaughlin PW, Narayana V, Troyer S, Hixson GV, Kessler ML. Use and uncertainties of 553

mutual information for computed tomography/ magnetic resonance (CT/MR) registration post permanent 554

implant of the prostate. Med Phys. 2005;32(2):473-482. 555

79. Dubois DF, Prestidge BR, Hotchkiss LA, Prete JJ, Bice WS, Jr. Intraobserver and interobserver variability of 556

MR imaging- and CT-derived prostate volumes after transperineal interstitial permanent prostate 557

brachytherapy. Radiology. 1998;207(3):785-789. 558

80. Lee WR, Roach M, 3rd, Michalski J, Moran B, Beyer D. Interobserver variability leads to significant 559

differences in quantifiers of prostate implant adequacy. Int J Radiat Oncol Biol Phys. 2002;54(2):457-461. 560

81. Nag S. Brachytherapy for prostate cancer: summary of American Brachytherapy Society recommendations. 561

Semin Urol Oncol. 2000;18(2):133-136. 562

82. Nag S, Beyer D, Friedland J, Grimm P, Nath R. American Brachytherapy Society (ABS) recommendations 563

for transperineal permanent brachytherapy of prostate cancer. Int J Radiat Oncol Biol Phys. 1999;44(4):789-564

799. 565






83. Nag S, Bice W, DeWyngaert K, Prestidge B, Stock R, Yu Y. The American Brachytherapy Society 566

recommendations for permanent prostate brachytherapy postimplant dosimetric analysis. Int J Radiat Oncol 567

Biol Phys. 2000;46(1):221-230. 568

84. Kollmeier MA, Stock RG, Stone N. Biochemical outcomes after prostate brachytherapy with 5-year minimal 569

follow-up: importance of patient selection and implant quality. Int J Radiat Oncol Biol Phys. 2003;57(3):645-570

653. 571

85. Lee WR, Bae K, Lawton CA, et al. A descriptive analysis of postimplant dosimetric parameters from 572

Radiation Therapy Oncology Group P0019. Brachytherapy. 2006;5(4):239-243. 573

86. Potters L, Cao Y, Calugaru E, Torre T, Fearn P, Wang XH. A comprehensive review of CT-based dosimetry 574

parameters and biochemical control in patients treated with permanent prostate brachytherapy. Int J Radiat 575

Oncol Biol Phys. 2001;50(3):605-614. 576

87. Stock RG, Stone NN, DeWyngaert JK, Lavagnini P, Unger PD. Prostate specific antigen findings and biopsy 577

results following interactive ultrasound guided transperineal brachytherapy for early stage prostate 578

carcinoma. Cancer. 1996;77(11):2386-2392. 579

88. Zelefsky MJ, Kuban DA, Levy LB, et al. Multi-institutional analysis of long-term outcome for stages T1-T2 580

prostate cancer treated with permanent seed implantation. Int J Radiat Oncol Biol Phys. 2007;67(2):327-333. 581

89. Merrick GS, Butler WM, Wallner KE, et al. The impact of radiation dose to the urethra on brachytherapy-582

related dysuria. Brachytherapy. 2005;4(1):45-50. 583

90. Sherertz T, Wallner K, Merrick G, et al. Factors predictive of rectal bleeding after 103Pd and supplemental 584

beam radiation for prostate cancer. Brachytherapy. 2004;3(3):130-135. 585

91. Tran A, Wallner K, Merrick G, et al. Rectal fistulas after prostate brachytherapy. Int J Radiat Oncol Biol 586

Phys. 2005;63(1):150-154. 587

92. Crook JM, Potters L, Stock RG, Zelefsky MJ. Critical organ dosimetry in permanent seed prostate 588

brachytherapy: defining the organs at risk. Brachytherapy. 2005;4(3):186-194. 589

93. Merrick GS, Butler WM, Wallner KE, et al. The importance of radiation doses to the penile bulb vs. crura in 590

the development of postbrachytherapy erectile dysfunction. Int J Radiat Oncol Biol Phys. 2002;54(4):1055-591

1062. 592

94. Solan AN, Cesaretti JA, Stone NN, Stock RG. There is no correlation between erectile dysfunction and dose 593

to penile bulb and neurovascular bundles following real-time low-dose-rate prostate brachytherapy. Int J 594


95. Pfeiffer D, Sutlief S, Feng W, Pierce HM, Kofler J. AAPM Task Group 128: quality assurance tests for 596

prostate brachytherapy ultrasound systems. Med Phys. 2008;35(12):5471-5489. 597

96. American College of Radiology. ACR–AAPM technical standard for diagnostic medical physics 598

performance monitoring of real time ultrasound equipment. 2016; Available at: https://www.acr.org/-599

/media/ACR/Files/Practice-Parameters/US-Equip.pdf?la=en. Accessed June 26, 2019. 600

97. Kutcher GJ, Coia L, Gillin M, et al. Comprehensive QA for radiation oncology: report of AAPM Radiation 601

Therapy Committee Task Group 40. Med Phys. 1994;21(4):581-618. 602

98. Nath R, Anderson LL, Meli JA, Olch AJ, Stitt JA, Williamson JF. Code of practice for brachytherapy physics: 603

report of the AAPM Radiation Therapy Committee Task Group No. 56. American Association of Physicists 604

in Medicine. Med Phys. 1997;24(10):1557-1598. 605

99. Butler WM, Bice WS, Jr., DeWerd LA, et al. Third-party brachytherapy source calibrations and physicist 606

responsibilities: report of the AAPM Low Energy Brachytherapy Source Calibration Working Group. Med 607

Phys. 2008;35(9):3860-3865. 608

100. American College of Radiology. ACR–ASTRO practice parameter for radiation oncology. 2018; 609

Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/RadOnc.pdf?la=en. 610

Accessed June 26, 2019. 611

101. Kuban DA, Levy LB, Potters L, et al. Comparison of biochemical failure definitions for permanent prostate 612

brachytherapy. Int J Radiat Oncol Biol Phys. 2006;65(5):1487-1493. 613







102. Roach M, 3rd, Hanks G, Thames H, Jr., et al. Defining biochemical failure following radiotherapy with or 614

without hormonal therapy in men with clinically localized prostate cancer: recommendations of the RTOG-615

ASTRO Phoenix Consensus Conference. Int J Radiat Oncol Biol Phys. 2006;65(4):965-974. 616

103. Morris WJ, Pickles T, Keyes M. Using a surgical prostate-specific antigen threshold of >0.2 ng/mL to 617

define biochemical failure for intermediate- and high-risk prostate cancer patients treated with 618

definitive radiation therapy in the ASCENDE-RT randomized control trial. Brachytherapy. 619

2018;17(6):837-844. 620

104. Bostancic C, Merrick GS, Butler WM, et al. Isotope and patient age predict for PSA spikes after permanent 621

prostate brachytherapy. Int J Radiat Oncol Biol Phys. 2007;68(5):1431-1437. 622

105. Cavanagh W, Blasko JC, Grimm PD, Sylvester JE. Transient elevation of serum prostate-specific antigen 623

following (125)I/(103)Pd brachytherapy for localized prostate cancer. Semin Urol Oncol. 2000;18(2):160-624

165. 625

106. Critz FA, Williams WH, Benton JB, Levinson AK, Holladay CT, Holladay DA. Prostate specific antigen 626

bounce after radioactive seed implantation followed by external beam radiation for prostate cancer. J Urol. 627

2000;163(4):1085-1089. 628

629

OLD REFERENCES 630

5. Blana A, Robertson CN, Brown SC, et al. Complete high-intensity focused ultrasound in prostate cancer: 631

outcome from the @-Registry. Prostate Cancer Prostatic Dis. 2012;15(3):256-259. 632

6. Jones JS, Rewcastle JC, Donnelly BJ, Lugnani FM, Pisters LL, Katz AE. Whole gland primary prostate 633

cryoablation: initial results from the cryo on-line data registry. J Urol. 2008;180(2):554-558. 634

7. Bul M, Zhu X, Valdagni R, et al. Active surveillance for low-risk prostate cancer worldwide: the PRIAS study. 635

Eur Urol. 2013;63(4):597-603. 636

21. Radiation Oncology/RTOG Trials/0232. Available at: 637

http://en.wikibooks.org/wiki/Radiation_Oncology/RTOG_Trials/0232. Accessed March 10, 2014. 638

639

**As of May 2010, all radiation oncology collaborative parameters are approved by the ACR Council Steering 640

Committee and the ACR Board of Chancellors and will not go through the ACR Council (ACR Resolution 8, 2010). 641

The effective date is displayed below: 642

643

Development Chronology for this Practice Parameter 644

2000 (Resolution 19) 645

Revised 2005 (Resolution 19) 646

Amended 2006 (Resolution 16g, 36) 647

Revised 2010 (Resolution 2) 648

Amended 2014 (Resolution 39) 649

Revised 2015 (CSC/BOC) 650

http://en.wikibooks.org/wiki/Radiation_Oncology/RTOG_Trials/0232

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