Authors (including presenting author) :
Lo KL (1), Ma SF (1), Leung KW (1), Li KM (1), Chu CM (4), Mak SK (1), Wong HM (1), Poon MC (3), Ng CF (1)(2)
Affiliation :
(1)Division of Urology, North District Hospital, New Territories East Cluster Urology Unit, Prince of Wales Hospital, Shatin, Hong Kong, (2)SH Ho Urology Centre, Department of Surgery, the Chinese University of Hong Kong, (3)Department of Oncology, Prince of Wales Hospital, Shatin, Hong Kong, (4)Department of Imaging and Interventional Radiology, Prince of Wales Hospital, Shatin, Hong Kong
Introduction :
According to the Hong Kong Cancer Registry 2017, prostate cancer was the third most common cancer in male population. The number of prostate cancer cases has been growing with the fastest pace in recent years.
After confirmation and staging of prostate cancer, some patients have opted for image-guided radiotherapy (IGRT). Randomized trials have shown that Escalated‐dose was better than standard‐dose conformal radiotherapy in terms of tumor control and oncological outcome. However, escalated‐dose associated with higher toxicity to the surrounding organs, particularly to the rectum. The cumulative incidence of late Grade 2 or greater gastrointestinal toxicity was increased with escalated‐dose group. Internal organ motion also limited the accuracy of targeting the prostate and was a limiting factor in margin reduction and dose escalation. Fiducial markers (FM) implantation was widely used to localize prostate before radiotherapy which was first reported by Crook et al. The efficacy of FM implantation for precise setup and real-time tumor tracking in radiotherapy has been well documented in the literatures.
Traditionally, FM implantation was accomplished by transrectal approach. However, this approach associated with fever, haematuria, acute retention of urine, per rectal bleeding and even migration. Although there were some possible complications related to transrectal fiducial gold markers implantation (TRFGM), not many studies have been reported about transperineal fiducial gold markers implantation (TPFGM). Until recently, some studies have reported the efficacy of TPFGM in reducing complications of FM implantation. De Cicco L et al. retrospectively reported 101 patients underwent gold seed fiducial marker transperineal ultrasound-guided implantation for prostate IGRT. It had one patient who developed a single episode of self-limiting urinary bleeding just after the procedure. No other complication was recorded. Currently, there was no well conducted study comparing the efficacy between TPFGM and TRFGM. In fact, TPFGM differed from TRFGM in terms of patients’ positions, puncture routes, puncture sites and ultrasound probes. TPFGM enabled the Urologists to thoroughly prepare the perineum with a disinfectant solution to eliminate skin bacteria. Also, it punctured perineal skin under the guidance of side-fire ultrasound probe without penetrating rectal mucosa, avoiding blood exposure to the bowel bacteria. With the above potential benefit, our center has introduced TPFGM in our service since January 2019. Since then, we have replaced TRFGM by TPFGM. In this study, we aimed to compare the clinical outcomes of our series of TPFGM and TRFGM prior IGRT.
Objectives :
To compare the clinical outcomes of transperineal fiducial gold markers implantation (TPFGM) and transrectal fiducial gold markers implantation (TRFGM) prior prostate image-guided radiotherapy (IGRT).
Methodology :
We have introduced the first TPFGM for the prostate cancer patient who was referred by Oncologist in January 2019. Here, we retrospectively compared between 50 cases of TPFGM and 25 cases of TRFGM done in our cluster of the hospitals. All patients’ clinical parameters, including patients’ ages, Eastern Cooperative Oncology Group Performance Status (ECOG), serum Prostate Specific Antigen (PSA) levels, prostate sizes, Gleason Scores, stagings as well as 30-days complication and readmission rates were retrieved from the clinical notes. All the parameters were collated and analyzed.
Result & Outcome :
The 50 cases of TPFGM were done from January 2019 to December 2019, while the 25 cases of TRFGM were performed from June 2018 to December 2018. There was no statistical difference between the mean ages (70.9 vs 70.0, p=0.685) and median ECOGs (0 vs 0, p=n/a) in both groups. The mean prostate sizes (41.2ml vs 39.0ml, p=0.676), median PSA levels (8.90ng/dL vs 9.30ng/dL, p=0.991), median Gleason Scores (7 vs 6, p=0.058) and stagings (p=0.219) were similar in both groups. Both approaches took 10 minutes to finish the whole procedure. For complications, there was no infection developed in TPFGM group, while 4 patients (16%) of TRFGM group developed infection after the procedure, requiring admission for a course of antibiotic (p = 0.01). Among these 4 patients, 1 patient developed sepsis and associated myocardial infarction requiring 5-days Intensive Care Unit (ICU) admission. No patient developed haematuria, per rectal bleeding, haematospermia, acute retention of urine (AROU) requiring admission after these two procedures. There was no migration of fiducial gold markers in both groups.
