In addition, Corner et al. (22) reported on a Phase II trial from the United Kingdom that includes 110 men with locally advanced

disease treated with HDR monotherapy to doses of 34 Gy in four fractions, 36 Gy in four fractions, or 31.5 Gy in three fractions. The rate of acute urinary retention requiring catheterization was 6.4%, and there see more were no PSA relapses with a median followup of 30 months (34 Gy), 18 months (36 Gy), and 11.8 months (31.5 Gy). Also, Yoshioka et al. (23) has reported on a Japanese series of 112 men treated with hormonal therapy and HDR monotherapy to 54 Gy in nine fractions over 5 days in which the 5-year PSA failure-free survival was 83%despite more than one-half of the patients having high-risk disease. Finally, Mark et al. (24) of Lubbock, Texas have presented

in abstract form on their large series of 312 HDR monotherapy patients treated to 4500 cGy in six fractions to the prostate and seminal vesicles given as two implants of three fractions each, spaced 4 weeks apart. None of the patients received ADT, and with a median followup of 8.2 years, the PSA failure-free survival was 84.6%. In the setting of prior pelvic radiation, UCSF investigators have published two series using a regimen of 36 Gy in six fractions given as three fractions per implants, with the implants being spaced 1 week apart. The first series by Lee et al. (1) in 2007 detailed 21 patients who had received prior external beam radiation (19) or LDR brachytherapy (2) for prostate cancer and developed a biopsy-proven local recurrence at an average of 5.25 years after initial radiation. ABT-263 Nine of the patients had extracapsular extension or seminal vesicle invasion. Eleven received neoadjuvant ADT before salvage HDR. The 2-year PSA failure-free survival was 89% and the maximum gastrointestinal toxicity was only Grade 2, but the median followup was only 18.7 months.

The second series by Jabbari et al. (2) was of 6 patients who developed prostate cancer after receiving a prior abdominopelvic resection. All had received prior pelvic radiotherapy to a median dose of 45 Gy (range, 21–73.8 Gy). however With a median followup of 26 months (range, 14–60months), no patient had experienced a biochemical recurrence, and none had higher than a Grade 3 acute toxicity, although 1 patient developed a urethral stricture that required dilation. Rectal fistula is a very rare complication of primary brachytherapy in patients who have not received prior radiation (25). However, it has been reported in 3.4% of the 251 cases of salvage brachytherapy reported in the literature from 1990 to 2007. The Dana–Farber Phase I/II study identified an interval to reirradiation of less than 4.5 years as a risk factor for developing a fistula, which placed our patient at higher risk because his interval to reirradiation was only 2.5 years. However, no dosimetric risk factors for fistula have been identified in this setting, and therefore the goal was to keep the rectal dose as low as possible.