It is interesting to note that men who have colorectalcancer are at increased risk for prostate cancer with thegreatest risk in men younger than 65 years (relative riskapproximately 2). Men with a first primary colorectal cancerare more likely to have prostate cancer than those withcolorectal second primary tumors and men who have a sec-ond primary prostate cancer are more likely to die of prostatecancer than of colorectal cancer.14 In addition, recent geneticevidence suggests that patients with HNPCC (hereditarynonpolyposis colon cancer) may be at increased risk for pros-tate cancer.15 Prior to this publication the recognized urolog-ical tumor spectrum of HNPCC included ureteral and renalpelvis malignancies. Based on these findings it would appearreasonable that patients scheduled to undergo abdominoper-ineal resection should also undergo prostate cancer screen-ing.16

CONCLUSIONS

Three-D CT guided brachytherapy of prostate cancer inpatients with prior colorectal cancer after external beamradiation and abdominoperineal resection is a technicallyfeasible method of treatment. Longer term followup and alarger number of patients would determine the efficacy ofthis treatment.

REFERENCES

1. Cancer Facts & Figures 2003. Atlanta, Georgia: American Can-cer Society, 2003

2. van Halteren, H. K.: Colorectal cancer in 2003: old principles,new strategies. Anticancer Drugs, 14: 97, 2003

3. Eastham, J. A., DiBlasio, C. J. and Scardino, P. T.: Salvageradical prostatectomy for recurrence of prostate cancer afterradiation therapy. Curr Urol Rep, 4: 211, 2003

4. Koutrouvelis, P. G.: Three-dimensional stereotactic posterior is-chiorectal space computerized tomography guided brachyther-apy of prostate cancer: a preliminary report. J Urol, 159: 142,1998

5. Koutrouvelis, P. G., Lailas, N., Katz, S., Sehn, J., Gil-Montero, G.and Khawand, N.: Prostate cancer with large glands treatedwith 3-dimensional computerized tomography guided pararec-tal brachytherapy: up to 8 years of followup. J Urol, 169: 1331,2003

6. Blasko, J. C., Mate, T., Sylvester, J. E., Grimm, P. D. andCavanagh, H.: Brachytherapy for carcinoma of the prostate:techniques, patient selection, and clinical outcomes. SeminRadiat Oncol, 12: 81, 2002

7. Galalae, R. M., Kovacs, G., Schultze, J., Loch, T., Rzehak, P.,Wilhelm, R. et al: Long-term outcome after elective irradiationof the pelvic lymphatics and local dose escalation using high-dose-rate brachytherapy for locally advanced prostate cancer.Int J Radiat Oncol Biol Phys, 52: 81, 2002

8. Kupelian, P. A., Potters, L., Khuntia, D., Ciezki, J. P., Reddy,C. A., Reuther, A. M. et al: Radical prostatectomy, externalbeam radiotherapy �72 Gy, external beam radiotherapy � or�72 Gy, permanent seed implantation, or combined seeds/external beam radiotherapy for stage T1–T2 prostate cancer.Int J Radiat Oncol Biol Phys, 58: 25, 2004

9. Porter, A. T., Blasko, J. C., Grimm, P. D., Reddy, S. M. andRagde, H.: Brachytherapy for prostate cancer. CA CancerJ Clin, 45: 165, 1995

10. Zelefsky, M. J., Fuks, Z., Hunt, M., Yamada, Y., Marion, C., Ling,C. C. et al: High-dose intensity modulated radiation therapyfor prostate cancer: early toxicity and biochemical outcome in772 patients. Int J Radiat Oncol Biol Phys, 53: 1111, 2002

11. Catalona, W. J. and Smith, D. S.: Cancer recurrence and survivalrates after anatomic radical retropubic prostatectomy for pros-tate cancer: intermediate-term results. J Urol, 160: 2428, 1998

12. Sohayda, C., Kupelian, P. A., Levin, H. S. and Klien, E. A.:Extent of extracapsular extension in localized prostate cancer.Urology, 55: 382, 2000

13. Koutrouvelis, P. G., Lailas, N., Hendricks, F., Gil-Montero, G.,Sehn, J. and Katz, S.: Three-dimensional computedtomography-guided monotherapeutic pararectal brachyther-apy of prostate cancer with seminal vesicle invasion. Ra-diother Oncol, 60: 31, 2001

14. Moot, A. R., Polglase, A., Giles, G. G., Garson, O. M., Thursfield,V. and Gunter, D.: Men with colorectal cancer are predisposedto prostate cancer. Aust NZ J Surg, 73: 289, 2003

15. Soravia, C., van der Klift, H., Brundler, M. A., Blouin, J. L.,Wijnen, J., Hutter, P. et al: Prostate cancer is part of thehereditary non-polyposis colorectal cancer (HNPCC) tumorspectrum. Am J Med Genet, 121A: 159, 2003

16. Terris, M. K. andWren, S. M.: Results of a screening program forprostate cancer in patients scheduled for abdominoperinealresection for colorectal pathologic findings. Urology, 57: 943,2001

EDITORIAL COMMENT

Patients with localized prostate cancer have a choice of severaltherapies that deliver successful outcomes. However, there may beextenuating circumstances that limit their choices, as is the caseafter combined modality therapy for colorectal cancer. APR elimi-nates the portal of entry for the traditional delivery of interstitialradiation, pelvic irradiation prohibits the delivery of required can-cercidal doses and chemotherapy may produce general systemic mor-bidity. What options remain? Radical prostatectomy is possible andabsent a rectum there is no concern for a fistula but post-radiationanastomotic stricture and a component of neurogenic bladder afterAPR would predict a high likelihood of intermittent or permanent

FIG. 6. CT dosimetry immediately after implantation in patientwithout rectum. Green circle and arrow indicate urethra. Red outlineindicates prostate. Purple outline indicates 100% isodose line of 144Gy 5 to 10 mm outside of prostate.

FIG. 7. Extensive seminal vesicle (blue outline) invasion. Notegood coverage without obstruction by coccyx. Purple outline indicates100% isodose line of 144 Gy.

BRACHYTHERAPY OF PROSTATE CANCER WITHOUT RECTUM 85

catheter drainage, although this was not necessary in the currentreport. Intermittent or continuous androgen deprivation to delayprogression is a consideration. Surveillance should not be consideredin low risk (Gleason 6 or less, PSA less than 10 ng/ml and a limitednumber of cores positive) situations.

These authors describe a posterior CT guided approach that theyhave routinely used (800 patients) in their practice to deliver inter-stitial therapy. In the 5 patients who are the subject of this report theapproach was eminently suited to the situation.

However, in addition to the risk profile of prostate cancer, the criticalinformation necessary before initiating any therapy in these cases in-cludes anticipated life expectancy based on comorbidity and specificallyrelating to the primary colorectal lesion (the disease-free interval fromcolorectal cancer treatment to prostate cancer diagnosis) and also anevaluation of post-APR bladder function. While the options of therapyare more limited in the circumstance described this report, all possibil-ities, including the methods used, require consideration.

Paul F. SchellhammerVirginia Prostate CenterEastern Virginia Medical SchoolNorfolk, Virginia

REPLY BY AUTHORS

Adjuvant hormone therapy was not considered an option becausewe do not recommend it as monotherapy for the management ofprostate cancer in patients with a mean age of 64 years and whosemedical condition was good. All of the patients were disease-freefrom colorectal cancer at least 5 years before 3-D CT guided brachy-therapy for second primary prostate cancer.

It is seldom that we do not recommend surveillance because pros-tate cancer is often multigraded and multicentric, and it is underes-timated with routine biopsy. We also routinely perform 3-D CTguided stereotactic biopsy of the seminal vesicles for staging. Wereported on 79 of 563 patients with positive biopsy.1 Valicenti et alalso reported 14% seminal vesicle invasion in post-prostatectomycases.2

1. Technology in Cancer Research and Treatment. Washington,D.C.: ISSN1533-0346, vol. 2, no. 4, August 2003

2. Valicenti, R. K., Gomella, L. G., Ismail, M., Mullholland, S. G.,Petersen, R. O. and Corn, B. W.: Pathologic seminal vesicleinvasion after radical prostatectomy for patients with prostatecarcinoma: effect of early adjuvant radiation therapy on bio-chemic control. Cancer, 82: 1909, 1998

BRACHYTHERAPY OF PROSTATE CANCER WITHOUT RECTUM86