Combined Modality

Treatment for
Prostate Cancer With Dynamic
Adaptive Radiation Therapy
Using Four-Dimensional
Image-Guided Intensity-
Modulated Radiation Therapy
and Brachytherapy
j Jennifer C. Cash, ARNP, MS, OCN; Jone Fay, BS, (R)(T), CMD; and Michael J. Dattoli, MD

ABSTRACT: Prostate cancer can be successfully treated using dynamic adaptive external beam radiation tech-
niques along with interstitial brachytherapy to deliver curative therapies with low urinary, rectal and erec-
tile function morbidity. Through the use of sophisticated, state-of-the art radiographic imaging for staging
and treatment planning, a precise, individual design for treatment is accomplished. Symptom management
and patient education are of paramount importance and are integrated throughout the treatment process.
(J Radiol Nurs 2009;28:87-95.)

KEYWORDS: IMRT; DART; Brachytherapy; Prostate cancer.

Men who are treated at the Dattoli Cancer Center in
Sarasota, Florida all have one thing in common: a diag-
nosis of prostate cancer. In some cases, even before
a pathologic confirmation of cancer is known, men
Jennifer C. Cash, Jone Fay, and Michael J. Dattoli are in Dattoli
Cancer Center, Sarasota, FL.
Corresponding author: Jennifer C. Cash, Dattoli Cancer Center, 2803
Fruitville Rd, Ste 1, Sarasota, FL 34237. E-mail: Brachyrn@aol.com
1546-0843/$36.00
Copyright Ó 2009 by the Association for Radiologic & Imaging Nursing.
doi: 10.1016/j.jradnu.2009.04.001
are seeking information and direction on treatment op-
tions not only because of the many modalities currently
available, but widely variable supportive outcome data.
Treatment options for prostate cancer are varied in
their focus, clinical outcomes, and associated side
effects. Brachytherapy-based treatment regimens are
not novel, yet are associated with very different treat-
ment protocols, mostly physician specific, with a wide
range of reported side effects. A combined regimen of
dynamic adaptive radiation therapy (DART) using
real-time imaging for beam placement precision and
quality assurance methods with four-dimensional im-
age-guided intensity-modulated radiation therapy (4D

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Cash et al JOURNAL OF RADIOLOGY NURSING
IG IMRT), in conjunction with interstitial brachyther-
apy with the palladium 103 (Pd-103) isotope (perma-
nent seeding,) has consistently resulted in highly
acceptable cure/control rates of cancer with low uri-
nary, rectal, and erectile morbidity at this center.
With the use of contemporary and novel radiographic
imaging for not only staging but also treatment plan-
ning purposes, a precision design for the delivery of
DART and brachytherapy is achievable in its optimal
form.
DYNAMIC ADAPTIVE RADIATION
THERAPY WITH FOUR-DIMENSIONAL
IMAGE-GUIDED INTENSITY-MODULATED
RADIATION THERAPY
DART is a Varian (T; Varian Medical Systems, Palo
Alto, CA) term for the advanced features available to
adjust a patient treatment plan in real time. This in-
volves using up-to-the-minute ‘‘captured’’ image data
to adapt a patient’s treatment to constantly evolving in-
formation, which occurs during a 4D IG IMRT treat-
ment course. IG IMRT is not considered add-on
technology, but represents cutting edge technology
that requires knowledge, and sometimes use of soft-
ware fusion techniques for more selective delivery of
radiation doses, by multimodality diagnostic imaging
such as (computed tomography [CT], ultra small parti-
cle iron oxide imaging [USPIO/Combidex] of lymph
nodes per magnetic resonance imaging [MRI]/CT; see
Figure 1) three-dimensional (3D) ultrasound and/or
positron emission testing (PET; Cash, 2006; Dattoli et
Figure 1. Combidex magnetic resonance raw imaging of abdominal/pelvic lymph nodes. Courtesy Dattoli Cancer Center, Sarasota, Florida.
88 www.radiologynursing.org
Combined Radiation in Prostate Cancer
al., 2008; Harisinghani et al., 2003). Other factors con-
sidered in this process are treatment set-up uncer-
tainties and internal organ motion (i.e., respiration,
digestion), tumor control probabilities, and normal
tissue complication considerations. DART with 4D
IG IMRT differs from older treatment planning tech-
niques as it divides each radiation beam into multiple
rays, or ‘‘beamlets,’’ and assigns different beam
strengths to the individual rays. These beamlets treat
very small areas of tissue, called voxels, which are a
cubic millimeter of space, thus concentrating the radia-
tion to specific areas of tumor, primarily in the periph-
ery of the prostate gland where most cancers are
located, while avoiding the urethra, nerve bundles,
and other critical surrounding structures. By modulat-
ing both the number of treatment fields and the inten-
sity within each field, there is greater control of the
radiation dose to the intended target (Dattoli et al.,
2008).
DYNAMIC ADAPTIVE RADIATION THERAPY
TREATMENT PLANNING AND DELIVERY
Similar to conventional radiation and 3D conformal
radiation, the DART process is composed of three
phasesdsimulation, treatment planning, and treatment
delivery. Simulation involves visualizing the tumor and
surrounding structures in three dimensions by CT
imaging to devise an optimal treatment plan. Comput-
erized inverse treatment planning generates treatment
plans that most closely match the intended target tissue
and radiation dose requirements specified by the
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Combined Radiation in Prostate Cancer JOURNAL OF RADIOLOGY NURSING
physician. Radiation therapists use a linear accelerator
(a high-energy X-ray machine) with a mounted multi-
leaf collimator (MLC) to deliver the actual treatment
(photons) external to the body.
SIMULATION
Simulation is the physical treatment planning process
for DART, which uses CT imaging to three dimension-
ally reconstruct a patient’s anatomy into the treatment
planning software system. The simulator mimics the
treatment machine, and allows for X-ray images of
the patient in the treatment position. This is a fine-
tuning of the plan and verifies that the treatment will
work as intended. A critical component of the simula-
tion process involves immobilization of the lower
body with a customized device (alpha cradle) to ensure
daily positioning accuracy and decrease (external) mo-
tion during treatment. The patient lies on a hard table
in the immobilization device while the imaging takes
place. Positioning on the table is typically supine.
Patients will be tattooed with small marks that will
align with lasers in the treatment room to ensure daily
accuracy of the treatment. Other procedures typically
include placement of urinary catheters with contrast
into bladder, as well as contrast instilled into rectum,
and in some cases, oral contrast is given for visualiza-
tion of small bowel when intra-abdominal lymph nodes
are treated. Depending on the complexity of the treat-
ment plan, the simulation may last 30 min to 2 hr.
COMPLEX INVERSE TREATMENT PLANNING
Once the simulation is complete, and the physician has
identified his treatment goals, a process called inverse
treatment planning, takes place using the CT imagery
of anatomy to identify the target volumes and normal
surrounding tissues. The medical dosimetrist, using
Figure 2. Computed tomography-based dynamic adaptive radia-
tion therapy dosimetry plan for intact prostate. Courtesy Dattoli
Cancer Center, Sarasota, Florida.
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Cash et al
Figure 3. Dynamic adaptive radiation therapy treatment plan
setup: Blue: prostate; pink: tumor; light blue: tumor; brown:
rectum; green: urethra; orange: penile bulb; yellow: bladder;
purple: lymph nodes; green cloud: radiation dose. Courtesy
Dattoli Cancer Center, Sarasota, Florida.
treatment planning software that contains the fused an-
atomical imaging, runs an optimization program that
selects the best combination of angles and beam inten-
sities to obtain the ideal treatment plan (see Figure 2).
There are literally thousands of beamlets coming from
every conceivable angle that make it possible to sculpt
radiation dose shapes to critical surrounding structures
such as nerve bundles, seminal vesicles, bladder, and
rectum, as well as avoiding such abdominal structures
of small bowel (see Figure 3). This allows the physician
to assign different weightings of dose to targets and
surrounding structures, and is particularly useful in
-delivering ‘‘boost’’ doses to prostate, lymph nodes or
other specific areas without compromising surrounding
critical structures or adding additional treatment
sessions (see Figure 4).
PRELIMINARY SETUP AND
TREATMENT DELIVERY
Before any DART treatment course begins, the patient
has a final check of setup and safety systems. The
patient lies on the treatment table in the treatment
position with the immobilization device used during
the simulation procedure. Digitally reconstructed
radiographs are obtained to verify patient setup before
the first treatment session. The planning process is
oriented to the initial simulation marks, and the treat-
ment fields (or ports) are simply translations of the
computer images, therefore, verification of the correct
setup is essential. Anterior-posterior and lateral
‘‘port’’ films are taken and compared with the original
simulation films. The MLC gantry is rotated through
each treatment port to ensure there will be no collision
with the patient or table during the treatment. Lasers
verify placement of the treatment fields. Once this
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Cash et al JOURNAL OF RADIOLOGY NURSING
Figure 4. Dynamic adaptive radiation therapy treatment plan
representation for prostate and pelvic lymph nodes. Courtesy
Dattoli Cancer Center, Sarasota, Florida.
step is completed, the prescribed treatment plan can
begin, which may be 3 to 4 days from the day of
simulation.
Daily treatments last approximately 15 to 20 min,
and involve strict quality assurance measures to ensure
accuracy of the treatment, as well as decrease patient
motion (external and internal). Setup and verification
of the patient before each treatment takes minutes,
and the treatment itself is delivered by computer out-
side of the room by radiation therapists. Quality assur-
ance methods used for verification of treatment setup
include Sonarray (Varian Medical Systems, Palo Alto,
CA), a noninvasive ultrasound imaging system for
daily localization of prostate that is interfaced with
the main computer; real-time portal imaging verifica-
tion systems (portal vision) that verifies exact treatment
position; real-time synchronous CT and/or portal
imaging with treatment; and respiratory gating, an
advanced video tracking technology that allows for
real-time monitoring and correction of physiologic
motion as a result of patient breathing (Dattoli et al.,
2008). These state-of-the-art technologies allow the
physician to make up-to-the-minute treatment deci-
sions while managing organ motion and dynamically
adapting the radiation therapy.
Patients are treated on a Monday through Friday
basis, over a period of 5 to 6 weeks (approximately
45 Gy). Radiation therapists deliver the daily treat-
ments, and patients are seen by the nurse weekly to
monitor their condition. Patients may undergo routine
blood work, urinalysis, or other imaging throughout
the treatment process to monitor their progress and/
or modify their treatment plan. Port films are obtained
a minimum of once a week, and are reviewed by the
physician to ensure ongoing accuracy of treatment.
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Combined Radiation in Prostate Cancer
Resimulations are scheduled accordingly to modify
the treatment plan throughout the treatment process.
TREATMENT PROTOCOL OF DYNAMIC
ADAPTIVE RADIATION
THERAPY + BRACHYTHERAPY
Patients who are receiving combination therapy of
DART plus interstitial brachytherapy undergo approx-
imately 5 weeks of DART before the brachytherapy
procedure. When IMRT is combined with brachyther-
apy in this sequence, the prostatic brachytherapy serves
as a ‘‘boost’’ to prostate, with the doses of each treat-
ment modality moderated to achieve optimal coverage
to target tissue, while at the same time limiting rectal,
bladder, and urethral doses as well as sensitive penile
vessel anatomy. By targeting intraprostatic tumor sites
and its microscopic extensions of cells in the peripro-
static margin with the DART first, the brachytherapy
procedure has been more effective as a boost of higher
doses of radiation to specific sites, as well as addressing
possible migrating cancer cells in the regions outside
the prostate. Neither target tissue nor surrounding
margins are considered as receiving an ‘‘overdose’’ of
radiation with this method, but is merely dividing the
dose between two separate radiation delivery modali-
ties. An advantage to this combination is that the
surrounding prostate margin(s) is essentially sterilized
with appropriate tumoricidal doses, and cancer cells
are rendered nonviable when DART is used before
seed implantation, thus lessening the risk of inadvertent
dissemination of tumor cells during the procedure itself
(Dattoli et al., 2005). The decision for recommending
a combination protocol is based on a number of con-
siderations, including the need to decrease a markedly
enlarged prostate gland with the DART before seeding,
thereby potentially decreasing urinary symptoms; for
patients with intermediate- or high-risk features of
Gleason scores greater than or equal to 7, prostate spe-
cific antigen (PSA) 10.0 ng/mL or greater, or very low
PSA levels of less than 1.0 ng/mL; and/or any other ad-
verse clinical or pathologic feature such as perineural
invasion, prostatic capsule involvement with cancer, ex-
tracapsular extension, high volume disease, elevated
prostatic acid phosphatase (PAP), all of which are wor-
risome for micro- or macroscopic spread of disease be-
yond prostate (Dattoli et al., 2007).
INTERSTITIAL BRACHYTHERAPY
Contemporary permanent seed implant techniques with
supplemental external beam radiation therapy has
evolved dramatically over the past 15+ years at the
Dattoli Cancer Center. Technologic advancements
have included the use of high speed helical CT scan-
ners, 3D color Doppler imaging capabilities,
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Combined Radiation in Prostate Cancer JOURNAL OF RADIOLOGY NURSING
sophisticated computerized treatment planning soft-
ware with fusion imaging, refinements of implant tech-
niques (peripheral seed loading and extracapsular seed
placement), and the almost exclusive use of Pd-103
(Dattoli et al., 2005, 2006, 2007). Symptom manage-
ment improvements have been streamlined with the de-
velopment of aggressive medication/diet and patient
education protocols throughout the treatment process.
After these improvements, bowel and bladder toxicity
has been greatly reduced, erectile function better pre-
served, while the radiation doses have been optimized
for increased survival (Dattoli et al., 2007).
Transperineal implantation of permanent radioac-
tive seeds is performed on an outpatient basis in
a local hospital, preferably under epidural/spinal anes-
thesia, guided by ultrasound and fluoroscopy, with the
seeds being inserted through small hollow needles
where sharp trochars have been removed that were
used to insert the needle through the perineum into
the prostate tissue. The prostate itself is anchored dur-
ing the procedure to prevent prostate motion. The
procedure lasts approximately 45 to 60 min and is
performed with the patient supine and his legs in an
extended lithotomy position. Prostatic ultrasound al-
lows for real-time imaging and dynamic visualization
during the procedure, which gives a more precise im-
age of the prostate resulting in more accurate place-
ment of seeds. Proper bowel preparation, with liquid
diets, enemas, and laxatives the day before the proce-
dure, is imperative to clear the rectum of feces to fa-
cilitate optimal ultrasound imaging. Predetermined
coordinates from the computerized preplan designate
the placement of the needles into the prostate via
a custom perineal template that is anchored to the op-
erating room table, which stabilizes both the template
and rectal ultrasound probe. This preplan, performed
within 2 to 3 days of the procedure, provides for op-
timal placement of seeds, desired depth for seeds to be
placed, as well as desired dosing to target tissue. All
placement needles are removed once the seeds have
been placed. An indwelling urinary catheter is placed
before the seeding procedure for monitoring of urine
output. The catheter also provides access for continu-
ous or intermittent bladder irrigation as needed during
the hospital stay. Intraoperative management includes
the use of corticosteroids, antibiotics, alpha-blockers,
pain medications, and placement of antiembolic
hose. Patients are typically kept overnight for obser-
vation. Patients are rarely sent home with an indwell-
ing catheter. Subsequent quality assurance measures
include postimplant dosimetry performed on day 1
postseeding through CT analysis to confirm proper
placement and appropriate radiation dose coverage
of target tissue.
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Cash et al
SYMPTOM MANAGEMENT/PATIENT
EDUCATION
Nursing management of the patient undergoing combi-
nation DART and interstitial brachytherapy is primarily
related to symptom management postseeding, and is
multifaceted (see Table 1) (Cash & Dattoli, 1997).
Patient care involves education of the entire treatment
process, and is not considered separate treatment regi-
mens, but more a continuing process. Symptoms related
to the 5-week course of DART are minimal urinary and
bowel irritability when prostate region treated. These do
not require any prescriptive intervention, but possibly
over the counter and supportive remedies as a result of
the decreased incidence of side effects associated with
DART and the attenuated dose delivered in preparation
for the seeding procedure. In cases of abdominal lymph
nodes being included in the treatment fields (as identified
by Combidex study; see Figure 5), scheduled oral anti-
emetics are used around the daily treatment the first
week of treatment and as needed thereafter. There is
a very small incidence of nausea associated with this
treatment regimen because of the precision of the fusion
techniques used in the treatment planning process for
this anatomy. Education of the DART treatment plan-
ning and delivery process will lessen patient anxieties
and dispel misconceptions that it is an experimental ther-
apy, reinforced by the fact that it is covered by Medicare
and most other insurance plans. Other education is di-
rected at compliance with daily treatment schedule, adher-
ence of any dietary recommendations made for urinary
and/or bowel changes, and confirmation of date of
seed implant (and preoperative medical clearance if indi-
cated), which is typically performed 2 to 3 weeks on com-
pletion of the DART. Patients are capable of performing
all activities of daily living and most exercise programs
throughout the DART and brachytherapy treatments.
Pretreatment and ongoing assessments of urinary,
bowel, and erectile functions are of paramount im-
portance to evaluate patient response to therapy.
Prebrachytherapy education involves the necessity of
anesthetic-related pretests, the procedure itself, and
postbrachytherapy expectations, including radiation
safety precautions (half life of Pd-103 is 17 days).
Long-standing radiation safety policies are institution
specific; however, under our protocol there is no re-
quirement of straining the urine and/or retrieval of
seeds, therefore, the patient is educated that neither
stool nor urine is radioactive, only the seeds emit radi-
ation. Discharge education is crucial to lessen patient
anxieties and reinforce expectations of anticipated
side effects. Patients will be discharged with instruc-
tions for diet, medications, and activity, as well as given
prescriptions and an appointment for follow-up
evaluation, the first of which is within 24 hr of the
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Cash et al JOURNAL OF RADIOLOGY NURSING Combined Radiation in Prostate Cancer

Table 1. Prostate symptom management protocol

Side effect Symptoms Interventions
Skin Acute  Bruising of scrotum/perineum  Apply ice packs to perineum as needed first 24 hr; to re-
related to brachytherapy duce swelling
procedure  Sitz baths two to three times daily; as a comfort measure
 Tenderness/discomfort  Avoid hot water temperature O100 as a comfort measure
 Hematoma  OTC analgesics (ibuprofen, naproxen, acetaminophen);
as a comfort measure

Urinary Acute  Frequency  Alpha blockers (titrate dose)

 Urgency Tamsulosin 0.4 mg QD-BID
 Hesitancy Doxazosin 1e8 mg QD
 Hematuria Terazosin 1e10 mg QD
 Dysuria Alfuzosin 10 mg QD
 Bladder spasms (uncommon) Educate patient about potential hypotensive episodes,
 Incomplete bladder emptying dizziness, GI upset, peripheral edema
 Nocturia  Short-term steroids vs. NSAIDS (OTC/prescriptive)
 Weakened stream Educate about peripheral edema, blood pressure
changes, blood sugar changes
 Avoid dietary bladder irritants (coffee, tea, alcohol, cit-
rus); as a comfort measure
 Increase water intake to maintain urine dilution and de-
crease dysuria
 Limit fluids after dark to reduce nocturia
 Antispasmodics (for bladder spasms)
Tolterodine tartrate 2e4 mg QD
Oxybutynin 5e15 mg QD
Belladonna and opium suppository 15a or 16a Q12 hr
Educate patient about dry mouth, constipation, somno-
lence, risk of urinary retention/infection
 Urinary antiseptics (combination products that include
methylene blue) Educate patient about discoloration
of urine, rash, flushing of skin, dizziness
 Urinary alkalinizers
Potassium citrate, sodium bicarbonate. Educate patient
about GI upset, bowel changes, electrolyte disturbance
 Activity modification: Avoid bicycle or motorcycle rid-
ing, long periods of sitting
 Urinary retention  Perform the voiding trial
 Phenoxybenzamine hydrochloride TID to increase urine
flow. Educate patient about hypotensive episodes, bowel
changes, flushing of skin
 Short-term steroids/NSAIDS
 Indwelling catheter vs. teaching intermittent self
catheterization
Late  Dysuria  Avoid dietary bladder irritants
 Hematuria  Urinary alkalinizers
 Increase water intake
 Pentosin polysulfate sodium 100 mg TID for 6e12
months to reduce symptoms of chronic dysuria
Educate patient about GI upset, bowel changes
 Antidepressants/anxiolytic-amitriptyline hydrochloride
25e50 mg QHS
 Alprazolam 0.25e0.5 mg QHS
Educate patient about drowsiness, dizziness, and caution
when driving and/or operating heavy equipment
 Dimethylsulfoxide bladder installations for chronic dys-
uria/cystitis not remedied by other short-term medications
Educate patient about garlic odor on breath and skin,
possible transient discomfort during installation
 Other workup: urine cytology, IVP, cystoscopy, CT uro-
gram to determine etiology of chronic hematuria

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Combined Radiation in Prostate Cancer JOURNAL OF RADIOLOGY NURSING Cash et al

Table 1. Continued
Side effect Symptoms Interventions
 If workup negative for bladder or kidney disease, insti-
tute finasteride 5 mg or dutasteride 0.5 mg
QD  6e12 months
Educate patient about decreased potency, libido, dimin-
ishment of ejaculate and depression of PSA level

Rectal Acute  Bowel changes  Low residue diet

 Looseness/constipation
 Frequency
 Urgency
 Painless rectal bleeding
 Rectal irritation
 Sitz baths as needed
 Sucralfate 1 gm 4e6  days to regulate bowel consis-
tency and protect rectal mucosa
Educate patient about GI upset
 Hydrocortisone or mesalamine suppository 1e2  days to
reduce rectal discomfort. To be used 6 weeks or less
Educate patient about bowel changes
 Nonprescriptive fiber laxatives to reduce incidence of di-
arrhea or constipation
 Avoidance of rectal manipulation/colonoscopy for 8e12
months to reduce aggravating effects to existing
rectal symptoms

Late  Proctitis  Mesalamine suppository QD

 Bleeding  Sucralfate 1 gm 4e6  days
 Rectal discomfort  Pentoxifylline 400 mg TID to reduce incidence of rectal
bleeding and aid in healing of tissue
Educate patient about GI upset, dizziness, headache
 Colonoscopy to evaluate chronic rectal bleeding not
remedied by medications taken for 3e4 months
 Laser coagulation to remedy chronic rectal bleeding not
remedied by medications

Erectile dysfunction Acute and late  Decreased ability  Address psychogenic causes (i.e., stress, marital prob-
to maintain erection lems, cancer diagnosis, job responsibilities, loss
of job). Professional referral as indicated
 PDE5 inhibitors (sildenafil, vardenafil, tadalafil)
Educate patient about contraindication of nitrates, vi-
sual changes, headache, nasal stuffiness, possible interac-
tion with alpha blockers, prolonged erection
 Alprostadil intraurethral suppository
Educate patient about penile irritation, urethritis
 Intracavernosal alprostadil self-injections
Educate patient about penile pain, prolonged erection,
hematoma
 Vacuum erection device (requires prescription)
 OTC supplements (no testosterone derivative). Supple-
ments do not increase testosterone levels
but enhance body’s ability to use existing testosterone
levels more efficiently

OTC, over the counter; QD, once daily; BID, twice daily; GI, gastrointestinal; NSAIDS, non-steroidal anti-inflammatory drugs; TID, three
times daily; QHS, at night time; IVP, intravenous pyelogram. Courtesy of Dattoli Cancer Center, Sarasota, Florida (Physician Desk Reference:
Urology Prescribing Guide, 2004).

procedure, then 3 months postprocedure. Education younger than 2 years should not sit directly on the lap
for radiation safety precautions with Pd-103 is minimal of the patient for any extended period of time. Pregnant
in that there is no precaution for proximity to adults women should avoid direct contact with lower pelvis of
(may sleep in same bed, have sexual activity). Children patient (or sitting directly on lap) for any extended

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Cash et al JOURNAL OF RADIOLOGY NURSING Combined Radiation in Prostate Cancer

period of time. Sexual activity is permissible immedi-

ately after seeding; however, a condom is recommended
for the first 3 to 4 weeks, or first two to three times of
sexual activity because of possibility of a seed being
passed through ejaculate. No straining of urine is nec-
essary. MRIs are not contraindicated in that Pd-103
seeds are non-ferromagnetic. When necessary, patients
are given a radiation identification card that contains
their specific treatment information regarding the radi-
ation dose of the seeds, when traveling through airports
that have highly sensitive radiation sensors.
Emotional support is also an important aspect of
care throughout the treatment process. Assessments
of associated emotional factors, such as anxiety, de-
pression, relationship difficulties, financial hardships, Figure 6. Mr. T dynamic adaptive radiation therapy dosimetry for
fear, and grief are considered to determine all appropri- treatment of two (1 mm) obturator lymph nodes only. Courtesy of
ate care needs of the patient, and identify any compli- Dattoli Cancer Center, Sarasota, Florida.
ance issues with treatment recommendations. Patient
education in all aspects of the treatment process,
indicated). The dose was initially chosen because early
DART, and brachytherapy focuses on resolution of
radiobiologic evaluations of EBRT + Pd-103 were not
knowledge deficits, alleviation of misconceptions and
characterized in the latter 1980s because Pd-103 was
fears of patient and family and/or significant other,
relatively new. These early physics analysis (performed
and reinforcement of supportive measures to manage
while Dr. Michael Dattoli practiced at Memorial Sloan
anticipated side effects.
Kettering in the latter 1980s) suggested that the EBRT
dose given along with an attenuated dose of Pd-103 of
POSTSEED DYNAMIC ADAPTIVE 8,000 to 9,000 cGy would not exceed rectal, urethral, or
RADIATION THERAPY bladder tolerances.
The dose of 41 to 45 Gy, however, is insufficient in
Traditionally, patients at the Dattoli Cancer Center are
most cases to eradicate microscopic, and especially po-
treated to an initial dose level of approximately 41 to
tentially macroscopic cancer cells, at a distance from
45 Gy before interstitial brachytherapy. This initial
the prostate gland. For this reason, after the implant
dose level typically covers not only the prostate, but
procedure, our physics/dosimetry staff generates pre-
also potentially surrounding target tissues including,
cise isodose curves eminating from the seed implant
but not limited to, seminal vesicles, periprostatic lymph
(both inside and outside the gland). The dose projected
nodes, obturator lymph nodes, and internal iliac lymph
by the seeds to a given distance from the prostate can
nodes (even common iliac and para-aortic nodes as
then be precisely calculated up to the point of near
complete decay of the Pd-103 at the 3-month mark sta-
tus postseeding. For this reason, most patients return
approximately 3-month status postseeding (at the point
of near decay of the isotope) to receive additional treat-
ments to peripheral target tissue sites while blocking the
prostate, bladder, rectum, and proximal penile tissues.
The individualization of the dose is multifactorial,
which may include taking into account the size of the
gland, stage, Gleason score, PSA, PAP, location of tu-
mor, prior TURP/TUIP, size of tumor(s), etc. The phy-
sician will designate the optimal dose he would like to
have to target points at distance from the gland. Subse-
quent physics analysis will determine the number of
treatments necessary to achieve the desired dose (typi-
cally 5 to 10 treatments). It is to be noted that this
Figure 5. Combidex computed tomography imaging for treatment methodology has been in place since the mid 1990s,
planning of abdominal/pelvic lymph nodes. Courtesy Dattoli Can- although, is now more liberally used with DART in
cer Center, Sarasota, Florida. view of the safety associated with dose escalation.

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Combined Radiation in Prostate Cancer JOURNAL OF RADIOLOGY NURSING
CONCLUSION
There have been significant technologic advancements
over the past 20 years in not only diagnostic imaging
techniques and radiation therapy treatment planning
protocols, but in the delivery systems as well. Subse-
quent higher cure rates and decreased side effects
have led patients to seek those therapies that will give
them the highest likelihood of cure and best quality
of life by using a combination protocol of two state-
of-the-art forms of radiation therapy, DART, and
transperineal interstitial brachytherapy. Patients have
the added security of addressing possible extracapsular
extension of cancer beyond prostate while experiencing
little to no additional side effects, thus providing a high-
er quality of life. Nurses are in a unique position to
enhance patient education through not only discussion
of available novel treatment options at experienced
treatment centers in a pretreatment setting, but also
promote an encouraging, positive attitude about effec-
tive side effect management throughout the treatment
and posttherapy periods.
CASE STUDY
Mr. T. is a 55-year-old white male who was originally
diagnosed in September 2006 with a prostate malig-
nancy associated with a bilobar combined Gleason
3 + 3 [ 6, highest PSA of 5.5 ng/mL (range, 0e4.0),
normal PAP of 1.73 ng/mL (range, 0e3.5 ng/mL), and
reportedly normal digital rectal exam. Subsequent stag-
ing studies of endorectal MRI prostate and 18F-Flour-
ide PET/CT scan did not demonstrate any evidence of
distant metastatic disease to bone or visceral areas,
but only higher tumor volume within prostate, with cap-
sule irregularity at right midgland and base, and proba-
ble involvement of neurovascular bundle on that side.
Mr. T. underwent definitive DART therapy to a dose
of 4,500 cGy targeting prostate, periprostatic tissues
and first station draining lymph nodes delivered over
25 treatment days before undergoing interstitial brachy-
therapy with the Pd-103 isotope to a dose of 9,000 cGy,
with adjunctive hormonal therapies (oral and inject-
able) and bone integrity agents used throughout the
treatment course. Postseed dosimetric analysis indi-
cated optimal dosing to periprostatic margin and imme-
diate adjacent lymph nodes to be at 5,940 cGy,
therefore patient received an additional 1,440 cGy
(with prostate blocked) over 8 treatment days approxi-
mately 90 days postseeding. Mr. T. had an excellent re-
sponse to therapy with minimal urinary, bowel, and
erectile morbidities, and a decrease of PSA to
0.020 ng/mL, as of April 2007. However, because of
VOLUME 28 ISSUE 3 www.radiologynursing.org
Cash et al
the high volume nature of his cancer, he elected to un-
dergo Combidex (USPIO) testing, outside of the United
States in Europe, in May 2007 to further evaluate total
body lymph node status. Unfortunately, two metastatic
lymph nodes were identified in the left obturator region
(both 1 mm in diameter; see Figure 6). Patient elected to
undergo further targeted therapy to these identified
lymph nodes, and subsequently received 6,600 cGy to
involved lymph nodes, completed August 2007. Patient
tolerated the lymph node-specific radiation extremely
well with no untoward side effects. Most recent PSA
of November 2008 is !0.003 ng/mL, with no radio-
graphic evidence of residual or recurrent disease. Uri-
nary, bowel, and erectile functions are stabilizing to
pretreatment levels with the use of prescriptive and
over-the-counter medications and supplements, and pa-
tient reports a fully active performance status.
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