There is good evidence in the literature that HDR monotherapy is a safe and effective treatment for prostate cancer. The large doses per fraction Galunisertib take advantage of the radiobiology (low alpha/beta ratio) to potentially render HDR the most efficient and convenient form of radiation therapy. Although patients with early- and intermediate-risk groups are optimal candidates, patients with high-risk group disease also have reported excellent outcomes with HDR monotherapy when compared with other treatment methods. HDR delivers a therapeutic margin of safety for patients with periprostatic or

seminal vesicle extension. Prostate HDR brachytherapy is versatile; it can be used as monotherapy, monotherapy salvage, combined with EBRT, or it can be used as an adjunct to systemic treatment to reduce disease burden to improve remission rates. HDR dosimetry is prospective (done before source delivery), consistent, and reliable because it is not impacted by setup errors, interfraction and intrafraction organ motion, prostate swelling, or shrinkage during treatment delivery. Furthermore,

target coverage is verifiable through pretreatment image guidance designed to avoid unrecognized “dwell position displacement”. Dose modulation of the stepping source can compensate for catheter spacing and volume discrepancies by using “optimization” programs so that dose painting and dose sculpting can be done for dose adjustments within the target boundaries. Such capacities make HDR an excellent choice for monotherapy or for EBRT boost; and in properly selected cases, it can be used to reduce or eliminate radiation AZD5363 purchase to parts of the prostate (focal therapy or dose de-escalation). These measures may enhance the therapeutic index by delivery of dose in proportion to the extent and severity of the disease, and it can aminophylline reduce morbidity by limiting dose to normal structures. The excellent results of HDR prostate brachytherapy coupled with the radiobiological advantage of higher doses per fraction especially

in tumors with low alpha/beta have prompted clinical trials of stereotactic body radiation therapy (SBRT) to deliver the full course of external beam therapy in 4–6 fractions like HDR [58], [59], [60], [61], [62], [63], [64] and [65]. Fuller et al. (66) performed an analysis to determine if SBRT could reproduce the dosimetry achieved with HDR brachytherapy in what was termed “virtual HDR”. The real stereotactic plans were compared with “simulated” HDR plans in which the theoretical brachytherapy trajectories were inserted on the same contours used for SBRT planning. Although the V125 and V150 were significantly higher with HDR, the urethral doses were lower with the SBRT plans suggesting to the authors that SBRT may limit urethra doses more effectively than HDR. Although such plan comparisons are valuable, they are highly dependent on the treatment planning process.