Use of 5-alpha-reductase inhibitors as alternatives to luteinizing-hormone releasing hormone (LHRH) analogues or anti-androgens for prostate downsizing prior to brachytherapy

Publication date: Available online 10 October 2017
Source:Practical Radiation Oncology
Author(s): Hee Joon Bae, Omar Mian, Dhananjay Vaidya, Theodore L. DeWeese, Daniel Y. Song
IntroductionProstate hypertrophy, median lobe hypertrophy (MLH) and pubic arch interference (PAI) are relative contraindications to brachytherapy due to potential morbidity and technical considerations. GnRH analogues or non-steroidal anti-androgens are currently utilized to achieve prostatic downsizing prior to brachytherapy. However, such agents have been associated with effects on body habitus, metabolism, and quality of life. In contrast, 5-alpha reductase inhibitors (5-ARI) are far less frequently associated with these morbidities.Materials and MethodsPatients with large gland size, MLH or PAI were offered 5-ARI therapy. Repeat TRUS was performed at 3–4months, followed by brachytherapy if resolution achieved. If downsizing was inadequate, then patients were offered continuation of 5-ARI for additional 3months, or GnRH agonist or antiandrogen therapy, or other curative treatment.ResultsOf 59 patients with follow-up available, 42 (71%) were deemed to have adequate downsizing; 37 (63%) after 3–4months of 5-ARI, and 5 (8%) after 7–8months. Seventeen patients (29%) received other treatments due to inadequate effect. Median volume reduction was 20%.Of 41 patients undergoing brachytherapy, 4 (9.7%) required temporary catheterization due to obstruction. Median follow-up after implantation was 25months (1–64months). Median time for return to IPSS ≤5 of baseline score was 7months (IQR 6–13months). All but 1 patient who received brachytherapy remain biochemically controlled.Discussion5-ARI monotherapy is an alternative for downsizing in patients with hypertrophy or PAI, with over 70% achieving adequate downsizing without use of GnRH analogues or antiandrogens. Patients who received brachytherapy experienced typical rates of post-implant urinary morbidity.SummaryAndrogen suppression in the form of luteinizing-hormone releasing hormone analogues or anti-androgens are currently utilized prior to brachytherapy for patients who have prostate hypertrophy or pubic arch interference. However, these agents have undesirable side effect profiles and have been associated with increased risk of cardiac mortality. We describe our experience with utilizing 5-alpha-reductase inhibitors alone as an alternative for this indication.



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