case_images: PMC10758911_01
case_images: Changes in PSA after salvage fLDR brachytherapy and the locations of the positive/negative biopsy cores. (a) The patient was diagnosed with BCR, with a PSA level of 5.08 ng/mL, and was performed re-salvage fLDR brachytherapy, with a PSA level of 7.88 ng/mL. At 7 months after salvage fLDR brachytherapy, the patient's PSA level decreased to 0.465 ng/mL (nadir), before gradually increasing to 3.4 ng/mL thereafter. At the 20-month follow-up after re-salvage fLDR brachytherapy, the patient's PSA level decreased to 0.044 ng/mL and has remained at low levels. (b) The locations of the positive/negative biopsy cores before salvage fLDR brachytherapy. Of the 22 biopsy cores, one core with a suspected LR lesion on MRI revealed PCa. (c) The locations of the positive/negative biopsy cores before re-salvage fLDR brachytherapy. Of the 17 biopsy cores, two cores with a suspected LR lesion on MRI revealed PCa. The cores that were biopsied within the target lesion of the salvage fLDR brachytherapy did not reveal PCa.
case_images: IJU5-7-68-g003.jpg
case_images: PMC10758911_01_IJU5-7-68-g003.jpg
case_images: iju512670-fig-0001
case_images: A 77-year-old man, who had received carbon ion radiotherapy for localized PCa 12 years prior (Fig. 1a), was diagnosed with BCR (as defined by the Phoenix criteria). Subsequently, we performed a combination MRI-targeted and systematic prostate biopsy, which revealed PCa with a GS of 4 + 4 (Fig. 1b). We focally implanted 15 iodine-125 seeds (Brachysource ), referring to ultrasound images fused with MRI images; the distribution of seeds on X-ray after implantation and the dosimetric parameters are shown in Figure 3b and Table 1, respectively. After salvage fLDR brachytherapy, the PSA level declined briefly but then increased to BCR level (Fig. 1a). The combination prostate biopsy was repeated, finding PCa with a GS of 4 + 4 (Fig. 1c). After re-salvage fLDR brachytherapy, the PSA level significantly decreased and has remained at low levels (Fig. 1a).
case_images: MRI images of LR. (a) MRI before salvage fLDR brachytherapy: LR (yellow arrow) was suspected on MRI because of the presence of a low signal intensity on T2-weighted images and a high signal intensity on diffusion-weighted imaging. (b) MRI before re-salvage fLDR brachytherapy: LR (orange arrow), distant from the site treated with fLDR brachytherapy, was suspected on MRI.
case_images: IJU5-7-68-g002.jpg
case_images: PMC10758911_01_IJU5-7-68-g002.jpg
case_images: iju512670-fig-0002
case_images: Although no distant recurrence was identified by CT and bone scintigraphy, LR was suspected by MRI (Fig. 2a). We next performed imaging examinations, which revealed a suspected recurrent lesion located at a different site from the previous recurrence without distant recurrence (Fig. 2b).
case_images: Dose distributions and pelvic X-rays of the seed implantations. The red, green, blue, light blue, and white lines indicate prostate, urethra, rectum, PTV, and tumor based on MRI, respectively. (a) Intra-implant dosimetry of salvage fLDR brachytherapy on transrectal ultrasound. The PTV was defined as the tumor area plus a 3-mm margin on the anterior, posterior, right, and left sides based on multiparametric 3 Tesla MRI. (b) Pelvic X-ray of the 15 seeds (Brachysource ) that were implanted in salvage fLDR brachytherapy. (c) Pelvic CT of the seeds (Brachysource ) that were implanted in the salvage fLDR brachytherapy. Brachysource  was displayed as an elongated high-density area on the CT. (d) Intra-implant dosimetry of re-salvage fLDR brachytherapy on transrectal ultrasound. The PTV included the tumor site plus a 3-mm margin on the anterior, right, and left sides based on multiparametric 3 Tesla MRI, but excluded the posterior margin to reduce the radiation dose to the urethra. (e) Pelvic X-ray of the 30 seeds (TheraStrand-SL ) that were implanted in re-salvage fLDR brachytherapy, in addition to the 15 seeds implanted in salvage fLDR brachytherapy. (f) Pelvic CT of the seeds (TheraStrand-SL ) that were implanted in the re-salvage fLDR brachytherapy, in addition to other types of seeds that were implanted in the salvage fLDR brachytherapy. TheraStrand-SL  was displayed as a thicker and rounder high-density area than Brachysource  on the CT.
case_images: IJU5-7-68-g001.jpg
case_images: PMC10758911_01_IJU5-7-68-g001.jpg
case_images: iju512670-fig-0003
case_images: We performed salvage fLDR brachytherapy using the VariSeed  system and a real-time ultrasound-guided technique (Fig. 3a). We focally implanted 15 iodine-125 seeds (Brachysource ), referring to ultrasound images fused with MRI images; the distribution of seeds on X-ray after implantation and the dosimetric parameters are shown in Figure 3b and Table 1, respectively. We performed re-salvage fLDR brachytherapy for the LR (Fig. 3d). We implanted 30 iodine-125 seeds (TheraStrand-SL ), which were different from those used in the previous salvage fLDR brachytherapy (Fig. 3e; Table 1).