3 ng/mL); MRI revealed seminal vesicle invasion and metastatic

left iliac and paraaortic nodal swelling. Hormonal therapy with 100 mg of chlormadinone acetate (progesterone analog) daily was immediately started and continued at the same dosage. Luteinizing hormone-releasing hormone therapy caused allergic responses and was not used. After 1 year, the patient noticed macroscopic hematuria. His PSA level had reelevated (4.8 ng/mL), and X-ray CT examination revealed an increase in the prostatic PD-0332991 ic50 tumor size. The patient underwent initial radiotherapy by external beam: a total of 70.4 Gy in 1.8–2.0 Gy fractions for the prostate and seminal vesicles and a total of 58.4 Gy for the metastatic left iliac node and paraaortic lymph nodes. These totals were a summation of a wide-field treatment of 50.4 Gy in 1.8 Gy fractions covering the whole pelvis and paraaortic area and boost treatments (Fig. 1b). One year later, his PSA level had reelevated (1.13 ng/mL),

and recurrent PALNM of 9.75 mL in volume was detected. The this website patient was referred to our clinic for reirradiation and chose to undergo IMRT-IGRT but changed his mind before treatment and requested brachytherapy instead. Before processing each treatment, informed consent was obtained from the patient. Treatments were performed with standard institutional approval. Using thin slice X-ray CT images (LightSpeed 16; GE Healthcare, Buckinghamshire, UK) and Brainscan (version 5.2; Brainlab AG, Feldkirchen,

Germany), an IMRT plan was created to deliver 60 Gy in 3 Gy per fraction for 4 Mephenoxalone weeks. The spinal cord and kidneys were the critical organs previously involved in the 50.4-Gy field. Forty milliliters of 0.16% sodium hyaluronate was prepared with saline in advance, using a commercially available high-molecular hyaluronate (3.4 million daltons of median molecular weight, 2.2 million of viscosity molecular size; Suvenyl; Chugai/Roche, Tokyo, Japan). This hyaluronate is a native-type bioproduct. Contrast medium (2 mL of iopamiron 300 mg I/mL; Bayer Healthcare, Leverkusen, Germany) was added to the gel. Treatment was performed at the outpatient clinic under awake sedation with 25 mg of hydroxyzine pamoate and 5 mg of intravenous diazepam. The patient was able to report his sensations during the procedure. Electrocardiogram, arterial pressure of oxygen, respiration, and blood pressure were monitored. A 21-gauge steepled needle with side holes (improved shape for straight-line insertion) was used for minimally invasive gel injection. Microselectron system applicator needles (1.1 mm in external diameter and 20 cm in length) were inserted to the target under X-ray CT guidance (10). The CT-guided HGI procedure took approximately 30 min. The space created by the gel injection was observed as an area of contrast enhancement around the target (Fig. 2). Injection of the gel created a spacer approximately 10-mm thick.