What is your approach for a brachytherapy boost in prostate cancer patients with extracapsular extension?

In general for patients with documented extracapsular extension, the combination of external beam radiation along with brachytherapy is a very appropriate treatment intervention. For such patients, we generally initiate treatment with the brachytherapy and make sure that seed placement is well covering the capsular area near the documented extracapsular extension. Isodose curves from the implant generally demonstrate at least a 5 mm radius of dose beyond the capsule and external beam radiotherapy would then follow covering the prostate and of course the region of extracapsular disease. So our approach is to utilize the implant first and then tailor the next phase of therapy, namely EBRT which we would actually call our boost. The EBRT phase...

In the days before MRI, there was a common concern that if one tried to treat established extracapsular disease with a brachy boost, one risked undertreating the disease. However, with high quality multiparametric MRI this concern is dramatically reduced. As a result, I routinely treat patients with limited extracapsular disease with a brachy boost, as long as all the disease seen on MRI is "implantable." Implantable to me means able to reliably cover the disease. In my experience, there are only rare cases in which I do not feel LDR brachythepray can achieve this (although HDR is also reasonable in these cases). In particular, seminal vesicle invasion is an area of concern regarding the ability to stably place seeds. Implanting the base of...