The importance of dose escalation, has been well documented, high radiation doses improve biochemical and clinical results for prostate cancer patients [4–7]. Kuban et al. reported an improvement in biochemical control of 78% for doses of 78 Gy, vs 59% for the 70 Gy arm .
The combination of EBRT and HDR brachytherapy allows the delivery of very high biologic equivalent doses to the prostate not achievable by intensity modulated treatments (IMRT) with image guided adaptive radiotherapy (IGART) techniques.
Based on these principles, since June 1998 we have been performing High dose rate brachytherapy boost for prostate cancer.
The high risk group in our report represented 100% of the patient population and the results of this combined therapy (EBRT + HDR boost) at 10-years are promising, with a biochemical control rate of 78%, cause specific survival of 93%, overall survival of 78%, and freedom from distant metastases of 86%. The 10-year actuarial biochemical control in patients classified as high risk only by Gleason and/or PSA, no by T-stage, was 86% for patients with two intermediate risk criteria, 73% with one high risk criteria and 71% for patients with 2 high risk criteria.
The results presented here for high risk group of patients, are superior to the series on radical prostatectomy and standard radiotherapy therapies published in the literature.
The Memorial Sloan Kettering reported in unfavorable risk cases 5-year PSA relapse-free survival rate for 81 Gy the 67% versus 43% for 75.6 Gy and 21% for 64.8 to 70.2 Gy .
Hanks et al. observed that patients with unfavorable disease (Gleason ≥ 8 and PSA ≥ 20 ng/ml) treated with three-dimensional conformal radiation therapy (3D CRT) a dose of 76 Gy achieved only 26% in the 5-year PSA relapse-free survival rate . Dearnaley et al., Sathya et al. and Zietman et al. reported similar results [16–18].
Our study shows an advantage to high-dose over conventional-dose conformal radiation in terms of freedom from biochemical failure for men with high risk prostate cancer.
Similar observations were reported by other institutions using conformal high dose rate brachytherapy. Martinez et al.  reported 5-year actuarial biochemical control rate of 85% for patients with 1 poor prognostic factor, 75% for 2 and 50% for all 3. Galalae et al. reported 8-year bNED survival rate (free of clinical or biochemical evidence of disease) in the high-risk prognostic group of 64% . Dattoli et al.  and Mate et al.  reported similar results. A recent report Stock et al. reported 8-year actuarial biochemical control rate of 73% for patients with Gleason score 8-10 prostate cancer .
On the other hand, surgery is not the best treatment for high risk patients. Catalona et al.  Studied 3478 men with tumors of clinical stages T1-T3 N0 M0 followed for an average of 65 months after radical retropubic prostatectomy. Actuarial 10-year biochemical progression-free probabilities were 59% for cT2b-c, 15% for cT3 disease and 50% for Gleason sum 4 + 3 and 32% for Gleason 8-10 disease. Actuarial 10-year biochemical progression-free probabilities were 49% for PSA greater than 10 ng/ml.
The Johns Hopkins group reported similar results [25, 26]. Kermen and Miles  reported a 5-year bNED rate of 54% after radical prostatectomy. Surgery results of Multi-institutional pooled analysis in men with locally advanced prostate cancer  published a 2.2-year of biochemical control rate of 16%.
The Memorial Sloan Kettering Center group analyzed the oncologic outcome after laparoscopy radical prostatectomy, 8-year probably of freedom from progression for high risk cancer was 53% .
In patients with high risk prostate cancer, the 10-year biochemical control was 16-54% for prostatectomy treated patients compared to 86-71% for our combined conformal EBRT with HDR boost.
Despite the wide diffusion of laparoscopic radical prostatectomy and robot-assisted laparoscopic radical prostatectomy, only few studies comparing the results of these techniques with the retropubic radical prostatectomy. The systematic review of the literature performed by Ficarra et al. , were not sufficient to prove the superiority of any surgical approach in terms of functional and oncologic outcomes.
Gleason score was in our paper the most significant predictor of biochemical failure and developing distant metastases. Other groups reported similar results [19, 21, 23].
Hormonal ablative treatment did not improved the outcome in the present analysis, this corroborate the findings of previous studies [21, 30, 31]. All prospective, randomized trials show a positive outcome of adding hormonal therapy [32–34] but these studies were done with low radiation doses (68-70 Gy), the BED equivalent of 70 Gy was 129 Gy, much lower than BED in our series (BED dose ranged from 292 Gy to 366 Gy).
The low toxicity observed in our series, despite the high radiation doses delivered, was the result of carefully executed real-time brachytherapy technique . Urinary and Gastrointestinal complications rates were in concordance with the experience of other institutions using conformal high doses rate brachytherapy [19–22] and favourably with other 3-D conformal radiotherapy escalating series [14, 15].
The cause specific survival at 10-year of 93% and biochemical control of 78% demonstrate the effectiveness of the described radiotherapy regime and the high curative potential of this therapy protocol.