Spatial Dosimetric-Based Prediction of Long-Term Urinary Toxicity After Permanent Prostate Brachytherapy

To explore the correlation between spatial dose distribution and post-implant urinary toxicity, aiming to assist decision making in low-dose-rate (LDR) treatment planning, thereby improving patient outcomes.

Eighty-five prostate LDR patients with >12-month follow-up were included. Patient-reported urinary toxicity was collected prospectively using the International Prostate Symptom Score (IPSS) questionnaire, from before implant (baseline) to post-implant follow-up. Patients were then grouped into those whose symptom scores returned to ≤2 points above baseline by 12 months (no long-term toxicity) vs. those who did not (long-term toxicity). A total of 106 features were extracted for each patient, including principal components of dose-volume histograms (DVHs) from multiple prostate subzones, the whole prostate and urethra, along with baseline IPSS, implantation characteristics, and additional DVH indicators for the prostate and the urethra. A machine learning (ML) model incorporating backward feature selection algorithm was developed to predict long-term toxicity status, using a shuffle-and-split validation strategy for model evaluation during feature selection. A univariate statistical analysis was conducted on the model's selected features.

Out of 85 patients, 41 (48%) had long-term urinary toxicity. Seven features were selected during model training, including baseline IPSS and six dosimetric features from several prostate subzones primarily located in the posterior prostate. The model achieved a high mean area under the receiver operating characteristic curve (AUC) of 0.81, with a balanced sensitivity and specificity of 0.78 by adjusting the probability threshold. In univariate analysis, only baseline IPSS and one selected dose feature were significantly correlated with long-term toxicity with AUC < 0.71.

The proposed ML model, integrating baseline IPSS and spatial dosimetric features, effectively predicts long-term urinary toxicity after prostate LDR. This approach offers a practical method for risk stratification, allowing clinicians to identify patients at elevated risk and prioritize them for targeted preventative measures and closer follow-up.