Radiotherapy after prostatectomy: prognosis, timing and outcomes
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Biochemical disease-free survival following radical prostatectomy can be improved with the use of adjuvant and salvage radiotherapy. However, there is a lack of consensus over the ideal timing to start adjuvant and salvage radiotherapy after surgery. The literature in relation to adjuvant and salvage radiotherapy following radical prostatectomy was reviewed, focusing specifically on the prognostic factors that influence the need for postoperative radiotherapy, outcomes following adjuvant and salvage radiotherapy and potential side effects. Post-surgery prognostic factors can be useful in identifying patients early on who may benefit from adjuvant radiotherapy. While there is literature examining the role of radiotherapy following radical prostatectomy, few dedicated trials investigate this area thoroughly.Keywords:
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We compared the treatment outcomes of salvage radical prostatectomy and salvage cryotherapy for patients with locally recurrent prostate cancer after initial radiation therapy.We retrospectively reviewed the medical records of patients who underwent salvage radical prostatectomy at the Mayo Clinic between 1990 and 1999, and those who underwent salvage cryotherapy at M. D. Anderson Cancer Center between 1992 and 1995. Eligibility criteria were prostate specific antigen less than 10 ng/ml, post-radiation therapy biopsy showing Gleason score 8 or less and prior radiation therapy alone without pre-salvage or post-salvage hormonal therapy. We assessed the rates of biochemical disease-free survival, disease specific survival and overall survival in each group. Biochemical failure was assessed using the 2 definitions of 1) prostate specific antigen greater than 0.4 ng/ml and 2) 2 increases above the nadir prostate specific antigen.Mean followup was 7.8 years for the salvage radical prostatectomy group and 5.5 years for the salvage cryotherapy group. Compared to salvage cryotherapy, salvage radical prostatectomy resulted in superior biochemical disease-free survival by both definitions of biochemical failure (prostate specific antigen greater than 0.4 ng/ml, salvage cryotherapy 21% vs salvage radical prostatectomy 61% at 5 years, p <0.001; 2 increases above nadir with salvage cryotherapy 42% vs salvage radical prostatectomy 66% at 5 years, p = 0.002) and in superior overall survival (at 5 years salvage cryotherapy 85% vs salvage radical prostatectomy 95%, p = 0.001). There was no significant difference in disease specific survival (at 5 years salvage cryotherapy 96% vs salvage radical prostatectomy 98%, p = 0.283). After adjusting for post-radiation therapy biopsy Gleason sum and pre-salvage treatment serum prostate specific antigen on multivariate analysis salvage radical prostatectomy remained superior to salvage cryotherapy for the end points of any increase in prostate specific antigen greater than 0.4 ng/ml (HR 0.24, p <0.0001), 2 increases in prostate specific antigen (HR 0.47, p = 0.02) and overall survival (HR 0.21, p = 0.01).Young, healthy patients with recurrent prostate cancer after radiation therapy should consider salvage radical prostatectomy as it offers superior biochemical disease-free survival and may potentially offer the best chance of cure.
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You have accessJournal of UrologyProstate Cancer: Advanced (including Drug Therapy) II (MP22)1 Apr 2019MP22-17 BIOCHEMICHAL RECURRENCE IN PROSTATE CANCER AFTER SALVAGE SURGERY IN CORRELATION TO THE SITE OF RECCURRENT DISEASE David Pfister*, Yasmin Pullankavumkal, and Friederike Haidl David Pfister*David Pfister* More articles by this author , Yasmin PullankavumkalYasmin Pullankavumkal More articles by this author , and Friederike HaidlFriederike Haidl More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000555602.59561.49AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: Due to improved diagnostic tools salvage surgery is getting more popular after failure of primary local treatment as radical prostatectomy or radiotherapy. We analyzed PSA progression free survival (PFS) after radical prostatectomy and or radiotherapy in accordance to the location of the recurrence and the performed salvage surgery. METHODS: We retrospectively analyzed 274 patients with salvage surgeries. 142, 18, and 114 patients underwent salvage radical prostatectomy (SPRE, Group1), locoregional recurrences mainly in seminal vesical remnants (SVR, Group2) or salvage lymph node dissection (SLND, Group3). All patients were diagnosed either by Choline- or more lately PSMA-PET CT. All surgeries had been done open. In Group1 radical prostatectomy and lymph node dissection, in Group 2 the seminal vesicals and in Group3 an ipsilateral pelvic lymph node dissection had been performed due to imaging results. RESULTS: Median age at time of surgery was 67(62-72)years. Median PSA was 3.1(1.45-5.45)ng/ml. Radiotherapy or hormone therapy before salvage surgery in Group 1,2,3 was done in 100%, 61,1%, 54,39% and 12,6%, 27,8%, 18,42% of the patients. Median progression free survival in Group 1, 2, 3 is 41(11.104), 29 (8-47) and 8 (2-21) months (p<0.001). PSA PFS in Group1/2 and Group 1/3 differed significantly with an HR of 1.85 (95%CI;1,0-3.44) and HR of 2.72 (95%CI; 1,84-4,04). Only age at time of surgery and interval from primary treatment to salvage procedure in months were significant predictors in an univariate Cox regression analysis. CONCLUSIONS: We demonstrate that the best biochemical control in salvage surgeries is achieved in patients with isolated recurrence in the prostate after radiotherapy. The effect of salvage surgery decreases with increasing distance of the site of recurrence to the prostate. Source of Funding: None Cologne, Germany© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e323-e323 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information David Pfister* More articles by this author Yasmin Pullankavumkal More articles by this author Friederike Haidl More articles by this author Expand All Advertisement PDF downloadLoading ...
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The optimal management of isolated local recurrence of prostate cancer following radical prostatectomy remains unknown. Salvage radiotherapy to the prostatic bed is one of management options. This article reviews the efficacy of salvage radiotherapy. The available data suggest that salvage radiotherapy offers excellent clinical local control. However, the probability of long-term disease free survival with salvage radiotherapy alone appears small as a significant proportion of patients develop distant metastases and rising prostate specific antigen (PSA) following radiotherapy. A strategy of combining systemic therapy with local salvage treatment needs to be explored for this poor prognostic group.
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To compare the toxicity profile and oncological outcome of salvage radical prostatectomy following focal therapy versus salvage radical prostatectomy after radiation therapies (external beam radiation therapy or brachytherapy).Data concerning all men undergoing salvage radical prostatectomy for recurrent prostate cancer after either focal therapy, external beam radiation therapy or brachytherapy were retrospectively collected from 4 high volume surgical centers. The primary outcome measure of the study was toxicity of salvage radical prostatectomy characterized by any 30-day postoperative Clavien-Dindo complication rate, 12-month continence rate and 12-month potency rate. The secondary outcome was oncological outcome after salvage radical prostatectomy including positive margin rate and 12-month biochemical recurrence rate. Biochemical recurrence was estimated using Kaplan-Meier methods and significant differences were calculated using a log rank test. Median followup was 29.5 months.Between April 2007 and September 2018, 185 patients underwent salvage radical prostatectomy of whom 95 had salvage radical prostatectomy after focal therapy and 90 had salvage radical prostatectomy after radiation therapy (external beam radiation therapy or brachytherapy). Salvage radical prostatectomy after radiation therapy was associated with a significantly higher 30-day Clavien-Dindo I-IV complication rate (34% vs 5%, p <0.001). At 12 months following surgery, patients undergoing salvage radical prostatectomy after focal therapy had significantly better continence (83% pad-free vs 49%) while potency outcomes were similar (14% vs 11%). Men undergoing salvage radical prostatectomy after radiation therapy had a significantly higher stage and grade of disease together with a higher positive surgical margin rate (37% vs 13%, p=0.001). The 3-year biochemical recurrence after focal therapy was 35% compared to 32% after radiation therapy (p=0.76). In multivariable analysis, men undergoing salvage radical prostatectomy after focal therapy experienced a higher risk of biochemical recurrence (HR 0.36, 95% CI 0.16-0.82, p=0.02).This multicenter study demonstrates the toxicity of salvage radical prostatectomy in terms of perioperative complications and long-term urinary continence recovery is dependent on initial primary prostate cancer therapy received with men undergoing salvage radical prostatectomy after focal therapy experiencing lower postoperative complication rates and better urinary continence outcomes.
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Prostate specific antigen (PSA) failure occurs in 20% to 50% of patients who undergo radical prostatectomy. There is no consensus on how PSA failure should be managed. Recently, salvage radiotherapy is reported to be an effective treatment for PSA failure, and 20%-70% of cases are recurrence-free. The aim of salvage radiotherapy is a cure and this is quite different from other options, for example, endocrine therapy. Salvage radiotherapy is likely to become more important as a treatment for PSA failure after radical prostatectomy.
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Biochemical disease-free survival following radical prostatectomy can be improved with the use of adjuvant and salvage radiotherapy. However, there is a lack of consensus over the ideal timing to start adjuvant and salvage radiotherapy after surgery. The literature in relation to adjuvant and salvage radiotherapy following radical prostatectomy was reviewed, focusing specifically on the prognostic factors that influence the need for postoperative radiotherapy, outcomes following adjuvant and salvage radiotherapy and potential side effects. Post-surgery prognostic factors can be useful in identifying patients early on who may benefit from adjuvant radiotherapy. While there is literature examining the role of radiotherapy following radical prostatectomy, few dedicated trials investigate this area thoroughly.
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Failure of non-surgical primary treatment for localized prostate cancer is a common occurrence, with rates of disease recurrence ranging from 20% to 60%. In a large proportion of patients, disease recurrence is clinically localized and therefore potentially curable. Unfortunately, due to the complex and potentially morbid nature of salvage treatment, radical salvage surgery is uncommonly performed. In an attempt to decrease the morbidity of salvage therapy without sacrificing oncologic efficacy, a number of experienced centers have utilized robotic assistance to perform minimally invasive salvage radical prostatectomy. Herein, we critically evaluate the existing literature on salvage robotic radical prostatectomy with a focus on patient selection, perioperative complications and functional and early oncologic outcomes. These results are compared with contemporary and historical open salvage radical prostatectomy series and supplemented with insights we have gained from our experience with salvage robotic radical prostatectomy. The body of evidence by which conclusions regarding the efficacy and safety of robotic salvage radical prostatectomy can be drawn comprises fewer than 200 patients with limited follow-up. Preliminary results are promising and some outcomes have been favorable when compared with contemporary open salvage prostatectomy series. Advantages of the robotic platform in the performance of salvage radical prostatectomy include decreased blood loss, short length of stay and improved visualization. Greater experience is required to confirm the long-term oncologic efficacy and functional outcomes as well as the generalizability of results achieved at experienced centers.
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PURPOSE: We compared the treatment outcomes of salvage radical prostatectomy and salvage cryotherapy for patients with locally recurrent prostate cancer after initial radiation therapy.MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients who underwent salvage radical prostatectomy at the Mayo Clinic between 1990 and 1999, and those who underwent salvage cryotherapy at M. D. Anderson Cancer Center between 1992 and 1995. Eligibility criteria were prostate specific antigen less than 10 ng/ml, post-radiation therapy biopsy showing Gleason score 8 or less and prior radiation therapy alone without pre-salvage or post-salvage hormonal therapy. We assessed the rates of biochemical disease-free survival, disease specific survival and overall survival in each group. Biochemical failure was assessed using the 2 definitions of 1) prostate specific antigen greater than 0.4 ng/ml and 2) 2 increases above the nadir prostate specific antigen.RESULTS: Mean followup was 7.8 years for the salvage radical prostatectomy group and 5.5 years for the salvage cryotherapy group. Compared to salvage cryotherapy, salvage radical prostatectomy resulted in superior biochemical disease-free survival by both definitions of biochemical failure (prostate specific antigen greater than 0.4 ng/ml, salvage cryotherapy 21% vs salvage radical prostatectomy 61% at 5 years, p < 0.001; 2 increases above nadir with salvage cryotherapy 42% vs salvage radical prostatectomy 66% at 5 years, p = 0.002) and in superior overall survival (at 5 years salvage cryotherapy 85% vs salvage radical prostatectomy 95%, p = 0.001). There was no significant difference in disease specific survival (at 5 years salvage cryotherapy 96% vs salvage radical prostatectomy 98%, p = 0.283). After adjusting for post-radiation therapy biopsy Gleason sum and pre-salvage treatment serum prostate specific antigen on multivariate analysis salvage radical prostatectomy remained superior to salvage cryotherapy for the end points of any increase in prostate specific antigen greater than 0.4 ng/ml (HR 0.24, p < 0.0001), 2 increases in prostate specific antigen (HR 0.47, p = 0.02) and overall survival (HR 0.21, p = 0.01).CONCLUSIONS: Young, healthy patients with recurrent prostate cancer after radiation therapy should consider salvage radical prostatectomy as it offers superior biochemical disease-free survival and may potentially offer the best chance of cure. PMID: 19524984
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