Radiation Oncology/Prostate/Recurrence after RT

Salvage treatments for biochemical failure after definitive radiotherapy. See also: Advanced disease for PSA-only recurrence. Androgen ablation Timing of Salvage HT: ICORG 97-01 (Irish Clinical Oncology Research Group) (1997-2001) -- early vs late salvage HT Secondary (retrospective) analysis of a randomized trial. ICORG 97-01 compared short (4 months) vs long (8 months) neoadjuvant HT before RT. RT following HRT, 70 Gy. See also: Adjuvant ADT for trial details. Purpose: compare survival outcomes of early vs late salvage HT. Treatment of biochemical failure was not specified per protocol. Group 1 (early salvage): biochemical failure, started on HT with PSA <= 10, no distant mets. Group 2 (late salvage): BF, started on HT with PSA > 10, no distant mets. Group 3 (late salvage with DM): distant mets. 2013 22658512 -- "Early salvage hormonal therapy for biochemical failure improved survival in prostate cancer patients after neoadjuvant hormonal therapy plus radiation therapy-a secondary analysis of irish clinical oncology research group 97-01." (Mydin AR, Int J Radiat Oncol Biol Phys. 2013 Jan 1;85(1):101-8.) Conclusion: overall survival was improved for pts with BF treated with early salvage HT. RTOG 85-31 (1987-92) "Non-bulky" trial. Long term (indefinite) HT vs none. See also: Adjuvant ADT for trial details. 2010 20356687 -- "Timing of Salvage Hormonal Therapy in Prostate Cancer Patients With Unfavorable Prognosis Treated With Radiotherapy: A Secondary Analysis of Radiation Therapy Oncology Group 85-31." (Souhami L, Int J Radiat Oncol Biol Phys. 2010 Mar 29. [Epub ahead of print]) Subset analysis, relapsing patients in RT alone arm. Defined early salvage as initiated with PSA <10 and late-salvage as >10. Median F/U 11 and 13 years Outcome: Early salvage significantly improved OS (HR 1.5, SS), no difference in local failure or cancer-specific mortality Conclusion: Early introduction of salvage hormonal therapy improved OS but not CSS. Randomized trial is warranted Intermittent androgen ablation: Canadian trial - phase II 16783817, 2006 — "Final results of the Canadian prospective phase II trial of intermittent androgen suppression for men in biochemical recurrence after radiotherapy for locally advanced prostate cancer: clinical parameters." Bruchovsky N et al. Cancer. 2006 Jul 15;107(2):389-95. 103 pts. Each cycle consisted of cyproterone acetate (CA) x 4 wks then Lupron plus CA for a total of 36 wks. Median f/u 4.2 yrs. Time off treatment averaged 53% of total cycle time. Brachytherapy U.Wisconsin, 2007 (Review) 17685384 -- "Management of prostate cancer recurrences after radiation therapy-brachytherapy as a salvage option." (Allen GW, Cancer. 2007 Oct 1;110(7):1405-16.) Review. Summarizes treatment of 226 pts reported in literature, including 12 pts from this institution not previously reported. Wisconsin experience: 12 pts, treated with brachy (I or Pd) + 3 mo neoadjuvant AA. Median f/u of 45 months after implant. Conclusion: salvage brachytherapy success rates are likely similar to salvage with surgery or cryotherapy. HDR: UCSF (1998-2005) 17197119, 2006 — "Feasibility of High-Dose-Rate Brachytherapy Salvage for Local Prostate Cancer Recurrence After Radiotherapy: The University of California-San Francisco Experience." Lee B et al. Int J Radiat Oncol Biol Phys. 2006 Dec 28. 21 pts. 36 Gy in 6 fractions. Conclusion: "feasible and effective" Prostatectomy Salvage Prostatectomy: Memorial Sloan-Kettering 12756084, 2003 — "Salvage radical prostatectomy for recurrence of prostate cancer after radiation therapy." Eastham et al. Curr Urol Rep. 2003 June. Incontinence rates are similar to incontinence rates after up front prostatectomy Note: Most other series report higher incontinence rates in the range of 50% UCSF, 2001 (Review) 11590813 -- "Salvage radical prostatectomy." (Shekarriz B, Urol Clin North Am. 2001 Aug;28(3):545-53.) Review. Baylor, 1995 7526002 -- "Salvage radical prostatectomy: outcome measured by serum prostate specific antigen levels." (Rogers E, J Urol. 1995 Jan;153(1):104-10.) 40 pts. pT3 or pN+ in 54% (more likely if PSA > 10). Mean 39 months f/u. 2 pts died from PCA, 5 developed DM; none had local recurrence. 5-yr PSA control 55%. (more likely if pre-surgery PSA < 10). In pts with pathologically localized disease (minimal T3), 82% had PSA control. Toxicity: 15% rectal injury (colostomy - 2 pts). Persistent urinary incontinence 58% (corrected with artificial sphincter in 9 of 18). Conclusion: salvage prostatectomy provides excellent control of recurrence cancer; best performed before PSA increases greater than 10-20. Cryotherapy UK, 2007 (2000-5) 17662081 -- "Salvage cryotherapy for recurrent prostate cancer after radiation failure: a prospective case series of the first 100 patients." (Ismail M, BJU Int. 2007 Oct;100(4):760-4. ) 100 pts. Mean f/u 33 mo. 5-yr bRFS 73% (low risk pts), 45% (int), 11% (high) Toxicity: incontinence 13%, erectile dysfunction 86%, recto-urethral fistula 1%. Conclusion: salvage cryo is safe and effective