Irradiation for locally recurrent carcinoma of the prostate following radical prostatectomy

High postprostatectomy prostate-specific antigen level prior to salvage radiation therapy is not always a bad sign

Although radical prostatectomy is a popular treatment modality for clinically localized prostate cancer, 10-year biochemical recurrence can reach 28%. Before salvage radiation therapy (SRT), prostate-specific antigen (PSA) values alone should be used cautiously in predicting SRT eligibility. A long, slow PSA rise may suggest locally confined disease still amenable to SRT; corresponding imaging to identify potential gross recurrence is useful. Patients with local disease may safely benefit from higher doses of radiation.

Utilité clinique de la tomographie par émission de positons dans le cancer de la prostate

In prostate cancer, use of FDG, the radiopharmaceutical currently most widely used in oncology, is limited to the most aggressive cancers and, in the absence of another tracer, to attempting to localise occult recurrences detected biochemically (elevated PSA serum levels). Four other PET tracers are currently suggested in various situations of prostate cancer development: for guiding biopsies, for diagnosis and staging of the primary cancer and of local or metastatic recurrences, especially in bone, and for localizing occult biochemical recurrence. This article is illustrated by cases summarising our experience with fluoromethylcholine-(18F) and PET/CT. They cover a wide spectrum of clinical settings: localisation of intraprostatic neoplastic lesions, initial staging, monitoring treatment by ultrasound, detection of occult recurrences and characterisation of images on conventional imaging modalities, which are questionable or difficult to interpret.

Treatment of Prostate Cancer Local Recurrence After Radical Retropubic Prostatectomy with 17-Gauge Interstitial Transperineal Cryoablation: Initial Experience

OBJECTIVES

Interstitial transperineal cryoablation with 17-gauge cryoprobes is an accepted treatment modality for localized prostate cancer. The effectiveness of cryoablation in the treatment of local prostate cancer recurrence after radical retropubic prostatectomy (RRP) is unknown.

METHODS

We reviewed the outcome of cryoablative treatment in 15 patients for biopsy-proven locally recurrent prostate cancer after RRP. The follow-up data included prostate-specific antigen (PSA) level, imaging findings, side effects, and an assessment of voiding habits.

RESULTS

The mean follow-up time for the entire group was 20 months (range 4 to 32). Of the 15 patients, 6 (40%) had sustained declines in the PSA level (cryoablation success group) and 9 (60%) had disease progression (cryoablation failure group), defined as a PSA increase greater than 0.1 ng/mL from the PSA nadir, or the addition of external beam radiotherapy or androgen deprivation therapy. The pre-RRP PSA level and pre-cryoablation PSA level were similar for both groups. The pre-RRP biopsy Gleason scores (P = 0.03), RRP Gleason scores (P = 0.03), and lesion size on magnetic resonance imaging (P = 0.001) were lower in the success group than in the failure group. All patients who were recurrence free after cryotherapy had a biopsy and Gleason score of 6 or less. Of the 15 patients, 3 (20%) developed worsening of post-RRP incontinence.

CONCLUSIONS

Our preliminary results suggest that salvage cryoablation can be an effective and safe treatment modality and a possible alternative to external beam radiotherapy for targeted control of confirmed local recurrences after RRP, especially in those with favorable biopsy or pathologic Gleason scores before cryotherapy. Larger cohorts and longer follow-up are needed to assess the viability of this treatment.

Diagnostic efficacy of transrectal ultrasound-guided biopsy of the prostatic fossa in patients with rising PSA following radical prostatectomy

To evaluate the diagnostic efficacy of transrectal ultrasound (TRUS)-guided biopsy of the prostatic fossa in men with biochemical relapse following radical retropubic prostatectomy (RP). Thirty patients, with detectable prostate specific antigen (PSA) and negative imaging for metastases after RP, were evaluated for local recurrence. All patients underwent TRUS-guided biopsies of the prostatic fossa, with at least six cores obtained. PSA and digital rectal examination (DRE) were correlated with biopsy results. Twelve patients (40%) were found with local recurrence. Sensitivities of TRUS and DRE were 75 and 50%, while specificities were 83 and 100%, respectively. Local recurrence was detected in 25% of the patients with PSA <or= 1 ng/ml, and higher PSA levels were correlated with an increased positive biopsy rate. All patients with positive DRE had positive biopsy and positive TRUS as well. When both TRUS and DRE were positive it was more likely for the patient to have positive biopsy than when both TRUS and DRE were negative. TRUS-guided biopsy is an efficient tool in detecting local recurrence after RP and should be offered to all patients with biochemical relapse and absence of metastatic disease irrespective of the level of PSA.

Therapy of recurrent disease after radical prostatectomy in 2007

Recurrence rates of 20-40% after prostatectomy are described. This review will discuss curative treatment options for salvage after primary therapy. Relevant information was identified through searches of published studies, abstracts from scientific meetings, and review articles. Clinical experience in salvage therapy is limited. Conformal radiotherapy to the prostatic bed for PSA relapse and biopsy proven local recurrences after prostatectomy remains the only potentially curative therapy. It can provide durable biochemical control in a range from 17 to 78%. Salvage radiotherapy is well tolerated. Some prognostic factors exist which can help to select the right patient for this treatment. Patients have to be treated early for PSA relapse. Conformal radiotherapy to the prostatic bed for PSA relapse and biopsy proven local recurrences after prostatectomy is a good documented curative therapy. In a patient with a high probability of local recurrence early radiotherapy for PSA relapse is suggested.

The potential value of power Doppler ultrasound imaging compared with grey-scale ultrasound findings in the diagnosis of local recurrence after radical prostatectomy

AIM

To determine the value of power Doppler ultrasound (PDUS) imaging during transrectal ultrasonography (TRUS) in detecting local recurrence after radical retropubic prostatectomy (RRP).

MATERIALS AND METHODS

Eighteen patients were evaluated in whom local recurrence of prostate cancer was suspected on the basis of elevated serum prostate-specific antigen (PSA) levels (above 0.4 ng/ml) after RRP with no evidence of metastatic disease. Grey-scale TRUS and PDUS-guided biopsies of the vesicourethral anastomosis (VUA) and perianastomotic soft tissues were obtained after TRUS examinations of the prostatic fossa. The ability to detect locally recurrent prostate cancer using grey-scale TRUS alone was compared with TRUS combined with PDUS.

RESULTS

Fifteen of the 18 patients (83%) had positive biopsies for local recurrent tumour at histological examination. TRUS alone detected grey-scale abnormalities in 15 of 18 patients (83%), of whom 14 (77%) had positive TRUS-guided biopsies. PDUS during TRUS showed hypervascularity in 14 of 18 patients (77%). Biopsies of these hypervascular regions were positive in all patients (100%). The sensitivity and specificity of TRUS alone in detecting recurrent tumour were 93 and 67%, respectively, with a positive predictive value (PPV) of 93% and a negative predictive value (NPV) of 67%. TRUS combined with PDUS had a sensitivity and specificity of 93 and 100%, respectively, with a PPV and a NPV of 100 and 75%, respectively.

Salvage radiotherapy for men with isolated rising PSA or locally palpable recurrence after radical prostatectomy: do outcomes differ?

OBJECTIVES

To compare, in a retrospective analysis, the outcome of salvage external beam radiotherapy (EBRT) for isolated prostate-specific antigen (PSA) elevation or palpable local recurrence after radical prostatectomy (RP).

METHODS

We evaluated 102 men who underwent EBRT from 1993 to 1999, 60 for a rising PSA level alone and 42 for palpable local disease after RP. Biochemical disease-free survival and overall survival were calculated. Prognostic factors were evaluated to determine associations with biochemical disease-free survival.

RESULTS

The 5-year rate of biochemical disease-free survival, local control, freedom from distant metastasis, and overall survival for all 102 patients was 38%, 94%, 87%, and 88%, respectively. All palpable disease resolved completely after salvage EBRT. The greatest 5-year rate of biochemical control (69%) was obtained in patients with a pre-EBRT PSA level of 0.5 ng/mL or less. The 5-year overall survival rate was significantly better for those who underwent salvage EBRT for a rising PSA level than for those with palpable recurrence (96% versus 78%, P = 0.02). A low pre-EBRT PSA level and a less than 2-year interval from RP to EBRT were independent predictors of biochemical failure. Five patients (5%) experienced chronic grade 3 or 4 RT-related toxicity.

CONCLUSIONS

Salvage EBRT provides excellent local control of recurrent disease after RP. Salvage EBRT before the development of palpable local disease may confer a survival benefit and decrease the risk of metastasis, and durable biochemical control was achieved best in those whose pre-EBRT PSA level was 0.5 ng/mL or less. Early referral and careful patient selection is vital for salvage EBRT to be of optimal benefit.

External beam radiotherapy as curative treatment of prostate cancer

External beam radiotherapy (RT) has been used as a curative treatment of prostate cancer for more than 5 decades, with the "modern" era emerging more than 3 decades ago. Its history is marked by gradual improvements punctuated by several quantum leaps that are increasingly driven by advancements in the computer and imaging sciences and by its integration with complementary forms of treatment. Consequently, the contemporary use of external beam RT barely resembles its earliest form, and this must be appreciated in the context of current patient care. The influence of predictive factors on the use and outcomes of external beam RT is presented, as is a selected review of the methods and outcomes of external beam RT as a single therapeutic intervention, in association with androgen suppression, or as a postoperative adjunct. Thus, the "state of the (radiotherapeutic) art" is presented to enhance the understanding of this treatment approach with the hope that this information will serve as a useful resource to physicians as they care for patients with prostate cancer.

Evaluation and Management of Prostate-specific Antigen Recurrence After Radical Prostatectomy for Localized Prostate Cancer

A radical prostatectomy has been established as one of the standard management options for localized prostate cancer. However, a substantial proportion of patients who undergo a radical prostatectomy develop prostate-specific antigen (PSA) recurrence which is commonly defined as a PSA cut-off point value of 0.2 ng/ml. Although the management of PSA recurrence after radical prostatectomy may depend on the site of recurrence, it is quite difficult to identify the recurrent lesion accurately based on the currently available imaging technology. Patients who have surgical margin involvement or a Gleason score < or =7 based on the radical prostatectomy specimens, who do not have nodal or seminal vesicle involvement, and who develop a PSA recurrence >1-2 years after surgery with a doubling time of >1 year, and whose pre-treatment PSA is < 1.0-1.5 ng/ml are considered to benefit from local treatment with at least 64 Gy of salvage radiotherapy. Patients with different characteristics are considered to have distant metastases or both local lesions and distant metastases, and thus may be candidates for hormonal manipulation rather than radiotherapy. Since local recurrent lesions are considered to be quite small at the early stage of PSA recurrence, hormonal manipulation may be sufficient to prevent disease progression instead of radiotherapy. However, the optimal type and timing of hormonal manipulation remain to be elucidated. As a result, no consensus regarding the treatment for PSA recurrence after radical prostatectomy has yet been reached.

Management of recurrent disease after radical prostatectomy

Prostate cancer has undergone a stage migration since the advent of widespread PSA testing, yet still a significant number of men develop PSA recurrence following radical prostatectomy. This causes anxiety to the patient and the urologist. This review examines the clinical significance of biochemical relapse and the role of imaging modalities and anastomotic biopsies. The importance of the radical prostatectomy pathological features and the PSA kinetics in determining the site of recurrence and the best treatment modality is emphasised. The optimal timing and dose of salvage radiotherapy and the role of hormonal therapy is discussed.

Limited efficacy of salvage radiotherapy for biopsy confirmed or clinically palpable local recurrence of prostate carcinoma after surgery

BACKGROUND AND PURPOSE

To assess the efficacy of salvage radiotherapy (RT) for biopsy confirmed or clinically palpable local recurrence of prostate adenocarcinoma after radical prostatectomy (RP).

PATIENTS AND METHODS

We retrospectively analyzed 44 patients treated with salvage RT for biopsy confirmed or clinically palpable local recurrence between 1991 and 2000. Thirty-six had positive biopsy for local recurrence and the rest without histological confirmation had clinically palpable disease. All had rising PSA at the time of RT (median: 3.7). Median interval from RP to RT was 2.6 years. Thirty-six received salvage RT alone, while eight had a short course (<4 months) of androgen ablation prior to RT. RT doses were 60-66Gy in 30-33 fractions. Freedom from PSA failure was defined as the maintenance of PSA<or=0.2.

RESULTS

Median follow-ups from RP and salvage RT were 8.7 and 5.5 years, respectively. All but one achieved local control clinically. The actuarial PSA relapse-free and survival rate at 5 years were 11 and 87%, respectively. On Cox regression analysis, significant predictors for relapse were PSA level prior to salvage RT, and Gleason score.

CONCLUSIONS

The efficacy of salvage RT alone for local recurrence was limited. This study suggests a need to explore other strategies incorporating systemic therapy, and the importance of timely referral for consideration of salvage RT in patients with rising PSA after surgery.

Feasibility and preliminary outcome of salvage combined HDR brachytherapy and external beam radiotherapy (EBRT) for local recurrences after radical prostatectomy

PURPOSE

Feasibility of combined fractionated intensity modulated brachytherapy (IMBT) and external beam radiotherapy (EBRT) as well as the effect of local dose escalation was investigated in a non-randomized retrospective observation trial for histologically-proven macroscopic local recurrences of prostate cancer after radical prostatectomy.

METHODS AND MATERIALS

Thirty-five patients with transrectal ultrasound (TRUS) detectable tumors were treated. Applied dose per IMBT fraction was 15 Gy, prescribed on the target (TRUS visible tumor) surface. For the first 21 patients, two fractions of IMBT were delivered in 2 weeks interval, complementary to 30 Gy EBRT to the small pelvis. Further, as second step of dose escalation, 14 patients were treated with 2 x 15 Gy IMBT combined with 40 Gy EBRT. The total treatment time was 4 and 5 weeks, respectively.

RESULTS

PSA was decreased in 34 out of 35 patients post-therapeutically. After a mean follow-up of 27 months, 32 out of 35 patients are alive. However, in 67% of the patients, we observed postimplant PSA elevation with or without detectable local and/or systemic progress. The mean duration of biochemical non-evidence of disease (bNED) after radiation was 12 months for all patients (31% in the 30 Gy group and 42% in the 40 Gy group). No RTOG/EORTC grade III or IV side effects were registered during/after radiotherapy.

CONCLUSION

Combined EBRT and IMBT-boost of TRUS detectable recurrences of prostate cancer after radical prostatectomy seems to be a feasible method of salvage treatment. These early results need to be confirmed by further prospective randomized trials and by longer follow-up in all dose groups.

Postprostatectomy adjuvant versus salvage radiotherapy

BACKGROUND

Radiotherapy (RT) has been used with success after radical retropubic prostatectomy (RRP), both in the adjuvant and salvage settings. The purpose of the current investigation was to systematically compare adjuvant versus salvage RT in a manner that incorporates both treatment efficacy and complications.

METHODS

A literature review was performed of reports of post-RRP salvage and adjuvant RT, and 12 trials comprising 1060 patients met the appropriate inclusion criteria. The biochemical failure-free survival in each study/arm was tabulated, and these values were entered into a model to compute an unadjusted number-needed-to treat (NNT). RT complications were then considered, accounting for differences in toxicity incidences in the salvage versus adjuvant setting, to compute complication-adjusted NNTs. In all the trials, the signs and magnitudes of the NNTs obtained were used to compare adjuvant with salvage RT.

RESULTS

The absolute NNT analysis showed an advantage of adjuvant compared with salvage RT. After adjustment for RT complications, however, the advantage shifted to salvage RT. This transition point from superiority of adjuvant RT to superiority of salvage RT was sensitive to the estimated incidence and severity of RT side effects.

CONCLUSIONS

Adjuvant post-RRP RT was advantageous in comparison to salvage RT if the side effects of RT were estimated to be negligible. However, with moderate incidence/severity of RT side effects, salvage RT was advantageous. The findings herein must be tested in a prospective study in which both health-related quality of life and cancer control are documented in patients receiving adjuvant versus salvage post-RRP RT. Further work is needed to better estimate parameters entered into the model to determine the precise transition point between adjuvant and salvage RT with modern RT techniques.

Radiotherapy after radical prostatectomy: does transient androgen suppression improve outcomes?

PURPOSE

The long-term biochemical relapse-free survival and overall survival were compared for patients receiving either radiotherapy (RT) alone or radiotherapy combined with a short-course of total androgen suppression for failure after radical prostatectomy.

METHODS AND MATERIALS

Between 1985 and 2001, a total of 122 patients received RT after radical prostatectomy at our institution. Fifty-three of these patients received a short-course of total androgen suppression (TAS) 2 months before and 2 months concurrent with RT with a nonsteroidal antiandrogen and an luteinizing hormone-releasing hormone (LHRH) agonist (combined therapy group); the remaining 69 patients received RT alone. Treatment failure was defined after postoperative RT as a detectable PSA >0.05 ng/mL. Clinical and treatment variables examined included: presurgical PSA, clinical T stage, pathologic Gleason sum (pGS), seminal vesicle (SV) involvement, lymph node involvement, surgical margins, pre-RT PSA, prostate dose, pelvic irradiation, indication for postoperative RT (salvage or adjuvant), and time interval between surgery and RT. Minimum follow-up after postoperative RT was 1 year and median follow-up was 5.9 years (maximum, 14 years) for patients receiving RT alone, and 3.9 years (maximum, 11 years) for patients receiving RT with TAS (combined therapy group). Kaplan-Meier analysis was performed for PSA failure-free survival (bNED) and for overall survival (OS). Cox proportional hazards multivariable analysis examined the influence all clinical and treatment variables predicting for bNED and OS.

RESULTS

The median time to PSA failure after postoperative RT was 1.34 years for the combined therapy group and 0.97 years for the RT alone group (p = 0.19), with no failures beyond 5 years. At 5 years, the actuarial bNED rates were 57% for the combined therapy group compared with 31% for the RT alone group (p = 0.0012). Overall survival rates at 5 years were 100% for the combined therapy group compared with 87% for the RT alone group (p = 0.0008). For pGS <or=7, the 5-year bNED rates were 58% for combined therapy and 38% for RT alone (p = 0.0155), and for pGS >or=8 the 5-year bNED rates were 65% for combined therapy and 17% for RT alone (p = 0.075). The 5-year OS rates for pGS <or=7 were 100% for combined therapy and 98% for RT alone group (p = 0.106), and the 5-year OS for pGS >or=8 was 100% for combined therapy and 54% for RT alone (p = 0.04). On multivariable analysis, only SV involvement (p = 0.0145) and the addition of short-course TAS to postoperative RT (p = 0.0019) were significant covariates predicting for bNED and, similarly, approached significance for overall survival (p = 0.0594 and p = 0.0856, respectively).

CONCLUSIONS

Radiotherapy combined with a short-course TAS after radical prostatectomy appears to confer a PSA relapse-free survival advantage and possibly an overall survival advantage when compared with RT alone. The hypothesis that a transient course of androgen suppression with salvage or adjuvant RT after prostatectomy improves outcomes will need to be tested in a randomized trial.

Comparison of adjuvant versus salvage radiotherapy policies for postprostatectomy radiotherapy

PURPOSE

We compared the long-term results of postprostatectomy radiotherapy (RT) from two institutions, one adapting a prospective policy of adjuvant RT and the other salvage RT.

METHODS AND MATERIALS

Between 1989 and 1997, 69 patients were referred for adjuvant RT to the institution using adjuvant RT and 88 patients with evidence of recurrence were treated in the institution using salvage RT. The salvage group underwent RT after longer postoperative intervals (median, 40.3 vs. 2.9 months; p <0.0001) and had higher prostate-specific antigen (PSA) values before starting RT (4.5 vs. 0.86 ng/mL; p = 0.003). Both groups were routinely treated to a minimal total dose of 60 Gy. The treatment groups were analyzed for overall survival, disease-specific survival, distant metastasis-free survival, and biochemical recurrence-free survival (BRFS) using Cox proportional hazards modeling.

RESULTS

Of the 69 patients referred for adjuvant RT, 22 (32%) had nonzero PSA values before RT. Multivariable modeling of BRFS found only the PSA value before RT to be statistically significant (p <0.0001). RT after prostatectomy was equally effective in either setting when the pre-RT PSA level was <1 ng/mL. When the PSA value before RT was >or=1 ng/mL, the 5-year BRFS for each group was inferior.

CONCLUSION

Although the adjuvant treatment policy was associated with significantly improved BRFS, this was attributable to low pre-RT PSA values. When the treatment groups were stratified for pre-RT PSA level, the differences in BRFS were not statistically significant. Patients with a rising PSA level after prostatectomy, regardless of their initial risk, should receive prompt referral for RT.

Salvage radiotherapy for palpable, locally recurrent prostate cancer after radical prostatectomy

PURPOSE

A retrospective study to evaluate the outcome of salvage radiotherapy (RT) for clinically apparent, palpable prostate cancer recurrence after radical prostatectomy (RP).

METHODS AND MATERIALS

Forty-two patients underwent RT for clinically apparent recurrent prostate cancer after RP between 1993 and 1999. The end points and treatment variables of biochemical disease-free survival were evaluated statistically.

RESULTS

The median follow-up was 4.3 years. All 42 patients experienced resolution of clinically detectable recurrence within 1 year after RT. The 5-year biochemical disease-free survival, local control, freedom from distant metastases, and overall survival rate was 27%, 94%, 82%, and 78%, respectively. The initial pathologic stage (T3 or T4; p = 0.04) and interval (<2 years from RP to RT; p = 0.01) were independent predictors of biochemical failure, and RT simulation without contrast (p = 0.05) was nearly significant on multivariate analysis. Three patients (7%) experienced chronic Grade 3 or 4 RT-related toxicity.

CONCLUSION

Salvage prostate bed RT for clinically apparent locally recurrent prostate cancer after RP provides effective local tumor control with modest durable biochemical control. Patients irradiated with a better simulation technique were found to have a more favorable outcome. A consensus on a definition of biochemical disease-free survival after salvage RT is critical for meaningful comparison of the available data and to future progress in treating this disease process.

Diagnosis of local recurrence after radical prostatectomy

In the long-term there is biochemical evidence of recurrent prostate carcinoma in approximately 40% of patients after radical prostatectomy (RP). Detecting the site of recurrence (local vs distant) is critical for defining the optimum treatment. Pathological and clinical variables, e.g. Gleason score, involvement of seminal vesicles or lymph nodes, margin status at surgery, and especially the timing and pattern of prostate-specific antigen (PSA) recurrence, may help to predict the site of relapse. Transrectal ultrasonography (TRUS) of the prostatic fossa in association with TRUS-guided needle biopsy is considered more sensitive than a digital rectal examination for detecting local recurrence, especially if PSA levels are low. Although it cannot detect minimal tumour mass at very low PSA levels (< 1 ng/mL) TRUS biopsy is presently the most sensitive method for detecting local recurrence. Nevertheless, the conclusive role of biopsy of the vesico-urethral anastomosis remains unclear. However, 111In-capromab pendetide scintigraphy and [11C]-choline tomography (which are better than conventional imaging for detecting metastatic tumour), have low detection rates for local disease and are considered complementary to TRUS in this setting. Patients with a high PSA after RP may be managed with external beam salvage radiotherapy. An initial PSA of < 1 ng/mL, Gleason score < 8 and radiation dose of 66-70 Gy seem to be key factors in determining success. Although a positive TRUS anastomotic biopsy may predict a better outcome after radiation therapy, the need to take a biopsy in the event of PSA failure remains under investigation. The value of salvage radiation to the prostatic bed for PSA-only progression after RP remains in question.

Multiple vesico-urethral biopsies following radical prostatectomy: the predictive roles of TRUS, DRE, PSA and the pathological stage

INTRODUCTION

The aim of this study is to verify the predictive role of transrectal ultrasound (TRUS) of prostatic fossa, digital rectal examination (DRE), prostate specific antigen (PSA) and pathological stage after radical prostectomy in the detection of a prostate tumor recurrence at the level of the vesico-urethral anastomosis by means of multiple TRUS biopsies (6-8 cores).

MATERIAL AND METHODS

From October 1997, following a radical prostatectomy, 119 consecutive patients (median age: 67.9 years) with a PSA>or=0.2 ng/ml (median PSA: 0.9 ng/ml) underwent DRE and TRUS examinations with a 5.0-7.5 MHz variable frequency end-fire probe (Hitachi Medical System) and an EUB-525 machine. All patients received six TRUS-guided biopsies of the vesico-urethral anastomosis, and 1-2 additional biopsies directed to hypo-echoic or suspicious areas, if detected by TRUS.

RESULTS

Biopsies revealed recurrent carcinoma in 50% of patients (60/119). TRUS proved more sensitive than DRE (75% vs. 50%; p=0.01) and, conversely, DRE proved more specific than a TRUS (85% vs. 66%; p=0.03). Cancer was detected in 45% of the 34 patients with a PSA<or=0.5 ng/ml. In the group of patients with a PSA>or=2.0 ng/ml (24 patients), TRUS was able to detect every biopsy-proven local recurrence lesion (sensitivity: 100%). Conversely, all patients with a PSA>or=2.0 ng/ml and a negative TRUS had a negative biopsy (negative predictive value: 100%). In a multi-variable logistical analysis, the most predictive parameters determining a positive biopsy rate among those values studied (PSA, DRE, TRUS, positive surgical margins, pathological stage and time to PSA elevation) were TRUS and DRE findings (p=0.003, with an odds ratio of 4.6 and p=0.02, with an odds ratio of 4.1, respectively).

CONCLUSION

TRUS and TRUS biopsies utilizing 6-8 cores are efficient tools in the detection of local recurrence after a radical prostatectomy, even with a PSA<or=0.5 ng/ml. A combination of TRUS and DRE findings seems to predict biopsy results best. In case of a PSA>or=2.0 ng/ml and a negative TRUS, a biopsy of the vesico-urethral anastomosis could be avoided since the negative predictive value is 100%. Cancer recurrence detection seems to be predicted by TRUS and DRE findings, but not by PSA levels, pathological stage, status of the surgical margins or time to PSA elevation.

Radiotherapy for a rising PSA following radical prostatectomy

Controversy exists regarding the management of recurrent disease, heralded by a rising prostate specific antigen (PSA), in men who have undergone primary treatment of prostate cancer by radical prostatectomy. Although retrospective in nature, the use of salvage radiation therapy (RT) after prostatectomy has been extensively investigated and reported. Salvage RT alone is likely not optimal for every man presenting with recurrent disease after RP. Those with palpable recurrent disease or unfavorable disease characteristics are less likely to benefit from salvage RT alone and may respond better to a combined modality approach. However, early referral and proper patient selection maximizes the potential for durable biochemical control after salvage RT in men with rising PSA alone.

Salvage radiotherapy in the treatment of prostate cancer

For patients undergoing radical prostatectomy for prostate adenocarcinoma, the most common cause of failure is an asymptomatic increase in levels of prostate-specific antigen (PSA). Salvage radiotherapy (RT) to the prostate bed has been used when there is no clinical evidence of metastatic disease. However, this is still not widely accepted because there is currently no consensus on the optimal management of an isolated PSA failure. Salvage RT given in a select group of patients is effective, with a 70% to 80% biochemical response rate and a long-term biochemical control rate as high as 35% to 40%. These data indicate that RT offers a substantial risk of curative salvage of patients who fail radical prostatectomy. Although there is interest in studying investigational modalities (eg, vaccine therapy) among patients with asymptomatic, PSA-detected recurrences after surgery, caution must be applied, and treatment modalities with known curative potential (ie, RT) should be used before noncurative techniques are attempted. This article outlines the rationale, results, and toxicity of salvage RT for an asymptomatic increase in PSA levels, with emphasis on identifying patients with favorable prognostic factors with higher rates of long-term biochemical control with local treatment.

Salvage radiotherapy for biochemical failure of radical prostatectomy: a single-institution experience

OBJECTIVES

To review the efficacy of salvage radiotherapy (RT), to treat elevated prostate-specific antigen (PSA) levels for presumed local recurrence of prostatic adenocarcinoma after retropubic prostatectomy, and identify the factors that may predict for successful treatment.

METHODS

Fifty-one patients with hormonally naive pT2-3N0-1M0 prostate cancer were treated with RT for locally persistent or recurrent disease. The patients received a median dose of 65.7 Gy (range 61.2 to 72.3) to the prostate bed. Successfully treated patients had undetectable PSA levels; the endpoint of the study was biochemical failure.

RESULTS

The median follow-up was 3.8 years; 42 of 51 patients had at least 2 years of follow-up. Twenty-three patients (45%) were biochemically free of disease. The estimated biochemically free of disease rate at 3 and 5 years was 56% and 16%, respectively. Whether the patients were treated for persistently elevated PSA levels or for rising PSA levels from undetectable levels after retropubic prostatectomy, their PSA values were equally likely to drop to undetectable levels (65%). Univariate analysis demonstrated two factors that significantly predicted for successful salvage treatment: the absence of seminal vesicle invasion and the absence of lymphovascular invasion. A pretreatment PSA level less than 0.425 ng/mL trended toward statistical significance (P = 0.059). Only seminal vesicle invasion maintained significance on multivariate analysis. The RT was well tolerated, and the gastrointestinal and genitourinary toxicity was largely Radiation Therapy Oncology Group grade 1.

CONCLUSIONS

Salvage RT is moderately effective in treating patients with locally persistent or recurrent prostate adenocarcinoma. Seminal vesicle invasion and lymphovascular invasion predicted for unsuccessful treatment.

Predictors of biochemical outcome with salvage conformal radiotherapy after radical prostatectomy for prostate cancer

PURPOSE

To identify predictors of biochemical outcome following radiotherapy in patients with a rising prostate-specific antigen (PSA) after radical prostatectomy for prostate cancer.

PATIENTS AND METHODS

One hundred fifteen patients with a rising PSA after radical prostatectomy received salvage three-dimensional conformal radiotherapy (3D-CRT) alone or with neoadjuvant androgen deprivation. Tumor-related and treatment-related factors were evaluated to identify predictors of subsequent PSA failure.

RESULTS

The median follow-up time after 3D-CRT was 42 months. The 4-year actuarial PSA relapse-free survival, distant metastasis-free survival, and overall survival rates were 46%, 83%, and 95%, respectively. Multivariate analysis, which was limited to 70 patients receiving radiation without androgen deprivation therapy, showed that negative/close margins (P =.03), absence of extracapsular extension (P <.01), and presence of seminal vesicle invasion (P <.01) were independent predictors of PSA relapse after radiotherapy. Neoadjuvant androgen deprivation did not improve the 4-year PSA relapse-free survival in patients with positive margins, extracapsular extension, and no seminal vesicle invasion (P =.24). However, neoadjuvant androgen deprivation did improve PSA relapse-free survival when one or more of these variables were absent (P =.03).

CONCLUSIONS

Salvage 3D-CRT can provide biochemical control in selected patients with a rising PSA after radical prostatectomy. Among patients with positive margins and no poor prognostic features, 77% achieved PSA control after salvage 3D-CRT. Salvage neoadjuvant androgen deprivation therapy may improve short-term biochemical control, but it requires further study.

Outcome, morbidity, and prognostic factors in post-prostatectomy radiotherapy: an Australian multicenter study

OBJECTIVES

To report the outcome and morbidity data for patients treated with post-prostatectomy radiotherapy (PPRT) in a multicenter collaboration.

METHODS

The case records of all patients treated with PPRT from 1996 to 1998 were reviewed. Survival was calculated using Kaplan-Meier methods. Potential prognostic factors were evaluated using the Cox proportional hazards regression model. Prostate-specific antigen (PSA) remission was defined as a PSA level of 0.2 ng/mL or less. Acute and late morbidities were documented.

RESULTS

We reviewed the data of 115 patients, with a median follow-up from the start of PPRT of 28.7 months. Patients were treated with adjuvant intent (n = 23), for local recurrence (n = 27), or for a detectable PSA level (n = 65). The overall and cause-specific survival rate at 5 years was 73.7% and 81.4%, respectively. The biochemical disease-free survival rate was 69.6% at 2 years and 50% at 5 years. Factors predicting for subsequent relapse on multivariate analysis were pre-PPRT PSA (P = 0.013) and post-PPRT nadir (P <0.0001). Patients with a PSA greater than 1 ng/mL fared significantly worse than those with lower levels (P <0.0001). For patients with a pretreatment PSA of less than 1 ng/mL and an operative Gleason score of 7 or less, the 5-year projected biochemical disease-free survival rate was 71%. One case of grade 3 late proctitis was recorded, and 4 patients had continued grade 3 late urinary incontinence.

CONCLUSIONS

Early use of PPRT is effective and well tolerated in patients at risk of, or with proven, local recurrence.

Predictive factors of radiation therapy for patients with prostate specific antigen recurrence after radical prostatectomy

OBJECTIVE

To assess the efficacy of salvage/adjuvant radiation therapy (RT) for patients with prostate-specific antigen (PSA) recurrence after radical prostatectomy (RP).

PATIENTS AND METHODS

Between 1997 and 2001, 52 patients were treated in our institution with RT for PSA recurrence after RP. The mean (range) delay between RP and RT was 30.5 (0.16-105.6) months. Eighteen patients received no hormonal therapy before RT. The failure of RT was defined as three consecutive increases in PSA levels with intervals of > or = 6 weeks.

RESULTS

Within a mean (range) follow-up of 27.7 (6-69) months, 18 patients presented with biochemical progression. The 3-year biochemical progression-free survival was 51%. Using univariate analysis, an age < 65 years (P = 0.0262), a Gleason score on the RP specimen of > or = 8 (P = 0.0024), stage pT3 (P = 0.02), a detectable nadir PSA after RT (P < 0.001) and the absence of hormonal therapy (P = 0.0359) were associated with a lower biochemical progression-free survival. However, only the Gleason score (P = 0.0395) and nadir serum PSA after RT (P = 0.028) remained independent predictive factors on multivariate analysis.

CONCLUSION

Half of the present patients treated with RT for an isolated high serum PSA level after RP were free of biochemical relapse at 3 years of follow-up. RT may be proposed to selected patients with mild morbidity. However, definitive evidence of the beneficial effect of adjuvant RT for patients with PSA recurrence after RP awaits the conclusion of randomized clinical trials.

Salvage radiotherapy for PSA failure after radical prostatectomy

BACKGROUND AND PURPOSE

Prostate-specific antigen (PSA) failure after radical prostatectomy is a common clinical scenario, and there is no consensus on how it should be managed. Salvage radiation to the prostatic bed is a potentially curative treatment option, and is the subject of this review. Patient selection, and the efficacy and toxicity of treatment will be discussed, and recommendations made for current practice and future studies.

METHODS

An English language MEDLINE search was performed, limited to the years 1989-2000, using the MeSH headings 'prostatic neoplasms' and 'radiotherapy'. The 660 abstracts identified were reviewed, and articles concerning patient selection for, or outcome of, post-operative radiation to the prostatic bed selected. After exclusion of articles concerning adjuvant, rather than salvage, radiation, this left a total of 22 case series, including 1062 patients for the review of treatment efficacy.

RESULTS AND CONCLUSIONS

The quality of the evidence makes it difficult to form a judgment regarding the efficacy of salvage radiation following radical prostatectomy, particularly in men with a PSA level in the range 0.01-0.2 ng/ml. Salvage radiation may be more effective given earlier rather than later. These considerations have important consequences for the interpretation of current trials of adjuvant radiation following radical prostatectomy.

The role of radiotherapy after radical prostatectomy

The results of radiotherapy (RT) as used at the Mayo Clinic are reviewed and compared with the available literature. An attempt is made to summarize the risks and benefits of RT in these settings. Additionally, avenues of future potential investigation are explored.

Local recurrence after radical prostatectomy: correlation of US features with prostatic fossa biopsy findings

PURPOSE

To evaluate the diagnostic accuracy of transrectal ultrasonography (US) in the detection of local recurrence following radical prostatectomy.

MATERIALS AND METHODS

Ninety-nine patients with biochemical recurrence after radical prostatectomy were evaluated at transrectal US and prostatic fossa biopsy. Location of suspected recurrence at transrectal US and clinical features, such as prostate-specific antigen levels and digital rectal examination findings, were correlated with biopsy results.

RESULTS

Forty-one (41%) of 99 cases of local recurrence were detected. The percentage of sites of lesions identified at transrectal US and corresponding positive biopsy rates were as follows: the urethrovesical anastomotic area, 56% and 61%; bladder neck, 26% and 54%; retrovesical space, 4% and 100%; and more than one site, 14% and 71%. By comparing transrectal US and digital rectal examination, the sensitivities were 76% and 44% (P =.007), while specificities were 67% and 91% (P =.004), respectively. An increased positive biopsy rate with increasing prostate-specific antigen levels was noted (P =.04).

CONCLUSION

Transrectal US is more sensitive but less specific than digital rectal examination in the detection of local recurrence. Biopsy findings in more than half of the suspected lesions at the urethrovesical anastomotic area and bladder neck were positive. Lesions in the retrovesical space, although less frequently encountered, had a high likelihood of representing cancer recurrence.

Prediction of response to salvage radiation therapy in patients with prostate cancer recurrence after radical prostatectomy

PURPOSE

To identify factors predictive of local recurrence as defined by a complete response to salvage radiation therapy in patients whose disease recurs after radical prostatectomy.

PATIENTS AND METHODS

Ninety-five patients with recurrence after radical prostatectomy who were evaluated by prostatic fossa biopsies, and a subset of 49 of these patients treated with radiation for control of presumed or biopsy-proven local recurrence, were studied.

RESULTS

Biopsies were positive in 40 (42%) of the 95 biopsied patients. Multivariate analysis revealed that prebiopsy prostate-specific antigen (PSA) level, postrecurrence PSA doubling time, and positive digital rectal examination (DRE) of the prostatic fossa were all statistically significant predictors of a positive biopsy. For the 49 patients subsequently treated with salvage radiation therapy, the overall actuarial 3- and 5-year PSA relapse-free probabilities were 43% and 24%, respectively. Univariate analysis showed no differences in the PSA relapse-free probabilities associated with any pathologic features of the radical prostatectomy specimen, biopsy confirmation of local recurrence, or DRE of the prostatic fossa. In multivariate analysis, controlling for all other variables, preradiation PSA and postrecurrence PSA doubling time measured before radiation were the only statistically significant predictors of outcome.

CONCLUSION

DRE of the prostatic fossa, prebiopsy PSA, and postrecurrence PSA doubling time predict which patients will have biopsy-proven local recurrence. However, response to salvage radiation therapy is associated with postrecurrence PSA doubling time and with preradiation PSA level only. DRE of the prostatic fossa and biopsy confirmation of local recurrence are not associated with salvage radiation outcome.

Radiotherapy after radical prostatectomy: treatment outcomes and failure patterns

OBJECTIVES

To define the optimal role for radiotherapy (RT) after radical prostatectomy (RP) and to characterize specific patterns of PSA failure in this setting.

METHODS

The records of 105 patients who underwent RT after RP (69 received therapeutic RT because of an elevated prostate-specific antigen [PSA] level, 36 received immediate adjuvant RT) were reviewed. The median follow-up was 35 months after RT and 57 months after RP. Radiation success was defined as achievement and maintenance of a PSA less than 0.2 ng/mL. Preoperative, pathologic, and postoperative characteristics were examined for their ability to predict success after RT. Patterns of PSA recurrence after RT were also examined by determining the PSA nadir, PSA velocity, and timing of androgen-deprivation therapy.

RESULTS

Of 105 patients, 47 experienced biochemical failure. Actuarial 3 and 5-year progression-free survival estimates for all patients were 55% and 43%, respectively. Significant favorable predictors of response to RT by multivariate analysis were preoperative PSA less than 20 ng/mL and the use of adjuvant RT. However, patients who received therapeutic RT with a pre-RT PSA less than 1.0 ng/mL demonstrated progression-free outcome equivalent to those who received adjuvant RT. Two distinct patterns of PSA failure were observed on the basis of PSA nadir after RT. Patients whose PSA failed to reach a nadir less than 0.2 ng/mL after RT had progression with a high PSA velocity (1.5 ng/mL/yr). Patients whose PSA reached a nadir less than 0.2 ng/mL but who subsequently had treatment failure progressed later with a lower PSA velocity (0.36 ng/ml/yr).

CONCLUSIONS

RT is effective in select patients after RP. Given the low PSA velocity consistent with persistent local disease in nearly 50% of patients in whom RT failed, more effective local therapy is needed after RP in high-risk patients.

Treatment outcome with adjuvant and salvage irradiation after radical prostatectomy for prostate cancer

OBJECTIVES

To determine the factors associated with outcome by reviewing our institution's experience treating patients with external beam radiation therapy (RT) after radical prostatectomy.

METHODS

Sixty-one patients received RT to the prostatic fossa after radical prostatectomy for prostate cancer (median dose 59.4 Gy). Thirty-eight patients received adjuvant RT within 6 months of surgery for adverse pathologic findings only. Therapeutic RT was administered to 23 patients either for a persistently elevated postoperative prostate-specific antigen (PSA) level (n = 2), a rising PSA level more than 6 months after surgery (n = 9), or a biopsy-proven local recurrence (n = 12). Preoperative and preradiation PSA values, Gleason score, pathologic findings, patient age, total RT dose, and indication for RT were analyzed for their impact on biochemical control. The median follow-up was 48 months.

RESULTS

Patients treated with adjuvant RT achieved 3 and 5-year biochemical control rates of 84% and 67%, respectively. Multiple clinical, pathologic, and treatment-related factors were analyzed for an association with biochemical control. No variable was associated with 5-year outcome. The 5-year actuarial rate of biochemical control for patients treated with therapeutic RT was 16%. Multiple clinical, pathologic, and treatment-related factors were analyzed for an association with biochemical control. Only a pre-RT PSA level of 2 ng/mL or less was associated with an improved rate of biochemical control at 3 years (80% versus 27%, P = 0.001). However, at 5 years, this difference was not statistically significant. A separate analysis was performed to determine the prognostic factors associated with outcome for the entire group of patients. Only the indication for RT (adjuvant versus therapeutic) was associated with 5-year outcome. Patients treated with adjuvant RT had a statistically significant improvement in 5-year actuarial rates of biochemical control (67% versus 16%, P <0.001) and disease-free survival (66% versus 46%, P = 0.037) but not in overall survival. There were no statistically significant differences between patient groups with respect to age, preoperative PSA, Gleason score, pathologic T stage, median follow-up, and total RT dose.

CONCLUSIONS

At our institution, patients treated with adjuvant RT after prostatectomy for adverse pathologic findings achieved excellent rates of biochemical control that were significantly better than that of similar patients treated therapeutically for persistent or rising PSA or clinical local recurrence.

Predictors of survival for prostate carcinoma patients treated with salvage radical prostatectomy after radiation therapy

BACKGROUND

Salvage radical prostatectomy is a treatment option for patients with recurrent cancer following radiation therapy. This study was conducted to identify predictors of survival for patients treated with salvage radical prostatectomy.

METHODS

The authors studied 86 prostate carcinoma patients who underwent salvage radical prostatectomy for locally persistent or recurrent prostate carcinoma at Mayo Clinic between 1967 and 1996. The mean interval from radiation therapy to biopsy-proven recurrence was 3.7 years (range, 6 months to 17 years). Patient age at surgery ranged from 51 to 78 years (median, 66 years). The mean follow-up after surgery was 5.8 years (range, 1.0-15.2 years). Cox proportional hazards models were used to identify clinical and pathologic factors associated with distant metastasis free survival and cancer specific survival.

RESULTS

Actuarial distant metastasis free survival, cancer specific survival, and overall survival were 83%, 91%, and 85% at 5 years and 69%, 64%, and 54% at 10 years, respectively. In multivariate analysis, radical prostatectomy Gleason score and DNA ploidy were independent predictors of distant metastasis free survival and cancer specific survival.

CONCLUSIONS

Postirradiation Gleason score and DNA ploidy were highly predictive of the clinical outcomes of patients treated by salvage radical prostatectomy after radiation therapy.

Quality of life in patients undergoing salvage procedures for locally recurrent prostate cancer

BACKGROUND AND OBJECTIVES

As patients are being treated for prostate cancer at a younger age, a significant number of them will ultimately fail the primary treatment and will be candidates for potentially curative salvage therapy. The purpose of this study was to evaluate the impact of salvage therapy for locally recurrent prostate cancer upon the patients' quality of life.

METHODS

A cohort of 68 men with locally recurrent prostate cancer undergoing salvage treatment was included in this analysis. Data were collected for the study by mailing the subjects a self-administered questionnaire that included a General Functional Assessment of Cancer Therapy (FACT-G) and a Prostate Cancer Treatment Outcome Questionnaire (FACT-P). Group comparisons were conducted using one-way analysis of variance (ANOVA).

RESULTS

Overall, 50% and 88.6% of patients were free of biochemical recurrence in the salvage surgery (SS) and salvage radiotherapy (SRt) group, respectively (P=0.4). The physical well-being (PWB) subscale of FACT-G was significantly higher for the SRt patients (P=0.008). Using the Trial Outcome Index Prostate subscale, the Trial Outcome Index Incontinence Urinary scores, and the Functional Assessment of Incontinence Therapy-Urinary score group comparisons, patients in the SRt group had a higher quality of life than patients in the SS group (P=0.038, P=0.001, and P=0.001, respectively).

CONCLUSIONS

In the current study, patients with clinically localized prostate cancer who are at high risk for local disease recurrence may have a trend toward better disease-free survival and a better urinary continence rates if the primary treatment is radical prostatectomy rather than radiation therapy.

Salvage surgery or salvage radiotherapy for locally recurrent prostate cancer

OBJECTIVES

To evaluate the efficacy and toxicity of salvage radiation or surgery for locally recurrent tumor after initial treatment for clinically localized prostate cancer.

METHODS

The treatment records of 70 patients with local treatment failure after definitive therapy for clinically localized prostate cancer were reviewed. Initial treatment consisted of external beam radiation therapy (RT) in 27 patients and radical retropubic prostatectomy (RP) in 43 patients.

RESULTS

The mean serum PSA levels were similar in both groups before initial treatment: 8.5 and 10.5 ng/mL for the salvage RP and salvage RT groups, respectively (P = 0.09). However, at the time of salvage treatment, the mean serum PSA levels were 9.1 and 1.1 ng/mL for the salvage RP and salvage RT groups, respectively (P = 0.0001). The mean time from tumor recurrence to salvage treatment was 15.6 months for the salvage RP group and 4.9 months for the salvage RT group (P = 0.0001 ). Although there was no statistical difference in the disease-free survival rate (P = 0.38), a trend for better disease control in the salvage RT group was evident (74.4% versus 44.4%). Patients treated with salvage RP had a higher rate of urinary incontinence than those undergoing salvage RT: 63% and 32.6%, respectively (P = 0.01).

CONCLUSIONS

The disease-free survival rate was similar between patients receiving salvage RP or RT, despite the significantly higher serum PSA levels at the time of treatment and the delay in time to treatment for the salvage RP patients. Salvage RP is associated with a high rate of urinary incontinence. Earlier identification of tumor recurrence after RT may improve the efficacy and safety of salvage RP.

Factors predicting cancer detection in biopsy of the prostatic fossa after radical prostatectomy

OBJECTIVES

To determine whether the results of anastomotic biopsy for prostate-specific antigen (PSA) recurrence after radical prostatectomy could be predicted by either PSA, PSA velocity, digital rectal examination (DRE), transrectal ultrasound (TRUS), or the interval from prostatectomy to biopsy.

METHODS

TRUS with biopsy of the anastomosis was performed for 91 postprostatectomy patients who had either an abnormal DRE or detectable PSA (greater than 0.2 ng/mL). The biopsy results were correlated with the findings of DRE, TRUS, PSA, PSA velocity, interval to PSA recurrence, and with the pathologic stage.

RESULTS

Of 131 examinations, there were 50 positive biopsy specimens for a detection rate of 38%. Of 34 patients with PSA 1.0 ng/mL or less, 8 (24%) had positive biopsy (P = 0.02). A negative DRE lowered (but did not eliminate) the probability of a positive biopsy. Of 100 patients with normal DRE, 28 (28%) had positive biopsy. None of the 11 patients with a negative DRE and a PSA of 0.5 ng/mL or less had a positive biopsy (P = 0.02). The mean interval between prostatectomy and biopsy was significantly greater in patients who had a positive biopsy (45 +/- 39) than in patients with a negative biopsy (27 +/- 21) (P = 0.001). The pathologic stage, Gleason score, and PSA velocity were not helpful in predicting the results of biopsy.

CONCLUSIONS

Although patients with a negative DRE can have a positive biopsy and patients with a PSA of 1.0 ng/mL or less can have a positive biopsy, no patient with a negative DRE and a PSA of 0.5 ng/mL or less has a positive biopsy.