Therapy of Treatment Failure After Curative Treatment of Prostate Cancer
Introduction
Recurrence rates of 40–60% after external beam radiotherapy or brachytherapy are described [1], [2]. An estimation for the USA showed that recurrences with rising PSA do occur in about 30000 new cases per year. Without any therapy median time from PSA-recurrence to clinical recurrence is about three years [3]. Patients with short PSA doubling times and a high grade malignancy are at the highest risk for early metastases and a significant mortality [4], [5].
Options for patients with biochemical recurrence after primary radiotherapy include wait- and see-strategy, hormonal treatment, or local therapy. Local treatment modalities are salvage-cyst-prostatectomy, salvage cryotherapy or salvage brachytherapy.
Expectant management is an adequate option for patients with limited survival prognosis or a low risk for tumor progression. Patients are characterized by low or intermediate grade of the tumor and long doubling-times for PSA.
The majority of patients with PSA-recurrence are treated with androgen-ablation. In the long term this is a palliative treatment, because in most of the cases the disease will become hormone refractory. Hormonal treatment can be started early or late. Continuous or intermittent therapy is possible.
In contrast to this strategy a local treatment can be curative if the disease is localized to the prostate. To potentially benefit from this therapy patients should have a long life expectancy. They should be in good health without radiation proctitis or cystitis. Patients with locally advanced tumors or evidence for lymph node metastases at the time of primary therapy should not undergo local salvage therapy [6], [7].
Rebiopsies from the prostate are positive in 60–70% of patients with rising PSA without distant metastases in imaging [8], [9]. Local salvage treatment has two aims: first to avoid local symptoms like bladder obstruction, recurrent hematuria or chronic pain [10] and second to improve survival, because an uncontrolled local recurrence is a risk factor for systemic progression and mortality [11], [12].
Radical prostatectomy is the most common primary treatment for prostate cancer. About 40% of those with high-risk pathologic features will develop biochemical failure at some point in the future. Radiotherapy, with or without concurrent androgen deprivation has been used in the management of patients with rising prostate-specific antigen (PSA) after prostatectomy. The knowledge on this therapy is based on retrospective analyses. Limited experience is reported for the treatment of patients with biopsy proven local recurrence. The rationale for recommending salvage radiotherapy is to reduce the risk of local failure and consequent progression to distant metastases and death from prostate cancer. Results of radiotherapy for isolated PSA-recurrence were separated from results of radiotherapy for biopsy proven local recurrences, because treatment strategies in terms of dose and prognosis are different.
Section snippets
Diagnosis
The detection of an isolated local recurrence remains a problem. The success rates of 30 to 40% for local salvage therapy can be put down to the fact that in a majority the disease is locally advanced or metastasized at the time of salvage treatment [13], [14], [15], [16]. The analysis of salvage prostatectomy series has shown a high incidence of infiltration of seminal vesicles or pelvic lymph nodes [13], [14], [17], [18], [19], [20], [21], [22]. A recurrence has to be differentiated from a
Treatment for isolated PSA-recurrence
For men with clinically localized prostate cancer and at least a life expectancy of at least 10 years radical prostatectomy is an accepted and effective treatment modality. The introduction of prostate specific antigen (PSA) has revolutionized the postoperative management of these patients allowing detection of recurrent disease months to years before its clinical appearance. PSA failure after radical prostatectomy is a common scenario occurring in 20–40% of men within 5 years of surgery [45],
Conclusions
Salvage prostatectomy for highly selected patients is an effective treatment with excellent long-term control. Complication rates were reduced in the last years by improvement of surgical and radiation therapy techniques. However strictures of the anastomosis and bladder incontinence remain a problem for one third of the patients. Patients with estimated local recurrence, a long-term survival prognosis, longer PSA doubling times, and PSA <10 ng/ml are good candidates for salvage prostatectomy.
CME questions
Please visit www.eu-acme.org/europeanurology to answer these EU-ACME questions on-line. The EU-ACME credits will then be attributed automatically.
- 1.
Progression-free survival 10 years after salvage prostatectomy is
- A.
between 10% and 23%
- B.
between 20% and 33%
- C.
between 30% and 43%
- D.
between 40% and 53%
- A.
- 2.
What is a curative therapy for local recurrence after prostatectomy
- A.
chemotherapy
- B.
androgenablation
- C.
immune therapy
- D.
radiotherapy
- A.
- 3.
Biochemical control following salvage radiotherapy for isolated PSA recurrence after
Statement
Recurrence rates of 40–60% after radiotherapy and 20–40% after prostatectomy are described. Salvage prostatectomy is an effective treatment. Radiotherapy to the prostatic bed after prostatectomy is a potentially curative therapy. Patients have to been treated early for PSA relapse.
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