Elsevier

EAU-EBU Update Series

Volume 4, Issue 6, December 2006, Pages 228-240
EAU-EBU Update Series

Therapy of Treatment Failure After Curative Treatment of Prostate Cancer

https://doi.org/10.1016/j.eeus.2006.08.001Get rights and content

Abstract

Objective

Recurrence rates of 40–60% after percutaneous radiotherapy or brachytherapy and 20–40% after prostatectomy are described. This review will discuss curative treatment options for salvage after primary therapy.

Methods

Relevant information was identified through searches of published studies, abstracts from scientific meetings, and review articles.

Results

Clinical experience in salvage therapy is limited. Salvage prostatectomy is an effective method to treat selected patients with recurrence after percutaneous radiotherapy. Cryoablation and brachytherapy are alternative methods. 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.

Conclusions

Salvage prostatectomy for highly selected patients is an effective treatment with excellent long-term control. Complication rates were reduced in the last years. 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.

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%

  • 2.

    What is a curative therapy for local recurrence after prostatectomy

    • A.

      chemotherapy

    • B.

      androgenablation

    • C.

      immune therapy

    • D.

      radiotherapy

  • 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.

References (109)

  • P. Link et al.

    Radical prostatectomy after definitive radiation therapy for prostate cancer

    Urology

    (1991)
  • A. Stein et al.

    Salvage radical prostatectomy after failure of curative radiotherapy for adenocarcinoma of prostate

    Urology

    (1992)
  • D.A. Kuban et al.

    Long-term multi-institutional analysis of stage T1-T2 prostate cancer treated with radiotherapy in the PSA era

    Int J Radiat Oncol Biol Phys

    (2003)
  • J.N. Kabalin et al.

    Identification of residual cancer in the prostate following radiation therapy: role of transrectal ultrasound guided biopsy and prostate specific antigen

    J Urol

    (1989)
  • J. Crook et al.

    Postradiotherapy prostate biopsies: what do they really mean? Results for 498 patients

    Int J Radiat Oncol Biol Phys

    (2000)
  • M.J. Zelefsky et al.

    High dose radiation delivered by intensity modulated conformal radiotherapy improves the outcome of localized prostate cancer

    J Urol

    (2001)
  • A. Pollack et al.

    Prostate cancer radiation dose response: results of the M.D. Anderson phase III randomized trial

    Int J Radiat Oncol Biol Phys

    (2002)
  • J. Crook et al.

    Postradiotherapy prostate biopsies: what do they really mean? Results for 498 patients

    Int J Radiat Oncol Biol Phys

    (2000)
  • A.L. Zietman et al.

    Use of PSA nadir to predict subsequent biochemical outcome following external beam radiation therapy for T1-2 adenocarcinoma of the prostate

    Radiother Oncol

    (1996)
  • F.A. Critz et al.

    Post-treatment PSA < or = 0.2 ng/ml defines disease freedom after radiotherapy for prostate cancer using modern techniques

    Urology

    (1999)
  • C.I. Sartor et al.

    Rate of PSA rise predicts metastatic versus local recurrence after definitive radiotherapy

    Int J Radiat Oncol Biol Phys

    (1997)
  • J.F. Ward et al.

    Salvage surgery for radiorecurrent prostate cancer: contemporary outcomes

    J Urol

    (2005)
  • S.E. Lerner et al.

    Critical evaluation of salvage surgery for radio-recurrent/resistant prostate cancer

    J Urol

    (1995)
  • P. Perrotte et al.

    Quality of life after salvage cryotherapy: the impact of treatment parameters

    J Urol

    (1999)
  • D.C. Beyer

    Permanent brachytherapy as salvage treatment for recurrent prostate cancer

    Urology

    (1999)
  • G.L. Grado et al.

    Salvage brachytherapy for localized prostate cancer after radiotherapy failure

    Urology

    (1999)
  • W.J. Catalona et al.

    5-year tumor recurrence rates after anatomical radical retropubic prostatectomy for prostate cancer

    J Urol

    (1994)
  • P.A. Kupelian et al.

    Stage T1-2 prostate cancer: a multivariate analysis of factors affecting biochemical and clinical failures after radical prostatectomy

    Int J Rad Oncol Biol Phys

    (1997)
  • M.S. Anscher et al.

    Radiotherapy for a rising prostate-specific antigen after radical prostatectomy: the first ten years

    Int J Radiat Oncol Biol Phys

    (2000)
  • D.M. Nudell et al.

    Radiotherapy after radical prostatectomy: treatment outcomes and failure patterns

    Urology

    (1999)
  • T.M. Pisansky et al.

    Radiotherapy for isolated serum prostate specific antigen elevation after prostatectomy for prostate cancer

    J Urol

    (2000)
  • M.S. Anscher et al.

    Radiotherapy vs. hormonal therapy for the management of locally recurrent prostate cancer following radical prostatectomy

    Int J Rad Oncol Biol Phys

    (1989)
  • C. Catton et al.

    Adjuvant and salvage radiation therapy after radical prostatectomy for adenocarcinoma of the prostate

    Radiother Oncol

    (2001)
  • M.J. Zelefsky et al.

    Tolerance and early outcome results of postprostatectomy three-dimensional conformal radiotherapy

    Int J Radiat Oncol Biol Phys

    (1997)
  • J.A. Kalapurakal et al.

    Biochemical disease-free survival following adjuvant and salvage irradiation after radical prostatectomy

    Int J Radiat Oncol Biol Phys

    (2002)
  • A.K. Chawla et al.

    Salvage radiotherapy after radical prostatectomy for prostate adenocarcinoma: Analysis of efficacy and prognostic factors

    Urology

    (2002)
  • R. Choo et al.

    (In)-Efficacy of salvage radiotherapy for rising PSA or clinically isolated local recurrence after radical prostatectomy

    Int J Radiat Oncol Biol Phys

    (2002)
  • O.K. Macdonald et al.

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

    Int J Rad Oncol Biol Phys

    (2004)
  • O.K. Macdonald et al.

    Radiotherapy for men with isolated increase in serum prostate specific antigen after radical prostatectomy

    J Urol

    (2003)
  • I.D. Kaplan et al.

    Serum prostate-specific antigen after postprostatectomy radiotherapy

    Urology

    (1992)
  • J.F. Montie

    Follow-up after radical prostatectomy or radiation therapy for prostate cancer

    Urol Clin North Am

    (1994)
  • A.W. Partin et al.

    Serum PSA after anatomic radical prostatectomy. The Johns Hopkins experience after 10 years

    Urol Clin North Am

    (1993)
  • D.F. Paulson

    Impact of radical prostatectomy in the management of clinically localized disease

    J Urol

    (1994)
  • P.A.S. Johnstone et al.

    Yield of imaging and scintigraphy assessing biochemical failure in prostate cancer patients

    Urol Oncol

    (1997)
  • M.L. Cher et al.

    Limited role of radionuclide bone scintigraphy in patients with prostate specific antigen elevations after radical prostatectomy

    J Urol

    (1998)
  • S.M. Eulau et al.

    Effect of combined transient androgen deprivation and irradiation following radical prostatectomy for prostatic cancer

    Int J Radiat Oncol Biol Phys

    (1998)
  • M.S. Anscher et al.

    Radiotherapy vs. hormonal therapy for the management of locally recurrent prostate cancer following radical prostatectomy

    Int J Rad Oncol Biol Phys

    (1989)
  • C.H. Crane et al.

    Preirradiation PSA predicts biochemical disease-free survival in patients treated with postprostatectomy external beam irradiation

    Int J Radiat Oncol Biol Phys

    (1997)
  • R. Mayer et al.

    Postprostatectomy radiotherapy for high-risk prostate cancer

    Urology

    (2002)
  • M.M. Morris et al.

    Adjuvant and salvage irradiation following radical prostatectomy for prostate cancer

    Int J Radiat Oncol Biol Phys

    (1997)
  • Cited by (6)

    View full text