International Journal of Radiation Oncology*Biology*Physics
Clinical investigationProstateLong-term oncologic results of salvage radical prostatectomy for locally recurrent prostate cancer after radiotherapy
Introduction
On the basis of the American Society of Therapeutic Radiology and Oncology definition for prostate-specific antigen (PSA) failure, an estimated 62% of patients will experience disease progression within 10 years after radiotherapy (RT) for clinically localized (Stage cT1-T2) prostate cancer (1, 2, 3). A substantial proportion of these patients may have isolated locally recurrent disease, defined by a positive prostate biopsy 1–2 years after RT in conjunction with a rising PSA level but without evidence of systemic disease (4, 5). The value of earlier biopsies has been questioned, because the cancer may still be regressing (4, 6). The prevalence of local recurrence in a recent multi-institutional study of 4,839 patients was 26% for the PSA-failure patients and 9% for the overall cohort (1). However, up to 70% of patients with biochemical progression after RT will have local persistence as the only site of recurrent disease (7). Treatment options for men with isolated local recurrence include expectant management, androgen deprivation therapy (ADT), or additional local therapy with salvage radical prostatectomy (RP), cryotherapy, brachytherapy, or hyperthermia (8). Only salvage RP has been shown to provide a durable cure (as determined by undetectable PSA levels) in the setting of radio-recurrent prostate cancer (9, 10, 11, 12).
In a consecutive cohort of patients with biopsy-confirmed, locally recurrent prostate cancer after external beam RT (EBRT) and/or brachytherapy, we report the long-term oncologic results of salvage RP and identify predictors of long-term cancer control and cancer-specific mortality.
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Methods and materials
Between June 1984 and July 2003, 100 consecutive patients underwent salvage RP with curative intent for biopsy-confirmed, locally recurrent prostate cancer after RT by one of two surgeons (J.A.E. and P.T.S.) at Baylor College of Medicine (n = 65) or Memorial Sloan-Kettering Cancer Center (n = 35). The selection criteria for salvage RP included life expectancy >10 years, the presence of clinically localized prostate cancer (at RT and before salvage RP), the absence of significant voiding
Results
The median follow-up after RT and salvage RP was 10 years (range, 3–24 years) and 5 years (range, 1–20 years), respectively. The median age at salvage RP was 65 years (range, 44–75 years). Table 1 lists the preoperative patient characteristics. The median preoperative PSA level was 5.9 ng/mL (range, 0.7–83 ng/mL), and 41 patients had preoperative PSA levels >10 ng/mL. The proportion of patients with a PSA level >10 ng/mL had decreased significantly since 1993 (56% vs. 13%, p = 0.001). Overall,
Discussion
The past 20 years have witnessed significant changes in the diagnosis and treatment of prostate cancer patients. The discovery and characterization of PSA has resulted in a stage migration, with most patients now diagnosed with clinically localized disease. Together with early diagnosis, improvements in surgical and RT techniques have resulted in greater cure rates and lower morbidities. There appears to have been significant progress in prostate cancer survival, as evidenced by the
Conclusion
Salvage RP, although technically challenging, provides excellent local control of radio-recurrent cancer and can eradicate the disease in a high proportion of patients who are treated while the cancer is confined to the prostate or immediate periprostatic tissue. Suspicion of radio-recurrent disease by an inconsistent PSA pattern in patients with good health and a life expectancy >10 years should prompt an early biopsy to identify the patients who may benefit from additional local therapy with
References (17)
- 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) - et al.
Critical evaluation of salvage surgery for radio-recurrent/resistant prostate cancer
J Urol
(1995) - et al.
Followup of irradiated prostatic carcinoma by aspiration biopsy
J Urol
(1977) - et al.
The source of pretreatment serum prostate-specific antigen in clinically localized prostate cancer—T, N, or M?
Int J Radiat Oncol Biol Phys
(1995) - et al.
Treatment options for localized recurrence of prostate cancer following radiation therapy
Urol Clin North Am
(1996) - et al.
Predictors for maximal outcome in patients undergoing salvage surgery for radio-recurrent prostate cancer
Urology
(1998) - et al.
Salvage radical prostatectomyOutcome measured by serum prostate specific antigen levels
J Urol
(1995) - et al.
Morbidity and functional outcomes of salvage radical prostatectomy for locally recurrent prostate cancer after radiation therapy
J Urol
(2004)
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2021, UrologyCitation Excerpt :This is the first reported series reporting on the outcomes of Retzius-sparing RARP in the salvage setting. Salvage prostatectomy is largely underutilized because of technical difficulties, increased complications, and disappointing continence outcomes.12,13 Recent studies however showed an improvement in continence and overall complications over historical data.3,14,15
F.J.B. and A.J.S. are supported in part by the American Foundation for Urologic Disease and a T32 Training Grant (82088) from the National Institutes of Health.