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

Salvage radiotherapy for biochemical relapse after complete PSA response following radical prostatectomy: outcome and prognostic factors for patients who have never received hormonal therapy

Objectives

To evaluate the results of salvage conformal radiation therapy (3DC-EBRT) for patients submitted to radical prostatectomy (RP) who have achieved complete PSA response and who have never been treated with hormonal therapy (HT).

To present the results of biochemical control, a period free from hormonal therapy and factors related to its prognosis.

Materials and methods

from August 2002 to December 2004, 43 prostate cancer patients submitted to RP presented biochemical failure after achieving a PSA < 0.2 ng/ml. They have never received HT and were submitted to salvage 3DC-EBRT. Median age was 62 years, median preoperative PSA was 8.8 ng/ml, median Gleason Score was 7. Any PSA rise above 0.2 was defined as biochemical failure after surgery. Median 3DC-EBRT dose was 70 Gy, biochemical failure after EBRT was defined as 3 consecutive rises in PSA or a single rise enough to trigger HT.

Results

3-year biochemical non-evidence of disease (BNED) was 71%. PSA doubling time lower than 4 months (p = 0.01) and time from recurrence to salvage EBRT (p = 0.04) were associated with worse chance of biochemical control. Biochemical control of 76% was achieved when RT had been introduced with a PSA lower than 1 ng/ml vs. 48% with a PSA higher than 1 (p = 0.19). Late toxicity was acceptable.

Conclusion

70% of biochemical control in 3 years can be achieved with salvage radiotherapy in selected patients. The importance of PSADT was confirmed in this study and radiotherapy should be started as early as possible. Longer follow up is necessary, but it is possible to conclude that a long interval free from hormonal therapy was achieved with low rate of toxicity avoiding or at least delaying several important adverse effects related to hormonal treatment.

Long-term results and predictive factors of three-dimensional conformal salvage radiotherapy for biochemical relapse after prostatectomy

PURPOSE

Salvage radiotherapy (RT) is used to treat patients with biochemical failure after radical prostatectomy (RP). Although retrospective series have demonstrated that salvage RT will result in biochemical response in approximately 75% of patients, long-term response is much lower (20-40%). The purpose of this study was to determine prognostic factors related to the prostate-specific antigen (PSA) outcome after salvage RT.

METHODS AND MATERIALS

Between 1991 and 2004, 171 patients received salvage RT at the University of Heidelberg. Patient age, margin status, Gleason score, tumor grading, pathologic tumor stage, pre-RP and pre-RT PSA levels, and time from RP to rise of PSA were analyzed.

RESULTS

Median follow-up time was 39 months. The 5-year overall and clinical relapse-free survival were 93.8% and 80.8%, respectively. After RT serum PSA decreased in 141 patients (82.5%). The 5-year biochemical relapse-free survival was 35.1%. Univariate analysis showed following statistically significant predictors of PSA recurrence after RT: preoperative PSA level (p = 0.035), pathologic tumor classification (p = 0.001), Gleason score (p < 0.001), tumor grading (p = 0.004), and pre-RT PSA level (p = 0.031). On multivariate analysis, only Gleason score (p = 0.047) and pre-RT PSA level (p = 0.049) were found to be independently predictive of PSA recurrence.

CONCLUSIONS

This study represents one of the largest retrospective studies analyzing the outcome of patients treated with salvage RT at a single institution. Our findings suggest that patients with Gleason score <7 and low pre-RT PSA levels are the best candidates for salvage RT, whereas patients with high-grade lesions should be considered for additional treatment (e.g., hormonal therapy).

Natural history of biochemical recurrence after radical prostatectomy: risk assessment for secondary therapy

PURPOSE

A persistently elevated or rising serum level of prostate-specific antigen (PSA) after radical prostatectomy is indicative of recurrent prostate cancer. The natural history of PSA-defined biochemical recurrence (BCR) is highly variable. While a rising PSA level universally antedates metastatic progression and prostate cancer-specific mortality (PCSM), it is not a surrogate for these endpoints. Thus, the management of patients with BCR is controversial.

METHODS

A literature review was conducted to determine the incidence and natural history of BCR, prognostic factors for clinical progression (CP), and the available evidence supporting local or systemic salvage therapy for these patients.

RESULTS

BCR is best defined as two successive PSA levels > or =0.4 ng/ml, as this correlates most accurately with CP. PSA doubling time (PSA-DT) and prostatectomy Gleason score are the variables that best predict the development of distant metastasis and PCSM. Prognostic models based on these and other variables are useful for assessing the need for salvage therapy and the anticipated outcome following local salvage therapy. A treatment algorithm for managing patients with post-prostatectomy BCR was devised.

CONCLUSIONS

Management of patients with BCR after prostatectomy continues to be a complex and challenging issue. Improved methods for risk stratification allow for identification of patients who require treatment. Furthermore, these methods aid in determination of the pattern of disease recurrence, thereby guiding treatment modality. Randomized trials are essential to determine the value of local or systemic salvage therapy strategies in this patient population.

Toxicity following high-dose salvage radiotherapy after radical prostatectomy

OBJECTIVE

To assess gastrointestinal (GI) and genitourinary (GU) toxicity in patients treated with salvage radiotherapy (SRT) at doses of 70.2 Gy after radical retropubic prostatectomy (RRP).

PATIENTS AND METHODS

Medical records were reviewed retrospectively to identify patients treated with SRT after RRP between January 1999 and December 2005. Of the 62 patients identified, 30 were included for analysis. GI and GU toxicity was assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events and the American Urological Association Symptom Index (AUASI), respectively.

RESULTS

The median AUASI score of the 17 patients with scores before SRT was 4, of the 24 with scores after SRT was 6, and of the 15 with scores before and after SRT the median increase was 3. Of the 29 patients with GI toxicity data, nine (31%) had diarrhoea after SRT (three after <70.2 Gy and six after 70.2 Gy). In all cases, the diarrhoea was mild (grade 1). Of all patients, 12 (41%) had proctitis after SRT (four after <70.2 Gy and eight after 70.2 Gy); the proctitis was grade 1 in four and grade 2 in eight, with no cases of grade 3 proctitis. There was no statistically significant difference in the median change in AUASI scores and GI toxicity incidence between patients receiving <70.2 or 70.2 Gy of SRT.

CONCLUSION

High-dose SRT (70.2 Gy) is generally well tolerated with acceptable low-grade GI toxicity and minimal changes in AUASI scores.

Variables which might predict the response to salvage radiotherapy in chinese patients with biochemical failure after radical prostatectomy

BACKGROUND/AIMS

To evaluate the relationship between the variables and the outcomes of salvage radiotherapy (sRT) to find some predictors of sRT.

METHODS

The medical records of 56 patients receiving sRT for biochemical failure after radical prostatectomy (RP) were available for retrospective review. sRT was defined as external beam radiotherapy for patients with a continuous increase in the prostate-specific antigen (PSA) level of >or=0.2 ng/ml after RP. Response was defined as achievement of a PSA nadir of <or=0.1 ng/ml.

RESULTS

The mean follow-up period after sRT was 31.6 months. The predictors of response to sRT were PSA doubling time (PSADT) and seminal vesicle invasion. The median PSADT in responders was 6.5 months versus 4.0 months in non-responders (OR=1.66, p=0.006). The patients with a PSADT of >6 months were all responders. The response rate in patients with seminal vesicle invasion was 42.9% (6/14) versus 76.2% (32/42) in patients without seminal vesicle invasion (OR=0.119, p=0.015).

CONCLUSION

PSADT and the state of seminal vesicle invasion were good predictors of response to sRT. sRT was especially effective when the PSADT was >6 months and in patients without seminal vesicle invasion.

Strahlentherapie beim Lokalrezidiv des Prostatakarzinoms

Approximately 25% of patients experience recurrent disease after radical prostatectomy. Most frequently, the only evidence of a relapse is a rising PSA level without clinical evidence. Without further treatment the natural history of PSA progression results in local recurrence or distant metastasis of prostate cancer. Since a proportion of these biochemical failures relate to a local recurrence, radiotherapy offers a potential curative approach. Up to now, no randomized studies are available. Therefore any decision can only be based on prospective observation studies or retrospective data. The data available indicate that optimal results can be obtained in patients with PSA levels below 1-2 ng/ml or even lower, a documented R1 resection, and a PSA doubling time>10 months. Doses of 64-66 Gy seem to be required for adequate control. Side effects are generally well acceptable and importantly no adverse effects on urinary continence have been documented. Taken together, radiotherapy is the only treatment option with curative potential in situations where a local failure is highly likely.

Long-term salvage radiotherapy outcome after radical prostatectomy and relapse predictors

PURPOSE

We assessed the efficacy of salvage radiotherapy (SRT) and analyzed predictors of biochemical progression-free survival (bPFS) and distant metastasis-free survival in patients with clinically localized disease recurrence after radical prostatectomy.

MATERIALS AND METHODS

The records of 114 patients treated with SRT at 2 institutions between 1991 and 2001 were retrospectively reviewed. Time to biochemical recurrence and to distant metastases was analyzed using the Kaplan-Meier estimation. Candidate predictors of bPFS and distant metastasis-free survival were analyzed using the log rank test and Cox regression. Acute and late complications were scored using Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer criteria.

RESULTS

At a median followup of 6.3 years (range 1.9 to 13.3) for SRT 4 and 6-year bPFS was 50% (95% CI 42% to 61%) and 33% (95% CI 24% to 43%), respectively. The 6-year actuarial probability of distant metastases after SRT was 14%. Multivariate analysis demonstrated an independent association of increasing Gleason score, lymphovascular invasion and lack of a complete response to SRT with decreased 5-year bDFS. These factors were associated with significantly less 5-year distant metastasis-free survival. Pre-RT prostate specific antigen greater than 2.0 ng/ml was associated with significantly decreased 5-year bDFS and distant metastasis-free survival, although it was not maintained on multivariate analysis.

CONCLUSIONS

SRT results in durable prostate specific antigen control in select patients. It is well tolerated with few severe late effects. Increasing Gleason score, lymphovascular invasion and lack of a complete response to SRT are significant risks for disease progression requiring additional management.

Approaching clinical problems in prostate cancer radiotherapy using the number needed to treat (NNT) technique

The goals of this article are to review the application of the number needed to treat (NNT) concept to selected clinical problems in prostate cancer radiotherapy. Particular emphasis will be placed on (1) comparison of radiotherapy with other treatment options for early-stage disease, (2) the role of hormone therapy in addition to radiotherapy over a spectrum of disease presentation, and (3) systematic comparison of adjuvant versus salvage radiotherapy in the post-prostatectomy setting. Limitations of NNT calculations based on non-randomized comparisons also are discussed.

Timing and patterns of recurrences and deaths from prostate cancer following adjuvant pelvic radiotherapy for pathologic stage T3/4 adenocarcinoma of the prostate

To determine the timing and patterns of late recurrence after radical prostatectomy (RP) alone or RP plus adjuvant radiotherapy (RT). Between 1970 and 1983, 159 patients underwent RP for newly diagnosed adenocarcinoma of the prostate and were found to have positive surgical margins, extracapsular extension and/or seminal vesicle invasion. Of these, 46 received adjuvant RT and 113 did not. The RT group generally received 45-50 Gy to the whole pelvis, then a boost to the prostate bed (total dose of 55-65 Gy). In the RP group, 62% received neoadjuvant/adjuvant androgen deprivation vs 17% in the RT group. Patients were analyzed with respect to timing and patterns of failure. Only one patient was lost to follow-up. The median follow-up for surviving patients was nearly 20 years. The median time to failure in the surgery group was 7.5 vs 14.7 years in the RT group (P=0.1). Late recurrences were less common in the surgery group than the RT group (9 and 1% at 10 and 15 years, respectively vs 17 and 9%). In contrast to recurrences, nearly half of deaths from prostate cancer occurred more than 10 years after treatment. Deaths from prostate cancer represented 55% of all deaths in these patients. Recurrences beyond 10 years after RP in this group of patients were relatively uncommon. Despite its long natural history, death from prostate cancer was the most common cause of mortality in this population with locally advanced tumors, reflecting the need for more effective therapy.

Management of the Patient with a Rising PSA Alone

PSA-only recurrence after definitive RP or RT for PCA is an increasingly com-mon scenario. The very definition of advanced prostate cancer is changing. Multimodal therapy improves cancer-specific outcomes especially in men with high-risk disease. After RP, a detectable serum PSA has been considered suggestive of PCA recurrence. After RT, the ASTRO definition of BCR has been widely used to define BCR. Both of these definitions of BCR are subject to dispute. The kinetics of a rising PSA (PSA doubling time) appears to be the best surrogate marker for disease risk, clinical progression, and ultimately cancer-specific death. Therapeutic options include salvage RT after primary RP or systemic HT through surgical/chemical castration, antiandrogens, or nontraditional HT. Re-cent studies suggest that early HT can provide modest survival benefits, but at both an economic cost and decreased quality of life. The diminished side effects of an oral antiandrogen are appealing, and may be as efficacious as castration therapies in low-volume disease. More clinical trials are needed to determine the best treatments, alone and in combination. The potential opportunities for novel therapeutic agents with low associated morbidity are great.

Salvage conformal radiotherapy for biochemical recurrent prostate cancer after radical prostatectomy

OBJECTIVE

Assess the results of salvage conformal radiotherapy in patients with biochemical failure after radical prostatectomy and identify prognostic factors for biochemical recurrence and toxicity of the treatment.

MATERIALS AND METHODS

From June 1998 to November 2001, 35 patients were submitted to conformal radiotherapy for PSA > or = 0.2 ng/mL in progression after radical prostatectomy and were retrospectively analyzed. The mean dose of radiation in prostatic bed was of 77.4 Gy (68-81). Variables related to the treatment and to tumor were assessed to identify prognostic factors for biochemical recurrence after salvage radiotherapy.

RESULTS

The median follow-up was of 55 months (17-83). The actuarial survival rates free of biochemical recurrence and free of metastasis at a distance of 5 years were 79.7% e 84.7%, respectively. The actuarial global survival rate in 5 years was 96.1%. The actuarial survival rate free of biochemical recurrence in 5 years was 83.3% with PSA pre-radiotherapy < or = 1, 100% when > 1 and < or = 2, and 57.1% when > 2 (p = 0.023). Dose > 70 Gy in 30% of the bladder volume implied in more acute urinary toxicity (p = 0.035). The mean time for the development of late urinary toxicity was 21 months (12-51). Dose > 55 Gy in 50%bladder volume implied in more late urinary toxicity (p = 0.018). A patient presented late rectal toxicity of 2nd grade.

CONCLUSIONS

Conformal radiotherapy showed to be effective for the control of biochemical recurrence after radical prostatectomy. Patients with pre-therapy PSA < or = 2 ng/mL have more biochemical control.

Conduite à tenir devant une ascension du PSA après rémission complète postprostatectomie ?

Between twenty and to forty percent of patients will develop an isolated PSA failure after a radical prostatectomy. Pelvic irradiation is a therapeutic option with curative intention. It is the best therapeutic option for young people with good prognostic factors. Combined radiation with hormonal or chemotherapy should be evaluated in patients with poor prognostic factors. For patients with a short life expectancy, hormonotherapy or a watch and see policy are acceptable options.

Biochemical Recurrence after Localized Treatment

The quoted incidence of biochemical recurrence (BCR) after localized treatment varies significantly and depends on numerous well-known prognostic factors; however, it likely occurs in at least 30%-40% of patients who receive localized treatment. Because the clinical significance of BCR is often unclear, and depends in many cases on unknown factors, it is difficult to select the best treatment and determine when best to institute that therapy. This review examines some of the issues associated with BCR and attempts to shed some light on this common but controversial clinical scenario. Some treatment strategies discussed in this article include salvage radiotherapy after radical prostatectomy, salvage therapy after radiotherapy, and hormonal therapy.

Radiothérapie pelvienne pour récidive biochimique isolée après prostatectomie pour cancer de prostate : quels volumes ?

After prostatectomy, radiotherapy is a potential curable treatment. From the surgery series, it is possible to identify all the localization at risk in case of biochemical relapse after prostatectomy. The target volume of irradiation has to be defined according to the pathological findings. The CTV is limited to the pelvic fascia laterally, to the anterior wall of the rectum behind. The inferior limit includes the anastomosis, and the superior is easier to define with the length of the prostatic gland. The inclusion of area of seminal vesicles and pelvic node areas should be discussed. The use of surgical clips on the anastomosis and image fusionning techniques including the preoperative imaging would help physicians to define the CTV's limits.

The value of radiotherapy in treating recurrent prostate cancer after radical prostatectomy

Approximately 25-40% of men who undergo radical retropubic prostatectomy (RRP) for the treatment of clinically localized prostate cancer will experience biochemical recurrence. A rapid prostate-specific antigen (PSA) doubling time or high-grade disease are risk factors for progression to bone metastases and cancer-specific mortality. Salvage external-beam radiotherapy (EBRT) to the prostate fossa is the only curative therapy for patients with biochemical recurrence after RRP, but it is used relatively infrequently to treat recurrent prostate cancer because of a widespread perception that most patients have systemic recurrence, and its reported lack of efficacy for high-risk disease. However, in a large, multicenter study of patients who received salvage EBRT for a rising PSA level after RRP, a substantial proportion of patients with high-grade disease and/or a rapid PSA doubling time were observed to have a favorable outcome after salvage EBRT if it was administered at low PSA values. This suggests that salvage EBRT could provide long-term cancer control for patients at the highest risk of progression to bone metastases and cancer-specific mortality. A nomogram that predicts the 3-year progression-free probability after salvage EBRT has been developed to facilitate the selection of patients for this potentially curative therapy. In the absence of other curative therapies, all patients with recurrent prostate cancer should be considered for salvage EBRT, particularly those with positive surgical margins. To be successful, salvage EBRT should be administered at the earliest evidence of recurrent disease, once a rising PSA trend as been confirmed.

Lymphovascular invasion in prostate cancer: prognostic significance in patients treated with radiotherapy after radical prostatectomy

BACKGROUND

Lymphovascular invasion (LVI) is found in approximately 5% to 53% of specimens after radical prostatectomy (RP). Although LVI is associated with higher rates of recurrence after RP, its prognostic significance after postprostatectomy radiotherapy (P-XRT) is unclear.

METHODS

The medical records of men who received P-XRT from 1991 to 2001 at 2 institutions were reviewed for the presence of LVI in RP specimens. Multiple patient variables were evaluated for their association with LVI using Fisher exact tests and Wilcoxon rank-sum tests. The time to biochemical recurrence (BCR) and the time to distant metastases (DM) after RP were analyzed using Kaplan-Meier estimations, log-rank tests, and Cox regression analyses.

RESULTS

Eighteen of 160 patients (11%) who received P-XRT had LVI in their RP specimen. High Gleason score and seminal vesicle invasion were associated significantly with LVI. After a median follow-up of 8.3 years after RP, 16 patients with LVI had BCR after P-XRT, 9 of whom developed DM. The median time to BCR in patients with LVI was 2.6 years (95% confidence interval [95% CI], 1.8-5.4) compared with 7.8 years (95% CI, 6.8-10.3) in patients without LVI (P < .001). Multivariate analysis revealed an adjusted relative risk for LVI of 5.5 (P < .001). Other significant factors were Gleason score, undetectable post-RP serum prostate-specific antigen (PSA) levels, preradiotherapy serum PSA levels, and the interval from RP to P-XRT. LVI was the only significant factor associated with an increased risk of DM in univariate analysis (hazard ratio, 7.4; P < .001).

CONCLUSIONS

LVI was useful as a pathologic marker for reduced efficacy of P-XRT after RP in terms of increased risk of BCR and DM. Future studies will be needed to validate these findings.

The effect of postprostatectomy external beam radiotherapy on quality of life

BACKGROUND

Postprostatectomy salvage radiotherapy may improve prostate-specific antigen (PSA) progression-free survival, but little is known about its effect on quality of life.

METHODS

From the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) data base, 1289 patients who had undergone radical prostatectomy (RP) without neoadjuvant or adjuvant hormone therapy completed validated health-related quality of life (HRQOL) questionnaires. Of these, 69 patients also received salvage radiotherapy at a median of 14 months after RP. The University of California-Los Angeles Prostate Cancer Index and the 36-item short form SF-36 questionnaire were used to compare HRQOL 12 to 18 months after external beam radiotherapy or 26 to 32 months after RP alone. Those responses also were compared with HRQOL responses from 55 men with data prior to and 12 to 18 months after primary radiotherapy. Multivariate regression identified differences between treatment groups.

RESULTS

Men who underwent salvage radiotherapy were younger (P = .03) and had lower incomes (P = .01) than men who underwent RP alone; they also were younger than men who underwent primary radiotherapy (P < .01). In addition, men who received salvage radiotherapy were more likely than men who underwent RP alone to have clinically high-risk prostate cancer (P < .01). Multivariate analyses revealed that men who received salvage radiotherapy experienced more marked decrements in sexual function (P = .01) and bowel function (P = .03) than men who underwent RP alone. Salvage radiotherapy led to less impairment of sexual function (P < .01) and less sexual bother (P = .04) than primary radiotherapy.

CONCLUSIONS

Although salvage radiotherapy is associated with unclear survival benefits, it adversely affects sexual and bowel function. Until randomized clinical trials demonstrate disease-specific survival benefits for salvage radiotherapy, the HRQOL detriments of additional therapy must be weighed against improved PSA progression-free survival.

Utility of prostate-specific antigen kinetics in addition to clinical factors in the selection of patients for salvage local therapy

A detectable and rising prostate-specific antigen (PSA) level after radical prostatectomy or a rising PSA above the nadir value after radiation therapy may represent a local failure, distant failure, or both. Determining the site or sites of failure is critical for selecting the appropriate salvage therapy. Nevertheless, although PSA failure precedes clinically evident failure by several years, determining the source of the biochemical failure is often not possible using currently available diagnostic studies. Selecting the optimal therapeutic approach may be guided by the initial clinical factors (eg, T-category, PSA, biopsy Gleason score). If the patient has had a radical prostatectomy, then the pathologic outcomes of the surgery (eg, pathologic T-category and prostatectomy Gleason score, nodal and margin status) may provide further information. Beyond pretreatment clinical and post-treatment pathologic factors, PSA kinetics, and specifically a pretreatment PSA velocity > 2 ng/mL/year, an interval to PSA failure < 3 years and a post-treatment PSA doubling time < 3 months place a man at increased risk for metastases and subsequent prostate cancer-specific mortality, making these men poor candidates for local-only salvage therapy. Therefore, the optimal candidate for local-only salvage therapy is a man whose pretreatment PSA velocity was 2 ng/mL/year or less, interval to PSA failure exceeds 3 years, and post-treatment PSA doubling time is at least 12 months, and who did not have biopsy or prostatectomy Gleason score of 8 to 10 or seminal vesicle or lymph node involvement.

Salvage radiotherapy for biochemical recurrence after radical prostatectomy

OBJECTIVE

To evaluate the clinical outcome of salvage radiotherapy (RT) for biochemical recurrence after radical prostatectomy (RP) at our institution.

PATIENTS AND METHODS

Between March 1999 and January 2004, 37 patients had salvage RT for prostate-specific antigen (PSA) failure after RP, including eight who had had neoadjuvant hormone therapy. After surgery, PSA was measured with ultrasensitive immunoassays. In all patients RT was delivered to the prostatic bed at a total dose of 60 Gy with a four-field box technique.

RESULTS

The median (range) PSA level before salvage RT was 0.146 (0.06-3.216) ng/mL and RT was started at a PSA level of <0.5 ng/mL in 34 of the 37 patients (92%). With a median follow-up of 31.9 (0-69.8), months, 11 patients (30%) had disease progression after RT and the 3- and 5-year progression-free probability was 74% and 54%, respectively. Univariate analysis showed that clinical and pathological tumour stages and PSA level before RT (>0.15 vs < or = 0.15 ng/mL) were significant predictors of disease progression. There were no late adverse events related to RT.

CONCLUSION

Salvage RT for biochemical failure after RP at a low PSA level, using ultrasensitive immunoassays for monitoring, is a reasonably effective treatment. A relatively low radiation dose (60 Gy) seems to be effective.

Parameters for Treatment Decisions for Salvage Radiation Therapy

Radical prostatectomy (RP) is the most common primary treatment for prostate cancer. About 40% of those with high-risk pathologic features, such as a positive margin or seminal vesicle involvement, will develop biochemical failure at some point in the future. Radiotherapy (RT), with or without concurrent androgen deprivation, has been used liberally in the management of men with a rising prostate-specific antigen (PSA) after RP, based mostly on relatively small retrospective series. Factors such as the prostatectomy Gleason score, seminal vesicle invasion, absolute pre-RT PSA level, and pre-RT PSA doubling time are emerging as important determinants of outcome after RT. These factors should be used as a guide to the options of local therapy alone (RT), local therapy plus systemic therapy (typically androgen deprivation therapy), and systemic therapy alone.

Salvage radiation therapy for prostate specific antigen progression following radical prostatectomy: 10-year outcome estimates

PURPOSE

We evaluated men treated with salvage radiation therapy for increasing serum prostate specific antigen (PSA) following radical retropubic prostatectomy (RRP).

MATERIALS AND METHODS

We retrospectively reviewed the records of 3,478 consecutive men who underwent radical retropubic prostatectomy (RRP) between 1983 and 2003, as performed by a single surgeon. A total of 307 men received salvage radiation therapy for persistently increased or increasing PSA after RRP. We compared perioperative and peri-radiotherapy clinicopathological parameters in men who achieved an undetectable PSA level after radiation therapy (responders) vs those who did not (nonresponders). We then evaluated the durability of the PSA response.

RESULTS

Median time from RRP to PSA progression was 23 months (range 1 to 129). Median followup from RRP was 104 months (range 7 to 225). Median followup from salvage radiotherapy was 56 months (range 0 to 188). Of 223 men with sufficient followup information 162 (73%) subsequently had undetectable PSA (less than 0.3 ng/ml) in response to salvage radiation therapy. There was no significant difference between responders and nonresponders in the distribution of clinical and pathological tumor stages, age at RRP, surgical margin status, and the interval between RRP and salvage radiation therapy. A Gleason score of 8 to 10 was more prevalent in nonresponders than responders (28% vs 13%). Median PSA at salvage radiation therapy was 1.2 ng/ml in nonresponders vs 0.7 ng/ml in responders. Actuarial 5 and 10-year progression-free (PSA less than 0.3 ng/ml) survival probabilities in all 223 men following salvage radiation therapy were 40% (95% CI 32 to 48) and 25% (95% CI 15 to 36), respectively. Actuarial 5 and 10-year biochemical progression-free survival estimates following salvage radiation therapy in responders only were 55% (95% CI 45 to 64) and 35% (95% CI 21 to 49), respectively. Only seminal vesicle invasion was significantly associated with progression-free survival following radiation therapy on multivariate analysis.

CONCLUSIONS

An undetectable PSA level following salvage radiation therapy is more frequently achieved in men with lower pre-radiation serum PSA and those without seminal vesicle or lymph node involvement. Overall approximately a fourth of men with PSA evidence of cancer progression following RRP had a durable response 10 years after the initiation of salvage radiation therapy in the protocols used in this patient cohort.

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.

[Adjuvant and salvage radiotherapy after radical prostatectomy]

After radical prostatectomy is important to identify patients who have a high risk of microscopic residual disease without micrometastatic disease. Adjuvant RT, in retrospective studies, reduce the risk of recurrence and is more efficacious than salvage RT and can improve PSA relapse-free survival and should have an impact on long-term overall survival. The benefit of androgen suppression could be due to a synergistic interaction and may possibly eliminate occult systemic disease. Appropriate selection to identify subgroups of patients who may benefit from salvage RT, even for those patients at the highest risk; and whether some form of hormone ablation should accompany. To predict the biochemical failure and the risk of metastatic disease after salvage RT. We analyze the references to select an appropriate therapy. Improved outcomes will need to be tested in randomized trials.

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.

Treating the Biochemical Recurrence of Prostate Cancer After Definitive Primary Therapy

As increasing numbers of men are living longer with prostate cancer, larger proportions will eventually present to our collective practices with increasing prostate-specific antigen (PSA) levels. Such PSA relapses, conservatively estimated to affect approximately 50,000 men each year, have become the most common form of advanced prostate cancer. Salvage radiation therapy and salvage prostatectomy have important roles in our therapeutic armamentarium and should be valid options for young, healthy men. Counseling patients regarding expectations for cancer control and treatment morbidity has become better because of reports from larger series of patients who have had salvage radiation therapy and surgery. Some patients may not be appropriate candidates for salvage local therapies. A growing body of evidence suggests early hormonal therapy improves progression-free survival (PFS) and could alter cancer-specific survival. This benefit seems to be greatest when hormonal therapy is initiated while PSA levels are low, before clinically measurable disease becomes apparent. However, there is a cost to be paid in side effects and health care dollars when androgen deprivation is administered over prolonged periods. The nonsteroidal antiandrogen agent bicalutamide could offer PFS equivalent to that seen with castration without the complications of androgen deprivation. Observational data seem to indicate that individuals at high risk could also receive benefit from therapy administered before PSA detection. The potential opportunities for novel therapeutic agents with low associated morbidity are great.

Biochemical recurrence after definitive prostate cancer therapy. Part II: Treatment strategies for biochemical recurrence of prostate cancer*

PURPOSE OF REVIEW

Through the prostate-specific antigen era, the proportion of men less than 55 years old with newly diagnosed prostate cancer more than doubled to almost 15%. As increasing numbers of men are living longer with prostate cancer, larger proportions will eventually present to our collective practices with rising prostate-specific antigen levels. Such prostate-specific antigen relapses, conservatively estimated to affect approximately 50 000 men each year, have become the most common form of advanced prostate cancer in the current period.

RECENT FINDINGS

Increasing evidence suggests that early hormonal therapy improves progression-free survival and may alter the cancer-specific survival. However, there is a cost to pay in side-effects when androgen deprivation is administered over prolonged periods. The non-steroidal anti-androgen bicalutamide may offer an equivalent progression-free survival to castration without the complications of androgen deprivation. Observational data seem to indicate that high-risk individuals (i.e. those with high-grade, high-stage disease or a prostate-specific antigen doubling time less than 12 months) may also receive benefit from early therapy.

SUMMARY

The definition of advanced prostate cancer has changed. Multimodal therapy improves cancer-specific outcomes especially in men with high-risk disease. The potential opportunities for novel therapeutic agents with low associated morbidity are great.

Contemporary survival results and the role of radiation therapy in patients with node negative seminal vesicle invasion following radical prostatectomy

PURPOSE

Seminal vesicle invasion (SVI) in a radical prostatectomy (RRP) specimen is associated with a guarded prognosis. We evaluated patients with SVI treated in the pre-prostate specific antigen (PSA) (1983 to 1991) and PSA (1992 to 2003) eras.

MATERIALS AND METHODS

Of patients with prostate cancer treated with RRP from January 1983 through March 2002, 220 with SVI were evaluated, including 67 in the pre-PSA era and 153 in the PSA era. Postoperative PSA greater than 0.2 ng/ml was considered biochemical evidence of cancer progression. Survival rates were compared using Kaplan-Meier estimates to calculate progression-free, cancer specific and all cause survival. Multivariate Cox proportional hazard models were used to correlate variables with disease progression.

RESULTS

The incidence of SVI in the PSA era was lower than in the pre-PSA era (6.0% vs 10.2%, p = 0.001). To date 124 patients (56%) have had evidence of cancer progression. The 4 and 7-year progression-free, cancer specific and all cause survival rates were significantly higher in men with SVI in the PSA era (p = 0.02). PSA at diagnosis, cancerous surgical margins and higher Gleason score were significantly associated with progression. Neither adjuvant nor salvage radiotherapy appeared to confer a significant progression-free survival benefit.

CONCLUSIONS

The incidence of SVI has decreased in the PSA era. Progression-free, cancer specific and all cause survival rates following RRP in patients with SVI have improved in the PSA era. This may reflect earlier detection in this pathological tumor stage and more favorable prognostic factors associated with PSA screening. Adjuvant radiotherapy does not appear to confer any therapeutic benefit. Salvage radiotherapy can lead to durable PSA regressions in a small percent of men, although no long-term survival advantage can be proved.

Rising prostate-specific antigen after primary prostate cancer therapy

An estimated 20-40% of men experience a biochemical recurrence within 10 years of definitive prostate cancer treatment. No single prostate-specific antigen (PSA) value is invariably associated with clinical metastasis or cancer-specific survival; PSA kinetics might prove to be a more important predictor of eventual progression-free survival and cancer-specific survival than absolute PSA level alone. With only one-third of patients progressing from biochemical recurrence to clinical disease, therapeutic morbidity should not outpace risk of disease progression. Salvage radiation therapy following radical prostatectomy has widely variable long-term biochemical control rates (from 18 to 64% depending on the follow-up period). Early hormonal therapy delivered as castration or complete androgen blockade might delay clinical metastasis in patients with high-risk pathologic disease; however, the adverse effects and morbidity of long-term therapy must not be underestimated. Non-steroidal antiandrogens as monotherapy for early biochemical recurrence, particularly for younger men who wish to preserve their libido and sexual potency, have received considerable attention, but there are conflicting data on long-term outcomes. Because of their favorable adverse-effect profiles, non-traditional therapies that exert localized hormonal or cellular effects are receiving considerable attention for treatment of early, PSA-only recurrence. Data from animal models provide a rationale for the use of these therapies, but there is a lack of evidence to support prolongation of progression-free survival or cancer-specific survival.

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.

The effectiveness of combining hormone therapy and radiotherapy in the treatment of prostate cancer

Hormone therapy is commonly used for many patients with prostate cancer. Radiotherapy occupies a prominent role in the treatment of locally-advanced, localised, and postsurgical prostate cancer. Hormone therapy and radiotherapy are often used in combination. In this article, the major features of the hormone/radiotherapy interactions are reviewed, with emphasis on the role of combination treatment for locoregional disease. The reported results suggest a biochemical survival advantage to the use of hormone therapy with radiotherapy, in virtually all settings of non-metastatic disease, with the weakest database being in the setting of low-risk, early-stage disease. Further data are needed in order to identify the optimum target population, combination of agents, and hormone duration, as a function of patient and disease factors.

What is the best postoperative treatment for patients with pT3bN0M0 adenocarcinoma of the prostate?

The purpose of this paper to identify the optimal therapy after radical prostatectomy (RP) for patients with adenocarcinoma of the prostate invading the seminal vesicles (pT3bN0M0 or SVI). A PubMed search using the keywords 'prostate', 'seminal vesicle', 'prostatectomy', 'radiotherapy', 'androgen blockade' was performed to identify literature regarding rates of disease failure in patients with SVI who are observed or treated with androgen blockade (AB), radiotherapy (RT) or RT + AB after RP. The outcome of 68 patients treated at Duke University with post-operative AB, RT or RT + AB for pT3bN0M0 is also presented. More than 70% of patients with SVI develop disease recurrence after surgery. For many, recurrence occurs within 2 y after RP. These patients have poor control rates with postoperative RT alone. While experience with AB and RT+AB is limited, control rates are generally superior to RT alone. At Duke University, after a median follow-up of nearly 4 y, patients treated with RT + AB or AB alone for pT3bN0M0 achieved better 5-y progression-free survival (PFS) compared with those who received RT alone (78 and 68 vs 30%, P = 0.03 and 0.046, respectively). There was no PFS difference between those who received AB alone or RT + AB (68 vs 78%, P=0.5). Seminal vesicle invasion confers a poor prognosis after RP. SVI is a consistent predictor of poor outcome after RT. The limited data available examining AB and RT + AB in pT3bN0M0 disease, including data from Duke University, are encouraging. Nonetheless, postoperative AB, RT and RT + AB for pT3bN0M0 disease require prospective evaluation, as RP alone is rarely curative.

Androgen ablation adjuvant to postprostatectomy radiotherapy: Complication-adjusted number needed to treat analysis

OBJECTIVES

To quantify the benefits and harm of androgen ablation (AA) adjuvant to radiotherapy in the postprostatectomy setting. AA is commonly used in the management of prostate cancer.

METHODS

A literature review was performed to estimate the absolute biochemical control advantage for the use of AA concomitant with postprostatectomy external beam radiotherapy. Additionally, a model was developed, with supporting published data, to estimate the utility-adjusted survival detriment due to the side effects of AA, using the number needed to treat (NNT) technique. Using these data, the unadjusted NNTs and the utility-adjusted NNTs for the addition of AA were computed. In all cases, the sign and magnitude of the NNTs obtained were used to gauge the effects of AA.

RESULTS

The unadjusted NNT analysis demonstrated very low values (far less than 20), suggesting a strong benefit for the use of AA, in both adjuvant and salvage radiotherapy settings. Even after adjustment for hormone-induced functional loss, a significant advantage of AA was demonstrated.

CONCLUSIONS

Using the complication-adjusted NNT method, AA appears to be advantageous in both adjuvant and salvage postprostatectomy radiotherapy settings. The results of the present investigation demonstrated the significant role of the NNT technique for uro-oncologic management decisions when treatment complications need to be considered and balanced against the beneficial effects of the treatment.

Long-term outcome of patients with prostate cancer and pathologic seminal vesicle invasion (pT3b): effect of adjuvant radiotherapy

OBJECTIVES

To evaluate the long-term outcome of patients with prostate cancer who have pathologic seminal vesicle invasion without lymph node metastasis (pT3bN0M0) and compare management strategies.

METHODS

From October 1987 to August of 1997, 43 men underwent radical prostatectomy at Thomas Jefferson University Hospital, had pT3bN0M0 disease, complete preoperative and postoperative prostate-specific antigen (PSA) data, and a minimum of 2 years of follow-up. Eighteen patients with undetectable postoperative PSA levels received adjuvant radiotherapy (RT) within 6 months of surgery. Twelve patients with undetectable PSA levels postoperatively were considered for salvage treatment at biochemical progression. Thirteen patients with persistently elevated PSA levels postoperatively underwent immediate salvage RT. We evaluated the prognostic factors for freedom from biochemical failure (bNED), distant metastasis (DM), disease-specific survival, and overall survival.

RESULTS

The median follow-up time was 5.9 years (range 2 to 10). Patients who received adjuvant RT had significantly greater 5-year bNED survival than patients who did not (80% versus 8%, P <0.001) and increased freedom from DM that was of borderline significance (P = 0.05). The 5-year survival estimates for DM were 0% for the adjuvant RT versus 17% for the observed patient group. In patients with undetectable postoperative PSA levels, the preoperative PSA level was an independent prognostic factor for later disease progression. Patients with a preoperative PSA level of less than 20 ng/mL showed significantly greater 5-year bNED survival than those with a preoperative PSA level of 20 ng/mL or greater (56% versus 32%, P <0.05). The survival curves for risk of DM and death from prostate cancer for those two patient groups were not significantly different statistically.

CONCLUSIONS

Although pathologic seminal vesicle invasion has been associated with poor prognosis and high DM risk, adjuvant RT may result in improved bNED survival in patients with undetectable PSA levels after radical prostatectomy. The effect on clinical outcome awaits additional follow-up.

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.

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.

Early Versus Delayed Hormonal Therapy for Prostate Specific Antigen Only Recurrence of Prostate Cancer After Radical Prostatectomy

PURPOSE

Hormonal therapy (HT) is the current mainstay of systemic treatment for prostate specific antigen (PSA) only recurrence (PSAR), however, there is virtually no published literature comparing HT to observation in the clinical setting. The goal of this study was to examine the Department of Defense Center for Prostate Disease Research observational database to compare clinical outcomes in men who experienced PSAR after radical prostatectomy by early versus delayed use of HT and by a risk stratified approach.

MATERIALS AND METHODS

Of 5382 men in the database who underwent primary radical prostatectomy (RP), 4967 patients were treated in the PSA-era between 1988 and December 2002. Of those patients 1352 men who had PSAR (PSA after surgery greater than 0.2 ng/ml) and had postoperative followup greater than 6 months were used as the study cohort. These patients were further divided into an early HT group in which patients (355) received HT after PSA only recurrence but before clinical metastasis and a late HT group for patients (997) who received no HT before clinical metastasis or by current followup. The primary end point was the development of clinical metastases. Of the 1352 patients with PSAR clinical metastases developed in 103 (7.6%). Patients were also stratified by surgical Gleason sum, PSA doubling time and timing of recurrence. Univariate and multivariate Cox proportional hazard models were used to evaluate the effect of early and late HT on clinical outcome.

RESULTS

Early HT was associated with delayed clinical metastasis in patients with a pathological Gleason sum greater than 7 or PSA doubling time of 12 months or less (Hazards ratio = 2.12, p = 0.01). However, in the overall cohort early HT did not impact clinical metastases. Race, age at RP and PSA at diagnosis had no effect on metastasis-free survival (p >0.05).

CONCLUSIONS

The retrospective observational multicenter database analysis demonstrated that early HT administered for PSAR after prior RP was an independent predictor of delayed clinical metastases only for high-risk cases at the current followup. Further study with longer followup and randomized trials are needed to address this important issue.

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.

Eligibility and outcomes reporting guidelines for clinical trials for patients in the state of a rising prostate-specific antigen: recommendations from the Prostate-Specific Antigen Working Group

PURPOSE

To define methodology to show clinical benefit for patients in the state of a rising prostate-specific antigen (PSA).

RESULTS

HYPOTHESIS

A clinical states framework was used to address the hypothesis that definitive phase III trials could not be conducted in this patient population.

PATIENT POPULATION

The Group focused on men with systemic (nonlocalized) recurrence and a defined risk of developing clinically detectable metastases. Models to define systemic versus local recurrence, and risk of metastatic progression were discussed.

INTERVENTION

Therapies that have shown favorable effects in more advanced clinical states; meaningful biologic surrogates of activity linked with efficacy in other tumor types; and/or effects on a target or pathway known to contribute to prostate cancer progression in this state can be considered for evaluation.

OUTCOMES

An intervention-specific posttherapy PSA-based outcome definition that would justify further testing should be described at the outset. Reporting: Trial reports should include a table showing the number of patients who achieve a specific PSA-based outcome, the number who remain enrolled onto the trial, and the number who came off study at different time points. The term PSA response should be abandoned.

TRIAL DESIGN

The phases of drug development for this state are optimizing dose and schedule, demonstration of a treatment effect, and clinical benefit. To move a drug forward should require a high bar that includes no rise in PSA in a defined proportion of patients for a specified period of time at a minimum. Agents that do not produce this effect can only be tested in combination. The preferred end point of clinical benefit is prostate cancer-specific survival; the time to development of metastatic disease is an alternative.

CONCLUSION

Methodology to show that an intervention alters the natural history of prostate cancer is described. At each stage of development, only agents with sufficient activity should be moved forward.

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.

Predictors of prostate-specific antigen progression among men with seminal vesicle invasion at the time of radical prostatectomy

BACKGROUND

Seminal vesicle (SV) invasion at the time of radical prostatectomy (RP) generally is considered to be indicative of poor outcome. The authors examined whether there was a subset of men with SV invasion who had long-term prostate-specific antigen (PSA) progression-free survival.

METHODS

Data were examined from 1687 men who underwent RP between 1988 and 2002 at 5 equal-access medical centers. Patients were grouped based on the presence or absence of SV invasion at the time of RP. Clinical and pathologic variables as well as biochemical outcome data were compared across the groups using rank-sum, chi-square, and log-rank tests. Multivariate Cox proportional hazards analysis was used to determine the significant predictors of time to PSA failure among men with SV invasion.

RESULTS

Men with SV invasion had significantly higher PSA values, higher clinical stage, higher grade tumors, and were more likely to have concomitant extracapsular extension or a positive surgical margin. The 5-year PSA progression-free rates for men who had SV invasion was 36%, compared with 70% among men who had no SV invasion. Among men who had SV invasion, using multivariate analysis, only age (P = 0.023), pathologic Gleason score (P = 0.041), and surgical margin status (P = 0.019) were found to be independent predictors of PSA failure. By combining significant prognostic variables, the authors identified a subset of men with SV invasion, low-grade tumors (Gleason score 2-6), and negative surgical margins who had a 5-year PSA progression-free rate of 69%. Men with SV invasion, Gleason scores 2-6 tumors, negative surgical margins, and age > or = 60 years (n = 11; 8%) had a 5-year PSA progression-free rate of 100%.

CONCLUSIONS

Although the majority of men with SV invasion have high-grade disease and a short time to biochemical failure, the authors identified a subset of men with low-grade disease, negative surgical margins, and older age who, despite SV invasion, had an extremely favorable clinical course. Thus, SV invasion does not uniformly suggest an unfavorable prognosis. prognosis.

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.

Prostate cancer: radical prostatectomy

Today, more men than ever before are being followed after radical prostatectomy. Prognosis and follow-up should be based on the pathologic specimen. Measurable prostate-specific antigen (PSA) after surgery defines failure, with time to detectable PSA and rate of PSA rise being useful prognostic factors. The natural history of untreated biochemical failure is protracted, a fact to be considered in discussions of adjuvant treatment. Early in disease recurrence, imaging studies to locate residual disease rarely are useful clinically. Both adjuvant and salvage radiation to the prostate bed have benefits and risks, but neither is superior in overall prostate cancer survival. The timing of hormone therapy remains largely empiric. The promise of effective cytotoxic chemotherapy still is greater than its actual benefits, although novel cytostatic agents are being developed. The future management of this disease will improve with better molecular definition of risk and therapeutic response.

Salvage radiotherapy in patients with persisting prostate-specific antigen after radical prostatectomy for prostate cancer

Salvage radiotherapy in patients with persisting prostate-specific antigen (PSA) after radical prostatectomy for prostate cancer offers an approach to reduce local recurrence rates and to improve the rate of biochemical freedom from relapse. 30-70% of these patients experience a decrease in their PSA to an undetectable range; in about 40-50% of these patients, PSA remains stable after 5 years. Therefore, radiation therapy offers these patients an ultimate chance of cure. The pre-irradiation PSA value is of particular importance. The PSA level should not exceed 2 ng/ml because otherwise the rate of distant metastases increases significantly. Serious side effects are apparently low, thus confirming the suitability of this therapeutic approach.