Postoperative radiotherapy in prostate cancer: Analysis of prognostic factors in a series of 282 patients

Predictive factors for disease progression after salvage radiation therapy in biochemical recurrent patients treated by radical prostatectomy

Objective

Salvage radiation therapy (SRT) is standard treatment for patients after radical prostatectomy (RP). However, the optimal timing of SRT remains to be elucidated.

Material and methods

We retrospectively reviewed 133 prostate cancer (PCa) patients who underwent SRT for biochemical recurrence after RP. Disease progression was defined as repeated prostate-specific antigen (PSA) level more than 0.2 ng/mL, greater than the post-SRT nadir or radiographic progression. A receiver operating characteristic curve analysis was used to identify the optimal pre-SRT PSA level for predicting progression after SRT. Cox regression analyses were performed to elucidate the association between clinicopathologic characteristics and disease progression.

Results

Fifty-one PCa patients (38.4%) experienced disease progression after SRT. The optimal cutoff value of the pre-SRT PSA for predicting disease progression was 0.44 ng/mL. In multivariable analysis, pre-SRT PSA >0.44 ng/mL was a significant independent predictor of post-SRT disease progression [hazard ratio (HR): 2.02, P = 0.02]. Although the pre-SRT PSA >0.44 ng/mL did not maintain its independent association with disease progression in the multivariable analysis of patients with adverse pathology (HR: 1.63, P = 0.22), PSA within 4 weeks after RP as a continuous variable was significantly associated with disease progression (HR: 1.19, P = 0.04).

Conclusions

Our results highlight that in PCa patients who undergo RP, SRT should be performed before their PSA reaches 0.44 ng/mL. In patients with adverse pathology disease, a high PSA level within the 4 weeks after RP might identify those who are likely to have disease progression, and these patients might require systemic therapy.

Quality of Life Changes >10 Years After Postoperative Radiation Therapy After Radical Prostatectomy for Prostate Cancer

PURPOSE

To analyze long-term quality-of-life (QoL) changes related to postoperative radiation therapy (RT) after radical prostatectomy.

METHODS AND MATERIALS

Patients who received postoperative 3-dimensional conformal RT in the years 2003 to 2008 with 1.8 to 2.0 Gy fractions up to 66.0 to 66.6 Gy (n = 181) were surveyed using the Expanded Prostate Cancer Index Composite questionnaire before the beginning of RT (A); on the last day (B); and 2 months (C), 1 to 3 years (D), 6 to 9 years (E), and 10 to 13 years (F) after RT.

RESULTS

Mean urinary bother, urinary incontinence bother, and bowel bother score changes (in relation to baseline at time A) of 13, 14, and 7 and 14, 15, and 7 were found at times E and F, respectively (P < .01 for all comparisons). Sexual function scores decreased 6 and 8 points on average (P < .01). Patient age at the time of RT had a considerable impact on urinary bother and urinary incontinence bother, with increasing differences over time when comparing patients aged <68 versus ≥68 years: 0 versus 7 and 0 versus 7 points at time D and 8 versus 23 and 6 versus 35 points at time F, respectively. Patients who did not respond to RT with a decreasing prostate-specific antigen level had greater urinary and urinary incontinence bother and bowel bother score changes >10 years after treatment (25 vs 12; P = .04, 36 vs 10; P = .03, and 20 vs 5; P = .07, respectively). A higher rectal dose was associated with greater acute and long-term bowel bother score decrease. No correlation was found between the dose to the bladder and QoL changes.

CONCLUSIONS

In contrast to early evaluations in the first years, significantly decreasing QoL in the urinary, bowel, and sexual domains was found >5 years after RT. Aging is likely to be a major factor. Younger patients who responded to the treatment had the most favorable long-term QoL results. As 3-dimensional conformal RT was used in this study, intensity modulated concepts could result in improved outcomes.

Salvage radiotherapy after radical prostatectomy: Long-term results of urinary incontinence, toxicity and treatment outcomes

•

We report on long-term toxicity of salvage radiotherapy with a focus on incontinence.

•

Salvage radiotherapy results in good long-term biochemical control.

•

Toxicity and urinary incontinence rates are high after salvage radiotherapy.

Purpose

For patients with local recurrent disease after radical prostatectomy (35–54%) salvage radiotherapy (SRT) is the treatment of choice. In the post prostatectomy setting, SRT may impose risk at increased toxicity. As data on long-term toxicity, especially on urinary incontinence, are scarce, we report on the long-term treatment outcomes, toxicity and urinary incontinence rates after SRT.

Materials and methods

Patients with biochemically recurrent prostate cancer after radical prostatectomy, who were treated with SRT (3D-CRT) at our institution between 1998 and 2012, were included in this retrospective cohort analysis. Primary endpoint was urinary incontinence rate. Secondary endpoints were acute and late grade ≥2 genitourinary (GU) and gastrointestinal (GI) toxicity rates, biochemical progression-free survival (bPFS), distant metastasis-free survival (DMFS), disease specific survival (DSS), and overall survival (OS).

Results

244 patients were included. Median follow-up after SRT was 50 months (range: 4–187 months). Before start of SRT 69.7% of patients were continent for urine. After SRT de novo urinary incontinence complaints (grade ≥ 1) occurred in the respective acute and late phase in 6.1% and 17.6% of patients. Respective acute grade ≥2 GU and GI toxicity was 19.2% and 17.6%. Late grade ≥2 toxicity for GU was 29.9% and for GI was 21.3%, respectively. The respective 5-year bPFS, OS, DSS and DMFS rates were 47.6%, 91.8%, 98.8% and 80.5%.

Conclusions

Experience at our institution with SRT demonstrates that this results in good long-term biochemical control. However, toxicity and urinary incontinence rates were high.

Volumetric image-guided highly conformal radiotherapy of the prostate bed: Toxicity analysis

AIM

To evaluate toxicity of high conformal image-guided radiotherapy of the prostate bed.

BACKGROUND

Radiotherapy of the prostate bed has a pivotal role in the post-operative and salvage settings, but few clinical data are available on the use of daily image guidance in combination with highly conformal techniques, and data on long-term results are lacking.

MATERIALS AND METHODS

We analyzed 118 patients irradiated on the prostate bed using conformal plans processed with a micro-multileaf collimator, and daily checking treatment set-up with a cone-beam CT system. Correlation between toxicity and clinical-dosimetric parameters was assessed by the Cox regression model and log-rank test. Survival analyses were performed with the Kaplan-Meier method.

RESULTS

Median follow-up was 54.08 months. Late grade ≥2 gastro-intestinal (GI) and genito-urinary (GU) toxicity were 3.4% and 4.2%, respectively. Actuarial 4-year late grade ≥2 GI and GU toxicities were 4% and 6%, respectively. Four-year relapse-free survival was 87%. At log-rank test, acute grade ≥2 GI toxicity is associated with the use of antihypertensives (p = 0.03), and there is a trend toward significance between the use of anticoagulants and late grade ≥2 GI toxicity (p = 0.07). At Cox analysis, acute grade ≥2 GU toxicity is correlated with the percentage of bladder volume receiving more than 65 Gy (p = 0.02, HR 1.87 CI 1.25-2.8), and the maximal dose to the rectum is correlated to the development of late grade ≥2 GI toxicity (p = 0.03, HR 2.75 CI 1.10-6.9).

CONCLUSIONS

Conformal volumetric image-guided radiotherapy of the prostate bed leads to low toxicity rates.