Salvage cryotherapy for recurrent prostate cancer after radiation failure: a prospective case series of the first 100 patients

The Role of Whole-Gland and Focal Cryotherapy in Recurrent Prostate Cancer

Prostate cancer is the most common non-cutaneous malignancy in men, with the majority of newly diagnosed patients eligible for active surveillance. Despite definitive treatment, a considerable percentage of men will experience biochemical recurrence and even regional and distant metastatic recurrence after radiation therapy or radical prostatectomy. Salvage prostatectomy, while oncologically effective, poses significant morbidity with poor functional outcomes. Salvage cryotherapy has emerged as a promising alternative for localized recurrence, demonstrating safety and efficacy. This review examines the oncologic and functional outcomes of whole-gland and focal salvage cryotherapy, including disease-free survival, cancer-specific survival, and overall survival. The crucial role of multiparametric prostate MRI and evolving role of next-generation PSMA-targeted PET imaging are also examined. The comparison of outcomes of cryotherapy to other salvage ablation modalities, such as high-intensity focused ultrasound (HIFU), is also explored.

Salvage Cryoablation for Recurrent Prostate Cancer Following Radiation-A Comprehensive Review

The treatment options for prostate cancer typically entail active surveillance, surgery, radiation, or a combination of the above. Disease recurrence remains a concern, with a wide range of recurrence rates having been reported in the literature. In the setting of recurrence, the salvage treatment options include salvage prostatectomy, salvage high-intensity focused ultrasound (HIFU), stereotactic body radiotherapy (SBRT), salvage brachytherapy, and salvage cryoablation. In this review, we analyze the currently available data related to salvage cryoablation for recurrent prostate cancer following radiation.

Nerve Protection During Prostate Cryosurgery

Cryosurgery is a minimally invasive approach to the treatment of focal prostate cancer (PCa). A major complication is the cryoinjury to the cavernous nerve in the neurovascular bundle (NVB). This nerve cryoinjury halts conduction of action potentials (APs) and can eventually result in erectile dysfunction and therefore diminished quality of life for the patient. Here, we propose the application of cryoprotective agents (CPA) to the regions of the nerves in the NVB, prior to prostate cryosurgery, to minimize non-recoverable loss of AP conduction. We modeled a cryosurgical procedure based on data taken during a clinical case and applied ex-vivo porcine phrenic nerves and rat sciatic nerve with temperature profile of NVB. The APs were measured before and after the CPA exposures and during 3 h of recovery. Comparisons of AP amplitude recovery with various CPA compositions reveal that certain CPAs (e.g., 5% DMSO + 7.5% Trehalose and 5% M22 for porcine and rat nerves, respectively) showed little or no toxicity and effective cryoprotection from freezing (on average 48% and 30% of recovered AP, respectively). In summary, we demonstrate that neural conduction can be preserved after exposure to freezing conditions if CPAs are properly selected and deployed onto the nerve.

Male sexual dysfunction and rehabilitation strategies in the settings of salvage prostate cancer treatment

Male sexual dysfunction, a common sequela following primary prostate cancer (PC) treatment, is likely to be more significant following salvage PC therapy. In general, these impairments in sexual domains can be divided into three groups, namely (1) sexual desire, sexuality and masculinity; (2) erectile function (EF); and (3) ejaculation and orgasm. However, there is considerable overlap between these sexual domains and male sexual response cycle, and various factors such as cancer status, mental well-being, medical conditions and social circumstances can adversely impact on the male sexual function. While several preventive and treatment strategies for the preservation and recovery of sexual function are available, there is limited consensus guidelines exist regarding the optimal rehabilitation or treatment protocol for men with sexual dysfunction following salvage therapy. While penile rehabilitation may be effective to restore erectile function and the ability to have coital sex, there is lack of effective treatments in other domains of male sexual function, thereby underscoring the importance of psychological and sexual counselling in sexual rehabilitation. Indeed, a comprehensive multidisciplinary approach is necessary to better understand and optimally assist and manage the men and their respective partners for better sexual health and activity.

Image-guided percutaneous cryo-ablation of peri-urethral unresectable recurrent pelvic malignancy: A case report and brief review

Recurrent or metastatic peri-urethral pelvic malignancies are a difficult-to-treat entity. Re-resection is recommended when possible but is frequently unfavorable due to scar tissue, fibrosis, and obliteration of tissue planes following previous interventions such as surgical resection and/or radiation therapy. Curative options for patients that have unresectable cancer are limited. Cryo-ablation has been extensively studied in the treatment of unresectable renal, liver and lung malignancies and has the potential to provide definitive treatment for recurrent pelvic malignancy. There is a paucity of reports of salvage cryo-ablation in patients with recurrent pelvic malignancies, as most of these tumors are located close to critical structures that could be irreversibly injured by thermal ablation and are hence treated with some form of radiation therapy. But, for patients who fail surgical and radiation treatments, options are limited. Here, we describe two cases of regional tumor recurrence in the pelvis treated with percutaneous cryoablation using protective techniques to avoid thermal injury to adjacent structures. In each case, cryo-ablation was performed successfully despite extensive previous surgical and radiation interventions. Salvage cryo-ablation resulted in a positive clinical and imaging response with an improvement in quality of life and absence of recurrence on follow-up imaging which continues to persist at the writing of this manuscript about 8 and 12-months following treatment.

Functional Outcomes after Local Salvage Therapies for Radiation-Recurrent Prostate Cancer Patients: A Systematic Review

PURPOSE

To assess the rate and severity of functional outcomes after salvage therapy for radiation recurrent prostate cancer.

METHODS

This systematic review of the MEDLINE/PubMed database yielded 35 studies, evaluating salvage radical prostatectomy (RP), brachytherapy (BT), high-intensity focal ultrasound (HIFU) and cryotherapy (CT) after failure of primary radiation therapy. Data on pre- and post-salvage rates and severity of functional outcomes (urinary incontinence, erectile dysfunction, and lower urinary tract symptoms) were collected from each study.

RESULTS

The rates of severe urinary incontinence ranged from 28-88%, 4.5-42%, 0-6.5%, 2.4-8% post salvage RP, HIFU, CT and BT, respectively. The rates of erectile dysfunction were relatively high reaching as much as 90%, 94.6%, 100%, 62% following RP, HIFU, CT and BT, respectively. Nonetheless, the high pre-salvage rates of ED preclude accurate estimation of the effect of salvage therapy. There was an increase in the median IPSS following salvage HIFU, BT and CT ranging from 2.5-3.4, 3.5-12, and 2, respectively. Extended follow-up showed a return-to-baseline IPSS in a salvage BT study. The reported data suffer from selection, reporting, publication and period of study biases, making inter-study comparisons inappropriate.

CONCLUSIONS

local salvage therapies for radiation recurrent PCa affect continence, lower urinary tract symptoms and sexual functions. The use of local salvage therapies may be warranted in the setting of local disease control, but each individual decision must be made with the informed patient in a shared decision working process.

EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer. Part II-2020 Update: Treatment of Relapsing and Metastatic Prostate Cancer

OBJECTIVE

To present a summary of the 2020 version of the European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy & Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Geriatric Oncology (SIOG) guidelines on the treatment of relapsing, metastatic, and castration-resistant prostate cancer (CRPC).

EVIDENCE ACQUISITION

The working panel performed a literature review of the new data (2016-2019). The guidelines were updated, and the levels of evidence and/or grades of recommendation were added based on a systematic review of the literature.

EVIDENCE SYNTHESIS

Prostate-specific membrane antigen positron emission tomography computed tomography scanning has developed an increasingly important role in men with biochemical recurrence after local therapy. Early salvage radiotherapy after radical prostatectomy appears as effective as adjuvant radiotherapy and, in a subset of patients, should be combined with androgen deprivation. New treatments have become available for men with metastatic hormone-sensitive prostate cancer (PCa), nonmetastatic CRPC, and metastatic CRPC, along with a role for local radiotherapy in men with low-volume metastatic hormone-sensitive PCa. Also included is information on quality of life outcomes in men with PCa.

CONCLUSIONS

The knowledge in the field of advanced and metastatic PCa and CRPC is changing rapidly. The 2020 EAU-EANM-ESTRO-ESUR-SIOG guidelines on PCa summarise the most recent findings and advice for use in clinical practice. These PCa guidelines are first endorsed by the EANM and reflect the multidisciplinary nature of PCa management. A full version is available from the EAU office or online (http://uroweb.org/guideline/prostate-cancer/).

PATIENT SUMMARY

This article summarises the guidelines for the treatment of relapsing, metastatic, and castration-resistant prostate cancer. These guidelines are evidence based and guide the clinician in the discussion with the patient on the treatment decisions to be taken. These guidelines are updated every year; this summary spans the 2017-2020 period of new evidence.

Minimally invasive strategies for the treatment of prostate cancer recurrence after radiation therapy: a systematic review

INTRODUCTION

The aim of this review was to conduct a comprehensive analysis of the role of minimally invasive salvage modalities in radio-recurrent prostate cancer and the associated clinical outcomes and toxicity profiles.

EVIDENCE ACQUISITION

A systematic review of the current literature was conducted through the Medline and NCBI PubMed, Scopus databases in January 2020. All papers published after 2000, concerning studies conducted on humans for radio-recurrent prostate cancer were considered for the review.

EVIDENCE SYNTHESIS

Overall, 545 studies were identified. After duplicate exclusion, initial screening, and eligibility evaluation, a total of 80 studies were included in the qualitative analysis, corresponding to a cohort of 6681 patients. The median age at initial diagnosis ranged from 59 to 75.5. Pre-treatment PSA ranged from 6.2 to 27.4 ng/mL. All patients underwent primary radiotherapy for localized prostate cancer. Cryotherapy, Brachytherapy, EBRT, HIFU were the minimally invasive options mostly used as salvage therapy. They showed to be promising approaches for recurrent prostate cancer (PCa) control, with acceptable toxicities.

CONCLUSIONS

Minimally invasive therapeutic options offer promising results in terms of biochemical control in the local recurrence setting. Unfortunately, the absence of high quality and comparative studies makes it difficult to establish which method is the best in terms of oncological and safety outcomes.

Candidates to salvage therapy after external-beam radiotherapy of prostate cancer: Predictors of local recurrence volume and metastasis-free survival

PURPOSE

The purpose of this study was to assess the predictors of metastasis-free survival (MFS) and of the volume of the local recurrence in patients with rising prostate-specific antigen (PSA) serum level after radiotherapy for prostate cancer and referred for prostate magnetic resonance imaging (MRI) and biopsy in view of salvage treatment.

MATERIALS AND METHODS

A total of 132 consecutive men (median age, 70 years; IQR, 66-77 years) with rising PSA after prostate radiotherapy who underwent prostate MRI and biopsy in view of salvage treatment between January 2010 and July 2017 were retrospectively evaluated at a single center. MFS predictors were assessed with Cox models. Predictors of the volume of the local recurrence (number of invaded prostate sectors at biopsy) were assessed using Poisson regression among variables available at PSA relapse.

RESULTS

At multivariate analysis, an initial Gleason score≥8 (OR=7 [95% confidence interval (CI): 1.2-40]; P=0.03), a recent radiotherapy (OR=17 [95% CI: 3.9-72]; P<0.0001), the use of androgen deprivation therapy at PSA relapse (OR=12.5 [95% CI: 2.8-57]; P=0.001) and the number of invaded prostate sectors (OR=1.5 [95% CI: 1.1-2]; P=0.007) and maximum cancer core length (OR=0.7 [95%CI: 0.6-0.9]; P=0.002) at biopsy performed at PSA relapse were significant MFS predictors. The PSA level at relapse was significant independent predictor of the volume of local recurrence only when used as a continuous variable (P=0.0002) but not when dichotomized using the nadir+2 threshold (P=0.41).

CONCLUSION

Pathological and clinical factors can help predict MFS in patients with rising PSA after prostate radiotherapy and candidates to salvage treatment. The PSA level at relapse has strong influence on the local recurrence volume when used as a continuous variable.

A Prospective Study of 18F-DCFPyL PSMA PET/CT Restaging in Recurrent Prostate Cancer following Primary External Beam Radiotherapy or Brachytherapy

PURPOSE

Radio-recurrent prostate cancer is typically detected by a rising prostate-specific antigen and may reflect local or distant disease. Positron emission tomography (PET) radiotracers targeting prostate-specific membrane antigen, such as 18F-DCFPyL have shown promise in restaging men with recurrent disease postprostatectomy but are less well characterized in the setting of radio-recurrent disease.

METHODS AND MATERIALS

A prospective, multi-institutional study was conducted to evaluate the effect of 18F-DCFPyL PET/computed tomography (CT) when added to diagnostic imaging (DI; CT abdomen and pelvis, bone scan, multiparametric magnetic resonance imaging pelvis) for men with radio-recurrent prostate cancer. All men were imaged with DI and subsequently underwent 18F-DCFPyL PET/CT with local and central reads. Tie break reads were performed as required. Management questionnaires were completed after DI and again after 18F-DCFPyL PET/CT. Discordance in patterns of disease detected with 18F-DCFPyL PET/CT versus DI and changes in management were characterized.

RESULTS

Seventy-nine men completed the study. Most men had T1 disease (62%) and Gleason score <7 (95%). Median prostate-specific antigen at diagnosis was 7.4 ng/mL and at relapse was 4.8 ng/mL. DI detected isolated intraprostatic recurrence in 38 out of 79 men (48%), regional nodal recurrence in 9 out of 79 (11%), distant disease in 12 out of 79 (15%), and no disease in 26 out of 79 (33%). 18F-DCFPyL PET/CT detected isolated intraprostatic recurrence in 38 out of 79 men (48%), regional nodal recurrence in 21 out of 79 (27%), distant disease in 24 out of 79 (30%), and no disease in 10 out of 79 (13%). DI identified 8 out of 79 (10%) patients to have oligometastatic disease, compared with 21 out of 79 (27%) with 18F-DCFPyL PET/CT. 18F-DCFPyL PET/CT changed proposed management in 34 out of 79 (43%) patients.

CONCLUSIONS

18F-DCFPyL PET/CT identified extraprostatic disease in twice as many men with radio-recurrent prostate cancer compared with DI and detected a site of recurrence in 87% of men compared with 67% with DI. Furthermore, 18F-DCFPyL PET/CT identified potentially actionable disease (prostate only recurrence or oligometastatic disease) in 75% of men and changed proposed management in 43% of men.

Salvage cryoablation for local recurrence of prostatic cancer after curative therapy

PURPOSE

The purpose of this study was to determine the efficacy of salvage cryotherapy for intra-prostatic and local extraprostatic recurrences after curative treatment of prostate adenocarcinoma.

MATERIAL AND METHOD

Twenty-eight men (mean age, 69±6 [SD] years; range: 51-82 years) treated with cryoablation for prostatic (N=21) or extraprostatic (N=7) recurrent prostate cancer after radiotherapy with or without associated prostatectomy were included. Technical success, complication and recurrences were reported. Biological recurrence was defined as an elevation ≥2ng/mL of prostate specific antigen (PSA) serum level after the treatment.

RESULTS

The mean follow-up was 18 months. Among the 21 patients with intraprostatic recurrence, 14 had successful cryotherapy with a mean decrease in serum prostate-specific antigen (PSA) levels of -5.7±2.6 (SD) ng/mL (range: -2.1 to -16.9ng/mL). Four patients (19%) had early progression and three patients (14%) had delayed biological recurrence (mean time: 15 months). Among the 7 patients with extraprostatic recurrence, 2/7 (291%) had successful cryotherapy with a decrease in PSA serum level of -2.7±1.6 (SD) ng/mL (range: -0.5--5.5ng/mL) and 4/7 (57%) had early biological recurrence after cryotherapy that required androgen deprivation therapy, whereas 1/7 (4%) was lost to follow-up. No major complications were observed for both intra- and extraprostatic recurrence.

CONCLUSION

Salvage cryoablation of locally recurrent prostate cancer after curative treatment is feasible and safe when the half prostate is treated. It could delay initiation of androgen deprivation therapy in these patients.

Nonsurgical Salvage Local Therapies for Radiorecurrent Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

Different nonsurgical therapeutic strategies can be adopted for intraprostatic relapse of prostate cancer after primary radiotherapy, including re-irradiation (with brachytherapy [BT] or external beam radiotherapy [EBRT]), high-intensity focused ultrasound (HIFU), and cryotherapy. The main issues to consider when choosing nonsurgical salvage local therapies are local tumor control and significant genitourinary toxicity.

OBJECTIVE

To conduct a systematic review and meta-analysis of the role of nonsurgical salvage modalities in patients with radiorecurrent prostate cancer and associated clinical outcomes and toxicity profiles.

EVIDENCE ACQUISITION

We performed a critical review of the Medline, Scopus, and ClinicalKey databases from January 1, 2000 through February 1, 2018 according to the Preferred Reporting Items and Meta-Analyses statement. To assess the overall quality of the literature reviewed, we used a modified Delphi tool for case-series studies.

EVIDENCE SYNTHESIS

A total of 64 case-series studies were included, corresponding to a cohort of 5585 patients. The modified Delphi checklist evidenced high methodological quality overall (mean quality score of 80.6%). Biochemical control rates were lowest for patients treated with HIFU (58%, 95% confidence interval [CI] 47-68%) and highest for patients treated with BT (69%, 95% CI 62-76%) and EBRT (69%, 95% CI 53-83%). The lowest prevalence of incontinence was for patients treated with BT (3%, 95% CI 0-6%; I²=63.4%) and the highest was among patients treated with HIFU (28%, 95% CI 19-38%; I²=89.7%).

CONCLUSIONS

Nonsurgical therapeutic options, especially BT, showed good outcomes in terms of biochemical control and tolerability in the local recurrence setting.

PATIENT SUMMARY

The current analysis demonstrated that nonsurgical salvage local therapies offer a chance of a curative local approach in radiorecurrent prostate cancer. However, high-quality data from prospective trials are needed to validate long-term outcomes from nonsurgical strategies for the treatment of intraprostatic recurrence after previous radiotherapy.

The incidence proportion of erectile dysfunction in patients treated with cryotherapy for prostate cancer: a meta-analysis

OBJECTIVES

With the maturity of cryotherapy for prostate cancer, the complications after operation are also decreasing, which can improve the prognosis of patients. However, erectile dysfunction (ED) is still one of the main complications after cryotherapy. Therefore, we performed a meta-analysis to evaluate the incidence of erectile dysfunction in patients after cryotherapy.

MATERIALS AND METHODS

A comprehensive literature search was performed in August 2018. PUBMED and EMBASE databases were searched to collect studies reporting the incidence rate of ED after cryotherapy from 2002 to 2018. Two reviewers independently screened the literatures, extracted data and assessed the risk of bias of included studies. Pooled ratio and its 95% confidence intervals (95% CIs) were performed by Stata 12.1.

RESULTS

Of the 157 articles identified on August 1st 2018, 23 studies which reported ED after cold ablative therapy were identified, however, only 12 used validated outcome measures and met inclusion criteria. A total of 12 studies were included in this meta-analysis. Overall, the results of this meta-analysis showed that the pooled incidence rate of ED was 0.27 (95% CI 0.26-0.28) which means that the incidence rate of ED after cryotherapy for prostate cancer was not high, but we still found that there are great heterogeneity between the 12 articles. By subgroup analysis, we found a statistically significant incidence rate of ED in primarily localized PCa which was 0.49 (95% CI 0.30-0.68), which is clearly lower than the incidence of recurrent prostate cancer after failed primary radiotherapy 0.61 (95% CI 0.43-0.79).

CONCLUSION

ED is one of the major complications after cryotherapy for PCa. Furthermore, subgroup analysis revealed a higher incidence rate in PCa undergoing radiotherapy. Significantly, with the development of cryotherapy technology, the incidence of ED after cryotherapy for prostate cancer is decreasing. While we still need further researches to advance knowledge in this field.

The role of salvage brachytherapy for local relapse after external beam radiotherapy for prostate cancer

Prostate cancer is the most prevalent cancer amongst men. For localized disease, there currently exist several reliable treatment modalities including surgery, radiotherapy and brachytherapy. Our growing understanding of this disease indicates that local control plays a very important role in prevention of subsequent dissemination. Many improvements to external beam radiotherapy over recent years have decreased toxicity and improved outcomes, but nonetheless, local relapse remains common. Many salvage options exist for locally recurrent prostate cancer, but are rarely offered, partly because of the fear of toxicity. Many men with isolated local recurrence therefore do not receive potentially curative second line treatment and are instead treated with palliative androgen suppression. Selection plays an important role in determining which individuals are likely to benefit from salvage. Those at high risk of pre-existing micro-metastatic disease despite negative staging scans are unlikely to benefit. Prostate brachytherapy has evolved over the more than 3 decades of experience. Modern techniques allow more precise tumor localization and dose delivery. Better understanding of dosimetric parameters can distinguish optimal from suboptimal implants. Salvage brachytherapy can be an effective treatment for locally recurrent prostate cancer after prior external beam radiotherapy. We review the literature pertaining to both low dose rate (LDR) and high dose rate (HDR) salvage brachytherapy and discuss patient selection, optimal dose, treatment volume and toxicity avoidance.

Functional outcomes after prostatic cryosurgery

OBJECTIVE

To assess the functional effects of prostatic cryosurgery on micturition.

MATERIAL AND METHODS

Prospective study of men who underwent cryosurgery (CS) for prostate cancer between 2013 - 2015. Low urinary tract symptoms (LUTS) and quality of life (QoL) were assessed 1 month before surgery using IPSS questionnaire, a three-day voiding diary (3DVD) and uroflowmetry with ultrasound-measured postvoid residual volume. Need of medical treatment for LUTS was also recorded. The same assessment was performed at 3, 6 and 12 months after CS. Outcomes after surgery were compared to those prior to surgery.

RESULTS

Forty-five patients underwent a CS during the study period, of whom 25 patients could be recruited in the study. Mean age was 73.5 years (range 66-84). Nineteen CS (76%) were performed as a primary procedure, while 6 CS (24%) as a salvage procedure. No statistical differences were found comparing results of IPSS, QoL, D3vd or uroflowmetry and PVR at 3, 6 or 12 months after CS compared to before surgery. Before CS, 8 (32%) patients were on medical treatment for LUTS, while at 6 and 12 months after surgery, 3 (13.6%) and 2 (9.5%) patients required some medication, respectively.

CONCLUSION

According to the punctuation of IPSS, QoL questionnaire, and a 3-day voiding diary, LUTS does not worsen after CS. Prostatic cryosurgery does not seem to impact uroflowmetry results.

In vivo optoacoustic temperature imaging for image-guided cryotherapy of prostate cancer

The objective of this study is to demonstrate in vivo the feasibility of optoacoustic temperature imaging during cryotherapy of prostate cancer. We developed a preclinical prototype optoacoustic temperature imager that included pulsed optical excitation at a wavelength of 805 nm, a modified clinical transrectal ultrasound probe, a parallel data acquisition system, image processing and visualization software. Cryotherapy of a canine prostate was performed in vivo using a commercial clinical system, Cryocare^® CS, with an integrated ultrasound imaging. The universal temperature-dependent optoacoustic response of blood was employed to convert reconstructed optoacoustic images to temperature maps. Optoacoustic imaging of temperature during prostate cryotherapy was performed in the longitudinal view over a region of 30 mm (long)  ×  10 mm (deep) that covered the rectum, the Denonvilliers fascia, and the posterior portion of the treated gland. The transrectal optoacoustic images showed high-contrast vascularized regions, which were used for quantitative estimation of local temperature profiles. The constructed temperature maps and their temporal dynamics were consistent with the arrangement of the cryoprobe and readouts of the thermal needle sensors. The temporal profiles of the readouts from the thermal needle sensors and the temporal profile estimated from the normalized optoacoustic intensity of the selected vascularized region showed significant resemblance, except for the initial overshoot, that may be explained as a result of the physiological thermoregulatory compensation. The temperature was mapped with errors not exceeding  ±2 °C (standard deviation) consistent with the clinical requirements for monitoring cryotherapy of the prostate. In vivo results showed that the optoacoustic temperature imaging is a promising non-invasive technique for real-time imaging of tissue temperature during cryotherapy of prostate cancer, which can be combined with transrectal ultrasound-the current standard for guiding clinical cryotherapy procedure.

[Salvage cryotherapy of prostate cancer after failed external radiotherapy and brachytherapy: Morbidity and mid-term oncological results]

OBJECTIVE

To study the oncologic and functional results of salvage cryotherapy after failure of external radiotherapy and brachytherapy.

MATERIALS AND METHODS

Patients treated by total salvage cryotherapy (3rd generation) in 2 centers (Groupe Hospitalier Saint-Joseph in Paris and Clinique Jule-Verne Nantes) in between January 2008 and April 2016 were included. The biochemical recurrence-free survival (BRFS) was calculated using the Phoenix criteria (PSA>nadir+2ng/mL). The functional results were assessed clinically.

RESULTS

Ninety-seven patients with an average follow up of 39.4months were evaluated retrospectively. The 5-year biochemical recurrence-free survival (5y-BRFS) among all patients was 58.1% (IC à 95% [45.9-68.5]). Low and intermediate risk patients (d'Amico classification) were less prone to biochemical recurrence than high risk (81.05% (IC à 95% [64.1-90.5]) 5y-BRFS as opposed to 35.09% (IC à 95% [20.1-50.4]) respectively) (P<0.0001). As were patients with a Gleason score≤7 75.35% (IC à 95% [59.7-85.6]) compared to 32.31% (IC à 95% [16.5-49.2]) for higher Gleason (>7 scores [P=0.0002]). A Gleason score>7 (OR=6.9; P=0.002), PSA nadir>1ng/mL (OR=25.8; P=0.0026) and peri-urethral invasion (OR=35.8; P<0.001) were major risk factors for local recurrence in univariate analysis. In multivariate analysis, only PSA nadir>1ng/mL (OR=12.9; P=0.042) and peri-urethral invasion (OR=21.6; P=0.0003) remain major risk factors for recurrence. About 13 (16.46%) patients were incontinent of which 3 (3.79%) required placement of an artificial urinary sphincter. Erectile dysfunction was present in 66 (83.5%) patients. Recto-urethral fistula was uncommon in 1 patient (1.27%).

CONCLUSION

Salvage cryotherapy after failure of external radiotherapy and brachytherapy is a reliable and reproducible technique with promising oncological and functional results. Study of prognostic factors will help better select eligible patients in the future.

LEVEL OF EVIDENCE

4.

Management of Biochemical Recurrence after Primary Curative Treatment for Prostate Cancer: A Review

How to manage patients with prostate cancer (PCa) with biochemical recurrence (BCR) following primary curative treatment is a controversial issue. Importantly, this prostate-specific antigen (PSA)-only recurrence is a surrogate neither of PCa-specific survival nor of overall survival. Physicians are therefore challenged with preventing or delaying the onset of clinical progression in those deemed at risk, while avoiding over-treating patients whose disease may never progress beyond PSA-only recurrence. Adjuvant therapy for radical prostatectomy (RP) or local radiotherapy (RT) has a role in certain at-risk patients, although it is not recommended in low-risk PCa owing to the significant side-effects associated with RT and androgen deprivation therapy (ADT). The recommendations for salvage therapy differ depending on whether BCR occurs after RP or primary RT, and in either case, definitive evidence regarding the best strategy is lacking. Options for treatment of BCR after RP are RT at least to the prostatic bed, complete or intermittent ADT, or observation; for BCR after RT, salvage RP, cryotherapy, complete or intermittent ADT, brachytherapy, high-intensity focused ultrasound (HIFU), or observation can be considered. Many patient- and cancer-specific factors need to be taken into account when deciding on the best strategy, and optimal management depends on the involvement of a multidisciplinary team, consultation with the patient themselves, and the adoption of an individualised approach. Improvements in imaging techniques may enable earlier detection of metastases, which will hopefully refine future management decisions.

Management Options for Biochemically Recurrent Prostate Cancer

Prostate cancer is the most common solid tumor malignancy in men worldwide. Treatment with surgery and radiation can be curative in organ-confined disease. Unfortunately, about one third of men develop biochemically recurrent disease based only on rising prostate-specific antigen (PSA) in the absence of visible disease on conventional imaging. For these patients with biochemical recurrent prostate cancer, there is no uniform guideline for subsequent management. Based on available data, it seems prudent that biochemical recurrent prostate cancer should initially be evaluated for salvage radiation or prostatectomy, with curative intent. In selected cases, high-intensity focused ultrasound and cryotherapy may be considered in patients that meet very narrow criteria as defined by non-randomized trials. If salvage options are not practical or unsuccessful, androgen deprivation therapy (ADT) is a standard option for disease control. While some patients prefer ADT to manage the disease immediately, others defer treatment because of the associated toxicity. In the absence of definitive randomized data, patients may be followed using PSA doubling time as a trigger to initiate ADT. Based on retrospective data, a PSA doubling time of less than 3-6 months has been associated with near-term development of metastasis and thus could be used signal to initiate ADT. Once treatment is begun, patients and their providers can choose between an intermittent and continuous ADT strategy. The intermittent approach may limit side effects but in patients with metastatic disease studies could not exclude a 20% greater risk of death. In men with biochemical recurrence, large studies have shown that intermittent therapy is non-inferior to continuous therapy, thus making this a reasonable option. Since biochemically recurrent prostate cancer is defined by technological limitations of radiographic detection, as new imaging (i.e., PSMA) strategies are developed, it may alter how the disease is monitored and perhaps managed. Furthermore, patients have no symptoms related to their disease and thus many prefer options that minimize toxicity. For this reason, herbal agents and immunotherapy are under investigation as potential alternatives to ADT and its accompanying side effects. New therapeutic options combined with improved imaging to evaluate the disease may markedly change how biochemically recurrent prostate cancer is managed in the future.

Imaging of local recurrence in prostate cancer

Diagnosis of prostate cancer (PCa) recurrence after therapy with curative intent currently depends primarily on biochemical serum analyses. When recurrence is suspected, further treatment decisions rely heavily on the confirmation of disease presence and determination of its extent. This is complicated by the fact that benign conditions can mimic biochemical recurrence, and serum studies do not reliably discriminate between local and distant recurrence. This review discusses the contemporary imaging paradigm for the evaluation of local PCa recurrence. The multidisciplinary implications for urologists, radiation oncologists and radiologists are examined. Emerging techniques and future directions of PCa imaging research are discussed.

EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part II: Treatment of Relapsing, Metastatic, and Castration-Resistant Prostate Cancer

OBJECTIVE

To present a summary of the 2016 version of the European Association of Urology (EAU) - European Society for Radiotherapy & Oncology (ESTRO) - International Society of Geriatric Oncology (SIOG) Guidelines on the treatment of relapsing, metastatic, and castration-resistant prostate cancer (CRPC).

EVIDENCE ACQUISITION

The working panel performed a literature review of the new data (2013-2015). The guidelines were updated, and the levels of evidence and/or grades of recommendation were added based on a systematic review of the literature.

EVIDENCE SYNTHESIS

Relapse after local therapy is defined by a rising prostate-specific antigen (PSA) level >0.2ng/ml following radical prostatectomy (RP) and >2ng/ml above the nadir after radiation therapy (RT). ¹¹C-choline positron emission tomography/computed tomography is of limited importance if PSA is <1.0ng/ml; bone scans and computed tomography can be omitted unless PSA is >10ng/ml. Multiparametric magnetic resonance imaging and biopsy are important to assess biochemical failure following RT. Therapy for PSA relapse after RP includes salvage RT at PSA levels <0.5ng/ml and salvage RP, high-intensity focused ultrasound, cryosurgical ablation or salvage brachytherapy of the prostate in radiation failures. Androgen deprivation therapy (ADT) remains the basis for treatment of men with metastatic prostate cancer (PCa). However, docetaxel combined with ADT should be considered the standard of care for men with metastases at first presentation, provided they are fit enough to receive the drug. Follow-up of ADT should include analysis of PSA, testosterone levels, and screening for cardiovascular disease and metabolic syndrome. Level 1 evidence for the treatment of metastatic CRPC (mCRPC) includes, abiraterone acetate plus prednisone (AA/P), enzalutamide, radium 223 (Ra 223), docetaxel at 75 mg/m² every 3 wk and sipuleucel-T. Cabazitaxel, AA/P, enzalutamide, and radium are approved for second-line treatment of CRPC following docetaxel. Zoledronic acid and denosumab can be used in men with mCRPC and osseous metastases to prevent skeletal-related complications.

CONCLUSIONS

The knowledge in the field of advanced and metastatic PCa and CRPC is changing rapidly. The 2016 EAU-ESTRO-SIOG Guidelines on PCa summarise the most recent findings and advice for use in clinical practice. These PCa guidelines are the first endorsed by the European Society for Therapeutic Radiology and Oncology and the International Society of Geriatric Oncology and reflect the multidisciplinary nature of PCa management. A full version is available from the EAU office or online (http://uroweb.org/guideline/prostate-cancer/).

PATIENT SUMMARY

In men with a rise in their PSA levels after prior local treatment for prostate cancer only, it is important to balance overtreatment against further progression of the disease since survival and quality of life may never be affected in many of these patients. For patients diagnosed with metastatic castrate-resistant prostate cancer, several new drugs have become available which may provide a clear survival benefit but the optimal choice will have to be made on an individual basis.

Salvage local therapy for radiation-recurrent prostate cancer - where are we?

INTRODUCTION

Prostate cancer is the most frequent cancer among males in Europe and a leading cause of cancer deaths, with similar proportion in other developed countries. For more than twenty years, external-beam radiation therapy, alongside with radical prostatectomy, has been used as a primary radical therapeutic approach for localized prostate cancer. Yet, EBRT failures relate to 22-69% following curative radiotherapy (± androgen deprivation therapy). Additionally, a proportion of these men will have a biopsy-proven local recurrence.

MATERIAL AND METHODS

The Medline and Web of Science databases were searched without a time limit during March 2016 using the terms 'prostate cancer' in conjunction with 'radiotherapy', 'recurrence', 'biochemical', 'salvage', 'brachytherapy', 'prostatectomy', 'HIFU', 'cryotherapy' and 'focal'. The search was limited to the English, Polish, German and Spanish literature.

RESULTS

Currently, salvage treatment after failed radiotherapy includes radical prostatectomy, brachytherapy and ablative whole-gland therapies, such as cryotherapy and high intensity focused ultrasound. New approaches, so called focal salvage therapy, involve ablation of only the zone of recurrence in order to decrease tissue injury and therefore to diminish morbidity.

CONCLUSIONS

At present no authoritative recommendations can be concluded because of the absence of randomized data with standardized definitions and protocols. Nevertheless, we believe that local salvage treatment should be at least considered in patients after biochemical relapse following radiotherapy.

Cryosurgery would be An Effective Option for Clinically Localized Prostate Cancer: A Meta-analysis and Systematic Review

Cryosurgery (CS) has been used on patients with clinically localized PCa for more than 10 years. However, clinical studies evaluating its effectiveness and safety have reported conflicting results. This systematic assessment was performed to obtain comprehensive evidence regarding the potential benefits and safety of CS compared with those of radiotherapy (RT) and radical prostatectomy (RP), respectively. All controlled trials comparing CS with RT or RP and single-arm studies reporting results of CS therapy were identified through comprehensive searches of PubMed, the Cochrane Library and Embase. Ten publications from seven trials, with totally 1252 patients, were included in the meta-analysis, which revealed no significant differences in comparisons of CS vs RT and CS vs RP for overall survival and disease specific survival. However, a significantly lower disease-free survival could be observed for CS than RP. Moreover, a systematic review of literature focusing on comparative data of databases and materials of single-arm trials revealed satisfactory survival results in both primary and salvage CS. Our results showed that cryosurgery would be a relatively effective method for clinically localized prostate cancer with survival results comparable to radiotherapy and radical prostatectomy. However, the large percentage of complications caused by cryosurgery should be carefully monitored.

Salvage high-dose-rate brachytherapy for locally recurrent prostate cancer after primary radiotherapy failure

BACKGROUND AND PURPOSE

To evaluate high-dose-rate brachytherapy (HDR BT) as a salvage modality for locally recurrent prostate cancer after primary radiotherapy failure.

MATERIALS AND METHODS

Eighty-three prostate cancer patients, who locally relapsed after radiotherapy, were treated with salvage HDR BT. The schedule was three implantations, every two weeks, with 10Gy per implant, to a total dose of 30Gy. Acute and late toxicity rates were evaluated. Overall survival (OS) and biochemical control were calculated using Kaplan-Meier method.

RESULTS

Median follow-up after salvage HDR was 41months. The 3-year and 5-year OS were 93% and 86%, respectively. The 3-year and 5-year biochemical disease-free survival (bDFS) were 76% and 67%, respectively. The single factor associated with biochemical control was time to achieve salvage PSA nadir (p-.006). OS was linked significantly with primary nadir level (p-.001) while primary biochemical relapse interval was of borderline significance (p-.07).

CONCLUSIONS

Salvage HDR BT is a promising treatment option for patients with localized relapse of previously irradiated prostate cancer. Lower PSA nadir after primary radiotherapy and longer primary disease-free interval influence the outcome.

Salvage Brachytherapy for Biochemically Recurrent Prostate Cancer following Primary Brachytherapy

Purpose. In this study, we evaluated our experience with salvage brachytherapy after discovery of biochemical recurrence after a prior brachytherapy procedure. Methods and Materials. From 2001 through 2012 twenty-one patients treated by brachytherapy within University of Kentucky or from outside centers developed biochemical failure and had no evidence of metastases. Computed tomography (CT) scans were evaluated; patients who had an underseeded portion of their prostate were considered for reimplantation. Results. The majority of the patients in this study (61.9%) were low risk and median presalvage PSA was 3.49 (range 17.41-1.68). Mean follow-up was 61 months. At last follow-up after reseeding, 11/21 (52.4%) were free of biochemical recurrence. There was a trend towards decreased freedom from biochemical recurrence in low risk patients (p = 0.12). International Prostate Symptom Scores (IPSS) increased at 3-month follow-up visits but decreased and were equivalent to baseline scores at 18 months. Conclusions. Salvage brachytherapy after primary brachytherapy is possible; however, in our experience the side-effect profile after the second brachytherapy procedure was higher than after the first brachytherapy procedure. In this cohort of patients we demonstrate that approximately 50% oncologic control, low risk patients appear to have better outcomes than others.

Emerging treatments for recurrent prostate cancer

Despite radical treatment, many men with prostate cancer will develop recurrence of their disease. In an exciting era of new therapies for prostate cancer in general, we focus on how these will specifically benefit those men with recurrent disease. We consider salvage treatments aimed at those with local recurrence confined to the prostate gland, therapies for those presenting with metastatic recurrence and the approach to men presenting with a rising prostate-specific antigen but no demonstrable disease (M0). In general, men with recurrent disease are often under-represented in randomized clinical trials. Consequently, evidence to guide treatment for these men is often lacking and this needs to be addressed in order to improve and better define our approach to this problem in the future.

Decision analytic cost-effectiveness model to compare prostate cryotherapy to androgen deprivation therapy for treatment of radiation recurrent prostate cancer

OBJECTIVE

To determine the cost-effectiveness of salvage cryotherapy (SC) in men with radiation recurrent prostate cancer (RRPC).

DESIGN

Cost-utility analysis using decision analytic modelling by a Markov model.

SETTING AND METHODS

Compared SC and androgen deprivation therapy (ADT) in a cohort of patients with RRPC (biopsy proven local recurrence, no evidence of metastatic disease). A literature review captured published data to inform the decision model, and resource use data were from the Scottish Prostate Cryotherapy Service. The model was run in monthly cycles for RRPC men, mean age of 70 years. The model was run over the patient lifetime, to assess changes in patient health states and the associated quality of life, survival and cost impacts. Results are reported in terms of the discounted incremental costs and discounted incremental quality-adjusted life years (QALYs) gained between the 2 alternative interventions. Probabilistic sensitivity analysis used a 10,000 iteration Monte Carlo simulation.

RESULTS

SC has a high upfront treatment cost, but delays the ongoing monthly cost of ADT. SC is the dominant strategy over the patient lifetime; it is more effective with an incremental 0.56 QALY gain (95% CI 0.28 to 0.87), and less costly with a reduced lifetime cost of £29,719 (€37,619) (95% CI -51,985 to -9243). For a ceiling ratio of £30,000, SC has a 100% probability to be cost-effective. The cost neutral point was at 3.5 years, when the upfront cost of SC (plus any subsequent cumulative cost of side effects and ADT) equates the cumulative cost in the ADT arm. Limitations of our model may arise from its insensitivity to parameter or structural uncertainty.

CONCLUSIONS

The platform for SC versus ADT cost-effective analysis can be employed to evaluate other treatment modalities or strategies in RRPC. SC is the dominant strategy, costing less over a patient's lifetime with improvements in QALYs.

TRIAL REGISTRATION NUMBER

This economic analysis was undertaken as part of the CROP RCT study

ISRCTN

72677390; it was a pre-trial economic model developed and analysed during the pre-results stage of the RCT.

Comparative Oncologic and Toxicity Outcomes of Salvage Radical Prostatectomy Versus Nonsurgical Therapies for Radiorecurrent Prostate Cancer: A Meta-Regression Analysis

CONTEXT

In the absence of randomised controlled trials comparing the oncologic, toxicity, and functional outcomes of salvage radical prostatectomy (SRP), salvage high-intensity focused ultrasound (SHIFU), salvage brachytherapy (SBT), and salvage cryotherapy (SCT), controversy exists as to the optimal salvage modality in radiorecurrent prostate cancer.

OBJECTIVE

We carried out a meta-regression analysis to determine whether there is a difference in oncologic, toxicity, and functional outcomes using data from original publications of salvage modalities in the postradiation setting.

EVIDENCE ACQUISITION

We performed a systematic review of PubMed/Medline citations according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. We included 63 articles in the analysis (25 on SRP, 8 on SHIFU, 16 on SCT, 14 on SBT).

EVIDENCE SYNTHESIS

Median values of the following variables were extracted from each study: patient age, length of follow-up, prostate-specific antigen (PSA) before radiotherapy (RT), PSA before salvage therapy, Gleason score before RT, and time interval between RT and salvage therapy. Functional, toxicity, and oncologic outcomes were measured according to rates of impotence, incontinence, fistula formation, urethral strictures, and biochemical recurrence. Meta-regression adjusting for confounders found no significant difference in oncologic outcomes between SRP and nonsurgical salvage modalities. SBT, SCT, and SHIFU appeared to have better continence outcomes than SRP. No significant difference in toxicity outcomes between modalities was found, although limitations such as reporting, selection, and publication bias and between-study heterogeneity must also be considered with these conclusions.

CONCLUSIONS

Oncologic outcomes are comparable for SRP and all three nonsurgical salvage modalities. We found no significant differences in toxicity outcomes among modalities; however, SRP appears to be associated with worse rates of urinary incontinence than SBT, SCT, and SHIFU.

PATIENT SUMMARY

We performed a meta-regression analysis to compare oncologic, functional, and toxicity outcomes between salvage radical prostatectomy and nonsurgical salvage modalities. Oncologic and toxicity outcomes appear to be similar; however, all nonsurgical salvage modalities may be associated with better continence outcomes.

The FORECAST study - Focal recurrent assessment and salvage treatment for radiorecurrent prostate cancer

BACKGROUND

One-third of men may experience biochemical failure by 8years following radical radiotherapy for localised prostate cancer. Over 90% of men are started on androgen deprivation therapy (ADT) which is non-curative and confers systemic side-effects. Focal salvage therapy (FST) limits collateral tissue damage and may improve therapeutic ratios. In order to deliver FST, distant disease must be ruled-out and intra-prostatic disease must be accurately detected, localised and characterised.

AIM

FORECAST - Focal Recurrent Assessment and Salvage Treatment - is a study designed to evaluate a novel imaging-based diagnostic and therapeutic complex intervention pathway for men who fail radiotherapy.

METHODS

Men with biochemical failure following radical prostate radiotherapy, prior to salvage therapy will be recruited. They will undergo whole-body multi-parametric MRI (WB-MRI), choline PET/CT, bone-scan and pelvic-mpMRI and then MRI transperineal-targeted biopsies (MRI-TB) and Transperineal Template Prostate Mapping Biopsy (TPM). Those suitable for FST will undergo either high intensity focused ultrasound (HIFU) or cryotherapy.

RESULTS

Primary outcome measures: a) the accuracy of WB-MRI to detect distant metastatic disease; b) accuracy of prostate mpMRI in local detection of radiorecurrent prostate cancer; c) detection accuracy of MRI-TB; and d) rate of urinary incontinence following FST.

CONCLUSION

Focal salvage therapy may confer lower rates of morbidity whilst retaining disease control. In order to deliver FST, intra- and extra-prostatic disease must be detected early and localised accurately. Novel diagnostic techniques including WB-MRI and MRI-TB may improve the detection of distant and local disease whilst reducing healthcare burdens compared with current imaging and biopsy strategies.

Uroncor consensus statement: Management of biochemical recurrence after radical radiotherapy for prostate cancer: From biochemical failure to castration resistance

Management of patients who experience biochemical failure after radical radiotherapy with or without hormonal therapy is highly challenging. The clinician must not only choose the type of treatment, but also the timing and optimal sequence of treatment administration. When biochemical failure occurs, numerous treatment scenarios are possible, thus making it more difficult to select the optimal approach. Moreover, rapid and ongoing advances in treatment options require that physicians make decisions that could impact both survival and quality of life. The aim of the present consensus statement, developed by the Urological Tumour Working Group (URONCOR) of the Spanish Society of Radiation Oncology (SEOR), is to provide cancer specialists with the latest, evidence-based information needed to make the best decisions for the patient under all possible treatment scenarios. The structure of this consensus statement follows the typical development of disease progression after biochemical failure, with the most appropriate treatment recommendations given for each stage. The consensus statement is organized into three separate chapters, as follows: biochemical failure with or without local recurrence and/or metastasis; progression after salvage therapy; and treatment of castration-resistant patients.

Stereotactic Body Radiation Therapy Salvage Reirradiation of Radiorecurrent Prostatic Carcinoma Relapsed in the Prostatic Bed

A 67-year-old man presented with a slow increase of prostate-specific antigen value after radical prostatectomy and postoperative radiotherapy for prostate cancer. The patient had received 3D conformal radiotherapy to a total dose of 66 Gy in 33 fractions of 2 Gy each on the prostatic bed. Three years later, a macroscopic local failure was diagnosed at the apical region. The patient could not receive androgenic deprivation therapy or other types of treatment owing to comorbid conditions. Thus, stereotactic body radiation therapy with helical image-guided tomotherapy was administered. The total dose was 30 Gy in 5 consecutive fractions of 6 Gy each to the site of the local failure. The treatment was preceded by a transperineal-guided injection of a self-absorbable hydrogel into the prostatic bed, between rectum and bladder, in order to preserve the rectal wall, which already had received significant doses from the first radiation course. Radiation therapy was well-tolerated. After a follow-up period of 6 months, the patient remains healthy, and there has been no further evidence of metastatic spread or recurrence.

Salvage radical prostatectomy after external beam radiation therapy: a systematic review of current approaches

BACKGROUND

Radical external beam radiotherapy (EBRT) is a standard treatment for prostate cancer patients. Despite this, the rate of intraprostatic relapses after primary EBRT is still not negligible. There is no consensus on the most appropriate management of these patients after EBRT failure. For these patients, local salvage therapy such as radical prostatectomy, cryotherapy, and brachytherapy may be indicated.

OBJECTIVE

The objectives of this review were to analyze the eligibility criteria for careful selection of appropriate patients and to evaluate the oncological results and complications for each method.

METHODS

A review of the literature was performed to identify studies of local salvage therapy for patients who had failed primary EBRT for localized prostate cancer.

RESULTS

Most studies demonstrated that local salvage therapy after EBRT may provide long-term local control in appropriately selected patients, although toxicity is often significant.

CONCLUSIONS

Our results suggest that for localized prostate cancer recurrence after EBRT, the selection of a local treatment modality should be made on a patient-by-patient basis. An improvement in selection criteria and an integrated definition of biochemical failure for all salvage methods are required to determine which provides the best oncological outcome and least comorbidity.

Current status of cryotherapy for prostate and kidney cancer

In terms of treating diseases, minimally invasive treatment has become a key element in reducing perioperative complications. Among the various minimally invasive treatments, cryotherapy is often used in urology to treat various types of cancers, especially prostate cancer and renal cancer. In prostate cancer, the increased incidence of low-risk, localized prostate cancer has made minimally invasive treatment modalities an attractive option. Focal cryotherapy for localized unilateral disease offers the added benefit of minimal morbidities. In renal cancer, owing to the increasing utilization of cross-sectional imaging, nearly 70% of newly detected renal masses are stage T1a, making them more susceptible to minimally invasive nephron-sparing therapies including laparoscopic and robotic partial nephrectomy and ablative therapies. This article reviews the various outcomes of cryotherapy compared with other treatments and the possible uses of cryotherapy in surgery.

Retreatment for prostate cancer with stereotactic body radiation therapy (SBRT): Feasible or foolhardy?

The most popular therapeutic option in the management of radio-recurrent prostatic carcinoma is represented by the androgen deprivation therapy, that however should be considered only palliative and hampered by potential adverse effects of testosterone suppression. Local therapies such as surgery, cryoablation or brachytherapy might be curative choices for patients in good conditions and with a long-life expectancy, but at cost of significant risk of failure and severe toxicity. The administration of stereotactic body radiation therapy (SBRT) in this setting have come about because of tremendous technologic advances in image guidance and treatment delivery techniques that enable the delivery of large doses to tumor with reduced margins and high gradients outside the target, thereby reducing the volume of rectum which already received significant doses from primary radiotherapy. So far, very modest data are available to support its employment. Rationale, clinical experience, and challenges are herein reviewed and discussed.

Cryotherapy in prostate cancer

Review objectives:

Cryotherapy use has increased due to technological advances. A review of the literature was performed to evaluate the efficacy and outcomes of whole gland, salvage and targeted focal cryotherapy in the management of prostate cancer.

Review findings:

Cryotherapy use has increased significantly over the last 10 years with a trend towards focal ablation. Whole gland cryotherapy, salvage cryotherapy and focal cryotherapy biochemical recurrence rates appear to be comparable to other treatment modalities for low risk disease, however biochemical failure remains difficult to compare across studies due to a lack of consensus regarding appropriate end points for evaluation of cryotherapy. Short-term focal cryotherapy outcomes are encouraging. Side effect profiles for cryotherapy have significantly improved with fourth generation systems while salvage cryotherapy continues to carry a slightly higher risk of incontinence than primary whole gland cryotherapy. The incidence of erectile dysfunction after focal cryotherapy is dramatically lower than that for whole gland ablation.

Conclusions:

Cryotherapy continues to have an active role in the primary and salvage treatment of prostate cancer. Targeted focal cryotherapy is a promising treatment with minimal morbidity. Further long-term data is needed to support targeted therapy in addition to direct comparison with other treatment modalities.

Complications and outcomes of salvage robot-assisted radical prostatectomy: a single-institution experience

OBJECTIVE

To determine the peri-operative outcomes of men undergoing salvage robot-assisted prostatectomy (RARP) and to examine the complications, functional consequences and need for additional treatments after salvage RARP.

PATIENTS AND METHODS

At total of 51 consecutive patients underwent salvage RARP after previous failed local therapy. Biochemical recurrence (BCR) was defined as two postoperative PSA measurements ≥0.2 ng/mL. Complications at any time postoperatively were recorded prospectively using a modified Clavien system. The Kaplan-Meier method was used for survival estimation, and regression models were used to identify the predictors of BCR or progression-free survival (PFS) and complications.

RESULTS

The median age at salvage RARP was 68 years and a median of 68 months had elapsed from the time of primary treatment. The median follow-up was 36 months. The median operation duration was 179 min with a median estimated blood loss of 175 mL. In all, 50% of patients had pathological stage 3 disease and positive surgical margins were found in 31% of patients. The estimated 3-year BCR-free or PFS was 57%. The overall complication rate was 47%, with a 35% major complication rate (Grade III-V). Potency was maintained in 23% of preoperatively potent patients and 45% of all patients regained urinary control. No clinical variables were predictive of major complications, but all patients with postoperative bladder neck contracture were incontinent. A higher PSA level and extracapsular extension were significantly associated with BCR or progression (P < 0.01).

CONCLUSIONS

Salvage RARP provides oncological control with potential avoidance of systemic non-curative therapy. Complication, incontinence and erectile dysfunction rates are significant but frequently correctable. This reinforces the need for proper patient counselling and selection.

A Phase II study of salvage high-dose-rate brachytherapy for the treatment of locally recurrent prostate cancer after definitive external beam radiotherapy

PURPOSE

We report the toxicity and biochemical tumor control outcome of a prospective Phase II study using high-dose-rate brachytherapy (HDR) alone as a salvage therapy for recurrent disease after external beam radiotherapy (EBRT).

METHODS

Forty-two patients with biopsy-proven recurrence were enrolled on a Phase II study of salvage HDR monotherapy using iridium-192. Median pretreatment EBRT dose was 8100 cGy (6840–8640 cGy) and the median time from completion of EBRT to salvage HDR was 73 months. The protocol prescription dose of 3200 cGy was delivered in four fractions over 30 hours in a single insertion. Median followup after salvage HDR was 36 months (6–67 months).

RESULTS

The actuarial prostate-specific antigen biochemical relapse-free survival and distant metastases-free survival rates at 5 years were 68.5% and 81.5%, respectively. Cause-specific survival was 90.3%. Late genitourinary Grade 1and 2 toxicities were found in 38% and 48%, respectively, and one patient developed Grade 3 urinary incontinence. Late Grade 1 and 2 gastrointestinal toxicity was noted in 17% and 8% of patients, respectively. Three patients (7%) developed Grade 2 late urinary toxicity (urethral stricture), which were corrected with urethral dilatation, and one patient developed Grade 3 urinary incontinence. No Grade 4 toxicities were observed.

CONCLUSIONS

Genitourinary toxicity was the most commonly encountered toxicity observed after salvage HDR but severe toxicities were uncommon. Salvage HDR is an effective and well-tolerated modality for locally recurrent prostate cancer and should be considered even for patients who have previously been treated with ultra-high dose levels of EBRT.

Focal salvage therapy for locally recurrent prostate cancer: a review

Objectives: To evaluate the current status of focal therapy as the salvage treatment option for patients with recurrent prostate cancer after established therapy (radiation, surgery) failure for localized tumor.
Methods: A MedLine search using specified search terms was done on December 23, 2011. This research rendered 346 papers related to High-Intensity Focused Ultrasound (HIFU), 644 papers related to cryosurgery, 180 related to photodynamic therapy and 3 articles related to radio frequency ablation. Very few of these papers presented original outcome data and are included in the present review.
Results: No controlled trial was available for analysis. 
Conclusions: Salvage HIFU in patients with local recurrence of prostate cancer after radical EBRT indicate is a reasonable treatment option, but better patient selection criteria are needed. It is a promising treatment option for local recurrence after radiation therapy, with morbidity comparable with other forms of salvage treatment. The side effects are not negligible but comparable with other forms of salvage treatment. Photodynamic therapy is a new option that could be suitable for organ-confined PC recurrence after radiotherapy, but the data are very few.

Salvage focal and salvage total cryoablation for locally recurrent prostate cancer after primary radiation therapy

OBJECTIVES

To present the oncological and functional outcomes of salvage focal (SFC) and salvage total (STC) cryoablation for recurrent prostate cancer (PCa) after failed primary radiotherapy.

PATIENTS AND METHODS

From March 2003 to August 2010, 50 men with biopsy-proven unilateral (n = 25) or bilateral (n = 25) radio-recurrent PCa underwent SFC or STC, respectively. Patients were assessed after treatment by prostate-specific antigen (PSA) testing, transrectal ultrasonography, biopsy and questionnaires. Biochemical failure (BF) was defined using the Phoenix criteria (PSA nadir + 2 mg/mL). Data were prospectively collected and retrospectively analysed.

RESULTS

The median pre-cryoablation PSA level and Gleason score were, respectively, 2.8 ng/mL and 7 for SFC, and 3.9 ng/mL and 7 for STC. The median follow-up was 31 and 53 months (P = 0.004) for SFC and STC, respectively. Oncological outcomes were as follows: no patient died; one patient who underwent STC developed bone metastases; eight patients who underwent SFC and three who underwent STC had BF and the 5-year BF-free survival rates were 54 and 86%, respectively. In those patients without BF, the mean PSA decreased by 86% for SFC and 90% for STC within the first year and remained stable. Functional outcomes were as follows: new onset urinary incontinence occurred in three (13%) patients in the STC group, whereas no patient in the SFC group developed incontinence (P = 0.10); Two of seven patients in the SFC group retained postoperative potency, but none of the four potent patients in the STC group recovered potency postoperatively (P = 0.48); one (4%) patient in the STC group developed a recto-urethral fistula, but none occurred in the SFC group (P = 0.48).

CONCLUSIONS

SFC and STC are feasible and safe with acceptable mid-term oncological outcomes. For carefully selected patients, SFC is an option that could be associated with lower treatment-related morbidity compared with STC. Although longer follow-up and more patient numbers are needed, our initial oncological and functional outcomes of SFC and STC are encouraging.

The dilemma of a rising prostate-specific antigen level after local therapy: what are our options?

Prostate cancer is the most common solid tumor diagnosed in men in the United States and Western Europe. Primary treatment with radiation or surgery is largely successful at controlling localized disease. However, a significant number (up to one third of men) may develop biochemical recurrence (BR), defined as a rise in serum prostate-specific antigen (PSA) level. A general presumption is that BR will lead to overt progression in patients over subsequent years. There are a number of factors that a physician must consider when counseling and recommending treatment to a patient with a rising PSA. These include the following (1) various PSA-based definitions of BR; (2) source of PSA (ie, local or distant disease, residual benign prostate); (3) available modalities to treat the disease with the least morbidity; and (4) timing of therapy. In this article we review the current and future factors that clinicians should consider in the diagnosis and treatment of recurrent prostate cancer.

Prostate gland lengths and iceball dimensions predict micturition functional outcome following salvage prostate cryotherapy in men with radiation recurrent prostate cancer

INTRODUCTION

Tissue cryoablation is a potential curative option for solid malignancies, including radiation recurrent prostate cancer (RRPC). Case series of salvage cryotherapy (SCT) in RRPC have reported promising disease free survival (DFS) outcomes and acceptable toxicity profile. While many men receive SCT, no predictive factors for treatment induced side effects are known. The aim of this study is to validate the oncologic outcome of SCT in a large multi-centre patient cohort and to identify potential parameters associated with an increased risk of micturition symptoms.

PATIENTS AND METHODS

In this retrospective analysis, we studied 283 consecutive patients with RRPC treated by SCT in three independent U.K. centres (between 2001 and 2011). Two freeze-thaw cycles of transperineal cryotherapy were performed under transrectal ultrasound guidance by a single surgeon in each of the 3 sites. We analysed clinico-pathological factors against tumour response. Functional outcomes were assessed by continence status and IPSS questionnaire. Predictive factors for SCT-induced micturition symptoms were analysed in a sub-group (n=42) of consecutive cases.

RESULTS

We found that nadir post-SCT PSA levels strongly associated with DFS. The DFS rates at 12- and 36-month were 84% and 67% for the ≤ 1 ng/ml group and 56% and 14% for the >1 ng/ml group, respectively (p<0.001). Correlative analysis revealed highly significant association between patients' post-SCT micturition status with prostate gland and iceball lengths following SCT. Finally, in a reduction model, both gland length and maximal length of iceball were highly associated with patients' IPSS outcome (p<0.001).

CONCLUSION

We report the largest European patient cohort treated with SCT for RRPC. Oncologic outcome guided by nadir PSA of <1 ng/ml is consistent with earlier single-centre series. For the first time, we identified physical parameters to predict micturition symptoms following SCT. Our data will directly assist on-going and future trial design in cryotherapy in prostate cancer.