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Background: The presence of adverse pathological features like extraprostatic extension, seminal vesicle involvement, or positive margins at radical prostatectomy incurs a high risk of postoperative recurrence. Currently, adjuvant radiotherapy (ART) is the standard of care in these patients, while early salvage radiotherapy (eSRT) is a potential alternative strategy. Aims: The purpose of this paper is to review the latest evidence comparing outcomes of adjuvant versus early SRT in this clinical scenario. Materials and Methods: A systematic review of Google Scholar, PubMed/Medline, and EMBASE was done to identify relevant studies published in the English language, regarding outcomes of adjuvant radiotherapy and early SRT in post radical prostatectomy patients. Twelve studies, including six randomized trials, four retrospective studies, one systematic review, and one metanalysis were included in the final analysis. Results: We found that initial randomized trials demonstrated better event?free survival with adjuvant radiotherapy when compared to observation alone. However, ART was associated with increased risk of overtreatment and thus increased radiation?related toxicity rates. Conclusion: Preliminary evidence from recently reported RCTs suggests that eSRT may provide equivalent oncological outcomes to ART in prostate cancer patients with adverse pathology on radical prostatectomy while decreasing unnecessary treatment and radiation?related toxicity in a significant proportion of patients. However, the final verdict would be delivered after the long?term metastasis?free survival and overall survival outcomes are available.
ABSTRACT
Radical prostatectomy(RP)was commonly used in localized prostate cancer. For patients with adverse pathological features (APF) after RP, it was controversial about choosing adjuvant radiotherapy or salvage radiotherapy (SRT). Recent studies have found that early salvage radiotherapy(ESRT) had both the same cancer control and reduced overtreatment compared to adjuvant radiotherapy. Nomogram and Gene Classifier(GC) could predict the risk of recurrence after RP and contribute to choose adjuvant radiotherapy or ESRT. PSMA PET/CT was more sensitive to detect distant metastasis after biochemical recurrence, which was helpful to decide whether to implement SRT.
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Objective:To investigate the prognosis after salvage radiotherapy with or without hormone therapy for prostate cancer.Methods:From May 2014 to December 2020, 248 patients undergoing salvage radiotherapy due to prostate-specific antigen (PSA)persistence or biochemical progression after radical prostatectomy at Sun Yat-sen University Cancer Center (n=157) and West China Hospital, Sichuan University (n=91) were analyzed. Median age was 66 (45-78) years old. Median PSA was 23.50 (0.18-845.00) ng/ml. The number of PSA persistence and biochemical progression were 143 (59%) and 105 (42%). The number of pT 2, pT 3a, pT 3b, pT 4, and unknown T stage was 99, 49, 78, 15 and 7 cases.The number of N 0, N 1 and unknown N stage was 153, 44 and 51 cases. 165 cases had positive surgical margin. Gleason score of 6, 7, 8, >8 score and unknown was in 12, 104, 34, 90 and 8 patients. Early and late salvage radiotherapy was performed in 117 and 131 patients, and 70 patients (28%) were CRPC. Hormone therapy was used combined with radiotherapy in 182 patients (73%). PSA decline after radiotherapy was compared with Chi-squre test. Kaplan-Meier method and log-rank test were used to compare progression free-survival (PFS)after radiotherapy. Univariate and multivariate analyses of PFS were performed using Cox proportional hazards model. Early salvage radiotherapy was defined as PSA≤0.5 ng/ml before radiotherapy, and late salvage radiotherapy was defined as PSA>0.5ng/ml. Results:PSA response (PSA decline ≥50%) rate was 94% (233/248), and 82% (203/248) patients had PSA decline ≥ 90%. Twelve (5%) patients had rising PSA after completing radiotherapy, but only 4 (2%) had real progression. The median PFS was 69 months (95% CI 68-70), and 3-year and 5-year PFS rate were 80% and 67%. PFS of PSA persistence and biochemical progression were similar ( HR =0.71, 95% CI 0.37-1.37, P=0.311). Compared with late salvage radiotherapy, early salvage radiotherapy had better PFS [69 (95% CI 68-70) vs. 59 (95% CI 44-74) months, P<0.001]. Compared with hormone sensitive, castration-resistant was associated with worse PFS (5-year PFS rate 74% vs. 51%, P<0.001). In multivariate analysis, Gleason score>8, castration-resistant and late salvage radiotherapy were unfavorable prognostic factors. Conclusions:In patients receiving salvage radiotherapy with or without hormone therapy for PSA persistence and biochemical progression after radical prostatectomy, high PSA level before radiotherapy and castration resistant is associated with poor prognosis.
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PURPOSE: To investigate interobserver variation in target volume delineations for prostate cancer salvage radiotherapy using planning computed tomography (CT) versus combined planning CT and magnetic resonance imaging (MRI). MATERIALS AND METHODS: Ten radiation oncologists independently delineated a target volume on the planning CT scans of five cases with different pathological status after radical prostatectomy. Two weeks later, this was repeated with the addition of planning MRI. The volumes obtained with CT only and combined CT and MRI were compared, and the effect of the addition of planning MRI on interobserver variability was assessed. RESULTS: There were large differences in clinical target volume (CTV) delineated by each observer, regardless of the addition of planning MRI (9.44–139.27 cm³ in CT only and 7.77–122.83 cm³ in CT plus MRI) and no significant differences in the mean and standard deviation of CTV. However, there were decreases in mean volume and standard deviation as a result of using the planning MRI. CONCLUSION: This study showed substantial interobserver variation in target volume delineation for salvage radiotherapy. The combination of planning MRI with CT tended to decrease the target volume and the variation.
Subject(s)
Humans , Magnetic Resonance Imaging , Observer Variation , Prostate , Prostatectomy , Prostatic Neoplasms , Radiotherapy , Tomography, X-Ray ComputedABSTRACT
Radiotherapy(RT) is one of the principle treatment options for prostate cancer.Modern RT and surgery show similar progression-free survival in localized prostate cancer.Adjuvant RT compared to observation significantly diminishes the risk of prostate-specific antigen (PSA) progression and local failure for patients at the highest risk for recurrence after radical prostatectomy,including with seminal vesicle invasion,extraprostatic extension,extensive positive margins,and detectable postoperative PSA.Salvage RT is effective at controlling local recurrence and reduces the risk of distant metastasis and prostate cancerspecific mortality (PCSM) for patients with PSA or local recurrence after prostatectomy.Hypofractionated radiotherapy of recent years' reports shows similar cancer control rates without an increased risk of late toxicity in comparison to conventional regimens.The addition of androgen-deprivation therapy (ADT) to radiation improves the overall survival and biochemical progression-free survival(bPFS) for intermediate-risk and high-risk patients.
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Several studies have evaluated the risk factors influencing biochemical recurrence (BCR) of prostate cancer in patients receiving salvage radiotherapy (SRT) for BCR after radical prostatectomy (RP), but the results remain conflicting. In this study, we performed a meta-analysis to resolve this conflict. We searched the following databases: PubMed, Embase, and Web of Science using the following terms in All fields: salvage radiation therapy, salvage IMRT, S-IMRT, salvage radiotherapy, SRT, radical prostatectomy, RP, biochemical recurrence, BCR, biochemical relapse. Eleven studies, with a total of 1383 patients, were included in our meta-analysis. Of all the variables, only Gleason score (GS) ≥7 (odds ratio [OR]: 3.82; 95% confidence interval [CI]: 2.60-5.64) and pathological tumor (pT) stage ≥3a (OR: 1.82; 95% CI: 1.36-2.42) were positively correlated with BCR. However, SRT combined with androgen deprivation therapy (ADT) (OR: 0.63; 95% CI: 0.44-0.90) and radiation therapy (RT) dose ≥64 Gy (OR: 0.35; 95% CI: 0.19-0.64) were negatively correlated with BCR. Perineural invasion (OR: 2.64; 95% CI: 1.11-6.26), preoperative prostate-specific antigen (PSA) ≥10 ng ml-1 (OR: 1.36; 95% CI: 0.94-1.96), positive surgical margin (OR: 0.92; 95% CI: 0.7-1.19), and seminal vesicle involvement (SVI) (OR: 1.09; 95% CI: 0.83-1.43) had no effect on BCR. Our meta-analysis indicated that pT stage, GS, RT dose, and SRT combined with ADT may influence BCR, while preoperative PSA, surgical margin, perineural invasion, and SVI have only a weak effect on BCR.
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Objective To analyze the efficacy of salvage therapy for postoperative recurrence or metastasis in patients with stage T3 N0 M0 thoracic esophageal squamous cell carcinoma ( ESCC ) and its influencing factors. Methods A retrospective analysis was performed in 108 patients with postoperative recurrence or metastasis in stage T3 N0 M0 thoracic ESCC who were admitted to our hospital from 2008 to 2009. In those patients, 59 had locoregional recurrence ( LR) , 26 distant metastasis ( DM) , and 23 both LR and DM. After recurrence, 53 patients received supportive therapy, 32 salvage radiotherapy, 9 chemotherapy, and 14 chemoradiotherapy. The overall survival ( OS) rates were calculated using the Kaplan?Meier method and analyzed using the log?rank test. The univariate and multivariate prognostic analyses were performed using the log?rank test and the Cox regression model, respectively. Results The follow?up rate was 100%. In all patients, the 1?, 3?, and 4?year OS rates were 29?9%, 16?5%, and 14?4%, respectively;the median OS time was 6 months. The univariate analysis showed that recurrence pattern and salvage therapy were associated with OS after recurrence ( P=0?017;P=0?000) . The multivariate analysis showed that salvage therapy was the only independent factor for OS after recurrence ( P=0?000) . Compared with supportive therapy, the risk of death after chemotherapy, radiotherapy, or chemoradiotherapy was reduced by 76?7%, 76?7%, and 86?1%, respectively. Conclusions The treatment outcomes are poor in patients with postoperative recurrence of stage T3 N0 M0 thoracic ESCC. Salvage therapy can substantially improve OS after recurrence.
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A progressively rising level of serum prostate specific antigen (PSA) after radical prostatectomy (RP) invariably indicates the recurrence of prostate cancer. The optimal management of patients with post-RP PSA relapse has remained uncertain due to a wide variability in the natural course of post-RP PSA relapse and the inability to separate a recurrent disease confined to the prostate bed from that with occult distant metastasis. Management uncertainty is further compounded by the lack of phase III clinical studies demonstrating which therapeutic approach, if any, would prolong life with no significant morbidity. Radiotherapy has been the main therapeutic modality with a curative potential for patients with post-RP PSA relapse. This review article depicts issues and challenges in the management of patients with post-RP PSA relapse, presents the literature data for the efficacy of salvage radiotherapy, either alone or in combination of androgen ablation therapy, and discusses future directions that can optimize treatment strategies.