Management of locally recurrent disease

Abstract

Introduction: Local failures following radical prostate treatment are of clinical importance, as there is a direct relationship between local control and distant metastasis and prostate cancer mortality. This chapter describes the different salvage options for a biochemical recurrence following primary prostatectomy or radiotherapy. Diagnostic Workup: Although there is no consensus regarding the use of imaging techniques prior to salvage treatment, the first step should be to exclude metastatic disease. In addition to imaging, PSA kinetics and nomograms might be used to improve patient selection. An overview of current available tools is presented. For local restaging, a biopsy of the prostate is generally recommended following radiotherapy. On the other hand, following RP, a biopsy of the vesicourethral anastomosis is no longer supported. Salvage Options: Following RP, salvage RT is the only therapeutic option offering a potential cure with improved prostate-specific and all-cause survival. It is recommended to start RT as early as possible before the PSA reaches 0.5 ng/ml. Generally, a dose of 66 Gy is delivered to the prostate bed with less than 5 % grade 3 toxicity. Adjuvant androgen deprivation therapy with bicalutamide might be considered based on the preliminary results of the RTOG 96-01 trial. Following RT, several options are available including prostatectomy, brachytherapy, and cryosurgery. Based on the current evidence, it is not possible to recommended one treatment over the other, and treatment choice should be balanced with possible side effects. Newer treatment techniques such as high-intensity focused ultrasound and photodynamic therapy should be considered investigational. Conclusions: For every patient with a biochemical failure following radical treatment and a life expectancy exceeding the time to distant metastases, referral for local salvage therapy should be considered. The proposed salvage modalities should be discussed with the patient, as the risk of therapy-induced morbidity should be balanced with the potential survival benefit.