Current Treatment Options in Oncology

, Volume 5, Issue 5, pp 357–365

Salvage therapy for locally recurrent prostate cancer after external beam radiotherapy

  • Andrew J. Stephenson
  • Peter T. Scardino
  • Fernando J. Bianco
  • James A. Eastham

Opinion statement

The greatest obstacle in the cure of patients with locally recurrent prostate cancer after radiation therapy is the lack of early detection markers. The majority of patients who are candidates for local salvage therapy have locally advanced disease, precluding successful salvage therapy. A low pretreatment prostate specific antigen (PSA) has shown to be a favorable prognostic variable for disease progression, regardless of the specific local salvage therapy used. Of all the local salvage treatment options for these patients, we believe that salvage radical prostatectomy (RP) offers patients the great-est likelihood of a cure. The salvage RP results approach those achieved with standard RP for patients of similar pathologic stage. When patients are treated early in the course of recurrent disease (preoperative PSA < 10 ng/mL), an estimated two-thirds of patients will be disease-free 5 years after salvage RP alone. With better patient selec-tion and continued technical modifications, the morbidity associated with salvage RP has substantially improved. Perioperative complications approach those observed with standard RP and approximately two-thirds of patients will recover urinary continence. Select patients may also recover functional erections when nerve-sparing techniques are used. Salvage cryotherapy and brachytherapy are minimally invasive alternatives to salvage RP. The cancer control results of these procedures appear to be inferior to results achieved with salvage RP. Each of these procedures is associated with signifi-cant morbidity and do not appear to provide a clear advantage over salvage RP in terms of posttreatment complications, urinary continence, and erectile function. A long-term cure is possible for patients with locally recurrent prostate cancer after radiation therapy. Local salvage therapy must be instituted early to be successful in the course of progressive disease.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Jemal A, Tiwari RC, Murray T, et al.: Cancer statistics, 2004. CA Cancer J Clin 2004, 54:8–29.PubMedGoogle Scholar
  2. 2.
    Lee WR, Moughan J, Owen JB, Zelefsky MJ: The 1999 patterns of care study of radiotherapy in localized prostate carcinoma: a comprehensive survey of pros-tate brachytherapy in the United States. Cancer 2003, 98:1987–1994.PubMedCrossRefGoogle Scholar
  3. 3.
    Brandeis J, Pashos CL, Henning JM, Litwin MS: A nationwide charge comparison of the principal treat-ments for early stage prostate carcinoma. Cancer 2000, 89:1792–1799.PubMedCrossRefGoogle Scholar
  4. 4.
    Shipley WU, Thames HD, Sandler HM, et al.: Radiation therapy for clinically localized prostate cancer: a multi-institutional pooled analysis. Jama 1999, 281:1598–1604.PubMedCrossRefGoogle Scholar
  5. 5.
    Kuban DA, Thames HD, Levy LB, et al.: Long-term multi-institutional analysis of stage T1-T2 prostate cancer treated with radiotherapy in the PSA era. Int J Radiat Oncol Biol Phys 2003, 57:915–928.PubMedCrossRefGoogle Scholar
  6. 6.
    Lee WR, Hanks GE, Hanlon A: Increasing prostate-spe-cific antigen profile following definitive radiation therapy for localized prostate cancer: clinical observa-tions. J Clin Oncol 1997, 15:230–238. Natural history of biochemical progression after EBRT.PubMedGoogle Scholar
  7. 7.
    Pollack A, Zagars GK, Kavadi VS: Prostate specific anti-gen doubling time and disease relapse after radiother-apy for prostate cancer. Cancer 1994, 74:670–678.PubMedCrossRefGoogle Scholar
  8. 8.
    Pinover WH, Horwitz EM, Hanlon AL, et al.: Validation of a treatment policy for patients with prostate specific antigen failure after three-dimensional conformal pros-tate radiation therapy. Cancer 2003, 97:1127–1133.PubMedCrossRefGoogle Scholar
  9. 9.
    D’Amico AV, Cote K, Loffredo M, et al.: Determinants of prostate cancer-specific survival after radiation ther-apy for patients with clinically localized prostate can-cer. J Clin Oncol 2002, 20:4567–4573.PubMedCrossRefGoogle Scholar
  10. 10.
    Sandler HM, Dunn RL, McLaughlin PW, et al.: Overall survival after prostate-specific-antigen-detected recur-rence following conformal radiation therapy. Int J Radiat Oncol Biol Phys 2000, 48:629–633.PubMedCrossRefGoogle Scholar
  11. 11.
    Grossfeld GD, Li YP, Lubeck DP, et al.: Predictors of sec-ondary cancer treatment in patients receiving local therapy for prostate cancer: data from cancer of the prostate strategic urologic research endeavor. J Urol 2002, 168:530–535.PubMedCrossRefGoogle Scholar
  12. 12.
    Zelefsky MJ, Leibel SA, Gaudin PB, et al.: Dose escala-tion with three-dimensional conformal radiation therapy affects the outcome in prostate cancer. Int J Radiat Oncol Biol Phys 1998, 41:491–500.PubMedCrossRefGoogle Scholar
  13. 13.
    Zagars GK, Pollack A, von Eschenbach AC: Prostate can-cer and radiation therapy--the message conveyed by serum prostate-specific antigen. Int J Radiat Oncol Biol Phys 1995, 33:23–35. Localization of the site of progressive disease among patients with an increasing PSA level after EBRT.PubMedCrossRefGoogle Scholar
  14. 14.
    Fuks Z, Leibel SA, Wallner KE, et al.: The effect of local control on metastatic dissemination in carcinoma of the prostate: long-term results in patients treated with 125I implantation. Int J Radiat Oncol Biol Phys 1991, 21:537–547.PubMedGoogle Scholar
  15. 15.
    Holzman M, Carlton CE Jr, Scardino PT: The frequency and morbidity of local tumor recurrence after defini-tive radiotherapy for stage C prostate cancer. J Urol 1991, 146:1578–1582.PubMedGoogle Scholar
  16. 16.
    Schellhammer PF, Kuban DA, el-Mahdi AM: Treatment of clinical local failure after radiation therapy for prostate carcinoma. J Urol 1993, 150:1851–1855.PubMedGoogle Scholar
  17. 17.
    Pound CR, Partin AW, Eisenberger MA, et al.: Natural history of progression after PSA elevation following radical prostatectomy. JAMA 1999, 281:1591–1597.PubMedCrossRefGoogle Scholar
  18. 18.
    Crook JM, Perry GA, Robertson S, Esche BA: Routine prostate biopsies following radiotherapy for prostate cancer: results for 226 patients. Urology 1995, 45:624- 631; discussion 631-632.PubMedCrossRefGoogle Scholar
  19. 19.
    Cox JD, Gallagher MJ, Hammond EH, et al.: Consensus statements on radiation therapy of prostate cancer: guidelines for prostate re-biopsy after radiation and for radiation therapy with rising prostate-specific antigen levels after radical prostatectomy. American Society for Therapeutic Radiology and Oncology Con-sensus Panel. J Clin Oncol 1999, 17:1155.PubMedGoogle Scholar
  20. 20.
    Hanlon AL, Pinover WH, Horwitz EM, Hanks GE: Pat-terns and fate of PSA bouncing following 3D-CRT. Int J Radiat Oncol Biol Phys 2001, 50:845–849.PubMedCrossRefGoogle Scholar
  21. 21.
    Rosser CJ, Kuban DA, Levy LB, et al.: Prostate specific antigen bounce phenomenon after external beam radiation for clinically localized prostate cancer. J Urol 2002, 168:2001–2005.PubMedCrossRefGoogle Scholar
  22. 22.
    Consensus statement: guidelines for PSA following radiation therapy. American Society for Therapeutic Radiology and Oncology Consensus Panel. Int J Radiat Oncol Biol Phys 1997, 37:1035–1041.Google Scholar
  23. 23.
    Pollack A, Zagars GK, Antolak JA, et al.: Prostate biopsy status and PSA nadir level as early surrogates for treat-ment failure: analysis of a prostate cancer randomized radiation dose escalation trial. Int J Radiat Oncol Biol Phys 2002, 54:677–685. Prognostic significance of a positive prostate biopsy 2 years after EBRT.PubMedCrossRefGoogle Scholar
  24. 24.
    Scardino PT, Frankel JM, Wheeler TM, et al.: The prognos-tic significance of post-irradiation biopsy results in patients with prostatic cancer. J Urol 1986, 135:510–516.PubMedGoogle Scholar
  25. 25.
    Eastham JA, Scardino PT: Salvage radical prostatec-tomy: improving outcome after failed radiation ther-apy. Contemp Urol 2004, In press. Analysis of cancer outcome following salvage radical pros-tatectomy alone including long-term cancer-specific sur-vival and multivariable analysis of factors associated with disease progression.Google Scholar
  26. 26.
    Pontes JE, Montie J, Klein E, Huben R: Salvage surgery for radiation failure in prostate cancer. Cancer 1993, 71:976–980.PubMedCrossRefGoogle Scholar
  27. 27.
    Rogers E, Ohori M, Kassabian VS, et al.: Salvage radical prostatectomy: outcome measured by serum prostate specific antigen levels. J Urol 1995, 153:104–110.PubMedCrossRefGoogle Scholar
  28. 28.
    Brenner PC, Russo P, Wood DP, et al.: Salvage radical prostatectomy in the management of locally recurrent prostate cancer after 125I implantation. Br J Urol 1995, 75:44–47.PubMedCrossRefGoogle Scholar
  29. 29.
    Link P, Freiha FS: Radical prostatectomy after definitive radiation therapy for prostate cancer. Urology 1991, 37:189–192.PubMedCrossRefGoogle Scholar
  30. 30.
    Amling CL, Lerner SE, Martin SK, et al.: Deoxyribonu-cleic acid ploidy and serum prostate specific antigen predict outcome following salvage prostatectomy for radiation refractory prostate cancer. J Urol 1999, 161:857–862; discussion 862-863.PubMedCrossRefGoogle Scholar
  31. 31.
    Stein A, Smith RB, deKernion JB: Salvage radical prostate-ctomy after failure of curative radiotherapy for adenocar-cinoma of prostate. Urology 1992, 40:197–200.PubMedCrossRefGoogle Scholar
  32. 32.
    Gheiler EL, Tefilli MV, Tiguert R, et al.: Predictors for maximal outcome in patients undergoing salvage sur-gery for radio-recurrent prostate cancer. Urology 1998, 51:789–795.PubMedCrossRefGoogle Scholar
  33. 33.
    Moul JW, Paulson DF: The role of radical surgery in the management of radiation recurrent and large volume prostate cancer. Cancer 1991, 68:1265–1271.PubMedCrossRefGoogle Scholar
  34. 34.
    Lerner SE, Blute ML, Zincke H: Critical evaluation of salvage surgery for radio-recurrent/resistant prostate cancer. J Urol 1995, 154:1103–1109.PubMedCrossRefGoogle Scholar
  35. 35.
    Stephenson AJ, Scardino PT, Bianco FJ Jr, et al.: Morbid-ity and functional outcomes of salvage radical pros-tatectomy for radiorecurrent prostate cancer. J Urol 2004, In Press. Comprehensive report of the perioperative complications, uri-nary continence results and potency rates associated with sal-vage radical prostatectomy.Google Scholar
  36. 36.
    Dillioglugil O, Leibman BD, Leibman NS, et al.: Risk fac-tors for complications and morbidity after radical retro-pubic prostatectomy. J Urol 1997, 157:1760–1767.PubMedCrossRefGoogle Scholar
  37. 37.
    Vallancien G, Gupta R, Cathelineau X, et al.: Initial results of salvage laparoscopic radical prostatectomy after radiation failure. J Urol 2003, 170:1838–1840.PubMedCrossRefGoogle Scholar
  38. 38.
    Gheiler EL, Wood DP Jr, Montie JE, Pontes JE: Orthoto-pic urinary diversion is a viable option in patients undergoing salvage cystoprostatectomy for recurrent prostate cancer after definitive radiation therapy. Urol-ogy 1997, 50:580–584.Google Scholar
  39. 39.
    Ahlering TE, Lieskovsky G, Skinner DG: Salvage surgery plus androgen deprivation for radioresistant prostatic adenocarcinoma. J Urol 1992, 147:900–902.PubMedGoogle Scholar
  40. 40.
    Pisters LL, English SF, Scott SM, et al.: Salvage prostatec-tomy with continent catheterizable urinary reconstruc-tion: a novel approach to recurrent prostate cancer after radiation therapy. J Urol 2000, 163:1771–1774.PubMedCrossRefGoogle Scholar
  41. 41.
    Izawa JI, Perrotte P, Greene GF, et al.: Local tumor con-trol with salvage cryotherapy for locally recurrent prostate cancer after external beam radiotherapy. J Urol 2001, 165:867–870.PubMedCrossRefGoogle Scholar
  42. 42.
    Izawa JI, Madsen LT, Scott SM, et al.: Salvage cryother-apy for recurrent prostate cancer after radiotherapy: variables affecting patient outcome. J Clin Oncol 2002, 20:2664–2671. Analysis of cancer outcome after salvage cryotherapy using liguid nitrogen cryoprobes.PubMedCrossRefGoogle Scholar
  43. 43.
    Ghafar MA, Johnson CW, De La Taille A, et al.: Salvage cryotherapy using an argon based system for locally recurrent prostate cancer after radiation therapy: the Columbia experience. J Urol 2001, 166:1333–1337; dis-cussion 1337-1338.PubMedCrossRefGoogle Scholar
  44. 44.
    Chin JL, Pautler SE, Mouraviev V, et al.: Results of sal-vage cryoablation of the prostate after radiation: iden-tifying predictors of treatment failure and complications. J Urol 2001, 165:1937–1941; discussion 1941-1932. Cancer outcome and complications of salvage cryotherapy using gas-driven cryoprobes.PubMedCrossRefGoogle Scholar
  45. 45.
    Leibovich BC, Izawa J, Zincke H, et al.: Recurrent pros-tate cancer after radiation therapy: salvage prostatec-tomy versus salvage cryosurgery. J Urol 2001, 165:1595A.Google Scholar
  46. 46.
    Perrotte P, Litwin MS, McGuire EJ, et al.: Quality of life after salvage cryotherapy: the impact of treatment parameters. J Urol 1999, 162:398–402. Comprehensive report of the long-term morbidity, urinary continence results and potency rates associated with sal-vage cryotherapy.PubMedCrossRefGoogle Scholar
  47. 47.
    Sylvester J, Grimm P, Blasco J, et al.: The role of andro-gen ablation in patients with biochemical or local failure after definitive radiation therapy: a survey of practice patterns of urologists and radiation oncolo-gists in the United States. Urology 2001, 58:65–70.PubMedCrossRefGoogle Scholar
  48. 48.
    Beyer DC: Permanent brachytherapy as salvage treat-ment for recurrent prostate cancer. Urology 1999, 54:880–883.PubMedCrossRefGoogle Scholar
  49. 49.
    Grado GL, Collins JM, Kriegshauser JS, et al.: Salvage brachytherapy for localized prostate cancer after radiotherapy failure. Urology 1999, 53:2–10. Analysis of cancer outcome and complications following sal-vage brachytherapy.PubMedCrossRefGoogle Scholar
  50. 50.
    Moul JW: Prostate specific antigen only progression of prostate cancer. J Urol 2000, 163:1632–1642.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2004

Authors and Affiliations

  • Andrew J. Stephenson
  • Peter T. Scardino
  • Fernando J. Bianco
  • James A. Eastham
    • 1
  1. 1.Memorial Sloan-Kettering Cancer CenterNew YorkUSA

Personalised recommendations