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Radiotherapy after radical prostatectomy: immediate or early delayed?

Strahlentherapie nach radikaler Prostatektomie: Sofort oder verzögert?

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Abstract

Background

Biochemical recurrence after radical prostatectomy (RP) is associated with risk indicators, including Gleason score, preoperative PSA level, tumor stage, seminal vesicle invasion, and positive surgical margins. The 5-year biochemical progression rate among predisposed patients is as high as 50–70%. Post-RP treatment options include adjuvant radiotherapy (ART, for men with undetectable PSA) or salvage radiotherapy (SRT, for PSA persisting or re-rising above detection threshold). Presently, there are no published randomized trials evaluating ART vs. SRT directly.

Methods

Published data on ART and SRT were reviewed to allow a comparison of the two treatment approaches.

Results

Three randomized phase III trials demonstrated an almost 20% absolute benefit for biochemical progression-free survival after ART (60–64 Gy) compared to a “wait and see” policy. The greatest benefit was achieved in patients with positive margins and pT3 tumors.

SRT can be offered to patients with elevated PSA after RP. In 30–70% of SRT patients, PSA will decrease to an undetectable level, thus giving a second curative chance. The rate of side effects for both treatments is comparably low.

The role of irradiation of pelvic lymph nodes and the additional use of hormone therapy and radiation dose are discussed.

Conclusion

It remains unclear whether early SRT initiated after PSA failure is equivalent to ART. Where SRT is indicated, it should be started as early as possible.

Zusammenfassung

Hintergrund

Zu den Risikoindikatoren eines biochemischen Rezidivs nach radikaler Prostatektomie (RP) gehören Gleason-Score, präoperativer PSA-Wert, Tumorstadium, Status der Samenblase und der Operationsränder. Prädisponierte Patienten haben eine biochemische 5-Jahres-Progressionsrate von 50–70%. Postoperative Behandlungsoptionen sind die adjuvante Strahlentherapie (ART, bei nicht detektierbarem PSA) oder die Salvage-Radiotherapie (SRT, bei persistierendem oder überschwellig werdendem PSA). Bisher liegen keine Publikationen randomisierter Studien vor, die ART und SRT direkt gegenüberstellen.

Methode

Publizierte Daten zu ART und STR wurden analysiert, um die beiden Therapieansätze zu vergleichen.

Ergebnisse

Drei randomisierte Phase-III-Studien zeigen für biochemische Progressionsfreiheit einen fast 20%igen Vorteil durch ART (60–64 Gy) gegenüber einer abwartenden Strategie. Den größten Gewinn haben Patienten mit Tumorstadium pT3 und positiven Schnitträndern.

Eine SRT kann Patienten mit postoperativem PSA-Wiederanstieg angeboten werden. Bei 30–70% dieser Patienten wird eine Absenkung des PSA unter die Nachweisgrenze erreicht und ihnen eine zweite Heilungschance eröffnet. Die Nebenwirkungsrate ist bei beiden Therapiemodalitäten vergleichbar gering.

Die Rolle der Mitbestrahlung der pelvinen Lymphabflusswege, einer zusätzlichen Hormontherapie und der strahlentherapeutischen Dosis wird diskutiert.

Schlussfolgerung

Es bleibt unklar, ob die SRT nach PSA-Rezidiv einer ART gleichwertig ist. Wenn die SRT indiziert ist, sollte sie möglicht früh beginnen.

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On behalf of all authors, the corresponding author states that there are no conflicts of interest.

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  1. University Hospital Ulm, Ulm, Germany

    D. Bottke, D. Bartkowiak, M. Schrader & T. Wiegel

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  1. D. Bottke
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Correspondence to D. Bottke.

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Bottke, D., Bartkowiak, D., Schrader, M. et al. Radiotherapy after radical prostatectomy: immediate or early delayed?. Strahlenther Onkol 188, 1096–1101 (2012). https://doi.org/10.1007/s00066-012-0234-9

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  • DOI: https://doi.org/10.1007/s00066-012-0234-9

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