Treatment options for locally recurrentTreatment options for locally recurrentProstate CancerProstate Cancer
Giuseppe SimoneGiuseppe Simone
Mediterranean School of Oncology
Roma 15-06-2012
Treatment options
Local recurrence after RPRadiotherapy
ADT if N+ M+
Other options (off label)
Treatment options
Local recurrence after Radiation treatmentsSalvage RP
Salvage Cryo
Brachy (small series)
Re-radiation (off label)
Salvage RP
Feasible?Safe?Effective? Select cases!
PSA free (3-yr 75% PSA<0.2)Continence (7/32 22%)Sexual function (3/32 9%)
Treatment options
Local recurrence after Radiation treatmentsSalvage RP
Salvage Cryo
Brachy (small series)
Re-radiation (off label)
p: ns
Treatment options
Local recurrence after Radiation treatmentsSalvage RP
Salvage Cryo
Salvage HIFU
Brachy (small series)
Re-radiation (off label)
Our experienceJan 2009 - Jan 2011
28 salvage cryo (radiorecurrent PCa)
Median age 73 (IQR 70-76)
Minimum follow-up 15 months
All patients underwent biopsy, and 18 F-choline PET-CT scan
4 cases underwent inguinal LNd excluded (pN+)
Patients characteristics
7 cases not receiving ADTMedian PSA 4.11ng/mL (IQR 1.3-5)Mean Gleason score 7.4 (range 6-9)
17 cases receiving ADT Median PSA 3.13 ng/mL (IQR 1.1-6.1)
Any of these successfully discontinued ADT!
PSA free survival 24-mo (Phoenix criteria) 56%
21-mo not ADT 65.6% 21-mo under ADT 57.6%
24-mo (ASTRO criteria) 53.6% 21-mo not ADT 80% 21-mo under ADT 60%
Local recurrence Biopsy at physician discretion! 2 positive out of 6 performed 1 seminal vesicle recurrence at 18F-chol PET-CT
Bifecta in patients not receiving ADT
72%
18 F-choline PET-CT
No report on nodal or distant metastasis
A step forward “biochemical recurrence”
In our series 2 cases of nodal recurrences4 cases with preoperative evidence of pos nodes
confirmed by hystology
Preop CT and bone scan negative
3 mo PSA 1 6 mo PSA 2
PET-CT Stereotaxic RT and ADT
32 mo PSA 0.8
Complications
Urinary Incontinence 20%
Rectal fistula 4%Previous simple prostatectomy and RT
Sloughing and AUR requiring TURP 12.5%
Hot Topics
Seminal Vesicles
Discontinuing ADT?N+? M+?2-yr ADT after adjuvant RT recommended
Sloughed tissue and AUR requiring TURP 12.5%
YesLow complication rate
Minimally invasive treatment
Learning curve salvage cryo vs salvage RP
Patients selection!!!Previous TURP-simple prostatectomy
Bifecta outcome >70%
Buts Cancer control lower than salvage RP
Pts receiving ADT should not discontinue it
Preoperative staging limits (rule out N+/M+) 18 F chol PET-CT has not 100% accuracy
Bifecta-ASTRO-Phoenix can not be compared with undetectable PSA after RP
Standardize outcome evaluation
Patient counseling
Salvage RP is the radical treatmentHealthy pts with life expectancy > 10yrs should be
counseled accordingly…
Local recurrence can be successfully treated with recryo or with ADT
10 yr Cancer specific survival 90%
Treatment options
Local recurrence after Radiation treatmentsSalvage RP
Salvage Cryo
Salvage HIFU
Brachy (small series)
Re-radiation (off label)
Patient counseling
Salvage RP is the radical treatmentHealthy pts with life expectancy > 10yrs should be
counseled accordingly…
Local recurrence can be successfully treated with recryo or with ADT
10 yr Cancer specific survival 90%
