The authors of a recent study from the Duke Prostate Center and Division of Urology, Department of Surgery, Duke University Medical Center, Durham, N.C. and the Department of Urology, Kitasato University School of Medicine, Kanagawa, Japan reviewed the current salvage methods for treating recurrent local recurrent prostate cancer after primary radiotherapy (RT). They used a search of Medline/PubMed articles published from 1982 to 2008, with the following search terms: ‘radiorecurrent prostate cancer, local salvage treatment, salvage radical prostatectomy (RP), salvage cryoablation, salvage brachytherapy, salvage high-intensity focused ultrasound (HIFU)’, and permutations of the above. They used only articles written in English in their analysis.
Their goals in performing this search was to analyze the criteria of suitable patients for salvage procedures and to evaluate the results and complications experienced for each method used to treat a prostate cancer recurrence. Their analysis showed that, as we already knew, there are four re-treatment options available; salvage RP (surgery), salvage cryoablation (freezing), salvage brachytherapy (seeds), and salvage HIFU.
Salvage RP has the longest history of data on a follow-up with acceptable results, but the surgery is a challenging and has a high complication rate. Salvage cryoablation can now be considered a feasible option as long as the procedure uses the third-generation technology. Surprisingly, the average biochemical disease-free survival rate is 50-70% and there are fewer occurrences of severe complications such as recto-urethral fistula which plagued earlier techniques. Salvage brachytherapy, with short-term cancer control, is comparable to other salvage methods but depends on cumulative dosage limitation to target tissues. HIFU is a relatively recent option in the salvage setting. Both salvage brachytherapy and HIFU require more detailed studies with intermediate and long-term follow-up before any valid analysis can be performed.
Since the authors relied on prospective reports and they were not randomized studies and the definitions of biochemical failure varied from one study to the next, there are in fact very limited comparisons that can be made about these different salvage method.
They did accurately conclude that the major the problem to effectively treat pmen with locally recurrent disease after RT is our current lack of diagnostic examinations with sufficient sensitivity and specificity to detect local recurrence at an early curable stage as well as to accurately find the location of the recurrence. Therefore, a more strict definition of biochemical failure, improved imaging techniques, and accurate specimen mapping are needed as diagnostic tools. Furthermore, universal selection criteria and an integrated definition of biochemical failure for all salvage methods are required to determine what method can provide the highest level of efficacy with the least negative side effects.
BJU Int. 2009 Jul 2. Epub ahead of print.
doi:10.1111/j.1464-410X.2009.08715.x; Kimura M, Mouraviev V, Tsivian M, Mayes JM, Satoh T, Polascik TJ.
Joel T Nowak MA, MSW