For patients with recurrent prostate cancer after radical prostatectomy (RP), salvage radiotherapy (SRT) offers a second chance of cure. European guidelines (EAU) recommend SRT at a PSA < 0.5 ng/ml. We analyze the efficacy of SRT given according to this recommendation and investigate the predictive power of the post-SRT PSA nadir.
Between 1998 and 2013, 301 patients of two university hospitals received SRT at a PSA < 0.5 ng/ml (median 0.192 ng/ml, IQR 0.110–0.300). Patients, who previously received androgen deprivation therapy, were excluded. All patients had 3D-conformal RT or intensity-modulated radiotherapy (IMRT, n = 59) (median 66.6 Gy). The median follow-up was 5.9 years. Progression and overall survival were the endpoints.
After SRT, 252 patients re-achieved an undetectable PSA. In univariate analysis, pre-RP PSA ≥ 10 ng/ml, pT3-4, Gleason score (GS) 7–10 or 8–10, negative surgical margins, post-RP PSA ≥ 0.1 ng/ml, pre-SRT PSA ≥ 0.2 ng/ml and post-SRT PSA nadir ≥ 0.1 ng/ml correlated unfavorably with post-SRT progression. In a multivariable Cox model, pT3-4, GS 7–10, negative margins and a pre-SRT PSA ≥ 0.2 ng/ml were significant risk factors. If the post-SRT PSA was added to the analysis, it dominated the outcome (HR = 9.00). Of the patients with a pre-SRT PSA < 0.2 ng/ml, only 9% failed re-achieving an undetectable PSA. Overall survival in these patients was 98% after 5.9 years compared to 91% in patients with higher pre-SRT PSA (Logrank p = 0.004).
SRT at a PSA < 0.2 ng/ml correlates significantly with achieving a post-SRT undetectable PSA (<0.1 ng/ml) and subsequently with improved freedom from progression. Given these overall favorable outcomes, whether additional androgen deprivation therapy is required for these men requires further study.
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Wiegel T, Bartkowiak D, Bottke D, Bronner C, Steiner U, Siegmann A, et al. Adjuvant radiotherapy versus wait-and-see after radical prostatectomy: 10-year follow-up of the ARO 96-02/AUO AP 09/95 trial. Eur Urol. 2014;66:243–50.
Stephenson AJ, Scardino PT, Kattan MW, Pisansky TM, Slawin KM, Klein EA, et al. Predicting the outcome of salvage radiation therapy for recurrent prostate cancer after radical prostatectomy. J Clin Oncol. 2007;25:2035–41.
Wiegel T, Lohm G, Bottke D, Höcht S, Miller K, Siegmann A, et al. Achieving an undetectable PSA after radiotherapy for biochemical progression after radical prostatectomy is an independent predictor of biochemical outcome—results of a retrospective study. Int J Radiat Oncol Biol Phys. 2009;73:1009–16.
Cornford P, Bellmunt J, Bolla M, Briers E, De Santis M, Gross T, et al. EAU-ESTRO-SIOG Guidelines on prostate cancer. Part II: treatment of relapsing, metastatic, and castration-resistant prostate cancer. Eur Urol. 2017;71:630–42.
Stish BJ, Pisansky TM, Harmsen WS, Davis BJ, Tzou KS, Choo R, et al. Improved metastasis-free and survival outcomes with early salvage radiotherapy in men with detectable prostate-specific antigen after prostatectomy for prostate cancer. J Clin Oncol. 2016;34:3864–71.
Bartkowiak D, Thamm R, Bottke D, Siegmann A, Böhmer D, Budach V, et al. Prostate-specific antigen after salvage radiotherapy for postprostatectomy biochemical recurrence predicts long-term outcome including overall survival. Acta Oncol. 2017;57:362–67.
Jackson WC, Johnson SB, Foster B, Foster C, Li D, Song Y, et al. Combining prostate-specific antigen nadir and time to nadir allows for early identification of patients at highest risk for development of metastasis and death following salvage radiation therapy. Pract Radiat Oncol. 2014;4:99–107.
Bottke D, Bartkowiak D, Schrader M, Wiegel T. Radiotherapy after radical prostatectomy: immediate or early delayed? Strahlenther Onkol. 2012;188:1096–101.
Budäus L, Schiffmann J, Graefen M, Huland H, Tennstedt P, Siegmann A, et al. Defining biochemical recurrence after radical prostatectomy and timing of early salvage radiotherapy: Informing the debate. Strahlenther Onkol. 2017;193:683–91.
Bolla M, van Poppel H, Tombal B, Vekemans K, Da Pozzo L, de Reijke TM, et al. Postoperative radiotherapy after radical prostatectomy for high-risk prostate cancer: long-term results of a randomised controlled trial (EORTC trial 22911). Lancet. 2012;380:2018–27.
Thompson IM, Tangen CM, Paradelo J, Lucia MS, Miller G, Troyer D, et al. Adjuvant radiotherapy for pathological T3N0M0 prostate cancer significantly reduces risk of metastases and improves survival: long-term followup of a randomized clinical trial. J Urol. 2009;181:956–62.
Hwang WL, Tendulkar RD, Niemierko A, Agrawal S, Stephans KL, Spratt DE et al. Comparision between adjuvant and early-salvage postprostatectomy radiotherapy for prostate cancer with adverse pathologic features. JAMA Oncol. 2018 [Epub ahead of print].
Fossati N, Karnes RJ, Boorjian SA, Moschini M, Morlacco A, Bossi A, et al. Long-term impact of adjuvant versus early salvage radiation therapy in pT3N0 prostate cancer patients treated with radical prostatectomy: results from a muti-institutional series. Eur Urol. 2017;71:886–93.
Hegemann NS, Morcinek S, Buchner A, Karl A, Stief C, Knüchel R, et al. Risk of biochemical recurrence and timing of radiotherapy in pT3a N0 prostate cancer with positive surgical margin: a single center experience. Strahlenther Onkol. 2016;192:440–8.
Shipley WU, Seiferheld W, Lukka HR, Major PP, Heney NM, Grignon DJ, et al. Radiation with or without antiandrogen therapy in recurrent prostate cancer. N Engl J Med. 2017;376:417–28.
Carrie C, Hasbini A, de Laroche G, Richaud P, Guerif S, Latorzeff I, et al. Salvage radiotherapy with or without short-term hormone therapy for rising prostate-specific antigen concentration after radical prostatectomy (GETUG-AFU 16): a randomised, multicentre, open-label phase 3 trial. Lancet Oncol. 2016;17:747–56.
Ervandian M, Høyer M, Petersen SE, Sengeløv L, Hansen S, Holmberg M, et al. Salvage radiation therapy following radical prostatectomy. A national Danish study. Acta Oncol. 2016;55:598–603.
Dal Pra A, Panje C, Zilli T, Arnold W, Brouwer K, Garcia H, et al. Salvage radiotherapy for macroscopic local recurrences after radical prostatectomy: a national survey on patterns of practice. Strahlenther Onkol. 2017;194:9–16.
Spratt DE, Dess RT, Zumsteg ZS, Lin DW, Tran PT, Morgan TM, et al. A systematic review and framework for the use of hormone therapy with salvage radiation therapy for recurrent prostate cancer. Eur Urol. 2018;73:156–65.
Ghadjar P, Aebersold DM, Albrecht C, Böhmer D, Flentje M, Ganswindt U, et al. Use of androgen deprivation and salvage radiation therapy for patients with prostate cancer and biochemical recurrence after prostatectomy. Strahlenther Onkol. 2018;194:619–26.
Abugharib A, Jackson WC, Tumati V, Dess RT, Lee JY, Zhao SG, et al. Very early salvage radiotherapy improves distant metastasis-free survival. J Urol. 2017;197:662–8.
Tendulkar RD, Agrawal S, Gao T, Efstathiou JA, Pisansky TM, Michalski JM, et al. Contemporary update of a multi-institutional predictive nomogram for salvage radiotherapy after radical prostatectomy. J Clin Oncol. 2016;34:3648–54.
Fossati N, Karnes RJ, Cozzarini C, Fiorino C, Gandaglia G, Joniau S, et al. Assessing the optimal timing for early salvage radiation therapy in patients with prostate-specific antigen rise after radical prostatectomy. Eur Urol. 2016;69:728–33.
Mir MC, Li J, Klink JC, Kattan MW, Klein EA, Stephenson AJ. Optimal definition of biochemical recurrence after radical prostatectomy depends on pathologic risk factors: identifying candidates for early salvage therapy. Eur Urol. 2014;66:204–10.
Freedland SJ, Sutter ME, Dorey F, Aronson WJ. Defining the ideal cutpoint for determining PSA recurrence after radical prostatectomy. Urology. 2003;61:365–9.
Royce TJ, Chen MH, Wu J, Loffredo M, Renshaw AA, Kantoff PW, et al. Surrogate end points for all-cause mortality in men with localized unfavorable-risk prostate cancer treated with radiation therapy vs radiation therapy plus androgen deprivation therapy: a secondary analysis of a randomized clinical trial. JAMA Oncol. 2017;3:652–8.
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The authors declare that they have no conflict of interest.
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Bottke, D., Bartkowiak, D., Siegmann, A. et al. Effect of early salvage radiotherapy at PSA < 0.5 ng/ml and impact of post-SRT PSA nadir in post-prostatectomy recurrent prostate cancer. Prostate Cancer Prostatic Dis 22, 344–349 (2019). https://doi.org/10.1038/s41391-018-0112-3
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