Treatment options for locally recurrent Prostate Cancer Giuseppe Simone Mediterranean School of Oncology Roma 15-06-2012.

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%