Focal salvage therapy for local prostate cancer recurrences after primary radiotherapy: a comprehensive review

Abstract

Background/AimPatients with locally recurrent prostate cancer after primary radiotherapy can be eligible for salvage treatment. Whole-gland salvage techniques carry a high risk of toxicity. A focal salvage approach might reduce the risk of adverse events while maintaining cancer control in carefully selected patients. The aim of this review was to evaluate current literature to assess whether focal salvage leads to a comparable or favourable recurrence rate and less toxicity compared to whole-gland salvage.MethodsA literature search was performed using PubMed, Embase and the Cochrane Library. A total of 3015 articles were screened and assessed for quality. Eight papers [on focal cryoablation (n = 3), brachytherapy (n = 3) and high-intensity focused ultrasound (n = 2)] were used to report outcomes.ResultsOne-, 2-, 3- and 5-year biochemical disease-free survival (BDFS) ranges for focal salvage are, respectively, 69–100, 49–100, 50–91 and 46.5–54.5 %. Severe genitourinary, gastrointestinal and sexual function toxicity rates are 0–33.3 %. One study directly compares focal to whole-gland salvage cryotherapy, showing 5-year BDFS of, respectively, 54.4 and 86.5 % with lower toxicity rates for focal salvage patients.ConclusionProvisional data suggest that BDFS rates of focal salvage are in line with those of whole-gland approaches. There is evidence that focal salvage could decrease severe toxicity and preserve erectile function.Electronic supplementary materialThe online version of this article (doi:10.1007/s00345-016-1811-9) contains supplementary material, which is available to authorized users.

Feasibility and safety of focal irreversible electroporation as salvage treatment for localized radio‐recurrent prostate cancer

“…Surgical treatment of radio‐recurrent PCa is challenging, with biochemical recurrence rates of between 28% and 93%, post‐intervention incontinence rates of between 5.4% and 67%, erectile dysfunction rates ranging from 23% to 100% and a significant incidence of high‐grade adverse events, e.g. recto‐urethral fistula in 1–5.3% of patients . A systematic review including 10 series on robot‐assisted radical prostatectomy for radio‐recurrent PCa showed that biochemical failure occurred in 29% (56/193 patients) and urinary continence was preserved in 60% (119/197 patients) at a mean follow‐up of 18.6 months, while the overall preserved potency rate was 26% in potent men (30/115 patients) ; therefore, the majority of patients receive androgen deprivation therapy without curative intent .…”

“…Focal ablative therapy has been evaluated for localized radio‐recurrent PCa, aiming to reduce treatment‐related toxicity while achieving local oncological control. In a recent systematic review on focal salvage therapy for radio‐recurrent PCa, the 5‐year biochemical disease‐free survival rate was 46.5–54.5% . Feasibility trials have been performed with HIFU, cryosurgery, iodine‐125 brachytherapy and HDR brachytherapy .…”

Comparative cost-effectiveness of focal and total salvage 125 I brachytherapy for recurrent prostate cancer after primary radiotherapy

“…On the contrary, one would expect TS to increase cancer control, since possible multifocal disease is more adequately targeted. However, a recent review of observational studies suggests cancer control of FS to be approximately equal to established TS modalities [15]. Furthermore, the difference in cancer control in our cohorts was minor and did not substantially influence cost-effectiveness.…”

“…These complications should be resolved with invasive interventions, which pose a significant burden to the patient and are associated with high costs. Increased accuracy in detecting organ confined recurrences and excluding distant metastases has made focal salvage (FS) possible [13, 14, 15]. This approach targets only the recurrent tumor, thereby, potentially limiting severe toxicity rates.…”

“…This approach targets only the recurrent tumor, thereby, potentially limiting severe toxicity rates. The first FS series show promising results with usually ≤ 5% grade 3 toxicity and cancer control rates comparable to total salvage (TS) [15, 16, 17, 18, 19, 20]. In the University Medical Center Utrecht (UMCU), two cohort studies of FS [19] and TS [10] 125 I brachytherapy have been performed.…”