Postoperative Radiotherapy after Radical Prostatectomy: Indications and Open Questions

Abstract

Biochemical relapse after radical prostatectomy occurs in approximately 15–40% of patients within 5 years. Postoperative radiotherapy is the only curative treatment for these patients. After radical prostatectomy, two different strategies can be offered, adjuvant or salvage radiotherapy. Adjuvant radiotherapy is defined as treatment given directly after surgery in the presence of risk factors (R1 resection, pT3) before biochemical relapse occurs. It consists of 60–64 Gy and was shown to increase biochemical relapse-free survival in three randomized controlled trials and to increase overall survival after a median followup of 12.7 years in one of these trials. Salvage radiotherapy, on the other hand, is given upon biochemical relapse and is the preferred option, by many centers as it does not include patients who might be cured by surgery alone. As described in only retrospective studies the dose for salvage radiotherapy ranges from 64 to 72 Gy and is usually dependent on the absence or presence of macroscopic recurrence. Randomized trials are currently investigating the role of adjuvant and salvage radiotherapy. Patients with biochemical relapse after prostatectomy should at the earliest sign of relapse be referred to salvage radiotherapy and should preferably be treated within a clinical trial.

Prognostic factors after salvage radiotherapy alone in patients with biochemical recurrence after radical prostatectomy

“…Recently, three randomized clinical trials have been carried out to provide answers with regard to the timing of radiotherapy . The Radiotherapy and Androgen Deprivation in Combination After Local Therapy trial involves two randomizations, one related to radiotherapy timing and the other pertaining to the combined use of ADT with radiotherapy.…”

Résultats de la radiothérapie de rattrapage pour récidive biologique après prostatectomie radicale dans la population africaine-caribéene de la Guadeloupe

“…Mais parmi les patients traités par radiothérapie adjuvante, environ la moitié n'aurait pas présenté de récidive biologique, et la chirurgie seule les auraient guéris [12]. La radiothérapie adjuvante réalisée de façon systématique après la chirurgie pourrait être un surtraitement de certains cancers de la prostate.…”

“…En revanche, l'efficacité de la radiothérapie de rattrapage ne semblait exister que pour les cancers à risques évolutifs faible et intermédiaire [12] : Gleason inférieur à 8, doublement du PSA supérieur à six mois, stade T inférieur à pT3 -niveau de preuve 4. À ce jour, aucune étude ayant un haut niveau de preuve ne permet de recommander la place de chaque technique [15].…”

“…Mais les patients aux stades pT2-R0, Gleason inférieur ou égal à 7 ou avec un risque évolutif faible ou intermédiaire bénéficierons plus d'une irradiation de rattrapage, afin d'éviter les effets secondaires d'une irradiation adjuvante quand celle-ci n'est pas nécessaire -niveau de preuve 4 - [12].…”

Surgical Oncology: Clinical Importance

“…The introduction of radiotherapy has radically changed prostate and rectal cancer prognosis. Neo-adjuvant chemo-radio therapy combined regimens reduce the recurrence rate and the complications due to extended surgery [4,5,6,7]. In prostate cancer, as in breast, rectal and anal verge cancer brachytherapy has demonstrated its usefulness also in the management of advanced disease [8,9].…”