Current Opinion in Urology Eprint - June 2011 - (Page 116)

Contemporary role of radiation therapy in the adjuvant or salvage setting following radical prostatectomy Cesare Cozzarini and Nadia Di Muzio Department of Radiotherapy, San Raffaele Scientiﬁc Institute, Milan, Italy Correspondence to Cesare Cozzarini, MD, Department of Radiotherapy, San Raffaele Scientiﬁc Institute, Via Olgettina, 60-20132 Milan, Italy Tel: +39 02 26437647; fax: +39 02 2643 7639; e-mail: cozzarini.cesare@hsr.it Current Opinion in Urology 2011, 21:206–210 Purpose of review Adjuvant and salvage radiotherapy after radical prostatectomy have an established role in the management of high-risk patients. We discuss contemporary data on optimal timing and doses of radiotherapy, role of hormonal therapy and pelvis irradiation, and toxicity. Recent ﬁndings Positive surgical margins are not predictive of reduced overall survival, even in patients treated with adjuvant radiotherapy. Salvage irradiation fails to decrease the risk of death. In both adjuvant and salvage settings, radiation doses more than 66–70 Gy result in a signiﬁcant improvement of biochemical relapse-free survival, whereas hormonal therapy is still of unproven effect. Early referral for salvage radiotherapy might be as effective as adjuvant irradiation, although only less than 50% of patients whose prostate-speciﬁc antigen is more than 0.5 ng/ml at referral beneﬁt from salvage radiotherapy. The prophylactic irradiation of pelvic nodal area may have a role in postprostatectomy irradiation owing to the risk of occult lymph-nodal metastases. New radiotherapy techniques lead to a signiﬁcant reduction in rectal, but not urinary, toxicity. Summary Ongoing Phase III trials will address the role of hormonal therapy and pelvic irradiation in combination with standard dose adjuvant and salvage radiotherapy. In the case of positive results, these ﬁndings should be conﬁrmed also in combination with high radiation doses. Keywords adjuvant, prostatectomy, radiotherapy, salvage, toxicity Curr Opin Urol 21:206–210 ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 0963-0643 Introduction Despite the reﬁnement of surgical techniques that have led to a signiﬁcant reduction in the more common side-effects from radical prostatectomy for the treatment of clinically localized adenocarcinoma of the prostate, a substantially unchanged fraction of patients (15–50%) still experience biochemical relapse after radical surgery. Risk factors for biochemical failure and, often, micrometastatic disease include capsular perforation, seminal vesicle invasion, and positive surgical margins (PSMs). Adjuvant and salvage radiotherapy (SRT) have a well established role in the management of locally recurrent prostate cancer, but with some limitations. Adjuvant radiotherapy (ART) is unnecessary in more than 30–50% of cases, whereas SRT, on the contrary, may not be curative in up to 90% of inadequately selected patients harboring micrometastatic, but still undetectable, disease. 0963-0643 ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Adjuvant radiotherapy Three large, randomized, prospective trials, European Organization for Research and Treatment of Cancer (EORTC) 22911, Southwest Oncology Group (SWOG) 8794 and German ARO 96–02/AUO AP 09/95) that altogether enrolled over 1500 patients compared ART with observation alone after radical prostatectomy. At initial publication, these studies showed the impact of ART on biochemical relapse-free survival (bRFS) and disease-free survival (DFS) but not on overall survival (OS). A subsequent update of the SWOG trial at 12.6-year follow-up demonstrated a beneﬁt in OS (hazard ratio 0.72, P ¼ 0.023) [1]. It should be noted, however, that one-third of the patients enrolled in the SWOG trial had a persistently detectable prostate-speciﬁc antigen (PSA) postoperatively; it may be, therefore, unlikely that this OS beneﬁt would be reproducible in a cohort of high-risk men with undetectable PSA. DOI:10.1097/MOU.0b013e3283449e06 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Table of Contents for the Digital Edition of Current Opinion in Urology Eprint - June 2011

Current Opinion in Urology Eprint - June 2011
Contents
Extended Lymph Node Dissection: Blabber, Kidney
Robotic-Assisted Laparoscopic Prostatectomy: A Critical Analysis of Its Impact on Urinary Continence
A Critical Analysis of the Long-Term Impact of Brachytherapy for Prostate Cancer: A Review of the Recent Literature
Contemporary Role of Radiation Therapy in the Adjuvant or Salvage Setting Following Radical Prostatectomy

Current Opinion in Urology Eprint - June 2011