Treatment options for locally recurrent Prostate Cancer

1. Mediterranean School of Oncology Roma 15-06-2012 Treatment optionsforlocallyrecurrent Prostate Cancer Giuseppe Simone

2. Treatment options • Local recurrence after RP • Radiotherapy • ADT if N+ M+ • Other options (off label)

3. Treatment options • Local recurrence after Radiation treatments • Salvage RP • Salvage Cryo • Brachy (small series) • Re-radiation (off label)

4. Salvage RP • Feasible? • Safe? • Effective?  Select cases!

6. PSA free (3-yr  75% PSA<0.2) • Continence (7/32  22%) • Sexualfunction (3/32  9%)

7. Treatment options • Local recurrence after Radiation treatments • Salvage RP • Salvage Cryo • Brachy (small series) • Re-radiation (off label)

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9. Treatment options • Local recurrence after Radiation treatments • Salvage RP • Salvage Cryo • Salvage HIFU • Brachy (small series) • Re-radiation (off label)

10. Our experience • Jan 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+)

11. Patients characteristics • 7 cases not receiving ADT • Median 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!

12. 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%

13. 18 F-choline PET-CT • No report on nodal or distant metastasis • A step forward “biochemical recurrence” • In our series 2 cases of nodal recurrences • 4 cases with preoperative evidence of pos nodes confirmed by hystology

14. 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

15. Complications • Urinary Incontinence  20% • Rectal fistula  4% • Previous simple prostatectomy and RT • Sloughing andAUR requiring TURP  12.5%

16. Hot Topics • Seminal Vesicles • Discontinuing ADT? • N+? M+? • 2-yr ADT after adjuvant RT recommended • Sloughed tissue andAUR requiring TURP  12.5%

17. Yes • Low complication rate • Minimally invasive treatment • Learning curve • salvage cryo vs salvage RP • Patients selection!!! • Previous TURP-simple prostatectomy • Bifecta outcome >70%

18. 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

19. Patient counseling • Salvage RP is the radical treatment • Healthy 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%

20. Treatment options • Local recurrence after Radiation treatments • Salvage RP • Salvage Cryo • Salvage HIFU • Brachy (small series) • Re-radiation (off label)

23. Patient counseling • Salvage RP is the radical treatment • Healthy 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%