Abstract
Biochemical recurrence is a clinical situation experienced by 20 to 40% of prostate cancer patients treated with radical prostatectomy (RP). Prostate bed (PB) radiation therapy (RT) remains the mainstay salvage treatment, although it remains non-curative for up to 30% of patients developing further recurrence. Positron emission tomography with computed tomography (PET/CT) using prostate cancer-targeting radiotracers has emerged in the last decade as a new-generation imaging technique characterized by a better restaging accuracy compared to conventional imaging. By adapting targeting of recurrence sites and modulating treatment management, implementation in clinical practice of restaging PET/CT is challenging the established therapeutic standards born from randomized controlled trials. This article reviews the potential impact of restaging PET/CT on changes in the management of recurrent prostate cancer after RP. Based on PET/CT findings, it addresses potential adaptation of RT target volumes and doses, as well as use of androgen-deprivation therapy (ADT). However, the impact of such management changes on the oncological outcomes of PET/CT-based salvage RT strategies is as yet unknown.
Highlights
Between 20 and 40% of patients treated with radical prostatectomy (RP) will develop biochemical recurrence (BCR) [1,2,3], defined as a confirmed rising prostate specific antigen (PSA) during the postoperative follow-up [4]
This study demonstrated excellent local outcomes, with no local recurrences when radiation therapy (RT) dose exceeded a biologically effective dose (BED) of >108 Gy (a/b = 3 Gy)
Positron emission tomography with computed tomography (PET/computed tomography (CT)) is gradually being incorporated into international guidelines and is increasingly performed at various stages of the disease. 18F-Fluciclovine, 68Ga-Prostate Specific Membrane Antigen (PSMA), and 18F-DCFPyL PET/CT are currently approved by the Food and Drug Administration (FDA) for men with suspected prostate cancer recurrence, but worldwide approval and funding awaits evidence of improved patient outcomes
Summary
Between 20 and 40% of patients treated with radical prostatectomy (RP) will develop biochemical recurrence (BCR) [1,2,3], defined as a confirmed rising prostate specific antigen (PSA) during the postoperative follow-up [4]. Adjuvant RT has been withdrawn in favor of early salvage radiotherapy (SRT), associated with the same oncological benefit for the majority of relapsing patients without high-risk features [11,12,13,14], when performed at low PSA values [15]. This shift in practice avoids the use of immediate adjuvant RT, and the associated toxicity, in approximately 40% of patients [12]
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