Triggers and oncologic outcome of salvage radical prostatectomy, salvage radiotherapy and active surveillance after focal therapy of prostate cancer

Jost Von Hardenberg,Johannes Bruendl,Niklas Westhoff,Hannes Cash,Daniel Schindele,Timur H Kuru,Daniel Koch,Sami-Ramzi Leyh-Bannurah,Martin Schostak,Angelika Borkowetz,Katharina S Mala, ,Andreas Blana,Karl-Friedrich Kowalewski

doi:10.1007/s00345-021-03700-x

Abstract

PurposeDue to the tissue preserving approach of focal therapy (FT), local cancer relapse can occur. Uncertainty exists regarding triggers and outcome of salvage strategies.MethodsPatients with biopsy-proven prostate cancer (PCa) after FT for localized PCa from 2011 to 2020 at eight tertiary referral hospitals in Germany that underwent salvage radical prostatectomy (S-RP), salvage radiotherapy (S-RT) or active surveillance (AS) were reported. Prostate specific antigen (PSA) changes, suspicious lesions on mpMRI and histopathological findings on biopsy were analyzed. A multivariable regression model was created for adverse pathological findings (APF) at S-RP specimen. Kaplan–Meier curves were generated to determine oncological outcomes.ResultsA total of 90 men were included. Cancer relapse after FT was detected at a median of 12 months (IQR 9–16). Of 50 men initially under AS 13 received S-RP or S-RT. In total, 44 men underwent S-RP and 13 S-RT. At cancer relapse 17 men (38.6%) in the S-RP group [S-RT n = 4 (30.8%); AS n = 3 (6%)] had ISUP > 2. APF (pT ≥ 3, ISUP ≥ 3, pN + or R1) were observed in 23 men (52.3%). A higher ISUP on biopsy was associated with APF [p = 0.006 (HR 2.32, 97.5% CI 1.35–4.59)] on univariable analysis. Progression-free survival was 80.4% after S-RP and 100% after S-RT at 3 years. Secondary therapy-free survival was 41.7% at 3 years in men undergoing AS. Metastasis-free survival was 80% at 5 years for the whole cohort.ConclusionWith early detection of cancer relapse after FT S-RP and S-RT provide sufficient oncologic control at short to intermediate follow-up. After AS, a high secondary-therapy rate was observed.

Highlights

Localized prostate cancer (PCa) is a heterogenous disease affecting one out of nine men during their lifetime in Germany [1]
Of the 98 men enrolled with proven cancer relapse after focal therapy (FT) between 2011 and 2020, 90 received the subsequent salvage strategy of interest: Salvage radical prostatectomy (S-RP), S-RT or Active surveillance (AS) (CONSORT diagramm see online resource)
FT was performed in these patients using high intensity focused ultrasound (HIFU) [n = 88 (97.8%)] or focal vascular targeted therapy [n = 2 (2.2%)]

Summary

Introduction

Localized prostate cancer (PCa) is a heterogenous disease affecting one out of nine men during their lifetime in Germany [1]. Focal therapy is emerging as a potential additional therapy option in highly selected patients with localized PCa [2]. Between 12.8 and 16.2% patients with fusion-biopsyproven PCa potentially qualify for focal therapy (FT) according to international consensus statements [3]. Despite a Extended author information available on the last page of the article comprehensive diagnostic pathway for patient selection before FT, local cancer relapse after FT can occur within or out of the ablation zone due to the tissue preserving strategy and potential ablation energy failure [4, 5]. Salvage-radiotherapy (S-RT) has only been described in one report [7]. Active surveillance (AS) and comparative reports in this setting have not been described hampering decision-making and exposing patients potentially to overtreatment and undertreatment

Methods

Results

Discussion

Conclusion