Salvage External Beam Radiotherapy Research Articles

Biochemical recurrence in patients with prostate cancer after primary definitive therapy: treatment based on risk stratification.

Nearly one-third of patients with prostate cancer (PCa) experience biochemical recurrence (BCR) after primary definitive treatment. BCR increases the risk of distant metastasis and mortality in patients with prognostically unfavorable features. These patients are best managed with a tailored treatment strategy incorporating risk stratification using clinicopathological factors, next-generation imaging, and genomic testing. This narrative review examines the utility of risk stratification for the management of patients with BCR in the context of clinical trial data, referencing the latest recommendations by European and US medical societies. PubMed was searched for relevant studies published through May 21 2023 on treatment of patients with BCR after radical prostatectomy (RP) or external beam radiotherapy (EBRT). European and US guidelines support the risk-stratified management of BCR. Post-RP, salvage EBRT (with or without androgen deprivation therapy [ADT]) is an accepted treatment option for patients with BCR. Post-EBRT, local salvage therapies (RP, cryotherapy, high-intensity focused ultrasound, stereotactic body radiotherapy, and low-dose-rate and high-dose-rate brachytherapy) have demonstrated comparable relapse-free survival rates but differing adverse event profiles, short and long term. Local salvage therapies should be used for local-only relapses while ADT should be considered for regional or distant relapses. In practice, patients often receive ADT, with varying guidance for intermittent ADT vs. continuous ADT, due to consideration of quality-of-life effects. Despite a lack of consensus for BCR treatment among guideline associations and medical societies, risk stratification of patients is essential for personalized treatment approaches, as it allows for an informed selection of therapeutic strategies and estimation of adverse events. In lower-risk disease, observation is recommended while in higher-risk disease, after failed repeat local therapy, ADT and/or clinical trial enrollment may be appropriate. Results from ongoing clinical studies of patients with BCR should provide consensus for management.

Reirradiation salvage radiotherapy for recurrent prostate cancer after primary low-dose brachytherapy.

Local recurrence of prostate cancer after low-dose rate brachytherapy is a clinical problem with limited salvage treatment options. This prospective study evaluated the tolerability and outcome of salvage external beam radiation therapy (S-EBRT) for locally recurrent prostate cancer after primary low-dose rate prostate brachytherapy (LDR-BT). Between October 2012 and 2022, 18 patients with biopsy-proven locally recurrent prostate cancer after primary LDR-BT and received S-EBRT. We evaluated biochemical failure (BF), overall survival (OS) and acute/late gastrointestinal and urinary toxicities (CTCAE v5.0 or CTCAE v4, only before 2017). Median follow-up was 32months (range, 5-124). The median age was at S-EBRT 68years (range 59-79). 34% (6/18) were low risk, 44% (8/18) intermediate risk, 5% (1/18) high risk, and 17% (3/18) not specified. All patients were treated with IMRT/VMAT and received 60Gy (2.5Gy/fraction) to the prostate and 40% (7/18) 55.2Gy (2,3Gy/fx) to the seminal vesicles. 56% received ADT The 3-year OS and biochemical relapse-free survival after S-EBRT were 100% and 89%, respectively, with a median PSA nadir 0,035ng/mL (0,01-0,34). Acute cystitis was present in 72% (13/18) of patients (27% of Grade > 2). Urethritis was present in 78% (14/18) patients (16% of cases Grade > 3), and acute rectitis occurred in 22% (4/18) of patients (no cases Grade > 3). Our data suggest that the treatment of locally recurrent prostate cancer with S-EBRT could provide adequate disease control safely and be used as an additional treatment in the natural history of prostate cancer patients. However, the results are still early and the sample is small; larger studies with longer follow-up would be mandatory.

Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography-Based Clinical Target Volume Delineation Guideline for Postprostatectomy Salvage Radiation Therapy: The PERYTON Guideline

Prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) scan is the standard imaging procedure for biochemical recurrent prostate cancer postprostatectomy because of its high detection rate at low serum prostate-specific antigen levels. However, existing guidelines for clinical target volume (CTV) in prostate bed salvage external beam radiation therapy (sEBRT) are primarily based on experience-based clinical consensus and have been validated using conventional imaging modalities. Therefore, this study aimed to optimize CTV definition in sEBRT by using PSMA PET/CT-detected local recurrences (LRs). Patients with suspected LR on PSMA PET/CT postprostatectomy were retrospectively enrolled in 9 Dutch centers. Anonymized scans were centrally reviewed by an expert nuclear medicine physician. Each boundary of the CTV guideline from the Groupe Francophone de Radiothérapie en Urologie (GFRU) was evaluated and adapted to improve the accuracy and coverage of the area at risk of LR (CTV) on PSMA PET/CT. The proposed CTV adaptation was discussed with the radiation oncologists of the participating centers, and final consensus was reached. To assess reproducibility, the participating centers were asked to delineate 3 new cases according to the new PERYTON-CTV, and the submitted contours were evaluated using the Dice similarity coefficient (DSC). After central review, 93 LRs were identified on 83 PSMA PET/CTs. The proposed CTV definition improved the coverage of PSMA PET/CT-detected LRs from 67% to 96% compared with the GFRU-CTV, while reducing the GFRU-CTV by 25%. The new CTV was highly reproducible, with a mean DSC of 0.82 (range, 0.81-0.83). This study contributes to the optimization of CTV definition in postprostatectomy sEBRT by using the pattern of LR detected on PSMA PET/CT. The PERYTON-CTV is highly reproducible across the participating centers and ensures coverage of 96% LRs while reducing the GFRU-CTV by 25%.

Comparison of salvage high dose-rate brachytherapy and external beam radiotherapy for treatment of prostate cancer local recurrence after radical prostatectomy

Aim. To compare clinical efficacy of salvage high dose-rate brachytherapy (HDR-BT) and external beam radiotherapy (EBR) in treatment of local recurrence of prostate cancer after radical prostatectomy (RP).Materials and methods. Between January 2017 and December 2020, 60 patients with local recurrence of prostate cancer after RP were treated at the Russian Scientific Center of Roentgenology and Radiology. Two groups were identified: group 1 included 30 patients who underwent salvage external beam radiation therapy (EBRT) according to the classical fractionation regimen; in group 2, within the framework of the scientific protocol, 30 patients underwent 2 fractions of salvage HDR-BT with single boost dose of 15 Gy for total boost dose of 30 Gy. All patients in group 2 underwent pelvic multiparametric magnetic resonance imaging and positron emission tomography-computed tomography with prostatespecific membrane antigen ligands. In the 2nd group, transrectal biopsy of the prostate bed was also performed. Overall and biochemical recurrence-free survival, as well as the profile of early and late radiation complications, were analyzed.Results. Mean age of the patients at the time of salvage radiation therapy was 67.5 years (95 % confidence interval 66.1–69). Median time before development of biochemical relapse after RP was 24 months (interquartile range 13–46 months). Median follow-up period for all patients was 45 months (interquartile range 36–63 months). There were no dropouts in this study. The overall survival rate was 100 % in both groups. Comparative analysis of prostate specific antigen (PSA)-specific recurrence-free survival showed a clear trend toward an increase in the brachytherapy group; however, with the number of observations, statistically significant differences could not be achieved (p = 0.075). Salvage EBRT is more toxic than salvage HDR-BT. Comparative assessment of radiation adverse effects revealed higher frequency of early genitourinary toxicity of grade I and intestinal toxicity of grades I and II in the salvage EBRT group than in the salvage brachytherapy group, as well as late gastrointestinal toxicity of grade I and II.Conclusion. Salvage HDR-BT with 15 Gy × 2 fractions with total boost dose of up to 30 Gy was proved to be a promising treatment for local recurrence of prostate cancer after RP with an acceptable toxicity profile. There was also a trend towards increased PSA-specific recurrence-free survival in the salvage brachytherapy group compared with the salvage EBRT group.

MP80-18 SURVIVAL AFTER RADICAL PROSTATECTOMY VS RADIATION THERAPY IN CLINICAL NODE POSITIVE PROSTATE CANCER PATIENTS: A MULTICENTRIC STUDY

MP80-18 SURVIVAL AFTER RADICAL PROSTATECTOMY VS RADIATION THERAPY IN CLINICAL NODE POSITIVE PROSTATE CANCER PATIENTS: A MULTICENTRIC STUDY

ESTRO-ACROP recommendations for evidence-based use of androgen deprivation therapy in combination with external-beam radiotherapy in prostate cancer

Background and purposeThere is no consensus concerning the appropriate use of androgen deprivation therapy (ADT) during primary and postoperative external-beam radiotherapy (EBRT) in the management of prostate cancer (PCa). Thus, the European Society for Radiotherapy and Oncology (ESTRO) Advisory Committee for Radiation Oncology Practice (ACROP) guidelines seeks to present current recommendations for the clinical use of ADT in the various indications of EBRT. Material and methodsA literature search was conducted in MEDLINE PubMed that evaluated EBRT and ADT in prostate cancer. The search focused on randomized, Phase II and III trials published in English from January 2000 to May 2022. In case topics were addressed in the absence of Phase II or III trials, recommendations were labelled accordingly based on the limited body of evidence. Localized PCa was classified according to D’Amico et al. classification in low-, intermediate and high risk PCa. The ACROP clinical committee identified 13 European experts who discussed and analyzed the body of evidence concerning the use of ADT with EBRT for prostate cancer. ResultsKey issues were identified and are discussed: It was concluded that no additional ADT is recommended for low-risk prostate cancer patients, whereas for intermediate- and high-risk patients four to six months and two to three years of ADT are recommended. Likewise, patients with locally advanced prostate cancer are recommended to receive ADT for two to three years and when ≥ 2 high-risk factors (cT3-4, ISUP grade ≥ 4 or PSA ≥ 40 ng/ml) or cN1 is present ADT for three years plus additional Abiraterone for two years is recommended. For postoperative patients no ADT is recommended for adjuvant EBRT in pN0 patients whereas for pN1 patients adjuvant EBRT with long-term ADT is performed for at least 24 to 36 months. In the setting of salvage EBRT ADT is performed in biochemically persistent PCa patients with no evidence of metastatic disease. Long-term ADT (24 months) is recommended in pN0 patients with high risk of further progression (PSA ≥ 0.7 ng/ml and ISUP grade group ≥ 4) and a life expectancy of over ten years, whereas short-term ADT (6 months) is recommended in pN0 patients with lower risk profile (PSA < 0.7 ng/ml and ISUP grade group 4). Patients considered for ultra-hypofractionated EBRT as well as patients with image based local recurrence within the prostatic fossa or lymph node recurrence should participate in appropriate clinical trials evaluating the role of additional ADT. ConclusionThese ESTRO-ACROP recommendations are evidence-based and relevant to the use of ADT in combination with EBRT in PCa for the most common clinical settings.

Safety and efficacy of stereotactic ablative brachytherapy as a salvage therapy for recurrent chest wall cancer: A retrospective, multicenter study.

To evaluate the safety and efficacy of stereotactic ablative brachytherapy (SABT) as a salvage therapy for patients with recurrent chest wall cancer (rCWC) who have previously received external beam radiotherapy (EBRT) or surgery. Between November 2013 and October 2020, a total of 130 patients (including 75 men with a median age of 63 years) with rCWC treated with SABT were enrolled in this multicenter retrospective study. There were 97 cases of non-small-cell lung carcinoma, 24 cases of breast cancer, and 9 cases of thymic cancer. Of the patients included, 102 patients previously received surgery and 58 patients received EBRT, with systemic treatment progressing after recurrence. None of them were suitable or refused to undergo salvage EBRT or surgery again. During the 22 (4-70)-month median patient follow-up, 59 patients died. The local control (LC) rates at 6, 12, 24, and 36 months were 88.3%, 74.3%, 50.4%, and 36.7%, respectively. The 1-, 2- and 3-year survival rates were 85%, 56%, and 42%, respectively. The median overall survival was 26 months (95% CI, 18.9-33.1 months). The pain relief rate was 81%, and the median to remission time was 10 days. Univariate and multivariate analyses showed that independent prognostic factors for LC included tumor size and postoperative D90. On the other hand, independent prognostic factors for survival include the Karnofsky performance status (KPS) score, tumor size, and D90 19 patients (14.6%) developed grade I/II skin reaction complications. No grade III or severer complications occurred. SABT is safe and effective as a salvage therapy for rCWC following EBRT/surgery. For patients with a KPS score greater than 80, prescribed dose greater than 130 Gy, and tumor size less than 4 cm may bring better results.

Clinical outcomes after salvage external beam radiotherapy combined with interstitial brachytherapy for locally advanced, recurrent endometrial cancer

AbstractSalvage external beam radiation therapy (EBRT) followed by interstitial brachytherapy is commonly used to treat patients with vaginal recurrence of endometrial cancer. The evidence for this is typically limited to case series treating small volumes of disease. For the present study, 12 consecutive patients with locally advanced, biopsy‐proven vaginal recurrence after surgically treated endometrial cancer who received salvage EBRT (45 Gy in 25 daily fractions to microscopic disease and 55–57.5 Gy to gross nodal disease) with magnetic resonance‐guided interstitial brachytherapy (20–21 Gy in 3 fractions over 2 days) were retrospectively reviewed. The median tumor size of recurrent disease on magnetic resonance imaging was 5 (3–6) cm. Three (25%) tumors involved the bladder wall, three (25%) involved the urethra, and four (33%) extended to the pelvic sidewall. Four (25%) patients had gross nodal disease. On follow‐up, no (0%) patient developed local recurrence. One patient (8%) developed nodal recurrence outside of the radiotherapy treatment volume and then distant metastases, and one patient (8%) developed distant metastasis 2.5 years post‐treatment and subsequently died from the disease. No (0%) other deaths were reported. Zero patients (0%) developed grade ≥4 bowel or bladder toxicity. These data support EBRT with interstitial brachytherapy using modern techniques for locally advanced, vaginal recurrences of endometrial cancer.

Comparative Outcomes of Robotic Radical Prostatectomy in Patients with Locally Advanced Prostate Cancer.

The effectiveness of radical prostatectomy alone for locally advanced prostate cancer is controversial owing to an increased complication rate and treatment-related morbidity. With technical advances and refinements in surgical techniques, robotic-assisted radical prostatectomy (RARP) has improved the outcomes of patients with locally advanced prostate cancer. RARP therefore plays a role in the treatment of locally advanced prostate cancer. In this study, we enrolled a total of 76 patients with pathologic stage pT3a, pT3b, pT4, or pN1. All patients were followed from surgery to June 2022, and their characteristics, perioperative outcomes, complications, adjuvant therapies and outcomes were analyzed. The median age of the patients was 69 years, and the initial PSA level was 20.5 (IQR 10.8-31.6) ng/mL. The median operative time was 205 (IQR 182-241) minutes. Sixty-six patients (86.8%) regained continence within 1 year, and the continence rate within 3 years of follow-up was 90.8% (69 patients). The overall survival rate was 100%. Twenty-two patients had BCR, of whom 13 received salvage androgen deprivation therapy (ADT), 2 received salvage external beam radiation therapy (EBRT) alone, and 7 received combined ADT and EBRT. No patient had disease progression to castration-resistant prostate cancer during a median 36 months of follow-up after salvage therapy. Our results suggest that RARP can also decrease tumor burden and allow for accurate and precise pathological staging with the need for subsequent treatment. Therefore, we recommend that RARP represents a well-standardized, safe, and oncologically effective option for patients with locally advanced prostate cancer.

Salvage external beam radiotherapy after HIFU failure in localized prostate cancer: A single institution experience

High-intensity focused ultrasound (HIFU) remains investigational as primary treatment for localized prostate cancer but is sometimes offered to select patients. At HIFU failure, data guiding salvage treatment is limited to small retrospective series with short follow-up. We evaluated our institutional experience using salvage radiation therapy (SRT) after HIFU failure. We conducted a retrospective analysis of patients with local failure post-HIFU who received salvage image-guided external beam radiation therapy (EBRT) delivered via intensity-modulated radiotherapy (IMRT). Our primary endpoint was biochemical failure-free survival (bFFS) defined as prostate-specific antigen (PSA) nadir + 2 ng/mL. Secondary endpoints included metastasis-free survival (MFS) and overall survival (OS). Endpoints were evaluated using Kaplan-Meier analysis. From 2013 to 2018, 12 out of 96 patients treated with primary HIFU received SRT via conventional or moderate hypofractionation. Median time from HIFU to SRT was 13.5 months. Seven patients had stage migration to high-risk disease at the time of SRT. Mean PSA prior to SRT was 8.2ug/L and mean nadir post-SRT was 1.2ug/L. Acute International Prostate Symptom Score (IPSS) as well as International Index of Erectile Dysfunction (IIEF) scores were similar to baseline (p = 0.5 and 0.1, respectively). Late toxicities were comparable to those reported after primary EBRT for localized prostate cancer. At a median follow-up of 46 months, the OS was 100%. The 5-year bFFS and MFS were both 83.3%. To our knowledge, we report one of the largest series on contemporary SRT post HIFU failure. We show that SRT is feasible, effective and carries no additional acute or delayed toxicity.

Is Hypofractionated Elective Nodal Irradiation Safe in High-Risk Prostate Cancer? A Single-Institution Prospective Study

<h3>Purpose/Objective(s)</h3> Hypofractionated EBRT is beneficial in localized prostate cancer in view of the low alpha by beta ratio of prostate cancer cells, however, the role of elective nodal irradiation with the hypofractionated regimen is not well established, as concern regarding toxicity with hypofractionated nodal irradiation remains. <h3>Materials/Methods</h3> Patients with Carcinoma prostate were prospectively selected for treatment with hypofractionated EBRT. Patients with high-risk prostate cancer (T3a-T3b, GS>/= 8, PSA>20ng/ml) with an estimated risk of nodal involvement > 30% were radically treated with 60Gy and 44 Gy in 20 fractions to the primary and elective nodal area, respectively. Similarly, postoperative patients with high-risk features (pT3a-T3b, GS>/=8, estimated risk of nodal involvement >30%) were treated with early salvage EBRT, upon two consecutive rises of serum PSA above 0.1ng/ml. The dose prescribed was 52.5Gy and 44Gy in 20 fractions to primary bed and elective nodal area, respectively. Contouring for radical and salvage EBRT was done as per CHHiP and RADICALS RT protocol, respectively. Nodal volume was contoured as per the RTOG contouring guideline. Acute toxicities were recorded during and 6 months after treatment, as per RTOG grading criteria. All patients were treated with IMRT or VMAT plan. All patients received concurrent & adjuvant hormonal therapy. <h3>Results</h3> Between 1^st January 2020 to 30^th June 2021, 26 patients were treated with the hypofractionated regimen and elective nodal irradiation, of which 14 patients (54%) received radical EBRT and 12 patients (46%) received early salvage EBRT. The median age of patients was 66 years. Patients were prospectively followed up with a median follow-up period of 12 months. For patients treated with radical EBRT, D95% to primary PTV was 60.06 Gy (Median, IQ range 59.8-60.2Gy) and D95% to nodal PTV was 44.1 Gy (Median, IQ range 43.7-44.3Gy). V48Gy of Bladder was 23.2% (Median, IQ range 21.5-26.6%). V40Gy for bowel bag was 112cc (Median, IQ range 90-145cc). Similarly in patients receiving early salvage EBRT, D95% to primary bed was 51.5Gy (Median, IQ range 51.2-51.7 Gy), D95% to the nodal area was 43.9Gy (Median, IQ range 43.1-44.5 Gy). V48Gy of bladder was 38% (Median, IQ range 28-47.6%) and V40Gy for bowel bag was 210cc (Median, IQ range 123-253cc). Overall, 5 patients (19%) had grade 2 genitourinary toxicities and 6 patients (23%) had grade 2 bowel toxicity. No patients experienced grade 3 or 4 bowel and bladder toxicity. Historical data for grade 2 or more acute bowel and bladder toxicities were 38% and 49% respectively in the CHHiP trial, which used IMRT plan for only 30% of patients. No patient in our study had a biochemical recurrence in the short follow-up period. <h3>Conclusion</h3> Hypofractionated elective nodal irradiation can be safely delivered in high-risk prostate cancer patients without any undue increase in acute bowel and bladder toxicities.

Single Fraction HDR Brachytherapy for Prostate Cancer: SiFEPI Phase II Trial Results

<h3>Purpose/Objective(s)</h3> To report the results of the <i>Single Fraction Early Prostate Irradiation</i> (SiFEPI) phase 2 prospective trial. <h3>Materials/Methods</h3> The SiFEPI trial (NCT02104362) evaluated a single fraction of high-dose rate brachytherapy (HDB) for low- (LR) and low-intermediate (LIR) risk prostate cancers. After injection of 10 ml of macromolecular hyaluronic acid (rectal spacer), needles were implanted under endorectal ultrasound guidance. After post-implant CT scan, a single fraction of 20 Gy was delivered to the prostate taking into account the dose constraints for CTV and organs at risk (urethra, rectum, anus). Oncological outcome (biochemical (bRFS), local (lRFS), and metastatic (mRFS) relapses and disease-free (DFS), cause-specific (CSS) and overall (OS) survivals), toxicity profile (acute [d30, d90, d180] and late [> 6 months] genito-urinary (GU), gastro-intestinal (GI) and sexual (S) toxicities) were investigated as well as quality of life (QLQ-C30 and QLQ-PR25). <h3>Results</h3> From March 2014 to October 2017, 35 pts were enrolled. Among them, 33 were evaluable. With a median age of 66 y [46 - 79], 25 (76%) and 8 (24%) pts were LR and FIR respectively. Median MRI prostatic volume was 41 cc [19 - 84]. Median peak-urinary flow and post-void residual volume were 17 ml/s [8 - 25] and 19 cc [0 - 165] while 30 pts (91%) had an IIEF score between 16 and 25. Median CTV, D90% and V100% were 50 cc [29 - 92], 106% [104 - 109], and 98% [96 - 99] respectively. With a MFU of 72.8 months [64 - 86], 6y-bRFS, lRFS and mRFS were 62% [45 - 85], 61% [44 - 85] and 93% [85 - 100] respectively while 6y-DFS, CSS and OS were 54% [37 - 77], 100% and 89% [77 - 100]. Acute GU, GI and S toxicities were observed in 27 pts (82%; 36 G1 & 8 G2), 5 pts (15%; 7 G1 & 3 G2) and 5 pts (15%; 3 G1 & 2 G2) respectively and no acute G3 toxicity was observed. Late GU, GI and S toxicities were observed in 11 pts (33%; 18 G1), 4 pts (12%; 4 G1) and 7 pts (21%; 1 G1, 5 G2 & 1 G3) respectively. QLQ-C30 and QLQ-PR25 will be reported later. Biochemical relapse (BR) was observed in 11 pts (33%; 7 LR & 4 FIR) with a median time interval between HDB and BR of 51 months [24 – 69]. Among them, 9 pts (82%) presented a histologically proven isolated local recurrence and underwent salvage prostate re-irradiation delivering a median dose of 78 Gy [73 – 78] (2 Gy/f). With a MFU from salvage EBRT of 27 months [3 – 59], 2^nd bRFS rate was 100%. One pt presented a G3 GU toxicity (hematuria) while no G≥3 GI complication was observed. <h3>Conclusion</h3> Long-term results of the SiFEPI phase 2 prospective trial showed that a single fraction of 20 Gy (HDB) leads to a sub-optimal biochemical control for LR and LIR prostate cancers. The reported oncological outcome is in line with the previous series of HDB single fraction protocols. However, late GU and GI toxicity profile is encouraging (especially compared to iodine implant series), leading to consideration of HDB as a safe irradiation technique. Salvage EBRT appears feasible with an acceptable risk of complications.

Salvage Interstitial Brachytherapy for Treatment of Recurrent Endometrial Cancers in the Vagina: 7-Year Single Institution Experience

<h3>Purpose/Objective(s)</h3> Interstitial brachytherapy (ISBT) is an effective, accepted treatment for vaginal recurrence of endometrial cancer (EC). This study reviews a large tertiary institution's experience and presents outcomes for recurrent EC in the vagina treated with ISBT. <h3>Materials/Methods</h3> Patients who underwent salvage ISBT for vaginal recurrence of EC from January 1, 2014 - August 31, 2021, were included. Patients with second primaries or distant metastases at diagnoses were excluded. Initial disease factors, treatment details, recurrence and salvage treatment details were recorded. Actuarial outcomes calculated include overall survival (OS), local (LF), nodal (NF), and distant failure (DF). <h3>Results</h3> Forty-two patients were included; median age was 67; most initial cancers were adenocarcinoma (81%; 34/42), grade 1 (43%; 16/37), and stage IA (62%; 24/39). Initial treatment included adjuvant external beam radiation (EBRT) (17%), vaginal vault BT (19%), EBRT plus vaginal vault BT (7%) and chemotherapy (12%). Median time from surgery to recurrence was 14 months. At recurrence, 19% (8/42) had lymph node involvement and 7% (3/42) distant metastases. For salvage, 26% (11/42) of patients received ISBT alone, 74% (31/42) EBRT plus ISBT and 29% (12/42) sequential chemotherapy. Thirty-nine cases used interstitial technique while 3 had interstitial technique then multi-channel cylinder for remaining fractions. The most common prescription for salvage ISBT alone was 42 Gy in 6 fractions while in combination with EBRT was 21 Gy in 3 fractions. Mean ISBT HRCTV D90 was 37.56 Gy, mean dose to Rectum D2cc 27.42 Gy and Bladder D2cc 19.85 Gy. Mean ISBT and EBRT HRCTV D90 was 77.65 Gy, mean dose to Rectum D2cc 67. 46 Gy and Bladder D2cc 61.98 Gy. Median follow-up after salvage BT was 20 months (range: 0-84). For patients undergoing salvage EBRT and ISBT, 2-year OS, LF, DF was 85.6%, 24% and 37.6%, respectively. With salvage ISBT alone, 2-year OS, LF, DF was 83.3%, 16.7% and 54.3%, respectively. Four patients received repeat BT for second vaginal recurrence. One patient experienced grade 3/4 late toxicity of radiation proctitis and small bowel obstruction. <h3>Conclusion</h3> ISBT is an effective treatment for recurrent EC of the vagina, with acceptable toxicities. Salvage BT alone is an option for patients with previous or contraindication to pelvic radiation.

The role of external beam radiation therapy in the management of thyroid carcinomas: A retrospective study in Iran Cancer Institute.

Thyroid cancers are histologically classified into three types; differentiated thyroid carcinoma (DTC), medullary thyroid carcinoma (MTC), and anaplastic thyroid carcinoma (ATC). Among the several therapeutic strategies for treatment and management of thyroid cancer, surgical resection in combination with radioactive iodine therapy (RAI) is indicated for moderate to high-risk differentiated thyroid cancer (DTC) patients- according to current guidelines. However, external radiation therapy (EBRT) can be a viable alternative treatment option for these patients and scarce evidence is available regarding the efficacy and effectiveness of EBRT on thyroid cancer. This study aims at evaluating the role of EBRT in the management of thyroid carcinomas. In this retrospective cohort study, the records of 59 patients with thyroid cancer were accessed who were treated by EBRT from 2008 to 2016. The indications for EBRT included unresectable primary (definitive) or loco-regional recurrences (salvage) not suitable for RAI, palliation for local disease or metastatic foci (palliative), and the adjuvant treatment for suspected residual disease following resection. Progression-free survival (PFS) and overall survival (OS) were calculated for different types of cancer. PFS was measured from the start of EBRT to the last uneventful follow-up, recurrence, or death. Kaplan-Meier model was used for the survival analysis. Fifty-nine patients were evaluated. The histopathology of the tumors was differentiated and poorly-differentiated, medullary and anaplastic thyroid carcinomas in 22 and 6, 15 and 16 patients, respectively. Twenty-seven patients received external beam radiotherapy (EBRT) as adjuvant therapy and 18 of the cases as palliative therapy while the remaining received salvage or definitive primary EBRT. The stage of patients' cancer was as follows: stage II in 3 and III in 1, IVA in 18 and IVB in 18 and IVC in 19. Stage-based median overall survival was 26 months for IVA, 44 for IVB, and 29 for IVC. The median PFS was 18, 22 and 21 months for stages IVA, IVB and IVC, respectively. Based on our findings, EBRT may still play a role in the management of patients with thyroid carcinoma and should be considered in the armamentarium against thyroid cancers.

V07-09 ROBOTIC-ASSISTED LAPAROSCOPIC PROSTATECTOMY AND URETHRAL PULL THROUGH OF MEMBRANOUS URETHRA TO BLADDER

You have accessJournal of UrologyCME1 May 2022V07-09 ROBOTIC-ASSISTED LAPAROSCOPIC PROSTATECTOMY AND URETHRAL PULL THROUGH OF MEMBRANOUS URETHRA TO BLADDER Safiya-Hana Belbina, Scott Spivey-Provencio, Pegah Taheri, E. Charles Osterberg, and Aaron A. Laviana Safiya-Hana BelbinaSafiya-Hana Belbina More articles by this author , Scott Spivey-ProvencioScott Spivey-Provencio More articles by this author , Pegah TaheriPegah Taheri More articles by this author , E. Charles OsterbergE. Charles Osterberg More articles by this author , and Aaron A. LavianaAaron A. Laviana More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002598.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While robotic assisted laparoscopic prostatectomy has been a durable treatment option for men with localized prostate cancer over the past two decades, salvage prostatectomies are performed less frequently. In this video, we report a unique case of a salvage prostatectomy and membraneous urethra pull-through in an individual who was treated with both high-intensity focused ultrasound and external beam radiation therapy complicated by prostate cancer recurrence and a severe bulbar urethral stricture that failed direct visual internal urethrotomy. METHODS: The case presents a 71-year-old male with a urological history of prostate cancer in 2010 treated with HIFU. Following biochemical recurrence in 2013 he subsequently underwent salvage EBRT. This was complicated by a severe bulbar urethral stricture necessitating two DVIUs In addition, the patient underwent transurethral resection of the prostate for obstructed voiding symptoms and placement of an inflatable penile prosthesis. From a cancer standpoint, his PSA slowly rose after EBRT from 1.3 in 2019 to 2.7 in 2021. Repeat prostate biopsy showed 1/14 cores positive for Gleason Score 4+4=8 prostate cancer. The patient proceed with a robotic-assisted laparoscopic prostatectomy with a urethral pull through and bilateral pelvic lymph node dissection. The video begins with dissection of the prostatic apex to entirely free up and remove the prostate. Once the prostate is separated from the urethra, the dissection continues until the old bulbar urethral scar is completely removed. After we ensure the remnant urethra is free of scar and patent, the urethra is seen being passed through from below into the pelvic cavity and the anastomosis is performed. We then proceeded with a bilateral pelvic lymphadenectomy using the synchroseal device which obviates the need for any clips. The patient’s inflatable prosthesis reservoir makes the right side more challenging, however, it is feasible with careful dissection. RESULTS: The patient was discharged on post-operative day 1 with all drains removed and his post-operative course remained uncomplicated. On post-operative day 19, he had a normal voiding cystourethrogram. CONCLUSIONS: This case discusses the surgical technique used in a salvage robotic-assisted prostatectomy with membranous urethral pull-through in a patient with previous history of HIFU, salvage EBRT, bulbar urethral stricture, and inflatable penile prosthesis. In this video, we show this is a feasible option in select men and may spare them the burden from undergoing a radical cystoprostatectomy. Source of Funding: n/a © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e661 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Safiya-Hana Belbina More articles by this author Scott Spivey-Provencio More articles by this author Pegah Taheri More articles by this author E. Charles Osterberg More articles by this author Aaron A. Laviana More articles by this author Expand All Advertisement PDF downloadLoading ...

Salvage External Beam Radiotherapy After HIFU Failure in Localized Prostate Cancer: A Single Institution Experience

<h3>Purpose/Objective(s)</h3> Standard treatment options for localized prostate cancer include active surveillance, radical prostatectomy, or local radiotherapy. While the use of high-intensity focused ultrasound (HIFU) as a primary treatment remains investigational, it is sometimes offered to select patients. At the time of HIFU failure, there is a lack of data in salvage treatment approach. Available data includes only small retrospective series with short-term follow-up. We therefore sought to evaluate our institutional experience in a cohort of patients treated with salvage radiation therapy (SRT) after primary HIFU failure. <h3>Materials/Methods</h3> We conducted a retrospective analysis of patients who had local failure after HIFU. This cohort of patients received salvage external beam radiation therapy (EBRT) delivered via intensity modulated radiotherapy (IMRT). Our primary endpoint was biochemical failure-free survival (bFFS) based on the 'Phoenix' definition of PSA nadir + 2 ng/mL. Secondary endpoints included metastasis-free survival (MFS) and overall survival (OS). Kaplan-Meier analysis was performed examining bFFS, MFS and OS. Genitourinary and erectile dysfunction adverse events were analyzed. <h3>Results</h3> From 2010 to 2018, 12 patients had local relapse post primary HIFU and received salvage EBRT with or without androgen-deprivation therapy, 75% and 25% respectively. The mean initial PSA prior to salvage EBRT was 8.2ug/L (2.9-14.4ug/L). The median time from HIFU to salvage EBRT was 13.5 months (6-42 months). EBRT was delivered as either conventional (76-78 Gy in 38-39 fractions, n = 11) or hypofractionation (66 Gy in 22 fractions, n = 1). Mean PSA nadir post RT was 1.2ug/L (0.1-2.6 ug/L). Acute International Prostate Symptom Score (IPSS) as well as International Index of Erectile Dysfunction (IIEF) scores were similar to baseline (<i>P</i> = 0.5 and 0.1, respectively). Late toxicities were comparable to those reported in men receiving EBRT as their primary treatment for localized prostate cancer. At a median follow-up of 46 months, only one patient had biochemical recurrence and radiological progression. The 5-year bFFS and MFS were both 83.3%. There were no deaths at the time of this analysis (OS = 100%). <h3>Conclusion</h3> To our knowledge this is one of the largest series reporting on modern SRT post HIFU failure. Our analysis shows that salvage EBRT is feasible, effective and carries no additional acute and delayed toxicity.

95: Salvage External Beam Radiotherapy After HIFU Failure in Localized Prostate Cancer: A Single Institution Experience

95: Salvage External Beam Radiotherapy After HIFU Failure in Localized Prostate Cancer: A Single Institution Experience

Radiation necrosis after a combination of external beam radiotherapy and iodine-125 brachytherapy in gliomas

PurposeFrequency and risk profile of radiation necrosis (RN) in patients with glioma undergoing either upfront stereotactic brachytherapy (SBT) and additional salvage external beam radiotherapy (EBRT) after tumor recurrence or vice versa remains unknown.MethodsPatients with glioma treated with low-activity temporary iodine-125 SBT at the University of Munich between 1999 and 2016 who had either additional upfront or salvage EBRT were included. Biologically effective doses (BED) were calculated. RN was diagnosed using stereotactic biopsy and/or metabolic imaging. The rate of RN was estimated with the Kaplan Meier method. Risk factors were obtained from logistic regression models.ResultsEighty-six patients (49 male, 37 female, median age 47 years) were included. 38 patients suffered from low-grade and 48 from high-grade glioma. Median follow-up was 15 months after second treatment. Fifty-eight patients received upfront EBRT (median total dose: 60 Gy), and 28 upfront SBT (median reference dose: 54 Gy, median dose rate: 10.0 cGy/h). Median time interval between treatments was 19 months. RN was diagnosed in 8/75 patients. The 1- and 2-year risk of RN was 5.1% and 11.7%, respectively. Tumor volume and irradiation time of SBT, number of implanted seeds, and salvage EBRT were risk factors for RN. Neither of the BED values nor the time interval between both treatments gained prognostic influence.ConclusionThe combination of upfront EBRT and salvage SBT or vice versa is feasible for glioma patients. The risk of RN is mainly determined by the treatment volume but not by the interval between therapies.

Oncologic outcome of radical prostatectomy versus radiotherapy as primary treatment for high and very high risk localized prostate cancer.

To compare the oncologic outcomes of radical prostatectomy (RP) versus external beam radiotherapy (EBRT) ± androgen deprivation therapy for primary treatment of high risk localized prostate cancer (CaP). We retrospectively reviewed a prospectively-populated database for cases who underwent primary treatment for high risk localized CaP, had more than 2 years follow-up, and were treated since 2006. A total of 335 cases were studied of whom 291 underwent RP and 44 underwent EBRT. Clinical characteristics, biochemical progression-free survival (BPFS), metastasis-free survival (MFS), cancer-specific survival (CSS) and overall survival (OS) were compared. EBRT cases were older (p < .01; mean 71 years vs. 61 years) and had longer PSA doubling time (PSADT) (p = .03; median 4.8 years vs. 3.5 years) than RP. Race, pretreatment PSA and biopsy Gleason score were similar. Median follow-up was 5.1 (range: 2.3-12.8) years for RP versus 3.3 (range: 2-12.4) years for EBRT. Three- and 5-year BPFS were 42% and 36% after RP versus 86% and 75% after EBRT (p < .01). The rate of adjuvant/salvage therapy was 58% after RP versus 20% after EBRT (p < .01). Three- and 5-year MFS were 80% and 77% after RP versus 91% and 91% after EBRT (p = .11). Three-year CSS was 98% in both groups and OS was 97% after RP versus 94% after EBRT (p = .73). RP had higher rates of biochemical failure and adjuvant or salvage treatment versus EBRT in high risk localized CaP. MFS trended toward benefit after EBRT, but CSS and OS remained high in both groups.

Salvage treatments for prostate-specific antigen relapse of cT3N0M0 prostatic adenocarcinoma after radical prostatectomy combined with neoadjuvant androgen deprivation

Abstract Objective The aim of the study was to evaluate the efficiency of salvage treatments for prostate specific antigen (PSA) relapse of cT3N0M0 prostatic adenocarcinoma (PCa) after radical prostatectomy (RP) combined with neoadjuvant androgen deprivation (ADT). Methods A total of 332 patients with cT3N0M0 PCa were enrolled in the prospective study and received RP and pelvic lymph node dissection with neoadjuvant ADT for 3 months. All patients with PSA relapse were treated with salvage external beam radiation therapy (RT) and ADT for 6 months. Results The 5-year postoperative PSA relapse rate was 40.96% (136/332). The patients have been divided into the PSA relapse and PSA relapse-free groups in order to compare patient characteristics. The ratio of patients with Gleason score ≥ 8 and positive surgical margin in the PSA relapse group were significantly higher than those of in the PSA relapse-free group (P = 0.01). The mean duration between the start of operative treatment and PSA relapse was 31 months. Salvage treatment to all 136 PSA relapse patients led to favorable outcomes. PSA relapse was not observed after salvage treatment by the end of follow-up. The 5-year overall survival rates of the PSA relapse and PSA relapse-free groups were 94.9% and 93.9%, respectively. Conclusion In pursuit of curative treatment, our study showed that RP combined with neoadjuvant ADT is an aggressive multimodality strategy associated with lower PSA relapse and better survival outcomes for stage cT3N0M0 PCa patients. Patients with PSA relapse after RP may benefit from early aggressive salvage RT combined with short-term ADT.