Predictive factors of radiation therapy for patients with prostate specific antigen recurrence after radical prostatectomy

OBJECTIVE: To assess the efficacy of salvage/adjuvant radiation therapy (RT) for patients with prostate-specific antigen (PSA) recurrence after radical prostatectomy (RP). PATIENTS AND METHODS: Between 1997 and 2001, 52 patients were treated in our institution with RT for PSA recurrence after RP. The mean (range) delay between RP and RT was 30.5 (0.16-105.6) months. Eighteen patients received no hormonal therapy before RT. The failure of RT was defined as three consecutive increases in PSA levels with intervals of > or = 6 weeks. RESULTS: Within a mean (range) follow-up of 27.7 (6-69) months, 18 patients presented with biochemical progression. The 3-year biochemical progression-free survival was 51%. Using univariate analysis, an age < 65 years (P = 0.0262), a Gleason score on the RP specimen of > or = 8 (P = 0.0024), stage pT3 (P = 0.02), a detectable nadir PSA after RT (P < 0.001) and the absence of hormonal therapy (P = 0.0359) were associated with a lower biochemical progression-free survival. However, only the Gleason score (P = 0.0395) and nadir serum PSA after RT (P = 0.028) remained independent predictive factors on multivariate analysis. CONCLUSION: Half of the present patients treated with RT for an isolated high serum PSA level after RP were free of biochemical relapse at 3 years of follow-up. RT may be proposed to selected patients with mild morbidity. However, definitive evidence of the beneficial effect of adjuvant RT for patients with PSA recurrence after RP awaits the conclusion of randomized clinical trials.     

Radiotherapy and Prostate Cancer: Quo Vadis?

ContextRadiotherapy (RT) is one of the curative treatment options for clinically localised prostate cancer. Technical developments over recent years have yielded better conformation to the target volume, thus increasing the therapeutic ratio and decreasing side-effects.ObjectiveOur aim was to summarise current controversies in prostate cancer RT.Evidence acquisitionThis paper is based on a presentation given at the 7th Meeting of the European Association of Urology Section of Oncological Urology in Vienna, Austria. Data from reviews and original papers were compiled and interpreted.Evidence synthesisEvidence from randomised trials has indicated that total doses >72 Gy are significantly better in cases of biochemical disease-free survival. Image-guided radiotherapy resulted in reduced safety margins around the prostate target volume and decreased acute and late side-effects. To date, data from two randomised controlled trials have indicated comparable results between hypofractionation and normofractionation without an increase of side-effects. Until now, no prospective data have been published to support the hypothesis that proton therapy decreases late side-effects with comparable results to three-dimensional conformal intensity-modulated RT. Adjuvant RT for positive margins after radical prostatectomy (RP) has proved to be an advantage. Three phase 3 trials achieved a significant better biochemical nonevidence of disease of 20% for 5 yr. In one of these trials, survival also improved significantly with adjuvant radiation. However, salvage radiotherapy (SRT) is a possible option for a persisting or increasing prostate-specific antigen after RP. To date, there are no published randomised trials to compare adjuvant RT with SRT.ConclusionsDuring the few last years, there have been tremendous technological improvements with a focus on boosting the cure rate by increasing dose delivery while maintaining a similar or improved side-effect profile. Currently, efforts are also focused on shortening treatment times and improving efficacy through new technology.     

Vermeidung des Lokalrezidivs durch eine adjuvante Strahlentherapie nach radikaler Prostatektomie

Depending on the tumor stage, 15-60% of patients develop a rise in PSA from levels around zero following radical prostatectomy. It is unclear whether this involves a local, systemic, or a mixed form of local/systemic progression. In addition to a multitude of retrospective studies, the results of three randomized trials are available that have already been published in full or in abstract form.For pT3 prostate cancer with extraprostatic extension, data are available from three randomized trials that consistently evidence an absolute decrease in biochemical progression rate of 20% after 4-5 years. These findings confirm the results of numerous retrospective studies. The large majority of authors employ total radiation doses of 60 Gy with single doses of 2 Gy. One randomized trial has shown that an increased local control rate is the basis for prolonged biochemical progression-free survival. The rate of acute and late radiation sequelae after three-dimensionally planned prostatic fossa radiotherapy (RT) with 60 Gy is very low; the rate of more severe late sequelae is <2%. Data on the status of pT2 prostate cancer with positive surgical margins are worse. The current findings are controversial and require further investigations. Basically, however, adjuvant RT is also possible for pT2 cancers with positive surgical margins. The efficacy of adjuvant RT for patients with positive surgical margins of pT3 carcinomas, whether or not they achieve PSA levels around zero, has been substantiated. A prolongation of survival time has, however, not yet been established because the follow-up period is too short. Randomized trials are still needed for cases of organ-confined prostate cancer (pT2 R1). It is unclear whether adjuvant RT is superior to RT when PSA levels increase beyond zero after radical prostatectomy. Randomized trials addressing this issue are still lacking.     

Management of High-Risk Localised Prostate Cancer

ContextHigh-risk localised prostate cancer (PCa) is defined as significant likelihood of death from PCa or development of distant metastases. It is important to identify patients at high risk of progression who may benefit from neoadjuvant or adjuvant therapies.ObjectiveTo review definitions for high-risk localised PCa and review outcomes of different treatment modalities.Evidence acquisitionRandomised and nonrandomised clinical trials addressing the characterisation of patients with high-risk PCa and treatment options for this patient population were reviewed, mainly focusing on comparison of monotherapy with multimodality approaches.Evidence synthesisRadical prostatectomy (RP) represents a treatment option for selected high-risk patients and can result in long-term progression-free survival (PFS) in a subset without hormone therapy (HT). HT prior to RP is not considered as a standard treatment in high-risk, clinically localised PC, because survival advantage has never been conclusively demonstrated. Adjuvant “early” androgen-deprivation therapy (ADT) is not recommended for patients with high-risk disease except for pathologically confirmed nodal disease. Adjuvant radiotherapy (RT) after RP in patients with adverse risk factors decreases biochemical recurrence risk with improved local control but without a clear advantage in overall survival (OS). RT with long-term adjuvant HT improves OS. However, the exact period of HT is still controversial, and one must consider the cardiovascular comorbidity status of the patients before initiating ADT. Neoadjuvant chemotherapy can be administered safely in patients with high-risk disease prior to definitive therapy. Although complete responders are very rare, prostate-specific antigen (PSA) responses were present in a substantial number of patients. Early results of adjuvant chemotherapy trials are promising, but ongoing phase 3 trials should be completed to establish any survival advantage.ConclusionsIntegrating local and systemic therapies may be beneficial in the management of high-risk localised or locally advanced PCa.     

Postoperative radiation therapy for pathologically advanced prostate cancer after radical prostatectomy

Context

Approximately 15-25% of men who undergo radical prostatectomy for localized prostate cancer (PCa) will experience recurrence of their cancer; men with poorly differentiated cancer, non-organ-confined disease, and positive surgical margins are at the highest risk.

Objective

Review accumulating evidence indicating that postoperative radiotherapy (RT) to the prostate bed favorably influences the course of disease in men with adverse pathologic features.

Evidence acquisition

Three phase 3 randomized trials of adjuvant RT versus observation have reported improved freedom from biochemical recurrence (BCR) and local control: Southwest Oncology Group (SWOG) 8794, European Organization for Research and Treatment of Cancer (EORTC) 22911, and the German Cancer Society (ARO 96-02).

Evidence synthesis

Conflicting evidence from these trials suggests that adjuvant RT can have a favorable impact on systemic progression, PCa-specific mortality, or overall survival. Observational studies have reported durable responses to salvage RT in a substantial proportion of high-risk patients (provided that it is administered at the earliest evidence of BCR) and reduced PCa-specific mortality. There is consensus that the outcome of patients receiving postoperative RT is best when the prostate-specific antigen (PSA) level is the lowest. However, it is unclear if better outcomes will be achieved administering adjuvant RT to all patients at increased risk for recurrent PCa who have an undetectable postoperative PSA level compared to close observation and timely salvage RT at the earliest indications of BCR.

Conclusions

Given the absence of data from randomized trials demonstrating superiority of one approach over the other in terms of quantity and quality of life, we advocate multidisciplinary input and shared and informed decision making among patients, urologists, and radiation oncologists based on the relative advantages and disadvantages of each approach.     

Early Salvage Radiotherapy Following Radical Prostatectomy

Context

Depending on the pathologic tumour stage, up to 60% of prostate cancer patients who undergo radical prostatectomy will develop biochemical relapse and require further local treatment.

Objectives

We reviewed the results of early salvage radiation therapy (RT), defined as prostate-specific antigen (PSA) values prior to RT ≤ 0.5 ng/ml in the setting of lymph node–negative disease.

Evidence acquisition

Ten retrospective studies, including one multicentre analysis, were used for this analysis. Among them, we received previously unpublished patient characteristics and updated outcome data from five retrospective single-centre trials to perform a subgroup analysis for early salvage RT.

Evidence synthesis

Patients treated with early salvage RT have a significantly improved biochemical recurrence-free survival (BRFS) rate compared with those receiving salvage RT initiated after PSA values are >0.5 ng/ml. Similarly, within the cohort of patients with pre-RT PSA values <0.5 ng/ml, improved BRFS rates were noted among those with lower rather higher pre-RT PSA levels. It is possible that higher RT dose levels and the use of adjunctive androgen-deprivation therapy improve biochemical control outcomes in the salvage setting.

Conclusions

Based on a literature review, improved 5-yr BRFS rates are observed for patients who receive early salvage RT compared with patients treated with salvage RT with a pre-RT PSA value >0.5 ng/ml. Whether the routine application of early salvage RT in patients with initially undetectable PSA levels will be associated with demonstrable clinical benefit awaits the results of ongoing prospective trials.     

Adjuvant and salvage radiotherapy after radical prostatectomy

After radical prostatectomy is important to identify patients who have a high risk of microscopic residual disease without micrometastatic disease. Adjuvant RT, in retrospective studies, reduce the risk of recurrence and is more efficacious than salvage RT and can improve PSA relapse-free survival and should have an impact on long-term overall survival. The benefit of androgen suppression could be due to a synergistic interaction and may possibly eliminate occult systemic disease. Appropriate selection to identify subgroups of patients who may benefit from salvage RT, even for those patients at the highest risk; and whether some form of hormone ablation should accompany. To predict the biochemical failure and the risk of metastatic disease after salvage RT. We analyze the references to select an appropriate therapy. Improved outcomes will need to be tested in randomized trials.     

Tumor response to induction chemoradiation: influence on survival after esophagectomy.

OBJECTIVE: Preoperative chemoradiation is becoming standard of care for locally advanced esophageal cancer. The objective of this study was to determine if the degree of pathologic response to preoperative chemoradiation could predict survival and recurrence after resection in patients with adenocarcinoma of the distal esophagus. METHODS: Between January 1998 and December 2001, 366 patients underwent esophagectomy for adenocarcinoma of the esophagus; 108 (30%) had induction chemoradiation prior to surgery. The records of these 108 patients were reviewed. RESULTS: Histologic examination of the resected specimens documented complete pathologic response (CR) in 24 patients (22%) and residual tumor (RT) in 84 (78%). Operative mortality was 3.7%. Follow-up was complete in all patients and ranged from 1 to 46 months (median, 11 months). Three-year survival for patients with CR was 64% as compared to 34% for patients with RT (P=0.17). Median survival for patients with CR has not yet been reached; however, median survival for patients with RT was 19 months. Three-year cancer free survival for patients with CR was 57% compared to 30% for patients with RT (P=0.03). While median survival free of recurrence for patients with CR has not yet been reached, median survival free of recurrence for patients with RT was 9 months. CONCLUSION: Complete pathologic response to induction chemoradiation is associated with improved early overall and disease-free survival following esophagectomy for adenocarcinoma of the distal esophagus. Because recurrent cancer still develops in many of these patients, even after complete pathologic response, the search for the optimal treatment continues.     

Adjuvant Radiotherapy for Patients with Locally Advanced Prostate Cancer-A New Standard?

CONTEXT: After radical prostatectomy (RPE) pathologically advanced disease is detected in 38% to 52% of patients. Retrospective data on the role of postoperative radiotherapy (RT) are controversial. OBJECTIVES: To clarify in how far an adjuvant radiation treatment (ART) in cases of locally advanced disease affects outcome, three randomised trials have been started. The available data are critically reviewed. EVIDENCE ACQUISITION: Relevant publications were detected by searching the Medical Literature Analysis and Retrieval System Online (MEDLINE) and the Public/Publisher MEDLINE (PUBMED; National Library of Medicine journal articles database) databases using the medical subject headings "prostatic neoplasms," "radiotherapy," and "adjuvant." A major emphasis was placed on the results of the randomised trials. EVIDENCE SYNTHESIS: The European Organization for Research and Treatment of Cancer (EORTC) trial number 22911, Southwest Oncology Group (SWOG) trial number 8794, and German Intergroup trial ARO 96-02/AUO AP 09/95 randomised patients to receive ART with 60 Gray (Gy) and 60-64 Gy (SWOG trial), respectively. The majority of patients had undetectable PSA levels postoperatively. The data concordantly show that ART improves biochemical progression-free survival rates (EORTC trial, progression-free survival rate after 5 yr: 74.0% with ART vs 52.6% without ART; SWOG trial, after 5 yr: approximately 73% vs approximately 44%, respectively; and ARO 96-02/AUO AP 09/95 trial, after 5 yr: 72% vs 54%, respectively). The EORTC trial shows improved local control of cancer progression (p<0.0001) for treated patients. The SWOG trial demonstrates an improved freedom from hormonal treatment (5-yr: 21% with ART vs 10% without ART). A statistically significant benefit with regard to metastasis-free survival and overall survival was not seen. Genitourinary and gastrointestinal toxicity was moderate, with late side-effects (> or = grade 3) between 3% (in the ARO 96-02 trial) and <5% (in the EORTC trial). CONCLUSION: Biochemical progression-free survival and local control are significantly improved by postoperative RT with 60 Gy. Patients should be offered adjuvant treatment when they are at high risk for local relapse (especially with positive surgical margins).     

Identification of factors predicting response to adjuvant radiation therapy in patients with positive margins after radical prostatectomy

PURPOSE: Radical prostatectomy (RP) is a highly effective treatment for patients with prostate cancer. However, patients with positive surgical margins after radical prostatectomy have less than ideal outcomes with 5-year progression rates between 36% and 50%. Postoperative radiation therapy (RT) is often advocated for improving these outcomes. We identified predictors of response to adjuvant RT given for positive margins after RP. MATERIALS AND METHODS: We retrospectively reviewed the clinical records of men who underwent RP between 1987 and 1999 at our institution and who received adjuvant RT for positive surgical margins. Only patients in whom prostate specific antigen (PSA) was undetectable after RP as well as before the initiation of RT were included. Numerous clinicopathological variables, including pre-RP PSA, pathological stage, margin length and location, and extracapsular extension or seminal vesicle involvement, were assessed for their adverse effect on the biochemical recurrence rate after adjuvant RT. RESULTS: A total of 62 men met our inclusion criteria. Median age at surgery was 60.7 +/- 6.1 years and median PSA at presentation was 9.0 ng/ml (range 1.4 to 64.9). The median RT dose was 60.0 +/- 3.6 Gy. RT was started a median of 5.0 +/- 3.6 months after RP. The 5 and 10-year biochemical disease-free survival rates for the whole group were 90.2% and 87.9%, respectively. Of all parameters tested only Gleason score 4 + 3 or greater (p = 0.037) and pre-RP PSA greater than 10.9 ng/ml (p = 0.040) were predictive of biochemical recurrence after adjuvant RT on univariate analysis. On multivariate analysis only pre-RP PSA greater than 10.9 ng/ml remained an independent predictor (p = 0.031). CONCLUSIONS: In the setting of true adjuvant RT in patients with positive margins after RP and undetectable PSA those with predominant Gleason grade 4 or greater, or PSA greater than 10.9 ng/ml at presentation are at increased risk for recurrence after adjuvant RT.     

The Role of postoperative external beam radiotherapy for differentiated thyroid carcinoma: A Systematic review and meta‐analysis

The indications for external beam radiotherapy (RT) in differentiated thyroid carcinomas (DTC) are still undefined. The objective of this study was to synthesize current evidence defining the role of postoperative RT in patients with DTC. A systematic review and meta‐analysis were done. Included studies compared oncologic outcomes and toxicity of RT vs no RT in patients with DTC. Nine studies were included, two prospective and seven retrospective cohorts. RT improved 5‐year locoregional recurrence‐free survival but not overall survival and distant metastasis failure‐free survival. The locoregional control benefit was seen in patients at increased risk for recurrence, including those with advanced age, locoregionally advanced disease, gross or microscopic residual tumor, and structural invasion. Serious RT‐related acute and late toxicities were rare. Available evidence suggests that postoperative RT can improve locoregional control in high‐risk DTC with acceptable toxicity. Further prospective studies are warranted.     

Modern External-Beam Radiation Therapy for Prostate Cancer: How and When?

ObjectivesThis paper reviews the latest technologic developments in the field of external-beam radiation therapy (RT) for prostate cancer (PCa) and their clinical applications in the postprostatectomy setting and in conjunction with hormonal manipulation.MethodsThis review is based on a presentation during the New Horizons in Urology 2007 meeting held in Monte Carlo, Monaco, and includes relevant data from recently published literature.ResultsModern computer imaging, for example, computer tomography or magnetic resonance imaging, allows three-dimensional treatment planning techniques and a better definition and delineation of the target (prostate with or without seminal vesicles) and of the organs at risk (rectum, bladder, and penile bulb). Intensity-modulated RT and image-guided RT approaches are now available for the RT of PCa. Several phase 3 randomized clinical trials have demonstrated that immediate adjuvant RT after radical prostatectomy (RP) for patients at high risk for local relapse is associated with improved biochemical-free survival and clinical progression-free survival, compared to salvage RT. Furthermore, for high-risk, locally advanced PCa, androgen-deprivation therapy (ADT) combined with RT has shown better overall survival, compared to RT alone and recent data have revealed that 3 yr of adjuvant ADT after RT is superior to 6 mo for this subgroup of patients.ConclusionsTechnologic progress has contributed to improved RT results in clinically localized and locally advanced PCa. Immediate, adjuvant RT should be considered for patients with high-risk pathologic features after RP. For patients with locally advanced PCa, ADT combined with RT yields better outcomes than RT alone.     

BREAST CANCER: THE ROLE OF RADIATION THERAPY AFTER TREATMENT BY CONSERVATIVE SURGERY

The role of conservative surgery (CS) as definitive treatment of invasive breast cancer has not been established. Previous studies have demonstrated high rates of local tumour recurrence if CS is not followed by radiotherapy (RT). At present, it is impossible to identify subsets of patients who may be at acceptably low risk of recurrence after CS. The treatment of breast cancer by CS alone remains an important research question as this may avoid over-treatment by radiation for some patients. In Australia, a trial has been proposed by the ANZ Breast Cancer Trials Group, comparing CS alone to CS + RT. This paper reviews all available data on CS alone in order to stimulate debate as to the appropriateness of the trial and its end-points. Given that all prospective randomized trials have failed to show a survival disadvantage for CS alone it is essential to consider the value of all outcomes after CS or CS + RT. The conventional end-points proposed in the Australian study (mastectomy rate, disease-free survival (DFS) and overall survival (OS)) are selective. Without the addition of quality of life measures, the utilities of the strategies addressed in the trial cannot be evaluated. Data are presented on the desirability (utility) of the alternative approaches of CS or CS + RT based on data obtained from a questionnaire completed by Westmead Hospital staff. This preliminary study indicates that the majority of respondents to the questionnaire perceived that the strategy of CS + RT to have a higher utility than the strategy of CS alone.     

Characterization of biochemical recurrence after radical prostatectomy

BACKGROUND: This study sought to characterize the variables that predict postoperative prostate-specific antigen doubling time (PSADT) and biochemical recurrence time (RT) in patients who have failed radical prostatectomy (RP). METHODS: A total of 477 patients underwent RP at our institution for clinically localized prostate cancer. Of these patients, 64 (13.4%) demonstrated evidence of postoperative biochemical failure. PSADT and biochemical RT were calculated for all patients. PSADT and RT were correlated with clinical variables including preoperative PSA level, patient age, race, prostate weight and with pathologic characteristics of the operative specimen using uni- and multivariate analyses. In addition, PSADT and RT were also correlated with each other and with the time to postoperative adjuvant therapy. RESULTS: Median postoperative PSADT for patients who recurred after radical prostatectomy was 9.7 months. Postoperative PSADT was predicted by lymph node involvement (p < 0.001) and Gleason grade (p = 0.06). Rapid PSADT also correlated with institution of postoperative adjuvant therapy (p = 0.003). Median biochemical RT for all patients was 6.7 months. Gleason grade and pathologic stage were found to be predictors of RT (p < 0.002). Postoperative PSADT did not correlate with RT (r = 0.08; p = 0.53). PSADT and RT were not different between Caucasian- versus African-Americans. CONCLUSIONS: These results serve to better characterize our cohort of patients who have evidence of biochemical recurrence after radical prostatectomy. Aggressiveness of recurrent disease (i.e. PSADT) seems to be predicted by lymph node involvement and higher pathologic grade. Furthermore, the lack of correlation of RT and PSADT suggests that early recurrences are not necessarily aggressive tumors: conversely, aggressive recurrences may occur at any point in the postoperative period. This information may aid in the postoperative treatment of recurrent disease and help to better define those patients who are at higher risk for developing clinical recurrence and who would benefit from greater vigilance during the postoperative period.     

Breast cancer: the role of radiation therapy after treatment by conservative surgery.

The role of conservative surgery (CS) as definitive treatment of invasive breast cancer has not been established. Previous studies have demonstrated high rates of local tumour recurrence if CS is not followed by radiotherapy (RT). At present, it is impossible to identify subsets of patients who may be at acceptably low risk of recurrence after CS. The treatment of breast cancer by CS alone remains an important research question as this may avoid over-treatment by radiation for some patients. In Australia, a trial has been proposed by the ANZ Breast Cancer Trials Group, comparing CS alone to CS+RT. This paper reviews all available data on CS alone in order to stimulate debate as to the appropriateness of the trial and its end-points. Given that all prospective randomized trials have failed to show a survival disadvantage for CS alone it is essential to consider the value of all outcomes after CS or CS+RT. The conventional end-points proposed in the Australian study (mastectomy rate, disease-free survival (DFS) and overall survival (OS)) are selective. Without the addition of quality of life measures, the utilities of the strategies addressed in the trial cannot be evaluated. Data are presented on the desirability (utility) of the alternative approaches of CS or CS+RT based on data obtained from a questionnaire completed by Westmead Hospital staff. This preliminary study indicates that the majority of respondents to the questionnaire perceived that the strategy of CS+RT to have a higher utility than the strategy of CS alone.     

Management of biochemical failure following radical prostatectomy: salvage radiotherapy - a case series

A retrospective analysis of the outcome of radical prostatectomy (RP) for prostate cancer in a single centre and assessment of the role of salvage radiotherapy (RT) for patients with biochemical relapse. Hundred and thirty-seven patients underwent RP for adenocarcinoma of the prostate in our centre between December 1994 and June 2003. Fifty-four of these patients developed a biochemical relapse prostate-specific antigen (PSA > or = 0.2 ng/ml). Thirty-two patients including five from elsewhere (one with a palpable local recurrence) received salvage RT. Twenty-five of these had positive margins at resection and four had involvement of seminal vesicles. Nine had Gleason score > or = 8. Median PSA before RT was 0.55 ng/ml (range 0.2-5.0). Median age at surgery was 63.5 years (range 52-71). Median age at RT was 65 years (range 53-73). Median time from surgery to biochemical relapse was 11 months (range 0-37) and median interval from surgery to RT was 22 months (range 3-71). Twenty-seven patients received 64 Gy in 32 fractions, three patients received 55 Gy in 20 fractions and two patients received 50 Gy in 20 fractions. Twenty-seven patients were managed by observation or hormone therapy. Twenty-seven patients (84%) achieved complete biochemical remission following RT. Eighteen (56%) remain in complete remission with a median follow-up since RT for the whole group of 30 months (range 8-85). Fourteen patients have relapsed, eight of whom had either clear margins or PSA >1.0 ng/ml at the time of RT (PSA > or = 0.2 ng/ml). Salvage RT is an effective treatment for achieving biochemical remission in selected patients who relapse following RP.     

Adjuvant radiation therapy after radical prostatectomy: When is it indicated?

Radical prostatectomy is the most commonly used treatment option in the United States for men with clinically localized prostate cancer. Up to 30% of these patients, particularly those with adverse pathological risk factors, will develop a biochemical recurrence within 10 years. Patients with a biochemical recurrence have a higher rate of local recurrence and cancer-specific mortality. Current accepted treatment options include salvage radiation therapy, hormone therapy, or a combination of both, depending on whether the disease recurrence is biochemical, local, or systemic. The role of adjuvant radiation therapy (ART) after prostatectomy in patients with adverse pathological risk factors prior to biochemical or clinical recurrence is unclear. Recent randomized trials have demonstrated that ART significantly improves multiple patient outcomes, including overall and cancer-specific survival, without major untoward effects. The evidence in support of using ART is evolving with the long-term follow-up of several long-term prospective trials. The decision to use ART should be based on the patient’s pathological characteristics, clinical status, side effects, and open communication between the patient and provider.     

Percutaneous radiotherapy for low-risk prostate cancer: options for 2007

Technical developments of radiotherapy (RT) over the recent years yielded in better conformation to the target volume thus increasing the therapeutic ratio and decreasing side effects. This paper discusses these options for low-risk prostate cancer. There has been evidence from randomized trials, that for low-risk PCA doses >70 Gy are significant better in case of biochemical disease-free survival (bNED). Image-guided radiotherapy (IGRT) has been proven in several studies for reduced safety margins around the prostate target volume. Intensity-modulated radiotherapy (IMRT) allow treatment with higher doses and 5-year results are reported from several studies. Data from several randomized trials about adjuvant RT after radical prostatectomy (RP) have been reported. In two phase-III trials a significant advantage of 20% bNED was demonstrated for doses between 76 and 79 Gy compared with 70 Gy. Using IGRT, the safety margin around the prostate can be reduced for about 30–50%. Doses of >80 Gy can be given safely to the prostate with IMRT and <5% grade-III/IV late side effects. Adjuvant RT for positive margins after RP has been of proven advantage. Three phase-III trials achieved a significant better bNED of 20% for 5 years. The effect of doses >70 Gy have been proven for low-risk PCA. IGRT resulted in reduced safety margins and a decrease of acute and late side effects. The addition of IMRT allowed higher doses to the prostate. Adjuvant RT after RP for positive margins achieved a significant better bNED.     

Induction chemoradiation compared with induction radiation for lung cancer involving the superior sulcus

BACKGROUND: The usual approach of induction radiation therapy (RT) followed by resection of superior sulcus tumors results in many incomplete resections, a high local recurrence rate, and suboptimal survival. Induction chemoradiotherapy (CT/RT) has been shown to reduce local and distant recurrences and improve survival in stage III lung cancer. We investigated the role of induction CT/RT in superior sulcus patients. METHODS: This was a single-institution, retrospective study. RESULTS: From 1985 to 2000, 35 consecutive patients underwent induction treatment followed by resection of a superior sulcus tumor. All patients had mediastinoscopy first to exclude N2 disease, and all were N0 at final pathologic examination. Twenty patients had induction RT (mean, 39 Gy), and 15 had induction CT/RT (mean, 51 Gy) with concurrent cisplatin-based chemotherapy. There was no treatment mortality. Complete resection was performed in 16 of 20 (80%) of the RT patients and in 14 of 15 (93%) of the CT/RT patients (p = 0.15). The pathologic response from the induction treatment was complete or near complete in 7 of 20 (35%) of the RT patients and in 13 of 15 (87%) of the CT/RT patients (p = 0.001). The median follow-up was 167 months in the RT patients and 51 months in the CT/RT patients. Two-year and 4-year survival was 49% and 49% (95% confidence interval, 26% to 71%) in the RT patients and 93% and 84% (95% confidence interval, 63% to 100%) in the CT/RT patients, respectively (p = 0.01). The local recurrence rate was 6 of 20 (30%) in the RT patients and 0 in the CT/RT patients (p = 0.02). CONCLUSIONS: Induction CT/RT for superior sulcus tumors appears to offer improved survival compared with induction RT alone.