Salvage Ablation for Locally Recurrent Prostate Cancer

Derek J. Lomas; David A. Woodrum; Lance A. Mynderse

Disclosures

Curr Opin Urol. 2021;31(3):188-193. 

In This Article

Abstract and Introduction

Abstract

Purpose of Review:This review aims to summarize the latest evidence for the use of salvage ablation of localized prostate cancer recurrences after primary therapy radiotherapy or prostatectomy.

Recent Findings: Savage ablation represents a treatment option in select patients with localized recurrences following primary therapy of prostate cancer. Following radiotherapy, salvage cryotherapy and high-intensity focused ultrasound (HIFU) demonstrate encouraging oncologic outcomes. Biochemical recurrence-free survival ranged from 71% at 2 years to 44.2% at 10 years for cryotherapy and from 51% at 5 years to 28.7% at 10 years for HIFU. Rates of adverse effects appear to be more favorable with ablation compared to salvage surgery. Focal salvage ablation may offer a further balance between oncologic control and adverse effects. Following radical prostatectomy, recent data on the use of salvage ablation of local recurrences are less robust with only a few small studies published in the last 2 years.

Summary: Salvage ablation is an option for localized disease recurrences following primary treatment. Its role is most established for postradiation recurrence. It can also be utilized in postprostatectomy recurrence, although published data is more limited. Future studies are needed to further explore the role of ablation in both cohorts.

Introduction

Despite the treatment of localized prostate cancer with radical prostatectomy and radiation therapy, between 27 and 53% of all patients undergoing radical prostatectomy or radiation therapy develop prostate-specific antigen (PSA) recurrence.[1]

Patients with localized recurrence may benefit from further local salvage treatment. Those with radiorecurrent disease have several options including radical prostatectomy, brachytherapy, cryotherapy, high-intensity focused ultrasound (HIFU), and stereotactic body radiotherapy.[2,3] The most definitive solution, salvage radical prostatectomy is challenging and is associated with significant risks even in well-selected patients including bladder neck contracture (10.9%), rectal injury (3.6%), and fistula (1.8%).[4] Continence rates vary significantly in the literature ranging from 21 to 90%.[5] Furthermore, salvage prostatectomy is still no guarantee of cure with 5-year biochemical recurrence-free survival estimates ranging from 47 to 82% and cancer-specific survival rates ranging from 70 to 83%.[3,5]

Even with salvage options available, many patients are still managed with noncurative androgen deprivation therapy (ADT). For patients with local recurrence following prostatectomy, salvage radiation therapy is the mainstay of treatment. Most that recur after salvage radiation are left with noncurative options including observation, ADT, chemotherapy, and in select cases additional radiation.[2] ADT is associated with significant adverse effect including but not limited to hot flashes, lowered libido, erectile dysfunction, decreased bone density and muscle mass, cardiovascular effects, fatigue, and prolonged use will lead to castrate-resistant disease in just a few years. Salvage ablation of local prostate cancer recurrences can be employed to potentially cure, debulk, or delay time to initiation of ADT and other systemic therapies.

To further explore the current state of salvage ablation in the management of recurrent prostate cancer, we reviewed contemporary literature (2019–2020) to update on the role of salvage local ablation therapy after primary treatment with radiation therapy or radical prostatectomy.

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