Among these men…
Among these men, 46 (94%) had undergone prior EBRT with a median primary treatment dose of 66.2 Gy (range = 20–70.2) administered in a median of 35 fractions (range = 5–39) over a median of 50 days (range = 7–74). In this study, only three men had received I-125 radioactive seed implants as primary therapy. The median time elapsed between primary radiotherapy and salvage brachytherapy was 41.7 months (range = 21.8–185.2). All patients underwent prostate biopsy before reirradiation, confirming poorly differentiated disease in 27 (55%). Thirty-seven patients (76%) were implanted with Pd-103, whereas 12 patients (24%) were implanted with I-125. Although a minority of patients received additional therapies before (11 patients (22%) received an orchiectomy or antiandrogens) or after re-implantation (four patients received adjuvant RT, eight received adjuvant hormones), salvage brachytherapy was associated with a 34% actuarial rate of biochemical disease-free survival at 5 years.
Physician-reported complication rates were slightly better than with other forms of salvage therapy and included rectal ulcers or bleeding requiring colostomy in 6%, significant dysuria in 6%, and the need for a channel TURP in 14%. However, equally importantly, these data provide proof of principle that re-irradiation is a technically feasible alternative to radiation failures. Salvage cryosurgery following brachytherapy failure Initial enthusiasm for cryoablation of the prostate as a curative treatment for localized prostate cancer waned with multiple reports of poor biochemical control rates and unacceptable complications.
However, several groups have continued to improve cryoablative techniques in both the primary and salvage settings. Although salvage cryosurgery has been reported to be more technically challenging than is primary therapy, multiple authors have noted acceptable response rates, with morbidities roughly equivalent to other modes of salvage therapy [89-91].
Chin et al recently reported their results of salvage cryotherapy in 118 patients with biopsyproven local recurrence following RT. Nearly all patients underwent posttreatment prostate biopsy, which identified persistent disease in only 3.1%. The posttreatment PSA nadir reached less than 0.5 ng/mL in 114 patients (96.6%) with 34% bNED at last follow-up. Complications included rectourethral fistula in 5 patients (4.2%), moderate to severe incontinence in 24 patients (20.3%), and bladder outlet obstruction in 10 patients (8.5%). Similar results have been published by de la Taille et al who showed a 66% bNED rate at 12 months following salvage cryosurgery. Despite these data demonstrating a therapeutic effect of salvage cryoablation following prostate radiation, to our knowledge there are no known reports specifically evaluating this technique following brachytherapy.
Ultimately, the role of salvage cryosurgery following brachytherapy theoretically may be limited by the cumulative effects of each modality on the urethra. References
