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Salvage Radiation in Men with PSA Failure following Radical Prostatectomy and the Risk of Death
Proceedings of the 52nd Annual ASTRO Meeting Conclusions: Pretreatment risk factors, including clinical tumor stage, Gleason score, and pretreatment PSA, strongly predict for patients who achieve nPSA\0.5ng/mL following brachytherapy. Patients who achieved this nPSA, particularly those who respond in #5 years, were more likely to have long-term FFBF. In addition, all patients who achieved this nPSA were more likely to be free of distant metastasis. This PSA endpoint demonstrates significant prognostic utility in the management of prostate cancer patients following brachytherapy. Author Disclosure: E.C. Ko, None; N.N. Stone, None; R.G. Stock, None.
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Salvage Radiation in Men with PSA Failure following Radical Prostatectomy and the Risk of Death
S. E. Cotter1, M. Chen2, J. W. Moul3, W. R. Lee4, B. F. Koontz4, M. S. Anscher5, A. V. D’Amico6 1 Harvard Radiation Oncology Program, Boston, MA, 2Department of Statistics, University of Connecticut, Storrs, CT, 3Division of Urologic Surgery and the Duke Prostate Center, Department of Surgery, Duke University, Durham, NC, 4Department of Radiation Oncology, Duke University, Durham, NC, 5Virginia Commonwealth University, Richmond, VA, 6Department of Radiation Oncology, Brigham and Women’s Hospital and Dana Farber Cancer Institute, Boston, MA
Purpose/Objective(s): While a survival benefit has been suggested with the use of salvage radiation therapy (RT) for prostatespecific antigen (PSA) failure in men with rapid rises in PSA (Doubling time \ 6 months) following radical prostatectomy (RP), it is unknown whether such a benefit exists in men with a protracted PSA rise (Doubling time $ 6 months). The goal of this retrospective study was to assess whether salvage RT was associated with a decreased risk of all cause mortality (ACM) for men with a protracted PSA rise adjusting for known prostate cancer prognostic factors and age at the time of PSA failure. Materials/Methods: Of 4039 men who underwent RP at an academic medical center between January 1988 and October 2008, 519 experienced a PSA failure and had information adequate to calculate a PSA doubling time (PSA DT). Univariate and multivariate Cox regression analyses were performed to evaluate whether the use of salvage RT in men with either a rapid (\ 6 months) or slow ($ 6 months) PSA doubling time was associated with the risk of all cause mortality (ACM) adjusting for age at the time of PSA failure and known prostate cancer prognostic factors. Results: After a median follow-up of 11.3 years after PSA failure, 195 men died. The use of salvage radiation therapy was associated with a significant reduction in ACM for men with either a PSA DT \ 6 months (adjusted hazard ratio [AHR], 0.53; 95% confidence interval [CI], 0.31 to 0.90; p = 0.02) or a PSA DT $ 6 months (AHR, 0.52; 95% CI, 0.34 to 0.80; p = 0.003). Increasing age (AHR: 1.05; 95% CI, 1.02 to 1.07; p\0.0001) and pGleason 8 to 10 cancer (AHR: 1.93; 95% CI, 1.28 to 2.92; p = 0.002) were associated with an increased risk of ACM whereas the converse was true in men who received ADT (AHR: 0.53; 95% CI, 0.35 to 0.81; p = 0.003). Conclusions: This study provides evidence for a decrease in the risk of death with the use of salvage RT following RP irrespective of the value of the PSA DT after radical prostatectomy. Author Disclosure: S.E. Cotter, None; M. Chen, None; J.W. Moul, None; W.R. Lee, None; B.F. Koontz, None; M.S. Anscher, None; A.V. D’Amico, None.
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Postoperative Radiotherapy in Prostate Cancer: The Case of the Missing Target
J. M. Croke1, S. Malone1, L. Avruch2, N. Delatour2, E. Belanger2, C. Morash2, J. Spaans1, C. Kayser1, K. Underhill1 1
The Ottawa Regional Cancer Centre, Ottawa, ON, Canada, 2The Ottawa Hospital, Ottawa, ON, Canada
Purpose/Objective(s): Postoperative radiotherapy increases survival in high-risk (pT3/margin positive) prostate cancer patients (pts). Despite the benefit of adjuvant radiotherapy (XRT) approximately 50% of pts in long-term follow-up relapse with the primary site of failure being local (SWOG 8794). Potential reasons for recurrence include inadequate XRT dose and inadequate clinical target volume (CTV) delineation. There are four published consensus guidelines (EORTC, FROGG, PMH, and RTOG) defining postoperative CTV in prostate cancer. We explore the possibility that inadequate CTV coverage is an important cause of local failure. This study evaluates the utility of preoperative MRI in defining postoperative prostate bed CTV. Materials/Methods: Twenty prostate cancer pts at The Ottawa Hospital receiving post-op XRT who also had pre-op staging MRI were identified. Pts underwent CT Simulation and the 4 CTV consensus definitions were applied. CTVs were expanded by 1 cm to create respective Planning Target Volumes (PTVs). Pre-op MRIs were fused with the post-op planning CT scans. MRI based prostate and gross visible tumor were contoured. 3DCRT plans were developed and Dose Volume Histograms (DVH) analyzed. Subtraction analysis was conducted to assess the adequacy of prostate and gross tumor coverage. Results: Mean pre-op prostate volume was 45cc (range, 25-79 cc) and gross tumor was visible in 17 cases. In all 20 cases, the consensus CTVs did not fully cover the pre-resection extent of the prostate seen on the MRI. On average, 38% of the prostate volume was missed by the CTVs (mean and range, CTV-RTOG 29% [5-65%], CTV-PMH 27% [4-61%], CTV-FROGG 43% [1767%], CTV-EORTC 52% [23-77%]). In only 1 case, the entire gross tumor was completely covered. On average, 41% of the visible gross tumor volume was missed (mean and range: CTV-RTOG 35% [0-67%], CTV-PMH 33% [0-64%], CTV-FROGG 48% [1892%], and CTV-EORTC 46% [9-88%]). Furthermore, the PTVs did not cover the prostate in 50% of cases. On average, 7% of the prostate volume was missed by PTVs (mean and range: PTV-RTOG 3% [0-13%], PTV-PMH 3% [0-13%], PTV-FROGG 8% [027%], PTV-EORTC 14% [0-36%]).The prostate base and mid-zones were the predominant site of inadequate coverage. CTV-PMH and CTV-RTOG were similar with respect to prostate and tumor coverage and yielded the best overall results. CTV-EORTC
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Salvage Radiation in Men with PSA Failure following Radical Prostatectomy and the Risk of Death
S. E. Cotter1, M. Chen2, J. W. Moul3, W. R. Lee4, B. F. Koontz4, M. S. Anscher5, A. V. D’Amico6 1 Harvard Radiation Oncology Program, Boston, MA, 2Department of Statistics, University of Connecticut, Storrs, CT, 3Division of Urologic Surgery and the Duke Prostate Center, Department of Surgery, Duke University, Durham, NC, 4Department of Radiation Oncology, Duke University, Durham, NC, 5Virginia Commonwealth University, Richmond, VA, 6Department of Radiation Oncology, Brigham and Women’s Hospital and Dana Farber Cancer Institute, Boston, MA
Purpose/Objective(s): While a survival benefit has been suggested with the use of salvage radiation therapy (RT) for prostatespecific antigen (PSA) failure in men with rapid rises in PSA (Doubling time \ 6 months) following radical prostatectomy (RP), it is unknown whether such a benefit exists in men with a protracted PSA rise (Doubling time $ 6 months). The goal of this retrospective study was to assess whether salvage RT was associated with a decreased risk of all cause mortality (ACM) for men with a protracted PSA rise adjusting for known prostate cancer prognostic factors and age at the time of PSA failure. Materials/Methods: Of 4039 men who underwent RP at an academic medical center between January 1988 and October 2008, 519 experienced a PSA failure and had information adequate to calculate a PSA doubling time (PSA DT). Univariate and multivariate Cox regression analyses were performed to evaluate whether the use of salvage RT in men with either a rapid (\ 6 months) or slow ($ 6 months) PSA doubling time was associated with the risk of all cause mortality (ACM) adjusting for age at the time of PSA failure and known prostate cancer prognostic factors. Results: After a median follow-up of 11.3 years after PSA failure, 195 men died. The use of salvage radiation therapy was associated with a significant reduction in ACM for men with either a PSA DT \ 6 months (adjusted hazard ratio [AHR], 0.53; 95% confidence interval [CI], 0.31 to 0.90; p = 0.02) or a PSA DT $ 6 months (AHR, 0.52; 95% CI, 0.34 to 0.80; p = 0.003). Increasing age (AHR: 1.05; 95% CI, 1.02 to 1.07; p\0.0001) and pGleason 8 to 10 cancer (AHR: 1.93; 95% CI, 1.28 to 2.92; p = 0.002) were associated with an increased risk of ACM whereas the converse was true in men who received ADT (AHR: 0.53; 95% CI, 0.35 to 0.81; p = 0.003). Conclusions: This study provides evidence for a decrease in the risk of death with the use of salvage RT following RP irrespective of the value of the PSA DT after radical prostatectomy. Author Disclosure: S.E. Cotter, None; M. Chen, None; J.W. Moul, None; W.R. Lee, None; B.F. Koontz, None; M.S. Anscher, None; A.V. D’Amico, None.
1022
Postoperative Radiotherapy in Prostate Cancer: The Case of the Missing Target
J. M. Croke1, S. Malone1, L. Avruch2, N. Delatour2, E. Belanger2, C. Morash2, J. Spaans1, C. Kayser1, K. Underhill1 1
The Ottawa Regional Cancer Centre, Ottawa, ON, Canada, 2The Ottawa Hospital, Ottawa, ON, Canada
Purpose/Objective(s): Postoperative radiotherapy increases survival in high-risk (pT3/margin positive) prostate cancer patients (pts). Despite the benefit of adjuvant radiotherapy (XRT) approximately 50% of pts in long-term follow-up relapse with the primary site of failure being local (SWOG 8794). Potential reasons for recurrence include inadequate XRT dose and inadequate clinical target volume (CTV) delineation. There are four published consensus guidelines (EORTC, FROGG, PMH, and RTOG) defining postoperative CTV in prostate cancer. We explore the possibility that inadequate CTV coverage is an important cause of local failure. This study evaluates the utility of preoperative MRI in defining postoperative prostate bed CTV. Materials/Methods: Twenty prostate cancer pts at The Ottawa Hospital receiving post-op XRT who also had pre-op staging MRI were identified. Pts underwent CT Simulation and the 4 CTV consensus definitions were applied. CTVs were expanded by 1 cm to create respective Planning Target Volumes (PTVs). Pre-op MRIs were fused with the post-op planning CT scans. MRI based prostate and gross visible tumor were contoured. 3DCRT plans were developed and Dose Volume Histograms (DVH) analyzed. Subtraction analysis was conducted to assess the adequacy of prostate and gross tumor coverage. Results: Mean pre-op prostate volume was 45cc (range, 25-79 cc) and gross tumor was visible in 17 cases. In all 20 cases, the consensus CTVs did not fully cover the pre-resection extent of the prostate seen on the MRI. On average, 38% of the prostate volume was missed by the CTVs (mean and range, CTV-RTOG 29% [5-65%], CTV-PMH 27% [4-61%], CTV-FROGG 43% [1767%], CTV-EORTC 52% [23-77%]). In only 1 case, the entire gross tumor was completely covered. On average, 41% of the visible gross tumor volume was missed (mean and range: CTV-RTOG 35% [0-67%], CTV-PMH 33% [0-64%], CTV-FROGG 48% [1892%], and CTV-EORTC 46% [9-88%]). Furthermore, the PTVs did not cover the prostate in 50% of cases. On average, 7% of the prostate volume was missed by PTVs (mean and range: PTV-RTOG 3% [0-13%], PTV-PMH 3% [0-13%], PTV-FROGG 8% [027%], PTV-EORTC 14% [0-36%]).The prostate base and mid-zones were the predominant site of inadequate coverage. CTV-PMH and CTV-RTOG were similar with respect to prostate and tumor coverage and yielded the best overall results. CTV-EORTC
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