EBRT as salvage therapy for refractory or progressive prostate cancer post-HIFU

An early release paper in the Canadian Urological Association Journal offers information on a series of patients treated with external beam radiation therapy (EBRT) as salvage therapy after biochemical progression following high-intensity focused ultrasound (HIFU) as their first-line treatment.

Rippert et al. offer a retrospective analysis on the outcomes of a small series of patients treated at their institution between 2004 and 2008. All patients had initially received HIFU using the Ablatherm technology. The authors provide detailed information on 7 patients who either did not meet the Stuttgart criteria for clinical success after HIFU (a PSA level lower than the nadir PSA + 1.2 ng/ml) or who had persistently posistive biopsies post-HIFU. (Note that 35 of 48 patients initially treated with HIFU as first-line therapy in this series failed one or other of these criteria, but only 7 elected to have salvage radiation therapy.)

The results of salvage EBRT in these 7 patients can be summarized as follows:

  • The average (mean) age of the patients was 68.8 years (range, 60 to 79 years).
  • Their average (mean) PSA level before EBRT was 5.57 ng/ml (range, 2.5 to 14.8 ng/ml)
  • The average (median) follow-up was 36.5 ± 10.9 months (range, 24 to 54 months).
  • No patient received adjuvant or neoadjuvant androgen deprivation therapy.
  • EBRT was well-tolerated and completed by all patients.
  • The average (mean) PSA nadir was 0.62 ng/ml (range, 0.03 to 2.4 ng/ml) and occurred after a median of 22 months (range, 12 to 36 months).
  • One patient experienced biochemical failure and was prescribed ADT 30 months after EBRT.
  • The biochemical progression-free survival rate was 83.3 percent at 36.5 months post-EBRT.
  • There was no major EBRT-related toxicity at 12 or 24 months.

This is believed to be the second report to demonstrate the feasibility of salvage EBRT in a series of patients whose cancer was not well managed with HIFU. An earlier report (by Pasticier et al.) gave data from rather larger but much earlier series of patients, many of whom had been treated with very early forms of HIFU as first-line therapy.

The “New” Prostate Cancer InfoLink would assume that as criteria for the use of HIFU as a first-line therapy have become more stringent, and the quality of the treatment has improved with improvements in the technology and the skill levels of the clinicians using this technique, that the rate of failure of HIFU has started to decline significantly. However, we now have data showing that both surgery and external beam radiation therapy can be used as salvage therapies for men who have less than  optimal outcomes with HIFU as a first-line treatment.

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