Salvage whole-gland cryoablation after failure of primary radiation therapy

After last Tuesday’s post on focal salvage therapy for management of radiorecurrent disease, we now have long-term data on the use of salvage whole-gland cryoablation in the same category of patients.

At the recent European Association of Urology (EAU) annual congress in Munich, Joseph Chin of the University of Western Ontario presented his analysis of outcomes of 157 patients treated with whole-gland salvage cryotherapy after primary radiotherapy failure between 1995 and 2004. After a median follow-up of 117 months:

  • 10-year overall survival was 76 percent.
  • 10-year metastasis-free survival was 74 percent.
  • Median biochemical disease-free survival was 56 months.
  • 10-year biochemical disease-free survival was 34 percent.
  • 15-year biochemical disease-free survival was 23 percent.
  • Of the 179 complications, 22 (12 percent) were serious.

While more than three-quarters of the patients had a biochemical recurrence after salvage cryotherapy, it’s not at all clear whether any salvage therapy on this group of patients could have increased survival any better or with fewer complications.

As far as I’m aware, this is the longest follow-up that has been reported in a salvage cryotherapy study, but, paradoxically, its greatest strength is also its greatest weakness. Many of the men treated in this study were selected for salvage treatment before we had well-established, advanced imaging techniques that might have identified small distant metastases in many of them. Also, over the past 15 or so years, cryotherapy has benefited from technological advances that have reduced morbidity considerably.

There are many outstanding questions:

  • How should patients be selected for salvage therapy after radiation?
  • Can we use advanced imaging to eliminate those patients in whom distant metastases have already occurred?
  • Did the salvage therapy delay progression?
  • Is there a survival advantage to salvage whole-gland cryoablation vs. focal or hemi-gland cryoablation?
  • Is there an advantage in terms of treatment morbidity to salvage whole-gland cryoablation vs. focal or hemi-gland cryoablation?
  • How does salvage cryotherapy compare to other ablative salvage therapies (e.g., high-intensity focused ultrasound [HIFU]), salvage radiotherapies, or salvage surgery after radiation failure?

Editorial note: This commentary was written for The “New” Prostate Cancer InfoLink by Allen Edel.

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