1. Treatment options for locally recurrent Prostate Cancer Giuseppe Simone Mediterranean School of Oncology Roma 15-06-2012

2. Treatment options Local recurrence after RP Radiotherapy ADT if N+ M+ Other options (off label)

3. Treatment options Local recurrence after Radiation treatments Salvage RP Salvage Cryo Brachy (small series) Re-radiation (off label)

4. Salvage RP Feasible? Safe? Effective?  Select cases!

6. PSA free (3-yr  75% PSA<0.2) Continence (7/32  22%) Sexual function(3/32  9%)

7. Treatment options Local recurrence after Radiation treatments Salvage RP Salvage Cryo Brachy (small series) Re-radiation (off label)

8. p: ns

9. Treatment options Local recurrence after Radiation treatments Salvage RP Salvage Cryo Salvage HIFU Brachy (small series) Re-radiation (off label)

10. Our experience Jan 2009 - Jan 2011 28 salvage cryo (radiorecurrent PCa) Median age 73 (IQR 70-76) Minimum follow-up 15 months All patients underwent biopsy, and 18 F-choline PET-CT scan 4 cases underwent inguinal LNd  excluded (pN+)

11. Patients characteristics 7 cases not receiving ADT Median PSA 4.11ng/mL (IQR 1.3-5) Mean Gleason score 7.4 (range 6-9) 17 cases receiving ADT Median PSA 3.13 ng/mL (IQR 1.1-6.1) Any of these successfully discontinued ADT!

12. PSA free survival 24-mo (Phoenix criteria)56% 21-monot ADT 65.6% 21-mounder ADT57.6% 24-mo (ASTRO criteria)53.6% 21-monot ADT 80% 21-mounder ADT60% Local recurrence Biopsy at physician discretion! 2 positive out of 6 performed 1 seminal vesicle recurrence at 18F-chol PET-CT Bifecta in patients not receiving ADT 72%

13. 18 F-choline PET-CT No report on nodal or distant metastasis A step forward “biochemical recurrence” In our series 2 cases of nodal recurrences 4 cases with preoperative evidence of pos nodes confirmed by hystology

14. Preop CT and bone scan negative 3 mo PSA 1  6 mo PSA 2 PET-CT  Stereotaxic RT and ADT 32 mo PSA 0.8

15. Complications Urinary Incontinence  20% Rectal fistula  4% Previous simple prostatectomy and RT Sloughing and AUR requiring TURP  12.5%

16. Hot Topics Seminal Vesicles Discontinuing ADT? N+? M+? 2-yr ADT after adjuvant RT recommended Sloughed tissue and AUR requiring TURP  12.5%

17. Yes Low complication rate Minimally invasive treatment Learning curve salvage cryo vs salvage RP Patients selection!!! Previous TURP-simple prostatectomy Bifecta outcome >70%

18. Buts Cancer control lower than salvage RP Pts receiving ADT should not discontinue it Preoperative staging limits (rule out N+/M+) 18 F chol PET-CT has not 100% accuracy Bifecta-ASTRO-Phoenix can not be compared with undetectable PSA after RP Standardize outcome evaluation

19. Patient counseling Salvage RP is the radical treatment Healthy pts with life expectancy > 10yrs should be counseled accordingly… Local recurrence can be successfully treated with recryo or with ADT 10 yr Cancer specific survival  90%

20. Treatment options Local recurrence after Radiation treatments Salvage RP Salvage Cryo Salvage HIFU Brachy (small series) Re-radiation (off label)

23. Patient counseling Salvage RP is the radical treatment Healthy pts with life expectancy > 10yrs should be counseled accordingly… Local recurrence can be successfully treated with recryo or with ADT 10 yr Cancer specific survival  90%