Photo Credit: Mr. Suphachai Praserdumrongchai
The following is a summary of “American Radium Society Appropriate Use Criteria for the Workup and Treatment of Local Intraprostatic Recurrence of Prostate Cancer Following Definitive Radiotherapy,” published in the September 2024 issue of Urology by Valle et al.
Intraprostatic radio recurrence of prostate cancer (IPR-PC) poses a significant clinical challenge due to its association with aggressive disease progression and adverse impacts on long-term survival. While timely local salvage interventions can offer curative potential, standardized best practices for diagnosing and managing IPR-PC remain inadequately defined. To address this gap, the American Radium Society (ARS) Genitourinary Appropriate Use Criteria (AUC) Committee sought to develop evidence-based recommendations for the evaluation and treatment of IPR-PC.
This effort was grounded in a comprehensive literature review, with searches conducted in PubMed and Embase to identify relevant peer-reviewed studies covering four key aspects of IPR-PC management. The evidence was carefully analyzed by three investigators who developed clinical variants for each topic. These variants were subsequently reviewed and voted on by a multidisciplinary expert panel from the ARS Genitourinary AUC. A modified Delphi method was employed to establish consensus-based recommendations.
The panel recommended the use of advanced radiographic staging techniques, specifically prostate-specific membrane antigen positron emission tomography (PSMA PET) and multiparametric magnetic resonance imaging (MRI), to exclude metastatic disease and accurately assess the extent of local recurrence. A mandatory biopsy is advised prior to salvage treatment to prevent overtreatment of patients whose imaging findings may reflect post-treatment changes rather than true recurrence. Local salvage therapy is preferred over noncurative hormonal therapy alone, emphasizing the importance of shared decision-making between physicians and patients. Reirradiation strategies should be employed cautiously to minimize toxicity, and hormonal therapy may be used for radiosensitization in the context of salvage radiotherapy, though limited to short-term use, with classic androgen deprivation therapies being preferred over newer agents.
Focal salvage therapy is recommended when radiographic and tissue sampling modalities confirm localized recurrence, with whole-gland salvage being an acceptable alternative given its favorable toxicity profile. Multiple salvage radiotherapy regimens are viable, typically delivered in six or fewer treatment fractions. It is important to note that the available data informing these recommendations primarily pertain to patients treated with conventionally fractionated external beam radiotherapy and those evaluated before the widespread adoption of PSMA PET.
In conclusion, this consensus guideline provides an evidence-based framework for the workup and management of IPR-PC. The panel emphasizes the need for prospective studies to further refine and expand these recommendations, particularly in the context of modern diagnostic technologies.
Source: sciencedirect.com/science/article/pii/S2588931124002141
