ABSTRACT:
Background: Treatment options when radiation fails to give adequate local therapy to patients with early stage prostate cancer include, androgen ablation, watchful waiting, seed implant, cryotherapy and in rare instances further surgery. Failure in this group of patients is often subclinical, indicated initially with an elevation in PSA.
Objectives: We retrospectively analysed our institutional experience using cryotherapy as salvage for external beam failures for locally recurrent prostate cancer. Methods: Forty-four sequential patients were analyzed who had biopsy proven local failure after radiation for T1 and T2 prostate cancer. Patients had been initially treated with radiation as their definitive treatment. All patient had a repeat work up for staging, and did not receive any adjuvant chemotherapy or hormonal therapy. The mean follow up in this group was 18(range 12-36) months. The follow up included physical exam, PSA and repeat biopsy at three months, six monthsand then yearly.
Results: Of the forty four patients, twelve patients presented at the time of initial evaluation as radiation failure with a PSA<4, sixteen patients with a PSA 4-10 and sixteen patients with a PSA>10 At the mean follow up, 75%(33/44) of patients were free of disease, with a nadir PSA and negative biopsy, 25% (11/44) failed salvage cryotherapy with a positive biopsy at follow up. 73% of all patients reached a nadir PSA<0.5. The ability of cryotherapy to salvage these patients was dependant on the PSA and gleason score at the time of failure. 83% (12/2) of patients who presented with a pre-cryo PSA<4 remained disease free 75% (16/4) with a PSA 4-10 and 68% (16/5) with a PSA>10. The local control by gleason score was the following, 100% for gleason score 4,5 or six (6/0), 70% for gleason 7(23/7) and 70% for gleason 8,9 (15/4). Complications are substantial and included rectal fistula in 6%, impotency in 83%, dribbling in 50% of patients and frank incontinence in 25%. Improvement in technique may lessen these effects.
Conclusions: As expected, the cure rates are dependant on the aggressiveness and bulk of disease at the time of failure. The most favourable outcomes are seen with patients with PSA<4 and gleason score<7 at the time of failure. Although the follow up is short, cryotherapy may prove to be a vaible tratment option for locally recurrent prostate cancer after radiation.