Post Proctectomy Flashcards
Risk factors
T3 disease
Positive margins
Who needs to get immediate RT
Adjuvant RT
pT3a
pT3b
Positive margins
Tertiary pattern of 4 or 5 in prostatectomy specimens
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Improves bRFS by 20-25%
Work-up to guide XRT
Genomic testing
PSMA PET-CT
General Treatment Paradigm
Labs- PSA
Should be undetectable post RP
BCF: PSA >0.2 (2 readings)
Bone Scan
higher PSA
short PSAD
symptomatic, concerning for bone mets
after prior ADT
CT Abdomen Pelvis
T1-T2 with >10% nodal risk on nomogram
for T3-T4 disease
if PSA does not go to undetectable post op
MRI Pelvis
to visualize post surgical recurrence
treatment planning
Types of FDA approved Nuclear imaging
F18 Fluciclovine
F18 Sodium fluoride (more sensitive, but not specific)
C11 Choline
Ga68 PSMA-11 (detection even with PSA <2.0)
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Used when conventional imaging is equivocal
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Prognostic factors
Surgical margins
Gleason score
PSA level
PSADT
PSA response to ADT
Interval from SX to bF
Lack of SV involvement
Common site for recurrence
VU anastomosis
Bladder neck
retrotrigone
median time from bF to bone mets
8 years without treatment
RT for high risk patients time frame -Adjuvant RT
3-4 months post SX
Once incontinence is recovered
RT Dose
64-72Gy (1.8-2Gy/fx) to prostate bed
At least 66Gy
Dose Constraints for adjuvant and salvage RT
Rectum: V65Gy <35%
Bladder V65 < 50% ( bladder - CTV)
Femoral heads v%0 < 10%
Bowel V45 < 150cc
TROG-RAVES
pT3a/b, +ve margins, PSA <0.1
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Adjuvant RT vs **Salvage RT ** ( PSA > 0.2)
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Both arms got 64Gy
ADT/APRT was not allowed
Adjuvant RT was 4-6 mnths
bF defined as PSA >0.4
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5 yr BPFS 86% vs 87% - (not non inferior)
8 yr BPFS 80% vs 75%
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GU toxicity - 70% vs 54%
GI toxicity - 14% vs 10%
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results were favorable in both arms but due to less toxicity in the salvage arm, that was preferred.
GETUG-AFU-17
+ve margins, pT3a/b, pT4a, PSA <0.1
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Adjuvant RT vs Salvage RT >0.2
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Both arms got 66Gy
6 months ADT for all
Optional WPRT 46Gy
Adjuvant RT started 3-6 mnths
BF defined as PSA >0.4
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5 yr EFS 90 vs 92%
5 yr OS 96% vs 99%, p=0.25
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GU toxicity - 27% vs 7%
GI toxicity - 8% vs 5%
ED grade >2 28% vs 8%
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results were favorable in both arms but due to less toxicity in the salvage arm, that was preferred.
50% avoided RT in salvage arm
RADICALS
+ve margins, pT3a/b, pT4a, PSA <0.2
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Adjuvant RT vs Salvage RT
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66Gy in 33 fx or 52.5Gy in 20 fx
WPRT was optional, 46Gy
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10 yr DM 7% vs 10%
10 yr PFS 75% in both groups
No change in OS
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Worse GI and GU toxicity in adjuvant arm
Urethral stricture 13% vs 6%
ARTISTIC Meta-Analysis
+ve margins, T2-T4 disease, bF defined as PSA >0.4
Meta analysis of RADICALS + RAVES + GETUG-AFU-17
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Adjuvant RT vs Salvage RT
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As of now no difference in BPFS (5-yr EFS 88vs89%)
OS, DM, ADT outcomes to follow.
Doing RT salvage spares the pt from RT and reduces adverse effects.
RTOG-0534
SPPORT - IMP
PSA >0.1 <0.2
T2-T3 N0/Nx with or without +ve margins, Gleason <9
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3 arms
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Prostate Bed RT 6480-7020 cGy
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PB RT + 4-6 months ADT
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**WPRT 4500cGy + PB RT + 4-6 months ADT **
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5 yr FFP 71% vs 81% vs 87%
5 yr DM 9% vs 6% vs 5%
5 yr BF 31% vs 21% vs 13%
5 yr OS not different (90-96%)
DADSPORT - IMP
patients getting salvage prostate RT
no ADT vs 6 months ADT vs 24 months ADT
RTOG 9601 - IMP
COPORT
T2-T3 with or without +ve margins
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66.6Gy in 37 fx vs 62.5 Gy in 25 fx
2Gy/Fx vs 2.5Gy/Fx
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GU toxicity was not different
GI toxicity was was worse with 2.5Gy/fx imm after RT but not different at 6,12,24 months post RT.
SWOG - 8794
German ARO - 9602
EORTC- 22911
Showed immediate RT for high risk patients had good bRFS
SWOG-8794 also showed improved DMFS & OS
SAKK 09/10
EMPIRE-1
Phase II-III
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165 pts with detectable PSA randomized to F-18 fluciclovine PET-CT for radiation decision making
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PET CT improved 3 year EFS when compared to conventional imaging.
76% vs 63% p=0.0028
