Recurrence After Surgery

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Salvage Therapies After Failed Radical Surgery

If you have experienced a recurrence following radical prostatectomy, your salvage therapy and prognosis will be based on your pre-surgical Gleason score and PSA, the time between surgery and PSA rise, the velocity of PSA rise and doubling time, the amount of tissue left from the surgery, and the location of the active cancer cells.

While radiation always works best as an initial treatment, good results can be achieved in many salvage cases by increasing radiation doses using highly sophisticated DART technology, which incorporates all the techniques associated with 4D Image-Guided Intensity Modulated Radiotherapy (4D IG-IMRT). To maximize the potential of radiation for recurrent patients, we often prescribe hormonal therapy, which creates a positive synergy with radiation resulting in mathematically boosting the cancer-killing effects (for instance, 1+1 = 3 or 4 or 5).

Post-surgery recurrence patients require the most individualized treatment of all. It is imperative to design the salvage treatment plan specifically to the current status of the patient, taking into consideration his prior treatment. Surgery, whether robotic or by hand, leaves the prostate bed significantly devascularized – robbed of normal blood flow that brings critical oxygen to the cells, which activates the killing power of radiation. Success with salvage DART will depend on many factors; primary among these are the location of the recurrence and whether it is local (prostate bed, seminal vesicles, etc.) or distant (spine, lung, etc.).

More and more men are experiencing failure of robotic radical prostatectomy. In fact, close to half of the patients currently treated at the Dattoli Cancer Center are those who have failed robotic surgery. Because the gland itself is often mangled by the attempt to remove it using robotic techniques, these men are not usually eligible for seed implantation. However, full course DART is being offered to these men with confidence of efficacy, depending on the amount and location of the cancer and rapidity of diagnosis of recurrence after primary treatment.

To recap, the challenges with treating recurrence with radiation after failed prostatectomy are:

1. The target (the prostate and tumor) is no longer in place and this void becomes occupied by critical structures such as the bladder and rectum.

2. Because of this postsurgical situation, only lower (suboptimal) doses can be achieved.

3. After surgery, the surgical bed is denuded of vessels (devascularized), but radiation works best in a vascularized, oxygenated region. In theory, even higher doses are necessary than when the prostate is intact.

Solution: Only the sophisticated technology of DART can achieve the required higher dose levels of radiation. Hormones are commonly used to work in synergy with radiation.

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