Salvage radiotherapy following radical prostatectomy

Biochemical relapse will occur in 17–64% of men who undergo radical prostatectomy, and up to a third of men with biochemical relapse will progress to develop metastatic disease and ultimately die of prostate cancer. Postoperative salvage radiotherapy (RT) to the prostatic fossa is well-tolerated and potentially curative treatment and should be considered for all men who have biochemical relapse following prostatectomy. Gleason score <8, prostate-specific antigen (PSA) doubling time >10 months and PSA re-emergence >2 years following surgery predict for a low risk of early metastatic failure, but even men with no favourable prognostic factors may have a long-term durable response to RT and should not be excluded from consideration of treatment on the basis of these factors alone. Positive surgical margin status and a positive anastomotic biopsy do not predict response to RT, and routine biopsy is not recommended. PSA level at time of RT is a strong indicator of durable response to RT. No one PSA cutpoint level appears to be more significant, and early RT is likely more effective than late. Contemporary PSA assays can detect biochemical relapse in the 0.01–0.2 range, and this may provide additional therapeutic advantage if treatment can be given when tumour burden is smallest. There is an urgent need for prospective data from randomised trials to optimally select patients for salvage RT, to determine the optimal time to initiate treatment and to determine the role of adjuvant hormone therapy, and all patients should be considered for entry into ongoing and future clinical trials.