NEW YORK (Reuters Health), Oct 2 - A management algorithm, based on a review of published reports, may assist clinicians in deciding on appropriate therapy for men with prostate cancer recurring after external-beam radiotherapy (EBRT), according to a paper in the September issue of BJU International.
"The algorithm we present," lead investigator Dr. Tim Dudderidge told Reuters Health, "is a starting point for clinicians managing patients with biochemical failure. We hope it stimulates debate and increases interest in technology in urology."
Dr. Dudderidge of University College London Hospitals NHS Foundation Trust and colleagues note that in 1997 the American Society for Therapeutic Radiology and Oncology (ASTRO) produced criteria to define biochemical failure after RT. These were revised at an ASTRO conference in Phoenix in 2006.
The European Association of Urology and the Royal College of Radiologists' Clinical Oncology Information Network have also developed guidelines for following patients with prostate cancer and there have been a number of studies in the area.
However, the researchers note that many patients with biochemical failure might not need or will not be suitable for salvage treatment. Among these are patients with metastatic disease and those in poor health. Patients might also refuse treatment due to the risks of associated with therapy.
After EBRT, the researchers note that follow-up should be three-monthly until the prostate-specific antigen level has reached a stable nadir after withdrawing androgen suppression. The Phoenix definition of biochemical failure, they add, is an increase of 2 ng/mL or more beyond that level.
Laparoscopic lymph-node dissection can useful in excluding micrometastases in high-risk patients and contrast-enhanced MRI can be used for both diagnosis and staging in conjunction with prostate biopsies. However, to avoid false positive results, it should be employed no sooner than three years after EBRT.
Patients should be offered as many options as possible, the authors advise. Deferred androgen suppression, laparoscopic or open radical prostatectomy, cryotherapy, and high-intensity focused ultrasound are among reasonable salvage treatment approaches, they observe.
However, they conclude, "minimally invasive salvage therapies seem to offer an advantage over salvage surgery to patients in whom the benefits and harms are so finely balanced."
In fact, Dr. Dudderidge added, "with salvage prostatectomy seeming unattractive for many patients, the emergence of minimally invasive techniques for radiorecurrent prostate cancer offers new hope for many."
By David Douglas
Last Updated: 2007-10-01 15:25:43 -0400 (Reuters Health)
BJU Int 2007;100:518-527.
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![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&dpr=2&fit=crop&h=167&q=70&w=250)
