Options for Salvage of Radiation Failures for Prostate Cancer

Biochemical failure after primary external beam radiotherapy for prostate cancer is common, and a significant proportion of these failures are due to local residual or recurrent disease. Early or delayed palliation using androgen deprivation therapy is the most common approach. Although a conservative approach is appropriate for many individuals, selected patients would benefit from retreatment with curative intent. We review the pertinent literature on salvage of locally recurrent prostate cancer after primary radiotherapy, including the modalities of surgery, cryotherapy, high-intensity focused ultrasound, or reirradiation with brachytherapy or stereotactic body radiotherapy. We discuss patient selection, outcomes, and toxicities. Patients with local recurrence and sufficient life expectancy, in the absence of metastatic disease, could be considered for local salvage. Although highly dependent on patient selection, the efficacy of the various salvage options seems comparable, with biochemical-recurrence-free survivals ranging approximately 50% at 5 years. The toxicity profiles differ, but all salvage treatments are more toxic than primary treatment. Management of isolated local failure after radiotherapy remains challenging. However, with the recent progress in salvage techniques, and more sensitive functional imaging for tumor localization and staging, salvage treatments are likely to play an increasingly important role.