Management of local relapse after prostate cancer radiotherapy: Surgery or radiotherapy?

Isolated local relapse after prostate cancer radiotherapy corresponds to 40% of biochemical failure. The management of these relapses is not well defined. Several strategies are available including surgery, high-intensity focused ultrasounds (HIFU), cryotherapy and reirradiation. Radical prostatectomy is the historical approach; biochemical control is obtained in 50 to 80% at 5 year. However, morbidity is higher after irradiation than as a first line treatment. Some limited series of HIFU and cryotherapy have been published with interesting results, but again the risk of urinary and rectal toxicity is high. However, new generation technologies could decrease the complication rate. Reirradiation could be performed with brachytherapy and more recently with stereotactic radiation therapy. The results of salvage low-dose-rate brachytherapy have been reported in some series with a 5-year biochemical control rate of 34 to 88%. High-dose rate brachytherapy seems to be better tolerated, but the number of patients treated and reported is too low to draw firm conclusions. This is the same for stereotactic radiation therapy salvage treatment. A prospective trial of salvage brachytherapy (CAPRICUR) is now open in France and inclusion in this trial is recommended.