The Evolving Management of Radiorecurrent Prostate Cancer

The detection of local radiorecurrence (LRR) of prostate cancer in the prostate or prostate bed after radiation therapy is increasingly common with the advent of advanced imaging modalities such as the PSMA PET/CT. Our aim is to review the literature and define the optimal workup for identifying LRR and discuss the key principals in management, with a focus on salvage re-irradiation. We performed a narrative review of the literature and ongoing studies centered on LRR workup and treatment. Workup for biochemical recurrence postradiation therapy includes PSMA PET/CT, multiparametric MRI, and systematic and targeted biopsy to confirm and define the extent of LRR. Historically, treatment options have included observation, palliative androgen deprivation therapy (ADT), or salvage local therapy to eradicate the LRR. Salvage local re-irradiation can be delivered using stereotactic body radiotherapy (SBRT), high dose rate (HDR) brachytherapy, or low dose rate (LDR) brachytherapy. Commonly used treatment regimens and practical considerations for the different salvage re-irradiation modalities based on the available literature are discussed. Salvage re-irradiation is a safe and effective treatment approach that offers a second chance to "cure" prostate cancer, while also delaying the need for palliative hormonal therapy. Salvage re-irradiation should be carefully considered in patients with LRR after weighing potential benefits against risks. Further data are needed to identify the optimal volume, dose and fractionation regimens.