title: Salvage of locally recurrent prostate cancer after external beam radiation using reduced-dose brachytherapy with neoadjuvant plus adjuvant androgen deprivation.
abstract: OBJECTIVE
  Local recurrence (LR) of prostate cancer after external beam radiotherapy (EBRT) is a serious problem. Our purpose was to determine if reduced-dose salvage brachytherapy could achieve high rates of biochemical control with acceptable toxicity if combined with androgen deprivation therapy (ADT).
  
  
  METHODS
  Thirty-three consecutive patients with LR after EBRT were treated with salvage brachytherapy plus ADT from 1998 to 2013. All had pathologically confirmed LR, disease-free interval ≥18 months after EBRT, no distant/nodal metastasis, and International Prostate Symptom Score ≤15. Whole-gland salvage treatment was delivered using low-dose-rate (median 100 Gy with103Pd, n = 25) or high-dose-rate brachytherapy (30 Gy in 6 fractions over 4 weeks, n = 8) plus 4-6 months of neoadjuvant plus adjuvant ADT.
  
  
  RESULTS
  Fifty-five percent had high-risk disease at diagnosis. Median EBRT dose was 70.2 Gy; median prostate-specific antigen nadir was 0.8 ng/mL. Median time to recurrence was 56 months; median presalvage prostate-specific antigen was 5.0 ng/mL. Median postbrachytherapy followup was 61 months (range 7-150 months). Five and 7-year relapse-free survival, distant metastasis-free survival, and overall survival were 79% and 67%; 93% and 86%; and 94% and 85%, respectively. Freedom from late Grade 3 GU toxicity at 5 years was 85%. There were no late Grade ≥2 GI toxicities.
  
  
  CONCLUSIONS
  This is the largest series of salvage brachytherapy combined with neoadjuvant plus adjuvant ADT and uses reduced-dose brachytherapy. Results suggest that reduced-dose salvage brachytherapy is feasible and reasonably well tolerated when combined with ADT. Compared to prior series, this approach was associated with favorable relapse-free survival. Prospective studies of reduced-dose salvage brachytherapy plus ADT are warranted.
authors.affiliation: Department of Radiation Oncology, Washington University in Saint Louis, Saint Louis, MO; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA. Electronic address: brian.baumann@wustl.edu.
authors.forename: Brian C
authors.initials: BC
authors.lastname: Baumann
authors.affiliation: Princeton Radiation Oncology, Princeton, NJ.
authors.forename: John C
authors.initials: JC
authors.lastname: Baumann
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA.
authors.forename: John P
authors.initials: JP
authors.lastname: Christodouleas
authors.affiliation: Princeton Radiation Oncology, Princeton, NJ.
authors.forename: Edward
authors.initials: E
authors.lastname: Soffen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000726:Androgen Antagonists / Q000627:therapeutic use*; D001918:Brachytherapy / Q000379:methods*; D017024:Chemotherapy, Adjuvant / Q000379:methods; D019583:Dose Fractionation, Radiation; D005240:Feasibility Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000379:methods; D009364:Neoplasm Recurrence, Local / Q000188:drug therapy / Q000532:radiotherapy*; D017430:Prostate-Specific Antigen / Q000627:therapeutic use; D011471:Prostatic Neoplasms / Q000188:drug therapy / Q000532:radiotherapy*; D011879:Radiotherapy Dosage; D020266:Radiotherapy, Conformal / Q000379:methods; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000379:methods
chemical_list: D000726:Androgen Antagonists; D017430:Prostate-Specific Antigen
keywords: Androgen deprivation therapy; Prostate cancer; Salvage brachytherapy