Session Item

The treatment of localized prostate cancer (PCa) usually consists of radical prostatectomy (RPE), external beam radiotherapy (EBRT), with the potential use of androgen deprivation therapy (ADT). Still, a considerable proportion of treated patients will suffer from a local relapse. However, with the recent advances in the field of stereotactic body radiation therapy (SBRT) and functional imaging with prostate-specific membrane antigen positron emission tomography (PSMA-PET), new treatment options in the recurrence setting arise. Moreover, previously reported irradiations usually target the whole prostate or prostate bed and not specifically the local recurrence. The objective of this analysis was to describe the results of single-fraction PSMA-PET- and multiparametric magnetic resonance imaging (mpMRI)-guided SBRT for the focused treatment of localized PCa recurrences in intensively pretreated patients.

Patients with PSMA-PET positive PCa local recurrences treated with focal single-fraction SBRT between June 2016 and December 2020 were included. Patients with previous and current distant metastasis were excluded. Identification for new tumor growth after SBRT was based on increasing prostate-specific antigen (PSA) levels and subsequent PSMA-PET imaging.

Sixty-four patients were identified. The majority of patients had a Gleason score of 7 (62%) or higher (17%) at first diagnosis. The median follow-up was 21.6 months. All patients received a single-fraction treatment with a median prescription dose and isodose line of 21 Gy and 65%, respectively. The median planning target volume was 2.8 cubic centimeters. The median pretreatment PSA of 1.47 ng/ml declined to 0.66, 0.57, 0.47, 0.42, and 0.43 ng/ml after the first five follow-up (p = 0.03, figure 1). A total of three local recurrences, i.e., new tumor growth inside the PTV, were detected throughout the follow-up. The progression-free survival (PFS) after 1-, 2-, and 3-years were 85.3%, 65.9%, and 51.2% (figure 2). The majority of disease progression (23/29 recurrences) occurred locoregionally, i.e., inside the prostate or pelvic lymph nodes. No significant factors for PFS were observed. The rates of newly started ADT after 1-, 2-, and 3-years were 1.8%, 7.3%, and 22.7%. Four of six patients with ADT at the time of SBRT were able to stop ADT during the available follow-up. Grade 1 or 2 toxicities occurred in six patients (9%), and no high-grade (≥ grade 3) toxicity was observed.

Figure 1.

Figure 2.

While the available SBRT data for PCa local recurrences usually describe outcomes for fractionated radiotherapy and non-focal irradiation, the findings of this first analysis of single-fraction, PSMA-PET- and mpMRI-guided focal SBRT are encouraging. Such treatment appears to be a safe, efficient, and time-saving therapy even in intensively pre-treated patients. Recurrence-directed treatments can delay the use of ADT and could avoid prostate bed irradiation in selected patients.