Marieke van Son

180 CHAPTER 10 II. Salvage treatment setting Lessons learned: • Several modalities are available for focal salvage treatment of localized radiorecur- rent prostate cancer, all with very low severe urinary and bowel toxicity ( chapter 4 ). • Follow-up of current focal salvage series is still limited ( chapter 4 ). • Ultrafocal salvage HDR-brachytherapy has varying tumor control, depending on individual characteristics indicating tumor aggressiveness ( chapter 5 ). • Whereas bowel symptoms rarely occur, patients do report acute urinary symptoms and deteriorating sexual functioning over time ( chapter 6 ). • Concordantly, physicians observe limited bowel toxicity while moderate urinary symptoms and erectile dysfunction are more prominent ( chapter 7 ). • Ultrafocal salvage HDR-brachytherapy seems to be a safe salvage treatment option with a low risk of severe morbidity ( chapters 6 and 7 ). • Age, tumor volume and baseline PSA kinetics are potential predictors of PSA pro- gression after treatment, indicating treatment failure ( chapter 8 ). • A second salvage treatment with ultrafocal HDR-brachytherapy seems feasible with a low risk of severe side-effects ( chapter 9 ). For patients with a localized recurrence after primary radiotherapy, whole-gland salvage treatments are not without risk due to the high incidence (15-30%) of severe toxicity such as urinary incontinence, rectal injury and erectile dysfunction, irrespective of the modality used(21-23). To minimize the risk of morbidity, focal salvage treatments have emerged as a promising alternative(24). Similar to the primary treatment setting, there are several modalities available for focal salvage treatment, with the most reported being focal salvage HIFU, focal salvage cryotherapy and focal salvage brachythera- py(25). Although technological differences between modalities may lead to different outcomes, there is no randomized evidence available showing superiority of one mo- dality over others. In a retrospective study comparing 300 men undergoing either focal salvage cryotherapy or focal salvage HIFU, the HIFU patients had higher rates of bio- chemical recurrence and progression to castration resistant prostate cancer, but there were no differences in prostate cancer-specific mortality after 10 years(26). Severe side-effects seem to occur in 5-10% of patients irrespective of the modality used. For each individual patient, the risk of side-effects should be carefully weighed against potential benefit from treatment. First, truly localized recurrence needs to be distinguished from unrecognized metastatic disease. Metastatic disease staging has improved significantly since the introduction of prostate-specific membrane antigen (PSMA) PET-CT(27, 28). For local disease assessment, mp-MRI has made it possible to largely differentiate glandular atrophy or radiotherapy-induced fibrosis from pathologic restricted diffusion or contrast enhancement(29, 30). Reported anatomical patterns of recurrence 8-10 years after primary radiotherapy are ±35% local relapse, ±25% pelvic nodal invasion and ±40% distant metastatic failure (Figure 2)(31, 32). It is likely that the actual local recurrence rate is even higher, since not all patients with biochemical failure