Gerard Morton

Local recurrence following external beam radiotherapy occurs in 10-40% of cases. Expectant management with androgen deprivation is often appropriate, but for some, particularly younger men with higher grade disease, local salvage is appropriate. Salvage prostatectomy has a success rate of 50-80%, but is associated with a Grade 3 or 4 toxicity rate of up to 33%, particularly bladder neck contracture and incontinence. Either LDR (as per RTOG 0526) or HDR brachytherapy can be used as salvage options with a similar range of cancer control rates for whole gland treatment, but with a range of Grade 3 or 4 toxicities of between 0 and 47%. Local recurrence is often first at the site of initial bulk disease, suggesting a role for focal or focal boost brachytherapy treatments. Multiparametric MRI is used to identify location of recurrence, and this may be targeted using co-registration during HDR planning. Our initial experience using 13.5 Gy x 2 to the focal lesion reveals excellent tolerance without grade 3 toxicity, but with recurrence elsewhere within the prostate in over 20%. Our current protocol delivers 13.5 Gy x 2 to the target lesion, but treats the remaining prostate to 10.5 Gy with each fraction. It is well tolerated acutely and efficacy data is awaited.

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