Background
Multi-institutional retrospective study of 1,540 men who received salvage radiotherapy after radical prostatectomy for biochemical recurrence (defined as PSA ≥0.2 ng/mL). Patients received salvage RT to the prostatic fossa at multiple academic centers. Analysis aimed to define clinical predictors of outcome and develop a prognostic nomogram.
Interventions and follow up
Arm A: Salvage radiotherapy (dose range 60–70+ Gy to prostatic fossa)
Arm B: N/A (single-arm retrospective analysis)
Primary endpoint: Progression-free probability at 6 years (PSA non-progression)
mFollow up: 53 month
Arm B: N/A (single-arm retrospective analysis)
Primary endpoint: Progression-free probability at 6 years (PSA non-progression)
mFollow up: 53 month
Results
6-yr progression-free probability (overall): 32%
Favorable cohort (pre-RT PSA ≤0.5, Gleason ≤7, negative margins, PSADT >10 mo, pT3a, no seminal vesicle invasion): ~77–80%
Poor-risk features (pre-RT PSA >2.0, Gleason 8–10, short PSADT): <10%
Favorable cohort (pre-RT PSA ≤0.5, Gleason ≤7, negative margins, PSADT >10 mo, pT3a, no seminal vesicle invasion): ~77–80%
Poor-risk features (pre-RT PSA >2.0, Gleason 8–10, short PSADT): <10%
Adverse events
Main adverse events: Retrospective; acute and late toxicity not systematically reported. Grade 3+ GU toxicity estimated ~3–5% across institutions.
Conclusions
Salvage radiotherapy can achieve long-term disease control in a subset of men with biochemical recurrence after radical prostatectomy, particularly when initiated at low PSA levels. A prognostic nomogram integrating pre-RT PSA, Gleason score, PSA doubling time, surgical margins, and pathologic stage identifies patients most likely to benefit from early salvage RT.
Key Limitations
Key Limitations: Retrospective design with inherent selection bias. Heterogeneous treatment eras (1987–2002) with variable RT doses and techniques. No comparison arm; progression defined as PSA rise, not clinical or survival endpoint. The nomogram has been externally validated but remains imperfect for individual patient decision-making.
Clinical Context
This study established the principle that lower pre-RT PSA levels at time of salvage RT yield better outcomes, driving current recommendations to initiate salvage RT early (PSA 0.1–0.5 ng/mL). The nomogram published in this paper remains widely used in clinical practice and guideline development.
References
References: Stephenson AJ et al, JCO 2007