Radiotherapy in the Management of Prostate Cancer After Radical Prostatectomy

Detlef Bartkowiak; Dirk Bottke; Thomas Wiegel

Disclosures

Future Oncol. 2013;9(5):669-679. 

In This Article

Target Volume

If the post-PR management of PC involves RT, then the clinical target volume (CTV) is a critical aspect. The sites of local recurrence can guide its optimization. There have been various attempts to define common outlines for CTVs of PC,[73–75] and also for organs at risk of normal tissue complications.[76] However, depending on the applied techniques and accepted constraints, a satisfactory consensus has not yet been achieved.[77] The RTOG consensus was achieved considering two PC cases, one T2c with positive margins at both sides of the apex and one T3b with extracapsular extension at the right base and right seminal vesicle, but with negative margins.[73] In summary, the CTV below the level of the superior edge of the symphysis pubis should extend from the posterior edge of pubic bone to anterior rectal wall, inferiorly 8–12 mm below the vesicourethral anastomosis and laterally to the levator ani muscles/obturator internus. Above the upper edge of the symphysis the volume lies between the posterior 1–2 cm of the bladder wall to the mesorectal fascia, superiorly up to the level of the cut end of the vas deferens or 3–4 cm above the top of the symphysis (whichever is higher) and laterally to the sacrorectogenitopubic fascia. In the post-RP situation, the CTV must include normal tissue (where microscopic dissemination might occur), while the planning target volume is significantly larger to account for tissue motions.

Extending the field to the whole pelvis has been beneficial in the adjuvant setting combined with HT for lymph node-positive patients who have a significantly decreased cancer-specific survival with two[78] or more than two involved[79,80] nodes. In a retrospective SRT cohort analysis (247 patients), whole pelvis exposure could not significantly improve bNED in patients with pre-RP high-risk markers compared with low-risk patients, but it did so in the subgroup of patients with pre-SRT PSA levels ≥0.4 ng/ml.[81] Data on a slightly smaller cohort (160 patients) indicated that men with a high risk (≥20% according to the Partin criteria[82]) of nodal involvement significantly profit from whole pelvic treatment, both in the ART and SRT setting.[61] Therefore, while whole pelvic treatment is still under discussion, it has already been recommended for consideration in patients with ≥20% risk of positive pelvic nodes.[83]

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