EURURO Vol. 72 No. 2

E39 320

Letter to the Editor
Re: Giorgio Gandaglia, Alberto Briganti, Noel Clarke,
et al. Adjuvant and Salvage Radiotherapy after Radical
Prostatectomy in Prostate Cancer Patients. Eur Urol.
In press.
Modern Considerations for an ‘‘Old Picture’’
We read with interest the recent review by Gandaglia et al
. The authors affirm that immediate adjuvant radiation
therapy (RT) following radical prostatectomy (RP) is
associated with an increase in the incidence of short- and
long-term side effects.
To date, the issue of the role of adjuvant RT versus early
salvage RT after RP in patients with adverse pathologic
features has been widely debated .
Unfortunately, the literature lacks mature findings
from well-designed randomized studies prospectively
comparing adjuvant RT versus salvage RT after RP. In
the era of personalized medicine, we believe that further
trials are strongly warranted to identify ‘‘high-risk’’
prostate cancer (PC) patients who could really benefit
from adjuvant RT . In the near future, results from the
ongoing RAVES phase 3 randomized controlled trial could
help clinicians in decision-making after RP on the basis of
a patient’s pathologic features. The RAVES trial is testing
the hypothesis that observation with early salvage RT is
not inferior to adjuvant RT with respect to biochemical
failure in patients with pT3 disease and/or positive
surgical margins after RP. Thus, appropriate selection of
PC patients for adjuvant versus early salvage RT remains
an open issue.
Another crucial question that remains unresolved is
whether the toxicity related to adjuvant postoperative RT,
as outlined by Gandaglia et al, is reliable in the modern era
of intensity-modulated RT (IMRT) and image-guided RT
(IGRT).
First, the cited series do not give any information about
the doses received by the bladder. As clearly stated in
Quantitative Analysis of Normal Tissue Effects in the Clinic
(QUANTEC), the risk of late severe bladder toxicity is related
not only to the maximal dose (which should be <65 Gy) but
also the dose to subvolumes of the bladder receiving a given
dose level.
Looking at their findings, most series used three-
dimensional conformal RT, and only a few adopted IMRT.
Furthermore, there is no reference to IGRT. Compared to
conventional techniques, IMRT/IGRT allows a reduction in
bladder, rectum, and bowel volume involvement, and can
consequently influence toxicity minimization IGRT is
particularly useful when high tumoricidal doses are
delivered, because of soft tissue localization, allowing
minimization of set-up uncertainties with the possibility
of less toxic side effects .
In a match-paired analysis, Azelie and colleagues
showed that among post-prostatectomy patients treated
with IMRT, addition of IGRT affected treatment tolerability,
reducing gastrointestinal and genitourinary toxicity. More-
over, patients treated with high-dose IMRT/IGRT had
significantly better 5-yr freedom from biochemical failure,
suggesting that IMRT could be improved by IGRT addition in
terms of not only toxicity reduction but potentially also
effectiveness because of dose escalation .
In conclusion, although the well-conducted review by
Gandaglia et al ‘‘freezes’’ an image in which early salvage RT
seems to be more intriguing than adjuvant RT, owing to the
lower toxicity for the same hypothetical outcome, it
remains an ‘‘old picture’’ because it ignores modern RT,
which is actually the standard of care for RT in the PC
setting.
Conflicts of interest: The authors have nothing to disclose.
References
[1] Gandaglia G, Briganti A, Clarke N, et al. Adjuvant and salvage
radiotherapy after radical prostatectomy in prostate cancer
patients. Eur Urol. In press.
.
[2]
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[3]
.
[4]
.
ava ilable at
journal homepage:
DOI of original article: .
0302-2838/# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.