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DOI: 10.1055/s-0034-1395656
Adjuvante vs. Salvage-Strahlentherapie nach radikaler Prostatektomie
Adjuvant vs. Salvage Radiotherapy after Radical ProstatectomyPublikationsverlauf
Publikationsdatum:
06. Februar 2015 (online)
![](https://www.thieme-connect.de/media/uro/201501/lookinside/thumbnails/10.1055-s-0034-1395656-1.jpg)
Zusammenfassung
Hintergrund: Nach radikaler Prostatektomie (RP) sind präoperativer PSA-Wert, Gleason-Score, pT-Stadium, der Status der Samenblasen und der Resektionsränder wesentliche Risiko-Indikatoren für ein biochemisches oder klinisches Rezidiv. Binnen 5 Jahren kommt es je nach Tumorstadium bei 50–70% der Hochrisikopatienten zum biochemischen Progress. Behandlungsoptionen unter diesen Bedingungen sind die adjuvante Strahlentherapie (ART, bei nicht detektierbarem PSA) oder die Salvage-Radiotherapie (SRT, bei persistierendem oder aus dem Nullbereich ansteigendem PSA). Daten laufender randomisierter Studien zum direkten Vergleich von ART und SRT sind noch nicht publiziert.
Methode: PubMed-Recherche zu ART und SRT nach RP bei Prostatakarzinom und Vergleich der publizierten Resultate beider Therapieformen.
Ergebnisse: 3 randomisierte Phase-III-Studien zeigen einen fast 20-prozentigen Vorteil bei der biochemische Progressionsfreiheit nach ART (60–64 Gy) gegenüber einer abwartenden Strategie. Bei Patienten mit Tumorstadium pT3 und positiven Schnitträndern ist der Effekt am größten. Patienten mit postoperativ persistierendem PSA oder PSA-Anstieg aus dem Nullbereich kann nach S-3-Leitlinie die SRT mit mindestens 66 Gy angeboten werden. In 30–70% der Fälle sinkt danach der PSA erneut unter die Nachweisgrenze. Damit besteht eine zweite kurative Option. Durch die niedrigere Gesamtdosis scheint die Rate der Spätfolgen nach ART geringer als nach SRT. Andererseits vermindert die SRT mögliche Wechselwirkungen mit postoperativen Komplikationen und das potentielle Übertherapie-Risiko. Die Mitbestrahlung der pelvinen Lymphabflusswege, eine zusätzliche antihormonelle Therapie und die Höhe der Gesamtdosis sowohl von ART als auch von SRT werden kontrovers diskutiert.
Schlussfolgerung: Die Wertigkeit der SRT nach PSA-Progression im Vergleich mit der ART bei PSA im Nullbereich unmittelbar postoperativ ist nicht abschließend geklärt. Die Indikation zur ART hängt von begleitenden Risikofaktoren ab, ist bezogen auf die biochemische Progressionsfreiheit jedoch durch hochrangige Evidenz gesichert. Wird bei biochemischer Progression die SRT eingesetzt, so sollte dies frühzeitig geschehen, d. h. bei möglichst niedrigem PSA-Wert.
Abstract
Background: After radical prostatectomy (RP) the pre-RP PSA value, Gleason Score, pT-stage, state of seminal vesicles and state of surgical margins are key indicators for the risk of biochemical or clinical recurrence. Depending on the tumour stage, 50–70% of the high-risk patients suffer biochemical progression. The treatment options in these circumstances are adjuvant radiotherapy (ART, for an undetectable PSA) or salvage radiotherapy (SRT, for persisting PSA or PSA re-rising above detection limits). Data from ongoing randomised trials that compare ART and SRT directly have not yet been published.
Method: A search in PubMed for ART and SRT after RP for prostate cancer was undertaken to compare the results of the 2 treatment approaches.
Results: 3 randomised phase-III studies have shown a nearly 20% advantage in terms of biochemical progression after ART (60–64 Gy) compared with a wait-and-see strategy. The largest effect was seen in patients with pT3 prostate cancer with positive surgical margins. According to the German S3-guidelines, SRT with at least 66 Gy can be offered to patients with a post-RP persisting PSA or a PSA re-rising above detection limits. 30–70% of these patients re-achieve an undetectable PSA. Thus, there is a second option for curative treatment. Due to the lower total dose, ART seems to be connected with fewer late complications than SRT. SRT, on the other hand, reduces the risk of potential interactions with post-RP complications and of overtreatment. There is a controversial discussion about the inclusion of the pelvic lymph nodes in the treatment volume, the additional application of anti-androgens and the total dose of both ART and SRT.
Conclusions: The comparison of SRT after PSA progression with ART at a PSA below the detection limits cannot yet be judged conclusively. The indication for ART depends on the associated risk factors. However, regarding freedom from biochemical progression, it is backed up by high level evidence. If SRT is applied for biochemical progression, then it should be initiated early, i. e., at the lowest PSA possible.
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