I don't think that salvage IMRT after IMRT failure is a good idea, however, let me suggest a few alternatives.
First - it has to be confirmed as a clinical local-only failure. That entails 2 parts:
(1) a full body search must be made to look for evident metastases outside of prostate. The best way for doing that is with one of the advanced PET scans, like a C-11 Choline or Acetate PET, or one of the newer PSMA-directed PET scans available now in several clinical trials. If distant mets are found, it would be futile to pursue local salvage of any kind.
(2) It has to be confirmed as a clinical failure and not just a biochemical failure. Don't forget that PSA can still rise that high owing to prostatitis or urinary retention. The best way for detecting a clinical failure is with an mpMRI-targeted biopsy, read by a radiologist who is adept at reading such things.
You may be interested in this article about
local-only IMRT failures:Site of cancer recurrence after first-line (primary) radiation therapy
So, if it has been confirmed as a local-only failure, you have several alternatives:
• Salvage SBRT. In the US, I am only aware of Don Fuller in San Diego who is doing this. This is relatively new and he only has two years of followup so far, but his cancer control is high and toxicity rates are low. You can read about
it here:Salvage SBRT for local recurrence after first-line (primary) radiation therapy
• Salvage brachytherapy. This has been done in several ways: focal LDR brachytherapy (seeds), focal HDR brachytherapy (temporary implants), and whole gland HDR brachytherapy. In my estimation, the top doctors for doing this would probably be Joe Hsu at UCSF or Michael Zelefsky at MSKCC.
• Salvage focal ablation. Both focal salvage cryo and focal salvage HIFU have been used after radiation failure. However, HIFU was only recently approved in the US and no one here has extensive experience in using it for focal salvage. There are a few doctors who may be able to deliver focal salvage cryo, notably, Aaron Katz, Gary Onik, and Duke Bahn. I'm not a fan of salvage whole gland
• Salvage surgery. There are a very few doctors who get good results with this, notably, Scardino and Eastham at MSKCC (see this link
). Few surgeons have the adequate experience it takes to successfully perform this delicate operation.
It matters A LOT who you choose to do salvage. Experience counts!