ArticleAdvances in radiation oncology2026
Delayed Salvage Radiation Therapy Guided by Contrast-Enhanced Local and Whole-Body Diffusion-Weighted Magnetic Resonance Imaging During Prostate-Specific-Antigen-Based Surveillance After Radical Prostatectomy: A Retrospective Cohort Study.
Article in Advances in radiation oncology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Purpose: Biochemical recurrence (BCR) after radical prostatectomy (RP) is common. Although early prostate-specific-antigen (PSA)-triggered salvage radiation therapy (SRT) improves outcomes, PSA elevation alone cannot reliably distinguish local recurrence from occult metastatic disease, leading to overtreatment. This study retrospectively evaluated long-term outcomes of a PSA-based surveillance strategy, wherein delayed SRT was guided by contrast-enhanced local and whole-body diffusion-weighted magnetic resonance imaging (MRI) and initiated only after radiologic confirmation of macroscopic local recurrence (MLR). Methods and Materials: Between January 2015 and June 2023, 226 patients with MRI-detected MLR in the prostate bed were identified during PSA-based surveillance incorporating serial PSA measurements and repeat contrast-enhanced pelvic MRI combined with whole-body diffusion-weighted imaging after RP. SRT was intentionally deferred and initiated only after imaging-confirmed local recurrence with exclusion of distant metastases. Ninety patients who underwent SRT and had ≥6 months of follow-up were included in the final analysis. Radiation therapy was delivered at a total dose of 64 to 68 Gy. The primary endpoint was BCR-free survival. Secondary endpoints included local-recurrence-free survival, distant-metastasis-free survival, overall survival, patterns of failure, and late toxicity. Results: The median follow-up was 67 months, and the median PSA level at SRT initiation was 0.98 ng/mL. The estimated 5-year BCR-free survival and local-recurrence-free survival rates were 84.8% and 91.3%, respectively. The 5-year distant metastasis-free survival and overall survival rates were 94.1% and 97.3%, respectively. Disease recurrence occurred in 14 patients (15.6%), predominantly as local recurrence after SRT. Two patients exhibited late grade ≥3 gastrointestinal toxicity. However, no grade ≥3 genitourinary toxicity was reported. Conclusions: The PSA-based surveillance strategy, incorporating serial MRI, facilitated the detection of localized recurrence and allowed delayed initiation of SRT in patients with imaging-confirmed MLR following RP. This approach achieved durable disease control with acceptable toxicity in the studied cohort. However, the broader clinical utility of this imaging-based strategy warrants further prospective evaluation.
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