Radiation therapy after radical prostatectomy: unresolved issues illustrated by clinical cases

Background. Despite advances and improvements in diagnostic and treatment methods, prostate cancer (PC) continues to be one of the most prevalent malignancies in men. The main treatment modalities for patients with localized and locally advanced PC are radical prostatectomy (RP), radiation therapy, and hormone therapy. After surgery, postoperative conformal external beam radiation therapy (EBRT) may be required in more than half of cases, taking into account individual risk factors. Discussion. Currently, there is an ongoing discussion regarding the indications and optimal timing of radiation therapy after RP: whether it should be administered in the adjuvant setting (i.e., when there is no disease recurrence, but unfavorable prognostic factors are present), or as so-called salvage radiation therapy, in cases of biochemical recurrence or macroscopically detectable tumors. We analyzed the most well-known international studies devoted to this issue. The lack of convincing data supporting the benefit of adjuvant EBRT in improving survival after RP, even in the presence of unfavorable factors, contributes to the ongoing debate about its appropriateness, given the known increased risk of treatment-related complications and the deterioration in patients’ quality of life. Clinical case descriptions. We present clinical cases illustrating the use of both adjuvant and salvage radiation therapy. Conclusion. After radical prostatectomy, adjuvant radiation therapy may be recommended for patients with unfavorable risk factors for recurrence. However, salvage radiation therapy reduces the risk of treatment-related complications, allows for dose escalation, and in nearly half of cases, helps avoid unnecessary and costly treatment.