For recurrent prostate cancer after prostatectomy with soft tissue mass in the prostate fossa, is hypofractionation an option or is standard fractionation recommended?

There is no standard, accepted modification of a treatment plan for the detection of gross residual/recurrent disease in the operative bed; however, a few common approaches have been reported. These options, as they pertain to hypofractionated treatment regimens are discussed below.

1. Treatment of the operative bed with a homogeneous dose without attention to the GTV: For this case, one could consider utilizing the experimental 25-fraction regimen in NRG GU003 (Buyyounouski et al., PMID 38483412). While this trial was not designed to establish equivalent efficacy of the hypofractionated regimen, the efficacy appeared similar. The 2-year quality of life was non-inferior and the rates of toxicity were similar. The grade 3 cystitis rates were n...

SIB 72/2 Gy to nodule and 64.8/1.8 Gy to entire prostate bed in 36 fractions with at least 6 months or up to 2 years ADT depending on risk factors and comorbidities.

I will have to read Dr. @Dr. First Last's essay above, and I may change what I do, but for 10 years I’ve been doing 70/70.2 to the fossa standard fraction with a sequential boost to the nodule taking to 75-76. Probably done it this way more than 100 times.

I used to go up to 79.2 many years ago because I thought of the nodule as a tiny hypoxic prostate, but more aggressive than de novo because it has been treated with surgery so the whole recurrence, hypoxia thing. I’ve backed off my dose since learning that others (Dr. @Dr. First Last, Chicago) did and having FOMO.

We will sometimes put hydrogel in these patients with a fiducial. However, my urologist has hundreds of cases of hydrogel, so don't try that at home. Plus, the rectum doesn’t wor...