How do you approach a locally recurrent prostate cancer after prior cryotherapy salvage and external beam?

These are tough cases and ones where multidisciplinary tumor boards are really helpful. For all these men, I recommend a PSMA PET as well as mpMRI and confirmatory biopsy. Want to be as certain as possible that we're dealing with a local-only recurrence.

Additionally, overall prognosis matters. If low PSA, slow doubling time, local recurrence and limited life expectancy then watchful waiting may be appropriate. If moderate life expectancy and tolerates ADT alone, then consider something like Enza monotherapy (EMBARK data shows 5-year DMFS of 80% in a cohort with PSA <9 mo). If young or moderately fit and wants to avoid/defer ADT, then let's talk about local salvage options.

A couple of things that would help include the timeline:

• How many years between EBRT, cryo, and current recurrence?
• If possible, can you identify if the 1st and 2nd recurrences are in the same lesion? Was it there at presentation?
• How is their urinary function and/or any signs of cystitis/proctitis?
• Is there any reason to think this was underdosed at initial RT (e.g., seminal vesicle disease either not covered or mobile and could've been missed)?
• Where is the tumor with regard to the urethra, rectum, and bladder? Can you get needles in it?

Our group has experience doing up to 3 rounds of RT in highly select patients as well as repeat focal therapies. One can imagine a patient with no DIL upfront who got, say, 74 Gy EBRT followed several years later by cryo to a small DIL, now several years later with a new DIL on the other side of the prostate with good urinary function and no RT tox, may be a great candidate for SBRT or brachy. On the flip side, a 75yo with rapid PSA doubling, recurrent cystitis after prior EBRT, and tumor back in the same area it was prior to RT, with a short interval between EBRT, cryo, and 2nd recurrence, might not move the cancer control needle with a 2nd round of RT but definitely could hit QoL.