How to tailor the radiotherapy after radical prostatectomy in the modern era of molecular imaging, genomic testing, and technology development

Sep 29, 2026

Radical prostatectomy is increasingly performed in patients with very high prostate cancer risk, where heterogeneous recurrence risk makes selection of salvage radiotherapy difficult. Some patients can be observed, others benefit from postoperative RT alone, and those with aggressive tumor biology may require RT combined with systemic therapy. Modern personalization is addressed through clinicopathological tools and advanced diagnostics: PET using PSMA-targeted radiotracers, validated genomic testing to identify candidates for ADT plus RT, and adaptive RT technologies enabling precise dose delivery to the tumor bed.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages12

Reading Time30 min

AccessFree to download

Introduction

Early adjuvant versus early salvage radiotherapy

PET-PSMA and molecular imaging personalization

Genomic testing for selecting combined treatment

Adaptive radiotherapy and technology-driven improvements

Predictive genomic tests for radiotherapy planning

© 2025 Greater Poland Cancer Centre. Published by Via Medica. All rights reserved. e-ISSN 2083–4640 ISSN 1507–1367 ISSN: 1507–1367 REVIEW ARTICLE Reports of Practical Oncology and Radiotherapy 2025, Volume 30, Number 6, pages: 828–839 DOI: 10.5603/rpor.110163 Submitted: 28.10.2025 Accepted: 12.12.2025 How to tailor the radiotherapy after radical prostatectomy in the modern era of molecular imaging, genomic testing, and technology development? Piotr Milecki1, 2 1Department of Electroradiology, Poznan University of Medical Sciences, Poznan, Poland 2 1st Radiotherapy Department, Greater Poland Cancer Poland, Poznan, Poland ABSTRACT In recent years, we have observed a significant increase in the number of radical prostatectomies (RP) performed in patients at very high risk of prostate cancer. This group of patients is very heterogeneous due to the presence of multiple risk factors for recurrence, which makes decisions regarding the use of salvage radiotherapy (RT) very challenging. On the one hand, there is a subgroup of patients who can only be observed. For a more advanced subgroup of patients postoperative RT alone is effective treatment. For patients with very aggressive biology characteristics RT should be combined with systemic therapy. Unfortunately, we still do not have ideal tools to precisely assign individual patients to these subgroups. Clinicopathological factors are very helpful in this regard. So, introduction of modern molecular diagnostics, i.e., positron emission tomography (PET) using a radiotracer that binds to prostate-specific membrane antigen (PET-PSMA), allowed for a change in the general strategy for salvage RT. Information from PET scans included in the RT plan allow for increasing the effectiveness of RT. Another method for personalizing RT planning is the use of genomic testing. To date, the most clinically validated method allows for the identification of a subgroup of patients in whom combined treatment [androgen deprivation therapy (ADT) + RT] yields the greatest clinical benefits. Improvement in RT outcomes is associated with the introduction of technologically advanced RT methods, such as adaptive RT (ART), which provides the opportunity for a precise delivery of dose to a tumour bed. Another very promising development involves new predictive tests for RT which are based on genomic analysis of cancer tissue. Keywords: prostate cancer; radical prostatectomy; salvage radiotherapy; molecular imaging; genomic classifier; adaptive radiotherapy Rep Pract Oncol Radiother 2025;30(6):828–839 Introduction In recent years, we have observed a significant increase in the number of radical prostatectomies (RP) performed in patients at high and even very high risk of prostate cancer [1] . In these risk groups, even in high-volume centers the biochemical recurrence, observed within 5 years from RP ranged from 40% to 70%, depending on case mix [2–4] . Generally, for loco-regional recurrences after RP the only effective local therapy is postoperative RT, which is considered to be a second-line treatment [5]. Depending on the timing of RT implementation, we distinguish early adjuvant Address for correspondence: Piotr Milecki, Chair of Electroradiology, Poznan University of Medical Sciences, Poznan, Poland; [e-mail: mipiotr1963@gmail.com](e-mail: mipiotr1963@gmail.com) This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially 828 [https://journals.viamedica.pl/rpor](https://journals.viamedica.pl/rpor) RT [prostate-specific antigen (PSA) levels below the biochemical recurrence threshold < 0.1 ng/mLand not rising] and salvage RT (early salvage; PSA levels > 0.1 ng/mL or rising in consecutive measurement

FAQs

Why is choosing salvage radiotherapy after radical prostatectomy challenging in very high-risk patients?

Very high-risk patients are heterogeneous because multiple recurrence risk factors lead to different disease behaviors, making it hard to determine who will benefit from observation, RT alone, or RT plus systemic therapy.

How does PSMA-based PET influence salvage radiotherapy strategy?

Information from PET scans included in the RT plan can increase the effectiveness of salvage RT by improving targeting based on molecular imaging signals.

Which genomic testing approach has the strongest clinical validation according to the article?

The article states that the most clinically validated method identifies a subgroup where combined treatment (androgen deprivation therapy plus RT) provides the greatest clinical benefits.

Sep 29, 2026

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