How to cite: Frank SJ. Salvage Post Radiation: When Can More Radiation Be Offered? Grand Rounds in Urology. February 2026. Accessed Oct 2026. https://grandroundsinurology.com/salvage-post-radiation-when-can-more-radiation-be-offered/
Summary
Steven J. Frank, MD, FACR, FABS, FASTRO, Professor of Radiation Oncology, and Executive Director, Technology and Innovation, University of Texas MD Anderson Cancer Center, Houston, Texas, reviews the role of salvage radiation therapy for patients with prostate cancer who experience recurrence after prior radiation treatment. He focuses on clinical scenarios in which additional radiation may be appropriate and discusses different reirradiation techniques, including brachytherapy and stereotactic body radiation therapy (SBRT).
Dr. Frank notes that the increasing use of external beam radiation therapy for prostate cancer has led to a growing population of patients who may later develop local recurrence. In these situations, salvage radiation approaches may provide an opportunity to control disease locally and delay the need for long-term androgen deprivation therapy. The clinical goal is not only a potential cure but also the prolongation of hormone therapy-free survival.
Dr. Frank outlines several categories of salvage radiation therapy. Low-dose-rate brachytherapy uses radioactive seed implants, such as iodine-125, palladium-103, or cesium-131. High-dose-rate brachytherapy uses temporary iridium-192 sources delivered through implanted catheters. External beam salvage approaches include SBRT.
Clinical data support the use of salvage brachytherapy. A Phase II NRG trial of low-dose-rate brachytherapy for recurrence after external beam radiation therapy (EBRT) showed low rates of local failure over long-term follow-up. Other studies from international groups describe different treatment approaches, including treating the whole gland, focusing on specific lesions, or targeting half of the gland. The prescribed dose varies depending on the isotope used and the treatment method.
Dr. Frank also reviews outcomes with high-dose-rate brachytherapy. Multi-institutional studies using regimens such as 36 Gy in six fractions demonstrate acceptable toxicity profiles and durable disease control. Emerging data for focal salvage approaches using magnetic resonance imaging (MRI)-guided targeting are discussed, including studies evaluating single-fraction and multifraction regimens.
External beam reirradiation with SBRT is also being studied. Systematic analyses suggest that biologically effective dose targets may influence outcomes when delivering five-fraction salvage regimens.
Dr. Frank argues that salvage radiation therapy following prior radiation can be safe and effective in selected patients. Treatment selection depends on factors such as imaging findings, saturation biopsy results, and prostate-specific antigen kinetics, which help determine whether a focal or whole-gland salvage approach is appropriate.
The International Prostate Cancer Update (IPCU), is a multi-day, CME-accredited conference focused on new developments in prostate cancer treatment, diagnosis, and prevention. IPCU 36 featured lectures, interactive discussions, panel roundtables, debates, and case reports. This conference is led by expert physicians and is designed for urologists, medical oncologists, radiation oncologists, and other healthcare professionals involved in the diagnosis and treatment of prostate cancer.The goal of this educational program is to equip healthcare professionals involved in the diagnosis and treatment of prostate cancer with the up-to-date clinical knowledge and tools they need to best treat their patients. The program will discuss the treatment of prostate cancer from diagnosis to treating advanced and metastatic disease. The conference aims to give physicians exposure to a comprehensive review of treating prostate cancer patients and to give them a chance to discuss the issues with peers and experts.
ABOUT THE AUTHOR
Steven J. Frank, MD, is an endowed tenured professor of Radiation Oncology and holds the Bessie McGoldrick Professorship in Clinical Research at The University of Texas MD Anderson Cancer Center. Dr. Frank is the Executive Director of the Particle Therapy Institute and Deputy Head of Strategy for the Division of Radiation Oncology.
Dr. Frank was instrumental in facilitating the restructuring of MD Anderson’s Proton Therapy Center through an asset acquisition and a subsequent expansion of a second Proton Therapy Center to advance Intensity Modulated Proton Therapy (IMPT). Dr. Frank is amongst the first, if not the first, to use IMPT to treat head and neck tumors, and he is the Principal Investigator of an NIH/NCI -sponsored multi-institutional Phase II/III randomized trial in advanced-stage oropharyngeal cancer that compares outcomes after chemoradiation given by IMRT versus IMPT.
Dr. Frank has approximately 300 peer-reviewed publications, has authored many book chapters, and has recently published the first textbook on Proton Therapy, based on the MD Anderson experience. Dr. Frank’s lab is studying the biologic enhancement factor of proton therapy and FLASH radiotherapy for head and neck cancer, as well as MRI-Assisted Radiosurgery (MARS) as the next generation of prostate brachytherapy. Dr. Frank’s expertise in MRI radiotherapy has led to the development and FDA approval of multiple novel positive-contrast implantable markers for use in MRI-guided LDR and HDR prostate brachytherapy and external beam radiation therapy.
As founder of the company, C4 Imaging, Dr. Frank has developed the MRI marker technology at MD Anderson, has been granted 31 national and international patents, developed three FDA-approved products, and has established MRI-Assisted Radiosurgery (MARS) at MD Anderson for the treatment of prostate cancer. He has funding from the NIH, the Prostate Cancer Foundation, the Texas Ignition Fund, Hitachi, and MD Anderson, and he has also raised multiple rounds of private equity financing to advance C4 technology.
Dr. Frank has served as the past President and Chairman of the Board of the American Brachytherapy Society and is the 2023 recipient of the Ulrich Henschke Award, the highest honor awarded by the ABS to a practitioner of brachytherapy. Dr. Frank has served as the chair for the head and neck oral boards for the American Board of Radiology over the last six years and will join the Board of Trustees in October 2023. Dr. Frank is a fellow of the ABS, ACR, and ASTRO.
Prior to entering medicine, Dr. Frank served in the military as a U.S. Navy Diver and submarine officer on the fast attack nuclear submarine USS Batfish (SSN-681). He is married to Dr. Ivy Frank, a veterinarian, and his hobbies include golf, flying, and coaching softball for his four daughters.
