Rising or persistently elevated serum PSA following radical prostatectomy for prostate cancer: Management
- W Robert Lee, MD, MS, MEd
W Robert Lee, MD, MS, MEd
- Section Editor — Prostate Cancer
- Professor of Radiation Oncology
- Duke University Medical Center
- Section Editors
- Nicholas Vogelzang, MD
Nicholas Vogelzang, MD
- Section Editor — Prostate Cancer
- Professor of Medicine
- University of Nevada School of Medicine
- US Oncology Research
- Jerome P Richie, MD, FACS
Jerome P Richie, MD, FACS
- Section Editor — Cancer of the Urethra, Penis, and Ureter
- Section Editor — Urologic Surgery
- Section Editor — Prostate Cancer
- Elliott Carr Cutler Professor of Surgery
- Harvard Medical School
Prostate specific antigen (PSA) is a sensitive and specific serum marker for prostate tissue. Serial measurements are routinely obtained to detect early disease recurrence in men who have received definitive treatment for localized disease. (See "Follow-up surveillance during and after treatment for prostate cancer".)
Following radical prostatectomy, the serum level of PSA should become undetectable since all normal prostate tissue as well as the tumor is removed. Thus, monitoring PSA after definitive treatment of localized prostate cancer leads to the identification of men with a PSA-only (biochemical) recurrence. In this situation, detection of very low levels of PSA or subsequent increases in serum PSA are not accompanied by signs or symptoms of recurrent or disseminated disease. For men in whom there is a significant likelihood that disease is confined to the prostatic bed, salvage therapy may result in prolonged disease-free survival.
The use of salvage RT for men who have a persistently elevated or rising PSA following radical prostatectomy for early stage disease will be reviewed here. Other topics relevant to patients with a rising PSA include:
- Ravery V. The significance of recurrent PSA after radical prostatectomy: benign versus malignant sources. Semin Urol Oncol 1999; 17:127.
- Cookson MS, Aus G, Burnett AL, et al. Variation in the definition of biochemical recurrence in patients treated for localized prostate cancer: the American Urological Association Prostate Guidelines for Localized Prostate Cancer Update Panel report and recommendations for a standard in the reporting of surgical outcomes. J Urol 2007; 177:540.
- Koulikov D, Mohler MC, Mehedint DC, et al. Low detectable prostate specific antigen after radical prostatectomy--treat or watch? J Urol 2014; 192:1390.
- Punnen S, Cooperberg MR, D'Amico AV, et al. Management of biochemical recurrence after primary treatment of prostate cancer: a systematic review of the literature. Eur Urol 2013; 64:905.
- Thompson IM, Valicenti RK, Albertsen P, et al. Adjuvant and salvage radiotherapy after prostatectomy: AUA/ASTRO Guideline. J Urol 2013; 190:441.
- Valicenti RK, Thompson I Jr, Albertsen P, et al. Adjuvant and salvage radiation therapy after prostatectomy: American Society for Radiation Oncology/American Urological Association guidelines. Int J Radiat Oncol Biol Phys 2013; 86:822.
- Pazona JF, Han M, Hawkins SA, et al. Salvage radiation therapy for prostate specific antigen progression following radical prostatectomy: 10-year outcome estimates. J Urol 2005; 174:1282.
- Buskirk SJ, Pisansky TM, Schild SE, et al. Salvage radiotherapy for isolated prostate specific antigen increase after radical prostatectomy: evaluation of prognostic factors and creation of a prognostic scoring system. J Urol 2006; 176:985.
- Ward JF, Zincke H, Bergstralh EJ, et al. Prostate specific antigen doubling time subsequent to radical prostatectomy as a prognosticator of outcome following salvage radiotherapy. J Urol 2004; 172:2244.
- Stephenson AJ, Scardino PT, Kattan MW, et al. Predicting the outcome of salvage radiation therapy for recurrent prostate cancer after radical prostatectomy. J Clin Oncol 2007; 25:2035.
- Macdonald OK, D'Amico AV, Sadetsky N, et al. Predicting PSA failure following salvage radiotherapy for a rising PSA post-prostatectomy: from the CaPSURE database. Urol Oncol 2008; 26:271.
- Wiegel T, Lohm G, Bottke D, et al. Achieving an undetectable PSA after radiotherapy for biochemical progression after radical prostatectomy is an independent predictor of biochemical outcome--results of a retrospective study. Int J Radiat Oncol Biol Phys 2009; 73:1009.
- Trock BJ, Han M, Freedland SJ, et al. Prostate cancer-specific survival following salvage radiotherapy vs observation in men with biochemical recurrence after radical prostatectomy. JAMA 2008; 299:2760.
- Boorjian SA, Karnes RJ, Crispen PL, et al. Radiation therapy after radical prostatectomy: impact on metastasis and survival. J Urol 2009; 182:2708.
- Pfister D, Bolla M, Briganti A, et al. Early salvage radiotherapy following radical prostatectomy. Eur Urol 2014; 65:1034.
- Briganti A, Karnes RJ, Joniau S, et al. Prediction of outcome following early salvage radiotherapy among patients with biochemical recurrence after radical prostatectomy. Eur Urol 2014; 66:479.
- Cox JD, Gallagher MJ, Hammond EH, et al. Consensus statements on radiation therapy of prostate cancer: guidelines for prostate re-biopsy after radiation and for radiation therapy with rising prostate-specific antigen levels after radical prostatectomy. American Society for Therapeutic Radiology and Oncology Consensus Panel. J Clin Oncol 1999; 17:1155.
- Bernard JR Jr, Buskirk SJ, Heckman MG, et al. Salvage radiotherapy for rising prostate-specific antigen levels after radical prostatectomy for prostate cancer: dose-response analysis. Int J Radiat Oncol Biol Phys 2010; 76:735.
- Tomita N, Kodaira T, Furutani K, et al. Early salvage radiotherapy for patients with PSA relapse after radical prostatectomy. J Cancer Res Clin Oncol 2009; 135:1561.
- King CR. The timing of salvage radiotherapy after radical prostatectomy: a systematic review. Int J Radiat Oncol Biol Phys 2012; 84:104.
- Bolla M, Van POPPEL H, Tombal B. 10-year results of adjuvant radiotherapy after radical prostatectomy in pT3N0 prostate cancer. Int J Radiat Biol Phys 2010; 78:s29.
- Thompson IM, Tangen CM, Paradelo J, et al. Adjuvant radiotherapy for pathological T3N0M0 prostate cancer significantly reduces risk of metastases and improves survival: long-term followup of a randomized clinical trial. J Urol 2009; 181:956.
- Lawton CA, DeSilvio M, Roach M 3rd, et al. An update of the phase III trial comparing whole pelvic to prostate only radiotherapy and neoadjuvant to adjuvant total androgen suppression: updated analysis of RTOG 94-13, with emphasis on unexpected hormone/radiation interactions. Int J Radiat Oncol Biol Phys 2007; 69:646.
- Pommier P, Chabaud S, Lagrange JL, et al. Is there a role for pelvic irradiation in localized prostate adenocarcinoma? Preliminary results of GETUG-01. J Clin Oncol 2007; 25:5366.
- National Institutes of Health Clinical Trials database. http://www.clinicaltrials.gov/ (Accessed on February 08, 2011).
- Peterson JL, Buskirk SJ, Heckman MG, et al. Late toxicity after postprostatectomy salvage radiation therapy. Radiother Oncol 2009; 93:203.
- Feng M, Hanlon AL, Pisansky TM, et al. Predictive factors for late genitourinary and gastrointestinal toxicity in patients with prostate cancer treated with adjuvant or salvage radiotherapy. Int J Radiat Oncol Biol Phys 2007; 68:1417.
- Abdollah F, Briganti A, Montorsi F, et al. Contemporary Role of Salvage Lymphadenectomy in Patients with Recurrence Following Radical Prostatectomy. Eur Urol 2014.
- Suardi N, Gandaglia G, Gallina A, et al. Long-term Outcomes of Salvage Lymph Node Dissection for Clinically Recurrent Prostate Cancer: Results of a Single-institution Series with a Minimum Follow-up of 5 Years. Eur Urol 2015; 67:299.
- Karnes RJ, Murphy CR, Bergstralh EJ, et al. Salvage lymph node dissection for prostate cancer nodal recurrence detected by 11C-choline positron emission tomography/computerized tomography. J Urol 2015; 193:111.
- Rischke HC, Schultze-Seemann W, Wieser G, et al. Adjuvant radiotherapy after salvage lymph node dissection because of nodal relapse of prostate cancer versus salvage lymph node dissection only. Strahlenther Onkol 2014.
- Rigatti P, Suardi N, Briganti A, et al. Pelvic/retroperitoneal salvage lymph node dissection for patients treated with radical prostatectomy with biochemical recurrence and nodal recurrence detected by [11C]choline positron emission tomography/computed tomography. Eur Urol 2011; 60:935.
- DEFINITION OF BIOCHEMICAL FAILURE AFTER RADICAL PROSTATECTOMY
- Low, persistently elevated PSA
- NATURAL HISTORY OF BIOCHEMICAL FAILURE
- SALVAGE RT
- Prognostic factors and impact on survival
- Dose of radiation
- Treatment volume
- Salvage RT versus adjuvant RT
- Salvage RT plus ADT
- ROLE OF SURGERY FOR ISOLATED PELVIC RECURRENCE
- OLIGOMETASTATIC DISEASE
- ADT ALONE
- SUMMARY AND RECOMMENDATIONS