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; Urologic Surgery; 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".)
The use of salvage radiation therapy (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.
- King CR. The timing of salvage radiotherapy after radical prostatectomy: a systematic review. Int J Radiat Oncol Biol Phys 2012; 84:104.
- Stish BJ, Pisansky TM, Harmsen WS, et al. Improved metastasis-free and survival outcomes with early salvage radiotherapy in men with detectable prostate-specific antigen after prostatectomy for prostate cancer. J Clin Oncol 2016.
- Tendulkar RD, Agrawal S, Gao T, et al. Contemporary Update of a Multi-Institutional Predictive Nomogram for Salvage Radiotherapy After Radical Prostatectomy. J Clin Oncol 2012.
- 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.
- 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.
- Carrie C, Hasbini A, de Laroche G, et al. Salvage radiotherapy with or without short-term hormone therapy for a rising prostate-specific antigen concentration after radical prostatectomy (GETUG-AFU 16): a randomised, multicentre, open-label phase 3 trial. Lancet Oncol 2016.
- Abdollah F, Briganti A, Montorsi F, et al. Contemporary role of salvage lymphadenectomy in patients with recurrence following radical prostatectomy. Eur Urol 2015; 67:839.
- 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 2015; 191:310.
- 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.
- GENERAL APPROACH
- DEFINITION OF BIOCHEMICAL FAILURE AFTER RADICAL PROSTATECTOMY
- Low, persistently elevated PSA
- NATURAL HISTORY OF BIOCHEMICAL FAILURE
- SALVAGE RT
- Prognostic factors and impact on survival
- Timing of salvage RT
- 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