Radiotherapy in the Management of Prostate Cancer After Radical Prostatectomy

Detlef Bartkowiak; Dirk Bottke; Thomas Wiegel

Disclosures

Future Oncol. 2013;9(5):669-679. 

In This Article

Salvage RT

After RP, patients should be followed up with PSA measurements. If the post-RP PSA value re-rises from subthreshold to >0.2 ng/ml and this is confirmed after at least 2 weeks, then this is commonly regarded as biochemical relapse.[201] A threshold as low as 0.02 ng/ml has been discussed, while on the other hand, there may be concerns about persisting normal prostate tissue.[21] Once relapse is established, SRT should commence as early as possible, ideally at a PSA <0.5 ng/ml.[21,29,36,66,206] More than 60% of patients who were treated like that could achieve an undetectable PSA level again,[19,27] thus enabling up to 80% progression-free survival 5 years later.[27] In the SRT setting, PSA kinetics, expressed as PSA doubling time or velocity, allows clues as to whether the recurrence is local or systemic, with a rapidly raising PSA more likely to be associated with metastatic disease and poorer clinical outcome.[28,67–69] However, a systematic analysis of the predictive value of pre-RP PSA kinetics has emphasized the importance of the definition of the dynamic parameter.[70] While there are still no randomized prospective studies available to prove the advantage from SRT for bNED, local or systemic failure, or survival, observational studies suggest a benefit especially for patients with a low pre-RT PSA. Table 1 summarizes published data on post-RP SRT results. Although comparability between studies is impaired by differing patient selection, treatment procedures (specifically HT) and end points, there is a trend toward improved bNED in patients with lower pre-RP PSA values, specifically below 1 ng/ml. This supports the expectation that SRT is most beneficial if administered at the earliest time point after biochemical relapse.

RT for post-RP PSA persisting above detection limit can be subsumed under SRT. Stephenson et al. have developed an 11-parameter nomogram to predict post-SRT recurrence where the contribution of status 'persistently elevated post-RP PSA' is minimal.[19] In a similar tool for 15-year PC-specific survival, that status does not occur.[71] Indeed, in a retrospective analysis of 159 patients comparing persisting PSA versus PSA rerising from subthreshold values, no significant difference (p > 0.2) was found in the Kaplan–Meier risk of bNED after a median follow-up of 42 months.[72]

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