SERUM PROSTATE-SPECIFIC ANTIGEN ELEVATION IN THE POST–RADICAL PROSTATECTOMY PATIENT - 11/09/11
Résumé |
Radical prostatectomy is one of the most effective methods of treating localized prostate cancer in men under the age of 70, yet the maturation of multiple large surgical series demonstrates that surgical failure represented by a postsurgical serum prostate-specific antigen (PSA) elevation is not uncommon. An overall actuarial failure rate of 22%, defined by serum PSA elevation, was recently reported for a very representative series of approximately 1000 men.10 The Mayo Clinic series reported 10-year and 15-year actuarial serum PSA progression of 48% and 60%.64 Another large series of 600 patients displayed a 5-year and 10-year PSA disease-free rate of 69% and 47% overall.58 When only patients treated after 1986 were analyzed, however, the 5-year disease-free rate measured by only serum PSA was 93%. Similarly, the review of the Johns Hopkins series of T1 and T2 patients showed a 5-year PSA-only recurrence of 13%. Clinical local recurrence at 5 years was 3% and distant recurrence in that time period was 5%.44 These data suggest that 10% to 40% of men who undergo a radical prostatectomy for control of localized disease will develop a detectable PSA level over 5 years.21, 36, 45, 54 Refinements in preoperative patient selection will undoubtedly tighten this range to its lower limits, yet contemporarily a significant amount of patients will still fail surgical therapy and one of the most common signs of treatment failure will not be a change in the digital rectal examination (DRE) or an imaging test, but rather a rising serum PSA.
Tumor progression rarely occurs in the absence of an elevated serum PSA.38, 55 A rising serum PSA after surgical treatment for localized prostate cancer presents a diagnostic and therapeutic dilemma that does not lend itself to routine treatment decisions. Most of the clinical data pertinent to the treatment of postprostatectomy elevations must be extrapolated from earlier studies involving the treatment of gross positive surgical margins. Some of this data may not be entirely appropriate for decision making in the contemporary setting because recent refinements in preoperative evaluation of patients select a population of postsurgical patients less likely to have gross positive margins or occult spread to regional lymph nodes. Additionally, the majority of studies related to the treatment of elevated postsurgical serum PSA describe the clinical outcome of a fairly small number of patients.
Data regarding androgen ablation therapy in patients with a postprostatectomy rise in serum PSA are similarly extrapolated from studies of patients with advanced metastatic disease. There are no data to prove or refute the value of androgen ablation therapy in patients with a postoperative rise in serum PSA. Such treatment may be costly and the long-term sequellae of different forms of androgen ablation unknown.
The positive effect of any therapy must be balanced against the potential side effects and true potential for having a beneficial impact. This article reviews the definition of an elevated post–radical prostatectomy serum PSA, the assessment of local or distant recurrence, and treatment recommendations based on current data.
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| Address reprint requests to S. Bruce Malkowicz, MD, Division of Urology, 1 Rhoads Pavilion, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104 |
Vol 23 - N° 4
P. 665-675 - novembre 1996 Retour au numéro
Article précédent
- INCIDENCE AND SIGNIFICANCE OF POSITIVE MARGINS IN RADICAL PROSTATECTOMY SPECIMENS
- Jonathan I. Epstein
- TREATMENT OPTIONS FOR LOCALIZED RECURRENCE OF PROSTATE CANCER FOLLOWING RADIATION THERAPY
- David A. Corral, Louis L. Pisters, Andrew C. von Eschenbach
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