PSA after RP

[luckypup]

Six weeks after radical prostatectomy (robotic) PSA is 0.04.  Pathology report was t3b.  Gleason 9 with seminal vesicle (1) positive, perineural invasion, and tumor 16mm outside the prostate, but no lymph node involvement and no positive margins. Does any PSA at all at this point mean metastatic disease, or could this still be residual from before surgery?  (PSA before surgery 5.6).  I really need to decide on follow up treatment or waiting for PSA increase.  Only 59y/o.
Thank you.

[Ash Tewari, MD, M.Ch.]

Thank you for your question. With Gleason 9 disease and SV involvement you are certainly a candidate for adjuvant radiation therapy. A recent study in 2008 showed that patients with pT3 disease had a lower risk of biochemical recurrence when treated with radiation following their prostatectomy.

In the early 1990s, 425 men were enrolled in SWOG (Southwest Oncology Group) 8794 with aggressive prostate cancer. They were randomly assigned within 16 weeks after prostatectomy into groups of adjuvant radiation or observation. Immediate radiation following the removal of the prostate significantly reduced recurrence (biochemical, local failure and metastatic disease) and increased metastatic disease-free and overall survival.

The Fifteen-year metastasis-free survival was 46 percent with radiation and 38 percent for observation respectively. The overall survival was 47 percent and 37 percent, respectively. Radiation therapy also significantly reduced biochemical and local failure as well as the need for androgen ablation (or hormone therapy).

A PSA rise at this point would not necessarily mean metastatic disease. It is not clear if distant micrometastases would evolve before PSA elevation. It could mean prostate tissue was left in the body (not necessarily a positive surgical margin but a capsular invasion) or micrometastases. It may be prudent for urinary function to return prior to starting radiation.

Best of luck

Ashutosh (Ash) K. Tewari, MD
www.cornellroboticprostate.org

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[luckypup]

Thank you Dr. Tewari.  You cited the SWOG 8794 study as showing adjuvant radiation reducing the need for androgen ablation.  Are you aware of any evidence that hormone therapy combined with adjuvant radiation therapy increases the survival rate or extends the time to biochemical failure, local recurrence or metatastic disease?  Is there any preparation that you recommend prior to treatment that can minimize side effects?

Thank you.

[Ash Tewari, MD, M.Ch.]

Sorry for the delay in response. Medhelp does not notify me when there are additions to threads.

There are several trials undergoing looking at adjuvant radiation with or without hormones:

http://clinicaltrials.gov/ct2/show/NCT00023829

It is important that related comorbidities of surgery are addressed prior to a radiation course. As radiation would only serve to exacerbate these symptoms.

Again, best of luck.

Ash