Salvage radiation therapy 11 years after a radical prostatectomy  
Valérie Hogues; Carole Lambert, MD; MD; Michael McCormack, MD  
Université de Montréal, Montreal, QC, Canada; Department of Radiology-Oncology, Université de Montréal, Montreal, QC, Canada; Department of Surgery, Université de Montréal, Montreal, QC, Canada  
Cite as: Can Urol Assoc J 2016;10(5-6):E189-91.  
Published online May 12, 2016.  
The patient was diagnosed with prostate cancer in 1997  
and had undergone sextant transrectal biopsies for a serum  
PSA of 5.1 ng/mL. Histopathological analysis showed ade-  
nocarcinoma with a Gleason score of 5 (3+2). The number  
of positive scores was 1 out of 6. As the digital rectal exami-  
nation showed no abnormal findings, the clinical stage was  
T1c N0 M0. During the same year, the patient underwent a  
RP and the definite pathological analysis revealed Gleason  
score 4 adenocarcinoma involving approximately 5% of the  
gland with negative margins, no capsular invasion, and no  
seminal vesicle invasion (SVI).  
We present a patient with a high prostate-specific antigen (PSA)  
value, who was successfully treated with salvage radiation therapy  
RT) 11 years after a radical prostatectomy (RP).  
After surgery, the patient did not receive any adjuvant  
radiation or hormone therapy. He was followed by his family  
doctor, who performed serum PSAs. The first postoperative  
serum PSA was done two years after the surgery and was  
determined to be 1.1 ng/mL. Fig. 1 shows the evolution  
of the patient’s serum PSAs. From June 1999 to October  
2004, his PSA went from 1.1 to 2.2 ng/mL. In June 2007,  
the PSA climbed 3.0 and reached 3.96 ng/mL in April 2008,  
at which time the patient was referred for consultation at  
our institution.  
A transrectal ultrasound (TRUS) was performed and  
biopsies were taken from the prostatic fossa. Pathological  
analysis confirmed local recurrence with adenocarcinoma  
Gleason score 7 (3 + 4) in 10% of two of six core biopsies.  
Digital rectal examination showed no palpable disease.  
Bone scan and abdominal computed tomography (CT) scan  
were negative.  
Approximately one in four men will have biochemical  
recurrence (BCR) after a radical prostatectomy (RP), which  
is indicative of the presence of residual prostatic epithelial  
tissue and is presumed to represent cancer. The natural his-  
tory of clinical progression after BCR is variable. However  
according to available data, about 20% of these patients  
will die from prostate cancer. As such, there has been  
considerable research to identify clinically significant mar-  
kers to determine which patients may benefit from salvage  
radiation therapy (RT) after BCR. The most important pro-  
gnostic factor involves giving salvage RT to patients before  
their prostate-specific antigen (PSA) reaches 1 ng/ml, since  
half of patients with BCR have a long-term PSA response  
to RT when treatment is administered early. Although pro-  
gnostic markers have been identified, it is not always easy  
to decide, on an individual basis, if RT is indicated or not  
and when it should be given. The variable clinical course  
of these patients leaves much uncertainty about how and  
The patient was then offered salvage radiotherapy (RT).  
He received 70 Gy in 35 sessions of 3D external beam radia-  
tion therapy to the prostatic fossa using nine coplanar fields  
with a 25 MV linear accelerator. The treatment took place  
between August and September 2008. There were no signi-  
ficant acute side effects except mild rectal irritation, relieved  
when to appropriately manage them. We present a patient  
with a high PSA value who was successfully treated with  
salvage RT 11 years after a RP.  
with zinc sulfate monohydrate suppositories (Anusol ). Two  
Case report  
months after RT, his PSA had dropped to 1.72 ng/mL and  
was still decreasing at last followup, reaching 0.10 ng/mL  
6.5 years after treatment (Fig. 1). Since receiving salvage  
RT, he has been monitored twice a year by a urologist and  
a radiation oncologist and has not developed any late side  
effects or toxicity.  
A 63-year-old Caucasian man with a medical history of  
hypertension and dyslipidemia was referred in 2008 by his  
family doctor for a rising serum prostate-specific antigen  
PSA) of 3.9 ng/mL following a radical prostatectomy (RP)  
in 1997. The patient had no significant comorbidity and  
was in good health.  
CUAJ • May-June 2016 • Volume 10, Issues 5-6  
2016 Canadian Urological Association  
Hogues et al.  
Fig. 1. Evolution of the patient’s serum PSA from 1997 to 2015.  
compare data sets assessing patient outcomes in prostate  
cancer over time. Unfortunately, the original pathological  
tissue was not available for re-evaluation by the pathologist  
at our institution.  
Prostatic fossa biopsies confirmed local recurrence  
of Gleason 7 prostate cancer. His RP surgical margins were  
negative, he had no SVI, no capsular invasion, and had an esti-  
mated PSA-DT of 4.9 years. He received an appropriate dose  
of salvage RT (70 Gy) in order to treat his local recurrence.1,8  
According to the American Urology Association (AUA)  
guidelines on adjuvant and salvage radiotherapy after pros-  
005 ISUP Modified Gleason System make it difficult to  
Clinical prognostic markers have been identified in order  
to determine which patients might benefit from salvage RT.  
A pre-radiation PSA <1 ng/mL, positive surgical margins,  
pathological Gleason score <7, no SVI, no capsular inva-  
sion and a PSA-DT 11 months correlate with a durable  
response to salvage RT. When patients with these favou-  
rable prognostic markers are treated with RT, a four-year  
recurrence-free probability of 45% has been reported. The  
most important prognostic factor is a PSA <1 ng/mL. In a  
recent review, Punnen et al concluded that salvage RT can  
provide durable PSA responses in a sizeable percentage of  
tatectomy, physicians should offer salvage RT to patients  
men, especially when given early (i.e., PSA <1 ng/ml).  
with PSA or local recurrence after RP in whom there is no  
evidence of distant metastatic disease (Guideline Statement  
7). Patients should be informed that the effectiveness of RT  
for PSA recurrence is greatest when given at lower levels  
of PSA (Guideline Statement 8). However, this case report  
illustrates that an elevated PSA is not a contraindication for  
salvage RT.  
Our patient had a peculiar history, having been referred  
to our institution 11 years after a RP with a PSA of 3.9 ng/  
mL. His low Gleason score may have been an undergra-  
ding since, for general pathologists, the main difficulty with  
the Gleason score system is undergrading. Moreover, the  
differences between the original Gleason system and the  
CUAJ • May-June 2016 • Volume 10, Issues 5-6  
Radiation therapy after radical prostatectomy  
Our patient was referred 11 years after RP with an ele-  
vated PSA of 3.96 ng/mL. Even with this unfavourable PSA,  
considering the very long PSA-DT, salvage RT was discussed  
with the patient, who then opted to receive treatment for his  
local recurrence. Following salvage RT, the patient’s PSA  
has decreased continuously over seven years and has now  
reached 0.10 ng/mL (Fig. 1). He reports an excellent quality  
of life with no signs of toxicity. This case illustrates that  
patients with proven local recurrence and elevated PSA may  
still benefit from salvage RT many years after a RP, when we  
take into account the favourable kinetics of a long PSA-DT.  
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;64:905-15. http://  
Simmons MN, Stephenson AJ, Klein EA. Natural history of biochemical recurrence after radical prostatecto-  
my: Risk assessment for secondary therapy. Eur Urol 2007;51:1175-84.  
Han M, Partin AW, Zahurak M, et al. Biochemical (prostate-speciꢀc antigen) recurrence probability following  
radical prostatectomy for clinically localized prostate cancer. J Urol 2003;169:517-23. http://dx.doi.  
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;25:2035-41. http://dx.doi.  
Competing interests: Dr. Lambert has received grants/honoraria from Ferring and has participated  
in clinical trials for Ferring and Janssen. The remaining authors declare no competing ꢀnancial or  
personal interests.  
5. Thompson IM, Valicenti R, Albertsen PC, et al. Adjuvant and salvage radiotherapy after prostatectomy:  
ASTRO/AUA guideline.  
After-Prostatectomy.pdf. Accessed April 7, 2016.  
Allsbrook Jr WC, Mangold A, Johnson MH, et al. Interobserver reproducibility of Gleason grading of  
prostatic carcinoma. General pathologist. Hum Pathol 2001;32:81-8.  
This paper has been peer-reviewed.  
Humphrey PA. Gleason grading and prognostic factors in carcinoma of the prostate. Modern Pathology  
004;17 :292-306.  
King CR. The timing of salvage radiotherapy after radical prostatectomy: A systematic review. Int J Radiat  
Oncol Biol Phys 2012;84:104-11.  
Correspondence: Dr. Michael McCormack, Department of Surgery, Université de Montréal, Montreal,  
QC, Canada;  
CUAJ • May-June 2016 • Volume 10, Issues 5-6