RESIDENTS’ ROOM
Salvage radiation therapy 11 years after a radical prostatectomy
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Valérie Hogues; Carole Lambert, MD; MD; Michael McCormack, MD
1
2
3
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. http://dx.doi.org/10.5489/cuaj.3400
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).
Abstract
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).
Introduction
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-
1
tory of clinical progression after BCR is variable. However
according to available data, about 20% of these patients
2
,3
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
4
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
1
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
E189
©
