Stephan L. Werner, M.D., F.A.C.S.
The goal of treatment of prostate cancer is a cure. Unfortunately, prostate cancer sometimes recurs after initial treatment. Treatment after recurrence depends upon the site of recurrence, the type of initial treatment, the potential for secondary cure and the patient's condition and desires.
The most common signs of recurrence of prostate cancer are a rising PSA, regrowth in the prostate or in the prostate bed and occurrence of distant metastases, usually marked by bone pain.
After radical prostatectomy the PSA should drop to 0.1 or less. Failure to drop to this level suggests the persistence of cancer, either at the site of surgery, or at other locations. A new lump in the prostate bed may signal recurrence though it may represent regrowth of benign prostate tissue.
After external beam radiation or brachytherapy, (seeds), the PSA should drop to 0.4 or below. This usually occurs within 2 years but may take up to five years, and frequently during this drop a slight rise may be seen lasting 3 to 6 months. This rise is usually not significant though it may be disturbing. PSA levels rising to >2 (some experts say 4.0) are of concern. Similarly a new nodule or enlargement of the prostate may be of concern.
After cryotherapy PSA should drop to below 0.4. This may take some time.
After hormonal therapy PSA may drop to extremely low levels but may not. A rise from the stable base number may be of concern.
Repeat sonography and biopsy may show local recurrence, although this is less reliable after radiation therapy.
Bone Scans should be done to rule out spread to the bones, and if negative, a Prostascint scan may be helpful in finding soft tissue spread, but this test is notoriously unreliable. Occasionally a CT scan or MRI of the abdomen and pelvis may be required.
Treatment of recurrence will vary widely with the type of primary therapy, the site of recurrence and the patients condition and wishes. If the recurrence is distant from the prostate, in the bones or lymph nodes or soft tissues, the treatment is hormonal. Hormonal therapy will eventually fail, as there are always some cancer cells that are not responsive to hormonal manipulation. In an attempt to kill these cells as well, there is considerable research going on combining early chemotherapy with hormonal therapy using many different drugs including taxotere, taxane, mitoxantrone, etc.
If the primary therapy was a radical prostatectomy, and recurrence is in the prostate bed and there is no sign of distant spread, external beam radiotherapy to the pelvis may afford a second chance for cure. Cryotherapy may be used as an experimental modality in these cases. In addition long term hormonal therapy is usually instituted.
If radiation or seeds was the primary therapy, cryotherapy may be used as a second attempt at cure or control. Rarely secondary or salvage prostatectomy may be performed, but the surgery is difficult, and the chance of complications is very high. There are some experimental treatments with high frequency sound waves being done at several centers. Usually hormonal therapy is instituted.
If after cryotherapy, there is little data available, perhaps repeat cryotherapy or radiation may be offered along with hormonal therapy.
Stephan Werner, M.D., F.A.C.S.
Werner - Francis Urology Associates llc - Mid Atlantic Urology Associates llc
Greenbelt - Bowie - Laurel Maryland
(301) 441-8900 Fax (301) 982 0453
7500 Hanover Parkway Suite 206 Greenbelt, MD 20770