Recurrance after Treatment
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Stephan L. Werner, M.D., F.A.C.S.

 

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Introduction 

 Demographics

 Anatomy & Physiology

 Symptoms

 Who Should be Evaluated

 Prostate Examination

 Digital Rectal

 PSA

 Total vs. Free Ratio

How to Evaluate for PCa

 Consultation

 Total vs. Free PSA

 Trans Rectal Ultrasound

 Needle Biopsy

 Biopsy Results

What if the Biopsy is Positive?

Gleason Grade

Stage

 Stage A

 Stage B

 Stage C

 Stage D

 High Risk PCA

Therapy Options

Surgery

 Radical Prostatectomy

 Standard Operation    

 Nerve Sparing Oper.

 Positive Margins

 Recurrence after Surgery

Radiation Therapy

 External Beam Therapy

 IMRT

 Interstitial Radiotherapy

 Brachytherapy or Seeds

 Rapid Interstitial Therapy

 Combined Therapy

 Neoadjuvant Therapy or

         Hormones + Radiation

Combined Therapy

Cryotherapy

Hormone Therapy 

 Hormonal Therapy

 Castration

 LHRH Inhibitors

 Total Androgen Blockade

 Neo Adjuvant Therapy or

    Hormones + Radiation

Observation

Late Stage Prostate Cancer

 Cycling antiandrogens

 Chemotherapy

 Cryotherapy

 Bony Metastases

   External Beam Radiation

   Strontium 89

   Bisphosphonates

   Immunotherapy

   Monoclonal Antibodies

   Alternate Medicine

Alternate Medicine

 

 

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    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.

 

Signs of Recurrence:  

    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.

 

Evaluation:

 

    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:

 

    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.

 

    If the cancer recurs after hormonal therapy many varied treatments are being offered. (see more)

 

Rev:09/04

Stephan Werner, M.D., F.A.C.S.

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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

e-mail: wfurology@gmail.com

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Rev:03/08