Andrew Siegel MD 8/3/2019
Although PSA is often used to screen for prostate cancer, it is best used for monitoring patients who have had prostate cancer diagnosed and treated.
PSA after robotic-assisted laparoscopic prostatectomy (RALP) should be and most often is undetectable, meaning zero. However, it is conceivable that prostate cancer cells may have spread beyond the prostate before the prostate removal, and at some point, these cells can become capable of multiplying and producing a detectable PSA. If a PSA elevation is detected following prostatectomy, it is usually an indication of a “biochemical recurrence” of the prostate cancer, although it can sometimes represent a small amount of retained benign prostate tissue, in which case the PSA velocity (rate of change over time) should be expected to be very slow. The most common site of recurrence after RALP is the prostate bed, the location of the prostate before removal.
Please note: The most widely accepted definition of a recurrence after RALP is a PSA of 0.2 or higher, with a second confirmatory test used to verify the initial test.
Ideal PSA trajectory after successful treatment of prostate cancer with RALP: a rapid drop to an undetectable PSA. Thank you, Pixabay, for image.
Biochemical recurrence following RALP
20-25% of men after prostatectomy will experience a biochemical recurrence within 10 years of surgery, despite the surgery performed by the most proficient and talented urological surgeons. This often responds to radiation therapy, although some patients will have an initial satisfactory response to the radiation (PSA drops to undetectable levels), but subsequently experience a second biochemical recurrence, indicative of a failure of the radiation therapy to cure the recurrence. Similarly, a small percentage of men after primary radiation therapy will experience a biochemical recurrence, despite the therapy delivered by highly competent radiation oncologists.
Biochemical recurrences are typically due to “micro-metastases,” small numbers of cancer cells that have spread from the primary tumor site to a separate part of the body and are undetectable despite the use of the most advanced imaging methods available. These cells can remain dormant for years and are the reason behind the importance of long-term follow up of any patient who has been treated for prostate cancer.
Important factors governing the likelihood of prostate cancer progression after RALP are the PSA doubling time (the longer the doubling time the better the prognosis), the interval from surgery to the time of biochemical recurrence (the longer the interval the better the prognosis) and the Gleason score (the lower the score the better the prognosis). PSA doubling time of less than 9 months, an interval to PSA recurrence of less than 3 years, and pathological Gleason score 8-10 are poor prognostic features suggesting microscopic metastatic disease.
Evaluation of rising PSA after RALP
Accurate staging provides guidance concerning the most appropriate form of management of a biochemical recurrence. Digital rectal exam is important to assess the possibility of a recurrent abnormality that can at times be felt at the site of the prostate bed. Biopsy of the recurrence can provide valuable information.
Imaging methods include computerized tomography (CT), nuclear bone scans, and magnetic resonance imaging (MRI). Positron emission tomography (PET) scanning can detect early metastatic prostate cancer by identifying metabolic changes at the cellular level before they become evident on traditional imaging tests. Since the PET scan shows functional changes in the body, it is combined with CT imaging, which shows anatomical details, sites where the functional changes could be occurring. The combined PET/CT scan provides images that localize the abnormal metabolic activity.
Management of local recurrence after RALP
“Adjuvant” radiation therapy is radiation therapy used after RALP for T3 disease (T3a tumors extend beyond the prostate capsule, sparing the seminal vesicles; T3b tumors invade the seminal vesicles) to significantly reduce the risk for PSA recurrence and metastasis and increase survival. Alternatively, “salvage” radiation therapy is radiation therapy applied to the prostate bed after demonstration of a biochemical occurrence, an effective method to treat locally recurrent disease. Those with recurrent disease with poor prognostic features likely have both local and distant recurrences and are best treated with combined salvage radiation therapy and androgen deprivation therapy (medication or surgery used to reduce testosterone levels and thus inhibit prostate cancer progression). Adjuvant or salvage radiation therapy can be highly effective, but may potentially exacerbate the side effects that occur after RALP.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.
The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
Prostate Cancer 20/20 on Apple iBooks
Dr. Siegel’s other books:
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
Tags: adjuvant radiation therapy, Andrew Siegel MD, biochemical recurrence, prostate cancer, Prostate Cancer 20/20, prostate specific antigen, PSA, RALP, robotic-assisted laparoscopic prostatectomy, salvage radiation therapy
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