Is there a role for digital rectal examination in the followup of patients after radical prostatectomy?

Magnetic resonance imaging in postprostatectomy radiotherapy planning

PURPOSE

To investigate whether the use of magnetic resonance imaging (MRI) in prostate bed treatment planning could influence definition of the clinical target volume (CTV) and organs at risk.

METHODS AND MATERIALS

A total of 21 consecutive patients referred for prostate bed radiotherapy were included in the present retrospective study. The CTV was delineated according to the European Organization for Research and Treatment of Cancer recommendations on computed tomography (CT) and T(1)-weighted (T(1)w) and T(2)-weighted (T(2)w) MRI. The CTV magnitude, agreement, and spatial differences were evaluated on the planning CT scan after registration with the MRI scans.

RESULTS

The CTV was significantly reduced on the T(1)w and T(2)w MRI scans (13% and 9%, respectively) compared with the CT scans. The urinary bladder was drawn smaller on the CT scans and the rectum was smaller on the MRI scans. On T(1)w MRI, the rectum and urinary bladder were delineated larger than on T(2)w MRI. Minimal agreement was observed between the CT and T(2)w images. The main spatial differences were measured in the superior and superolateral directions in which the CTV on the MRI scans was 1.8-2.9 mm smaller. In the posterior and inferior border, no difference was seen between the CT and T(1)w MRI scans. On the T(2)w MRI scans, the CTV was larger in these directions (by 1.3 and 1.7 mm, respectively).

CONCLUSIONS

The use of MRI in postprostatectomy radiotherapy planning resulted in a reduction of the CTV. The main differences were found in the superior part of the prostate bed. We believe T(2)w MRI enables more precise definition of prostate bed CTV than conventional planning CT.

Is Routine Digital Rectal Examination Required for the Followup of Prostate Cancer?

PURPOSE

With more men being diagnosed and radically treated for prostate cancer there is an increasing number of patients requiring followup. A proportion of radically treated patients have recurrence and require early salvage treatment. Traditionally followup involved physical examination, urinalysis, imaging and biopsy. Since the development of the prostate specific antigen assay, followup has largely consisted of digital rectal examination and prostate specific antigen determination. Although digital rectal examination is routinely used, its efficacy for detecting recurrent cancer in the absence of biochemical evidence of disease progression was questioned in recent studies.

MATERIALS AND METHODS

We performed a literature search using the key words digital rectal examination, per rectal examination, radical prostatectomy and radical radiotherapy, and cross-referenced all results.

RESULTS

The literature that supports digital rectal examination as part of patient followup after radical prostatectomy is based on case studies and it is less applicable with more sensitive prostate specific antigen assays. In almost 5,000 patients after prostatectomy a prostate specific antigen increase reliably preceded disease recurrence, making digital rectal examination superfluous to requirements. No published literature supports repeat digital rectal examination after radical radiotherapy.

CONCLUSIONS

Prostate specific antigen allows the early detection of disease recurrence. Although digital rectal examination is widely used to follow patients, contemporary studies consistently show that disease progression does not occur in the absence of increasing prostate specific antigen. This suggests that remote followup of patients with prostate specific antigen alone is a safe practice, although caution should be exercised in those with higher grade tumors, which may not produce significant amounts of prostate specific antigen.

Natural history of biochemical recurrence after radical prostatectomy: risk assessment for secondary therapy

PURPOSE

A persistently elevated or rising serum level of prostate-specific antigen (PSA) after radical prostatectomy is indicative of recurrent prostate cancer. The natural history of PSA-defined biochemical recurrence (BCR) is highly variable. While a rising PSA level universally antedates metastatic progression and prostate cancer-specific mortality (PCSM), it is not a surrogate for these endpoints. Thus, the management of patients with BCR is controversial.

METHODS

A literature review was conducted to determine the incidence and natural history of BCR, prognostic factors for clinical progression (CP), and the available evidence supporting local or systemic salvage therapy for these patients.

RESULTS

BCR is best defined as two successive PSA levels > or =0.4 ng/ml, as this correlates most accurately with CP. PSA doubling time (PSA-DT) and prostatectomy Gleason score are the variables that best predict the development of distant metastasis and PCSM. Prognostic models based on these and other variables are useful for assessing the need for salvage therapy and the anticipated outcome following local salvage therapy. A treatment algorithm for managing patients with post-prostatectomy BCR was devised.

CONCLUSIONS

Management of patients with BCR after prostatectomy continues to be a complex and challenging issue. Improved methods for risk stratification allow for identification of patients who require treatment. Furthermore, these methods aid in determination of the pattern of disease recurrence, thereby guiding treatment modality. Randomized trials are essential to determine the value of local or systemic salvage therapy strategies in this patient population.

Prognostic factors in lymph node-positive prostate cancer

OBJECTIVES

To characterize lymph node metastasis of prostate cancer (PCa) and identify the parameters associated with patient outcome. The incidence of clinically localized PCa with concurrent lymph node metastasis has decreased to less than 1% in the United States but is between 10% and 15% in other countries.

METHODS

Our study cohort of 1148 patients underwent radical prostatectomy in Ulm, Germany, between 1986 and 2002, and 201 (18%) had lymph node-positive PCa.

RESULTS

The metastases showed growth architecture resembling primary PCa. We assigned a Gleason pattern and evaluated for size, extranodal extension, and lymphovascular invasion (LVI). Of 201 patients, 155 had original pathology slides available; 36 of the 155 were excluded because of preoperative hormonal ablation therapy. Of the remaining 119 patients, 22 (19%) were assigned Gleason pattern 3, 93 (78%) Gleason pattern 4, and 4 (3%) Gleason pattern 5. Extranodal extension was present in 66 (55%) of 119 patients and LVI in 29 (25%). An increased risk of prostate-specific antigen (PSA) recurrence was found for Gleason pattern 4/5 (hazard ratio [HR] 2.5, P = 0.038), LVI in the lymph nodes (HR 1.9, P = 0.038), and nuclear grade of the primary tumor (HR 2, P = 0.025). Independent predictors of PSA recurrence included LVI and nuclear grade (HR 1.9, P = 0.03 and HR 2, P = 0.03, respectively).

CONCLUSIONS

Lymph node metastases of PCa are heterogeneous and have a close relation to the corresponding primary tumor. Most patients with lymph node-positive PCa remained disease free for up to 13 years after radical prostatectomy. Independent predictors of PSA recurrence among those with lymph node-positive PCa included LVI in the lymph nodes and the nuclear grade of the primary tumor. These parameters may be useful in predicting PSA recurrence in lymph node-positive PCa and could be included in patient follow-up.

Digital Rectal Examination is no Longer Necessary in the Routine Follow-up of Men with Undetectable Prostate Specific Antigen after Radical Prostatectomy: The Implications for Follow-up

OBJECTIVES

We determined the role of Digital Rectal Examination (DRE) in the follow-up of those patients treated with radical prostatectomy for clinically localised prostate cancer having an undetectable PSA. We discuss the implications of our findings.

MATERIALS AND METHODS

An analysis was performed of a prospectively organised data base of 1118 patients treated at our institution by radical prostatectomy after the introduction of PSA in 1987. A strict definition of PSA progression was used, that is any elevation above undetectable PSA or lowest recorded post-operative PSA (nadir), in order not to miss a single patient who may have recurrent local disease or distant metastases without PSA progression. We counted local recurrent disease as those patients having histologically proven adenocarcinoma on TRUS directed biopsies, and distant disease as those patients having detectable metastatic disease on radionuclide bone scan.

RESULTS

The median follow-up was 4.0 years (3 months to 15 years). 524 men (46.9%) had a follow-up of more than 5 years and 88 men (7.9%) of more than 10 years. A total of 397 men (35.5%) had biochemical progression according to our strict definition. 53 patients (4.7%) developed a histological local recurrence and 57 men (5.1%) developed bony metastases; none of these men had an undetectable PSA or a stable PSA at nadir level at the time of detection. They all demonstrated a rising PSA.

CONCLUSIONS

DRE is no longer necessary in the routine follow-up of patients with an undetectable PSA after radical prostatectomy. Following a period of approximately 2 years of out-patient clinic follow-up post-operatively in which issues such as incontinence and erectile dysfunction are addressed and treated, it is possible to restrict follow-up to PSA determinations alone and as long as the PSA remains undetectable counselling can be carried out by a nurse practitioner.

[PSA recurrence after primary curative therapy--local or systemic? When is a second curative therapy still possible?]

PSA recurrence after primary curative therapy for localized prostate cancer is a common problem. Further curative treatment is only reasonable in the case of local recurrence. Therefore, minimizing the likelihood of metastatic disease is crucial. So far, imaging techniques cannot distinguish between local recurrence and distant metastasis. It is therefore reasonable to orientate on PSA kinetics and pathological criteria. Histologic confirmation of suspected local recurrence after radical prostatectomy before salvage therapy is not required. However, after initial radiation therapy histologic confirmation of suspected isolated local recurrence should be obtained. The optimal treatment for a PSA recurrence depends on the initial therapy and the life-expectancy of the patient.

Evaluation and Management of Prostate-specific Antigen Recurrence After Radical Prostatectomy for Localized Prostate Cancer

A radical prostatectomy has been established as one of the standard management options for localized prostate cancer. However, a substantial proportion of patients who undergo a radical prostatectomy develop prostate-specific antigen (PSA) recurrence which is commonly defined as a PSA cut-off point value of 0.2 ng/ml. Although the management of PSA recurrence after radical prostatectomy may depend on the site of recurrence, it is quite difficult to identify the recurrent lesion accurately based on the currently available imaging technology. Patients who have surgical margin involvement or a Gleason score < or =7 based on the radical prostatectomy specimens, who do not have nodal or seminal vesicle involvement, and who develop a PSA recurrence >1-2 years after surgery with a doubling time of >1 year, and whose pre-treatment PSA is < 1.0-1.5 ng/ml are considered to benefit from local treatment with at least 64 Gy of salvage radiotherapy. Patients with different characteristics are considered to have distant metastases or both local lesions and distant metastases, and thus may be candidates for hormonal manipulation rather than radiotherapy. Since local recurrent lesions are considered to be quite small at the early stage of PSA recurrence, hormonal manipulation may be sufficient to prevent disease progression instead of radiotherapy. However, the optimal type and timing of hormonal manipulation remain to be elucidated. As a result, no consensus regarding the treatment for PSA recurrence after radical prostatectomy has yet been reached.

Management of recurrent disease after radical prostatectomy

Prostate cancer has undergone a stage migration since the advent of widespread PSA testing, yet still a significant number of men develop PSA recurrence following radical prostatectomy. This causes anxiety to the patient and the urologist. This review examines the clinical significance of biochemical relapse and the role of imaging modalities and anastomotic biopsies. The importance of the radical prostatectomy pathological features and the PSA kinetics in determining the site of recurrence and the best treatment modality is emphasised. The optimal timing and dose of salvage radiotherapy and the role of hormonal therapy is discussed.

Is DRE essential for the follow up of prostate cancer patients? A prospective audit of 194 patients

BACKGROUND

Prostate cancer follow up forms a substantial part of the urology outpatient workload. Nurse led prostate cancer follow up clinics are becoming more common. Routine follow-up may involve performing DRE, which may require training.

OBJECTIVES

The aim of this audit was to assess the factors that influenced the change in the management of prostate cancer patients during follow up. This would allow us to pave the way towards a protocol driven follow up clinic led by nurse specialists without formal training in DRE.

RESULTS

194 prostate cancer patients were seen over a period of two months and all the patients had DRE performed on at least one occasion. The management was changed in 47 patients. The most common factor influencing this change was PSA trend. A change in DRE findings influenced advancement of the clinic visit in 2 patients.

CONCLUSIONS

PSA is the most common factor influencing change in the management of these patients. Nurse specialists can run prostate cancer follow-up clinics in parallel to existing consultant clinics and reserve DRE only for those patients who have a PSA change or have onset of new symptoms. However larger studies are required involving all the subgroups of patients to identify the subgroups of patients who will require DRE routinely.

Radionuclide bone scintigraphy in patients with biochemical recurrence after radical prostatectomy: when is it indicated?

OBJECTIVE

To evaluate the use of radionuclide bone scintigraphy following biochemical recurrence after radical retropubic prostatectomy (RRP) for localized prostate cancer.

PATIENTS AND METHODS

Of 1197 patients undergoing RRP we identified those with biochemical recurrence and who had also had a bone scan. Biochemical recurrence was defined as a prostate specific antigen (PSA) level of > or = 0.4 ng/mL. Patients with indeterminate bone scan findings and those in whom the interval between the PSA test and the bone scan was >3 months were excluded. Patient age, PSA level and other relevant pathological details were recorded. Clinical symptoms at the time of bone scan, androgen deprivation after RRP, bone scintigram details and time to recurrence were documented.

RESULTS

Of the 1197 patients, 153 (12.8%) had a biochemical recurrence and 35 (23%) of these had a total of 44 bone scans taken over a mean (sd) follow-up of 70.4 (35.6) months; 34 (77%) bone scans were negative (group 1) and 10 (33%) positive (group 2). In group 1 the mean PSA at the bone scan was 5.2 ng/mL; 76% of the patients had a PSA of < 7 ng/mL. In group 2 the mean PSA at the bone scan was 30.7 ng/mL and all patients had a PSA of >7 ng/mL. The only significant difference between the groups was the PSA at the time of the bone scan (P < 0.001).

CONCLUSION

Bone scintigraphy is a sensitive diagnostic tool for detecting prostate cancer metastases to bone. A bone scan in patients with a serum PSA of <7 ng/mL on biochemical recurrence after RRP is unlikely to be positive, whereas a PSA of > or = 20 ng/mL is. The presence of skeletal symptoms or a PSA level of >7 ng/mL should prompt the clinician to obtain a bone scintigram.

Diagnosis of local recurrence after radical prostatectomy

In the long-term there is biochemical evidence of recurrent prostate carcinoma in approximately 40% of patients after radical prostatectomy (RP). Detecting the site of recurrence (local vs distant) is critical for defining the optimum treatment. Pathological and clinical variables, e.g. Gleason score, involvement of seminal vesicles or lymph nodes, margin status at surgery, and especially the timing and pattern of prostate-specific antigen (PSA) recurrence, may help to predict the site of relapse. Transrectal ultrasonography (TRUS) of the prostatic fossa in association with TRUS-guided needle biopsy is considered more sensitive than a digital rectal examination for detecting local recurrence, especially if PSA levels are low. Although it cannot detect minimal tumour mass at very low PSA levels (< 1 ng/mL) TRUS biopsy is presently the most sensitive method for detecting local recurrence. Nevertheless, the conclusive role of biopsy of the vesico-urethral anastomosis remains unclear. However, 111In-capromab pendetide scintigraphy and [11C]-choline tomography (which are better than conventional imaging for detecting metastatic tumour), have low detection rates for local disease and are considered complementary to TRUS in this setting. Patients with a high PSA after RP may be managed with external beam salvage radiotherapy. An initial PSA of < 1 ng/mL, Gleason score < 8 and radiation dose of 66-70 Gy seem to be key factors in determining success. Although a positive TRUS anastomotic biopsy may predict a better outcome after radiation therapy, the need to take a biopsy in the event of PSA failure remains under investigation. The value of salvage radiation to the prostatic bed for PSA-only progression after RP remains in question.

Follow-up surveillance strategies for genitourinary malignancies

BACKGROUND

Genitourinary cancers account for more than 20% of all malignancies in the United States. These cancers do not usually yield rapid mortality, thereby necessitating longer-term surveillance strategies.

METHODS

A review and analysis of relevant studies were performed. Follow-up strategies are proposed to reflect effective methods to detect recurrent prostate, bladder, renal, and testicular cancers. Cost analysis was performed using Medicare reimbursement rates.

RESULTS

For genitourinary tumors, follow-up tests can be planned rationally based on detection rates and patterns. Tumor grade and stage drive follow-up strategies, along with therapeutic implications of detecting a recurrence. Symptomatic recurrences often obviate the need for radiographic tests and can minimize costs. Stage- specific plans for these four urologic malignancies are outlined specifically.

CONCLUSIONS

Not all surveillance approaches have been critically tested for follow-up of genitourinary tumors, but ample data are available to propose sound medical and economic strategies.

Risk of positive margins and biochemical recurrence in relation to nerve-sparing radical prostatectomy

PURPOSE

To assess the effect of nerve-sparing (NS) radical retropubic prostatectomy (RRP) on surgical margins and biochemical recurrence.

PATIENTS AND METHODS

Location and incidence of positive surgical margins, recurrence, and time to recurrence were assessed in a consecutive series of 734 men who underwent RRP for localized prostate cancer from 1992 through February 2000. NS procedures were used in 33% (n = 240) of 734 patients studied.

RESULTS

Surgical margins were positive for 24% (n = 58) and 31% (n = 152) of NS and non-NS patients, respectively (P =.06). No significant difference between the groups was found in location of positive margins (P =.92). Prostate-specific antigen level greater than 10 ng/mL, extraprostatic extension, tumor volume more than 20%, capsular penetration, Gleason score > or = 7, positive margins, and seminal vesicle invasion were associated with significantly increased risk of recurrence. However, NS patients were not at increased risk of recurrence compared with non-NS patients (hazard ratio, 0.96; 95% confidence interval, 0.53 to 1.72). The cumulative risk of recurrence within 3 and 5 years of surgery in NS patients was 9.7% and 14.4%, respectively, as compared with 17.1% and 21.1% for non-NS patients.

CONCLUSION

In patients with localized prostate cancer, neither margin status nor biochemical-free survival within 5 years of surgery were altered by the nerve preservation technique. Given our experience, we recommend preservation of neurovascular bundles in these patients whenever the procedure is technically feasible.

Immediate hormonal therapy compared with observation after radical prostatectomy and pelvic lymphadenectomy in men with node-positive prostate cancer

BACKGROUND

Because the optimal timing of the institution of antiandrogen therapy for prostate cancer is controversial, we compared immediate and delayed treatment in patients who had minimal residual disease after radical prostatectomy.

METHODS

Ninety-eight men who underwent radical prostatectomy and pelvic lymphadenectomy and who were found to have nodal metastases were randomly assigned to receive immediate antiandrogen therapy, with either goserelin, a synthetic agonist of gonadotropin-releasing hormone, or bilateral orchiectomy, or to be followed until disease progression. The patients were assessed quarterly during the first year and then semiannually.

RESULTS

After a median of 7.1 years of follow-up, 7 of 47 men who received immediate antiandrogen treatment had died, as compared with 18 of 51 men in the observation group (P=0.02). The cause of death was prostate cancer in 3 men in the immediate-treatment group and in 16 men in the observation group (P<0.01). At the time of the last follow-up, 36 men in the immediate-treatment group (77 percent) and 9 men in the observation group (18 percent) were alive and had no evidence of recurrent disease, including undetectable serum prostate-specific antigen levels (P<0.001). In the observation group, the disease recurred in 42 men; 13 of the 36 who were treated had a complete response to local treatment or hormonal therapy (or both), 16 died of prostate cancer, and 1 died of another disease. The remaining men in this group were alive with progressive disease at the time of the last follow-up or had had a recent relapse. Except for the treatment group (immediate therapy or observation), no clinical or histologic characteristic significantly influenced the outcome.

CONCLUSIONS

Immediate antiandrogen therapy after radical prostatectomy and pelvic lymphadenectomy improves survival and reduces the risk of recurrence in patients with node-positive prostate cancer.