Local recurrence after retropubic radical prostatectomy for prostate cancer does not exclusively occur at the anastomotic site

Prostate ductal adenocarcinoma exhibiting a late recurrence in the anterior urethra 13 years post-total prostatectomy: a case report

BACKGROUND

Prostate ductal adenocarcinoma, a rare histology observed in 0.4-0.8% of all prostate cancers, is treated similarly to acinar adenocarcinoma but tends to have a higher likelihood of metastasis, recurrence, and poorer prognosis.

CASE PRESENTATION

A 73-year-old Asian-Japanese male presented with gross hematuria, with investigations revealing a prostate ductal adenocarcinoma. Subsequent radical prostatectomy indicated a Gleason score of 8 with no lymph node metastasis. Despite initial prostate-specific antigen level reductions post-prostatectomy and salvage radiation therapy due to recurring elevated prostate-specific antigen levels, no recurrence was evident until 13 years later. A tumor in the anterior urethra was identified as metastasis of his prostate ductal adenocarcinoma.

CONCLUSION

This report presents an uncommon case of prostate ductal adenocarcinoma exhibiting a late recurrence in the anterior urethra 13 years post-radical prostatectomy.

Intra-prostatic gold fiducial marker insertion for image-guided radiotherapy (IGRT): five-year experience on 795 patients

INTRODUCTION

Prostate cancer is the second most commonly diagnosed cancer in males. The use of intra-prostatic fiducial markers (FM) for image-guided radiotherapy (IGRT) has become widespread due to their accuracy, relatively safe use, low cost, and reproducibility. FM provides a tool to monitor prostate position and volume changes. Many studies reported low to moderate rates of complications following FM implantation. In the current study, we present our five years' experience regarding the insertion technique, technical success, and rates of complication and migration of intraprostatic insertion of FM gold marker.

METHODS

From January 2018 to January 2023, 795 patients with prostate cancer candidate for IGRT (with or without a history of radical prostatectomy) enrolled in this study. We used three fiducial markers (3*0.6 mm) inserted through an 18-gauge Chiba needle under transrectal ultrasonography (TRUS) guidance. The patients were observed for complications up to seven days after the procedure. Besides, the rate of marker migration was recorded.

RESULTS

All procedures were completed successfully, and all patients tolerated the procedure well with minimal discomfort. The rate of sepsis after the procedure was 1%, and transient urinary obstruction was 1.6%. Only two patients experienced marker migration shortly after insertion, and no fiducial migration was reported throughout radiotherapy. No other major complication was recorded.

DISCUSSION

TRUS-guided intraprostatic FM implantation is technically feasible, safe, and well-tolerated in most patients. The FM migration can seldom occur, with negligible effects. This study can provide convincing evidence that TRUS-guided intra-prostatic FM insertion is an appropriate choice for IGRT.

Utilizing clinical, pathological and radiological information to guide postoperative radiotherapy in prostate cancer

INTRODUCTION

A detectable and rising PSA following radical prostatectomy is indicative of recurrent prostate cancer. Salvage radiotherapy (SRT) with/without androgen deprivation therapy represents the main treatment option for these patients and has been historically associated with a biochemical control rate of ~70%. To determine the optimal timing, diagnostic workup, radiotherapy dosefractionation, treatment volume, and use of systemic therapy, several informative studies have been conducted in the last decade.

AREAS COVERED

This review examines the recent evidence to guide radiotherapy decision making in the SRT setting. Key topics include adjuvant vs salvage RT, utilization of molecular imaging and genomic classifiers, length of androgen deprivation therapy, inclusion of elective pelvic volume, and emerging role for hypofractionation.

EXPERT OPINION

Recently reported trials, conducted in an era prior to the routine use of molecular imaging and genomic classifiers, have been pivotal in establishing the current standard of care for SRT in prostate cancer. However, decisions about radiation treatment and systemic therapy may be tailored based on available prognostic and predictive biomarkers. Data from contemporary clinical trials are awaited to define and establish individualized, biomarker-driven approaches for SRT.

Mapping of Local Recurrences After Radical Prostatectomy Using 68-Gallium-Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography: Implications for Postprostatectomy Radiation Therapy Clinical Target Volumes

PURPOSE

Our objective is to describe the distribution of local recurrences after radical prostatectomy (RP) as delineated using 68-Gallium-prostate-specific membrane antigen positron emission tomography/computed tomography (⁶⁸Ga-PSMA PET/CT) to identify areas where current consensus guideline clinical target volumes (CTVs) are insufficient or excessive and to identify predictors of recurrence location within the fossa.

METHODS AND MATERIALS

Retrospective review of databases from 2 tertiary referral centers was performed to identify patients who underwent ⁶⁸Ga-PSMA PET/CT for biochemical recurrence after RP. Those with a component of local recurrence were included for further analysis. The epicenter of each recurrence was defined relative to reference points in 3 axes, categorized into 1 of 7 levels in the superior/inferior axis relative to the vesicourethral anastomosis, and recorded as within or outside the Faculty of Radiation Oncology Genito-urinary Group (FROGG) and Radiation Therapy Oncology Group consensus CTVs. Univariate and multivariate analysis was performed to identify predictors of recurrence location based on clinical and histopathologic variables.

RESULTS

One thousand forty-nine ⁶⁸Ga-PSMA PET/CT scans were reviewed. One hundred forty sites of local recurrence were identified on 132 scans. Relative to the vesicourethral anastomosis, 13 (9%), 31 (22%), 17 (12%), 24 (17%), 27 (19%), 20 (14%), and 8 (6%) recurrences occurred >5 mm inferior; within 5 mm above or below; and 6 to 15 mm, 16 to 25 mm, 26 to 35 mm, 36 to 45 mm, and >45 mm superiorly, respectively. Thirteen (9%) and 2 (1.4%) recurrences occurred beyond the FROGG and Radiation Therapy Oncology Group consensus CTVs, respectively, with all below the inferior CTV margin.

CONCLUSIONS

In the largest study to date mapping local recurrences after RP in 3-dimensions, we provide several insights to inform future contouring guidelines; in particular, 9% of recurrences occurred inferior to the FROGG CTV.

Imaging assessment of local recurrence of prostate cancer after radical prostatectomy

Definitive therapy for prostate cancer includes radical prostatectomy and radiation therapy. Treatment is elected based on patient preference, biological tumor factors, and underlying health. Post prostatectomy, men are surveyed for disease recurrence with serial PSA measurements, digital rectal exam, and imaging studies depending on nomogram predicted risk of local disease recurrence and distant metastasis. In men with rising PSA levels, pathologically incomplete surgical margins or, if symptoms of metastasis develop, imaging may be obtained to localize disease. In cases of known biochemical recurrence, imaging is used to target biopsy, to contour in salvage radiation therapy and to assess disease response. For local disease recurrence, the most commonly performed exams are pelvic MRI and transrectal US. CT can evaluate for lymph node metastasis, but is suboptimal in the evaluation of the prostatectomy bed. PET/CT and PET/MRI have been used successfully to evaluate for local disease recurrence. The PI-RADSv2.1 manual provides a risk level and lexicon for use in description of prostate carcinoma prior to prostatectomy, but does not address imaging features post-surgery. A detailed description of nodal, bony, and visceral metastasis is given elsewhere. This manuscript outlines the context in which appropriate imaging exams may be obtained and focuses on imaging findings concerning for local disease recurrence after prostatectomy on various imaging modalities including CT, US, MRI, and PET.

Imaging of Prostate Cancer Recurrence in the Vas Deferens With 68Ga-PSMA PET/CT

Two cases with Ga-PSMA-avid prostate cancer recurrence in the vas deferens are presented. These cases highlight the clinical importance of imaging the pattern of local prostate cancer recurrence and the potential difficulties that arise due to the altered anatomy in the prostate bed after prostatectomy or radiotherapy.

MRI-guided Dose-escalated Salvage Radiotherapy for Bulky Bladder Neck Recurrence of Prostate Cancer

Nearly 30% of patients treated with radical prostatectomy for prostate cancer ultimately develop biochemical recurrences, and nearly a quarter of men with nonpalpable biochemical recurrences have gross local recurrences identified with magnetic resonance imaging (MRI). The only curative intervention for patients with recurrent disease after radical prostatectomy is salvage radiotherapy – this is particularly true for patients with gross local recurrences. Furthermore, even in patients with an incurable metastatic disease, a local recurrence can be the source of significant morbidity and should be addressed.

Delivering a sufficient dose of radiation in the postoperative setting to control gross disease while minimizing toxicity poses a significant technical challenge. Because of the inherent uncertainty in the verification of gross disease positioning with standard onboard imaging technologies, large margins must be used. Larger margins, in turn, will lead to larger volumes of tissue receiving high doses of radiation, potentially increasing long-term toxicity.

Herein, we present the case of a patient with a bulky gross recurrence (>40 cm³) at the bladder neck and synchronous metastatic disease who was referred for salvage radiotherapy after a multidisciplinary consensus recommendation to pursue local therapy for mitigating urinary morbidity from the bulky tumor. The case illustrates the utilization of MRI-guided radiotherapy to allow significant margin reduction, thereby facilitating the delivery of an escalated dose of radiotherapy to a bulky recurrence.

Detection of Local Recurrence with 3-Tesla MRI After Radical Prostatectomy: A Useful Method for Radiation Treatment Planning?

BACKGROUND/AIM

Salvage radiotherapy improves biochemical control in patients with recurrence of prostate cancer after prostatectomy. Radiotherapy target volumes of the prostatic fossa are based on empirical data and differ between different guidelines. Localization of recurrence with multiparametric magnetic resonance imaging (MRI) might be a feasible approach to localize recurrent lesions.

PATIENTS AND METHODS

Twenty-one patients with biochemical recurrence after radical prostatectomy were included (median prostate-specific antigen (PSA) =0.17 ng/ml). Multi-parametric MRI was performed using a 3-T MR system.

RESULTS

Lesions were detected in seven patients with a median PSA of 0.86 ng/ml (minimum= 0.31 ng/ml). Patients without detectable recurrence had a median PSA of 0.12 ng/ml. All patients with detectable lesions responded to radiotherapy. Eleven out of 14 patients without detectable recurrence also responded. Plasma flow in suspicious lesions was correlated with PSA level.

CONCLUSION

Detection of recurrence at the prostatic fossa with our approach was possible in a minority of patients with a low PSA level. Clinical relevance of plasma flow in suspicious lesions should be further investigated.

Magnetic resonance imaging for prostate cancer before radical and salvage radiotherapy: What radiation oncologists need to know

External beam radiotherapy (EBRT) is one of the principal curative treatments for patients with prostate cancer (PCa). Risk group classification is based on prostate-specific antigen (PSA) level, Gleason score, and T-stage. After risk group determination, the treatment volume and dose are defined and androgen deprivation therapy is prescribed, if appropriate. Traditionally, imaging has played only a minor role in T-staging due to the low diagnostic accuracy of conventional imaging strategies such as transrectal ultrasound, computed tomography, and morphologic magnetic resonance imaging (MRI). As a result, a notable percentage of tumours are understaged, leading to inappropriate and imprecise EBRT. The development of multiparametric MRI (mpMRI), an imaging technique that combines morphologic studies with functional diffusion-weighted sequences and dynamic contrast-enhanced imaging, has revolutionized the diagnosis and management of PCa. As a result, mpMRI is now used in staging PCa prior to EBRT, with possible implications for both risk group classification and treatment decision-making for EBRT. mpMRI is also being used in salvage radiotherapy (SRT), the treatment of choice for patients who develop biochemical recurrence after radical prostatectomy. In the clinical context of biochemical relapse, it is essential to accurately determine the site of recurrence - pelvic (local, nodal, or bone) or distant - in order to select the optimal therapeutic management approach. Studies have demonstrated the value of mpMRI in detecting local recurrences - even in patients with low PSA levels (0.3-0.5 ng/mL) - and in diagnosing bone and nodal metastasis. The main objective of this review is to update the role of mpMRI prior to radical EBRT or SRT. We also consider future directions for the use and development of MRI in the field of radiation oncology.

Prognostic Significance of Vas Deferens Invasion After Radical Prostatectomy in Patients with Pathological Stage T3b Prostate Cancer

BACKGROUND

Seminal vesicle invasion (SVI) is associated with adverse clinical outcomes in prostate cancer (PCa) patients. Despite its anatomical similarity and close proximity to the seminal vesicle, the prognostic significance of vas deferens invasion (VDI) by PCa has not been elucidated. For these reasons, we investigated the impact of VDI on the oncological outcome of pT3b PCa in association with SVI.

METHODS

We retrospectively reviewed the medical records of 3359 patients who had undergone a radical prostatectomy at our institution between January 2000 and December 2014 for PCa. Patients who received neoadjuvant or adjuvant treatment (radiation, androgen deprivation therapy, or both) and those without adequate medical records were excluded. A Kaplan-Meier analysis was performed to analyze biochemical recurrence-free survival (BCRFS), and a Cox regression model was used to test the influence of VDI on biochemical recurrence (BCR).

RESULTS

Of 350 patients with pathologically confirmed SVI (pT3b), 87 (24.9%) had VDI, while the remaining 263 patients (75.1%) had isolated SVI. Compared with SVI patients without VDI, SVI patients with VDI were noted to have a significantly worse 5-year BCRFS (25.1 vs. 17.1%, respectively). VDI was a significant predictor of BCR in multivariate Cox regression analysis (hazard ratio 1.39, 95% confidence interval 1.02-1.90; p = 0.039).

CONCLUSIONS

Our results shows that the prognosis of PCa with SVI might be further stratified by VDI status, thus suggesting the role of VDI either as a surrogate for poor prognosis or as a determinant for adjuvant therapy.

Pelvic MRI findings in relapsed prostate cancer after radical prostatectomy

PURPOSE/OBJECTIVE

Little is known about the clinical impact of using multiparametric MRI to plan early salvage radiotherapy after radical prostatectomy. We aimed to evaluate the incidence and location of recurrence based on pelvic multiparametric MRI findings and to identify clinical variables predictive of positive imaging results.

MATERIALS AND METHODS

We defined radiological criteria of local and lymph node malignancy and reviewed records and MRI studies of 70 patients with PSA recurrence after radical prostatectomy. We performed univariate and multivariate analysis to identify any association between clinical, pathological and treatment-related variables and imaging results.

RESULTS

Multiparametric MRI was positive in 33/70 patients. We found local and lymph node recurrence in 27 patients and 7 patients, respectively, with a median PSA value of 0.38 ng/ml. We found no statistically significant differences between patients with positive and negative multiparametric MRI for any variable. Shorter PSADT was associated with positive lymph nodes (median PSADT: 5.12 vs 12.70 months; p: 0.017).

CONCLUSIONS

Nearly half the patients had visible disease in multiparametric MRI despite low PSA. Positive lymph nodes incidence should be considered when planning salvage radiotherapy, particularly in patients with a short PSADT.

External beam radiotherapy for localized prostate cancer

Radiotherapy (XRT) is a curative treatment option for prostate cancer (PCa). Recent XRT technologies allow higher dose therapy that lead to increased local control with less adjacent tissue damage. Additionally, receiving neo-adjuvant or adjuvant hormonotherapy (HT) during radiation therapy increases the curative effect. The aim of this paper is to review the current literature and guidelines on external beam radiation therapy for PCa. However, brachytherapy and radiosurgery, a recently evolving relatively new technology for the radiotherapeutic management of localized PCa, are beyond the scope of this paper.

Vas deferens invasion: A neglected issue in the sampling of radical prostatectomy materials

A radical prostatectomy affects the prostate, bilateral seminal vesicles (SV), and the distal parts of the bilateral vasa deferentia (VD). SV invasion (SVI) is associated with an increased risk of lymph node metastasis and recurrence. However, the significance of VD invasion (VDI), either with or without the involvement of their surgical margins, has not been fully appreciated. We think VDI might have an independent prognostic significance, as does SVI, and should be incorporated into the pathology guidelines and the staging systems of prostatic adenocarcinoma. Our case illustrates this.

Multiparametric MRI for recurrent prostate cancer post radical prostatectomy and postradiation therapy

The clinical suspicion of local recurrence of prostate cancer (PCa) after radical prostatectomy (RP) and after radiation therapy (RT) is based on the onset of biochemical failure. The aim of this paper was to review the current role of multiparametric-MRI (mp-MRI) in the detection of locoregional recurrence. A systematic literature search using the Medline and Cochrane Library databases was performed from January 1995 up to November 2013. Bibliographies of retrieved and review articles were also examined. Only those articles reporting complete data with clinical relevance for the present review were selected. This review article is divided into two major parts: the first one considers the role of mp-MRI in the detection of PCa local recurrence after RP; the second part provides an insight about the impact of mp-MRI in the depiction of locoregional recurrence after RT (interstitial or external beam). Published data indicate an emerging role for mp-MRI in the detection and localization of locally recurrent PCa both after RP and RT which represents an information of paramount importance to perform focal salvage treatments.

Margin status of the vas deferens in radical prostatectomy specimens: relevant or waste of time?

AIMS

Positive surgical margins (PSM) after radical prostatectomy are of great interest, but investigation of the vas deferens (VD) is not recommended. This study examined the VD margins in radical prostatectomy patients to report the incidence of PSM and their clinical staging.

METHODS AND RESULTS

A total of 2701 consecutive specimens (1995-2009) were reviewed for tumour infiltration of the VD margin and correlated with clinicopathological data. Forty-one of 2701 cases (1.5%) had a positive VD margin. Thirteen cases had bilateral infiltration. All tumours were locally advanced [pT3a (n = 1), pT3b (n = 34), pT4 (n = 6)]; 15 (37%) had lymph node metastases. While Gleason scores ranged from 7 to 9, mean PSA was 22.3 ng/ml (1.68-127 ng/ml). In all cases with seminal vesicle infiltration (40 of 41) the PSM of the VD was seen ipsilaterally. In 11 of 15 patients (73%) with pN1 status, seminal vesicle infiltration and PSM of the VD were seen on the same side. In 16 cases (39%) the VD was the only PSM.

CONCLUSIONS

A PSM of the VD is an infrequent finding, but might appear as the only PSM. Histological evaluation of the VD therefore seems reasonable, especially as biochemical recurrence has been reported with positive VD margins, and awareness of them might assist in making clinical decisions for adjuvant therapy.