Biochemical Recurrence After Radiation Therapy

Our patient was considered intermediate risk status prior to his original treatment. At this point he has experienced a biochemical failure and has a very strong potential for disease recurrence. With a PSA of 4.5, metastasis is less likely, but imaging modalities are not adequately sensitive to eliminate the possibility of metastatic foci. At this point we have a very healthy gentleman with what appears to be local recurrence of previously intermediate risk prostate cancer. Without any treatment, this recurrence has the potential to metastasize and cause morbidity and even mortality in this patient. We recommend discussing the local salvage therapy options. We might recommend salvage radical prostatectomy in this case, ensuring the patient has a good understanding that the procedure has a significant risk of altering his quality of life and that these risks are elevated above the typical patient undergoing primary radical prostatectomy. If the patient selects this treatment option, we would recommend both a TRUS biopsy to confirm local disease and a fluciclovine PET scan to increase our confidence in the presence of both local recurrence and absence of nodal disease or metastasis. Other local salvage therapies are certainly options as well. The patient could also consider a watchful waiting approach with plans to initiate ADT at the time of detection of clinical metastasis. Note that ongoing studies will soon further our understanding of the role of newer ADT modalities in the BCR setting.