UROLOGICAL ONCOLOGY

doi: 10.1590/S1677-553820100001000030

Long-term rates of undetectable PSA with initial observation and delayed salvage radiotherapy after radical prostatectomy
Loeb S, Roehl KA, Viprakasit DP, Catalona WJ
Department of Urology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
Eur Urol. 2008; 54: 88-94

• Background: Randomized trials have shown an improvement in progression-free survival rates with adjuvant radiation therapy (ART) after radical prostatectomy for patients with a high risk of cancer recurrence. Less is known about the relative advantages and disadvantages of initial observation with delayed salvage radiation therapy (SRT).
  Objective: To examine the results of SRT in a large single-surgeon radical prostatectomy series.
  Design, Setting, and Participants: From a radical prostatectomy database, we identified 859 men with positive surgical margins (SM+), extracapsular tumor extension (ECE), or seminal vesicle invasion (SVI) who chose to defer ART. Following a period of initial observation, 192 ultimately received SRT for prostate-specific antigen (PSA) progression.
  Measurements: Survival analysis was performed to examine the outcomes of initial observation followed by SRT.
  Results and Limitations: In patients with SM+/ECE and SVI, the 7-yr PSA progression-free survival rates with observation were 62% and 32%, respectively. Among those who had PSA progression, 56% and 26%, respectively, maintained an undetectable PSA for 5 yr after SRT. The long-term rates of undetectable PSA associated with an SRT strategy were 83% and 50% for men with SM+/ECE and SVI, respectively. In the subset of 716 men who did not receive any hormonal therapy, the corresponding long-term rates of undetectable PSA were 91% and 75%, respectively.
  Conclusions: Following radical prostatectomy, initial observation followed by delayed SRT at the time of PSA recurrence is an effective strategy for selected patients with SM+/ECE. Some patients with SVI may also benefit from this strategy. However, additional prospective studies are necessary to further examine the survival outcomes following SRT.

• Editorial Comment
  The debate goes on and on. Should a patient with positive surgical margins (SM+) or seminal vesicle infiltration (SVI) after radical prostatectomy be irradiated, and if so – when? This paper supports an affirmative standpoint. In short, positive surgical margins might have a relative benign course with a 62% PSA no progression rate if left untreated. In contrast, patients with SVI do worse with only 50% of them not showing up with increasing PSA during the 7-year follow-up. Thus, one may safely choose to wait until PSA becomes measurable after radical prostatectomy.
  When should I offer adjuvant radiation if PSA shows up? The answer from this paper is – as soon as possible, because the final outcome was better if radiation started when PSA was < 1 ng/ml.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany
E-mail: boehle@urologie-bad-schwartau.de