Salvage Radiotherapy for Biochemically Recurrent Prostate Cancer After Prostatectomy

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 67-year-old man had presented to his primary physician for routine health maintenance. A digital rectal examination was performed and revealed a suspicious nodule in the right lobe of the prostate without any extraprostatic extension. A serum prostate-specific antigen (PSA) test was 12.4 ng/mL. He had no previous PSA tests. Transrectal ultrasound-guided prostate biopsy showed Gleason 3 + 4 prostate adenocarcinoma in seven of 12 cores. Bone scan and computed tomography scan of the pelvis showed no evidence of metastatic disease, and the patient underwent a robotic-assisted radical prostatectomy with bilateral pelvic lymphadenectomy. Pathology revealed Gleason 3 + 4 adenocarcinoma bilaterally, with extracapsular extension, no seminal vesicle invasion, a 2-mm positive margin at the right mid gland, and 0 of 15 lymph nodes containing adenocarcinoma. Two months after surgery, he had mild stress urinary incontinence and PSA of < 0.1 ng/mL. Adjuvant radiotherapy was discussed, but he elected to have careful follow-up. His PSA was monitored every 6 months and gradually increased from < 0.1 ng/mL to 0.4 ng/mL over the next 3 years. He was asymptomatic. He was referred to discuss the role of salvage radiotherapy.