Medical expert of the article
New publications
Prostate cancer recurrence after radical treatment
Last reviewed: 07.07.2025
All iLive content is medically reviewed or fact checked to ensure as much factual accuracy as possible.
We have strict sourcing guidelines and only link to reputable media sites, academic research institutions and, whenever possible, medically peer reviewed studies. Note that the numbers in parentheses ([1], [2], etc.) are clickable links to these studies.
If you feel that any of our content is inaccurate, out-of-date, or otherwise questionable, please select it and press Ctrl + Enter.
The risk of prostate cancer recurrence (local or systemic) within 10 years after prostatectomy or radiation therapy is 27-53%. Within 5 years after initial treatment, 16 to 35% of patients receive anti-relapse treatment.
Previously, relapse was understood as a tumor palpable through the rectum, as well as distant metastases. Now, relapse is considered to be an increase in the PSA level. The criterion for relapse after prostatectomy is usually considered to be a PSA level of 0.2 ng/ml or more in two consecutive measurements. According to the ASTRO criteria, relapse after radiation therapy can be considered with three consecutive increases in the PSA level.
Where does it hurt?
Local and systemic recurrence of prostate cancer
If an increase in PSA is detected, it is important to establish the nature of the relapse - local or systemic. After prostatectomy, we may be talking about a local relapse, in other cases - only a systemic relapse or a combination of both.
The time until the PSA level increases, the rate of increase and the doubling time of the PSA content, its initial level and the Gleason index help to distinguish local relapse from systemic relapse.
An increase in the PSA level in the first six months after surgery usually indicates a systemic relapse. The median time for doubling the PSA level in systemic relapses can be 4.3 months, in local relapses - 11.7 months. The rate of increase in the PSA level of less than 0.75 ng/ml per year is observed in patients with local relapses, more than 0.7 ng/ml per year - in patients with distant metastases.
Local recurrence after radiation therapy is indicated by a slow delayed increase in the PSA level. Local recurrence is confirmed by a positive biopsy result performed 18 months after radiation and later (in the absence of distant metastases according to CT, MRI and scintigraphy).
The probability of local recurrence after prostatectomy is 80% with a late PSA rise (more than 3 years), a PSA doubling time of more than 11 months, a Gleason score of less than 6, and a disease stage below pT 3a N 0 and pT x R 1. The probability of systemic recurrence after prostatectomy exceeds 80% with an early PSA rise (less than one year), a PSA doubling time of 4-6 months, a Gleason score of 8-10, and a pT 3b stage and pT x N 1. Local recurrence after radiotherapy and HIFU is diagnosed with a positive biopsy result in the absence of distant metastases. Prostate biopsy is indicated only in selected patients when planning repeat local treatment (e.g., prostatectomy or a repeat HIFU session).
Examination for suspected recurrence of prostate cancer
To confirm recurrence when PSA levels rise, physical examination, ultrasound, CT or MRI of the pelvis, and biopsy of the tumor bed and anastomotic area are usually performed. In the absence of symptoms, these studies rarely detect a tumor, since PSA levels usually rise 6-48 months before overt recurrence.
Digital rectal examination with zero or very low PSA levels usually does not yield results. With an increase in the PSA level, MRI of the pelvis, CT of the abdominal cavity and bone scintigraphy are prescribed, but due to low sensitivity and specificity in early relapse, these studies are of little information. With an increase in the PSA level after prostatectomy, the scintigraphy result is positive in only 4.1% of patients. The probability of a positive scintigraphy result does not exceed 5% until the PSA level reaches 40 ng/ml. The average PSA level at which scintigraphy detects metastases should exceed 60 ng/ml, and the rate of increase in the PSA level should be 22 ng/ml per year. The level and rate of increase in the PSA content allow one to predict the scintigraphy result, and the rate of increase in the PSA level - the CT result. Thus, with a PSA level of less than 20 ng/ml or a PSA growth rate of less than 20 ng/ml per year, scintigraphy and CT do not provide additional information. Endorectal MRI detects local recurrence in 81% of patients with an average PSA level of 2 ng/ml.
PET is recommended for early diagnosis of recurrence of various tumors.
Scintigraphy with antibodies to prostatic membrane antigen (prostascint) is one of the new methods for detecting relapses. Its diagnostic accuracy reaches 81%. Regardless of the PSA level, the method detects the occurrence of relapse in 60-80% of patients, which can help in choosing treatment tactics. Scintigraphy with these antibodies is positive in 72 of 255 patients with a PSA level of 0.1-4 ng/ml after prostatectomy, and the accumulation of the isotope is observed at any PSA level.
A biopsy of the anastomosis zone can detect a relapse in only 54% of patients. Only in the presence of a palpable or hypoechoic formation is the probability of a positive result close to 80%. There is a clear relationship between this indicator and the PSA level: with a PSA content of less than 0.5 ng/ml, the result is positive in 28% of patients, with a PSA level of more than 2 ng/ml - in 70% of patients. Given these data, a biopsy from the anastomosis zone is usually not taken and is guided by the PSA level and its doubling rate. In addition, survival in case of proven relapses is approximately the same as when registering an isolated increase in PSA.
According to ASTRO recommendations, if PSA levels increase after radiation therapy, prostate biopsy is not indicated. However, biopsy is key to deciding on prostatectomy or HIFU in such patients. After radiation therapy (distance or brachytherapy), biopsy is usually performed no earlier than 18 months after cryodestruction or 6 months after ultrasound destruction.
What do need to examine?
How to examine?
What tests are needed?
Who to contact?
Treatment of recurrent prostate cancer
Treatment of recurrent prostate cancer after radical prostatectomy
The timing and tactics of treatment for PSA elevation after prostatectomy or radiation therapy are controversial. In case of relapse after surgery, observation, irradiation of the tumor bed, HIFU therapy of relapse, hormone therapy for prostate cancer (including combined, periodic or combined use of finasteride and antiandrogens), as well as a combination of hormone and chemotherapy are possible. These methods are also applicable for relapse after radiation therapy.
Hormone therapy
In case of high preoperative PSA level (more than 20 ng/m, Gleason index more than 7, non-radical surgery and locally advanced tumors pT 3b, pT x N 1 ) early hormonal therapy is advisable. However, its effect on survival has not yet been established. With early hormonal therapy, metastases occur less frequently than with delayed therapy, survival in both cases is approximately the same. The need for hormonal therapy is confirmed by the MRC trial, in which a relapse was noted in all patients who received radiation therapy for the rise in PSA levels after prostatectomy for tumors pT 3b, pT x N 1, and Gleason index 8.
Patients tolerate monotherapy with antiandrogen drugs better than combined therapy (hot flashes, decreased potency, loss of sexual desire occur less frequently), but antiandrogens cause gynecomastia and nipple pain. In patients without distant metastases, bicalutamide (150 mg/day) significantly reduces the risk of disease progression. Thus, antiandrogens can be an alternative to castration when PSA levels increase after radical treatment (especially in relatively young patients without concomitant diseases).
Surveillance for recurrent prostate cancer
Dynamic observation is usually performed with a Gleason index of less than 7, a late (2 years after surgery) increase in the PSA level and a doubling time of more than 10 months. In such cases, the median time to the occurrence of metastases is 8 years, and the median time from the occurrence of metastases to the onset of death is another 5 years.
HIFU therapy
Recently, more and more data have appeared on the results of HIFU therapy for local recurrence after RP. Most often, recurrence is detected by TRUS and confirmed histologically (biopsy). However, HIFU therapy often delays the time of hormone therapy. There are no exact survival data.
Clinical guidelines for the treatment of recurrence after prostatectomy
In case of local recurrence and PSA level less than 1.5 ng/ml, radiation therapy up to SOD 64-66 Gy is indicated.
If the patient is weakened or objects to irradiation, dynamic observation is possible in case of local relapse.
If the PSA level increases, indicating a systemic relapse, hormone therapy is indicated, as it reduces the risk of metastasis.
Hormonal therapy can include gonadotropin-releasing hormone analogues, castration, or bicalutamide (150 mg/day).
Treatment of relapse after radiation therapy
Most often, patients with relapse after radiation therapy receive hormone therapy (up to 92%). Without treatment, the time from the increase in the PSA level to the manifestation of relapse is about 3 years. In addition to hormone therapy, local treatment is also possible for relapse after radiation - prostatectomy, HIFU therapy, cryotherapy, brachytherapy. Prostatectomy has not found wide application due to frequent complications (urinary incontinence, damage to the rectum), as well as due to the high risk of local relapse. However, with careful selection of patients, this operation can provide a long relapse-free period,
According to the latest data. 5-year relapse-free survival after radiation therapy corresponds to that after primary prostatectomy performed at the same stages of the disease, 10-year survival is 60-66%. Within 10 years, 25-30% of patients die from tumor progression. In localized tumors, the absence of tumor cells at the resection margin, seminal vesicle invasion and metastasis to the lymph nodes, relapse-free survival reaches 70-80% compared to 40-60% in locally advanced tumors.
Prostatectomy for local recurrence is justified in the absence of severe concomitant diseases, life expectancy of at least 10 years, tumors with a Gleason index of less than 7 and a PSA level of less than 10 ng/ml. In other cases, it is difficult to determine the extent of the tumor before surgery, which increases the risk of anterior or total exenteration, complications, and recurrent recurrence.
Dynamic observation is recommended for patients with probable local recurrence (from the low-risk group, with late recurrence and slow growth of the PSA level), who are against repeated radical treatment. Retrospective analysis did not reveal any advantages of hormonal therapy compared with dynamic observation when the PSA doubling time was more than 12 months; 5-year metastasis-free survival was 88% with hormonal therapy and 92% with observation.
Clinical guidelines for investigation of suspected recurrent prostate cancer
After prostatectomy, if the PSA level is less than 20 ng/ml and its growth rate is less than 20 ng/ml per year, CT of the abdominal cavity and pelvis is of little information.
Endorectal MRI helps detect local recurrence at low PSA levels (1-2 ng/ml). PET has not yet become widely used.
Scintigraphy with labeled antibodies to prostate membrane antigen allows detection of relapse in 60-80% of patients regardless of the PSA level.
A biopsy to confirm local recurrence is performed 18 months or more after irradiation.
[ 6 ], [ 7 ], [ 8 ], [ 9 ], [ 10 ], [ 11 ]
Clinical guidelines for the treatment of relapse after radiotherapy
In selected patients with local recurrence, prostatectomy may be performed.
If there are contraindications to surgery, brachytherapy, HIFU therapy or cryodestruction may be performed.
In case of probable systemic recurrence, hormone therapy for prostate cancer is possible.
Clinical guidelines for the treatment of relapses after radical treatment
Probable local recurrence after prostatectomy |
Radiation therapy at a dose of at least 64 Gy is possible and should preferably be started when the PSA level is less than 1.5 ng/ml. |
Probable local recurrence after radiation therapy |
In some cases, prostatectomy is possible, but the patient should be informed of the relatively high risk of complications. |
Probable systemic relapse |
Early hormonal therapy slows progression and may increase survival compared with delayed therapy. Local treatment is used only for palliative purposes. |