Date Published: September 15, 2012
Publisher: Hindawi Publishing Corporation
Author(s): Andreas Sommerhuber, Verena Traxlmayr, Wolfgang Loidl.
Radical prostatectomy, external beam radiotherapy and permanent brachytherapy are the most common treatment options for nonmetastatic localised adenocarcinoma of the prostate (PCa). Accurate pretherapeutic clinical staging is difficult, the number of positive cores after biopsy does not imperatively represent the extension of the cancer. Furthermore postoperative upgrading in Gleason score is frequently observed. Even in a localised setting a certain amount of patients with organ-confined PCa will develop biochemical progression. In case of a rise in PSA level after radiation the majority of patients will receive androgen deprivation therapy what must be considered as palliative. If local or systemic progressive disease is associated with evolving neuroendocrine differentiation hormonal manipulation is increasingly ineffective; radiotherapy and systemic chemotherapy with a platinum agent and etoposide are recommended. In case of local progression complications such as pelvic pain, gross haematuria, infravesical obstruction and rectal invasion with obstruction and consecutive ileus can possibly occur. In this situation palliative radical surgery is a therapy option especially in the absence of distant metastases. A case with local and later systemic progression after permanent brachytherapy is presented here.
A 65-year-old patient was referred to our urological clinic for a prostate biopsy indicated for a PSA elevation of 4,5 ng/mL. The patient presented without any previous morbidities in his medical or urological history and was entirely asymptomatic. Digital rectal examination (DRE) and transrectal ultrasound (TRUS) of the prostate were normal, the size of the gland was 36 mL. An octant biopsy was conducted in January 2002 by which adenocarcinoma of the prostate (PCa) was diagnosed in 1 out of 8 cores. The lesion was circumscribed with a length below 2 mm and a Gleason grade of 2, WHO grade was 1, all the other seven biopsies were classified as benign prostatic hyperplasia and chronic inflammation. Following discussion of all therapeutical options, the patient decided to undergo permanent brachytherapy with J125. 62 seeds with 0,467 mCi/seed were implanted, total activity was 28,95 mCi, and postoperative course was without any complications.
Accurate staging of prostate cancer on the basis of clinical features such as PSA, DRE, and histology of biopsy is difficult. The number of positive cores does not imperatively represent the extension of the cancer, furthermore, in about 50% an upgrading in Gleason score has to be observed after performing radical prostatectomy. Besides, radical prostatectomy and external beam radiotherapy, permanent brachytherapy is one treatment option of nonmetastatic-localised PCa . Even in a localised setting, 10–20% of patients with organ-confined PCa will develop biochemical progression within 5–10 years; if the cancer is locally advanced at the time of treatment, the progression rate increases to up to 30–50% [2–4]. 70% of the patients with PSA relapse after brachytherapy, present with local persistence as the only site of recurrence, depending on the initial tumour stage [2, 5]. In case of a rise in PSA level after radiation therapy the majority of patients will receive androgen deprivation therapy. Since this must be considered as palliative, a reverse strategy is salvage radical prostatectomy (SRP). Heidenreich et al. reported a retrospective series of 55 men with biopsy-proven, locally recurrent PCa after primary radiotherapy. Predictors of organ-confined PCa with negative surgical margins were biopsy Gleason score prior to salvage radical prostatectomy, <50% positive biopsy cores, PSA doubling-time >12 months, and low-dose brachytherapy. SRP was judged as a surgically challenging but effective secondary local treatment with curative intent . Furthermore, studies about cryotherapy, brachytherapy and high-intensity focused ultrasound (HIFU) with partly encouraging results but smaller numbers of patients were published .