11C-choline positron emission tomography in prostate cancer: primary staging and recurrent site staging

OBJECTIVES: To evaluate the usefulness of 11C-choline positron emission tomography (PET) for primary staging and re-staging of prostate cancer. PATIENTS AND METHODS:11C-choline PET, a total of 22 scans, was performed on 13 patients with histologically proven prostate cancer in primary staging (n = 6) and recurrent site staging; following radical prostatectomy (n = 5) and following radiation therapy (n = 3). In 1 patient, 11C-choline PET was performed in both primary staging and re-staging. Also, 3 patients histologically proven to have no malignant prostate were included. RESULTS: Because urinary 11C-choline activity was low, it did not interfere with the visualization of pelvic structures. 11C-choline PET visualized normal prostate with a mean SUV of 2.99 (range 2.27-3.68) and primary prostate cancer as a hot spot in 5/6 scans with a mean SUV of 4.21 (range 2.99-6.2). In re-staging, 11C-choline PET was true positive in 9/16 scans and true negative in 2/16 scans. 5/16 scans in 2 patients were false negative with negative conventional imaging. CONCLUSIONS: In primary staging, 11C-choline PET may not be of use because of no reliable differential 11C-choline uptake of BPH and prostate cancer. On the other hand, 11C-choline PET may be of value in recurrent site staging and monitoring for the prostate cancer.     

PET and PET/CT in relapsing prostate carcinoma

Of patients with carcinoma of the prostate undergoing therapeutic regimes with curative intent, 15-23% will ultimately relapse and 16-35% will need some sort of salvage therapy within 5 years. Of relapsing patients, 50% will have local recurrence and 50% systemic disease with or without local recurrence. Therefore, localization of recurrent prostate cancer is critical for selecting a local or systemic therapeutic strategy. Modern fusion imaging with PET/CT and 11C/18F-choline or 11C-acetate has augmented the diagnostic imaging spectrum for assessment of relapsing prostate cancer. In 60-70% of patients with biochemical relapse, recurrent tumor can be detected and anatomically precisely localized. Detection sensitivity is probably negatively correlated with serum PSA concentration. Below a PSA level of 1 ng/ml, mean detection sensitivity is probably 50-66%. Fusion imaging with 11C-choline PET/CT and MRI possesses a high potential for early localization of recurrent prostate carcinoma.     

Visualization of prostate cancer with 11C-choline positron emission tomography (PET): localization of primary and recurrent prostate cancer

A total of 33 11C-choline positron emission tomography scans for 23 patients with prostate cancer were performed to elucidate the localization of primary site within the prostate gland (primary group) and of recurrent site after radical treatment (recurrent group) from 2000 to 2005. As a control group, one scan for benign prostate hyperplasia and 3 scans for bladder cancer were also studied. Mean PSA values of 14 scans in the primary group and 19 scans in the recurrent group were 39.8 ng/ml (range 1.6-150) and 5.0 ng/ml (range < 0.2-11), respectively. The primary cancer could be visualized as a hot spot within the prostate gland in 10 out of 14 scans and histopathological analysis of biopsy and prostatectomy specimens verified the correct laterality. Positive scans were demonstrated in 2 out of 4 local recurrent sites, 4 out of 4 lymph node recurrent sites and 4 out of 4 bone recurrent sites with a mean PSA value of 6.22 ng/ml (range 2.3-11). Four scans with a PSA value of 2.3 ng/ml or less, no positive spot was demonstrated. These 4 scans consisted of 2 false negative and 2 true negative studies. 11C-choline PET seems to be useful to detect primary prostate cancer and could play a complementary role for conventional imaging methods in recurrent site staging.     

Is anastomotic biopsy necessary before radiotherapy after radical prostatectomy?

PURPOSE: External beam radiotherapy may be given after radical prostatectomy as adjuvant (immediate) or therapeutic (delayed) treatment, the latter in response to evidence of disease recurrence. In patients receiving delayed radiotherapy the necessity of a positive anastomotic biopsy before treatment remains unclear. We determined whether a positive anastomotic biopsy predicted the response to radiation in this setting. MATERIALS AND METHODS: We reviewed the records of 67 patients who received radiotherapy for biochemical or biopsy proved recurrent prostate cancer after radical prostatectomy. Patients underwent surgery at our institution or its affiliated hospitals, or were referred to our institution for radiotherapy. All patients had a negative metastatic evaluation before receiving radiotherapy. Biochemical failure after radiotherapy was defined as serum prostate specific antigen (PSA) 0.2 ng./dl. or greater on 2 or more consecutive occasions. Biochemical recurrence-free survival was calculated using the Kaplan-Meier method. Independent predictors of PSA failure after radiotherapy were identified using the multivariate Cox proportional hazards model. RESULTS: Of the 67 patients evaluated 33 and 34 received radiotherapy for biochemical failure and biopsy proved local recurrence, respectively. The 3-year recurrence-free survival rate was 49% in patients treated for biochemical failure and 39% in those with biopsy proved local recurrence. There was no significant difference in PSA-free survival in these 2 groups. Only pre-radiotherapy PSA 1 ng./dl. or greater (p = 0.02) and seminal vesicle invasion (p = 0.02) were significant independent predictors of biochemical failure. CONCLUSIONS: A positive anastomotic biopsy did not predict an improved outcome after radiotherapy following radical prostatectomy. Anastomotic biopsy was associated with a longer time to salvage radiotherapy. However, this delay did not translate into worse disease-free outcomes in patients who underwent anastomotic biopsy. High pre-radiotherapy PSA greater than 1 ng./ml. was the most significant predictor of biochemical failure after therapeutic radiotherapy. Decisions regarding local radiation therapy after radical prostatectomy may be made without documenting recurrent local disease.     

Histological verification of 11C-choline-positron emission/computed tomography-positive lymph nodes in patients with biochemical failure after treatment for localized prostate cancer

OBJECTIVES

To evaluate the potential of ¹¹C‐choline‐positron emission tomography (PET)/computed tomography (CT) for planning surgery in patients with prostate cancer and prostate‐specific antigen (PSA) relapse after treatment with curative intent.

PATIENTS AND METHODS

We retrospectively reviewed the charts of 10 patients with PSA recurrence after either external beam radiation (two) or radical retropubic prostatectomy (eight) for prostate cancer, and who had a laparoscopic lymphadenectomy for suspicious lymph nodes detected on ¹¹C‐choline‐PET/CT. The histological results and PET/CT findings were compared.

RESULTS

In all, 22 suspicious lymph nodes were found on PET/CT, and 14 on conventional CT or magnetic resonance imaging. Comparing the conventional imaging showed concordance in 13 lymph nodes. Three of the 10 patients had no metastatic lymph node disease on definitive histology. The mean (sd ) PSA level for these patients was 1.0 (0.4) ng/mL, whereas that in patients with lymph node metastases was 15.1 (9.2) ng/mL (statistically significant difference, P < 0.05). The positive predictive value was seven of 10. All of the patients initially regressed, with PSA increases after lymphadenectomy. Two of the patients are being managed by watchful waiting, two had radiotherapy of the prostate fossa and two had chemotherapy with docetaxel. Four patients were treated by hormone‐deprivation therapy. After a mean (sd ) follow up of 11 (7) months, one patient died, one has PSA progression, but none of those with negative histology has clinical signs of local recurrence.

CONCLUSIONS

¹¹C‐choline‐PET is a valuable tool for detecting recurrent prostate cancer, but the limited positive predictive value should lead to a critical interpretation of the results.     

PET und PET/CT in der Rezidivdiagnostik des Prostatakarzinoms

Of patients with carcinoma of the prostate undergoing therapeutic regimes with curative intent, 15–23% will ultimately relapse and 16–35% will need some sort of salvage therapy within 5 years. Of relapsing patients, 50% will have local recurrence and 50% systemic disease with or without local recurrence. Therefore, localization of recurrent prostate cancer is critical for selecting a local or systemic therapeutic strategy. Modern fusion imaging with PET/CT and ¹¹C/¹⁸F-choline or ¹¹C-acetate has augmented the diagnostic imaging spectrum for assessment of relapsing prostate cancer. In 60–70% of patients with biochemical relapse, recurrent tumor can be detected and anatomically precisely localized. Detection sensitivity is probably negatively correlated with serum PSA concentration. Below a PSA level of 1 ng/ml, mean detection sensitivity is probably 50–66%. Fusion imaging with ¹¹C-choline PET/CT and MRI possesses a high potential for early localization of recurrent prostate carcinoma.     

Prostate specific antigen levels in the follow up of localised prostate cancer: how does radiotherapy compare to radical prostatectomy?

This study aimed to evaluate tumor progression as assessed by PSA level of curative treatment for localised prostate cancer by either radiotherapy or prostatectomy. From 1987 to 1993, 180 patients were treated for clinically localised prostate cancer either by radiotherapy or prostatectomy. One hundred and five patients with clinical T1T2N0M0 were eligible for this study. Forty five underwent external beam radiotherapy and 60 had a radical prostatectomy. After radiotherapy PSA slowly decreased to reach a nadir 18 months after treatment. Any subsequent increase from this lowest post treatment level is associated with tumor progression. After radical prostatectomy PSA becomes undetectable and any increase will be regarded as evidence of tumor progression. The median PSA level before treatment and the median length of follow-up were comparable for the two groups. There was no statistically significant difference in overall survival and biological evidence of disease progression at 5 y. Analysis of the evolution of median PSA level shows a progressive decline during the 4 y after radiotherapy. After radical prostatectomy PSA become undetectable, 4 y after treatment PSA levels become comparable in the two groups. The biochemical free survival was 60% for the prostatectomy group and 62% for the radiotherapy group. PSA is an effective marker of tumour progression after surgery or radiotherapy for localised prostate cancer. In our retrospective study recurrence rates at 5 y were not significant but direct comparisons are limited due to the Gleason score of the two groups. PSA levels can take up to 4 y to reach a nadir after radiotherapy.     

Is there a role for positron emission tomography imaging in the early evaluation of prostate cancer relapse?

The patient population with a rising prostate specific antigen (PSA) post-therapy with no evidence of disease on standard imaging studies currently represents the second largest group of prostate cancer patients. Little information is still available regarding the specificity and sensitivity of positron emission tomography (PET) tracers in the assessment of early biochemical recurrence. Ideally, PET imaging would allow one to accurately discriminate between local vs nodal vs distant relapse, thus enabling appropriate selection of patients for salvage local therapy. The vast majority of studies show a relatively poor yield of positive scans with PSA values < 4 ng ml(-1). So far, no tracer has been shown to be able to detect local recurrence within the clinically useful 1 ng ml(-1) PSA threshold, clearly limiting the use of PET imaging in the post-surgical setting. Preliminary evidence, however, suggests that 11C-choline PET may be useful in selecting out patients with early biochemical relapse (PSA < 2 ng ml(-1)) who have pelvic nodal oligometastasis potentially amenable to local treatment. The role of PET imaging in prostate cancer is gradually evolving but still remains within the experimental realm. Well-conducted studies comparing the merits of different tracers are needed.     

Salvage radical prostatectomy for recurrent prostate cancer after radiation therapy

Salvage radical prostatectomy is considered for patients with locally recurrent prostate cancer after external beam radiotherapy. Between 2001 and 2004, 32 men treated with curative intent with radiotherapy for prostate cancer were subsequently treated with salvage surgery for clinically localized prostate cancer. We assessed the morbidity associated with this procedure and the outcome of the patients. Thirty-two patients underwent salvage radical prostatectomy. Initial pre-radiation median prostate-specific antigen was 13 ng/ml. Pre-radiation disease was clinical stage T1b in five cases, T2a in 10, T2b in 10 and T3a in seven. Mean operative time was 122 minutes, intraoperative blood loss was 550 ml and hospital stay and catheterization time were 5 and 12 days, respectively. There was biochemical failure in eight patients after salvage radical prostatectomy and 24 patients are biochemical non evidence of disease (bNED). In recurrent prostate local disease with prostate-specific antigen <10 ng/ml and life expectancy greater than 10 years, salvage radical prostatectomy is a reasonable treatment option.     

ERG蛋白表达与前列腺癌患者根治术后生化复发风险关系的研究

目的 探讨临床局限性前列腺癌行根治性切除术后,组织ERG蛋白表达情况与术后生化复发的相关性。方法 选取2012年3月至2016年2月在本院治疗的121例局限性前列腺癌并行根治性切除术的患者作为研究对象,通过住院病历及门诊随访资料收集患者确诊时年龄、血清前列腺特异性抗原（PSA）水平、格里森评分（GS）、病理分期及切缘状态等参数。结果 共有98例患者完成最终随访,ERG蛋白表达阳性率为35.7%（35/98）。Kaplan-meier生存分析提示,确诊时PSA水平（P=0.007）、GS（P=0.024）及ERG蛋白表达状态（P<0.0001）,与术后生化复发相关。Cox回归多因素分析显示,确诊时PSA水平（HR=2.134,P=0.001）、GS（HR=1.361,P=0.030）及ERG蛋白表达状态(HR=2.024,P=0.044)分别为前列腺癌根治性切除术后生化复发的独立危险因素。结论 ERG蛋白表达状态是前列腺根治性切除术后生化复发的独立危险因素,通过对其检测及分析,可以为患者制定个体化的随访及临床治疗方案提供参考依据。     

Fluorine-18-fluorodeoxyglucose positron emission tomography is useless for the detection of local recurrence after radical prostatectomy.

OBJECTIVE: After radical retropubic prostatectomy a rise of the prostate-specific antigen (PSA) indicates a local recurrent or metastatic disease. If the bone scan shows no apparent bone metastasis, morphological imaging methods like x-ray computed tomography, magnetic resonance imaging or transrectal ultrasound often cannot distinguish between postoperative scar and local recurrence. Therefore we investigated the feasibility of fluorine-18-fluorodeoxyglucose positron emission tomography (F-18 FDG PET) for metabolic characterization of prostatic cancer, especially for differentiation of scar or recurrent prostate cancer after radical prostatectomy. METHODS: Dynamic PET with 370 MBq F-18 deoxyglucose (F-18 FDG) up to 60 min p.i. was performed in 2 patients with biopsy-proven benign prostatic hyperplasia, in 11 patients with a histologically proven prostate cancer prior to radical retropubic prostatectomy (RRP) and 7 patients with suspected local recurrence (with negative bone scan) after RRP prior to biopsy of anastomosis (3 local recurrence, 4 postoperative scar). RESULTS: Prostate cancer showed a very low F-18 FDG uptake. The placement of regions of interest was only possible by the use of other imaging methods. There was not difference between the F-18 FDG uptake of benign prostate hyperplasia, prostate carcinoma, postoperative scar or local recurrence after radical prostatectomy. CONCLUSION: F-18 FDG seems not to be useful to distinguish between postoperative scar and local recurrence after radical prostatectomy.     

Imaging with prostate-specific membrane antigen (PSMA) in prostate cancer

Radioimmunoscintigraphy using a radio-labelled antibody to prostate-specific membrane antigen (PSMA) has growing applications as a means of tissue-specific imaging based on functional characteristics and complements traditional staging investigations. Clinical applications in men with carcinoma of the prostate are being refined, and this study reports outcomes with this technique in our practice. Prostatic immunoscintigraphy scans were performed with In-111 CYT 356 in 49 men with carcinoma of the prostate, obtaining sequential images in two and three dimensions at 10 min, 24 and 48 h. Of the 49 men, 36 had clinically localized cancer, 10 had recurrent disease after radical radiotherapy or radical prostatectomy and three had rising PSA after primary endocrine treatment. Scan findings are discussed in the context of clinical management. Of the 36 men with clinically localized cancer, seven had increased uptake in regional and distant lymph nodes. Of these seven, three were treated with hormone manipulation, two by radical prostatectomy and two by radical radiotherapy. Among 10 patients who had recurrence after radical treatment of the primary tumour, scans showed local recurrence alone in four, and six had regional or distant metastases. Three patients treated with primary hormone manipulation had scans for rising PSA, and of these one had a positive regional node and two had distant soft tissue and bone metastases. In conclusion, prostatic radio-immunoscintigraphy scans highlight tissues involved by prostate cancer, including the prostate, lymph nodes, soft tissues and bone metastases as well as pelvic recurrence. Results may contribute to the clinical management of individual patients, although histological confirmation may be appropriate when considering alternative treatment. Prostate Cancer and Prostatic Diseases (2000) 3, 47-52     

Diagnostic methodology for the biochemical recurrence of prostate cancer after radiotherapy

OBJECTIVES: Due to the permanence of the prostate, PSA does not descend to undetectable levels after radical radiotherapy the way it happens after radical prostatectomy. PSA as response parameter after radiotherapy or for the characterization of biochemical recurrence is very sensitive but not much specific. The positive predictive value for local or systemic clinical recurrence is low, so that the use of PSA alone for the indication of rescue therapies is open to debate. There are different definitions of biochemical recurrence after radiotherapy. To date, the most standardized definition was that of the American Society for Therapeutic Radiology and Oncology (ASTRO) in 1996, but it was exclusive for patients treated with external beam radiotherapy as monotherapy. It was very sensitive to the follow-up time, but it was based on retrospective data, and its correlation with clinical progression was suboptimal. With the aim of improving the definition of biochemical failure ASTRO reunited a new expert commission in 2005 that gave a new definition of biochemical failure more specific for clinical events and valid in the context of short-term androgen deprivation or brachytherapy. The final recommendations were to consider biochemical recurrence a PSA increase of 2 ng/ml or greater over the nadir, or patients that have received rescue therapies. Prostate biopsy after radiotherapy is employed in patients with suspicion of exclusively local recurrence to direct them to rescue therapies. The criteria for the diagnosis of post-therapy carcinoma must be homogenized before establishing this test as a routine in the evaluation of treatment response. Standard imaging techniques for the localization of clinical recurrences (99-technetium bone scan, CT scan and MRI) are not much sensitive and it is predictable that other diagnostic tests which have a metabolic character (such as PET with various tracers, MR spectroscopy) will be used for the study of biochemical recurrence after radiotherapy in the near future.     

Cryosurgery for prostate cancer: new technology and indications

Patients diagnosed with prostate cancer who elect to pursue active treatment of their disease must choose among the many available treatment alternatives. Several treatment options now exist for similar-stage disease (clinical T1-3N0M0), including radical prostatectomy, external beam radiation, prostate brachytherapy (PB), and cryosurgical ablation of the prostate (CSAP). This article reviews the current role of CSAP in the treatment of clinically localized prostate cancer. CSAP has a role in the primary treatment of men with high-risk, clinically localized prostate cancer (defined as PSA >10, Gleason score ≥ 7, or clinical stage ≥ cT2B). CSAP (occasionally followed by external beam radiotherapy) appears to offer improved rates of cancer control over other types of single or combination therapies for this high-risk prostate cancer, and it is associated with an acceptable side-effect profile. CSAP should also be the treatment of choice for men with recurrent local disease who have undergone external beam radiotherapy or PB.     

The value of radiotherapy in treating recurrent prostate cancer after radical prostatectomy

Approximately 25-40% of men who undergo radical retropubic prostatectomy (RRP) for the treatment of clinically localized prostate cancer will experience biochemical recurrence. A rapid prostate-specific antigen (PSA) doubling time or high-grade disease are risk factors for progression to bone metastases and cancer-specific mortality. Salvage external-beam radiotherapy (EBRT) to the prostate fossa is the only curative therapy for patients with biochemical recurrence after RRP, but it is used relatively infrequently to treat recurrent prostate cancer because of a widespread perception that most patients have systemic recurrence, and its reported lack of efficacy for high-risk disease. However, in a large, multicenter study of patients who received salvage EBRT for a rising PSA level after RRP, a substantial proportion of patients with high-grade disease and/or a rapid PSA doubling time were observed to have a favorable outcome after salvage EBRT if it was administered at low PSA values. This suggests that salvage EBRT could provide long-term cancer control for patients at the highest risk of progression to bone metastases and cancer-specific mortality. A nomogram that predicts the 3-year progression-free probability after salvage EBRT has been developed to facilitate the selection of patients for this potentially curative therapy. In the absence of other curative therapies, all patients with recurrent prostate cancer should be considered for salvage EBRT, particularly those with positive surgical margins. To be successful, salvage EBRT should be administered at the earliest evidence of recurrent disease, once a rising PSA trend as been confirmed.     

Targeted salvage lymphadenectomy in patients treated with radical prostatectomy with biochemical recurrence: complete biochemical response without adjuvant therapy in patients with low volume lymph node recurrence over a long-term follow-up

Background

Choline positron emission tomography/computed tomography (PET/CT) represents an option in restaging of prostate cancer patients with disease relapse after local treatment. The present study assess whether salvage resection of lymph node metastases detected on choline PET/CT imaging in prostate cancer patients with biochemical recurrence after radical prostatectomy can result in a long-term complete biochemical remission, without adjuvant therapy.

Methods

We analysed 13 patients with prostate specific antigen (PSA) recurrence (PSA median 1.64 ng/ml, range 0.5-9.55) after radical prostatectomy and suspicious lymph nodes (median 1; range 1–3) detected on [11C]choline and [18F]fluoroethylcholine PET/CT scans. An open salvage lymphadenectomy of positive lymph nodes in a PET/CT scan and nearby lymph nodes was carried out. We examined PSA outcome without adjuvant therapy; defined complete biochemical remission as PSA <0.01 ng/ml. Histological and PET/CT findings were compared.

Results

Ten of 11 patients with histologically confirmed lymph node metastases showed a PSA response. Three of ten patients with single lymph node metastases had a complete biochemical remission (median follow-up 72 months, range 31.0-83). In five cases with single lymph node metastasis PSA decreased <0.02 ng/ml. Histologically confirmed 13 of 16 metastasis suspicious lymph nodes. No lymph node metastases were detected in two patients. All of the additionally removed 30 lymph nodes were correctly negative.

Conclusions

This is the first confirmation of a complete biochemical remission after PET/CT guided secondary resection of a single lymph node metastasis in prostate cancer patients with biochemical recurrence after radical prostatectomy, over the long-term (>6.5 years), without adjuvant therapy. In order to improve these promising results, longer-term studies with more patients are required.     

Salvage radical prostatectomy for radiorecurrent prostate cancer: morbidity revisited

PURPOSE: With the advent of prostate specific antigen (PSA) testing and transrectal ultrasound guided prostate biopsy there has been stage migration in the diagnosis of prostate cancer, so that more younger men are being diagnosed with organ confined prostate cancer. Many patients elect radiation therapy, while some have recurrent or new prostate cancer with absent systemic disease and life expectancy greater than 10 years. We present our experience with salvage radical prostatectomy in these cases. MATERIALS AND METHODS: Between 1995 and 2000, 6 men treated with curative intent with radiotherapy for prostate cancer were subsequently treated with salvage surgery for clinically localized prostate cancer. All men had biopsy proved recurrent or persistent prostate cancer, increasing serum PSA, no evidence of systemic disease at surgery and life expectancy greater than 10 years. We assessed the morbidity associated with this procedure and compared results to those in the contemporary literature. RESULTS: Six patients underwent salvage radical prostatectomy. Initial pre-radiation PSA was 4.5 to 15.7 ng./ml. Pre-radiation disease was clinical stage T1c in 5 cases and B2 in 1. The interval from radiotherapy to repeat biopsy was 12 to 48 months. A mean of 6.3 months after local recurrence was detected and before salvage radical prostatectomy was performed 4 patients underwent androgen deprivation therapy. Mean operative time was 195 minutes, intraoperative blood loss was 680 cc, and hospital stay and catheterization time were 3.2 and 13.8 days, respectively. There were no rectal injuries. All 6 patients are impotent, 5 are continent and 1 has mild stress incontinence. There was biochemical failure in 1 case 36 months after salvage radical prostatectomy and no evidence of recurrence in the remaining 5 at a mean followup of 27 months. CONCLUSIONS: Salvage radical prostatectomy is a technically challenging procedure. In the past it was associated with a high incidence of rectal injury, urinary incontinence and anastomotic stricture. The results of our relatively small series are encouraging and concur with those of recent studies that the morbidity of salvage radical prostatectomy is lower than previously reported. We believe that salvage radical prostatectomy may be considered a reasonable treatment option in appropriate patients with radiorecurrent prostate cancer.     

Salvage-Prostatektomie

Organ-confined prostate cancer can be treated with curative intent by different types of radiotherapy or by radical surgery. Regardless of improvements in radiotherapy about 60% of patients with prostate cancer develop biochemical recurrence (BCR) which is defined by the progressive increase in serum prostate-specific antigen (PSA) and necessitates further diagnostic procedures. If non-organ-confined cancer and metastasis are categorically excluded by cross-sectional imaging using computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography CT (PET-CT) and bone scintigraphy, a prostate biopsy should be performed. Biopsy proven detection of recurrent or persisting prostate cancer after irradiation is essential prior to a salvage prostatectomy. The function of the lower urinary tract should be evaluated prior to surgery. Preoperative PSA measurement is the best prognostic indicator prior to surgery. Salvage prostatectomy in irradiated patients is more challenging and requires extensive skill. The most common complications are incontinence, rectal injury and anastomotic strictures. Both functional and oncologic outcome have improved due to better irradiation techniques and surgical skills. Provided post-radiotherapy recurrence of prostate cancer is diagnosed early enough, curing is possible by salvage prostatectomy.     

Salvage prostatectomy. Principles of diagnostics and operative therapy

Organ-confined prostate cancer can be treated with curative intent by different types of radiotherapy or by radical surgery. Regardless of improvements in radiotherapy about 60% of patients with prostate cancer develop biochemical recurrence (BCR) which is defined by the progressive increase in serum prostate-specific antigen (PSA) and necessitates further diagnostic procedures. If non-organ-confined cancer and metastasis are categorically excluded by cross-sectional imaging using computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography CT (PET-CT) and bone scintigraphy, a prostate biopsy should be performed. Biopsy proven detection of recurrent or persisting prostate cancer after irradiation is essential prior to a salvage prostatectomy. The function of the lower urinary tract should be evaluated prior to surgery. Preoperative PSA measurement is the best prognostic indicator prior to surgery. Salvage prostatectomy in irradiated patients is more challenging and requires extensive skill. The most common complications are incontinence, rectal injury and anastomotic strictures. Both functional and oncologic outcome have improved due to better irradiation techniques and surgical skills. Provided post-radiotherapy recurrence of prostate cancer is diagnosed early enough, curing is possible by salvage prostatectomy.     

Localized prostate cancer. Local treatment and what place for lymphadenectomy

The pretreatment PSA level, the Gleason score, the presence of lymph-node metastases, the status of surgical positive margins are poor pathological risk factors for patients who have a pathologic stage T3 prostate cancer. The increase in PSA level during the year prior to diagnostic is associated with the risk of death due to prostate cancer following radical prostatectomy or external beam radiation therapy. The assessment of Locoregional extension is indicated for such patients. The extended pelvic lymphadenectomy remains the most accurate procedure for a correct staging of the detection of nodal involvement in these patients with high-risk localized prostate cancer. For such patients with a high-risk of progression and, whose the life expectancy is greater than 10 years, treatment must be a combined modality therapy since radical prostatectomy alone correlates with a poor clinical outcome. Adjuvant hormonal therapy following local curative treatment by prostatectomy (or radiotherapy) needs to be often considered. Collegial decision-making is by far the most appropriate setting for the discussion among medical specialists of these complex clinical cases for patients often having associated medical conditions and whose adjuvant treatment will have a significant impact of their future quality of life.