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EAU 2020

EAU 2020: Biochemical Recurrence after Radical Prostatectomy

(UroToday.com) As part of a plenary presentation at the European Association of Urology (EAU) Virtual Annual Meeting assessing “Modern prostate cancer imaging in daily practice,” Annika Herlemann, MD, presented the case of a patient who developed biochemical recurrence following radical prostatectomy. At the time of presentation, he was 57 years old with a family history of prostate cancer in his father that was treated with external beam radiotherapy at the age of 72 with subsequent metastatic disease treated with androgen deprivation therapy. The patient had an initial prostate specific antigen (PSA) of 7.2 ng/mL which was subsequently repeated at 7.6 ng/mL. Digital rectal exam demonstrated no lesions, though TRUS demonstrated a 48cc gland with a hypoechoic lesion concerning extraprostatic extension. Subsequent 3T multiparametric magnetic resonance imaging (MRI) demonstrated a PiRADs 5 lesion in the left mid-gland with concerns for extraprostatic spread. The remainder of his medical history was relatively non-contributory, including open appendectomy, hypertension, and mild lower urinary tract symptoms treated with tamsulosin.

MRI targeted fusion biopsy showed GGG3 disease in 2/3 cores from the region of interest as well as GGG2 in 4 of 12 systemic cores. Staging investigations were negative so he proceeded to local therapy, opting for radical prostatectomy. He underwent RALP and extended pelvic lymphadenectomy with final pathology showing pT3a pN0 (0/16) Gleason score 4+3 (GGG3) prostate cancer with negative margins. His initial post-operative PSA was undetectable but approximately 1 year following surgery, he presented with a rising PSA. This was observed over the course of 6 months where it rose to 0.4 ng/mL and he underwent salvage radiotherapy to the prostate bed and pelvis, along with 6 months of concurrent androgen deprivation therapy. His PSA then became undetectable again but rose again just over 1 year following salvage radiotherapy.

To investigate this rising PSA, a prostate-specific membrane antigen (PSMA) PET/CT was performed when his PSA was 0.7 ng/mL. As shown here, this showed no evidence of local recurrence and no bony lesions but a small, suspicious lymph node in the perirectal fat.

case_study_Herlemann.png

This was treated with a 35 Gy SBRT boost, without concurrent androgen deprivation. PSA then remained low, but detectable (0.1 ng/mL).

This case set the stage for subsequent presentations assessing the role of imaging first or treatment first in patients with biochemically recurrent disease.

Presented by: Annika Herlemann, MD, Ludwig-Maximilians-University of Munich, Munich, Germany

Written by: Christopher J.D. Wallis, Urologic Oncology Fellow, Vanderbilt University Medical Center, Twitter: @WallisCJD at the 35th Annual EAU Congress, 2020 Virtual Program #EAU20, July 17-19, 2020.