Delayed Prostate-specific Antigen Recurrence After Radical Prostatectomy: How to Identify and What Are Their Clinical Outcomes?

doi:10.1016/j.urology.2009.02.049

Urology

Volume 74, Issue 3, September 2009, Pages 643-647

https://doi.org/10.1016/j.urology.2009.02.049 Get rights and content

Objectives

To identify factors that predict delayed (> 5 years) prostate-specific antigen recurrence (PSAR) after radical prostatectomy (RP) and to analyze the associated clinical outcomes.

Methods

A cohort of 4561 men who underwent RP between 1988 and 2008 was retrieved from the Duke University Prostate Center database. Among them, 1207 (26.5%) had PSAR and were included in this study. The cohort was then divided into 2 groups; PSAR before 5 years (early PSAR) and PSAR after 5 years (delayed PSAR), and Kaplan Meier analysis was performed. Univariate and logistic regression analysis was carried out to determine significant predictors of delayed PSAR, using factors such as race, age, body mass index, PSA, surgical margin status, pathologic Gleason sum, pathologic tumor stage, and prostate weight.

Results

There was a marginal difference between the early and delayed PSAR groups with regard to metastasis-free survival (P = .062). A significant difference in disease-specific survival was found between the 2 groups (P = .025). Patients with pathologic Gleason sums < 7 were more likely to have delayed PSAR as compared to those with pathologic Gleason sums > 7 (OR = 2.38). Patients with a PSA < 10 ng/mL were more likely to have delayed PSAR in comparison to those with PSA > 20 ng/mL (OR = 2.38).

Conclusions

Approximately 90% of PSAR occurred within 5 years after RP. Lower pathologic Gleason sums and lower PSA at diagnosis were associated with delayed PSAR. Patients with delayed PSAR have a disease-specific survival advantage as compared to men with early PSAR.

Section snippets

Material and Methods

A cohort of 4561 men who underwent radical prostatectomy (RP) between 1988 and 2008 was obtained from the Duke Prostate Center database. PSAR was defined as a PSA level of ≥ 0.2 ng/mL, 30 days after RP.¹ Of 4561 men, 1207 (26.5%) had PSAR and were included in this study. Patients were then divided into 2 groups; PSAR before 5 years (early PSAR) and PSAR after 5 years (delayed PSAR). Metastases were defined as a patient having a positive bone scan, CT scan, or chest x-ray. The cause of death was

Results

Of the original cohort of 4561 men, 1207 (31.4%) patients had PSAR. Approximately 90% of PSAR occurred within 5 years after RP (Fig. 1). There was a marginally significant difference (P = .062) in metastasis-free survival between the 2 groups (Fig. 2A). Patients with delayed PSAR had a disease-specific survival advantage (P = .025) compared to patients with early PSAR (Fig. 2B). The median time to metastasis in the delayed PSAR group was 10.5 years after RP, with an interquartile range of

Comment

Our study showed that delayed PSAR (PSAR after 5 years) has significant clinical implications. PSAR had been a well-established marker for failed local therapy.⁶ Many models have been established that use variables such as race, prostate weight, pathologic Gleason sum, clinical stage, and preoperative PSA to predict patients who are at increased risk of PSAR.2, 3 Outcomes of PSAR can range from recurrence with minimal clinical implications, to metastatic disease and death from prostate cancer.

Conclusions

Approximately 90% of PSAR occurred within 5 years after RP. Time to PSAR is an independent variable predictive of disease-specific survival. A lower pathologic Gleason sum and lower PSA at diagnosis are associated with delayed PSAR. There is a marginal significance between delayed PSAR and metastasis-free survival. Patients with delayed PSAR have greater disease-specific survival as compared to patients with early PSAR.

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The Mount Sinai Genitourinary Cancer Biorepository, an institutional review board–approved, single-institution database containing all consented genitourinary cancer patients seen between 2010 and 2018, was used to identify and stratify patients into the following cohorts based on their PSA at or near death: <100 ng/mL, 100–1000 ng/mL, and >1000 ng/mL. Analyses were performed to assess clinical characteristics of disease, treatment response, and outcomes.
We identified 1097 patients with prostate cancer, and 101 were confirmed to be deceased following a diagnosis of mCRPC. In patients with mCRPC, cohorts of higher PSA level at death were associated with lower Gleason score at diagnosis and a trend toward longer time to mCRPC and longer time from diagnosis to death, despite a higher burden of disease at death. Conversely, subgroup analysis of PSA < 10 ng/mL at death was associated with lower rates of imaging within 6 months of death, lower treatment rate, and worse clinical outcomes.
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BCR refers to rising PSA levels from the nadir following initial treatment with curative intent, be that surgery or radiotherapy. It is estimated to occur in 20–30% of patients.39,40 In patients with BCR, imaging is undertaken in order to find the site of recurrence, which can be local recurrence within the prostate bed, loco-regional nodal disease, or distant metastases (Fig. 4).
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OncologyDelayed Prostate-specific Antigen Recurrence After Radical Prostatectomy: How to Identify and What Are Their Clinical Outcomes?

Objectives

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Conclusions

J Urol

J Urol

Actas Urol Esp

J Urol

JAMA

J Urol

Urology

Int J Radiat Oncol Biol Phys

Natural history of progression after PSA elevation following radical prostatectomy

JAMA

Oncology
Delayed Prostate-specific Antigen Recurrence After Radical Prostatectomy: How to Identify and What Are Their Clinical Outcomes?