Specialist Brian Helfand, MD, PhD, reviews the case of a 65-year-old man with prostate cancer and shares insight on strategies to monitor for recurrence.
Brian Helfand, MD, PhD: Hello, I’m Brian Helfand. I’m a urologist at NorthShore University HealthSystem in Chicago, Illinois. Today I’m going to talk about 2 cases. The first presentation is a gentleman who’s 65 years old who was previously diagnosed with clinically localized favorable intermediate-risk prostate cancer. He previously underwent radical prostatectomy and pelvic lymph node dissection. Although lymph nodes at the time of surgery were negative, he had positive surgical margins. Subsequently, he received external beam radiation therapy and was started on leuprolide with instructions to follow up and recheck his PSA [prostate-specific antigen] levels every 6 months.
We subsequently followed this patient, and while he was on hormone deprivation therapy, his PSA remained undetectable through 18 months. However, the PSA level increased to 0.8 ng/mL at his 24-month follow-up. His PSA levels were checked 3 months later and were determined to be 1.2 ng/mL, which is a significant increase. The patient then underwent a fluciclovine F-18 PET [positron emission tomography] imaging for suspicion of reoccurrence, and the results demonstrated 2 positive pelvic lymph nodes.
In discussion of this patient who underwent a definitive curative therapy and subsequently had a relatively quick PSA recurrence within the first 24 months, what are we starting to think when we see these type of patients? The truth is that this is a very common scenario. Whether it’s the first 18 months, 24 months, or even 5 years of following patients, you will see a significant number of biochemical recurrences. When you look at the actual numbers, within 15 to 20 years, you see that 40% to 50% of patients—depending on their initial pathology—may experience recurrence. When you think about this, this is something we have to be able to identify because localizing where that recurrence is imperative to subsequent therapy and certainly a personalized treatment plan.
When we look at the grand scope of things, this has been a problem for a long time. When we’ve used the technologies that we’ve had available, meaning a CT scan, a bone scan, or more recently an MRI, we haven’t had the sensitivity or specificity to diagnose these patients or [pinpoint] where their recurrences are localized to. That’s why we’ve had a very high rate of recurrence after we treated these patients with salvage therapies. And the ability to localize where the recurrence is coming from is imperative.
Transcript edited for clarity.