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Biochemical relapse after radical prostatectomy — MSRA MCQ

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HardProstate CancerBiochemical relapse after radical prostatectomyMSRA

A 67-year-old man is followed in primary care under an agreed shared-care protocol, 3 years after radical prostatectomy for localised prostate adenocarcinoma. His postoperative PSA had been undetectable. Using the same assay, PSA values are now 0.10 ng/mL, 0.20 ng/mL and 0.40 ng/mL at 0, 3 and 6 months respectively. He is well, has no bone pain, weight loss, neurological symptoms or troublesome urinary symptoms. He would accept further curative treatment if appropriate. What is the most appropriate management now?

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Correct answer: D — Refer to the urological cancer MDT for salvage prostate-bed radiotherapy assessment

Explanation lettering: C = shown as A · D = shown as B · A = shown as C · E = shown as D · B = shown as E

This is biochemical relapse after radical prostatectomy: PSA has risen reproducibly on three measurements obtained over 6 months using the same assay. He has no symptoms or other evidence suggesting metastases and remains suitable for curative-intent treatment. NICE recommends offering radical radiotherapy to the prostate bed for biochemical relapse after radical prostatectomy when there are no known metastases. A is incorrect because NICE advises against routine MRI before salvage radiotherapy in this setting. B is a close distractor: the PSA doubling time is 3 months, but NICE does not routinely recommend hormonal therapy for biochemical relapse unless there is symptomatic local progression, proven metastasis, or a PSA doubling time of less than 3 months. C is incorrect because an isotope bone scan is indicated when symptoms or PSA trends suggest metastases; the low absolute PSA and absence of symptoms here do not establish that indication. D fails because serial testing has already established relapse and delaying specialist assessment may forfeit the opportunity for salvage treatment.

Reference: NICE NG131: Prostate cancer: diagnosis and management — managing relapse after radical treatment (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations NICE NG131: Prostate cancer: diagnosis and management — managing relapse after radical treatment (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations NICE NG131: Prostate cancer: diagnosis and management — managing relapse after radical treatment (Last updated 15 December 2021) — https://www.nice.org.uk/guidance/ng131/chapter/recommendations