Post-prostatectomy adverse pathological features with undetectable PSA — MSRA MCQ

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ModerateProstate CancerPost-prostatectomy adverse pathological features with undetectable PSAMSRA

A 65-year-old man is reviewed 8 weeks after radical prostatectomy for prostate adenocarcinoma. Histology shows pT3a disease, Gleason score 4+3=7 (grade group 3), with a focal positive posterolateral surgical margin. Pelvic lymph nodes were negative. His postoperative PSA is <0.1 micrograms/L using the same assay as before surgery. He is fit for further radical treatment if required and has no symptoms suggestive of metastatic disease. Which management strategy is most appropriate now?

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Correct answer: D — Continue PSA surveillance and, if biochemical relapse occurs without known metastases, refer for salvage prostatic-bed radiotherapy

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

The positive surgical margin and extracapsular extension increase the risk of recurrence, but they do not justify routine immediate adjuvant treatment when the postoperative PSA is undetectable. NICE advises against immediate postoperative radiotherapy after radical prostatectomy, including for margin-positive disease, other than in a clinical trial. It also advises against adjuvant hormonal therapy after prostatectomy outside a trial. PSA should be checked no earlier than 6 weeks after radical treatment, then at least every 6 months for the first 2 years and at least annually thereafter. If biochemical relapse develops and there are no known metastases, salvage radiotherapy to the prostatic bed should be offered. A prostatic-bed biopsy is not routinely indicated after radical prostatectomy. A and B are attractive because adverse pathological features historically prompted adjuvant radiotherapy, but this is not the recommended routine sequence. C is inappropriate because adjuvant androgen deprivation after prostatectomy is not routinely offered. D is incorrect because biopsy of the prostatic bed should not be offered after radical prostatectomy.

Reference: NICE NG131: Prostate cancer: diagnosis and management — Recommendations (Last updated 15 December 2021; last reviewed 13 August 2025) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations