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Biochemical relapse after radical prostatectomy — MSRA MCQ

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HardProstate CancerBiochemical relapse after radical prostatectomyMSRA

A 69-year-old man had radical prostatectomy 14 months ago for pT3a, Gleason score 4+4=8 prostate adenocarcinoma. His PSA was <0.1 micrograms/L 8 weeks after surgery. Using the same assay, PSA has subsequently risen from 0.11 micrograms/L at 8 months to 0.23 micrograms/L at 10 months and 0.47 micrograms/L at 12 months. He has no bone pain, weight loss, neurological symptoms or urinary symptoms. He is fit for salvage treatment and the urology MDT is considering salvage radiotherapy. What is the most appropriate next investigation?

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Correct answer: A — Arrange an isotope bone scan to assess for metastatic disease

This man has biochemical relapse after radical prostatectomy, demonstrated by a confirmed serial PSA rise using the same assay. His PSA has approximately doubled every 2 months, so the PSA trend is sufficiently concerning for metastatic disease despite the absence of bone pain or other symptoms. NICE recommends offering an isotope bone scan when symptoms or PSA trends suggest metastases in a person with biochemical relapse who is being considered for radical salvage therapy. Pelvic MRI should not be performed routinely before salvage radiotherapy. Biopsy of the prostatic bed is not recommended after radical prostatectomy. Spinal MRI is not indicated without spinal symptoms or established extensive vertebral metastatic disease. DRE is not a useful routine investigation for biochemical relapse after prostatectomy and would not exclude metastatic disease. The rapid PSA kinetics should also prompt calculation of PSA doubling time from at least 3 measurements over 6 months, but this does not replace appropriate staging.

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