Positive Margins after Surgery for Prostate Cancer: Part Two

When surgical margins are positive, several studies show that immediate radiation to the prostate fossa will lower the relapse rates and may slightly improve ten-year survival rates. However, since only 50% of men will relapse, waiting for evidence of a PSA rise before starting radiation may be a reasonable alternative (see Part One of this article). Generally, the monitoring process consists of checking PSA every 3 months.

  Radiation is initiated if the PSA rises above 0.1 or 0.2.

Radiation is the most common treatment for management of a local relapse after surgery.  While radiation is often effective, the possibility of microscopic metastases outside the prostate fossa in another area of the body needs to be considered. Radiation to the fossa alone will not be curative if the disease has spread.  Unfortunately, a final determination about the presence or absence of microscopic metastasis can never certain.  No technology consistently detects microscopic disease with 100% accuracy.  Experienced professionals have learned through experience that microscopic metastases are more likely to be present when the Gleason score is high and when the positive surgical margins are more extensive.  In these situations, the radiation field should probably be expanded to cover the lymph nodes.  Hormone therapy with Lupron is also commonly recommended.

Monitoring prostate cancer without immediate treatment is not appropriate for men who have multiple positive margins.  Multiple margins usually mean that the original cancer was large and high grade.  A monitoring program in this situation is inappropriate because aggressive cancers will almost always recur at some point.

Delaying treatment simply allows more time for ​the cancer to grow and spread. 

Men with multiple positive margins after surgery should be managed with a multimodality treatment approach that includes radiation, hormone therapy and possibly even chemotherapy.  Basically, it’s time to make an aggressive, final effort to cure the disease.  There is substantial variation among experts as to the exact protocol to be recommended.  However, in general, treatment programs tend to mimic the way that high-risk, newly-diagnosed disease is managed (see below). Investigational programs are also looking into the addition of more powerful hormonal agents such as Xtandi or Zytiga or the addition of 4 to 6 cycles of chemotherapy with Taxotere to see if cure rates can be further improved. 

It is a good idea to wait a few months after the operation before starting treatment.  This provides some healing time and hopefully will allow for the restoration of urinary control before starting treatment. Further delay, in the hope that erectile function will resume, a process that may require up to two years, is usually not prudent.

 Assuming there have been no unanticipated complications, hormone therapy with Lupron and Casodex is initiated and continued for 12-18 months.  A consultation with an experience radiation therapist, one who has experience with treating the pelvic lymph nodes, is also obtained.

The usual advice for men with multiple positive margins, is to start radiation therapy that is directed at the prostate fossa and the pelvic lymph nodes.  The pelvic nodes are the first jumping off point for the cancer if it is going to spread.  The radiation starts about 60 days after the initiation of the Lupron and Casodex. (Hormone therapy is associated with a number of potential side effects, some of which can be diminished with medications, diet and exercise.)  I suggest all men considering reading a article I have written on this topic. 

After the completion of radiation and hormone therapy, ongoing surveillance is necessary.  Testosterone and PSA levels are monitored every three months for two years, then every six months for the next three years.  Testosterone monitoring can stop once normal levels recover.  All men who have had radiation, even the ones who have been cured, will need lifelong annual monitoring due to the risk of radiation-induced secondary tumors of the bladder or rectum.  While these types of tumors are rare, early detection leads to less-toxic, more effective therapy.   

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