Prostate cancer recurrence is the re–development of a malignant tumor after radical treatment of prostate cancer. It can be local, systemic or biochemical. It is asymptomatic or manifested by pain, dysuria, hematuria, erectile dysfunction, hematospermia and other symptoms. With systemic pathology, violations of the functions of various organs are revealed. In the later stages, there is a pronounced general oncological symptoms. The diagnosis is made taking into account the analysis to determine the level of PSA, MRI, CT, PET-CT, scintigraphy and biopsy. Treatment – radiotherapy, hormone therapy, surgery, ultrasound ablation.
Information
Prostate cancer recurrence is a malignant neoplasm that has arisen several months or years after radical conservative or surgical treatment of prostate cancer. It can be local (developed in the irradiated prostate tissue or in the area of the bed of the removed prostate gland), systemic (accompanied by metastatic damage to distant organs) or biochemical (manifested only in the form of an increase in PSA levels). Within 10 years after the end of therapy, local and systemic form is detected in 27-53% of patients. Data on the prevalence of biochemical relapses vary. Treatment is carried out by oncologists, urologists and andrologists.
Symptoms
The clinical symptoms of the disease are determined by the localization of recurrent neoplasm and the prevalence of the oncological process. In the initial stages, the prostate cancer recurrence may be asymptomatic. With an increase in the diameter of local recurrent neoplasia, symptoms occur due to mechanical compression of the urethra passing through the prostate gland or the bed of the removed prostate (in the case of previous surgery). There are frequent urge to urinate, intermittent painful urination, hematuria, nocturia, burning sensation during and after urination.
Along with the listed symptoms, with the prostate cancer recurrence, disorders of the sexual sphere can be observed, including impotence, erectile dysfunction and hematospermia. There may be pain in the groin area. During rectal palpation of the prostate gland, a tumor is detected. With a further increase in the size of the local recurrence, germination of the neck of the bladder and rectum is noted. Acute urinary retention, constipation and blood impurities in the feces occur.
Manifestations are determined by the localization of metastases. Most often, the musculoskeletal system suffers. With bone metastases (usually in the lumbar spine, less often in the thoracic vertebrae, pelvic bones, femurs and other bone structures), pain occurs in the affected area, with large foci, pathological fractures are possible. When the spine is affected, neurological disorders are observed. Along with secondary foci in the bones with systemic prostate cancer recurrence, metastases to the lungs, liver, kidneys and brain can be detected.
Metastases in the lungs are manifested by chest pains, coughing and hemoptysis. The lesion of the peripheral parts of the lungs may be asymptomatic. Prostate cancer recurrence with liver metastases is characterized by pain, hepatomegaly and jaundice of varying severity. Metastasis to the kidneys is accompanied by pain in the lumbar region, dysuria and hematuria. With metastatic brain tumors, persistent headaches, nausea, vomiting are detected. The nature of neurological disorders is determined by the localization of metastatic prostate cancer recurrence. In the later stages, exhaustion, hyperthermia and symptoms of cancer intoxication are observed.
Laboratory symptoms
In 1999, it was found that the recurrence of a malignant prostate tumor is necessarily accompanied by an increase in the level of PSA (prostate specific antigen). This discovery changed the approach to the diagnosis of the disease and led to an increase in the role of laboratory research in the detection of prostate cancer recurrence. A new concept has appeared – biochemical prostate cancer recurrence (PSA-relapse). The widespread introduction of laboratory methods for the diagnosis of this pathology made it possible to provide early diagnosis of recurrent processes and to increase the proportion of radical methods of treatment.
An increase in PSA levels may be due to both the development of a prostate cancer recurrence and the presence of remaining normal prostate cells in the area of the bed of the removed organ. Differential diagnosis of local recurrences of prostate cancer, systemic processes and an increase in the level of PSA caused by the remaining prostate cells is carried out taking into account the initial level of prostate specific antigen, its growth rate and doubling time.
It was found that after 5 years from the moment of detection of a biochemical relapse, 4% are fatal, after 15 years – in 15% of patients with biochemical prostate cancer recurrence. Only 15% of patients die from the progression of the disease, while the average duration of the period between an increase in PSA levels and the onset of death is 13 or more years. These statistics indicate the existence of a high-risk subgroup within the group of patients with a diagnosed biochemical prostate cancer recurrence, however, determining the selection criteria for persons belonging to this subgroup is still a serious problem.
Diagnosis and treatment
Along with the determination of PSA, in the process of diagnosing prostate cancer recurrence, data from objective examination and rectal examination, CT, MRI and ultrasound of the pelvic organs, biopsy of the prostate bed and the anastomosis zone are used. To detect systemic prostate cancer recurrence with damage to the musculoskeletal system, skeletal scintigraphy is performed. In the absence of clinical symptoms and a PSA level below 20 ng/ml, ultrasound and CT usually do not show any pathological changes. More reliable results can be obtained using an endorectal MRI.
During a biopsy, a sample containing malignant cells can be obtained in 54% of patients. In the presence of palpable or ultrasound-determined prostate cancer recurrence, the effectiveness of biopsy increases to 80%. To detect liver metastases, ultrasound, CT or MRI of the liver is performed. With relapses of prostate cancer with metastatic kidney damage, urography is performed, with foci in the lungs, chest radiography is performed. With metastases in the brain, a neurological examination is performed, CT and MRI of the brain are performed.
Treatment tactics are determined taking into account the localization, diameter of neoplasia and the prevalence of prostate cancer recurrence. Radiotherapy and hormone therapy are usually used (independently or in combination with radiation). Surgical techniques for the prostate cancer recurrence are rarely used. Surgical interventions are usually performed with small local processes in young patients. Ultrasound ablation is considered as a promising method of treating local relapses. If there is no effect after the use of radiation therapy and hormone therapy, patients with systemic prostate cancer recurrence are prescribed chemotherapy.