PSA bounce after permanent implant prostate brachytherapy may mimic a biochemical failure: A study of 295 patients with a minimum 3-year followup
Introduction
After radical prostatectomy, prostate-specific antigen (PSA) drops rapidly (1) and levels should remain undetectable. These levels fall to low but usually detectable levels after prostate brachytherapy (2).
A commonly used definition of biochemical failure after radiation was developed by the ASTRO 8 years ago at a consensus conference. The criteria for failure are three consecutive increases in PSA, with the date of failure defined as the midpoint between postirradiation nadir PSA and the first of the three consecutive rises (3).
Although elevated PSA after treatment can be a sign of disease recurrence, it has also been reported that patients treated with prostate brachytherapy (and external beam radiotherapy) can have a temporary PSA elevation without evidence of disease recurrence. This phenomenon has been termed PSA bounce, bouncing or spike [4], [5], [6], [7], [8].
PSA bounces often result in patient and physician anxiety, as well as subsequent unnecessary therapeutic interventions. In particular, because patients are often treated with hormonal therapy based on postimplantation PSA increases, a benign PSA “bounce” should be ruled out before a therapy with possible side effects is initiated [9], [10].
As permanent prostate brachytherapy is being more widely used (11), PSA bounce will assume more importance for both patients and physicians.
Section snippets
Patients
Between January 1999 and December 2001, 295 prostate cancer patients were treated with 125I seed implantation by the Paris Institut Curie/Hospital Cochin/Hospital Necker Group. Patients were selected according to criteria slightly different from those recommended by the American Brachytherapy Society [12], [13], [14]. Patients were considered eligible for such a treatment if they had clinical stage T1–T2 cancer, Gleason ≤7 (3 + 4), and PSA level ≤15 ng/mL. Systematic endorectal MRI revealed no
Results
The median followup of the entire cohort of 295 patients was 40.3 months (range 9–66).
The majority of patients have a minimum of 3 years followup (230/295, i.e., 78% of patients), with only four patients with less than 24 months of followup (one is lost for followup and three are deceased).
D90 was superior to 145 Gy in almost all patients (294/295), with 77 patients (26.1%) with a D90 superior to 200 Gy, on the CT-based dosimetry obtained on day 60 after prostate implantation. One hundred
Discussion
No definition of PSA failure has, as yet, proved to be a perfect surrogate for clinical progression or survival. Nadir PSA is a strong prognostic factor, but no absolute level could be identified as a valid cutoff for separating successful and unsuccessful treatments.
The recognition of a PSA bounce seems to be important in treating patients who underwent brachytherapy for prostate cancer. Unlike radical prostatectomy, for which the PSA level should fall to undetectable levels, brachytherapy
Conclusion
Posttreatment PSA bouncing occurs frequently in men treated with permanent implant brachytherapy for prostate cancer: 32% of the patients in the present series of 295 cases showed a transitory PSA increase of at least 0.4 ng/mL. The median time to bounce after brachytherapy was 19 months, with almost all cases (95%) occurring within the first 3 years after implantation.
In multivariate analysis, age <70 and D90 >200 Gy were identified as independent factors for a PSA bouncing of at least 0.4 ng/mL,
Acknowledgment
We are grateful to Dr. Wendla Citron for fruitful discussion and translation assistance.
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