Prostate cancer is a common malignancy among men, and robotic-assisted radical prostatectomy is a frequently utilized treatment option for localized disease. While this surgical approach offers benefits like precise tumor removal and reduced recovery times, cancer recurrence is a possibility for some patients. Recurrence means prostate cancer cells have returned after initial surgical treatment.
Understanding Recurrence
The primary indicator of prostate cancer recurrence after robotic prostatectomy is a rise in Prostate-Specific Antigen (PSA) levels, known as biochemical recurrence. After surgical removal of the prostate gland, PSA levels should become very low, often undetectable (less than 0.1 ng/ml). A detectable and rising PSA level, defined as 0.2 ng/ml or greater, signals that prostate cancer cells are present again.
Monitoring PSA levels is a routine part of follow-up care after robotic prostatectomy. PSA tests are conducted every three months for the first year after surgery, then biannually, and annually thereafter to detect any increase as early as possible.
Recurrence can occur because microscopic cancer cells may have escaped the prostate gland before its removal or were not detected during initial treatment. These lingering cells can grow, leading to a detectable rise in PSA. The cancer may also have been more extensive than initially believed, with small clusters of cells outside the prostate not targeted by surgery.
Factors Influencing Recurrence
Several factors can increase the likelihood of prostate cancer recurrence after robotic surgery. These relate to the initial tumor’s characteristics, assessed through pathological examination of the surgically removed prostate. Pre-operative PSA levels, biopsy Gleason score, and clinical stage are considered.
Post-operative pathological factors indicate risk. A higher Gleason score (e.g., 8-10) in the surgical specimen, indicating a more aggressive cancer, is associated with a higher risk of recurrence. Pathological stage, which describes the extent of the cancer’s spread within and beyond the prostate, is also important. Advanced stages, such as T3 (cancer extending beyond the prostate capsule) or T4 (cancer invading nearby structures), carry a higher risk.
Seminal vesicle invasion (cancer cells in the seminal vesicles) or lymph node involvement (cancer cells in nearby lymph nodes) are additional indicators of higher recurrence risk. Another factor is positive surgical margins, meaning cancer cells were found at the edge of the tissue removed during surgery, suggesting some cancer cells may have been left behind. The length and multifocality of positive margins can further influence the risk of biochemical recurrence.
Treatment Approaches for Recurrence
When prostate cancer recurs after robotic surgery, various treatment options are available, tailored to the recurrence’s extent, location, and the patient’s overall health. One common approach is external beam radiation therapy, or salvage radiation. This treatment delivers high-energy rays to the prostate bed to destroy remaining cancer cells. Salvage radiation can be given alone or with hormone therapy.
Hormone therapy, also known as androgen deprivation therapy (ADT), is a treatment option. Prostate cancer cells rely on male hormones (androgens) to grow, so ADT works by reducing these hormone levels or blocking their action. This can slow cancer cell growth and spread, and is often used when recurrence is outside the immediate prostate area or with radiation therapy.
Salvage surgery, including robotic salvage prostatectomy, may be considered if recurrence is localized. This procedure involves removing the prostate bed and surrounding tissues. While more complex than initial prostatectomy, robotic assistance can offer advantages such as reduced blood loss and shorter hospital stays. The decision for salvage surgery is carefully weighed, considering potential complications and the patient’s overall health.