[ RadSafe ] Prostatectomy vs RT

[Alston, Chris]

Mr/Ms Okkalides

Each to his own, of course.  But the radical prostatectomy is the gold standard for the tx of early stage prostate Ca.  It is true that it is a very challenging operation, which should only be attempted by the best surgeons, even laparoscopically with robotic assistance.  There are many urologists doing this work who should not be doing it.  However, I'll warrant that the same is true for the urologists and radiation oncologists who do IMRT, SBRT, and seed implantation.

I must say that, contrary to this statement:  "Excision will
also ruin our chances of monitoring any possible such cancer recurrence with
PSA tests.", the radical prostatectomy improves PSA monitoring.  The second sign of a possibly successful operation is that the PSA nadirs to undetectable levels very quickly (one to three months).  It should remain there permanently.  If detectable amounts of PSA are found, subsequent to prostatectomy, it means that there is prostate tissue remnant in the corpus.  If the amount detected increases with time, it means that likely that tissue contains tumor.  At that point, one might do a Prostascint scan in Nuclear Medicine.  Here again, that test is more sensitive and specific when the prostate proper is gone entirely.  These are problems in signal to noise ratio.

Another advantage to the prostatectomy is the regional pathology, which is unattainable by any other method.  The first sign of a possibly curative operation is that the glandular margins, surgical margins, and local lymph nodes, are free of tumor.

By contrast, in RT (of whatever variety), because the prostate does not leave the body, there will be detectable PSA indefinitely.  The test in that case is that PSA should nadir to a low level, and remain there.  One standard for judging recurrence is three (3) successive rises in PSA.

Cheers
cja

P.S.  The risk of dying by prostate cancer is going to increase with decreasing age at diagnosis, and the degree of de-differentiation of the tumor, no?

P.P.S.  Which address for Radsafe are we supposed to use?



-----Original Message-----
From: Δημήτριος Οκκαλίδης [mailto:od at tlmq.com] 
Sent: Thursday, September 16, 2010 3:27 AM
To: The International Radiation Protection (Health Physics) Mailing List
Subject: Re: [ RadSafe ] Radiation exposure poses similar risk of first and second cancers

I would not agree with the prostatectomy vs. RT. It is my experience
(although no formal study has been made here yet) that many patients present
secondary tumors, mostly bone metastases, within a few years after the
operation. I would even go as far as suggesting that biopsy should also be
avoided since multiple piercing of the colon to get to the prostate has been
shown to cause severe infection if not some dissemination of cancer cells.
In addition to all this, complete excision of the prostate is very difficult
because of the gland's shape and position. So there is always the chance
that some small part has remained and will cause recurrence. Excision will
also ruin our chances of monitoring any possible such cancer recurrence with
PSA tests.

So my suggestion is a) monitor, watch and see and b) have RT if needed.
After all there is a greater chance that most men will die with their
prostate cancer rather that because of it.


D.Okkalides
"THEAGENEION" Anticancer Hospital
Thessaloniki
Greece


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