After surgical removal of the prostate, and depending on the initial tumor stage, one-third of treated prostate cancer patients experience a rebound PSA increase. What therapy might be the optimal treatment option in the event of a local recurrence? This is a question we are often asked here at ERCM, and we answer it on this page.
With the innovative CyberKnife therapy, we at the European Radiosurgery Center Munich offer highly effective tumor therapy at the highest international scientific standards. For recurrent prostate cancer, the CyberKnife can be a highly effective and safe treatment alternative.
We are here for you and will provide you with comprehensive information about all the options for the best possible treatment strategy for you.
A PSA increase – despite initial therapy – is also referred to as biochemical recurrence, PSA recurrence or PSA progression. After conventional radiotherapy, a relapse or recurrence occurs in up to 2050% of treated prostate cancer cases.
Using modern imaging techniques or combined diagnostic examination methods, it must now be determined whether tumor tissue can be detected again. Diagnostic techniques used include MRI and PSMA PET-CT for functional imaging of prostate tissue. The prostate-specific membrane antigen, or PSMA for short, serves as the target structure.
PSMA is a specific protein that is present only in small amounts on the surface of healthy prostate cells, but is produced in large quantities, particularly in cases of prostate cancer or recurrences. [1]
It is important to distinguish whether it is a local recurrence in the prostate or the prostate itself or a distant recurrence in the form of metastases: Over 50% of all recurrences are local recurrences.
Which therapy is appropriate in each individual case must be carefully considered, especially in older or multimorbid patients. Depending on the individual medical history, numerous treatment options are available: surgery, conventional radiation therapy, cryotherapy, high-intensity focused ultrasound (HIFU), brachytherapy, and even robot-guided CyberKnife therapy [2].
After a previous operation, a local recurrence usually cannot be treated again due to scarring. Likewise, after conventional radiation therapy, a local recurrence can no longer be treated conventionally. Systemic anti-hormonal therapy is usually preferred when patients are not suitable for invasive surgery due to poor general health or do not consent to it.
Last but not least, the risks of invasive treatment must always be considered and weighed, including bleeding, scarring of the urethra (urethral strictures), fistulas, incontinence, or impotence. Robot-guided treatment with the CyberKnife represents an effective and gentle alternative to previously known treatment options for recurrent prostate cancer – with excellent tumor control and few side effects [3].
Cyber Knife therapy can be used after both prostatectomy and conventional radiotherapy. This radiosurgical procedure using a precision robot significantly expands the treatment spectrum.
Another advantage of this robot-guided precision medicine in cases of recurrence is that anti-hormonal therapy can be delayed after prior prostate removal [4]. Anti-hormonal therapy is often also referred to as hormone deprivation therapy. The administered active substances (in the form of medications or injections) bind to specific hormone binding sites in the pituitary gland, resulting in fewer neurotransmitters being released in the brain that control testosterone production in the testes. Testosterone production is suppressed.
Even high-risk structures such as the urethra, bladder, or rectum can usually be protected very effectively with CyberKnife therapy. With the utmost precision (less than 1 mm), small, clearly demarcated tumors can be treated with high doses on an outpatient basis – in a single session.
High-resolution imaging (MRI and PSMA PET-CT) as well as precisely placed gold markers for tumor tracking are the basic requirements for effective and safe CyberKnife therapy in the treatment of local recurrence – as well as in the initial treatment of prostate cancer.
Given that the prostate is a mobile organ, the gold markers serve to precisely guide the subsequent robot-guided, non-invasive treatment. Applying the gold markers requires a minor procedure, which is performed on an outpatient basis with our urology partners under local anesthesia shortly before the actual treatment. This procedure is similar to taking a prostate biopsy, but significantly less complex and with fewer complications.
Close collaboration with highly specialized radiological diagnostic experts is extremely important because only appropriate imaging ensures precise target volume definition. These are essential prerequisites that we at ERCM are provided by our collaborating partners.
To monitor the success of the treatment, consistent cancer follow-up is important: 3 months after your treatment, the PSA level will be checked, and 6 months after CyberKnife therapy, further laboratory tests to determine PSA levels and MRI scans will be performed.
Possible complications depend on the size and location of the recurrence. In principle, the same side effects and risks apply in the event of a recurrence as described in our overview of prostate cancer – only the likelihood of these risks occurring is lower due to the significantly smaller radiation dose in the case of a recurrence.
The exact procedure and individual questions will be discussed in detail with you and our experts during our consultation hours.
This article discusses in detail the possibilities of CyberKnife therapy for prostate cancer recurrence with our cooperation partners. A patient who was treated for a recurrent tumor several years ago describes his personal experiences with this therapy and how he has fared since then.
Have you been treated for prostate cancer, yet your PSA level has subsequently risen again? The fear of a relapse can be extremely stressful, not only physically but also mentally and emotionally, over time, and can significantly impact your quality of life. As a patient, you don't have to walk this path alone. Contact us anytime – we're here for you. Use the contact form, contact us by phone, or via our social media channels.
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Prostate cancer recurrences, when still small, are typically very treatable and therefore not particularly dangerous. However, if left untreated, a recurrence can continue to grow and invade neighboring organs such as the bladder or rectum. In these cases, treatment is usually extremely difficult, so early detection of a recurrence is crucial for a good prognosis.
Immediate treatment is not always necessary; in some cases, careful monitoring may be considered to determine the best time for treatment.
PSA recurrence typically occurs more than 18 months after surgery or conventional radiotherapy. The PSA value usually only increases slowly.
If prostate cancer recurrences are detected early and the recurrence is limited to a specific area (local recurrence), the prognosis is generally very good. The precision of radiosurgical treatment (less than 1 mm) allows for the treatment of prostate cancer recurrences in a single session, while maximizing damage to surrounding healthy tissue.
Yes, recurrence can occur even after successful treatment. Post-treatment monitoring is therefore very important to detect a possible relapse early and treat it appropriately. Regular follow-up examinations and PSA tests are crucial for monitoring the progression of the disease.
[1] Cappel, C. C., Dopcke, D., Dunst, J. PSMA-PET-CT zum primären Staging von Patienten mit fortgeschrittenem Prostatakarzinom. Strahlenther Onkol. 2021;197(3):257-260.
https://link.springer.com/article/10.1007/s00066-020-01732-7
[2] Valle, L. F., Lehrer, E. J., Markovic, D., Elashoff, D., Levin-Epstein, R. et al., A Systematic Review and Meta-analysis of Local Salvage Therapies After Radiotherapy for Prostate Cancer (MASTER). European Urology 2021;80(3):280-292.
https://www.sciencedirect.com/science/article/abs/pii/S0302283820308745?via%3Dihub
[3] Schröder, C., Tang, H., Lenffer, B., Buchali, A., Zwahlen, D. R. et al., Re-irradiation to the prostate using stereotactic body radiotherapy (SBRT) after initial definitive radiotherapy. A systematic review and meta-analysis of recent trials. Clin Transl Radiat Oncol. 2024;48:100806.
https://www.ctro.science/article/S2405-6308(24)00083-1/fulltext
[4] Spek, A., Graser, A., Habl, G., Muacevic, A., Fuerweger, C. et al., Single-fraction image-guided robotic radiosurgery efficiently controls local prostate cancer recurrence after radical prostatectomy. BJUI Compass. 2020;1:139-145.
https://bjui-journals.onlinelibrary.wiley.com/doi/10.1002/bco2.32