Editing Biochemical Recurrence (section)

=== Diagnosis and Evaluation ===
* '''<span style="color:#ff0000">Need to define extent of disease local vs. distant) to guide management</span>'''
** '''<span style="color:#ff0000">If local failure: salvage radiation</span>'''
** '''<span style="color:#ff0000">If distant failure: treat as metastatic castrate-sensitive disease</span>''' (see AUA and CUA Guideline Notes)
** '''PSA velocity, doubling time, interval from surgery to biochemical recurrence, and Gleason score usually help determine whether failure is local or distal, both of which are informative in deciding management.'''

==== Imaging ====
* '''Local failure'''
** '''MRI'''
*** '''Useful even in low PSA values'''
*** Sensitivity, specificity, and accuracy of 98%, 94%, and 93%, respectively, in identifying local recurrence after RP when validated by PSA level decrease after external beam radiotherapy and had sensitivity, specificity, and accuracy of 100%, 97%, and 91% when validated by ultrasound-guided biopsy§
**'''Novel PET-CT imaging'''
***See below; also used to evaluate distant failure
* '''Distant failure'''
**'''Median PSA at the time of a newly detected bone metastasis''' '''is 32 ng/mL''' in hormone therapy–naive men after radical prostatectomy,
*** ≈25% of those metastases occurred at PSA < 10 ng/mL.
** '''"<span style="color:#ff0000">Conventional" imaging: CT scan and bone scan</span>'''
*** '''<span style="color:#ff0000">Diagnostic yield is significantly influenced by the PSA level</span>'''
**** '''<span style="color:#ff0000">Limited if PSA < 10 ng/mL; very limited if PSA 0.2-1 ng/mL</span>'''
*** '''CT scan'''
**** Advantage
***** Good at detecting nodal and visceral metastases
**** Disadvantage
***** Bone metastases are difficult to detect
**** Meta-analysis (2004)
**** 25 studies evaluating prostate cancer staging
**** Results:
***** Detection of lymph node metastasis on CT scan based on PSA:
****** <20 ng/mL: 0%
****** >20 ng/mL: 1.1%
**** Abuzallouf, Sadeq, Ian Dayes, and Himu Lukka."Baseline staging of newly diagnosed prostate cancer: a summary of the literature." ''The Journal of urology'' 171.6 Part 1 (2004): 2122-2127.
*** '''Bone scan'''
**** Time consuming (3 - 4 hours)
**** Costs: 600-1000$ USD
**** Advantage
***** Good at detecting bone metastases
**** Disadvantage
***** Limited sensitivity at detecting bone metastases with low PSA
**** Meta-analysis (2004)
**** 23 studies evaluating prostate cancer staging
**** Results:
***** Detection of bone metastasis on bone scan based on PSA:
****** < 10 ng/mL: 2.3%
****** ≥10 - 20 ng/mL≤l: 5.3%
****** >20 - 49.9 ng/mL: 16.2%
**** Abuzallouf, Sadeq, Ian Dayes, and Himu Lukka."Baseline staging of newly diagnosed prostate cancer: a summary of the literature." ''The Journal of urology'' 171.6 Part 1 (2004): 2122-2127.
** '''Novel PET-CT imaging'''§
*** See Prostate Cancer: Diagnosis and Evaluation Chapter Notes
*** '''Advantage over conventional imaging'''
**** '''Higher sensitivity for the detection of prostate cancer recurrence and metastases at low PSA values (<2.0ng/mL).'''
*** '''FDA approved after biochemical recurrence to evaluate for role of locoregional salvage treatment'''
*** '''2021 CUA Best Practice Report: may be helpful after biochemical recurrence to evaluate for role of locoregional salvage treatment§'''
** '''Newer generation prostate-specific membrane antigen (PSMA) antibodies''' '''are promising for both prostate cancer detection and potential therapy.'''