Can RP be performed for patients with very High PSA Levels?

Dear All, I read this article with considerable interest. The reason being is that I vociferously objected once at a conference when a paper was presented where RP was performed with very high PSA. We were all under the impression that PSA over 20ng/mL represented higher incidence of metastatic P Ca and not picking up Mets by Bone scan of yesteryears did not rule out no bone mets. After reading this article, wherein though the authors have confessed to the limitations of the study, I have to openly apologize to those whom I openly hurled my comments which includes a close associate of mine as well. https://jnccn.org/view/journals/jnccn/17/8/article-p941.xml?utm_source=Email&utm_medium=Email&utm_campaign=JNCCN%20ETOC%20In%20Focus%209.4.19%20Ongoing&email=0547bdc5929119da8f7018d8b3235272ebad352f176fcf6585a304d025ad2bc6 (PDF available) Recently with the advent of 68Ga-PSMA PET scan more exact staging can be achieved and especially in patients with high PSA levels need exact Staging. As informed to me by an expert in Nuclear Medicine, PSMA scan can be considered as a one stop test for P Ca. Recently functional Imaging such as these are also able to provide information as regards the disease within the prostate and also able to give information regarding its aggressiveness. What piques me is the fact that if RP can be offered in most instances, High PSA levels as indicated, in Oligometastatic Disease and as salvage therapy after other modalities of treatment, the why do we have to study the disease so extensively prior to offering treatments. If all these advanced disease have favourable outcomes with RP, why not perform RP for all P Cas irrespective of advanced nature of the disease. With warm regards Venu

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Comments(7)

  • Venugopal P
    Venugopal P
    03 Jan 2020 06:08:10 PM

    I am uploading the PDF of the article

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  • Dr. Anil Takvani
    Dr. Anil Takvani
    03 Jan 2020 06:31:53 PM

    https://jnccn.org/view/journals/jnccn/17/8/article-p941.xml?utm_source=Email&utm_medium=Email&utm_campaign=JNCCN%20ETOC%20In%20Foc Link of article

  • Amrith Raj Rao
    Amrith Raj Rao
    04 Jan 2020 07:03:12 PM

    Dear Prof, Interesting paper. I am just curious as to why the authors did not use PSA 100 as the cut off. My feeling is that they might have tried 100 as the cut off and it didnt work for their stats and therefore brought it down to >98.0 Only a statistician will be able to shed some light on this.

  • Nitesh Jain
    Nitesh Jain
    06 Jan 2020 10:25:21 PM

    CaP is a disease where simple orchidectomy gives a favourable result which at present is being questioned but many of the seniors will vouch that they have patient doing well for many years ... its a disease with slow progression so all the players in the market claims there superiority At one place cytoreductive surgery is being questioned in kidney but Same is being promoted in CaP and ironically most of the papers give example of Ca Kidney

  • Dr. Anil Takvani
    Dr. Anil Takvani
    18 Jan 2020 09:19:18 AM

    I am seeing urologists performing RP and bilateral orchiectomy simultaneously or few weeks apart when they notice PSA still higher side even after RP. Can someone explain logic behind....thanks

  • Prabir Basu
    Prabir Basu
    18 Jan 2020 11:46:29 PM

    RP for NoM0 PSA>100 in PSMA PET CT negative patients may stretch the indication too far. This will likely open up a paradigm shift in conventional pre treatment risk stratification criteria. Anyways , the index case becomes a high risk localised disease, where there are recommendations that long term ADT can be given with EBRT. So if we extrapolate this for our primary surgical cause, then the concept of RP + BLO in the above scenario may not be very illogical.

  • Amrith Raj Rao
    Amrith Raj Rao
    19 Jan 2020 05:51:23 PM

    Dear Anil, So far I havent come across such a scenario that you have described. If there is persisting PSA post RP, then it suggests residual disease. THe question is where is the residual disease. If it is local, then Salvage RT is indicates, which can have potential for cure. However, if it is systemic disease, then one could go down the route of other therapies. However, unless one establishes what they are dealing with, performing a non-reversible procedure such as Bilateral Orchiectomy is not right.

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