On 9 October 2002, a 57-year-old male underwent nerve-sparing radical prostatectomy (RP), orchidectomy, vesiculectomy, and bilateral lymphadenectomy for prostate adenocarcinoma. The pre-operative serum PSA was >30 ng/mL. pT3a No Mo was the post-operative TNM classification, G2, 4-5 Gleason, stage III. On 27 January 2003, biochemical recurrence (BCR) (two consecutive values higher than 0.2 ng/mL) was detected [,] with a serum PSA level of 0.60 ng/mL. On 1 April 2003, a PSA level of 1.17 ng/mL was found. From 19 April 2003 to 3 June 2012, intermittent androgen deprivation therapy (IAD) was administered with 250 mg flutamide pills, three pills/day, and an luteinizing hormone-releasing hormone (LHRH) agonist was given subcutaneously once every four weeks. From 3 June 2012 to 12 October 2013, because of increasing serum PSA levels (on 29 May 2012, a PSA of 2.24 ng/mL was found), flutamide was replaced with 50 mg bicalutamide, one pill/day, and an LHRH agonist was given subcutaneously once every four weeks. Because PSA levels continued to increase (on 7 October 2013, a PSA value of 9.85 ng/mL was found), from 12 October 2013 to 15 April 2014, bicalutamide was replaced by 300 mg of cyproterone acetate, which was administered i.m. once a week, and an LHRH agonist was given subcutaneously once every four weeks. A trans-rectal ultrasound on 4 November 2013 and whole body (WB) computed tomography (CT) on 30 November 2013 detected a 27 × 26 mm nodule adherent to the bladder wall, and it was suspected to be local recurrence; this suspicion was confirmed by biopsy. On 17 December 2013, the serum PSA level was 18.28 ng/mL. From 18 April 2014 to 18 June 2014, he received external beam radiotherapy (EBRT; 7000 cGray in total). Following the fractioned EBRT, the serum PSA levels continuously decreased and, on 5 May 2016, the PSA value was 0.24 ng/mL. On 1 June 2016, the patient started cyclic IT, which was consistently administered according to the above-reported schedule. The serum PSA levels further and progressively decreased. On 27 August 2018, 50 months after EBRT, serum PSA was undetectable, and then it fluctuated between 0 and 0.01 ng/mL. The last PSA observation on 5 August 2019 was 0.01 ng/mL.\nA study [] recruited 35 prostate cancer patients submitted to RP. Ten of these patients were pT2a-b N0M0 and 24 pT3a-b N0M0. All 35 patients with a macroscopic histologically-proven local recurrence received 30 Gy (21 patients) or 40 Gy (14 patients) of intensity-modulated brachytherapy (IMBT), combined with 30 Gy of EBRT. In the subgroup of 21 patients, after a mean follow-up of 29 months, PSA progression-free survival (PFS) was 24%, and the mean time interval to a PSA increase was 16 months. In the other subgroup of 14 patients, the mean follow-up was 26 months, the PSA progression-free survival (PFS) was 43%, and the mean time interval to a PSA increase was 10 months. Rising PSA values of <2 to 4 ng/mL have been reported to be predictive factors for successful radiotherapy of local recurrences after RP [,]. In the above-mentioned study, the mean rising PSA prior to salvage radiotherapy was 5.02 ng/mL, while it was 18.28 ng/mL in our reported patient. Moreover, the serum PSA nadir has been reported in the literature to occur 12–24 months after radiotherapy (RT) []; in our patient, it was reached after 50 months and maintained at 62 months.
On 22 April 2010, a 65-year-old male underwent RP and vesiculectomy for prostate adeno-carcinoma. The pre-operative serum PSA was 13.66 ng/mL. pT3b No Mo was the post-operative TNM classification, G3, 4 + 4 Gleason, stage III. On 7 July 2010, the serum PSA was 0.01 ng/mL. On 10 April 2013, three months after RP, BCR was found to have occurred with two consecutive serum PSA values higher than 0.2 ng/mL (PSA level of 0.23 ng/mL). From 22 April 2013 to 10 May 2015, he received IAD therapy with 150 mg bicalutamide pills (once a day) and, on 9 February 2015, the serum PSA level was 0.02 ng/mL. From 11 May 2015 to 1 November 2015, no adjuvant therapy was given and, on 6 October 2015, the serum PSA level was 0.27 ng/mL. From 2 November 2015 to 29 October 2017, cyclic IT was administered. On 5 October 2017, the serum PSA level was 0.65 ng/mL. From 30 October 2017 to 13 May 2018, he received only 150 mg bicalutamide pills (once a day) and, on 9 May 18, the serum PSA level was 0.24 ng/mL. After that, as a result of a misunderstanding, the patient delayed the beginning of cyclic IT from 14 May 2018 to 11 June 2018. Moreover, during the first cycle of this new round of cyclic IT (from 11 June 2018 to 7 July 2018), he took one instead of four celecoxib pills a day. On 11 July 2018, the serum PSA level was 0.58 ng/mL. From 22 July 2018, he correctly underwent IT cycles and, on 11 May 19, the serum PSA was 0.99 ng/mL. He started on 50 mg bicalutamide pills (once a day), and an LHRH agonist was given subcutaneously once every three months. On 10 August 19, PSA was undetectable; therefore, he again started the IT schedule. On 10 October 19, the last PSA determination was 0.04 ng/mL.\nIn a study [], researchers examined 148 patients who prospectively enrolled in sequential Institutional Review Board approved vaccine protocols. The T stage was T1–T2 in 54% and T3–T4 in the remaining 46%; Gleason was 6–7 in 71% and 8–9 in the remaining 29%. All subjects had recurrent disease and no detectable radiological metastases. Recurrent disease manifested as BCR after surgery or as clinically localized disease at the sites for which they had undergone radiation therapy. The median PSA value at the time of protocol enrollment was 8.2 ng/mL and the median PSA double time (PSADT) was 4.7 months. Overall, 110 (74%) of the 148 patients showed metastatic progression at a median of 19 months and metastases were detected in 68% and 84% of them at 3 and 5 years, respectively. Patients with a T3 stage and Gleason score of 7 or more at the time of diagnosis were more likely to develop metastatic disease (log-rank test; p = 0.006), while the type of primary therapy and the presence of nodal disease were not predictive. In another study [], the researchers analyzed 1590 patients who developed recurrent disease, among 5277 patients who had undergone either RP (1003 patients) or EBRT (587 subjects). In the RP group, about 13% of the 1003 patients had received neo-adjuvant or adjuvant androgen deprivation therapy (ADT) and the mean time between primary treatment and recurrence was 34 months. PSA data after salvage therapy were available for 1050 patients (430 patients who had received initial EBRT and 620 patients from the RP group). In 367 patients (59.2%) in the RP group, ADT was the most common salvage treatment, followed by EBRT, which was carried out in the other 248 patients (40%). ADT was also administered to 402 subjects (93.5%) in the EBRT group. Failure after salvage therapy was defined as a PSA level of >0.2 ng/mL after treatment. Overall, 420 (68%) of the 620 patients in the RP group and 319 (74%) of the 430 patients in the EBRT group recurred after salvage therapy. Among these, 739 patients (24.8%) died. The mean survival was 81.1 months (median of 59.9 months) compared with 103.2 months (median of 101.2 months) for those who did not recur after salvage therapy. This difference in overall survival was statistically significant (p < 0.001). A report of a phase III randomized trial [] presented the long-term results of immediate androgen suppression and external irradiation in patients with locally advanced prostate cancer. In a subgroup of 127 high-risk patients, eight-year clinical disease-free survival (DFS) was about 40%. The high-risk category was defined as having at least two of the following three risk factors: WHO performance status > 0, G3, and initial PSA > 10. Our patient, who shares these characteristics, is alive and in good health 114 months after RP.