The second peak correlates with recurrence after local therapy or metastatic disease. We will discuss it one by one.
Recurrence after surgery may be in the form of PSA persistence, that is a failure to fall to normal, or PSA recurrence, that is, rising after becoming undetectable.
And recurrence after radiation therapy may be in the form of rising in PSA or positive DRE.
For localized recurrence, the treatment options are observation, surgery if initially treated with radiotherapy, radiotherapy if initially treated with surgery and androgen deprivation therapy.
And for metastatic recurrence, androgen deprivation therapy is the mainstay of treatment.
The patients who present directly with metastatic disease are treated directly with hormonal therapy and chemotherapy may be added in some patients who present with high volume disease.
When we use androgen deprivation therapy for the first time for localized, metastatic or recurrence after local therapy, it may be in form of medical or surgical castration.
GnRH agonists or antagonists are used for medical castration, and for surgical castration, both the testes are removed, called as bilateral orchiectomy.
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