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Indigo (Relapsed Disease) occurs when surgery, radiation, or some form of focal therapy fail to cure the disease. Men who are Low-Indigo are judged to be at very low risk for harboring any lymph node metastases. To qualify as Low-Indigo the PSA must be under 0.5 after previous surgery, less than 5.0 after previous radiation or focal therapy and the PSA doubling time must be over 8 months. In addition, the original Stage of Blue prior to initial therapy with surgery, radiation or focal therapy must be Sky, Low- or Basic-Teal. Men with High-Indigo have metastases, but only into the pelvic lymph nodes. The metastases are proven to exist by either by surgery or with scans showing unequivocal pelvic node involvement. Scans and surgical pelvic lymph node staging in men with Basic-Indigo show no overt lymph node metastases. However, in men with Basic-Indigo, various factors suggest a significant likelihood that microscopic pelvic lymph node disease is present. Such factors include higher PSA levels, a fast PSA doubling time or a Stage of Blue prior to initial treatment with surgery or radiation that was higher than Basic-Teal. The intensity of treatment selected for Low-Indigo may be relatively mild since less aggressive therapy may be curative and further options can subsequently be implemented if necessary. Aggressive combination therapy is often used for Basic- and High-Indigo for two reasons: To enhance longevity and to eliminate the need for lifelong hormonal therapy, resulting in a better quality of life.
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