PSA tests after salvage radiation

Arcticfox44 · New User Joined: 05 Sep 2009 Posts: 6

Hello - I was diagnosed with PC in early 2002 at the age of 57. I had a radical prostatectomy in May 2002 at Sloan-Kettering. My Gleason score after the pathology report was 3+4=7. There was spread to a seminal vesicle but clear margins and no lymph node involvement.
After surgery total PSA fell to less than 0.1 and at its lowest was only 0.004, about six months after the operation. It stayed below 0.1 for about four years, but by December 2007 had risen to 0.19 -- just short of the 0.2 level which S-K uses as the benchmark for recurrence. It then went above 0.2 in early 2008 and by Sept 4 2008 -- one year ago -- it was 0.5.
I began salvage radiation at S-K in early October 2008 and finished in early December. I did not have hormone therapy. As of May 18 2009, total PSA had fallen to 0.33 (as measured at S-K) but on Aug 31 (last Monday) it had risen to 0.447 (as measured by a lab in Cyprus where I live).
I've been told there can be PSA "noise" in the months after salvage radiation, so maybe the only thing to do is wait until a year or so has elapsed since the end of radiation. I have an appointment at S-K on Dec 21. But I'm worried by the upward move in this last test and wonder how significant it is. It could be due to lab variations or otherwise some kind of rogue result, or possibly it might go down before the next test. Anyway at this rate the doubling time would appear to be quite slow. It's not easy to find detailed accounts of PSA fluctuating in the months after salvage radiation, so the question is: How worried should I be?
_________________
Graham

Hawk · Senior User Joined: 22 Nov 2006 Posts: 406

Your story is somewhat like mine since my PSA begain to rise almost 48 month after surgery at MSKCC and is dropping 6 months after Salvage radiation (SRT). A difference is that I pulled the trigger on SRT when my PSA hit .15 rather than waiting.

I think the PSA noise you talk about after radiation is for intact prostates only and does NOT apply to SRT for removed prostates. I am told however that sensitive 2 decimal tests have noise inherent in them and that not much can be made of numbers BELOW .05

However, I think it is important ESPECIALLY when dealing with such low numbers (below .20) to compare only numbers from 1 lab. I know MSKCC draws there own PSA regardless of other tests you have but I mainly compare MSKCC PSA with themselves and MY LAB's results with themselves. At these low numbers you have to focus on the trend and you can only do that with multiple tests from one lab over time.

Good Luck

PS: You mention a 3 decimal PSA test and I was not familiar that there were tests that sensitive for PSA.
_________________
History: PSA's 6.7 neg. biopsy - PSA 16.6 neg. biopsy - PSA's 8.2, 8.1, 8.7 - Biopsy. 4+4 Gleason 8. Lap RP Apr 2004, age 52 All neg margins, nodes, and structures. (T2a). Post RP PSA: every 6 mo. <.1 until Feb, 08 (46 mos) PSA .1 - I then got sensitive tests (all in 2008) showing:
Feb .06, May .09, Jun .10, Aug .10, Nov .15 -SRT

Replicant · Moderator Joined: 01 Nov 2006 Posts: 744

Arctic Fox,
I would be concerned. I would think that lab variation *could* be an explanation, but if that's not it....well, your PSA should be trending lower at this point. As far as I know, months after SRT, it should not rise.

There's probably not much to do but wait for the next test, which should confirm or deny the trend.

I would ignore the very small decimal places and concentrate on the bigger picture. Rounding off, if the labs are correct, your PSA fell to 0.3 at 6 months post-SRT and now it has risen to 0.4.

Hopefully there's been some error or variation. Only time will tell. I think two subsequent rises will be the point at which your doctors say something's wrong. I hope that doesn't happen.

Best wishes.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NXMX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 (and thereafter) <0.1
http://pcabefore50.blogspot.com

johnT · Senior User Joined: 27 Apr 2009 Posts: 176

Artic fox,

I would generally agree with Hawk and Replicant, but the seminal vessel invasion would concern me. Recent studies in Germany and Holland (not yet published) indicate that there is a high probability of lymphnode involvement with seminal vessle invasion. This could be the reason for your rising psa as niether the RP or the salvage radiation would have cured this. Seminal vesssel invasion follows a different lymphatic path and is difficult to detect using normal lymphnode dissection.
There is a test, Combidex MRI, which is done in Holland, that can spot smal lymp node involvement. If you need more information on this please contact me.
JohnT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

srtimmons

I think I would get a second opinion and would not wait. You need tp stay agressive with PCa. If it is nothing, then you wasted some extra time. But, if it is something you may save your life.
_________________
Age 58
Dx 6/15/2009; PSA 7.1; 7/12 cores positive; Gleason 6 (3+3) and 7 (3+4); PNI observed. Bone Scan and CT scan negative. Robotic RP 7/20/2009

Path report 8/11/2009 - clean margins, negative lymph nodes, negative seminal vesicles, Gleason 3+4, Stage T2c; 15% of prostate involved; NoMx.

Post-RRP PSA: 9/09: .006

Hawk · Senior User Joined: 22 Nov 2006 Posts: 406

Aaarrrrrrrgggggggggggghhhhhh,

Sorry, Replicant is correct. That is just one reason he is so valuable here. I misread the decimal place I was thinking your current PSA was in the .03 -.04 range.

Your need for a trend is important to assess VELOCITY but 8 months post SRT your PSA needs to be at or below .1 to suggest a likely durable response. It at least needs to be dropping if above .1 You are not near that number and you do not seem to be dropping.

I also recommend 3 month testing not 6 months. Too much time is wasted without forming a game plan.

Thanks again to Replicant!
_________________
History: PSA's 6.7 neg. biopsy - PSA 16.6 neg. biopsy - PSA's 8.2, 8.1, 8.7 - Biopsy. 4+4 Gleason 8. Lap RP Apr 2004, age 52 All neg margins, nodes, and structures. (T2a). Post RP PSA: every 6 mo. <.1 until Feb, 08 (46 mos) PSA .1 - I then got sensitive tests (all in 2008) showing:
Feb .06, May .09, Jun .10, Aug .10, Nov .15 -SRT

Arcticfox44 · New User Joined: 05 Sep 2009 Posts: 6

Thanks John. I do appreciate this and would like more info on the Combidex MRI test, when you have time. Feel free to email me at g_colville@yahoo.com, if you prefer.

[quote="johnT"]Artic fox,

I would generally agree with Hawk and Replicant, but the seminal vessel invasion would concern me. Recent studies in Germany and Holland (not yet published) indicate that there is a high probability of lymphnode involvement with seminal vessle invasion. This could be the reason for your rising psa as niether the RP or the salvage radiation would have cured this. Seminal vesssel invasion follows a different lymphatic path and is difficult to detect using normal lymphnode dissection.
There is a test, Combidex MRI, which is done in Holland, that can spot smal lymp node involvement. If you need more information on this please contact me.
JohnT[/quote]
_________________
Graham

Arcticfox44 · New User Joined: 05 Sep 2009 Posts: 6

Many thanks for your reply. I thought it would be worth the small fee to get a second test from a different lab here in Nicosia, Cyprus, and I did that yesterday (Sept 7) -- one week after the result of 0.447 for total PSA. This time it was 0.480. These are both reputable labs I've used regularly over the past seven years since RP and the tests are obviously sensitive.
I'll be reporting these results to Sloan-Kettering later today. Since my next scheduled appointment there isn't until Dec 22, I'll also ask about getting a consultation sooner than that.
I want to keep a cool head and avoid charging off in different directions unnecessarily. However, I'd be interested in your views on second opinions in a case like mine. S-K is of course highly regarded and justifiably so. Other places that come to mind are the Mayo, the Cleveland, and Johns Hopkins. As it happens, my father had nerve-sparing RP under Patrick Walsh almost exactly 20 years ago when he was 69. He is still living and has never had a recurrence. Of course, he and I are genetically different people!
Thanks again.

[quote="Replicant"]Arctic Fox,
I would be concerned. I would think that lab variation *could* be an explanation, but if that's not it....well, your PSA should be trending lower at this point. As far as I know, months after SRT, it should not rise.

There's probably not much to do but wait for the next test, which should confirm or deny the trend.

I would ignore the very small decimal places and concentrate on the bigger picture. Rounding off, if the labs are correct, your PSA fell to 0.3 at 6 months post-SRT and now it has risen to 0.4.

Hopefully there's been some error or variation. Only time will tell. I think two subsequent rises will be the point at which your doctors say something's wrong. I hope that doesn't happen.

Best wishes.[/quote]
_________________
Graham

Replicant · Moderator Joined: 01 Nov 2006 Posts: 744

Well, that's a confirmation, IMO. My reaction is dismay, as is yours, I imagine.

If those were my numbers, I would believe that salvage had failed, and that I should find a top-notch oncologist, preferably one who specializes in prostate cancer.

That's me. That's what I would do. I already have Plan B sketched out in my mind should my PSA start to rise, now that I've had surgery and SRT. Plan B for me does not include a urologist. I already have an oncologist in mind, in another city (even though I live in a metro area of over 3 million.)

I realize things may be more complicated for you because of geography.

I don't want to second guess your doctors, though. I don't see anything wrong with a December appointment with Sloan Kettering. If you're in the Walsh camp, you know that Walsh is not a fan of early hormonal intervention.

But if you know of a great oncologist on Cyprus who is an expert in prostate cancer, I would seek him or her out.

You know that I'm not a doctor, and not to take any of this as a substitute for medical advice.

Best wishes.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NXMX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 (and thereafter) <0.1
http://pcabefore50.blogspot.com

Arcticfox44 · New User Joined: 05 Sep 2009 Posts: 6

Thanks again.
I've passed on the results to Sloan, specifically Dr. Mike Morris who specializes in advanced PC. I last saw him on May 19. There are people in my region who may be worth talking to. Last summer, when this was starting to get serious, I had scans at Hadassah Medical Center in Jerusalem and met the specialist there, Dr. Dov Pode. This was with the approval of Sloan, where Dr. Pode has spent some time. So I may go and see him before the December appointment in NY.

[quote="Replicant"]Well, that's a confirmation, IMO. My reaction is dismay, as is yours, I imagine.

If those were my numbers, I would believe that salvage had failed, and that I should find a top-notch oncologist, preferably one who specializes in prostate cancer.

That's me. That's what I would do. I already have Plan B sketched out in my mind should my PSA start to rise, now that I've had surgery and SRT. Plan B for me does not include a urologist. I already have an oncologist in mind, in another city (even though I live in a metro area of over 3 million.)

I realize things may be more complicated for you because of geography.

I don't want to second guess your doctors, though. I don't see anything wrong with a December appointment with Sloan Kettering. If you're in the Walsh camp, you know that Walsh is not a fan of early hormonal intervention.

But if you know of a great oncologist on Cyprus who is an expert in prostate cancer, I would seek him or her out.

You know that I'm not a doctor, and not to take any of this as a substitute for medical advice.

Best wishes.[/quote]
_________________
Graham

	Cancer Forums Forum Index -> Prostate Cancer Forum	All times are GMT - 5 Hours
Page 1 of 1

A website for discussions about any type of cancer, including lung cancer, breast cancer, mesothelioma, prostate cancer, laryngeal cancer, leukemia, lymphoma, multiple myeloma and others