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Thread: After almost six years... Not a Zero

  1. #21
    Quote Originally Posted by Duck2 View Post
    According to Cleveland Clinic concerning high risk prostate cancer, 95% of recurrence is distal or in other words not left in the prostate bed.
    Just because pattern 4 is present doesn't make it high-risk. With regard to G score (not the only criterion for high risk, I wouldn't be surprised if it was G8-10, excluding all G6-7.

    With regard to overall recurrence (BCR) location this study found 38% were outside the pelvis:

    Location of Recurrence by Gallium-68 PSMA-11 PET Scan in Prostate Cancer Patients Eligible for Salvage Radiotherapy

    Abstract

    OBJECTIVE:
    To identify locations of recurrence after radical prostatectomy (RP) with prostate-specific antigen (PSA) <2 by Gallium-68 prostate-specific membrane antigen (PSMA)-11 Positron Emission Tomography (PET) imaging, and to determine whether standard nodal radiation fields would cover the location of prostate cancer recurrence.

    MATERIALS AND METHODS:
    We performed a retrospective review of patients with PSMA-PET imaging for biochemical recurrence following RP with PSA ≤2.0 ng/mL and assessed if the recurrent disease was within standard radiation target volumes. We compared patient and clinical variables between men with recurrences covered by standard salvage radiation fields and those with recurrences outside of standard fields.

    RESULTS:
    We identified 125 patients for study inclusion. The median PSA at imaging was 0.40 ng/mL (interquartile range 0.28-0.63). PSMA-avid disease was found in 66 patients (53%). Of these, 25 patients (38%) had PSMA-avid lesions found outside of the pelvis, 33 (50%) had lesions confined to the pelvic lymph nodes and prostate bed, and 8 (12%) men had PSMA-avid recurrence only in the prostate bed. Salvage radiation including standard Intensity Modulated Radiation Therapy (IMRT) pelvic nodal volumes would not cover PSMA-avid nodal disease in 38 men (30%). PSA at the time of imaging was statistically associated with having PSMA-avid disease outside of standard nodal fields (P <.01).

    CONCLUSION:
    The 68Ga-PSMA-11 PET detects disease in a majority of patients with PSA ≤2.0 following RP. Nearly one-third of men had PSMA-avid disease that would be missed by standard radiation fields. This imaging modality may dramatically impact the design and use of post-RP salvage radiotherapy.
    [Emphasis mine]

    I think I located the webpage with your stat:

    Cleveland Clinic Cancer Center (Taussig) Outcomes

    Analysis was limited to patients with at least 2 post-treatment PSA determinations. Patients with local failure or distal failure were categorized as clinical failure. Over 95% of failures were distal.
    which was based on two studies. The treatment period was 1996-2012. One of the two studies states:

    Biochemical relapse-free survival (bRFS), clinical relapse-free survival (cRFS), and prostate cancer-specific mortality (PCSM) were assessed.
    I'm thinking that the distal failure rate you cited was based on clinical relapse and not BCR (they didn't have sophisticated PET scans during those years to assess the location/source of BCR). It's reasonable that clinical symptoms and signs are the result of metastatic PCa, which is going to be predominately non-local.

    One of the two studies was for Intermediate- and High-risk, the other for High-risk.

    If 95% of BCR were distal (non-local), there would be little point in treating large numbers of men with SRT to the fossa.
    Last edited by DjinTonic; 06-19-2019 at 02:24 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg., then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day retest)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015
    08-28-19 (2 yr. ) 0.016
    Avg. = 0.013

  2. #22
    According to Cleveland Clinic, post prostatectomy 61% of men with high risk will have BCR by year 15. More than 55% that had BCR will have metastasis at 15 years.

    I suppose if you want a glass full v empty statement, 2/3 of high risk men at 15 years do not have metastasis, but for the 1/3 that do, >95% have metastasis that is distal.
    YOB 1957

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM <5%, Right side negative.

    3/6/19. Pathology - Grade Group 4 Intraductal Carcinoma
    T3aNO, 1 mm EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.

    7 Nodes, SV, SM, PNI, and BNI were negative.

    LVI and Cribriform pattern present.

    Decipher .86 High Risk.

    Post Surgery PSA
    3/25/19 .03. (<1 month)
    4/25/19 <.03. (2 months)
    5/25/19 <.02. (3 months)
    9/10/2019. <.02. (6 months)
    11/27/2019. <.02. T<3. (9 months)

    3 Part Modality Treatment

    2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic,

    ADT - started 6/19, end date 6/21.

    ART - Completed 9/26/19. (78 Gy, yes, I glow in the dark)

  3. #23
    Quote Originally Posted by Duck2 View Post
    According to Cleveland Clinic, post prostatectomy 61% of men with high risk will have BCR by year 15. More than 55% that had BCR will have metastasis at 15 years.

    I suppose if you want a glass full v empty statement, 2/3 of high risk men at 15 years do not have metastasis, but for the 1/3 that do, >95% have metastasis that is distal.
    That's different. Yes most metastases are outside the prostate bed and are non-local. Some men do have mets limited to pelvic node(s). However, I'm not sure how high-risk enters the thread.

  4. #24
    Experienced User
    Join Date
    May 2019
    Posts
    80
    Quote Originally Posted by Duck2 View Post
    According to Cleveland Clinic, post prostatectomy 61% of men with high risk will have BCR by year 15. More than 55% that had BCR will have metastasis at 15 years.

    I suppose if you want a glass full v empty statement, 2/3 of high risk men at 15 years do not have metastasis, but for the 1/3 that do, >95% have metastasis that is distal.
    Hi Duck,

    Just trying to do some ciphering on your numbers, so basically 0.61x0.55x0.33x0.95=.105. So 10.5% of high risk patients will have distant metastasis at 15 years. Is this correct?

    I don't know where I've come about my numbers but I was under the impression that there was as 50% probability that a high risk patient - like myself - would have recurrence and, if I indeed did, then there would be a 75% chance that it would be local and 25% distal. So 0.50x0.25=0.125% or 12.5% distant metastasis. Btw, this is about 7-8% lower that what is predicted with my decipher score - albeit that is calculated for 5 year metastasis.

    Actually, is the Decipher score specific on whether or not the probability of metastasis is local or distant?

    IG
    DOB: 10/1962

    6-01-15 PSA 2.5
    Having urination flow issue in first half of 2018. Flomax 6/1-6/21 - no help.
    6/25/18 PSA 14.25; Cipro 14 days
    8/1/18 PSA 17.44; rec. Urologist appt
    8/15/19 First Uro appt. + for bacteria. Cipro 4 weeks
    10/2/19 PSA 22.4; Still + for bacteria. Antibiotics 4wks
    12/28/19 PSA 27.5
    1/15/20 Biopsy results 6/12 cores positive - all left side; GS 4+3
    1/18/19 Bone scan and CT scan both negative
    2/15/19 Di Vinci RP
    2/18/19 Path report pT3a, GS 4+3 (60%+35%) 5% GS5, SM +, EPE +; LVI -, SVI -, LNI(9) - ; Tumor size: 3.5cmx3.5cmx1.5cm; single foci left side; right side nerves spared; SM+ at apex limited <1mm; benign prostatic cells at spared right nerve bundle. Prostate size 45gm.
    Cath out at 7 days: 100% continent with some ED; ok with 10mg Cialis.
    Decipher 0.73

    3/26/19 (6 weeks) 0.033
    5/10/19 (3 months) 0.010
    8/02/19 (6 months) 0.019
    8/30/19 (7 months-recheck) 0.024
    9/26-11/19/19 eSRT (70.2 Gy)

  5. #25
    We have to be careful about how we define recurrence. Usually it is BCR (PSA only). Some men with BCR will go on to clinical recurrence with lesions, often mets, in 3-8 yrs (avg. 5 yr) across all risk groups, I believe. Obviously high-risk men have higher odds of both, and, on the average, earlier than lower-risk men.

    Death from PCa is invariably caused by metastases that compromise the functioning of vital organs and systems (metabolic decline). You don't die from prostate-confined PCa; all death is from mPCa.

    Quote Originally Posted by IndyGuy View Post
    ...

    Actually, is the Decipher score specific on whether or not the probability of metastasis is local or distant?

    IG
    I believe the answer is No. Decipher looks at theoretical risk based on your cancer's RNA. Basically, actual mets can travel almost anywhere, although we know the typical locations for PCa mets: lymph nodes, bone, liver, lungs, etc. Many men who progress go on first to what's called oligometastatic PCa (1-5 mets which can be local and/or distant), which can be managed. Of course RT can deal with local recurrence whether metastatic or not (see the above study I cited that warns about SRT missing local lymph nodes.)
    Last edited by DjinTonic; 06-19-2019 at 03:02 PM.

  6. #26
    In another 2017 study the results were a bit different:

    164 Subjects Post-RP with a rising PSA between .05 and 1.0 ng/ml

    102 ( 62% ) had positive PSMA response
    23% of ALL subjects ( 38 ) were in Fossa (37% of the men with positive PSMA)
    25% of ALL subjects ( 41 ) were in pelvic nodes ((22% of the men with positive PSMA)
    14% of ALL subjects ( 23 ) were distant from fossa/pelvis ((37% of the men with positive PSMA)

    Of the 62 men with NO PSMA response (n=62)
    34 chose NOT to have SRT and 65% of them (n=22) subsequently showed an increasing PSA value

    These seems to confirm what my MO told me in April - if even the µPSA is showing a continual, albeit very small, increase, measured over two or three tests, there is no explanation for the increase other than PCa cells somewhere that are producing PSA. Further, very few men with continually increasing µPSA ever see their PSA level out or decline. Thus, he tells me to prepare myself for SRT at some point in the future.

    The GOOD news is that 81% of those with PCMA response in the fossa showed a PSA < .01 or PSA reduction > 50% subsequent to SRT. It does seem that SRT is quite effective when treating localized post-RP BCR.


    J Nucl Med. 2017 Dec;58(12):1972-1976. doi: 10.2967/jnumed.117.196683. Epub 2017 Jul 26.
    Treatment Outcomes from 68Ga-PSMA PET/CT-Informed Salvage Radiation Treatment in Men with Rising PSA After Radical Prostatectomy: Prognostic Value of a Negative PSMA PET.
    Emmett L1,2,3, van Leeuwen PJ2, Nandurkar R3, Scheltema MJ2, Cusick T2,4, Hruby G5,6, Kneebone A4,6, Eade T4,6, Fogarty G6, Jagavkar R6, Nguyen Q2,4, Ho B3, Joshua AM2, Stricker P7,2.

    Abstract
    68Ga-PSMA (prostate-specific membrane antigen) PET/CT is increasingly used in men with prostate-specific antigen (PSA) failure after radical prostatectomy (RP) to triage those who will benefit from salvage radiation treatment (SRT). This study examines the value of PSMA-informed SRT in improving treatment outcomes in the context of biochemical failure after RP. Methods: We analyzed men with rising PSA after RP with PSA readings between 0.05 and 1.0 ng/mL, considered eligible for SRT at the time of PSMA. For each patient, clinical and pathologic features as well as scan results, including site of PSMA-positive disease, number of lesions, and a certainty score, were documented. Subsequent management, including SRT, and most recent PSA were recorded using medical records. Treatment response was defined as both PSA ≤ 0.1 ng/mL and >50% reduction in PSA. Multivariate logistic regression analysis was performed for association of clinical variables and treatment response to SRT. Results: One hundred sixty-four men were included. PSMA was positive in 62% (n = 102/164): 38 of 102 in the prostatic fossa, 41 of 102 in pelvic nodes, and 23 of 102 distantly. Twenty-four patients received androgen-deprivation therapy (ADT) and were excluded for outcomes analysis. In total, 99 of 146 received SRT with a median follow-up after radiation treatment of 10.5 mo (interquartile range, 6-14 mo). Overall treatment response after SRT was 72% (n = 71/99). Forty-five percent (n = 27/60) of patients with a negative PSMA underwent SRT whereas 55% (33/60) did not. In men with a negative PSMA who received SRT, 85% (n = 23/27) demonstrated a treatment response, compared with a further PSA increase in 65% (22/34) in those not treated. In 36 of 99 patients with disease confined to the prostate fossa on PSMA, 81% (n = 29/36) responded to SRT. In total, 26 of 99 men had nodal disease on PSMA, of whom 61% (n = 16/26) had treatment response after SRT. On multivariate logistic regression analysis, PSMA and serum PSA significantly correlated with treatment response, whereas pT stage, Gleason score, and surgical margin status did not. Conclusion: PSMA PET is independently predictive of treatment response to SRT and stratifies men into a high treatment response to SRT (negative or fossa-confined PSMA) versus men with poor response to SRT (nodes or distant-disease PSMA). In particular, a negative PSMA PET result predicts a high response to salvage fossa radiotherapy.
    Last edited by OldTiredSailor; 06-19-2019 at 03:53 PM.
    DOB: July 1947
    PSA: 2.0/2004 4.0/2010 5.8/2010 4.5/2012 5.6/2013 Normal DRE
    5/18 PSA: 9.2
    6/18 PSA: 10.2 & 8.4% Free
    6/28 3T mpMRI PIRADS 3
    18 cc gland=PSD 0.57 ng/cc
    0.32 cc lesion in apical PZ with subtle T2 signal hypointensity
    mild restricted diffusion of contrast into lesion prostate unremarkable intact capsule
    7/18 4KScore 34% Probability Gleason =>7

    8/03/18 Bx: Adenocarcinoma 6 of 13 cores ONLY L lobe
    T1c / Grade II / unfavorable intermediate
    extent of G3-G4 tissue far greater than indicated by MRI
    G6 (3+3) 70% LL Base 50% L Lateral Mid 20% L Base
    G7 (3 +4) 100% LL Apex 20% L Mid 60% L Apex
    8/15/18 Clear CT scan and Bone Scan
    RALP 8/23/18 pT3a, G7 (3+4), 20% involvement, SM+ (Focal 2mm G6), EPE(Focal G6)+, PNI+, LNI-, SVI-, LVI-
    7g Tumor 20x size in MRI & biopsy report & in BOTH lobes not just L as biopsy reported

    PSA
    10/3/18 0.021
    01/4/19 0.018
    04/03/19 0.022
    06/26/19 0.028
    10/1/19 0.035

    Decipher RP = 0.47 Average Risk

  7. #27
    I have been down that road. You did great by being on top of this with 6-month testing. In order to take advantage of that edge, I would immediately go to at least a 2 decimal PSA. In all likelihood, you PSA just bumped.05 You do not want to fool yourself into thinking it is standing still when it could go; .05, .07, .09, .11 This would all give you a .1 reading with your current test. IF salvage radiation is in your future, studies show that the earlier you hit the greater chance of an actual cure.

    Best wishes.
    History: age 53 It took 3 biopsies (34 cores) to find 2 cores 4+4 Gleason 8
    Lap RP at MSKCC Apr 2004, age 54 All neg margins, nodes & structures. (T2a).
    Post RP PSA: <.1 until Feb, 08 (46 mos) PSA 0.1 - I then got sensitive tests -> 2008: Feb 0.06,
    May-08 0.09 - Jun-08 0.10, - Aug-08 0.10, - Nov-08 0.15
    SRT Dec-2008 ---Post SRT PSA 2009, Feb-09 0.10, May-09 0.09, Aug-09 0.06, Dec-09 .04, - 2010 Mar-09 0.04, 2011 .02, 2012 .02,
    STARTED UP Feb 2014-0.06, Jul-2015 0.10, Oct-2015 0.10, Feb-2016 0.15, Jun-2016 0.17, Dec-2016 0.25, Jan-2019 0.74, Jun -2019 0.72
    Aug 2018 Auximin scan - nothing
    Had an inflatable penile implant 2018 for ED. Best decision ever https://www.peyroniesforum.net/index...oard,56.0.html

  8. #28
    Had my PSA tested this morning, it's PSAnxiety Wait time....

  9. #29
    Remains a .1 ... Retest in two months...

  10. #30
    Quote Originally Posted by ddayglo View Post
    Remains a .1 ... Retest in two months...
    Hi ddayglo. Are you certain that the original lab report shows your PSA as just .1 ??
    I refuse to believe any actual lab paperwork would leave off a leading zero and report a number in the form .1
    So either you or someone's transcription is removing the leading zero (never a good idea when reporting decimal numbers; no journal would ever do it). If it wasn't you, I you always get the original lab report to exclude any transcription error. (How were your previous "undetectable" recorded, as <0.1, or <0.064, as you seemed to indicate in a previous post?

    Assuming your recent values have been 0.1's, with no further digits to the right, I fear you concern of a rise expressed by your now frequent retesting (e.g. every month or two) is negated by an insufficiently precise test. 0.1, 0.1, 0.1, etc. means your PSA could be stable; or it could be going up or down. Your result (with 2 places) could be 0.95, 0.98, 0.12, 0.14. Then again, 0.1, 0.1, 0.1 ... could represent 0.14, 0.12, 0.98, 0.94. You have no way of knowing if your PSA is stable or not, and, if not, which way it's going. Yes, you could assume your PSA it's stable; but you might get a surprise if it goes over 0.14 and rounds up to a 0.2.

    Logically, to detect a rise or fall after after a short interval, you want more precision, since the amount of change might be fairly small and not revealed by a less precise test. A one-decimal PSA test might be fine for low-risk men after primary treatment, but their test might be every 6 or 12 months!

    Djin
    Last edited by DjinTonic; 07-01-2019 at 09:17 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg., then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day retest)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015
    08-28-19 (2 yr. ) 0.016
    Avg. = 0.013

 

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