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Thread: Second Biochemical Recurrence of Prostate Cancer--SEEKING ADVICE & CONVERSATION

  1. #11
    Top User garyi's Avatar
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    Quote Originally Posted by Another View Post
    Time to focus on the next level of treatment. The curable conversation has little value and can be a distraction to acceptance and QOL. Longing for a different future can rob you of your presence in the one you have.

    In truth, none of us are cured. The use of the work cured with almost all cancer is only a matter of time, 5 years, 10 years, 20 years.

    PCa is treatable and managable even in advanced stages.
    Well said, Another

  2. #12
    Quote Originally Posted by Duck2 View Post
    MF, At this point how could he be curable? Once in the lymphatic system it is very unlikely it would be isolated to 2 nodes.
    Hi D2! I can only speculate that this may still be curable. Only expert MDs can make that judgement/prediction. My thought process is: If the PCa is fully contained in the lymph nodes and the involved lymph nodes can be accurately identified, then there may be an opportunity to treat with curative intent vs management only of disease. My guess is: surgical retrieval of the chain of nodes proximal and distal to the (+) LNs. This sure seems logical and very easy to suggest from my keyboard! The clinical reality may well be that prior radiation might make successful surgical retrieval impractical or impossible. I'm not sure if focal radiation to the (+) LNs is still an option. Possibly HIFU could be used.

    At this point, we have very little data or stats from mkp2m. Our hope is that Vanderbilt can offer a potentially curable treatment protocol. Most important is to immediately get this rapidly rising PSA reversed.

    We all aim for Cure. To get there, one must have a truly Curable status. Lastly, Cure is somewhat of a vague term in the world of PCa. Those of us with measurable uPSAs occasionally wonder if/when the Beast is going to Re-rise!

    Vigilance remains best!

    MF
    Last edited by Michael F; 11-04-2019 at 05:37 PM.

  3. #13
    Top User garyi's Avatar
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    Quote Originally Posted by Michael F View Post
    .....Lastly, Cure is somewhat of a vague term in the world of PCa.....

    MF
    Cure, IMHO, is a pipe dream...but a nice one. Do stay vigilant everyone
    72...LUTS for the past 7 years
    TURP 2/16,
    G3+4 discovered
    3T MRI 5/16
    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    CIPRO antibiotic = C. Diff infection 7/16
    Cured with Vanco for 14 days
    Second 3T MRI 1/17
    Worsened bulging of posterior capsule
    Oncotype DX GPS 3/17, LFP risk 63%, Likelihood of Low
    Grade Disease 81%, Likelihood of Organ Confined 80%
    RALP 7/13/17 Dr. Gonzaglo @ Univ of Miami
    G3+4 Confirmed, Organ confined
    pT2 pNO pMn/a Grade Group 2
    PSA 0.32 to .54 over 3 months
    DCFPyl PET & ercMRI Scans - 11/17
    A one inch tumor still in prostate bed = failed surgery
    All met scans clear
    SRT, 2ADT, IMGT 70.2 Gys @1.8 per, completed 5/18
    Radiation Procitis, and Ulcerative Colitis flaired after 20 years
    PSA <.006 9/18, .054 11/18, .070 12/18, .067 2/19, .078 5/19, .074 7/19, .081 9/19, .116 11/19
    We'll see....what is not known dwarfs what is thought to be fact

  4. #14
    Quote Originally Posted by DjinTonic View Post
    Even when found in a lymph node or elsewhere, ologometastatic PCa (1-5 metastases, distant or local) is recognized as a distinct stage of the disease, with its own set of possible treatments and distinct from widespread mPCa.

    Djin
    Treatments yes, cure very unlikely.
    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)

  5. #15
    Quote Originally Posted by DjinTonic View Post
    Even when found in a lymph node or elsewhere, ologometastatic PCa (1-5 metastases, distant or local) is recognized as a distinct stage of the disease, with its own set of possible treatments and distinct from widespread mPCa.

    Djin

    Quote Originally Posted by Duck2 View Post
    Treatments yes, cure very unlikely.
    I never mentioned "cure" BTW. But ASCO does:

    Oligometastatic Prostate Cancer: A Shrinking Subset or an Opportunity for Cure? [2019, Full Text, ASCO Educational Book]

    Abstract

    Oligometastatic prostate cancer (OMPC), generally defined by presence of five or fewer metastatic sites on imaging, represents a transitional state between localized and widespread metastatic disease and encompasses a wide spectrum of disease biologies and clinical behaviors. A collaborative effort is ongoing to determine the genomics of OMPC. The prevalence of OMPC varies significantly in the literature and is likely to change further as substantial improvements in imaging improve our ability to reclassify a subset of patients with biochemical recurrence by conventional imaging as OMPC and another subset from OMPC to polymetastatic disease. The mainstay of OMPC treatment remains systemic therapy, either with androgen-deprivation therapy (ADT) alone or in combination with other agents (docetaxel, abiraterone, etc.). Focal therapies, including resection or radiotherapy (RT), to the primary tumor have demonstrated an improvement in outcomes, including failure-free survival in several retrospective studies. RT to the prostate has specifically demonstrated an overall survival (OS) advantage in patients with low-volume disease in a clinical trial. Improvement in outcomes has been observed with focal therapies for retroperitoneal and more distant metastatic sites in retrospective studies. Advancements in our understanding of the biology, imaging modalities, and treatments may allow for aggressive multimodality therapies in an effort to obtain deeper responses and, potentially, cures for selected patients with OMPC with favorable clinicopathologic characteristics. Participation in clinical trials or institutional registries is strongly encouraged for patients with OMPC who opt for an aggressive multimodality approach.
    [Emphasis mine]

  6. #16
    “ Advancements in our understanding of the biology, imaging modalities, and treatments may allow for aggressive multimodality therapies“.

    I talking the here and now.
    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)

  7. #17
    I've seen a case report on another forum of someone having a few distant metastases radiocuted and a significant drop in PSA afterwards. Took him about 2 years to get back to prevoius levels of PSA. That's no cure, but may have bought him as much time as HT would have, with HT still being an option.

    I think that's one way of looking at it. Don't ask if it's a cure, but whether a treatment promises enough of a stay from the inevitable.

  8. #18
    Long-Term Mortality in Patients with Positive Lymph Nodes at the Time of Radical Prostatectomy [2019]

    Abstract

    Background: The aim of this study was to determine prognostic factors and to provide long-term mortality data in patients with positive lymph nodes at the time of radical prostatectomy in a sample with long-term follow-up. Methods: A total of 527 patients with complete data sets treated in the years 1992–2014 were studied. The median follow-up was 7.2 years. The median number of removed lymph nodes was 15. Age, year of surgery, Gleason score, local tumor stage, prostate-specific antigen level, lymph node density, lymph node count and the number of positive lymph nodes were included in multivariable competing risk analyses with prostate cancer mortality as endpoint. Results: After 20 years, 28% of patients (95% CI 20–36%) died from non-prostate cancer (competing) causes, whereas 29% (95% CI 23–36%) died from prostate cancer. Only lymph node density (stratified by the median of 11.1%; hazard ratio [HR] 1.66, 95% CI 1.04–2.64, p = 0.0340) and Gleason score (8–10 vs. <8: HR 5.97, 95% CI 3.18–11.23, p < 0.0001) were independent predictors of prostate cancer mortality. Patients with a Gleason score <8 and a lymph node density < median had a 20-year prostate cancer mortality of only 5% (95% CI 0–10%), whereas this rate in patients with Gleason score 8–10 and a lymph node density ≥ median was 44% (95% CI 32–56%), p < 0.0001. Conclusions: Mortality in patients with positive lymph nodes was determined by tumor aggressiveness and the relative extent of spread; neither the year of surgery nor the number of removed lymph nodes was associated with outcome. Patients with a lymph node density of <11.1% and a Gleason score <8 had an excellent long-term outcome.
    [Emphasis mine]

  9. #19
    The median number of removed nodes was 15? That is far greater than what we see reported here.
    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)

  10. #20
    Quote Originally Posted by Duck2 View Post
    The median number of removed nodes was 15? That is far greater than what we see reported here.
    I don't have the Full Text, but I think the large number of nodes removed (ELND--extended lymph node dissection either with, or separate from, the RP) may have been because a positive node(s) was suspected before surgery, or known after surgery. For comparison, for my RP, although we had indications from the CTs and hopes that my G10 PCa was node-negative, my uro/surgeon nonetheless removed 16 nodes, all of which were determined to be negative, either in the frozen sections or subsequently.

    The study attests that some men with node-positive PCa do have very good outcomes. While this is still metastatic cancer, oligometastatic PCa (1-5 mets) differs from a more serious stage. If the mets are few and can be limited to, say, lymph nodes and bone, and not vital organs, you shouldn't have the metabolic decline of full-blown mPCa that is the final cause of death.

    Surgeons have templates -- geometric areas bounded by anatomical structures like specific muscles, nerves, arteries, etc -- inside of which they remove all the lymph nodes they find. I believe there are different size templates that are chosen according to, say, the biopsy G score or estimated organ-confined/not confined status. When, a few visits ago, I asked about how many and which nodes are removed, my uro sketched the template he uses for patients like me (high-grade disease).

    Djin
    Last edited by DjinTonic; 11-05-2019 at 03:29 AM.
    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
    12-18-19 (24 m)
    Avg. = 0.013

 

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