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Thread: Bio chemical reoccurrence

  1. #1
    Regular User
    Join Date
    Dec 2013
    Posts
    49

    Bio chemical reoccurrence

    So after prostate removal over 5 years ago with undetected psa I know have a 0.2 for two tests in a row. I was given a ct with tracer and a pet with radiation marker. Both tests are negative. Oncologist sent me to consult with radiology and the recommended 20 sessions of salvage radiation treatments to my pelvic area.

    It seems odd to not have a target to hit.

    My oncologist says I can do the radiation or not and wait . She also said that I have gone from cured to Cancer Management

    Of course the radiologist wants me to have the treatment.

    Im tending to lean torwards my oncologist recommend.

    There has been no movement in my psa since the .2 for 4 months .

    Thoughts ?
    Blood test 10.0
    DRE and Biopsy
    3 0f 12 cores 3+3
    AS 2 Years with blood every 3 months, stable at 10.1
    2nd Biopsy 9 of 12 cores 3+3
    RARP 11/26/13 by Dr. S Conely
    Catheter out in 7 days
    Pathology 3+4
    1 light pad at 1 week past catheter
    Continence at 3 weeks no pads
    PSA undetectable at 7 weeks
    At 13 Months Erections both with and without meds, its all coming together .
    July 2019 psa detected at.2
    Sept psa .2
    Oct psa .2
    Nov ct negative
    Nov Pet negative
    Nov Radiologist consult

  2. #2
    Senior User
    Join Date
    Aug 2017
    Posts
    302
    Sorry that you are in this position, especially considering the low risk pathology report.

    I have no first hand experience, but if it were me I would be concerned that after 6 years there is a good chance that any leftover cancer cells may have migrated away from the prostate bed. I wouldn't want radiation in any area unless cancer was verified to exist there.

    I would explore getting a PSMA Pet scan. The sensitivity is much better than what you had. I dont think its been FDA approved yet, but there are trials and opportunities to have the test done at some locations.

    Good luck!
    PSA 8/31/15 4.01
    PSA 3/03/16 4.15
    PSA 8/28/16 3.94
    PCA3 9/16 low risk
    PSA 5/10/17 7.49,
    PSA 9/2/17 9.77
    Biopsy 6/7/17 Left Apex Gleason 6, less than 5% of core. Right Apex Gleason 6, 35% of core.
    OncotypeDX GPS score 43- high risk.
    Bone scan 7/11/17. 11th left rib iffy.
    Bone biopsy 8/11/17. Negative.
    3T MRI 7/19/17. 3.5 cm liposarcoma found behind bladder.
    CT Scans of chest and pelvis 7/31/17. Negative
    RALP 9/25/17
    Histologic Type: Adenocarcinoma
    Total Gleason Score: 6
    Tumor Quantitation: Less than 5%
    Location of dominant tumor nodule: Left posterior lobe apex to mid
    Extraprostatic Extension: Not identified
    Seminal Vesicle Invasion: Not identified
    Margins: Uninvolved by carcinoma
    Lymph-Vascular Invasion: Not Identified
    Primary Tumor: pT2c (organ confined; tumor involves both lobes)
    Regional Lymph NodesN0 (No metastasis)
    Number of lymph nodes examined 6 ;nodes involved 0
    Distant Metastasis: cM0
    Working Stage Grouping: Stage IIB (T2c N0 M0)

  3. #3
    You state .2 in the narrative and .02 in the signature. If you are .2 get treated now.

    https://consultqd.clevelandclinic.or...oved-survival/
    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)

  4. #4
    Regular User
    Join Date
    Dec 2013
    Posts
    49
    Updated my signature

    Thank you for the reply and link
    Blood test 10.0
    DRE and Biopsy
    3 0f 12 cores 3+3
    AS 2 Years with blood every 3 months, stable at 10.1
    2nd Biopsy 9 of 12 cores 3+3
    RARP 11/26/13 by Dr. S Conely
    Catheter out in 7 days
    Pathology 3+4
    1 light pad at 1 week past catheter
    Continence at 3 weeks no pads
    PSA undetectable at 7 weeks
    At 13 Months Erections both with and without meds, its all coming together .
    July 2019 psa detected at.2
    Sept psa .2
    Oct psa .2
    Nov ct negative
    Nov Pet negative
    Nov Radiologist consult

  5. #5
    I would suggest that when typing decimal numbers less than one, we always use a leading zero. For example, 0.2 rather than .2, 0.34 rather than .34, and <0.1 rather than <.1 -- this is the way these numbers are always written and communicated in journals, scientific publications, math, etc.. The leasing zero serves as a check that the decimal point is in the correct position. Otherwise the reader may think a typo has been made, especially those accustomed to seeing a leading zero

    Djin

  6. #6
    So after prostate removal over 5 years ago with undetected psa I know have a 0.2 for two tests in a row.
    When you say "undetected" do you mean <0.1?

    What was the date and PSA value immediately prior to the July 2019 value at 0.2?

    OR - How long did it take to go from <0.1 to 0.2?

    With only a single significant digit your 0.2 could be anywhere between 0.151 and 0.249.

    What you really want to know now is - what is the trend in your current PSA? Is it continuing to increase?
    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. #7
    Senior User
    Join Date
    Jul 2017
    Posts
    137
    I was in a similar situation, no target. That really confused me. In my situation, my PSA was 0.02, but I am high-risk due to seminal invasion. I finally decided to go ahead with the radiation (Proton) because I wanted to be able to look back someday if it comes back and be content that I did everything I could to kill it off.

    The prostate bed is the target. Which means they are zapping "healthy tissue" and/or organs with the idea that any stray cancer cells will get caught in the crossfire. There's nothing else to shoot at!

    I chose Proton because of the precision of the beam and there is no exit radiation. Protons release their energy at the target, and don't exit, unlike IMRT or similar. Maybe not a huge advantage, but any edge I can get, I'll take. Medicare pays for Proton (as of now... it is under discussion to cut Proton reimbursement to be equivalent to IMRT which will doom Proton treatments).

    So I did 35 Proton treatments at MD Anderson. No problems at all... until about 3 months later when I started moderate leaking, even when just standing. Prior to radiation I was about 98% dry. So the beams set me back in the leaking department. I'm hoping it will resolve with time, but who knows. (I'm considering sling surgery next Spring if things don't get better.)

    Your case IS a bit different since you are a lower risk, BUT you have the 0.2 PSA. I think most folks here would say... go do it. Yes, it's a pain in the butt. But I think you'll have better peace of mind.

    The scans don't generally pick anything up at such low levels, to my knowledge. I had the fancy expensive one (Auxmin?) prior to Proton treatment and nothing was found.

    I know it's a tough choice. I resisted. I saw 3-4 docs. Everyone I talked to said I should do it. So I did. I parked my RV south of Houston for two months and made an adventure out of it!

    Happy to answer any questions your may have about Proton... if interested in that treatment.

    Mike in Kerrville
    Age 63 at Dx
    PSA History
    07/10 - 0.5
    05/12 - 0.5
    08/13 - 0.9
    02/14 - 1.2
    10/15 - 1.3
    07/16 - 3.3
    12/16 - 4.4 with Free PSA 52% (low risk)
    04/17 - 5.03
    08/17 - 3.5
    09/17 - 3.2
    11/17 - <0.01
    2/18 - <0.01
    05/18 - <0.01
    08/18 - 0.01 (CPL says they don't use the "<" any more. ???)
    10/18 - 0.02
    11/18 - 0.01
    01/19 - 0.02
    05/19 - 0.02
    07/19 - <0.02
    09/19 - <0.02


    Biopsy 07/11/17 PSA 5.02 T1c, revised to T3b after RALP
    Results 07/26/17 - Gleason 4+3 = 7 (two 4+3's, five 3+3's)
    RALP at MDA Oct. 23. Confirmed Gleason 4+3

    Pathology:
    Bladder neck (microscopic) and seminal vesicle involvement + large volume of PC, clear margins
    Bone Scan and CT Abdomen, lymph nodes are clear
    Decipher test result: .78 - High Risk
    Dry after six months post surgery.
    Axumin PET and Pelvic MRI are clean 11/09/18
    Completed 35 Proton treatments at MDA 03/28/19
    Considering AdVance Sling procedure


  8. #8
    Is a BCR after 5 years as likely as shortly after surgery to be caused by malignant growth in the pelvic area? They are shooting at a thing of which they don't know if it's there with guarantees only for the side effects.

    If some tumor kept growing for another 5 years post RP, what's the rush to radiocute it? It already had ample time to spread, and if it didn't yet, why do we assume it would do so in the next year? Because the alternative is to wait and repeat a PET CT at a later time with higher PSA.

  9. #9
    Quote Originally Posted by KarlEmagne View Post
    Is a BCR after 5 years as likely as shortly after surgery to be caused by malignant growth in the pelvic area? They are shooting at a thing of which they don't know if it's there with guarantees only for the side effects.

    If some tumor kept growing for another 5 years post RP, what's the rush to radiocute it? It already had ample time to spread, and if it didn't yet, why do we assume it would do so in the next year? Because the alternative is to wait and repeat a PET CT at a later time with higher PSA.
    There is an argument to be made to wait until one's PSA is higher than 0.2 for the very reason that higher PSAs are more likely to result in positive scans. SRT done in the 0.2-0.5 range is still referred to as early SRT.

    Djin

  10. #10
    Quote Originally Posted by PeterG View Post
    So after prostate removal over 5 years ago with undetected psa I know have a 0.2 for two tests in a row. I was given a ct with tracer and a pet with radiation marker. Both tests are negative. Oncologist sent me to consult with radiology and the recommended 20 sessions of “ salvage radiation “ treatments to my pelvic area.

    It seems odd to not have a target to hit.

    My oncologist says I can do the radiation or not and wait . She also said that I have gone from “ cured “ to “ Cancer Management “

    Of course the radiologist wants me to have the treatment.

    I’m tending to lean torwards my oncologist recommend.

    There has been no movement in my psa since the .2 for 4 months .

    Thoughts ?
    Hi PeterG! Sorry to see you return with BCR. Let's try to get this into proper perspective.

    Several questions:

    - What is your age?

    - How frequently were you testing your PSA since surgery?

    - Where do you get your PSA tested: MD's Office, Hospital Lab, Outside Lab?

    - Do you get copies of the Lab Report?

    - What is listed on the report? (As DjinTonic points out: ".2" is NEVER the way a PSA result is listed. It should be listed as "0.20"

    - What was the date and value of your PSA prior to your 1st value of ".2" (the result before July 2019)?

    Re "I was given a ct with tracer and a pet with radiation marker..:"

    - Do you know which "tracer & marker" that were used? As Consult1 suggests, the newest type of scan = PSMA PET is the best at detecting recurrent PCa at very low PSA levels.
    "Standard" CT scans and Bone Scans can not identify PCa at such low PSA levels.

    The "good news" is it has taken > 5 years to reach BCR. Your last 3 consecutive PSAs appear to be stable at ".2" So you are not likely experiencing an aggressive recurrent PCa. If your latest scans were not state of the art, I would look into clinical trials that evaluate recurrent PCa following RP at very low PSA levels using the "PSMA PET" technology. My opinion is: it is important to pinpoint locate the site(s) of recurrence and treat them. Here is a link to the clinical trial website with the PSMA trials.

    https://clinicaltrials.gov/ct2/resul...e=&city=&dist=

    I'm NOT suggesting delaying treatment for any extended period of time. I'm suggesting looking into the option of identifying the exact location(s) of recurrence and determining if it can be treated focally with RT or other treatment modality.

    Re "She (oncologist) also said that I have gone from “ cured “ to “ Cancer Management :“ I find this statement misleading, baffling and somewhat shocking. Because:

    - You have experienced BCR, implies that you were never quite "cured." So, IMO, the Onc MD is incorrect.

    - You are 6 years post primary treatment (RP) without ART/SRT and/or ADT. The RO should be focused on offering a high % possibility of Complete Cure and not solely management of disease. I would seek another opinion asap.

    If you have any doubts, get a 2nd opinion consultation at a top Tier Urology Program from a URO Oncologist who specializes in treating PCa.

    Keep asking questions and demand correct answers.

    Keep us updated on this "2nd PCa Journey."
    Last edited by Michael F; 11-14-2019 at 09:29 PM.
    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free = 0.39ng/ml, % PSA Free = 13%)
    Referred to URO MD
    Jan '12: DRE = Positive: "Left induration"
    Jan '12: Biopsy = 6 of 12 Cores were Positive: 1 = G7 (3+4) and 5 = Gleason 6
    Referred to URO Surgeon
    March '12: Robotic RP: Left: PM + EPE. MD waited in surgery for preliminary Path Report then excised substantial left adjacent tissue(s) down to negative margins and placed 2 Ti clips for SR guidance, if needed in future.
    Pathology: Gleason (3+4) pT3a pNO pMX pRO c tertiary pattern 5 / Prostate Size = 32 grams / Tumor = Bilateral: 20% / PNI: present
    3 month Post Op standard PSA = <0.1 ng/ml
    1st uPSA at 7 months Post Op = 0.018 ng/ml
    uPSA remains "stable" at 91 Months Post Op: Mean = 0.022 (22x uPSAs: Range 0.017 - 0.032) LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%)
    ED = present

 

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