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PSA levels of 3 and 7 after surgery.

pinot
Posts: 12
Joined: Nov 2009

My Dad had prostate surgery in mid-September. Prior to his surgery, he had a bone scan which came up as clean. His pathology report came back so-so - it said that there was pueraneural (sp?) invasion. The urologist said that this was probably minor.

8 weeks after the surgery he went in for his PSA check. It came back as 3! The urologist was baffled, and it took another sample that same day and sent it to a different lab. The second lab sent back a PSA of 7!

How can the PSA level vary so much between labs? What would cause such a high PSA level with a mostly ok pathology report and a clean bone scan?

He goes to see the oncologist tomorrow - what will the oncologist be likely to recommend?

My Dad is only 66 - too young for all of this.

And lastly, how can I be the best, most supportive daughter that I can be? My Dad internalizes things because he doesn't want to cause us worry, but I am worried and I want to do whatever I can to make things better.

gkoper's picture
gkoper
Posts: 174
Joined: Apr 2009

A PSA of 3. , then 7. a few days later is hard to believe.

I am 65 & had Davinci in March. My PSA was 0.3, 6 weeks later. 4 months later it was 0.7.

I am now half way through (37 total) IMRT radiation treatment.

My guess is the oncoligist will recommend the above & possibly hormone therapy.

Your Dad is lucky to have a supportive daughter like you.

Good luck.

pinot
Posts: 12
Joined: Nov 2009

The PSA levels of 3 and 7 were actually taken on the same day one hour apart.

The blood was drawn at the doctor's office and sent to 2 different labs. After the reading of 3 came back, the urologist wanted a "second opinion" from another lab, so he had my Dad's blood drawn again and sent to a lab off-site.

My Dad had his blood drawn on Friday and this time the PSA level was 1.3. Has anyone else had wild fluctuations like this?

My Dad goes in for another MRI Monday in an attempt to see what is going on.

gkoper's picture
gkoper
Posts: 174
Joined: Apr 2009

I have heard of PSA fluctuations, but none so dramatic.
I was told by my uroligist that c-scans are better at finding PCa related cancer cells then MRI. Keep us posted on how it goes...we are pulling for you & Dad.

William Parkinson
Posts: 60
Joined: Oct 2009

I will have to be brief, since I am just a few days out from my own surgery. First, perineural invasion is quite serious. This is the most documented route by which prostate cancer can spread outside the prostate gland. I am quite worried, in that both readings were so high. One lab may have mishandled his blood specimen, but it is very unlikely that both labs made an error. So, for now, I will assume that your father has a very significant
PSA level after his radical prostatectomy. Also, it should be noted that some men harbor circulating prostate cancer cells which can reside in bone marrow, so it is quite possible that the cancer has spread outside his prostate gland, one way or another. First, I would ask for another PSA test and I would seek it from another urologist. I would go to the best hospital in your area and do it there, with the resident urologist there. So, find out first what that reading comes out as. Secondly, I would consult with the very best urological oncologist (prostate cancer urologist obviously) there you can find. If you need help you can call Memorial Sloan-Kettering in NYC and ask for any recommendations. If you let me know where you live, I can find out for you. If it turns out that the cancer has spread you need to find out if it is regional (within the pelvic field) or if it is systemtic (outside the region and growing in other areas). Scans can be deceptive when it comes to prostate cancer. This is not a sarcoma ( a cancer of hard tissue like bone or cartiledge) after all. There are many treatment options. He can have the entire pelvic field irradiated to a dose of roughly 45 Gy and the prostate bed much, much higher (as much as 85 Gy). There is also androgen deprivation (stopping the production of androgens like testosterone), all of which together can have a significant impact even in the face of systemic disease. If you can, pls let us know what his pathology report said; e.g., Gleason score, extra capsular extentions and the like. There are many men here who can tell you what has likely happened. Best wishes to both you and your father.
Cheers
Bill

pinot
Posts: 12
Joined: Nov 2009

Thank you for your well-thought-out reply. I hope that your own surgery went well and that you're on the road to recovery. Hopefully you can join the "zero club" and have better luck than my Dad!

Here's the update:
After receiving post-surgery PSAs of 3 and 7 (taken within an hour of each other, sent to separate labs) my Dad was referred to an oncologist.

His oncologist did his residency at Sloan-Kettering, and he supposedly still has a mentor there. After reading your post, Bill, I felt pretty good about this. Of course, the first thing the oncologist did was order another PSA.

This one came back as 1.3.

So, the oncologist ordered another 2-hour-long MRI. Supposedly they did one pass without dye and one pass with dye, from the neck downwards. The MRI came back showing no evidence of cancer.

So, the urologist is baffled, as well. He took no action, but instead scheduled my Dad for another PSA test at the end of December.

Anyone else have any ideas of what could be causing his PSA to go all over the place?

As far as the pathology report goes, his Gleason score was 4+3. The tumor took up 30% of his prostate. Seminal vesicles were okay. They said something about having an "external foci" but my Dad said this was different than having positive margins. Lymph nodes were ok. Perineural invasion was present ... his prostrate weighed about 45 grams ... I think that's all that I remember for now.

*sigh*

William Parkinson
Posts: 60
Joined: Oct 2009

I am sorry to hear about this new PSA test, even though it is much lower than the other two. And thank you for your kind words about my surgery. In may case, I had no ECE, seminal vesicle invasion, nodal involvement, or positive surgical margins, so I stand a good chance at cure, but as you can tell, nothing is certain when it comes to cancer (I was forced not to participate in the test for circulating tumor cells based on the chance of infection, since prior to surgery they use needle aspiration of the bone marrow for that test). Anyway, I just posted a reply on a case of biochemical recurrence. I mention CellSearchTM there. It would prove useful if your father had this test done, for at least it would lend some indication if he is in real trouble. Read what I posted there (I wrote about other ways to control the cancer, at least a little bit, for the time being). Although I have no answer for why the PSA is bouncing around like this (consistent with radiotherapy but not surgery), the good news is that so long as his PSA is under 2.0 ng/ml radiation can usually help in controlling the progression of the disease. You mentioned an "external foci" on your father's pathology report; did your father mean an extra capsular extension? For now, not knowing more, I would be tempted to have at least 81 Gy of directed radiation to the prostate bed with an additional 45 Gy to the rest of the pelvic field. Also, I gave some suggestions in the other post I just mentioned. If you can provide more details on his pathology report that would be helpful. There are usually only three possibilites for continued PSA: occult micrometastasis (occult just means hidden), where the cancer spreads before it is detected systemically, positive surgical margins, and circulating tumor cells. If I know more, I might be able to direct you to some possible areas to interest in solving what happened here.
Cheers
Bill

pinot
Posts: 12
Joined: Nov 2009

Bill,

Thank you again. Sorry that it's taking me so long to reply to your questions - I have a new baby and she takes up a lot of my time.

Yes, I believe that the external foci was the same as an extra capsular extension.

The last MRI report refers to an enlarged left commom iliac lymph node, and then also an enlarged external iliac node on the left. They give different measurements for each.

My Dad has another appointment with his oncologist today - I told him to ask about the CellSearch technology and some of the other things that you mentioned. We'll have to see what his doctor has to say. I just want him to beat this!

JohnK11
Posts: 23
Joined: Nov 2009

I also have high though so-far non-fluctuating PSA (7/6.4) 6 weeks after Robotic prostate removal surgery (4+3=7, T3b, right seminal vesicle cancerous, prior-to-surgery CT Pelvic and chest scans clean). My pre-surgery PSA was only 6.7. Will try to do another one next week, about 1 month after the 7/6.4 reading.

So, I just did a bone scan (negative--though it will only find the most advance cancer and thus will missed many of the less obvious or smaller cancer elements)
and will do a fused-MRI/prostascint) scan next Friday. The prostascint (to be injected
96 hours prior to MRI) is supposed to attached itself to soft cancerous cells, and thus show up on the MRI scan, though there are apparently not universal agreement on how useful it is.

If the MRI/Prostascint finds a (hopefully just one) cancerous area, then radiation treatment is called for (even though my urinary incontinence is still really bad).
If nothing shows up, it's Lupron (hormone--i.e., chemical castration). Which is supposed to keep cancer at bay for 5-8 years (though, with my apparent really fast PSA doubling time, I'm scared).

May I suggest that your father look into fused MRI/Prostascint (if you have not already done so)--I have to go to a hospital 15 miles away, since it is available only in few hospitals (my 280-physician medical group does not do it, even though it has at least
7 diagnostic imaging labs).

Good Luck (though I might need more of the good luck myself).

pinot
Posts: 12
Joined: Nov 2009

JohnK11 - How did your MRI/Prostascint scan go? I suggested that my Dad ask his doctor about the procedure. He has an appointment today, so I am hoping that maybe they can arrange to have it done.

I will say some prayers for you as well ... good luck to you.

JohnK11
Posts: 23
Joined: Nov 2009

Both the Bone scan and the Prostascint/MRI scans are negative (the uro says that most of the time, one would not see cancerous modules in these scans until your PSA is 40+.
Note that Prostascint/MRI scan can not detect liver problems (though Prostate cancer cells almost always attack lymph nodes and bone preferentially) since the liver will be hot
due to dead red-blood cells collected there regardless.

However, my PSA is now 9.2 (it was 7/6.4 1 month ago, which was 6 weeks post DaVinci--so my doubling time is 2+ months, pretty bad); so, I just got a hormone injection (Trelstar) and hopefully my reaction (which is not due for another 2 weeks or so) will be mild and my PSA will drop to 0. Wish me luck.

jertle
Posts: 2
Joined: Jun 2012

I recently underwent a prostatectomy in Mar 2012 via the daVinci procedure. I am 68 yrs old and in very good health.
All has gone well and the recovery has been good with no issues or problems. I am back to all normal activities.
The post-op pathology report stated that the tumur was present in both lobes with radial margins free of tumor, seminal vesicles were free of tumor but perineural invasion was identified. Lymph nodes,both right and left were taken and were negative for metastatic carcinoma. At this point the Dr was pleased.

I have recently went for my 3 month PSA test and was told it was 6.5, 7.7(follow-up) and 7.7(additional test) with a free PSA of 0.3. The Dr. is quite surprised and after doing over 1,000 procedures has not seen any results of this nature. The Dr. has ordered follow-up Cat scan of abdomen and pelvis along with another bone scan to compare with the pre-op tests.

I am meeting with the Dr. and an oncolgist today to review tests and their recommendations for future treatment.

Has anyone seen results such as this and what treatment will I be looking at?

VascodaGama's picture
VascodaGama
Posts: 1552
Joined: Nov 2010

Jertle

Welcome to the board.
Can you share info on your diagnosis before surgery?
What was your Gleason score, PSA and DRE before surgery and what made you to have a biopsy. Were there any symptoms?

Surely other facts may be behind such high PSA, they are rare but exist. Laboratory errors or a portion of the prostate left behind during surgery, etc.
The image studies done before surgery could also have been negative if the equipment was not high in resolution. Small tumours (1.5 mm) are difficult to detect, and your case could be micrometastases.
I would recommend you to get a MRI with a Tesla 3 capability and a bone scan (CT or PET)the latest contrast agents. Search the net for details (C11-choline, F18, etc).

Recurrence is usually handled with salvage radiation therapy. In any case, radiation should be done with a defined target which in your case may not be localized. I say that because of your pathological report indicating a negative diagnoses for local metastases;
(“…radial margins free of tumor, seminal vesicles were free of tumor but perineural invasion was identified. Lymph nodes,both right and left were taken and were negative for metastatic carcinoma…”)

Hormonal treatment is better in systemic cases. Check the net for details on HT, or scroll in this forum for past threads on HT.

You cannot do anything without a proper diagnosis. Wait for test results.

Hope for the best.
VGama

jertle
Posts: 2
Joined: Jun 2012

Prior to surgery the Gleason scores from the biopsy were 6, 6 and 8.
The PSA was 12.4 which doubled from the prior years PSA of 6.4.
The biopsy was ordered by my urologist after seeing the high PSA.
My only symptom that something was wrong was ED.

The CT scans of both bone and pelvic were negative and were similiar to the pre-op scans.
I am now working with an oncolist who has ordered additional tests - a CT scan of my lungs since nodules were observed and additional bloodwork. The lungs were studied pre-op, but they are checking everything at this point.

She is not recommending radiation since there is nothing to target the radiation at.
Based upon the results of these new tests, she is recommending HT at this time.

tarhoosier
Posts: 182
Joined: Aug 2006

J:

I recommend a new post to start a new string for your questions. Adding to the bottom of a three year old string fails to bring new comments, in many cases.
Nonetheless, your case is an unusual one. With no identification of source of spread, with negative signs of local spread, radiation has limited usefulness. If it were me I would hold off radiation until there were technology that can identify targets. Feraheme USPIO with 3 Tesla magnet or Carbon-11 choline (or acetate) imaging is just now coming into use and may be available in your area now or in the near future. Radiation has lifetime limits. I would save my ammunition, so to speak.
You do not mention the Gleason score or pre-operative psa. I suspect post op G score included some G4, at least.
You are facing a systemic therapy of anti-hormone treatment. This can be intermittent. With the best of care, some luck (not really too much), and acceptance of side effects of all options, you have many years to go. It is quite possible that you will not die of prostate cancer.

VascodaGama's picture
VascodaGama
Posts: 1552
Joined: Nov 2010

Jertle

You are in the right “direction”. RT would not assure you success with no targets to aim.
HT can control responsive type of cancer well, in some cases over 15 years. Some guys experience nasty side effects from the drugs but some (my case) gets it mild.
Physical fitness and a change in some habits are important to counter the effects. Read about diets too.

Wishing you peace of mind.

VGama

shipjim's picture
shipjim
Posts: 130
Joined: Apr 2006

So this post started with a lady concerned about her Dad, it ended in 2009 does anybody know what happened?

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