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PSA spike

lew_in_marietta
Posts: 14
Joined: Jul 2010

Last July I had a robotic radical prostatectomy. My biopsy showed a Gleason 9 but post-surgery pathology showed a Gleason 7. I had extraprostatic extension but negative margins. Lymph nodes and seminal vesicles were also negative. I was very happy.

Post surgical PSA was 0.1. 3 month PSA was 0.16. 6 month PSA was 0.87! Wow! I hope it's a mistake - I'm going to get another one soon - but this puts me in a panic.

My Urologist is recommending radiation and hormones. I called my surgeon and he suggested radiation only, adding hormones if PSA doesn't go down.

I'm not sure if my immunosuppressants (kidney transplant) are affecting this, but I'm going to tweak the meds since some (one in particular) limit the body's ability to fight cancer.

Has anybody had their PSA rise this fast after surgery with negative margins? What was the result?

Lew

bdhilton
Posts: 756
Joined: Jan 2010

Lew… Sorry to hear this news as it is something that is in the back of all of us that have had surgery…I would recommend you do your own research but from what I understand from my own research is that if you get a recurrence (psa reading) with negative margins radiation to the prostate bed is typically not the line of treatment…Since you have negative margins in theory all cancer was removed from the prostate bed… Again do your own research into this matter and then talk to a couple of oncologist…You will be in my prayers today for the best for you…

B

ob66
Posts: 215
Joined: Apr 2010

bdhilton, Are you sure that "negative margins" means that all cancer was removed? I have read and re-read this, and I would be happy to be corrected, but I thought negative margins was that the surgeon and/or pathologist found the cancer in their opinion to be contained within the prostate gland that was examined. In other words, based on what they see, they do not "think" cancer cells have extended beyond the prostate per se. I don't think what they are saying is that there are no cancer cells in the prostate bed or beyond, for they just don't know that from looking at a path sample. They cannot, in my opinion, project what is beyond the prostate gland from looking at a surgically removed prostate gland. They can speculate and be pretty accurate, but how do they know with certainty that cancer cells have not escaped pre-surgically or during surgery?

Now, if what I project is correct, then it would be advisable to radiate the prostate bed, for if the cells are still there radiation is effective. If not, and the CA extends beyond the bed, then bigger problems exist. Please, those of you who have done more research than myself, correct anything that is right in my post. Hope this helps.

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

Bob,

As I understand the pathology of margins, it applies to how close the cancer comes to the ink which is used to stain the prostate sample and not a definitive opinion of whether or not the cancer has spread beyond the prostate. From what I have read of the pathologic guidelines in this area is that extracapsular extension is more indicative of the potential (even if microscopic) spread beyond the prostate. In other words, "negative margin" is nothing more than a pathologist's reading of the tissue on a slide based on arbitrary guidelines...not actual, definitive evidence of the spread of cancer one way or the other.

I have never read of a study that suggested that radiation to the prostate bed was not appropriate for a man with extracapsular extension or with rising PSA after RP as that is the area where the cancer is adjacent to.

Perhaps BD will enlighten us with more information.

K

bdhilton
Posts: 756
Joined: Jan 2010

There are numerous studies from impressive research facilities(Google it) that suggest that adjuvant radiation therapy to the prostate bed is less successful with guys with negative margins, seminal vesicles invasion or lymph node invasion …The studies all suggest that the probability of cancer elsewhere in the body in biochemical failure (defined as a detectable PSA level =/>0.2 ng/ml may be outside of the prostate bed…. So radiation to the prostate bed is being questioned as the first line of treatment…

I am for sure not the expert here but I have given this a lot of my time with research and discussions with professionals as this could have an impact on me in the future….I would seek the advise of an oncologist that is known to recommend all flavors of treatments and then select the one you believe in…

tarhoosier
Posts: 181
Joined: Aug 2006

This is just to qualify something mentioned in this thread. "Margins" in the Prostate Cancer Pathology sense means the edge(s) of the tissue provided from the surgeon. This usually includes tissue outside of the prostate proper. Occasionally a surgeon will cut too tight and leave a sliver (or more) of the gland inside. Most commonly the tissue presented to the pathologist includes fatty, fibrous, and muscular tissue which was surrounding the prostate itself. This is where the positive margins will be identified, if they exist. Closer examination of the slices of tissue will then identify if cancer cells exist between the margin inward to the edge of the gland. This area will be extra-prostatic or extracapsular extension if it exists.
Kongo is correct, that the absence of evidence (negative margins) is not the same as evidence of absence. I, myself, was pT2c, N1. Negative margins and positive nodes. Lympho- and vascular spread, despite pathology which might suggest otherwise. Psa told the tale.

lew_in_marietta
Posts: 14
Joined: Jul 2010

I agree that radiation is necessary. My surgeon recommended post surgical radiation, to start when my continence returned. I've been pad free for about a month, so it's time. The decision I have to make is whether to start radiation AND hormones now or wait to see if the radiation is effective. I have read a lot and haven't heard of a jump a large as 0.16 to 0.87 in 3 months. I've been pretty level headed addressing the cancer but this has thrown me for a loop. Thanks for the replies.

VascodaGama's picture
VascodaGama
Posts: 1528
Joined: Nov 2010

Hi Lew

One important point to consider is the number of lymph nodes dissected during surgery and how many were positive to cancer. Extraprostatic Extension (ExPE) indicates spread of cancer out of the prostate. In other words, it is like saying that the cancer was not totally removed (in the gland).
The site where cancer remained is unknown; it could be in the prostatic fossa or at distant parts of the body. A case like yours with Gleason score of 9 down to 7 could be termed as a later stage of prostate cancer indicating “systemic”. This is exactly my case.
After surgery the PSA was 0.12 (I never got to remission) and it rapidly rose to 0.18 in 6 weeks; recurrence was declared on the 6th month with a PSA of 0.26.
With a Gleason score of 2+3=5 I was declared with “micro metastasis” (in 2000), which is more like your case. Doctors do not know if cancer is still localized and in present times, they tend to consider it as Systemic. This is a status appropriate for hormonal therapy.

In my times SRT alone was the protocol of choice, however, the radiation is done to localized areas alone where cancer is “supposed” to be (bed and iliac lymph nodes) and distant metastasis do not make part of the protocol. Recently, a combination of HT together with RT has shown betters results in terms of time to progression.

I advise you to discuss the matter with your doctor. You may find many articles on the subject (SRT after radical prostatectomy) which will give you more insights.

Hope all goes well with you.
VGama

subu1970
Posts: 12
Joined: Jan 2011

Hello Vasco,
I read your comments with great interest. You case appears almost like mine. I also had
psa rise just like you did - history is in postings. May I ask if you went with RT and when and if so what was the psa following RT. Did you also go with HT? which HT? When? and what is the psa now. As you know my psa is slowly rising and I am terrified. Please share info.
Thanks and the best,
Subu

subu1970
Posts: 12
Joined: Jan 2011

Please see my psa rise is postings.
My RT therapist, and medical Oncologist, strongly favored RT. Now, one year after RT psa
is 0.4 - now they are strongly advocating HT - not right away, but if this psa incline
continues over next two months. I am in a loop too!
The best to you,
Subu.

VascodaGama's picture
VascodaGama
Posts: 1528
Joined: Nov 2010

Hi Subu

I tried to find your post about your PSA chronology and events but could not see it. Maybe you could give me the link to your post, so that I could check your details and pass you insights for your case.
Do not be anxious or terrified, because there are solutions to your case. Do some research and trust your believes. I can guide you in your researches.

Your PSA should get to nadir firstly (lowest level after RT). The third rise after nadir indicates recurrence. These tests should be done not less than 6 weeks apart. Mine was done every three months. The trigger for starting HT is usually considered less than PSA=2.0 after recurrence is confirmed, however, the PSA after radiation is not a stable marker as after RT. In some cases it gets to levels much higher of 2, 3 or even 4, but the third rise is then considered the trigger. My doctor threshold in cases of guys in micro metastasis, is PSA=1.0.

Regarding my case, at diagnosis the PSA before surgery was 24.2, Gleason score 2+3=5, 6 cores biopsy all positive to a median extent of 50% involvement, negative DRE and clinical stage B (T2).
After surgery, the pathological report confirmed the Gleason score and set me at stage pT3apN0 (Negative S-vesicles & lymph node (9); positive capsular penetration and margins). Nadir PSA got me to 0.12 and biochemical recurrence was declared at a PSA=0.26, just 6 month after RP.
Diagnosed with Micro-metastases, I was recommended to be under observation (Watchful Waiting). Micro metastasis cases are not suitable for radiation because the mets may be not localized and radiation is done directional not like “brush sweeping” an area. The success of RT is therefore controversial in such cases. This WW period lasted 6 years until my PSA reached 3.80 (PSADT > 14 months).

In Nov/2006 my doctor in JH recommended to go through salvage radiation with HT but I rejected because I wanted a real marker PSA (not masked by HT) to verify success. From PSA=3.80 before RT, I got to a nadir PSA of 0.05 on the thirteen’s month in a constant down trend followed by a sort of plateau then a slow rising. Biochemical Recurrence was at PSA=0.26 on the 29th month post SRT. In Oct/2010 the PSA reached 0.95 (= 1.0) and this was the trigger to start ADT.
After ten years with two major failed treatments (RP + RT) but of a successful control of the cancer, represented on the PSA which come down from 24.2 to 0.95 ng/ml, asymptomatic, no apparent side effects except for a not so normal ED. This is supposed to be typical of a micro metastasis case.

In Nov/2010 I was given Cyproterone acetate (antiagonist) 2x50mg/daily for one month, plus LHRG agonist Eligard (Leuproline acetate) 45mg 6-months shot.
So far, I had minor side effects from the drugs (fatigue, mood swings and hot flash) in the first 6 weeks, all gone now. Incredibly I have experienced natural nocturnal erections, which made me worried if my cancer is refractory. But that turned to be ok with a testosterone test to check its levels in castration.

My goal is ten years on hormonal treatment. After this initiation on HT, and if my body shows that I have no problem in metabolizing the drugs, I will be adding an antiagonist like bicalutamide and hopefully will start the intermittent modality (IADT) in 18-months cycles. I may as well add a 5-ARI drug to the “cocktail” to make it IADT3.

I am now investigating new drugs in the pipeline which have shown to be more effective than the traditional antiagonists and with lesser side effects. One of them is called Abiraterone which taken in combination with a LHRG agonist has shown improvements from a trial III.

I hope this post will help you with ideas.

Wishing you the best in your case.
VGama

subu1970
Posts: 12
Joined: Jan 2011

Much appreciate your posting. Thanks for the time invested. I will keep in touch with
you all and keep you informed on what happens next with me.
Subu.

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

Here's the abstract of a paper presented yesterday at The American Society of Clinical Oncology on the effect of pomegranite juice (using POM) on PSA doubling times for men with rising PSAs following RP. It indicates that in a relatively short time, the PSA DT for men who drank POM increased by at least six months. A rather impressive list of participating institutions. Men who are experiencing a PSA rise after RP should investigate this and discuss it with their doctors.

A phase II study of pomegranate extract for men with rising prostate-specific antigen following primary therapy.

Meeting:
2011 Genitourinary Cancers Symposium

Session Type and Session Title:
General Poster Session B: Prostate Cancer
Oral Abstract Session A: Prostate Cancer

Abstract No:
11

Citation:
J Clin Oncol 29: 2011 (suppl 7; abstr 11)

Author(s):
M. A. Carducci, C. J. Paller, P. Wozniak, P. Sieber, R. Greengold, B. Stockton, B. Hertzman, R. Roper, H. Liker, X. Ye, The Pom Wonderful Working Group; Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD; Advanced Clinical, Bannockburn, IL; Urological Associates of Lancaster, Lancaster, PA; South Orange County Medical Research Center, Laguna Hills, CA; Lakeside Urology, St. Joseph, MI; The Urology Group, Cincinnati, OH; Urology Enterprises, Marietta, GA; University of California, Los Angeles, Beverly Hills, CA; Johns Hopkins University, Baltimore, MD

Abstract:

Background: Pomegranate extract (POMx) demonstrates promising antitumor effects in prostate cancer (PCA). Prior published work reveals an increase in PSA doubling time (PSADT) in a single arm study of pomegranate juice (POM) in PCA patients (pts) with a rising PSA after local therapy. We sought to determine the effects of low (1 gram) or high (3 grams) daily POMx on PSADT in a similar but broader population of men seeking to defer androgen deprivation therapy. Methods: Our multi-center, double bind phase II trial randomized men with rising PSA and without metastases to receive high or low dose POMx, stratified by baseline PSADT and Gleason score, and with no restrictions for PSADT and no upper limit PSA value. Men were treated until progression or for 18 months. PSA levels were obtained every 3 months. This study was designed to detect a 6 month increase in PSADT from baseline. Results: 104 patients were enrolled and treated for up to 6 (92%), 12 (70%) and 18 months (36%). Median PSADT lengthened in the Intent to treat population (96% white, median age 74.5 years, median Gleason score 7) from baseline 11.9 (range 1.6-54.6) compared to 18.5 (2-1523) months after treatment (p<.001).There was no significant treatment difference on PSADT between the dose groups (p=.920). Declining PSA levels were observed in 13 pts (13%) during the study. No significant changes occurred in testosterone in either group. Although no clinically significant toxicities were seen, mild to moderate diarrhea was seen in 8 pts (7.7%).

Conclusions: POMx treatment significantly increased the PSADT by over 6 months in both treatment arms, with no effect on testosterone. This IND-conducted study confirms slowing of PSADT after treatment with POMx as was found with POM, yet in a PCA patient population with greater high risk progression features.

VascodaGama's picture
VascodaGama
Posts: 1528
Joined: Nov 2010

Kongo
I like the conclusions of the abstrat. It says "with no effect on testosterone".
Well, it is credible. As I commented before in another post I am thinking in start taking some supplements of the Pomes but only after confirmation that they have no inter-action/reaction with my red wine.
Thanks for posting the news.
VG

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

Don't forget the potential to celebrate AND cut down on your PSADT!

VascodaGama's picture
VascodaGama
Posts: 1528
Joined: Nov 2010

I thought that PSADT should go up not down.

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

and I haven't even had a regular martini today ....

VascodaGama's picture
VascodaGama
Posts: 1528
Joined: Nov 2010

"Regular" goes both ways. As "daily" or with a gree-olive. Hummmm ! olives fit with red wine too. I accompany you on the "toast" to a higher PSADT.

lew_in_marietta
Posts: 14
Joined: Jul 2010

Thanks, I'm getting some POMx tomorrow. What's one more pill?

lew_in_marietta
Posts: 14
Joined: Jul 2010

I talked today with the Chairman of Radiation Medicine at the hospital system in NY where I had my surgery and I feel much better. He wasn't alarmed by my last PSA and recommended radiation but not HT. He also recommended a local doctor to handle my radiation. He has followed my case since surgery and says the cancer is probably localized and I've got plenty of time to start HT if it's not.

Thanks for all the advice and encouragement. I've been pretty level headed during this journey, and after a couple of weeks of panic, I'm on program again.

VascodaGama's picture
VascodaGama
Posts: 1528
Joined: Nov 2010

Lew

Your doctor’s advice is logical. HT can be taken as adjuvant just after RT or when the PSA rises. There is no “earlier or late regulation” to start HT in systemic cases. Without HT one can at least ascertain if his cancer was in fact localized. That was my principle when deciding in 2006, by declining HT+RT modality. RT assured me the kill of cancer at the lymph nodes which are the “gate” to spread.

After RT, my PSA decreased to remission levels of 0.05 which, according to the comment from my surgeon of 2000, “….indicated that the bulk of cancer was localized as it was demonstrated by the success of the radiation in bringing down the PSA. Fewer cancer cells were not cached by the radiation…”.
That was when I finally understood the diagnosis of “micro metastasis” given to my case by all the doctors I consulted (in 2000) at excellent institutions (MSKCC, JH, TH and NCI).

I would also to suggest you to check about the possibility of any interaction of your “immunosuppressants case” with any medications you may need to take later for any problematic side effect from radiation. A healthy kidney is a must for metabolizing those drugs.

Trust your doctor and be confident in the treatment.

I wish you the best.
Vgama

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