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Treating Recurrence

Optimistic2
Posts: 1
Joined: Jun 2012

I am a new member of this forum and having recently read a lot of the threads really appreciate the participation and knowledge of all the contributors.

August 20, 2010 PSA Total 4.9 ug/L.

November 12, 2010 - Radical Prostatectomy (Da Vinci) followed by 5-units blood and 48-hours later open surgery to stop bleeding.

Pathology Diagnosis:
1. Tissue from left apical margin showing benign connective tissue, negative for malignancy.
2. Prostatectomy specimen showing:
a. Prostatic adenocarcinoma, Gleason grade 4 + 3 = 7 of 10.
b. Carcinoma involves both right and left lobes of prostate occupying approximately 10% of gland by volume.
c. Carcinoma reaches the resection margin of the left anterior quadrant of the gland. All other resection margins are negative for malignancy.
d. Positive for extracapsular extension by carcinoma.
e. Positive for perineural invasion by carcinoma.
f. Negative for lymphovascular invasion by carcinoma.
g. Seminal vesicles are negative for malignancy.
h. pT3a;N0.
3. Right pelvic lymph nodes showing 2 benign lymph nodes, both negative for metastatic carcinoma.
4. Left pelvic lymph nodes showing 2 benign lymph nodes, both negative for metastatic carcinoma.

Recent PSA Total test results below indicate “recurrence”:
1. Aug 26, 2011 0.00 ug/L
2. Mar 21, 2012 0.06 ug/L
3. May 22, 2012 0.10 ug/L
4. July 22, 2012 will have another PSA test.

My Present Considerations:
1. Owing to cancer being exterior of capsule and extent of bleeding during following 48-hours is there an indication in the recent PSA Total tests above that the cancer is still in the prostate bed or elsewhere?
2. Should I, before starting the recommended regime of 2-months Hormone Therapy (HT) followed by 2-months Radiation Therapy (RT), receive tests to determine the location of the cancer?
3. Is the practice of following RT with 20-months of HT really necessary and beneficial or should I just do 2-months of each and rely on repeating HT and RT once the future PSA tests indicate close to 0.20 ug/L?
4. In my case for the RT could I consider Sterotactic Body Radiation Therapy (5 sessions, each about 40 minutes) or would the TomoRadiation (40 sessions, each about 5 minutes).

Good wishes to all and appreciate any replies to this thread.

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

Hi, Optimistic.

Welcome to the forum and thanks for a very readable and consise post. I think it's unlikely that they will know for sure where the PCa may have spread but the most likely place is in the prostae bed area. Imaging will probably not deetect any distant metastasis at this point but I would ask your medical team to set you up for the full monty in that area to make sure you are covering all possibilities.

The upward trend in your PSA history since RP is worrisome and if it continues you will technically be experiencing recurence which is not uncommon. About 35% of patients who have RP experience a recurrence and the higher the initial Gleason score the more likeley this will happen. The good news in your case was that post RP pathology showed no involvement with lymph nodes or seminal vesicules so the prostate bed is the most likely source of the continued growth but obviously some of the cancer could have been spread through your blood system which took a pretty severe hit during surgery so it could be almost anywhere.

I have read several papers that indicate that RT in conjunction with HT is more effective in curbig prostate cancer growth than either protocol alone. The 20 month duration stems from the average life of a prostate cancer cell which is about 18 months give or take. Depriving the cells of testosterone during this period means that more of the cells will be unable to undergo mitosis. The downside of that is the side effects of HT which can vary from mild to severe and seems to be different for every individual. There are differences of opinions about whether or not you should have continual or intermittent HT and some recent threads in this forum discuss some new studies that suggest continual is more effective. I don't think any of the experts really know the right answer to that.

To my knowledge (I had SBRT for initial mono treatment) SBRT is not appropriate for radiation of the prostate bed. It is fundamentally a different form of radiation from IMRT or tomography in the dosage levels and the manner of delivery. You would need to speak with a SBRT specialist to get a professional answer and you might want to pose this question on the CyberKnife patient forum for prostate cancer where it will be addressed by one of the physician moderators who interact with patients. You can find this at www.cyberknife.com

K

joe1530
Posts: 2
Joined: Jun 2012

Hi Optimistic:
My situation sounds similar to yours
1. Biopsy: 12-10
Cancer in both lobes involving 8 of 12 cores.
original gleason score 3+3 with more than 1 core > 50% involvement
Psa 4.2
DRE: positive
cancer in 30% of total tissue volume.

2. Da Vinci RP 2-17-11
wt: 38g
Gleason now 3+4
25% of gland involved with tumor
right posterior extraprostatic extension
no seminal vesicle involvement
Perineural invasion present
only left nerve could be spared
multifocal margins present
pT3a
pNO (3 lymph nodes on either side were negative)

3. Post psa's of 3/32/11, 7/5/11, 9/23/11, and 1/27/12: psa undetectable

4. Now psa of 6/12/12 shows psa of .05
My doctor claims there is nothing to worry about but I am scared.
When should I go back for repeat psa?
I have read that biochemical recurrence is defined as psa > .2. But other recent studies seem to suggest that salvage therapy should be started as soon as possible.
What is the most up to date thinking on when to start salvage therapy?
Do you or anyone else have any other advice?

Thanks!

VascodaGama's picture
VascodaGama
Posts: 1549
Joined: Nov 2010

Joe

Your doctor suggestion is correct. I do understand your worries for receiving a PSA result with numbers instead of the word “undefeatable”, but 0.05 is low and it is considered by the majority as remission.
It is common in some clinics to indicate progress to their patients with a simple definition of “detectable” or “undetectable”. This classification is done with basis on the doctor’s threshold PSA value he uses to access success in a treatment of a certain patient. Some doctors use a cut-off PSA value of 0.1 ng/ml, meaning that all PSA results below <0.1 are “undetectable” and above it are “detectable”. You could inquire with your doctor about his threshold PSA which has been considered in the previous tests (3/32/11, 7/5/11, 9/23/11, and 1/27/12).

In any case, the result of the last PSA of 0.05 is very low and the AUA norms indicating recurrence is still a threshold of 0.2 ng/ml mark.
You are right for having a salvage treatments the earliest but the fact should only be done after confirming recurrence. This is considered when several PSA results attest a continuous rising.
You could try in getting the values of previous tests to verify for any continuous climbing.

Looking back at your stats, the voluminous cancer (8 out of 12 cores positive) and positive extra capsular extensions are indicative of possible future localized recurrence. Nevertheless, many guys with these similar stats never recurred.
Your next PSA done 3-month apart will indicate in which side your case stands.

If worried while waiting for confirmed recurrence you could advance with researches in image studies (C11 MRIs, PET scan, F18 Bone scan). These are important to locate any metastasis. However, low PSA cases refer usually to micro-metastases which are hard to find. Your path report post op indicates negative lymph nodes too.

You can research about salvage treatments, their risks and side effects. These may be nasty and will add to the ones you got from surgery.

Welcome to the board.

VGama

joe1530
Posts: 2
Joined: Jun 2012

Thanks VascodaGama. You have confirmed what I already know in my head objectively. But my fears are real, so thanks for the words on encouragement.

laserlight's picture
laserlight
Posts: 165
Joined: May 2012

Joe, I had surgery in feb of 2011 and my levels have been between 0.01 and as high as 0.05. My current level is at a 0.03, this was last week. On prior results I have been in the 0.02 range. I spoke in lenght with my doctor about this and he indicated to me that this can happen, it is still considered to be undetectable. He also said that 0.20 is the indication that cancer might be returning. The range that was quoted to me was from a 0.20 to a 0.40 is the range that flags the doctors. Now keep in mind that Pc, is a numbers game. Look at all of the lab results, they are based on numbers. When certain levels are seen, then it indicates something is going on. I follow these numbers and watch for any large shifts. I hope this helps, this is just my own outlook on this. In my current job I look at number results all day. I work in the semiconductor industry, we are heavy numbers driven, so I have learned to not get to excited when I see a shift. Have your self a good day. I have these same fears.

Kurt

Swingshiftworker
Posts: 634
Joined: Mar 2010

My understanding is that the general criteria for PCa recurrence is either a rise of 2 ng/ml between any 2 tests (Phoenix) OR a rise of any amount for 3 tests in a row (ASTRO).

PSA tests are generally done quarterly for 2-5 years following treatment (or until it appears that the PSA nadir -- the lowest level -- has been reached), in which case PSA tests may be done every 6 months to a year thereafter.

I understand your concern but you have not met either of those criteria yet. You should continue to test your PSA quarterly and monitor the results in terms of these criteria.

Don't know what the "most up to date thinking of the topic is" but I think that salvage therapy should begin when you (and your physicians) are certain based on further testing (including but not limited to MRI/MRSI, CAT or bone scans, etc. but not PSA testing alone) that the growth of your cancer has resumed.

For post surgical patients, this generally involves radiating the prostate bed and other suspect areas using IMRT in addition to hormone therapy.

Good Luck!

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