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Any possible negative effect to PCA/psa or rectal areas with sigmoidoscopy/biopsy 2 years after IMRT ?

hopeful111
Posts: 13
Joined: Nov 2010

SUBJECT:
Is there any risk that by having a sigmoidoscopy and biopsy during it, that there might be a
negative effect on the prostate or rectal areas radiated by IMRT ?

Would really appreciate your opinions or personal experiences on this topic.
Here's some background info followed by my questions in the QUESTIONS section below.
Sorry for so long a post.


BACKGROUND

1. I had 2 months of IMRT for pca in May-June, 2011. (gleason 7 (4+3), multiple cores)
(and 6 months of lupron starting 5 months before and one month after imrt)

2. I had a colonoscopy before IMRT began, back in 11/2010, soon after the pca was diagnosed.
The colonoscopy results were negative at that time.

3. I had IBS for many years before the imrt, but since early 2012, its gotten a lot
worse in severity and frequency.

4. My gastroenterologist recently suggested he perform a sigmoidoscopy on me soon
to find out if:

a. there might be other problems than the IBS, like IBD.

b. to see if perhaps there might be some irritation or other effects
from the IMRT on the rectal area to see if those might contribute to the IBS kind of symptoms I'm having.
(or to see if there is any evidence that other rectal problems might be happening or might happen
soon that might be a result of the imrt)

c. to make sure there are no colon cancer signs.

5. Due to the colonoscopy 2 1/2 years ago before the prostate IMRT of 2 years ago,
the Dr. does not feel a colonoscopy is needed at this time, and that's why is suggesting the
sigmoidoscopy..

6. I've not any other such invasive testing nor even a DRE since the IMRT was completed.
(nor any Fleet or other enemas)

7. While doing the sigmoidoscopy, he wants to take some samples/biopsies to see if IBD is involved
or if there might be other problems than the IBS.

8. He is aware in general that samples should not be taken near where the IMRT
happened in the rectal or other areas near the prostate.

9. Some articles and medical journals reports have spoken of harmful effects when
surgery or biopsy samples were taken from rectal areas that had received imrt as part
of pca treatment.

http://lenus.ie/hse/bitstream/10147/233372/1/Article6362.pdf

10. I'm aware that delayed problems from imrt, like proctitis, can happen even if
a colonoscopy or sigmoidoscopy would not be done.


QUESTIONS:

---> a. is it ok for the sigmoidoscopy to happen without any risk for having something done
during it, including taking biopsy samples, to irritate or otherwise negatively affect the prostate or nearby rectal areas that had the imrt,
and which irritation  might then cause the psa to be raised or otherwise  cause the cancer to start regrowing ?

(or that the sigmoidoscopy could irritate any scarred or sensitive rectal areas that were affected by the IMRT, which might now or later cause proctitis or other problems even if not related to raising psa or making the pca return) ?

---> b. is there a chance that the prostate or rectal areas affected
from the IMRT could be irritated or disturbed just by insertion and
exploration of the sigmoidoscope itself or even by the Fleet enemas themselves, which I'm
supposed to take to prepare for the procedure ?

---> c. how far up and in the rectum should the Dr. not probe or take any samples/biopsies
to make sure any areas affected/radiated by the IMRT are not irritated ?

---> d. or to phrase question c. a different way, since obvious or visual signs of proctitis or other rectal irritation as a result of imrt might not be present at this time, since have read that these problems can come years after imrt --

    then it seems like Dr. might not necessarily be able to depend on visual evidence to know where not to take samples
from, thus wouldn't it be safer for Dr to just avoid in rectum some specific number of inches
or centimeters from where the beam of the imrt *might* have touched ?

(that is, are there some standard number of centimeters or inches up the rectum
or within certain parts of the rectum where a biopsy should not be taken if one had imrt of the
prostate, whether if visible or not visible rectal irritated or scarred areas.

PS - If there is any possible risk from the sigmoidoscopy or Fleet enemas that the prostate cancer
could become active again
or that the procedure might cause or make worse irritation of the prostate or rectal areas that received the IMRT
(which perhaps might be sensitive or scarred already), I really would like to wait to have it done
until can have more time to think about it and discuss with doctors.

VascodaGama's picture
VascodaGama
Posts: 1568
Joined: Nov 2010

 

Hopeful

Specialist physicians are the ones where to get trustful answers. I think that you should consult your radiologist to get a second opinion on your gastroenterologist suggestion.

My lay opinion is that the sigmoidoscopy is not so invasive so that it can be done to check for any scar tissue, etc., as far as it can reach deep (the end of the colon/rectum area), but a colon biopsy is very invasive and risky, particularly if there are any kind of colitis-like tissue that were caused by the radiotherapy (tissue not yet cured or healed).
Some patients have reported about problems (as bad as fistulas) from biopsies done at rectum tissue.

The radiologist knows the scope (radiated field) he has used in your treatment so that he can provide with an idea about the present status (degree of healing) of the tissue at the area. You could do a sigmoidoscopy alone and decide later on doing a biopsy at a different occasion.

It is typical to have a cystoscopy and colonoscopy done one year after the radiotherapy to check for scar tissue. I think that the practice is done because it is considered OK. Medications or enemas, etc., would not affect or cause prostate cancer to “flourish” so that it would not have any effect on the PSA levels.
In fact, you should be cured by now and you should care more for the after effects from the treatment or any other illness event.

Please consider using doctors that have experiences in similar cases as that of yours. In cancer centres (like JH, Mayo clinic, etc) doctors of different trades work together and manage to deliver better diagnosis (and satisfactory answers).

Radiation may have caused IBM or you had already ulcerative colitis without knowing, which would have been proibitive for IMRT treatment. IBS symptoms can be aliviated with a change in diet, but it takes time to get down the results. 
Have you discussed with your doctor about the above or have considered to get the opinion of a nutritionist ?

 

Can you share info on the progress of your PCa case?

 Best wishes.

VGama  Wink

 

hopeful111
Posts: 13
Joined: Nov 2010

Vasco,

 

I think you've summed it up well - the difference between having the sigmoidoscopy at all

vs having one with a biopsy in the rectal area.

 

I did call radiation place and a dr looked at my records and said not to have biopsy within 20 cm

of where rectum starts; I read that rectum area usually up to 18-20 cm so don't know if he

was just covering whole area to be safe or if the imrt might have touched the full area. I'll

discuss this with gi dr. 

 

I guess if gi dr does feel a need to do biopsy within rectal area, then it can be discussed with

rad dr and i guess would be a potentially serious situation - since gi dr knows why not to take

biopsy in rectal area,  it would be a real serious thing if he felt one was needed.

 

But still want to make sure its ok to have it at all as to just the scope going in itself in case there

might be some areas that are problematic that might be affected just by scope going in and doing exploration;

and since even if no signs of rectal problems from imrt, things could have happened/be happening there,

and will keep thinking about this whole topic.

 

as to controlling the ibs I have been controlling food for a long time; some of those mental medications for it have too many side

effects, but its mostly that since 9 mos post imrt the ibs had gotten so much more frequent and severe than in the past when was able to more or less manage it though tough even then; that increase in severityis what is leading to this possible sigmoidoscopy, though really in 2yrs am due to colonoscopy again and do need to do that to monitor about colon cancer, etc in any case.

 

Thanks again for your comments.

 

VascodaGama's picture
VascodaGama
Posts: 1568
Joined: Nov 2010

Hopeful,

Probably the gastroenterologist wants to perform the sigmoidoscopy with a rigid apparatus. This tool is enough to check the end portion of colon at the sigmoid. To go further inside he will need a flexible endoscope. The procedure would not affect any cancer (if it exists) at the area or at the gland.  You shouldn’t be so concerned.
You may experience some discomfort or pain if you got any open wound like an
ulcerative colitis. In any case, without checking the colon your doctor cannot diagnose the origin of your problem.

The biopsy should be avoided as per your radiologist so that the matter should be further discussed at a latter occasion, if the gastro finds (this time) something suspicious. He can always identify the spot at another sigmoidoscopy and perform the biopsy under the guidance of your radiologist.

IBS is commonly reported by Pca patients of radiotherapy. In my case, RT has weakened my colon walls causing me a partial loss of sensation when passing stool. Fortunately, I am continent but I do “puff” more often after RT then before. In my last colonoscopy the doctor found diverticulosis (outpocketings along the colon) that fill up with detritus and cause occasional intestinal gazes. Diverticulosis causes rectum bleeding too but it seems to be a natural way of our system to clean up/empty those pocketings.

Surely your best shot is that the gastroenterologist calls the radiologist. If he doesn’t want to call him then change doctors. You would be the one to surfer the consequences arising from the procedure, not your gastro.

I hope they find nothing in your rectum and that you fully recover from the condition.

Wishing you peace of mind.

VGama

hopeful111
Posts: 13
Joined: Nov 2010

I'm the original poster and wanted to give an update on what was discussed in this thread so far.

 

1. 6 weeks ago I had the sigmoidoscopy.

 

2. The Dr did a digital rectal exam first and said the prostate felt flat which he said was a good sign.

 

3. Biopsy's taken to see if IBD were negative and he did not report and problems with the rectum as to

effects seen from imrt though I realize those problems can manifest later (its been 2 1/3 years since imrt).

 

4. I was due to have psa and asked how long it could be good to wait to avoid artificial rise in psa

due to dre and sigmoidoscopy - he suggested one week.

 

5. one week later i had the psa and it was 0.2, which was different than the 0.1  I'd had for a year or so

(and before that at least 9 months of mostly <0.1, which is as low as the psa test I take goes.)

 

6. I thought the 0.2 might still be related to the dre and sigmoidoscopy effects on prostate so asked

if I could take psa again after one month.

 

7. HOWEVER, it is 0.2 again, which is what is troubling, being that it was 6 weeks after the sigmoidoscopy

that I took it.

 

===> Question - could it be that the sigmoidoscopy and dre might have stimulated or otherwise affected

prostate to become more active as to the remaining cancer cells -- and that is why its again 0.2

(after having been 0.1 for such a long time, and < 0.1 for a long time before that)  ?

 

OR could it be that its still just the effects of the DRE and sigmoidoscopy itself causing

an artificial increase of the psa, even though it was 6 weeks after the sigmoidoscopy/dre

that the recent lab was done ?

 

Thanks again for comments or suggestions.

VascodaGama's picture
VascodaGama
Posts: 1568
Joined: Nov 2010

Hopeful,

I wonder what your doctor answered to your questions.

Cancer is not awaken from a “deep sleep” with a massage to the gland, and the effect caused on the level of the PSA from a DRE or sigmoidoscopy, in any patient, should be null at the 6 weeks point after the procedure. Our body takes approximately ten days to clean extra “floating” PSA serum from our system.

You may be thinking that the 0.2 ng/ml mark has a meaning of “recurrence” but it is too premature to be taken as such. The origin of this surge in PSA may be related to your radiation treatment, if you still got your prostate in place (?). Typically RT patients experience a bounce PSA that in some cases can take four years before stabilizing. The PSA goes firstly high (very high in some cases) then it slows down to increase again till it starts to gradually decline to a nadir value. This may take years to be accomplished. Read these;

http://www.ncbi.nlm.nih.gov/pubmed/12705989

http://www.medpagetoday.com/MeetingCoverage/ASTRO/4464

http://link.springer.com/chapter/10.1007%2F978-1-4471-2864-9_68#page-1

Your treatment protocol was the combo HT+RT which makes the bounce more accentuated. The effect of the Lupron could have lasted 12 months (a testosterone test could reveal its effect). The goody of a bounce experience in guys with RT as prime (prostate in place, no RP) is that by statistics these patients have an assured longer period of biochemical free survival.

I would suggest you to forget about recurrence (if any) and give a chance to get your nadir PSA. Recurrence has several “forms” of judgment in regards to the PSA as a marker in RT cases. Typically doctors allow three consecutive increases of PSA done two or more months apart to consider recurrence.

Hope for the best and think positively. Take your case as not in recurrence yet.  Cool

Best

VGama  Wink

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