Rising PSA

giopar

Dear all,

I'm 61 yo man and 4 years ago my prostate was removed with nerve sparing Da Vinci surgery (PSA=5.01). While my biopsy Gleason was 6, it was upgraded to 7 (3+4) after histology, and the outcome was PT2c (cancer inside the gland), and no further treatment necessary. However, at subsequent follow-up, my PSA exhibited steady slow growth:

after 1 month of surgery  PSA= 0.00

after 1 year                            0.01

after 2 years                          0.02

after 3 years                          0.03

after 4 years (now)                 0.05

 

My urologist says no to be concerned, while the radiotherapist I've contacted suggests immediate RT salvage treatment in order to have the best benefit.

I'm rather confused. Can anyone help me?

 

Thanks everybody

 

Giopar

ralph.townsend1

Listen

Listen to your Urologist for now, if the psa hit 0.1???? Your doctor's knows best, that if he is a specialist in prostate cancer???

VascodaGama

ralph.townsend1 said:

Listen

Listen to your Urologist for now, if the psa hit 0.1???? Your doctor's knows best, that if he is a specialist in prostate cancer???

Do things timely and coordinately

Giopar

 

Welcome to the board. My lay opinion in regards to the info you share here is that the progressive curve of the results of PSA indicates existing prostatic cells still activity in your body.

Since you have no prostate in place, either you got metastases or the rise is due to a small piece of benign prostatic tissue left behind. This is no joke. There are many cases (for not saying that it is common) in NS robotic type surgeries, in particular on “nerve sparing” performance where pieces are not cut off.

They are left behind alive and kicking.

Apart of the prostate, a portion of the urethra walls also produce tinny amounts of PSA; however, these are so small that are negligible in the assays reading tolerances.

I agree with Ralph for you to listen to your urologist at this time. A value of 0.05 is still within the “brackets” of remission (<0.06) and your PSADT at over 24 months is far from the critical threshold of 14-months, recommended as a critical limit for successful (longer biochemical free rates) salvage treatments after RP.

 

At this 4-year milestone of your surgery the increase could also be indicative of recurrence but the threshold recommended by AUA is PSA=0.2 ng/ml. They also recommend a SRT at levels of 0.4, which is still far in your case.

ASTRO (your radiologist association) recommends EARLIER attacks because the outcomes are better. However, the term your radiologist used “…IMMEDIATE”, is not reasonable in a patient with your status. Your Gleason score of 7 was indicative of probable metastases but the pathologist does not indicate findings of positive margins and/or positive extra capsular extensions, in the specimen (your incised prostate) given to him. We do not know if any lymph node was anylised but the classification of pT2c, would judge it as negative to cancer.

https://crawb.crab.org/txwb/CRA_MANUAL/Vol2/chapter05_Genitourinary.pdf

 

There are no thresholds for EARLIER attacks. Much of the decision is done solo on one’s believe and reasoning. After all, what we want is to get rid of the cancer but we should do it with a treatment that assures to fix the problem. And that becomes the problem itself.

Radiation success is not dependent of an earlier attack but on the chances it has in hitting the targets (the cancer) with precision. Radiation must be directional to targets pre established, which may be at far places not those imaginarily fixed. No one can assure hitting the “bull’s eye” throwing arrows in the dark.

Your radiologist may have an established field for attacking but he cannot assure you the cure if you do it rather now than latter. It is solo based on guessing and rates.

 

I would suggest you to get a second opinion from a PCa specialist medical oncologist. Prepare a long list of questions for your next meetings with the doctors and do not worry if they seem bizarre to you.

Remember that treatments involve side effects that will superimpose on the ones we got from previous treatments. Be reasonable when thinking on what to do but do things timely and coordinately. You have loads of time to ponder on the matter.

 

Wishing you peace of mind and luck in your journey.

 

VGama 

giopar

VascodaGama said:

Do things timely and coordinately

Giopar

 

Welcome to the board. My lay opinion in regards to the info you share here is that the progressive curve of the results of PSA indicates existing prostatic cells still activity in your body.

Since you have no prostate in place, either you got metastases or the rise is due to a small piece of benign prostatic tissue left behind. This is no joke. There are many cases (for not saying that it is common) in NS robotic type surgeries, in particular on “nerve sparing” performance where pieces are not cut off.

They are left behind alive and kicking.

Apart of the prostate, a portion of the urethra walls also produce tinny amounts of PSA; however, these are so small that are negligible in the assays reading tolerances.

I agree with Ralph for you to listen to your urologist at this time. A value of 0.05 is still within the “brackets” of remission (<0.06) and your PSADT at over 24 months is far from the critical threshold of 14-months, recommended as a critical limit for successful (longer biochemical free rates) salvage treatments after RP.

 

At this 4-year milestone of your surgery the increase could also be indicative of recurrence but the threshold recommended by AUA is PSA=0.2 ng/ml. They also recommend a SRT at levels of 0.4, which is still far in your case.

ASTRO (your radiologist association) recommends EARLIER attacks because the outcomes are better. However, the term your radiologist used “…IMMEDIATE”, is not reasonable in a patient with your status. Your Gleason score of 7 was indicative of probable metastases but the pathologist does not indicate findings of positive margins and/or positive extra capsular extensions, in the specimen (your incised prostate) given to him. We do not know if any lymph node was anylised but the classification of pT2c, would judge it as negative to cancer.

https://crawb.crab.org/txwb/CRA_MANUAL/Vol2/chapter05_Genitourinary.pdf

 

There are no thresholds for EARLIER attacks. Much of the decision is done solo on one’s believe and reasoning. After all, what we want is to get rid of the cancer but we should do it with a treatment that assures to fix the problem. And that becomes the problem itself.

Radiation success is not dependent of an earlier attack but on the chances it has in hitting the targets (the cancer) with precision. Radiation must be directional to targets pre established, which may be at far places not those imaginarily fixed. No one can assure hitting the “bull’s eye” throwing arrows in the dark.

Your radiologist may have an established field for attacking but he cannot assure you the cure if you do it rather now than latter. It is solo based on guessing and rates.

 

I would suggest you to get a second opinion from a PCa specialist medical oncologist. Prepare a long list of questions for your next meetings with the doctors and do not worry if they seem bizarre to you.

Remember that treatments involve side effects that will superimpose on the ones we got from previous treatments. Be reasonable when thinking on what to do but do things timely and coordinately. You have loads of time to ponder on the matter.

 

Wishing you peace of mind and luck in your journey.

 

VGama 

Thank you very much for quick

Thank you very much for quick and clear answer.

As you suggest, I'll contact a PC oncologist for a guidance at this stage of disease. I just ask you, VGama: is the rate of my PSA increase suggestive of  local or systemic relapse?

Wishing you the best

 Giopar

VascodaGama

giopar said:

Thank you very much for quick

Thank you very much for quick and clear answer.

As you suggest, I'll contact a PC oncologist for a guidance at this stage of disease. I just ask you, VGama: is the rate of my PSA increase suggestive of  local or systemic relapse?

Wishing you the best

 Giopar

Cure after treatment failure is not easy to attain

Giopar

PSA tests cannot diagnose your cancer as localized or systemic. These are attributed to the status of a patient after biopsy and results of image studies. The PSA is expected to increase when prostatic cells are active wherever they may exist.

Localized recurrent cancer is typical in micrometastases voluminous cancer cases. Usually the patient initially had an high PSA above 20, all biopsy needles positive but low grade Gleason. After surgery the pathological stage refers to pT3.

In any case, the size of the tumours is more or less related to the amounts of prostatic specific antigens circulating in our bodies. Often small amounts of PSA relate to small sizes, which may be easy to treat if they form one colony at one place, but they are difficult to find in image studies. Micro metastases (small colonies spread) are still more difficult to treat because of the many targets.

Locating the cancer is the goal but unfortunately the traditional CTs and MRIs produce many false negatives.

If affordable to you I would suggest you to get involved in cross reference tests before commiting to a treatment. The latest contrast agents (C11 choline or acetate) done with PET plus MRI (3T high resolution) and the Feraheme-MRI image studies are the best in the “market” and have been successful in locating metastases.

Surely other matters (like family opinion, job, age, health, etc.) must be taken into consideration in a decision. Salvage treatments should consider the quality of life too. Free of cancer after failure is not easy to attain and got low rates for total cure.

Hope for the best.

 

VGama

tarhoosier

giopar said:

Thank you very much for quick

Thank you very much for quick and clear answer.

As you suggest, I'll contact a PC oncologist for a guidance at this stage of disease. I just ask you, VGama: is the rate of my PSA increase suggestive of  local or systemic relapse?

Wishing you the best

 Giopar

G:

My amateur opinion is that any radiologist cannot proffer a treatment opinion without reading the operation notes from the surgeon and the pathology report from post surgery. If the radiologist is offering an opnion based only on clinical details then he is wrong, whatever he is saying.

If the radiologist has fully inspected the op notes and path report then he can make an nformed opinion. You offer none of that nformation here so our amateur opinions are without value.

The urologist is out of the picture now, nonetheless. His job is complete, unless you have continuing urological issues. It is time to move to an oncologist who can make a disinterested (unbiased) opinion. Your rise is so slow that I wish the urologist had said worry a tiny, microscopic amount, equal to your psa rise, rather than dismissing your concern completely. Most often when doctors say "Do not worry" they truly mean "Worry if you wish but do not bother me with it".