Possible recurrence of prostate cancer

David7143

I am 71 years old and had a brachytherapy six years ago for a Gleason 6 rating and a bioply showing a small amount of cancer in the right lobe .  At the time of the procedure the PSA was around 11 and had increased rapidly from 4 at which time I had the 6 needle probe. The BT treatment was I-125 50 seed total dose of 145 Grays.  

For three years my PSA was at 0.9 and then started to increase.  About this time, I was placed on finasteride and Terazosin to shrink the prostate and improve urine flow.  I had also experienced ED.  In the next thre years the PSA increased to 2.32 at which time I began to become concerned and found that the finasteride was masking as much as 50% of the PSA readings so the increase was probably more like 4.5.  I also ran the velocity and doubling numbers and the velocity was around 0.5 for the last three month intervals with a coubling of 1.28 years.  

I was given a PET CT scan neck to knees and there is no sign of cancer outside the prostate.  I was given a urine test to look for prostities and it was clear.  The Free PSA test showed a Percentage of around 5.  So it appears the cancer is there and confined to the prostate. 

I have not had an MRI or a biopsy as my urologist indictes the targeting of a biopsy or the analysis of an MRI is diffilcut due to the metal seeds interferring with both these procedures.  I am being encouraged to begin harmone therapy.  Additional radiation treatment appears not to be an option due to the high dosage I received by the BT.  I am also being told the results of either robotic or nornal radical protatectomy has a greater risk of incontenance due to the previous BT, and I am having trouble finding info about any surgeon sho can perform this procedure.  

Any suggestions on a future plan for my situation other than watchful waiting or harmony therapy.  If it is HT, which treatment would be the best to begin with.  I am willing to start with the treatment that provides the less side effects. My insurance idicates the robot radical is not covered.  My urologist indicates I might think about cryotherapy, but that is more experimental than robotic procdures.   

 

 

   

VascodaGama

A lay view of your case

David

Welcome to the board.

From what you write, the increase is of concern but nobody can tell if the increase is due totally to recurrence. I wonder if your doctor has declared biochemical failure or recurrence.

You are doing well for investigating on a salvage treatment, including a surgeon to remove the gland. This could mean cure if the exams were 100% correct. In any case the increase of the PSA could be thought to be due in part from chronic inflammation. Finasteride and Terazosin are alpha blockers used in the treatment of BPH. These influence the PSA readings but Finasteride (5-ARI) also blocks the conversion of testosterone to dihydrotestosterone (DTH), a refined androgen that feeds prostatic cells. The decrease of the PSA was therefore expected. It was not a “masked” reading. Both, cancerous and benign cells would respond to the effect of the drug.
Accordingly, the PSA tests can only be used for certifying recurrence after stopping Finasteride. This drug has a short half-life so that you could trust the PSA results once you stop taking it. Three constant increases are the usual way to declare recurrence.

I am not a doctor but my lay opinion on the typical urine tests is that these are useless for judging chronic UTI. In PCa related analyses, the best way is always to try “cleaning” the tract with a complete protocol and dose of an effective medication, and then, check the PSA again. I also think that free PSA is good to judge the presence of cancer but it should be used in naïve PCa patients. The effect of Finasteride would also render this test obsolete.

From the exams one may think that the cancer (if existent) is localized. However, the choice in removing the gland is best if in fact the cancer is confined. This is an important judgement because the initial decision in the BT treatment has been identical. Contained and Localized. And you now believe that the treatment is a failure.

The radiation was enough to “kill” prostatic cells within the gland and at its peripherals. It may have not given identical results to the lymph nodes at the iliac. These are the ones typical “accessed” by the cancer once it spreads out of the prostate gland.

There are better exams than the PET/CT for checking PCa in the lymph nodes. It is called USPIO exam that uses feraheme contrast agent. At The Nederland, this test (named Combidex) is said to detect tumour sizes of 4 mm, contrasting with the C11 PET/CT that detects at 7 mm.
For details you can search the net google-ing the above names.

For your next step, in your shoes I would exhaust all possible ways to procure the reason for the increasing PSA. In other words I would verify cure firstly with PSA testing in a “clean” environment. Then I would try locating the bandit and decide on the best way to treat it. The present PSA is high but it does not mean death. Hormonal therapy would pull down the cancer to the canvas even if the PSA reaches above 10, which is the level of your first intervention.
All treatments for PCa got risks and side effects. The choice is yours but why enduring a therapy if that does not assure you your goal.

Please note that I am a survivor and base my opinions solo on my 14 years of PCa experiences.

Best wishes in your journey.

VGama

 

David7143

VGama

Thanks for the info in your comment.  After some research on internet, I see that a trans rectal coil MRI with good practictioners can tell a lot abot seed location and active cancer location.  I am starting a regiment of anti biotic to see if the higher PSA could be due to an infection of the prostate, however if it is a virus it will not show.  

Yes is went off Finasteride for a month and the PSA went from 2.3 to 2.9 so that sort of proves the finastride was impacting the PSA levels.  So I have gone back on finastide which I now understand does not support agressive cance as once thought.  I went back on the finastride as a smaller prostate is more condusive to a radical prostatectomy procedure if that is what I decide to go to. 

I agree that much more investigation needs to be done to determine my course of action from here forward.  At this time it is clear I need an MRI to determine if the cancer is in the prostate.  If so the USPIO could be used to see it is outside the prostate.  Eather way I would be looking at a radicay prostatectomy and or hormone treatment.  The MRI would tell how much damage the previous radiation has done to the bladder connection and if the seeds are contained inside the prostate.  Some of my researse has shown the seeds could well have been placed outside the prostate, in the bladder, or other locations.  If this is so the redical prostatectomy would be out and I would be considering a cyrotherapy and or hormone therapyh.  

My window of oppourunity is not to long with the velocity of the PSA increase, and I am having a time coordinating second opinions and even getting my urologist to move off his original assessments.  He will agree to tests, but as they become the more complex type it appears his resources are becoming limited.

David  

VascodaGama

David7143 said:

VGama

Thanks for the info in your comment.  After some research on internet, I see that a trans rectal coil MRI with good practictioners can tell a lot abot seed location and active cancer location.  I am starting a regiment of anti biotic to see if the higher PSA could be due to an infection of the prostate, however if it is a virus it will not show.  

Yes is went off Finasteride for a month and the PSA went from 2.3 to 2.9 so that sort of proves the finastride was impacting the PSA levels.  So I have gone back on finastide which I now understand does not support agressive cance as once thought.  I went back on the finastride as a smaller prostate is more condusive to a radical prostatectomy procedure if that is what I decide to go to. 

I agree that much more investigation needs to be done to determine my course of action from here forward.  At this time it is clear I need an MRI to determine if the cancer is in the prostate.  If so the USPIO could be used to see it is outside the prostate.  Eather way I would be looking at a radicay prostatectomy and or hormone treatment.  The MRI would tell how much damage the previous radiation has done to the bladder connection and if the seeds are contained inside the prostate.  Some of my researse has shown the seeds could well have been placed outside the prostate, in the bladder, or other locations.  If this is so the redical prostatectomy would be out and I would be considering a cyrotherapy and or hormone therapyh.  

My window of oppourunity is not to long with the velocity of the PSA increase, and I am having a time coordinating second opinions and even getting my urologist to move off his original assessments.  He will agree to tests, but as they become the more complex type it appears his resources are becoming limited.

David  

A long Window of Opportunity

David

I am glad about your perseverance in keeping you ahead of the bandit. You are in the driver’s seat guiding your course. After six years on the run it is difficult to say that the rise in PSA is not due to cancer but you should be more precise in the present diagnosis to choose better.

My help is limited. I believe that you should consider giving up with Finasteride and let the PSA take its course clean for a while. Finasteride benefits at this time are limited. The e-MRI (endorectal coil) is a very good choice for detecting any spread. It will also provide the measurements (present size) of the prostate that seems to be worrying you in the possibility of a surgical procedure. Allowing the PSA to increase freely is not bad in small amounts. It will benefit the chances of the eMRI to detect and locate the hidden bandit.

I think that your doctor has recommended the drug before to help with the urinating problem issue, but this would not improve things if the problem has been due to scars from the radiation. Have you done any cystoscopy at the time to access the problem from within?

The impact of Finasteride in the PSA is that it is slowing down the activity of prostatic cells (cancerous and/or benign) that produce the serum. It also treats hyperplasia but it does not assure a smaller sized gland.

The hormonal treatment you are considering as salvage for the brachy may include Finasteride but this alone does not complete the protocol. Interestingly, you have a PSADT of over 14 months which is considered “good” above the limit (9.5 months) when is recommended to start hormonal therapy.

Your "window of opportunity" is long enough to choose better. Gleason 6 is not an aggressive type of cancer. I think you should continue with the tests and get to grips with the data that can provide more info in your present status. Get second opinions from other RT specialists.

Here are links you may have interest in seeing;

http://theoncologist.alphamedpress.org/content/10/10/799.full

http://www.prostatevideos.com/prostate-cancer/treatment-options-for-rising-psa-after-local-therapy/rising-psa-after-brachytherapy/

 

Best wishes.

VGama