PSA Following Salvage Radiation Treatments

Max Former Hodgkins Stage 3 said:

Unbelievable

Timon,

What I hardly believe in your account is that the urologist could have ever interpreted "margins involved" to mean "negative surgical margins."  That is like saying to someone, "Luckily, your biopsy was positve; I sure hate hearing it when they are negative."   This (in my non-trained understanding) was not just wrong, but an illiteracy !  Your whole pathology report shouted "Cancer Escaped !"  The radiation oncologist rightly noted this error.

Your salvage radiation began about four years after surgical removal. The radiation oncologist's opinion that any cancer present remained in the bed area was (as he admitted) an educated guess, and pretty reasonable, especially with the still quite low PSA.  The full dose radiation was what most rad oncologists would have most likely tried first. 

Since your treatment future might involve HT, I would seek out a MEDICAL ONCOLOGIST with special experience in third-line treatment of PCa.  (Medical oncologists are virtually NEVER cross-trained with radiation oncology, or vice versa.)   Not  a guy "who had done third-line cases," but a guy who focuses on it.

Disclaimer: I have never myself needed salvage therapy. My thoughts here are based upon what I have read on the subject.  HT seems to me (if you ever need it) to be quite complex and more of a poker match than an exact science.  Hopefully after the radiation effects reach nadir, it will indicate no remaining cancer.  And your PSA is so low at the moment that it should indicate that any remaining disease is very treatable/managable, very long-term.

I would not need to "vent" if I were you; more likely I would be throwing stuff at my walls !

 

max

Timon

I understand your worries and the frustration In Max above comments. I also vote for a wait-and-see approach till the next PSA to verify RT’s outcomes.

In my interpretation of your physicians opinions, the "negative surgical margins" means that cancer was not found at the places of dissection (in the proximity to the sphincter at the bladder, and at the colon (where the prostate is “attached”). These analyses are suggestive that extra prostatic extensions ("Margins involved”) were found at tissues in the prostate bed and surrounding adipose tissues. The above would be then used by the radiologist for planning the best field of radiation, which probably would use lesser amounts of rads at the sphincter area to avoid damage that would most certainly cause permanent incontinence issues.

I believe that the highest concern goes to the pathologist’s comment regarding his findings of “tumor extensively present within lymphatic and vascular channels”. These are the routes used by the cancer to travel to far places.
In such a case, a salvage RT alone attacking the prostate bed may be not sufficient. The radiation field should include the lymphatic’s areas close to the prostate and at the iliac. Furthermore, it would include a combination therapy (neoadjuvant and adjuvant) composed of ADT and/or Chemo (as commented by Old Salt above), to care for any cancer already “travelling” in the vascular channels.

Surely the above is only guessing suggestions, but PCa treatments are no more than guessing approaches trying to “catch” the cancer in a whole, and then waiting to see the results. In your case the future PSA curve will tell about your fate. I hope the radiation caught it all successfully.

A note to Old-timer: Jerry you are lovely. I send you my best wishes for continuing life filled with enjoyment. It is a thrill reading your posts.

Thinking of you all.

VG

Timon said:

LATEST POST SALVAGE RADIATION PSA WAS 0.80

Gents --

This is an update to the history supplied in the first entry of this chain.

As noted, when my PSA rose to 0.78 approximately 3 years and 8 months after prostatectomy, I was referred to a radiation oncologist who, having studied my history, concluded that cancer cells remained in the "prostate bed." He prescribed Salvage Radiation and I began 37 treatments starting in January 2015 and concluding on March 5, 2015. 

On April 27, 2015 my PSA was 0.79 but the Radiation Oncologist said those results were premature since it often takes several months before the radiation's effectiveness is obvious.(WHICH BEGS THE QUESTION, WHY ORDER A TEST THAT WILL PROVIDE ONLY INCONCLUSIVE RESULTS?)

My second post-Salvage Radiation PSA on October 23, 2015 was 0.76. Both the urologist and radiation oncologist were "puzzled" by those results but encouraged me by pointing out that the PSA had fallen slightly and that trend should continue.

My latest PSA test on January 23, 2016 however, revealed a PSA of 0.80. The radiation oncologist was once again "puzzled" by the fact that there was so little movement with regard to the PSA.  (He suggested another MRI and bone scan but I declined on the theory that the PSA was still too low and tumors would probably be too tiny to show up in the test.)

Here's my question to the learned members of the network:

DOES THIS LATEST PSA RESULT TEND TO RULE OUT THE INITIAL THEORY THAT CANCER REMAINED IN THE "PROSTATE BED" AFTER SURGERY?

IN OTHER WORDS DOES THE RESULT INDICATE INSTEAD THAT THE CANCER HAS NOW SPREAD ELSEWHERE?

WHAT'S THE LIKLIHOOD THAT FURTHER PSA TESTING WILL REVEAL A DROP IN THE PSA?

IS IT STILL "TOO EARLY" TO ARRIVE AT ANY CONCLUSIONS?

Thanks for any information.

Timon

 

While your PSA is low, the lack of change (either up or down) following surgery and radiation treatment is indeed puzzling.  The only definitive way to find out if there is still anywhere near where your PCa was located is to do a MRI/MRSI scan -- also referred to as a multiparametric MRI or 3.0 Tesla MRI.

While different equipment may be used, they all involve the injection of a dye into the body and the placement of an endorectal coil in your rectum while the MRI is being done.  This results in a spectroscopic scan of the region which will highlight the location of choline which is a marker for cancer.   No choline concentration, no cancer.  There is no better test currently available.

So, if you can have this test done, I'd highly recommend it.

One could think of laboratory error too. In any case, the value of 0.8 is not zero and nobody knows if the serum is due to prostatic cells located at far places (not at the bed) or still at the lymph nodes in the iliac. It is hard to expect it to be from prostatic cells radiated in the SRT’s field of attack (isodose planning). What was the RT protocol?

The pathological report post op (2011) described above in your first post was suggestive of possibilities in spread via the lymphatic system (“tumor extensively present within lymphatic and vascular channels”), which we could argue that some cells have travelled and got stacked at some place.

The problem of guys with failed radicals (RP and RT) is that cancer may still be treatable with intent of cure but such is dependent on the location of the tumour. They call it oligometastatic therapy. A fewer number of cancer spots located in areas possible of being radiated. These can be at the same areas previously radiated whose tissues have not absorbed yet the maximum (limits) of radiation.

For such purposes one needs firstly to pinpoint the tumour, which is not easy via traditional CT/MRI or bone scan, but possible through newer image techniques using specific contrast agents with PET scan, if the tumour is close to 2mm thick (approximately PSA>1.5 ng/ml). F18 choline seems to be the best choice in contrasts. C11 choline and C11 acetate are also available but require proper facilities for administration. For details on these exams google F18 PET or C11 PET scan.

The scan indicated by Old Salt above, the 68Ga-PSMA, makes part of newer ways to locate PCa using radiopharmaceuticals that “attack” a membrane protein specific to the prostatic cells, the PSMA. This practice is not new. Back in 2000, ProstaScint was using an anti-PSMA monoclonal antibody to detect PCa but their substance of the time was not feasible enough providing false positives. More recently, researchers found better substances, providing more reliable results. These are on trials and you may find it proper to you. Please read the links indicated in my comment to another survivor of this forum, in here;

http://csn.cancer.org/node/299511#comment-1528349

You may read details on the PSMA in this link;

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472940/

My suggestion in regards to the “flatten” PSA result is for you to wait till an increase becomes apparent. The next step would be ADT and that can be started at much higher levels of the PSA. Your oncologist will have thresholds to trigger the treatment according to your specific case. Meanwhile do some researches regarding the side effects of hormonal therapies and get informed about the latest “discoveries”.

Best wishes,

VG