Any advice would be appreciated. PSA rising 6 weeks after RP

Donna,

I am sorry for the situation. You need to recover the strengths and continue the good fight against the bandit. Be positive.

You did not specify which tests have been done before surgery or the ones now being requested by the new oncologist but I guess they were the traditional bone scan and CT/MRI. These tests are typical in providing false negatives because they cannot detect cancer of small sizes. The initial negative results may have been the reason for choosing surgery as prime. Most probably the newer tests will also fail if they are the same, so that you should insist in getting image studies via PET scans with the newer contrast agents.
Please read my post to another survivour in here; https://csn.cancer.org/comment/1553746#comment-1553746

Without defined targets, the radiologist may direct the radiation to common areas of salvage treatments that includes the prostate bed and localized lymph nodes. Unfortunately this sort of blind administration is done on guessing and it may fail again. I would recommend you to get copies of previous tests and exams for comparison by the radiologist, but I would be looking for the possibility in having PET exams.

Gleason 9 is of aggressive type of cancerous cells. They spread fast and need prompt attention. In any case, your husband needs to recover from the surgery and be fit for the RT. Usually doctors recommend 4 months of rest before any administration, though this period can be extended further without prejudice of the outcome. Do not rush but be attentive and do things coordinately.

Just curious about the type of surgery. Was it open RP or robotic?

Best wishes and luck.

VGama 

DonnaS67 said:

Thank you for your response.

Thank you for your response. The RP was robotic and the tests prior were the routine prostascint, ct scan, bone scan an chest X-ray. I have read a little about the PET scan. What can I do if his Doctor is resistant to this type of test?  Any help is appreciated as we are getting conflicting stories from different doctors.

Donna, 

Prostate cancer is extremely hard to locate outside the gland. Your husband's surgeon guessed wrong about the containment, and what was obviously a positive margin. 

Ensure that his radiation oncologist is well experienced with prostate cancer specifically.  As Vasco noted, enhanced PET scanning could be of great value. PETS are not massively expensive, and his situation medically warrants one.

Disease that has escaped the capsule is in most cases still treatable toward curative effect via radiation only. His case is not hopless; radiation, done right with good imaging to guide it, may eliminate all of the disease.    Radiation is the obvious next step. But your husband's particulars demand real expertise; doctors who have worked on PCa a lot.

Hormonal Therapy (HT) can extend life many years, but is not curative. The same for chemo.   

Best of luck with this stressful development,

max

Donna,

I sense anxiety in your words. The situation may seem pretty bad to you at the moment because you dealing with the unknown, you are not educated in PCa (prostate cancer) affairs, your husband is young and the doctors you are meeting just pass you conflicting stories. It is confusing but try keeping your posture. Listen to them, collect as much information as possible, read a lot about similar cases and digest the data before acting. You do not have to follow blindly the doctor’s recommendations, in particular if he is resistant to your wishes or you have no full understanding of his recommendations.

Thought I do not know details of your husband’s status or the advancement of the disease, I would reinforce above Max’s opinion that the case may “still be treatable toward curative effect”. Finding its location is vital in your next step. Doctors use the word “Localized” when referring to cancer in the proximity of the prostate gland (further than contained). This is the traditional area for the attack with all weapons when surgery fails. If the cancer has spread to far places (not localized) then the case is treatable but the curative purposes become ambiguous, depending on the areas where cancer is set. I guess that this is what doctors are telling you in their style of wording but you cannot understand it all.

The insurance or health care system you have may “prohibit” certain exams or therapies if these are not considered standard. The doctor can tell you about the coverage but even uncovered exams can be done privately or through other means with a referral letter from a physician.

I wonder if someone is insisting to repeat the exams with the solo commercial purposes. I would like to know the details of previous exams. Can you describe what is written in their reports?
Get copies of all tests and exams because you can still get a second opinion on those results from a specialist radiologist. He then would tell if repeating the tests is in fact necessary.

In particular the ProstaScint should be able of localizing PCa if they used recent tracers in a MRI 3T machine. Can you tell which substance was used? And in which machine (MRI, CT, PET, Gamma-Ray, etc) were the test done?

Back to the initial phase of ProstaScint (in 2001), the tracer they used at the time were very unreliable, commonly providing false negatives and/or false positives. Later they improved the monoclonal antibody Indium based (7E11C5.3 antibody) which at higher resolution machines become more reliable but still providing only 68 % in accuracy in SPET or CT machines. This test was approved by the FDA (2005?) and it is administered in several clinics since. Never the less, other tracers with Choline base (C11, F18, etc) emerged and become more popular than the ProstaScint for easy of administration (apart from providing higher levels of accuracy due to PET). PSMA based tracers (like the ProstaScint or Ga 68) are more reliable but they should take the benefits of a higher resolution machine for specificity.

In the end the goal is to locate the bandit so that one can choose the best plan for eradicating it. Radiation is usually done only one time to the same area. Rads over rads is not practical so that the field of attack should be defined from the best information we can get.

The modality with added HT (hormonal) commented by Hopeful above, may still improve the therapy outcome if the cancerous cells are AR+++ and PSMA+ (genomics of your husband’s cells) which information you may find in the pathologist’s report from surgery. Do you have a copy?

I am sorry if my comments still add more confusion to the situation. I will try explaining the facts while you gather the details on the matter. Just ask and the survivors here will help.

Best wishes and peace of mind.

VGama

Donna, if it is a lot of documents, scanning them and then a cut-and-paste or other technique to get them here would be easiest. But I recocmmend redacting (blacking out) any personal ID information, since this is a public site (name, SS number, date of birth, address, patient ID) -- I recommend that all of that be removed first, for security and confidentiality reasons.

Donna -

I had Da vinci in April 2016 and my post operative PSA was 2.6.

Before I started any Salvage Radiation or HT therapy I opted to have a 68 Gallium PSMA PET/CT at UCSF. This is the most sensitive scan for Prostate Cancer. Unfortunatly it is not yet FDA approved so either get into a clinical trial for it or travel to Germany or Austrailia where they can do them. More trials are coming out for this PSMA Scan.

The reason I wanted the scan before Salvage Radiation was to see if it has matistized to the bones or any soft tissue areas. If it had, Radiation would be fruitless. I didn't want to start HT before the scan because it may have prevented the scan from picking up cancerous areas.

Best wishes to you and your husband.

Bob

Please read above

I agree with Old Salt. You may discuss the matter with a SBRT radiologist and try to locate the spots with one of those "sate-of-art" image exams. Spot radiation kills cancerous cells, but this is applied when the spots are located at feasible and appropriate places, where the required intensity (grays) can be deposited. T6 is at the thoracic, close to several vital organs, difficult to treat with external radiation. The isodose should be planned looking into the best angles of delivery.

My comments in previous post generalizes the whole situation based on the location of the metastases. Salvage therapies with ER commonly include the lower abdomen with spots at lumbar bones. Here the attack is wider (tissue and bone) providing higher possibilities of success. Oligometastases treatment are also successful at this areas but for a fewer number of spots that could be isolated at far places.
Radiologists abstain from treating with intent at cure when assurances of success are low, reserving radiation for other purposes as when treating unbearable pain (due to metastases in bone). The cancer is controlled with palliative manipulations that can last many years. 

Here is a simplified image of T6 location;

http://www.chiroone.net/interactive-spine

Best,

VG