PCa progression and metastasis without detectable PSA levels?

Thank you for your support and interest!

AJCC stage (6^th edition) T3a NO MX).  Gleason was 7 (3 + 4).

After his Radical Prostatectomy in 2010, the Surgical Pathology Reportindicated that the 10 studied lymph nodes were negative for carcinoma, there was no definitive lymphovascular invasion noted, nor any tumor present in seminal vesicles nor at soft tissue resection margins.  However, perineural invasion was seen and tumor was focally present in extraprostatic soft tissue. 

Best - Paella

VascodaGama said:

Unlocking the mystery

Paella,

The best way to certify doubts is to get a second opinion on CT images from another radiologist, or do another image exam this time with PSMA PET, even if the possibilities of detection are limited to cells with PSMA capability.

In my view, the pathologist report of 2010 on the gland confirms the probability of cancer in the lymph nodes but the ones dissected by the surgeon were found "clean" by the same pathologist. However, we know that Davinci surgery limits the access to lymph nodes so that surgeons can only investigate/dissect the closer pack. Accordingly it is no surprise that some with cancer could have been left behind. After surgery the PSA becomes the only marker of treatment success and the negative results lead the doctor to question the results of CT's radiologist.
Another fact is that there are about 24 types of prostate cancer some of them producing zero PSA. For instance, Small Cell Cancer do not produce the serum. Aggressive types of acinar adenocarcinoma become so poorly differentiated (disfigured) that cannot produce the serum. Please read this;

http://www.cancerresearchuk.org/about-cancer/type/prostate-cancer/about/prostate-cancer-types

http://www.wsj.com/articles/SB10001424052748703279704575334982806405218

There is always the possibility that these thertiary type of cells were existent in the biopsy cores of 2010 but disregarded by the pathologist. They are in such fewer number that "escaped" diagnosis which chose the first numerous type (Gleason grade 3) and the second numerous risky type (Gleason grade 4). Surely, cancerous cells traped in the lymph nodes would be expected to grow for the plenty supply of blood at their "bed". Such activity would be enough for detection by a choline based contrast agent. CT limits the finding and depends much on the radiologist expertise.

I wonder if your husband case would be of interest to the clinical trial on the 68Ga PSMA PET scan. You can discuss with his doctor about possibilities of getting involved in the trial. This is full but there are vacancies at certain clinics. The mystery can also be "unlocked" with microscopy analysis of those infested nodes:

, “…lymphadenopathy suspicious for recurrent metastatic malignance, most likely prostate cancer”.   

The trial;
https://clinicaltrials.gov/ct2/show/NCT02488070

Best wishes,

VGama

Hello, VGama !

     Thanks for your input.  We are now waiting for the results from a CT-guided needle biopsy of one of the swollen lymph nodes; this took place 3 days ago, a week after the CT itself.  It takes 7 days to complete microscopy analysis, get markers, do staging, etc., so we’re talking about the 25^th or 26^th of October before we know anything microscopy-wise (next week). 

     Here’s one of my questions to you:  In Mac’s case was it the perineural invasion and/or the extraprostatic extension in the soft tissue that alerted you to confirm the probability of his having had cancer in the lymph nodes back in 2010?  You indicate that a daVinci surgeon, being limited to lymph node access, would only dissect closer nodes.  So, if those are clean (and this is determined while the surgery is still going on) does an open surgeon routinely bisect more distant nodes?     

     Maybe I’m placing too much faith in Mac’s pathology report from 2010, but it clearly states PROSTATIC ADENOCARCINOMA…a typical acinar adenocarcinoma; nothing rare.  And, again, no detectable PSA for 6 years.  Although, as you indicated, some aggressive types of acinar adenocarcinoma become so disfigured that they cannot produce PSA.  As Max just indicated in his message it’ll be a super-anomaly if this is recurrent metastatic PCa.  Hoping for the best.

     Thanks for the articles you suggested…also the clinical trial.  Here’s a version of that Wall Street Journal article doesn’t require a subscription.   http://www.wsj.com/articles/SB10001424052748703279704575334982806405218

     Again, thanks - Paella

Thanks again, Max (et al), for writing.  Turns out that there is no prostate cancer progression.   Actually worse news, as if we needed it.  We had a call on Saturday (1 week ago today; 10/22) from Mac’s Urological Surgeon with a report on the CT-guided needle biopsy of about a dozen swollen lymph nodes.  Hearing from a doctor on Saturday while she’s waiting for a plane is simply terrifying.  Particularly terrifying is what she had to say.  Briefly, the lymph node biopsied was found to be metastasized cancer most probably from an Upper GI organ or from the Pancreatobilliary tract, although she verbally used the term “cancer of unknown primary”…apparently not a good thing at all.  “Poorly differentiated” is also not a good thing.  The good news is that we are very quickly (on 11/1) getting into see a City of Hope oncologist who specializes in Upper GI & Pancreas.   We are both super-stressed and worried.  More tests are certain to be coming up but we may learn at least a bit more in 3 days.

Since I told you I’d include it, here is the written part of the CT-guided lymph node biopsy report (which I didn’t receive until Wednesday 10/26):

Diagnosis:    L Retroperitoneal

• Poorly differentiated carcinoma involving fibrous connective tissue

• Microscope description (results – paraffin immunohistochemistry):

  CK7                                 Focally positive in tumor cells      (upper GI)

  CK20                              Negative in Tumor Cells                 (lower GI)

  CDX-2                            Focally positive in tumor cells      (pancreatobilliary tract)

  GATA-3                         Negative in Tumor Cells                

  TTF-1                             Negative in Tumor Cells                               

  SYNAPTOPHYSIN         Negative in Tumor Cells                

  CHROMOGRANIN       Negative in Tumor Cells                

  S100                               Negative in Tumor Cells                

  Pax-8                            Negative in Tumor Cells

  NKX3.1                         Negative in Tumor Cells

  PSA                                Negative in Tumor Cells

  CK5/6                            Negative in Tumor Cells

  P63                                Negative in Tumor Cells (Weak Cytoplasmic Stain)

INTERPRETATION:  The immunohistochemical staining features are suggestive of tumor from upper gastrointestinal or pancreatobilliary tract.  Negative staining results argue against tumor from lower GI, urothelial, renal, prostatic, neural or melanocytic origin.  No neuroendocrine differentiation is seen based on negative staining.

Trying to stay positive - Paella