Pathology report in - should we commend with HT?

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  • Pathfinder
    Pathfinder Member Posts: 55
    edited September 2016 #62
    Thanks Old Salt for the

    Thanks Old Salt for the response. We checked some details of the pathological report to try to glean some information regarding the HT. He has an AR +++ rating, which falls into the category "AR OVEREXPRESSED" according to a chart for Bicultamide treatments.

    Is this a bad thing? I can't seem to find any direct information regarding 'overexpressed' AR readings. The doctor didn't flag it as an issue (or mention it at all), but my Father-in-law's side effects from the HT are quite pronounced.

    Could someone enlighten us as to what the expression readings mean?

    Thank you for your help!

     

  • VascodaGama
    VascodaGama Member Posts: 3,701 Member
    #63
    AR+++

    The AR+++ finding means that the cancerous cells are of the type "hormone dependent" (those that live by feeding on androgens). In other words, they respond well to hormonal treatments (treatments that block feeding), providing the patient with wider possibilities in control of his disease. The hormonal arsenal is vast with several types of drugs used at several levels of action, keeping the cancer in an indolent sort of status.

    The side effects experienced by patients are almost all due to hypogonadism (low levels of testosterone in circulation) or due to the lack of androgens being absorbed into body systems (blockade of cells AR). Menopause like symptoms are common. Others nasty symptoms are caused by imparred pituitary function (blurred vision, miss-recognition, mood chances, etc.).

    In this regards, intermittent administration of HT drugs becomes a better modality but it requires a proper schedule of ON/OFF periods (typically 18 months ON). The ware off drug's effects takes approximately 3 to 6 months after the end of its effectiveness period (the end of one month Zoladex would occur at the end of 4 months counting from the date of administration).

    These links may be of help to you;

    http://csn.cancer.org/node/244938

    http://csn.cancer.org/node/241249

    http://www.mayoclinic.org/diseases-conditions/male-hypogonadism/basics/symptoms/CON-20014235

    http://www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/hormone/general-side-effects-of-hormone-therapy

    Best

    VG

     

  • Pathfinder
    Pathfinder Member Posts: 55
    edited September 2016 #64
    Fantastic, that's very useful

    Fantastic, that's very useful.

    So essentially the A+++ reading indicates that the drugs are having a positive (and required effect) on cancerous cells.

    At the moment we haven't stopped the HT. It's still in discussion. Now we understand what overexpression means, that's one aspect not to worry about. However we have spoken to several sources in China regarding whether or not to stop the HT temporarily to check the real PSA result. Some people suggest because he was a Gleason 8 with a PSA of 25 prior to surgery, that staying on HT for an extended period post surgery may be for the best. We know there was a minor infection of the nerves, which is another reason why perhaps HT could be worth continuing. But at the same time, as Old Salt suggested, it may be better to check the PSA after suspending HT for 3 months to see the effects of the surgery. If the PSA is low enough, HT may not even be necessary.

    Of course we're looking to avoid recurrence, and at the moment, it's a case of whether or not to keep on HT until salvage therapy via radiation treatment.

    His side effects are general feelings of discomfort brought about by hot flashes and several large itchy bumps that appear on the neck. I would imagine he was a person of lower testosterone levels normally (that's not scientific, more an observation!) that would explain the side effects based on your information.

    I appreciate the help guys, if you have any further advice regarding the HT question, please feel free to share your thoughts.

    Thank you!

  • VascodaGama
    VascodaGama Member Posts: 3,701 Member
    #65
    Turn the guessing observations into realities doing the tests

    You got enough information on HT to make a decision on how to proceed, and to pass "instructions" to China, if your fatherinlaw has no power to decide by himself. Both ways you pointing out are good.

    In any case, your relative should have a doctor he trusts and feels confident to help in following his case. PCa is not a mere cold disease to be treated over the counter. It is a serious affair and it should follow a coordinated strategic plan with timely actions. I have suggested above a number of important tests you should request to evaluate his case and status. Don't sleep on that.

    VG

     

  • RobLee
    RobLee Member Posts: 269 Member
    #66
    Probably best to wait

    All of your concerns are valid, except for the rapid PSA rise. Going back on ADT would likely be coiunterproductive for the reasons you stated... it will shrink any tumors making them more difficult to visualize, and may even hasten the onset of catrate resistance. I would say it's best to wait for the most effective scan available, even if that means waiting three weeks. You want to use the best equipment and for the disease to be as bad a possible.  0.4 is not really that high. Some scans cannot detect anything at PSA's under 2.0 and many oncologists still use 0.2 as the threahold for intervention... some even higher.

  • Pathfinder
    Pathfinder Member Posts: 55
    edited March 2018 #67
    Hello all,

    Hello all,

    Bringing this thread back to life after almost two years to update you and ask for your continued advice and support. 

    Synopsis:

    All the Gleason information and pathology reports were provided above. Following all our previous discussions and your advice, my father in-law went for open surgery to remove the prostate in Shanghai (expensive but the best option in China). He resumed ADT immediately after surgery and stayed with it for about a year. 

    His PSA reading was around 0.03 post surgery and even when on ADT. Approximately 3 months ago it was recommended stopping ADT as the side effects were fairly strong, and monitoring the PSA for changes. 

    Although the post surgery pathology report suggested that the cancer had not broken through the capsule and no lymph nodes were infected, his PSA velocity after stopping ADT is alarming and (possibly?) suggests otherwise. 

    Here are the PSA readings post ADT:

    ADT STOPPED: 2017/6

    2017/9 - 0.01

    2018/1/2 - 0.03

    2018/2/28 - 0.10

    2018.3.20 - 0.12

    2018/3/23 - 0.16

    As you can see the velocity is increasing at a worrying rate. And we're worried! Last two checks and it's moved 0.04 in only 3 days.

    We're now prepared to go into salvage RT as quickly as possible, but we're faced with a predicament.

    The city in which he lives only has a PET CT scanner. We have been informed at the current PSA level the machine may not detect anything at this level. In Shanghai there is a PSMA scanner, which is far superior and fit for purpose, and in Beijing there is a PSMA-PET CT which is top of the line. The problem with both of those options is a waiting time of 3 weeks +.

    We estimate at 3 weeks + his PSA will be at 0.4+, which is well beyond the risk we would like.

    My idea, and I hope you can comment on this, would be to return him to ADT immediately to control the speed of the PSA increase while he waits to get onto a machine that will have a better chance of finding the location of the cancer cells. Some suggest this will either make the scan even more difficult to find anything because the ADT shrinks the cancer cells, or that on/off use of ADT will more quickly lead to permanent ineffectiveness. 

    But I'm wracking my brains and I can't think of any other solution. Other people seem to have slow to moderate PSA rises, giving them time. We don't seem to have that luxury sadly, but we seem stuck with the following options:

    - Do the basic PET CT and hope for a result. If no result go on the waiting list for the PSMA in Shanghai, wait 3 weeks by which point the PSA will be 0.4+

    - Save money, don't bother with the PET CT, wait until Shanghai to do the PSMA scan by which point the PSA will be 0.4+

    - Go back on ADT, control the PSA, wait for Shanghai or Beijing machines and then hope that they will pick something up in the scan that's usable after the ADT has shrunk the cancer cells.

     

    Any advice here is greatly appreciated. At stage one you guys helped us so much, and I studied everything and anything you said and in the end it helped us make an informed decision. I hope you can give us whatever advice you may have now. Thank you for your help!

     

     

  • VascodaGama
    VascodaGama Member Posts: 3,701 Member
    edited March 2018 #68
    Do not rush

    I agree with Rob's comment. Wait for the PSA to increase further and get a PSMA PET/CT scan done before the salvage RT. I never heard of such traditional CT doing a PSMA scan. Probably you miss interpreted the information. The exam involves PET and CT machines individually or the modern one that does both (PET + CT) in one unit. In any case, the exam done at his place could be using the radiopharmaceutical PSMA too but using a different isotope. Check the specifications at each place and chose the 68Ga PSMA PET/CT scan. This tracer seems to be reliable at a PSA above 0.6 ng/ml.

    Without the image study, the field of attack in the radiation treatment would be done guessing and the protocol would be the same if the PSA were 0.4 or 1.0. He can wait with no prejudice to the outcome. Do not rush again. His type of PCa was hormone dependent so that ADT will surely work again no matter the level of the PSA when he starts it.

    VG

     

     

  • Pathfinder
    Pathfinder Member Posts: 55
    #69
    Thank you for your comment

    Thank you for your comment Rob, much appreciated! So just so I'm clear, 0.4 is not something we should worry about regarding a threat of metastases? Because in my head the PSA velocity is tied to a risk of that kind of thing.

    Also, would you then suggest a higher PSA is better for visibility in the scan? For example, if we went to Beijing where they have the best scanner (PSMA-PET CT) what are the chances that that wouldn't be able to detect anything meaningful at the current 0.16?

    Thanks once again!

  • Old Salt
    Old Salt Member Posts: 1,505 Member
    #70
    Agree

    The two comments posted above make sense. Moreover, you need to consider that each PSA measurement has some error. The apparent rise from 0.12 to 0.16 ng/mL (in three days) may not be as bad as it seems.

  • Pathfinder
    Pathfinder Member Posts: 55
    #71
    Thank you all for your

    Thank you all for your responses. We're now realigning our approach to this. Additionally there is some new information to share and request your advice regarding.

    Shanghai has a PSMA-SPECT CT machine with a waiting time of 3 weeks. There is currently a special reduced price for this machine, which is contributing to the queue time.

    Beijing has a PSMA-PET CT (apparently the best possible) with a queue time of just 2-3 days. It's more expensive but it's also the best technology.

    There's one thing we're confused about particularly. Although your advice is well taken and much appreciated, the EUA guideline confirmed that patients treated with a lower PSA with RT have a better prognosis compared to those starting treatment at PSA>0.2.

    Now PSA detection technology is becoming more accurate many scholars suggest the value of 0.2 for chemical recurrence should be reduced.

    With this in mind, and knowing the options for either Shanghai and Beijing's machines (and associated queue times) is there any reason we should go for the shorter queue time in Beijing at this current moment? Because at the current PSA velocity he will be at 0.2 fairly soon. Our only worry regarding going earlier is spending the money on the treatment and having the machine not detect anything valuable.

    Thanks again for your insights regarding this.

  • VascodaGama
    VascodaGama Member Posts: 3,701 Member
    #72
    EUA guideline chapter 6.3

    My lay opinion in the best approach is what I describe in my above post (PSMA-PET CT ). In regards to the EUA guideline, the prognoses you point out refer to the period of biochemical free failure not the elimination of cancer. Surely starting RT earlier is not prejudicial but if the RT protocol includes targets found in image studies it will surely has higher chances for a better outcome. If interested in details, please read the chapter 6.3 "Management of PSA-only recurrence after treatment with curative intent" (which also explains in detail the PET/CT capabilities in detecting cancer) in this link;

    https://uroweb.org/guideline/prostate-cancer/#6

    Best,

    VG

  • Pathfinder
    Pathfinder Member Posts: 55
    #73
    VascodaGama said:

    EUA guideline chapter 6.3

    My lay opinion in the best approach is what I describe in my above post (PSMA-PET CT ). In regards to the EUA guideline, the prognoses you point out refer to the period of biochemical free failure not the elimination of cancer. Surely starting RT earlier is not prejudicial but if the RT protocol includes targets found in image studies it will surely has higher chances for a better outcome. If interested in details, please read the chapter 6.3 "Management of PSA-only recurrence after treatment with curative intent" (which also explains in detail the PET/CT capabilities in detecting cancer) in this link;

    https://uroweb.org/guideline/prostate-cancer/#6

    Best,

    VG

    Thank you for your response.

    Thank you for your response. I and other members of the family read through chapter 6.3 and it's been very insightful. Based on the information provided we feel that Beijing with the PSMA-PET CT is our only good option. It's the only one in the country and the rest are under par. By the time we have arranged the trip to Beijing and been queued, the PSA will likely be around 0.2+, possibly close to 0.3. According to the guidelines you linked, a result should be possible with the PSMA-PET CT when the PSA is in this range. Would you agree with that estimate?

    Thank you for your continued support!

     

     

  • Old Salt
    Old Salt Member Posts: 1,505 Member
    edited March 2018 #74
    Be prepared

    Notwithstanding the increase in sensitivity, your Dad is at, or close to, the detection limit of the PSMA-PET technology. The skill of the radiologist will play a role in interpreting the results. But be prepared for a negative ('couldn't find anything') outcome.

  • VascodaGama
    VascodaGama Member Posts: 3,701 Member
    #75
    Best outcomes link to the most experienced team of physicians

    There is always the probability of a negative result even with a PSA of 0.3 ng/ml. Micrometastases are at risk of not being judged as cancerous because it doesn't form a solid tumor. Old Sal tries to reflect this aspect because the interpretation of the images (in SUVs) is subjective to the interpreter, the nuclear physician judging the image and providing the results. It is always better to get a second opinion on the images. In any case, at present, the 68Ga PSMA PET/CT exam is the best one can do to identify and locate the bandit.

    This is your best to advance further. Next comes the experience of the radiologist that will define the RT protocol using this exam's information.

    Best wishes,

    VG

  • Pathfinder
    Pathfinder Member Posts: 55
    #76
    Hello all,

    Hello all,

     

    Today we got the results back from a simple MRI done locally. The result is that the cancer appears to have invaded the bladder. This would explain the fast PSA rise. 

    The hospital says that this finding is enough to start RT, and we do not need to go to Beijing to do the PSMA-PET CT. We are now confused about the next step. The local hospital recommends we do a bone scan to check for any metastases, but we're worried that the machine is not powerful enough to detect the detail properly after hearing of a case where nothing was revealed on a bone scan but later metastases was discovered on a PSMA-PET CT.

    Would you advise going to Beijing immediately to do the PSMA-PET CT or go straight into RT locally? Also, we do not know if RT can be performed on the bladder area?

    We do not know the complications a spread into the bladder entails, but we are all devastated by the news today. We don't understand how after the good prognosis following prostate surgery and a year of ADT has still resulted in this spread. It's impossible to predict of course, but it's a difficult time. 

    Any advice would be genuinely wonderful at this stage, as China isn't the best place to get help. They don't have your interests at heart.

    Thanks once again.

     

    EDIT:

     

    Here is some of the MRI information:

    Surgery area found a fat-like lump measuring 5.8cmx4.4cm (908IM36). The line between the lump and the top of the bladder wall is unclear. Conclusion is BCR with bladder invasion.

  • VascodaGama
    VascodaGama Member Posts: 3,701 Member
    #77
    You need to consult specialists

    I am sorry but I cannot help you in decisions. The PSMA-PET CT also detects cancer in bone and it is much better than the traditional bone scan. You should choose the image exam you feel more confident with. In regards to the radiation treatment you should also get the opinion from a radiologist, not just the urologist.

     

  • Old Salt
    Old Salt Member Posts: 1,505 Member
    #78
    Second opinion

    Sorry about the bad news. But I would ask for a second opinion on the MRI, especially since the result may be crucial in mapping therapy.

  • Pathfinder
    Pathfinder Member Posts: 55
    #79
    Thank you again for all your

    Thank you again for all your comments. 

    Since this tumour has been found we're back in sprint mode. Everyone is rushing like crazy to make a decision and it's killing us because of all the conflicting information.

    The local doctors advise that travelling to Beijing is not worth the expense. In their opinion since something has been found on the MRI it's now only necessary to do the bone scan and then maybe the PET CT afterward to check for metastases in other organs.

    My judgement is telling me to go to Beijing and do the PSMA PET CT for the extra expense because that will give peace of mind regarding all the possibilities and then we will have a clearer idea of our treatment options. 

    The only problem is time: locally things will be speedier. Going to Beijing could add several days to the process.

    At this stage would you also consider time to be a pressing factor?

    Thank you for your help!

  • Old Salt
    Old Salt Member Posts: 1,505 Member
    #80
    Tough decision, but

    In My Humble Opinion, a few days won't matter. 

    Also, IMHO, finding spots with the more sensitive PSMA-PET procedure that would be missed otherwise, would be helpful. If such a spot would be identified, one could irradiate it. Just an amateur/armchair opinion, of course!

  • Pathfinder
    Pathfinder Member Posts: 55
    #81
    Old Salt said:

    Tough decision, but

    In My Humble Opinion, a few days won't matter. 

    Also, IMHO, finding spots with the more sensitive PSMA-PET procedure that would be missed otherwise, would be helpful. If such a spot would be identified, one could irradiate it. Just an amateur/armchair opinion, of course!

    Not at all, we find your help

    Not at all, we find your help invaluable!

    As it stands we're slightly stuck because there's a traditional festival in China that will see all hospitals close for 3 days (yes, this happens) meaning we can't be seen until around the 7th or 8th. 

    On the upside we have made a decision. The original Shanghai surgeon has requested we return to him, he wants to inspect the patient and review the MRI. He will be providing a second opinion and has PSMA-PET that we can use for closer inspection. Flight there is on the 6th. We're hoping we have some options going forward. 

    Thank you again for your kind support.

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