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PSA Following Salvage Radiation Treatments

Timon
Posts: 16
Joined: Nov 2012

A routine PSA test in December 2010 revealed a PSA of 5.55. Biopsy thereafter revealed cancer in 10/12 cores and a Gleason of 4+4=8. MRI and scans were negative so I opted for Robotic prostatectomy in March 2011 at age 62.

Surgical pathology report downgraded Gleason to 4+3=7 but noted that the tumor involved 50% of the prostate, was multifocal, bilateral, and present from apex to base. Pathologist noted "Margins involved by invasive carcinoma, multifocal, right and left posterior lobe. Tumor also comes multifocally within 0.5 mm of the margin." Lymph vascular and perineural invasion were noted as present and multifocal and the tumor was staged pT3a (extraprostatic extension); the pathologist concluded, "Tumor is focally present in periprostatic adipose tissue at base of prostate and is extensively present within lymphatic and vascular channels in extraprostatic adipose tissue."

The urologist/surgeon advised me that the term "margins involved" in the pathology report indicated negative surgical margins.

First post-surgical PSA in July 2011 was 0.00. However, thereafter, the following results were noted:

March 2012 - 0.12; October 2012 -- 0.22; April 2013 -- 0.24; October 2013 -- 0.43; May 2014 -- 0.39.

Then, in November 2014 it doubled to -- 0.78. Another round of scans and MRI were negative and I was referred to a radiation oncologist. Based on his reading of the surgical pathology report, he was of the opinion that the term "margins involved" indicated positive surgical margins and he concluded that there was a great liklihood that cancer cells remained in the prostate "bed" following surgery and he recommended salvage radiation.

I received 37 salavage radiation treatments -- from early January to March 5, 2015.  Thereafter on April 27, 2015, first post-salvage radiation (about 6 weeks after completing the treatments) PSA was 0.79. Radiation oncologist said not to worry since it takes quite a bit of time for the radiation to succeed in its goal of disrupting the tumor's DNA.

Last PSA on October 23, 2015 was 0.76 and both he and the urologist said we should be "encouraged" because the PSA is not rising. Although both seemed a bit "puzzled" by the results. He recommended another round of bone scans to determine whether the cancer has metastasized but I declined based on my belief that if nothing showed up when the PSA was 0.78 back in November 2014, it would be unlikely that anything would show up with my current PSA reading. I have PSA tests scheduled for January and April 2016.

I am a bit concerned now. My question is -- if the radiation oncologist is correct, and the cancer was localized to the prostate bed, how long a period of time must elapse before the PSA drops to 0 or to a level that indicates that the salvage radiation worked a definitive cure?  And, when should I consider the next step, i.e. ADT or hormone therapy? To add to the frustration, I should note that I have been incontinent and impotent since the surgery and following the salvage radiation, I'm having hemorrhoids like crazy and some other issues, namely difficulty urinating in the a.m. although I still remain incontinent. Honestly I don't look forward to any further treatment since nothing so far has seemed to work and has left me dealing with those pesky side effects.  Thanks for letting me vent.

Old Salt
Posts: 736
Joined: Aug 2014

Rather, you are describing, factually, what has happened. Unfortunately, what has happened would make anybody depressed or anxious. I guess we all agree that the prostatectomy failed to remove all cancer. Whether the subsequent salvage radiation has been successful remains to be seen. Your doctors seem to be cautiously optimistic. Let's hope they are correct. I strongly encourage you to get another PSA test in three months (Jan 23, 2016). If the result isn't significantly lower, androgen deprivation therapy (ADT; also known as hormone therapy) should be considered. I, a non-expert (!) believe that there are schools of thought that advocate combining ADT with chemotherapy for a more agressive approach to kill all cancer cells.

I agree that a conventional scan wouldn't show metastases because your PSA is still less than 1. There is a new scanning method that targets Membrane PSA and is supposed to be more sensitive. Right now, 68Ga-PSMA scanning is not widely available, but you might look into any clinical trials exploring that method.

Timon
Posts: 16
Joined: Nov 2012

Thanks, Old Salt. 

I guess the thing that continues to be so difficult to deal with is the uncertainty. But then, that's the case with just about all aspects of life when you think about it.

I was just hoping to get some definitive answer as to WHEN we would finally know for sure whether the PSA that's still showing up relates to cancer cells that remained in the prostate bed after surgery which were (hopefully) zapped by the salvage radiation treatments; or whether these current PSA findings are instead evidence of distant metastases that will require yet another round of treatment and more uncertainty.

I guess, like the old saying goes, "time will tell"!!

Thanks again for your reply.

Timon

Old-timer's picture
Old-timer
Posts: 198
Joined: Apr 2011

Timon,

I understand that no two prostate cancer experiences are exactly the same. However, your numbers are so similiar to mine that it's errie. I am a few years down (or up) the road from you. I began my cancer journay at the age of 65; I am now 89!

Here's a brief summary of where i have been. I had radical prostatectomy in 1991 at the age of 65. Gleeson score of 7 (3+4) and PSA at 4.0. PSA dropped to 0 after surgery and remained at that level 11 years. In 2002, a routine annual check, revealed that it was .2. It took it two years to reach 1.16. I took 36 sessions of radiation in 2004. My PSA continued to rise. My urologist said I should go on hormone therapy when the PSA reached 5.0. In 2005 I moved to another city and changed urologists. The new person said we could wait until the PSA reached 10.0. It reached that level in 2007. For reasons too lengthy to explain, we ended up waiting until 2008. By then the PSA was at 20.4. In June, 2008, I went on hormone therapy. The PSA dropped to undetectable and is still at that level. The side effects of the hormone therapy have been tolerable. I expect that this would be more of an issue if I was a younger man.

Yes, I have had and still have incontenance and impotence. Nuisances, to say the least. Nevertheless, there are many good things in life. Attraction for and enjoyment of the company of the opposite sex are among those joys. Sex is different, and perhaps not as enjoyable; but there are compansating aspects of it. My bride of 66 years has been, and continues to be, by my side all the way.

Of course, I have experienced concerns and worries. I know that I have been, and continue to be, lucky.

I send words of encouragement and wish you good luck.

Old-timer (Jerry)

Timon
Posts: 16
Joined: Nov 2012

Jerry --

Thanks for those words of encouragement. Having read your story, you are the living proof of Yogi's famous statement, "It ain't over 'til it's over." May you have many, many more years of good health and happiness!

 

Timon

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3087
Joined: May 2012

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

VascodaGama's picture
VascodaGama
Posts: 2898
Joined: Nov 2010

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
Posts: 16
Joined: Nov 2012

Vasco--

 

Thanks for your response which has allowed me to put things into perspective.

I've been looking for a definitive answer to the questions IS IT CURED YET? or HAS IT SPREAD? and the answer I keep getting is "TOO SOON TO SAY!" I will content myself with that answer for now!

Best wishes to you.

T

Timon
Posts: 16
Joined: Nov 2012

Max--

Thanks for your analysis of my situation. I guess I'm looking for a definitive answer when none is to be had? Another PSA is scheduled in January and then again in April. Hopefully the results of those tests will clear up the uncertainty.

Again, thanks for your response and best wishes for your swift recovery.

 

T

Will Doran
Posts: 207
Joined: Sep 2015

Timon,

Your case sounds very much like mine.  Numbers and counts are almost the same, except my starting PSA was 69 and I had 40% prostate involvement.  I also opted for the Robotic Surgery. The surgery was done December 10, 2013.  It's took 5 1/2 hours to complete because of heavy muscle mass  in my legs from road cycling, and mesh from a double abdominal hernia repair.   I had one lymph node involved. The doctors treated me as if I was an advanced Stage 4. They said they were going to be very aggresive and they were.   I was on the line between a high end Stage 3 and an Early Stage 4. PSA was at 2, two weeks after the surgery.   Then went on Lupron one month later, followed by 40 Radiation treatments.  PSA has dropped to <0.010 and has stayed there for two years as of Dec 10, 2015.  I've been on Lupron for two years and am on my last shot right now.  Lupron will be "run out" in February.  However the side effects will linger for up to a year.  We will continue to do PSA tests every three months and by June I should know whether the PSA is going to stay at "0".

Every one of us is different.  So, hang in there.  There is light at the end of the tunnel.  Follow you Doctors and Oncologist recomendations.  Thats' what I have done, and I seem to be beating the ods at this time.  This will always be hanging over our heads, but don't get discouraged.  My doctors are now using the word remission.  We can never feel as though we are cured.  But I hope you hear the word "remission"  soon. 

Take Care

Have a great Holiday Season and enjoy all the litte things in life.

Peace and God Bless

Will

Timon
Posts: 16
Joined: Nov 2012

Will --

Your post is encouraging. Thanks for that! I am feeling much more confident lately after reading all of these responses.

May your remission continue!

Peace,

T

Timon
Posts: 16
Joined: Nov 2012

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

 

Swingshiftworker
Posts: 1013
Joined: Mar 2010

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.

 

 

hopeful and opt...
Posts: 2218
Joined: Apr 2009

I don't know where you are located, but there is an advanced pet scan using a c11 acetate . This test is not covered by insurance, and costs 3,000.  Dr. Almeida, director of the Arizona Molecular Imaging Center in Phoenix runs the center. Basically, this test will show exactly where the cancer(s) are in your body , and radiation can be directed to those locations by a radiation oncologist.

You can google "c11 acetate pet scan phoenix" which includes a presentation and description.

(I'm not sure but I think that you need to have a PSA of 2.0 or better for this scan to be effective....you can call the center)

There are also other type pet scans at other locations that also provide excelellent results...

I believe that Vasco Da Gama is in a clinical trial using one of these advanced pet scans; is knowledgeable about these diagnostic pet scan tools and can provide knowledge. Hopefully he will respond to this thread. 

Also, may I suggest that you  want to have a Medical Oncologist handle your case.

VascodaGama's picture
VascodaGama
Posts: 2898
Joined: Nov 2010

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

Timon
Posts: 16
Joined: Nov 2012

Thanks, fellows.

If I understand correctly, I have to wait and see when (or if) the PSA crosses the 1.5 ng/ml threshold to determine the location and extent of the disease and thereafter an appropriate treatment.

Meanwhile, I'll use the time to do more thorough research into treatment options should that become necessary. The radiation oncologist has scheduled another PSA in 3 months so I'll have a better idea of what's going on at that time.

Thanks again for your wisdom and compassion.

 

Timon

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