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Father has had a possible PSA recurrence.

Steelchuggin26
Posts: 36
Joined: Mar 2013

Hello everyone. My father had his prostate removed April 23 2013 as a result of prostate cancer. His biopsy results stated he had 5 cores positive for cancer, with greatest involvement in any core 40%, both left and right lobes, Gleason score was 6, stage T1c. Following surgery, pathology report stated the following:

Prostate: adenocarcinoma 

Left midline positive for malignancy. Gleason 6

Left base positive for malignancy. Gleason 6

Right midline positive for malignancy. Gleason 6

Right base positive for malignancy. Gleason 6

Right Apex Positive for malignancy. Gleason 6

All other areas negative for malignancy, with benign prostatic hyperplasia

Margins: Clear except for a small foci adjacent to a surgical defect. Clinical impression is minimal focal involvement, though others may disagree with this assessment.

Tumor quantification: Adenocarcinoma involved 25% of prostate gland

Seminal vesicles: negative

EPE: negative

Lymphovascular invasion: negative

Perineural invasion: positive

Pathogical stage: pT2c pN0 pM0

 

Sorry for the long read, but thought it was a good idea to start with the biopsy and surgical pathology reports. But my dad'said PSA after surgery had read <0.04 ng/mL every time, which is as low as the machine at the clinic there could read. This was considered undetectable. Well, my father just had a PSA test again Jan 31st, and it came back as 0.13 ng/mL. Dr said not to worry just yet, as it is possible this could have been a "blip" in the machine, as he put it.

 

Dr. has scheduled a retest of the PSA in 4 months, and also at that time, he said he will have x rays and "stuff" ordered. This has me worried, as everything I've read about prostate cancer says that when it spreads either before treatment, or spreads after recurring, it tends to favor the bones. So I am fearing we may be dealing with what could now be metastatic prostate cancer. Gleason 6 is supposed to be the least likely of all prostate cancers to recurr and spread. Could it be possible there was a tertiary gleason 4 missed I'm the surgical pathology, or perhaps there was some gleason 7 present? I'm getting rather worried, as my father has said he's been having trouble going to the bathroom the last month (going #2), so I'm not only worried about bone spread, but also bowel involvement as well.

 

Has anyone ever heard of Gleason 6 prostate cancer returning and metastasizing to other areas of the body? Also what would the Dr mean by "and stuff" when talking about ordering x rays. Would this "stuff" include bone scans, CT scans, MRI, etc?

 

VascodaGama's picture
VascodaGama
Posts: 3007
Joined: Nov 2010

Brandon (this is your real name, right?)

At first glance I would follow the doctor's suggestion for the PSA test in 4 months, however for your peace of mind you can repeat the test to confirm his comment on the "blip" in the testing machine. You can do it by yourself.

I know from your previous posts (http://csn.cancer.org/node/256782 and http://csn.cancer.org/node/258379) that you easily turn anxious when things go out of the usual. The increase of the PSA is significative but it is still low to judge recurrence. According to the recommendations of the AUA (maybe followed by your doctor), recurrence after RP is declared when the PSA reaches 0.20 ng/ml. A salvage treatment is then started and recommended to be done once the PSA reaches 0.40 ng/ml.

We cannot compare cases but I was also Gleason 6 and recurred from surgery and latter from salvage radiotherapy. I was diagnosed with micrometastases which cases are hard to be cured via the present means of treatments. I would recommend you again to reread our exchanged posts in the link above and try to become educated reading the links pointed out. Image studies will be required but some of these (the traditional CT, MRI, X-ray and bone scans) are limited to the size of tumours, providing false negatives. I would recommend you to investigate on PET exams using more sophisticated contrast agents better for cancer cases with low PSA serum.

Can you specify about his "trouble going to the bathroom" comment. I recall you informing about his frequent urination problem in 2013. His present symptoms could be related to the same cause. I also notice that the pathologist reports finding cancer in the base region of the gland which directly stand bellow the bladder sphincter. Could this be the affected area involved in this preliminary PSA increase?

My suggestion is that you follow his doctor's recommendation in waiting for a PSA that represents recurrence and then consult specialists (radiologists, medical oncologists) to get second opinions on a salvage treatment.

Best wishes,

VGama

 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3292
Joined: May 2012

Steel,

While the PSA reading is objective cause for diligence 3.5 years after RPT, it also seems that Vasco is on to something: You need not become frantic.

An advantage of surgery (when it is clinically a sound choice) as an initial treatment is that as with his post-surgical pathology report, the doctors know exactly what was where, in a detail no current scans can match.  The pathologist's comment in "Margins" is suspect, and the doctor used some weasel-terminology...if there was escape of PCa cells, it sounds like that was where it occured.

Vasco and several others here are masters at the micrometastatic card game, which is really as much art as science.  RT as salvage is often fully curative, and I have seen friends on subsequent HT well for a dozen years or more beyond RT.  Objectively, 3.5 years is a substantial amount of time for the disease to "wander around", if it has done so.   I am just trying to give a reasonable overview of statistical possibilities.

Hopefully he will never meet the relapse PSA thrershold, but if so , there is much cause to hope for a long and well life nonetheless.  I am myself "undetectable" thus far following DaVinci two years ago, but go for my annual PSA check in two weeks, so I have been attuned to all possibilities.  Despite a fully clean pathology report, I guess we all get what the lymphoma crown calls "scanexity" -- anxiety regarding pending scans.

Be more Winnie-the-Pooh, less Eeyore at this stage,

max

Steelchuggin26
Posts: 36
Joined: Mar 2013

Thanks guys. As far as his troubles using the bathroom, that is in regards to bowel movements. At the time of his surgery, he had been having issues with urinating frequently, but that has no longer been a problem. He had a pretty good size gland that weighed around 60 grams, so it was definitely enlarged, and that caused his urinary symptoms. Dr told us at the time he was diagnosed, the cancer was at such an early stage, it was asymptomatic, and not responsible for any of the urinary symptoms.

Fast forward to now, with his PSA being 0.13, there appears to be a bit of a grey area in regards to post prostatectomy psa. On one hand I've heard 0.1 as the threshold for recurrence, and on the other hand, as vascoda said, 0.2 is the threshold that determines a recurrence. As far as the base of the gland and it's relationship to this rise in psa, I am honestly not sure, as the doctor did not elaborate into that. Just merely noted the rise, and ordered a retest in 4 months plus x rays and other stuff.

Now one thing I have read in regards to gleason 6 cancers is that they are the least likely of all prostate cancers to become problematic following treatment. They supposedly don't quite carry the metastatic potential of higher grade cancers, such as a 4+3=7 prostate cancer. I read a study that said out of a little over 2500 subjects with G6 treated with prostatectomy, only 0.28% of them exhibited noticeable spread to pelvic lymph nodes, and other regions outside the gland itself, thus the conclusion of the study indicates that such an event was extremely rare in g6 cancers, and that perhaps in those cases, there was the possibility of some G4 pattern that was under diagnosed. It is hinted that if G6 does return, it often returns in the area where the prostate once was, and it's said that Gleason 6 does not survive well outside of the gland. So for now, we will just have to wait and see. If there are micrometastases present, it could take a while for it to become clinically significant, and at his age of 67, it's possible that would never become an issue with him. This of course is based on if there actually is a real recurrence.

 

Steelchuggin26
Posts: 36
Joined: Mar 2013

Also there was a link to the originally thread that vascoda provided that took me to cancer.gov website. And I went to the subsection of recurrent prostate cancer there, and it stated that the mean time for any metastases to show up following a biochemical recurrence is 8 years, and that onset of death takes a mean of an additional 5 years after that, so it appears while a recurrence is possible, it likely would not be to the point of being a threatening entity yet. 

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