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IMRT recurrent w psa rising, false negative scans but the MRI

kainasar
Posts: 12
Joined: Aug 2017

Hey, I am under investigation for radioi recurrent pc after IMRT.

The latest MRI results came in and I think I have to do the MRI

fusion type biopsy.

thanks.

-k

 

PSA -
11/16/10 to 09/20/13      8.2 to 0.2  (2012 Focused IMRT 75g)
09/20/13 to 10/05/16      0.2 to 2.8
10/05/16 to 10/27/17      2.8 to 5.7

(Now 66) 65 year old man with is a history of prostate cancer, Gleason 7,low volume,

with presenting (before IMRT) PSA 7.3, who completed a course of definitive
external beam radiotherapy on August 8, 2012. He has since developed a
biochemical recurrence, with a very slowly rising PSA from 0.3 in 2014 to 1.0
in 2015 to 2.1 in May of 2016 to 2.4 in July of 2016. This is consistent with
recurrent prostate cancer.)

11/22/17 MRI

TECHNIQUE: MRI of the prostate gland was obtained at 3T without
an endorectal coil before and after intravenous administration of
8 mL Gadavist.
 
COMPARISON: MR images from MRI guided prostate biopsy on November
23, 2016.
 
FINDINGS:
PROSTATE GLAND SIZE: 3.7 x 4.8 x 4.5 cm, volume 42 mL. Fiducial
markers in the prostate gland.
 
FOCAL LESION(S):
There is a 1.1 x 0.6 cm focal lesion in the peripheral zone,
located in right mid prostate gland, posterolateral region
(400:11). The lesion is diffusion restricting, dynamic contrast
enhancement is positive, and is hypointense on T2WI. Contiguous
with this lesion, there is a 1.3 x 1.1 cm focal lesion in the
transitional zone, located in right mid prostate gland,
posterolateral region (3:15). The lesion is hypointense on T2WI,
diffusion restricting, and dynamic contrast enhancement is
positive.
 
There is extraprostatic extension at the right mid prostate gland
posterolateral region (3:14 , 11:113).
 
There is a focus of enhancement and restricted diffusion at the
medial aspect of right seminal vesicle (11:100 and 400:4), could
reflect a small lymph node.
 
TRANSITIONAL ZONE: Changes of glandular and stromal hyperplasia
(BPH)
 
PERIPHERAL ZONE: Diffuse low T2 signal
 
EXTRA-PROSTATIC EXTENSION: Present.
 
NEUROVASCULAR BUNDLE: Normal
 
SEMINAL VESICLES: Normal
 
URINARY BLADDER: Underdistended
 
PELVIC LYMPH NODES: No enlarged pelvic lymph nodes.
 
BONES: The visualized pelvic bones are unremarkable.
 
OTHER: Left varicocele.
 
IMPRESSION:
PI-RADS 5 focal lesion involving the peripheral and transitional
zone, right mid prostate gland, posterolateral region,
approximately 2.0 x 1.0 cm in extent with extraprostatic
extension in the posterolateral region.
 
Focus of enhancement and restricted diffusion at the medial
aspect of right seminal vesicle could reflect a small lymph node.
 
 
 
NOTE:
PI-RADS (Prostate Imaging Reporting and Data System) assessment
uses a 5 point scale based on the likelihood (probability) that a
combination of multi-parametric MRI findings on T2W, DWI, and DCE
correlates with the presence of a clinically significant cancer
for each lesion in the prostate gland. A clinically significant
cancer is defined on pathology/histology as Gleason score > or
equal to 7 (including 3+4 or 4+3 and/or volume > 0.5cc), and/or
extra-prostatic extension (EPE).

Nov. 2016 - MRI biopsy

INDICATION: 65 year old man with is a history of prostate cancer, Gleason 7,
low volume, withpresenting PSA 7.3, who completed a course of definitive
external beam radiotherapy on August 8, 2012. He has since developed a
biochemical recurrence, with a very slowly rising PSA from 0.3 in 2014 to 1.0
in 2015 to 2.1 in May of 2016 to 2.4 in July of 2016. This is consistent with
recurrent prostate cancer. He recently underwent an MRI on August 6, 2016,
and this demonstrated a right anterior apical prostate nodule suggestive of
recurrent prostatecancer.

 MRI-guided transrectal prostate biopsy.
 Once the biopsy approach was determined, the biopsy device
was placed in the proper position under MR guidance, using oblique T2 weighted images parallel to the plane of the needle.
The specimens were obtained from the transition zone of the right anterior
apex. Three 18-G core samples were obtained.

PATHOLOGIC DIAGNOSIS:

Prostate, core biopsies, three:
1A)  Right apex medial I:
-Benign prostatic tissue with radiation atypia, no malignancy
identified.

2A)  Right apex lateral II:
-Benign prostatic tissue with radiation atypia, no malignancy
identified.

3A)  Right apex anterior:
-Benign prostatic tissue with radiation atypia, no malignancy
identified.

-------------------------------

Aug 2016 MRI w Coil

TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 3.0 T
magnet.
This study was performed with endorectal coil for high resolution detail.
1 mg of intramuscular glucagon was administered to reduce artifact related to
bowel motion.
Intravenous contrast: 8 mL Gadavist.

COMPARISON: Prostate MRI from 5 February 2012

FINDINGS:

The prostate gland measures 2.8 x 5.5 x 4.7 cm (AP x SI x TV), yielding a
calculated volume of 38 cc. There are 4 foci of susceptibility corresponding
to the fiducial markers placed for external beam radiation. The prostate
gland has decreased in size compared to the prior MRI from February 2012,
likely relating to treatment response.

Within the right anterior gland, at the apex, there is a T2 hypointense nodule
(05:27) which is ill-defined, more conspicuous on the ADC map (602:9), were it
measures 1.7 x 1.2 cm. If measured in a similar fashion on the current and
prior examinations on contrast-enhanced images, the greatest dimension on the
current study is approximately 1.0 x 1.3 cm on axial images (series 8, image
221); compared to 1.2 x 1,7 cm on the prior examination (series 7, image 168
from February 2012). Compared to the prior MRI, the lesion is further towards
the apex, possibly secondary to global prostatic atrophy related to radiation
treatment. No other suspicious lesions are appreciated.

The neurovascular bundles appear free of tumor. The seminal vesicles appear
normal in signal intensity and morphology. There is no significant adenopathy
and the visualized osseous structures appear grossly unremarkable.

IMPRESSION:

1. Right anterior apical prostate nodule still shows abnormal kinetics and
restricted diffusion, but is slightly smaller and more towards the apex
compared to February 2012.
2. No lymphadenopathy or evidence of extracapsular extension.

-------------------------------

11/11/16 BONE SCAN

TECHNIQUE: ISOTOPE DATA: (11/11/16) 26.6 mCi Tc-99m MDP.

Anterior and posterior whole-body images were obtained approximately 3 hours
following intravenous injection of the radiopharmaceutical.

FINDINGS: The images do not show any foci of increased tracer uptake suspicious
for metastatic disease.

The above described findings are consistent with normal physiologic uptake.

The kidneys and urinary bladder are visualized, the normal route of tracer
excretion.

IMPRESSION: No evidence of osseous metastatic disease.

---------------------------------------

First MRI in comparison -

Feb 2012 MRI w Coil

TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained before,
during, and immediately after the intravenous injection of 8 mL of Gadovist
contrast, 1 mg of intramuscular glucagon and 200 mg of lidocaine were
administered. An endorectal coil was also placed.

3D series were sent to an independent workstation for computerized assessment
of the contrast dynamics.

FINDINGS:
The prostate gland measures 4.7 x 3.5 x 5.0 cm (CC x AP x TV), yielding a
calculated volume of 43 cc. The central gland is enlarged and shows a
heterogeneous swirled and whorled appearance with well-defined nodules
indicative of benign prostatic hyperplasia.

A focal area of low signal on T2-weighted images relative to normal prostate
is noted in the apex of the right central gland measuring 1.9 x 1.3 x 1.4 cm
(CC x TV x AP). In the axial images it extends to the midline (5:25 and
301:48), although the area of abnormality is confined to the right gland.
This area enhances avidly and washes out on delayed images. This area shows
mild restricted diffusion. This is concerning for central gland prostate
cancer that is both posterior and anterior to the urethra. This area is at
the most inferior aspect of the apex and bulges approximately 2 mm inferior to
the adjacent left glandular apex (4:16) but remains well circumscribed and
there is not definite extension outside the gland. There is a large area of
involvement along the periphery anteriorly and laterally at the left apex of
the central gland with slight bulging anteriorly as well.

There is no evidence for tumor in the right peripheral zone. The left
peripheral zone has mildly decreased signal intensity on T2-weighted images
and increased signal intensity on T1-weighted images in the left apex and mid
gland with a geographic non-mass-like configuration and no corresponding
abnormal enhancement. Sensitivity for tumor is decreased here though none is
seen.

The neurovascular bundle is free of tumor. The seminal vesicles are normal in
signal intensity and morphology. There is no significant adenopathy and the
visualized osseous structures are normal. No clear diffusion-weighted
abnormalities are noted.

IMPRESSION:
1.9 cm abnormality in the right apex central gland highly suspicious for
prostate cancer with 2 mm of smooth inferior bulging in the deep apex relative
to the left glandular apex, but not definite evidence of extracapsular
extension. No definite peripheral gland tumor.

PSA -
11/16/10 to 09/20/13      8.2 to 0.2  (2012 Focused IMRT 75g)
09/20/13 to 10/05/16      0.2 to 2.8
10/05/16 to 10/27/17      2.8 to 5.7

-k

 

 

VascodaGama's picture
VascodaGama
Posts: 2958
Joined: Nov 2010

Kainasar,

As commented before, spot radiation is possible after a prime RT therapy if the tissues at the area have not received the full RT dose based on the limits of absorption. You need to consult the radiologist who did your RT to check if additional radiation is possible at the locations identified in the image study. He has the previous isodose planning and can provide you his opinion.

Otherwise, you should consult a medical oncologist and procure a continuous treatment within the palliative approaches of ADT (hormonal) or a combination of Chemo plus ADT.

Your previous posts are here; https://csn.cancer.org/comment/1605193#comment-1605193

Best wishes and luck in your continuing journey.

VG

kainasar
Posts: 12
Joined: Aug 2017

Thanks again VG. Rad Onc said no to more IMRT and felt SBRT would only help for abt 2 yrs. Focal brachy was discussed w side effect warnings, and advice on how long brachy would help.

I have yet to find research that shows long term trade off for QOL frm salvage brachy, but seems far better than salvage RP.

-k

 

 

Old Salt
Posts: 720
Joined: Aug 2014

I am not an MD, but it seems to me that the possibility that the cancer has escaped the prostate should be considered. This hypothesis is based on the relatively rapid rise in PSA (2.8 to 5.7 in one year). At that PSA level, various scans are possible. The most sensitive ones are based on the PSMA marker. Not sure whether you will have (easy) access to one of those, but I do recommend that you look into appropriate scans.

kainasar
Posts: 12
Joined: Aug 2017

thanks.

I was given a CT scan and Axumin PET scan last Summer. Results of PET scan showed acc to report, organ confined, but significant uptake.

Not sure how long one should wait before 68g PSMA can be administered. Not having any major symptoms, urine frequency but emptying,

urgency controllable, no pain except from radiation proct.

-k

 

 

VascodaGama's picture
VascodaGama
Posts: 2958
Joined: Nov 2010

Axumin (fluciclovine f 18) has a short half-life of 110 minutes. At 24 hours post injection 5% has been already excreted in the urine. At one month time your body will be ready for additional testing. Gallium 68 is a friendlier contrast (half-life 68 minutes) but I think you should inquire at the clinic doing the 68 Ga PSMA PET exams in regards to precautious and any interaction with other medication you may be taking. In the following link you have the details regarding Fluciclovine f 18. This radiotracer works better if the PSA is above 1.80 ng/ml but the exam may confuse PCa with other types of cancer and vice versa;

https://www.rxlist.com/axumin-drug.htm

Please note that they inform that a negative Axumin does not equal to negative recurrence;

"Image interpretation errors can occur with Axumin PET imaging. A negative image does not rule out the presence of recurrent prostate cancer and a positive image does not confirm the presence of recurrent prostate cancer."

Best wishes,

VG

 

kainasar
Posts: 12
Joined: Aug 2017

Thanks. Helpful to know source of quote. 

Based on the Axumin scan seems to indicate the presence of mets. 

Either way my sense is that biopsy is necessary and the mri fusion pi-rads is better than the other types.

 

-k

 

kainasar
Posts: 12
Joined: Aug 2017

What to do? Surgeon wants to do min inv salvage prostatectomy, and medical oncologist says to wait before ADT. Radiation onc says Gleason 9 tumor below is in transition zone, so cant do anything. Salvage proct has known complications esp bowel injuries and incontenance.

So far its all organ confined.

-k

biopsy-

A. RIGHT TRANSITION ZONE POSTERIOR MID:
PROSTATIC ADENOCARCINOMA, Gleason score 4+5=9 (Grade group 5) involving
50% of multiple love fragments.
No perineural invasion.
No lymphovascular invasion.
B. RIGHT APEX:
PROSTATIC CARCINOMA, Gleason score 4+5=9 (Grade group 5) involving 75%
of one (1) of one (1) (1:1) core.
No perineural invasion.
No lymphovascular invasion.
C. RIGHT MID:
PROSTATIC ADENOCARCINOMA, Gleason score 4+5=9 (Grade group 5) involving
70% of one (1) of one (1) (1:1) core.
No perineural invasion.
No lymphovascular invasion.
D. RIGHT BASE:
PROSTATIC ADENOCARCINOMA, Gleason score 3+3=6 (Grade group 1) involving
less than 5% of one (1) of one (1) (1:1) core.
E. LEFT APEX:
Benign prostatic tissue.
F. LEFT MID:
PROSTATE ADENOCARCINOMA, Gleason score 3+4=7 (Grade group 2)involving
5% of one (1) of one (1) (1:1) core.
No perineural invasion.
No lymphovascular invasion.
G. LEFT BASE:
Benign prostatic tissue.

VascodaGama's picture
VascodaGama
Posts: 2958
Joined: Nov 2010

Kainasar,

I am sorry for knowing about the negation by the radiation oncologist to use RT in your salvage treatment. I do understand his worry regarding the “rads over rads” approach. The risk for fistulas is great and that would be something you should avoid at all risks. Unfortunately, brachy (LDR or HDR) is also not free of the danger in genitourinary/gastrointestinal toxicities. However, I believe that the experience of the practitioner would make some different in the outcomes regarding the success in eliminating cancer and on the quantity/quality of side effects. Surely removing the whole prostate (surgery) is a possible method too and probably would not carry complicated consequences, in comparison with brachy.

In any case, my lay opinion regarding your clinical stage at the moment is that you should be certain about the “containment” so reported in the several scans. I am curious in particular to the PET results which you said before to have shown “… organ confined, but significant uptake …”
Can you please paste here the PET results? What was the SUV indicated in the report?
You do understand that the above approaches would just treat the wound not cure it if metastases exists at other areas.

The GS 9 creature (as you call it) must be subdued. I do not think that ADT is the best choice to hold it for good. Chemo would be probably a better approach but not the killing bullet.

I am also facing a similar situation with regards to the option of additional radiation to previously radiated tissues (the prostate bed in my case). My F18 FCH PET exam found no cancer in bone or at LN but it shows high SUV at the prostate bed (still waiting for confirmation on the findings). I am concerned with the grade of toxicity that I could incur from a spot RT intervention. Some fellas here have reported about their survival without scars from repeated RT treatment that involved the same number of areas of their previous treatment. And the question is; should we give it a try?

Best wishes in your continuing journey.

VGama

 

kainasar
Posts: 12
Joined: Aug 2017

Senor VGama -

Nice to hear from you, and once again appreciate the input.

I am due for a bone scan to search for bone mets, in order to make a decision about the surgery. Rad Onc guy says creature is to close to something to be worth the trouble. I could ask for 2nd opinion about that.

My limited knowledge of the radiation treatments is that the toxicity varies according to strength and type - focal v whole gland, focused beam SBRT v other kinds. One could try looking through the research

studies of salvage radiotherapy.

 

-K

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