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Post surgery persistent psa

nup0k1
Posts: 5
Joined: Feb 2018

Prostate cancer diagnosed last late August, 

 

Cancer staged as T1cN0MO, 1 out of 12 biopsies sample, lesion about 0.8 mm butting Capsule boundary. 

Gleason score at 8; PSA 5.2

All bone scan negative. 

Surgery in early Jan shows 10% Tumor; Extraprostatic Extension but negative in Margin and Negative in both Lymph nodes and vesicles; Restaged as pT3a

Post Surgery 6 weeks PSA @ 0.7 and rises to 1.0 in 4 weeks.

Against such dire reading, is my cancer curable. There is current research case where I can participate to receive HT, RT followed by 6 rounds of Chemo. 

Q1. Should I participate in such program ?  Or just HT and then RT? Really concerned with Chem side effect ? 

 

Please help me !

Clevelandguy
Posts: 440
Joined: Jun 2015

Hi Nup,

Am I missing something?  Can you have Extraprostatic Extension and negative margins? I thought Extraprostatic Extension meant the tumor had grown outside of the prostate. Gleason 8 is aggressive(4+4 or 3+5 or 5+3), you need to find out what the combo of numbers are, it will tell you how aggressive the cancer is. But with that being said there are other treaments like HT & radiation that should be able to help.  You need to talk with your urologist/oncologist to map out a treament plan, does not sound to me that the show is over.  My personal opinion is that I don't think your ready for the chemo yet, that's kind of last resort after every other thing has failed from what I have heard other members talking about.  Hopefully you will be around for a long time, get going on working out a treament plan with your doctors, don't be afraid to get a second or third opinion from other doctors/hospitals.

Dave 3+4

RobLee's picture
RobLee
Posts: 259
Joined: Feb 2017

Dave, yes you can have both.  I was G8(4+4), 25% involved with three foci EPE and SVI, stage T3b.  The surgeon used a broad cut and removed all potentially cancerous tissue... therefore negative margins as well as negative nodes.  My PSA at biopsy was 25 and post-op was .03 ... I was started on Lupron and underwent 39 Tx adjuvant IMRT at one year.  First post-RT PSA is now 0.00 ... next PSA draw is in two weeks, and after three consecutive 0.00's I am officially in remission.

For the OP, early chemo has been used recently in cases where there is persistent PSA post-op but without adverse pathology (LVI/SVI). The thinking being that there are already micromets circulating and no longer localized in the prostate bed, therefore docetaxel either following or in lieu of SRT is intended to knock out the escaped cancer cells before they become established tumors. Your shockingly high PSA makes you an ideal candidate for combined Tx.

Old Salt
Posts: 720
Joined: Aug 2014

Are you considering enrolling in a clinical trial that would add taxotere to hormone treatment + radiation? Please clarify with specifics (like the trial number and the institution).

nup0k1
Posts: 5
Joined: Feb 2018

Taxotere is normally used for advanced case and to my understanding, it has been approved by FDA for used as adjuvant Treatment. Thus it is now used in Trial case which I can volunteer for usch Trial. However, it can be overkilled if I can be cured by just RT and HT.  My dilemma is the doctor has no evidence of spread. All biopsy testing results are negative except the persistent post surgery PSA. Doctor said that post surgery RT and HT have 75% curative rate. I don't know the extra Taxotere at early stage has added benefit. The Trial is to find out. I don't have to volunteer for such Trial.

contento
Posts: 76
Joined: Jul 2017

nup, your situation is not very uncommon in that the imaging cannot see the cancer. I know from other Pca survivors that they had received RT along with HT without knowing where the cancer is located. It's hit or miss as far as success since the cancer could be located beyond the radiated zone which is the pelvic/prostate bed area. Before I had any imaging done my demographics were such that I was told I had a 50/50 chance of success but once we did the imaging and did locate the cancer, ( there was debate among the docs as to whether or not the image MRI even showed the cancer ) , the success probability went much higher. Regardless I hope the RT/HT works for you. You probably won't have an answer for about 6 months following treatment  assuming your cancer is hormone sensitive.

contento

contento
Posts: 76
Joined: Jul 2017

Sorry for the situation. Since your docs just performed surgery they must not have seen the spread beyond the prostate otherwise they would have probably recommended radiation. But whats done is done. Unless your talking about some clinical trial ( which sounds like you are contemplating )  I doubt very much that your a candidate for Chemo. As Dave already mentioned Chemo for Pca is a much later stage treatment usually after all else fails. That certainly doesn't sound like your situation. I can't decide for you and I don't know all your details to even provide an opinion about a HT,RT and Chemo trial. I was a gleason 8 also with stage 3 but we initially thought my cancer was contained. Turns out it wasn't.

I had to do HT and RT simultaneously. So far ( it's been 2 1/2 yrs since HT/RT) my psa has been non-detectable. My opinion would be to persue adjuvant RT most likely with some HT. The trial that includes Chemo ? consult with a good radiation oncologist first..

Good Luck -- contento

Old Salt
Posts: 720
Joined: Aug 2014

Although, as was mentioned, taxotere has typically been used once the cancer had metastasized extensively, the results of the CHAARTED trial suggest that taxotere can be of benefit when applied 'early' after metastasis. Of course, in nup's case, there is no evidence that it has from the data presented.

I will quote from a (very) recent publication (Kyriakopoulos et al):

The clinical benefit from chemohormonal therapy in prolonging overall survival (OS) was confirmed for patients with high-volume disease; however, for patients with low-volume disease, no OS benefit was discerned.

 https://www.ncbi.nlm.nih.gov/pubmed/29384722

PS: I now see that Rob Lee made this point as well, I think...

RobLee's picture
RobLee
Posts: 259
Joined: Feb 2017

Yes, I know a couple guys who are getting Taxotere following adjuvant RT for persistent PSA. It is not part of a trial, but had been recommended by their oncologists. I believe both had some LNI but not extensive. Still, LNI indicated likely distant spread and therefore unaffected by the RT. I'd call it a "belt and suspenders" approach.

nup0k1
Posts: 5
Joined: Feb 2018

Mr. RobLee

     Thanks for your input to my case.  Since I have Extrapostatic extension and post RPP PSA is 0.7, the canceous cells must have escaped even though post surgery biopsy shows that the cancers are only 10% of the prostate and all other limph nodes and (Perineal) PNI and .seminal vesicles are negative. What are the chances these cancerous stay within the prostate bed ? My pre RPP PSA is 5.2. Can we correlate roughly how much % of the cancer cells has escaped outside. I don't understand why isnt my pre RPP PSA higher than 5.2 when the spread has occcured ( presumably cancerous generate higher PSA than regular prostaste cells). What is your gute feeling what has happened ? Rigth now I am receiving HT awaiting RT. Should I push the doctor to try CT also since there appears no cure once the cancer cells escape beyond the prostate bed.

RobLee's picture
RobLee
Posts: 259
Joined: Feb 2017

Nup, you have asked me a very difficult question, and one which I am certainly not qualified to answer.  But I will tell you what I do know and my gut feeling on the matter, as that's all you have asked for.  G8 is very aggressive cancer, and in your case was found to have penetrated the prostate capsule.  However your local organs (SV and LN) were clear.  There's a good chance that the cancer did not travel very far and would still be in the prostate bed.  Normal protocol is to start six months of hormone therapy, as you already have... two months before RT, two months during, and two months after completion.

Your case is unusual in that your pre-op PSA was low and post-op PSA is very high, and is progressing upwards. However the ADT will suppress your PSA now so further measurements will be only to ascertain that the HT is working. Right now your treatment should be in the hands of your RO.  Before starting my RT I asked my RO directly if I should get a medical oncologist (MO) involved, and he said no.  You could do the same, just as a formality and ask your RO to note it in your chart.

A CT (and/or PET) scan at this point would likely not show anything. Vasco or one of the more senior members here could give you more information on this. I suspect that at your low PSA and apparent lack of distant spread the cancer did not have time to travel very far.  I think maybe your surgeon was not completely thorough in investigating the surrounding tissues.  Usually he/she (as I understand it) squirts ink on various tissues and if it turns blue then they have to cut it out.  I do remember that my surgeon told me that he "had to remove a lot of tissue" (his words) and left me not only with negative nodes and negative margins, but also impotent and incontinent.  There's a tradeoff between getting all the cancer out while trying to preserve vital tissues.  It's the surgeon's call and does not necessarily mean anythng was done wrong. The trick is to kill the cancer without also killing the patient.

Regarding chemo, yes docetaxel is very harsh. You would likely lose your hair (temporarily) and might end up with peripheral neuropathy. It is not something that one goes into lightly.  However, there are advantages to throwing everything you possibly can at your cancer while the battle is on.  If you are inclined to join a clinical trial, then by all means investate whatever you can.  The trial team could at least tell you whether or not you are an eligible candidate. There is a strong likelihood that the HT/RT combo will be enough to knock out whatever cancer remains. Because I do not know your full PSA history, I can't guess what are the chances that there are distant micromets already circulating.  That is what the chemo would be targeted toward. However, if after the radiation has concluded your PSA is still high, your RO's next step would likely be to refer you to a MO for chemical treatments anyway.  But as I said, there's a good chance that will not be necessary. Good luck to you!

hopeful and opt...
Posts: 2224
Joined: Apr 2009

There are various PET scans that are available that will provide diagnostic help, and may pinpoint exactly where the cancer is located.

Axumin is  medicare approved and covered, while other are considered investigational and actually provide better imaging. These generally are cash paid or part of a clinical trial.

Some use C11 Acetate and even better psma.

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