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Increasing PSA after RP/SR

GeorgeG
Posts: 127
Joined: May 2017

Been a while since I have been here, so hello again to the group - VG, Max, et al.

 

RP in 2016 after PSA 22, 4+3. PSA detectable a few months after surgery, had SR (37 fractions up to 70 GY) at PSA 1.0 with 6 months of Firmagon. Testosterone and PSA undetectable starting a few weeks into Firmagon and for about 6 months after the last shot. Testosterone made it to 70% of baseline and PSA is detectable and climbing rapidly again - 0.3/0.4/0.7 every 30 days.

I know that I have more hormone therapy and bone scans/PET scans in my future. What's the latest treatment thoughts/studies/trials for someone in my situation? Who do you guys consider to be some of the best Medical Oncologists for my situation? I would love to hear what VG, Max or any of the other well read members has for me to study/consider. I had my RP at Johns Hopkins and my SR at Mayo. I live in Florida but I am willing to travel.

 

Thanks,

 

George

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

George,

I am sorry but I cannot find your past threads with details of your case. Can you give us a copy of the links?
The search engine of CSN is the worse I ever encounter in similar forums. The admini never attempt to attend our requests to provide a button to direct searches to entries by the members..

Based on what you describe above, you got oligo-treatment that can lead to cure or chemo that is palliative and linked to nasty side effects. There are also a series of clinical trials with the latest drugs/modalities in PCa treatments.

In any case it all depends on your age, past history, symptoms, status (systemic?), etc.

Best wishes,

VG 

redbelly7
Posts: 34
Joined: Jul 2017

I am on Zytiga plus prednisone (oncologist got me on that one).  I had a secondary urologist suggest Provenge.  You have plenty of options in FL for good hospitals, but not sure who is best in US.  Good luck, you will be fine.

GeorgeG
Posts: 127
Joined: May 2017

Age 63, otherwise excellent health, no medications except when on ADT

 

2016: PSA 22, clean bone scan and CT scan. RP at Johns Hopkins. GS 4+3, SV involvement, no LN involvement, negative margins

2017: Biochemical failure three months after surgery. Clean bone scan and local 3T enhanced MRI. started SR with 6 mo Firmagon at Mayo when PSA 1.0, 37 fractions, 70 GY. Good Firmagon response with Testosterone and PSA undetectable after 30 days.

2018: Biochemical failure 6 months after last Firmagon shot, testosterone at 70% of baseline. PSA tests 30 days apart 0.3/0.4/0.7.

 

Thanks,

 

George

 

 

Georges Calvez
Posts: 305
Joined: Sep 2018

I am suprised that you got away with only 6 months of Firmagon as you are at least an intermediate risk case.
I suspect that it will be back to Firmagon or Luperon maybe with Casodex, there is no need to worry about testosterone flare and aggravation of any metastases in your case.
A lot of men play the game of intermittent ADT for years, it all depsnds on the cancer and its ability to change so that it becomes independent of androgens.
Most scanning techniques will find nothing with a PSA around your level.
VG likes to call prostate cancer the bandit, yours is rustling the bushes, you know he is there but you cannot see him.

GeorgeG
Posts: 127
Joined: May 2017

I understand that with current PET scan technology, we will probably get our radiological evidence at a PSA of around 2-2.5. I got very good response to Firmagon but the insomnia was brutal and I had elevated liver enzymes. We are talking about my docs more typical approach for the next round of one month of Firmagon then Lupron. He still advocates intermittent with scanning. I’m getting up to speed on the latest thinking like Provenge, early chemo with ADT, etc to see if I should consider anything else besides constant or intermittent ADT.

 

Thanks,

 

George

 

GeorgeG
Posts: 127
Joined: May 2017

VG

 

in addition to any other comments that you may have for me, by Oligo do you mean micronutrients, biological, gene or immunotherapy?

 

thanks,

 

George

 

Old Salt
Posts: 720
Joined: Aug 2014

Oligo = oligo metastases. Or, in other words, metastases that cannot be detected by currently available scans.

GeorgeG
Posts: 127
Joined: May 2017

George C

Recommendations for treatment were all over the map. They ranged from no radiation to radiation with no HT to SR+ 6 mo HT to SR + 2 years HT. In addition, the SR dose profile was different at every recommendation. Its an area with very little consensus so I read, asked and listened until I had what I thought made sense and went with it. I overweighted the most recent study outcomes as confirmed by the Rad Onc that I had the most faith in.

 

George

 

Georges Calvez
Posts: 305
Joined: Sep 2018

That is one of the problems with prostate cancer, there is no general agreement on the best course of treatment, it is almost prescientific, each doctor tries to use his experience and judgement to decide on the best course of treatment.
I have read a lot of personal histories and although there are general rules eg cancers with low stages tend to result in favourable outcomes and cancers with high stages tend to result in poorer outcomes there are no absolutes, there are a lot of exceptions.
One of the problems is that prostate cancer is not one but around twenty diseases with each having a specific genetic make up, this decides the aggression of the disease and its tendency to metastase, its need for testosterone, etc.
Thre is also a personal effect, some men just seem to have a physiology that resists the progress of the disease better than others.
One ray of hope for you and it is a big one is that your cancer seems to respond well to ADT, maybe you will be able to play this card over and over again.

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

George,

The additional info you share above confirms recurrence (three rises from a nadir) after RT. Your doctor may consider your case systemic advancing with ADT (hormonal) or a combo of Chemo+ADT (Firmagon will do well again), but you can try checking possibilities on an oligometastatic treatment that could lead to cure.

This oligo-therapy refers to a fewer number of metastatic spots located at places feasible for added radiation. Several members of this forum have done the therapy successfully (I am also procuring the same), but all patients were in proper status to repeat the radiation. In other words, the tissues in the field for radiation were confirmed to be OK to absorb added radiation. Tissues have limits in terms of rads but they manage to recuperate to certain extent after 5 years of the initial RT treatment.
In your case the field of the SRT of 2017 cannot be radiated today unless the absorbed rads were lesser than the established limits.

If interested in this oligo-therapy you should firstly get a PET scan to identify the spots. Then you need to compare its location with the RT field of 2017 (checking with the previous radiologist). To avoid false negatives from a PET exams you need to wait for further rising of the PSA. You also should use facilities that do the exam with PSMA isotopes, such as the 68Ga PSMA PET exam. This test manages to detect PCa at PSA levels above 0.5 ng/ml but in your shoes I would do it at a PSA > 1.0. You have nothing to lose by waiting because your next treatment would start with hormonal manipulations that can be done at such levels. Moreover, the higher PSA would provide higher assurances of a positive scanning which is what you need. I know that Datolli at LA is doing this oligometastatic treatment. You could consult his clinic to verify your possibilities, including the exam.

A note on the findings of 2016; I want to say that recurrence after RP is common in guys that were diagnosed with SV involvement, These cases are also propitious for involvement of lymph nodes at the upper area of the abdomen and the deep iliac ones. These are typically missed at RP done with robots. I wonder if the lymph nodes dissected and analyzed by the pathologist were from those areas.
As commented above, the best exam to certify any involvement of PCa is the 68Ga-PSMA PET. Your insurance may not cover such a test but the results are worth any penny you spend on it.

Best wishes,

VGama

 

 had checked   

GeorgeG
Posts: 127
Joined: May 2017

VG

Thanks for the response.

this was the exact discussion with my Rad Onc on Friday. Wait for my PSA to rise to around 2.0 - 2.5 then scan to look for opportunities for spot radiation treatment. This seems consistent with newer IADT protocols were you wait until the PSA rises to either 2.0 or 3.0 before starting ADT again. 

it looks like there are a handful of PET scan isotopes. You mentioned 68 gamma but there is also choline, Axumin F18, C11, etc. some of the literature says that that PMSA shows the greatest promise but is not released yet. Mayo, where I had my SR uses choline But it won’t be available at the Florida location for a few more months. What are your thoughts on the different isotopes?

My RP was open and he removed about a dozen lymph nodes which were all negative.

i had very good response to Firmagon (undetectable PSA and testosterone) but the insomnia was terrible and I had elevated liver enzymes. My doctors normal protocol is Firmagon first to avoid flare and then Lupron. We discussed switching to this next time, what are your thoughts?

He also gave me his recommendations for Medical Oncologists to get second opinions from at both MSK and Anderson so I will be following up on that.

Thanks,

George

 

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

Image studies have been one of my major researches since my failed surgery of 2000. I wanted a picture of the bandit to attack it, did many scans and exams with several contrast agents and tracers along the years but all come with false negatives (even a MRI in 2006 with PSA=3.6). I only managed to get a positive result this January, 2018, from a scan done with the tracer F18 Choline (FCH) PET/CT. The PSA was 1.8 ng/ml (T=294 ng/dL).

As you may already know, there are differences among the tracers as these have limitations on detection at several areas in the body. Some are better (FDG) than others to identify lesions in bone, and some are better for soft tissues (Axumin), and some are better in specific type of cells such as the C11 and F18-FCH. All of these depend on their half-life so that the facilities doing the exam need to have  a cyclotron to make the substance straight for injection, or if procured outside then the timing of the exam must be carefully scheduled. This is the problem with C11 for its short half-life of 22 minutes. Choline has a longer half-life of 110 minutes so it is more practical. Axumin (fluciclovine F 18) is not dependent of such requirements so that it is practical but it is not specific to one cancer alone. It detects PCa but it confuses the interpretation as the positive result could be from a different malignancy. In this regard, the F18-FCH (flurocholine) PET seems to be better because choline is well absorbed by the prostatic cells. All these tracers require high PSA (above 1.8 ng/ml) levels to assure detection.

The Gallium 68  (Ga68) together with a PSMA isotope is more specific than the ones above, exactly because it aims the prostatic cell's membranes. The PSA is also used as the threshold to trigger the exam as the isotope takes time to be absorbed by certain PCa cells. From trials they comment that a PSA above 0.5 ng/ml is feasible, however one can allow higher levels to be certain of a positive result.
The technique requires facilities with a cyclotron too, so not many clinics want to install nuclear facilities. In any case, apart from detecting well PCa, the software used in these PET facilities is the same used by the computers of modern RT facilities (ex; true beam) making it possible to use the exam's data directly in the RT machine to pinpoint the spots for radiation. There are loads of information on the net. Just google and read the many articles.

Whatever exam you chose, you should do it before starting ADT or chemo. Cells with be indolent not proper for absorbing the radiopharmaceutical.

Regarding ADT; Firmagon is an antagonist so that it may be associated with different symptoms when comparing against Lupron, an agonist. Firmagon is friendlier to cardiovascular issues. It may also be better in terms of problems with the kidneys.
I used Eligard (leuprolide same as Lupron) in 6-month shots. To avoid flare I started with an antiandrogen (one month) taking the first shot two weeks later. My intermittent ADT is regulated by the PSA levels. Switch-off after one year in remission (PSA< 0.05 ng/ml) and switch-on at a PSA of 2.5. So far I have accomplished one cycle started in 2010 and gone off drugs in 2012. This corresponds to more than 5 years in vacations (off drugs) away from ADT's side effects (no chemical castration, etc). My present PSA is 1.75. Still waiting to restart ADT.

Link on the exam;

https://www.carcinoid.org/2017/04/06/gallium-68-petct-scanning-neuroendocrine-tumors-information-locations/

Best,

VG

 

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