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Post-Surgery PSA disappointment...seeking some insight.

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Posted 12/21/2013 12:06 PM (GMT -5)
Hi all,

Just had my first PSA post-op (8 weeks). Felt like a punch in the stomach when Dr. said my PSA was .49 Appears my surgery is a failure so SRT will be in my future. My final pathology indicates Gleason upgraded to 7 (3+4), bilateral w/ right 3-4% & left 20% pT2c, dominant tumor lft-mid-anterior, 1.4 CM. Seminal vessel invasion not identified, Lymph N/A. focally positive margin (1), perineural invasion focally present. EPE not identified but a small portion of capsule was missing (per report comments section). Dr. recommends PSA in 4 wks.
Is there any indications the cancer will only be in the prostate bed vs. migration elsewhere? My feeling is that some cancer was left behind at the surgical site. Of coarse, I'm not qualified to make any interpretation. My final pathology does not look too bad...I just can't get my head wrapped around a .49 I'm thinking of getting a 2nd opinion from UCLA Med Ctr. Thank you for any insight!

T
Posted 12/21/2013 1:01 PM (GMT -5)
Get the re test as your Dr. indicates. That will give you more good information to make your decision. My 1st one was higher and the next 5 were much better to better. I had a rise last week to .137 and will have a retest in about 7 weeks. I am 3 years out of a Da Vinci surgery.

A 2nd opinion is an excellent idea. Cedars, USLA, USC and City of Hope would be good choices as you seem to be in that area. I am in South Orange County and will be going to Cedars if needed.

Best of luck,

Scott
Posted 12/21/2013 1:05 PM (GMT -5)
What was your PSA prior to surgery? Waiting another 4 weeks and testing again certainly seems appropriate. In the mean time I would consult with a good radiation guy so that you can pull the trigger on SRT right away if needed. Best of luck to you.

Tom
Posted 12/21/2013 4:32 PM (GMT -5)
Welcome aboard, tarawa98,
Sorry your first post doesn't have any better news. Hopefully it will go down some more when you take your next PSA. The rest of your path report looks pretty good.

With a T2c staging, it looks like it was contained in the capsule.
Wishing you good luck on the retest.

Bill from Florida cool
Posted 12/21/2013 5:17 PM (GMT -5)
You've come to the right place for feedback. I'm sorry that you're experiencing this on your first PSA. I wish you the best!
Posted 12/21/2013 5:41 PM (GMT -5)
Follow-on radiation, if done within six months of surgery, is generally called "Adjuvant" Radiation Therapy not "Salvage". ART tends to have a bit better success rate than SRT. I did ART and found it quite doable. The side effects aren't usually too bad and it would let you continue to pursue a cure.
Posted 12/21/2013 6:05 PM (GMT -5)
Welcome to HW, sorry you need to be here but it's a great place.

Sorry to hear about your problems. Radiation is the normal next step. Sadly some of the PC can be left behind for a lot of reasons. Sounds like your doc is follow the normal path here. A retest for sure. You never know, there could have been something wrong with the test. Best to confirm the result. A second opinion is always good.

The question that is so hard is answer is, "Is the PC confined to the prostate bed?" At low PSA like yours it's hard to see the PC on any imaging (MRI, CT, and so on) so you can't really confirm where it is. All you can do is play the odds. Most likely it's still in the bed but you never know. You can get bone scans and stuff but likely they won't show where the PC is. They might but that's a long shot. If your PC is confined, radiation will blast it away just fine. RT isn't fun but it can be done and is more of an endurance test.

Keep us updated on your progress,
Andrew
Posted 12/21/2013 8:18 PM (GMT -5)
Hi tarawa,

Welcome and sorry to hear about these complications.

tarawa said...
a small portion of capsule was missing

Sounds like the surgeon left a chunk inside. UCLA has some of the best state-of-the-art imaging equipment in the area, including mpMRI and C11 Acetate PET. May I suggest you talk to Dr. Kapulien or Dr. King - both have a lot of experience dealing with salvage radiation.

Key questions are (1) whether or not to treat the pelvic lymph nodes in addition to the prostate bed and the chunk left behind. That will probably depend on whether there seem to be infected lymph nodes and on your nomogram results.And (2) whether neoadjuvant ADT will improve your outcome. My layman's guess is probably not with a pGS3+4.

- Allen
Posted 12/21/2013 9:09 PM (GMT -5)
Tarawa,

Welcome and sorry to hear your news. I am just under six weeks out from my RALP and scheduled for my first PSA on the 30th then meet my doc on the 8th for the results. More than apprehensive to say the least. hang in there, you are in the right place for support!
Posted 12/22/2013 4:46 AM (GMT -5)
Tarawa

I had post opp. PSA of 0.60 in 8 weeks of surgery. It stayed there for to months then I was put on casodex for three weeks and then zoladex had IGRT 33 sessions a few SEs diarrhea mosty from the casodex, but developed proctitis and rectal bleeding everything cleared up with in a month. The zoladex knocked psa down to 0.01 and holding. Surgery was in Jan. 2013. Hoping to see your next test on the down trend. Did your pat report mention negative margins.
Posted 12/22/2013 6:19 AM (GMT -5)
Got to agree with "Tall Allen". From your pathology report it seems a part of the prostate sent to pathology was missing. In all probability the surgeon has cut through a portion of the gland while removing it and left a bit behind ----- this may be the reason for the residual PSA. It may or may not contain tumour and the answer to this might be the trigger as to whether to radiate or not. It would be beneficial to have someone have another careful look at the gland slices in the region of the "cut portion" and estimate what may have been left (size wise) as well as ascertaining if there was tumour at that location. Even with successful surgery Perineural invasion is not uncommon nor is a focally positive margin (this always narks me ----it is never clear whether they taking about the gland's margin {capsule} or the actual surgical margin). It is confusing to say in a report "1 focally positive margin" and in the same breath "EPE (extraprostatic extention) not identified". Lymph nodes were not sampled and seminal vesicles were clear while there was not a huge amount of tumour in the gland. With the possibility the current PSA may be due to benign residual tissue left in place your doc's view of checking PSA again in 4 weeks may not be bad advice.
The question to ask may be "why did you leave that portion in there?"
Bill
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