Rapid rise in PSA only 4.5 months after Prostate surgery

JNF said...
....Surgeons should be held to higher standards when they explaining treatment options. Actually salvage surgery after radiation is possible, but very difficult and infrequently used.....

....The incidence of radiation failure is generally less than surgery and significantly less than surgery in the high risk cases.

So the lesson is to do your research and get information from the expert source.

I sure do agree that everyone should do in-depth research and get the best data they can from expert sources, like printed material, large medical center web sites, visiting expert physicians, and reading clinical research studies, NOT from, one-off, anecdotal stories on a public forum.

I have been seen by specialists at no less than five would class medical facilities, have read literally thousands of medical studies, and corresponded with at least a dozen other, world class physicians, mostly very generous radiation oncologists. If there is one thing I've learned, it's that there are no "for-sure" answers, or perfect treatment paths. I've gone though surgery, radiation and hormone therapy. Without any "ax to grind", none of them are a picnic.

We are also in agreement that too many surgeons oversell surgery, just as too many radiation oncologists undersell the side effects of being zapped and even more so, the lifelong altering impact of hormone therapy. That, in my experience, is just as egregious as surgeons not understanding the fine points of radiation.

I have never seen definitive data proving the conjecture of radiation being more successful than surgery. Prostate cancer variables are just to infinite to prove either is better than the other, and monitoring the results over a lifetime are far to arduous. I suspect one reason some believe radiation is better, is that the after effects of surgery are usually obvious and immediate, while the after effects of radiation tend to be milder, more insidious and occur over a much longer time horizon. So the complaints about surgery are also immediate, and in some cases very loud.

Everyone of us has an inherent bias. We've all have had very different journeys, successes, and failures in treating our PCa, and it usually firms up our individual opinions on what does, or does not work, even as every situation is different. The one thing we all agree on however, is that one size does not ever fit all, and as was said earlier, "do your own research and get the best information you can from expert sources" about your own unique situation.

Good luck on the journey of discovery....

Post Edited (garyi) : 3/14/2019 2:40:27 PM (GMT-6)

LJK I did very well healing from my surgery and no trouble with incontinence. I even can sleep better now with not having to go to the bathroom so often. Thought everything was going great.

Had an appointment at the Oncology Clinic today March 14, 2019. Given a shot of Eligard (6 month dose) and Casodex pills for 30 days. April 15, 2109 will doing a RT Simulation to prepare for radiation treatments (7 week 5 days a week) So will be starting radiation in about 2 months after ADT has time to kick in.

Cancer like a train that I can't seem to get off of. (I think its a Quote from a book April to April by Iain McLean) A friend who has cancer said that "Cancer is a gift wrapped in Barbed Wire"

Bobby Mac
I was told yesterday that my PSA is to low to show up on any scans.

Who has these machines?

Thanks

I’m going to go to a radiation class next Tuesday and there I’ll find out if there’s any scanning machines like this in Canada.
Unless someone on this form knows of one.

My Pathology Report:

Specimen Description
A. Left pelvic lymph nodes - Devitalization Time: 0845
B. Right pelvic lymph nodes - Devitalization Time: 0852
C. Prostate gland - Devitalization Time : 0925
Clinical Information
PSA: 23. (L) is 4 + 3 in 5/6 bx. Palpable disease
Diagnosis
A. Left Pelvic Lymph Nodes, Resection:
- Three lymph nodes, negative for malignancy
B. Right Pelvic Lymph Nodes, Resection :
- Two lymph nodes, negative for malignancy
C. Prostate, Radical Prostatectomy :
-Adenocarcinoma of prostate, Grade Group 3/5 (Gleason score 4+3=7/10)
- Extraprostatic extension present
- Resection margins negative for malignancy
- Stage: pT3a pNO RO
I
I
Synoptic Report
Grade Group: 3/5 (Gleason Score: 4+3 = 7/10)
Tumor volume : approximately 11 % of total gland volume
Tumor distribution:
Left: Mostly left-sided involvement mid to apex
Right: Superior mid
Apex : Left
Extraprostatic extension :
Periprostatic fat or tissue : Present ; focal ; slides C18, C22
Seminal Vesicle Invasion: Present ; left; slides C4, C5
Surgical Resection Margins : Negative for malignancy
Cribriform pattern : Present
lntraductal carcinoma : Absent
Lymphovascular invasion: Absent
Pelvic lymph nodes:
Right: 2 of 2, negative for malignancy
Left: 3 of 3, negative for malignancy
Gross Description
Received are specimen containers A to c. All requisitions and specimen containers are
labelled with the patient's name ,~The cassettes and AP identifiers are
labelled with the Surgical Numbe~
A The specimen is received fresh. The container is designated 'left pelvic lymph nodes'
The specimen consists of multiple fibrofatty tissue fragments aggregating to 5.0 x 4.8 x
1.5 cm. Dissection reveals three possible fat replacement nodes, largest 3.6 cm in
maximum dimension .
Nodes submitted as follows :
A 1-A2 largest single lymph node bisected and submitted in two cassettes
A3-A4 single possible bisected fat replaced lymph node per cassette .
8 . The specimen is received fresh. The container is designated 'right pelvic lymph
node'.
The specimen consists of fibrofatty tissue measuring 6.4 x 4.0 x 1. 7 cm. Dissection
reveals two probable lymph nodes, the larger elongated and measuring 5. 7 cm in greatest
dimension , both showing fat replacement.
Lymph nodes submitted as follows :
81-84 single largest lymph node sectioned into four pieces and submitted in four
cassettes
85 single probable lymph node submitted bisected.
C. The specimen is received fresh . The container is designated 'prostate gland'.
A 58 g prostate measuring 4.2 cm apex to base, 5.6 cm transversely, and 3.8 cm anterior
to posterior. The attached right and left seminal vesicles measure 3.2 and 3.0 cm in
length respectively. Margins are dyed as follows: anterior strip with green ink, left
lateral prostate gland with black ink, right lateral prostate gland with blue ink.
Seminal vesicles are amputated and the interface between seminal vesicles and prostate
gland is dyed with orange ink.
The prostate is blocked in its entirety from base to apex. The base and apex are
sectioned in the sagittal plane and the remainder of the prostate is sectioned
transversely.
Photograph taken.
Sections are taken as follows :
Right seminal vesicle C1 through C3 with orange interface in C3
Left seminal vesicle C4,C5
Right base C6
Left base C7
Right half CB, 27, 30, 33
Left half C34
Right anterior 11, 15, 19, 23
Right posterior 12, 16, 20, 24
Left anterior 9, 13, 17, 21, 25, 28, 31
Left posterior
Right apex
Left apex
10, 14, 18, 22, 26, 29, 32
C35
C36
/ I

Rather than continuing to push personal biases of surgery vs radiation, we should just focus on helping Big John's continuing journey. I may stand corrected, but from BJ's signature, he was a T1C following biopsy, and there wasn't any indication of extraprostatic extension at the time, so despite a relatively high PSA and 4+3, surgery was a reasonable and fair choice at that stage. IMHO, no criticism of his decision or his doctor is warranted at all.

Post surgery, a pathologist had the prostate to examine determined extraprostatic extension, hitherto undetected. So despite negative margins, and an undetectable post surgery PSA, the cancer had escaped the capsule and Big John went from a T1C to a pT3a, a much more serious diagnosis. pT3a's often require follow on radiation. Perhaps if the EPE had been suspected before surgery, say through a MRI, radiation might have been a better option.

I think the good news is that the PSA was undetectable post Prostatectomy. There is an implication here that because PSA was undetectable, whatever escaped is still close by in the prostate bed and that Salvage Radiation or SRT will take care of it and result in a complete cure.

If Big John can get one of the new PSMA scans, it would be helpful to determine if it is worth doing radiation, but given the rapid rise in PSA, he should start treatment as soon as possible, whether ADT or radiation. Once on ADT, the scans will probably not work well. At the current PSA of 0.8, a PSMA Pet Scan should be able to determine if its still possible to radiate the prostate bed.

BJ, something to look into. Pathology report staging pT3a. However, in the report under Synoptic Report is contained:
Seminal Vesicle Invasion: Present: left; slides C4, C5

If correct then staging would be
pT3b. Just wondering. Either which way it would seem ADT and RT are in play.

glad to hear you've finished. Do keep us updated on your progress and what the PSA is. Should be close to zero.

I've purchased travel insurance post treatment. It's never been a problem.

Andrew

Big John said...
Was we wondering if anyone has any experience with travel insurance after treatments...?

I'm leaving on Thursday for 17 days in Europe, and I bought travel insurance...there were no questions relating to to any sort of PC treatments in my travel insurance policy in terms of anything that would happen on a trip. It's not health insurance.

Extraprostatic extension is not usually a good thing. But if PSA goes up after surgery, EPE is good because it offers an explanation for why your PSA is rising -- some cancerous tissue was left in the prostate bed. That suggests that radiation may be successful. If there is no evidence of EPE, SV+, or PSM, and PSA goes up after surgery, that may mean the cancer has spread beyond the prostate area and the radiation wold not be curative. We are all wishing you the best possible outcome with your radiation.

That's good news John. And I do believe staying active helps with ADT SEs - both mental and physical. Good luck with RT!

I just got my PSA back this week with a reading of 2.3 after being off of ADT for a year (last September it was still undetectable) ... the oncologist told me that I have cancer recurrence and will be back on ADT soon and for the rest of my life.

It’s been hard to take in.

BobbyMac said...
You may want to have one of the newer scans, 68 Gallium PSMA or Axumin PET

This advice is more pertinent now. Who knows it could be a nearby node or two that escaped detection last time.