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Posted 7/12/2024 5:48 PM (GMT -5)
I'm a Gleason 9 who was undetectable for over 4 years after surgery in Feb 2019. Everything (margins, lymph nodes, seminal vesicles) was clean after surgery except I was a PT3A with extraprostatic extension. The tumor present in the extraprostatic location was close to, but not at the surgical margin. I'm having a recurrence now. My PSA keeps going up and latest is .15. I realize I need to act quickly and am.

I have an appt with a RO soon as it seems like I should be radiating the prostate bed plus hormone therapy. My PSMA PET a few weeks ago showed nothing though. Is there any thinking here where I would not radiate the prostate bed until a scan shows something? I do have an MRI coming up next week and possibly could take at least one more PSMA PET.

In this video, Eugene Kwon from the Mayo Clinic says there is only a 33% chance it's a local recurrence.
"Remember, only 33% of men have "pure" local recurrence after prostatectomy. Do NOT get radiation therapy until you are absolutely certain about the kind of recurrent prostate cancer you have !!!"
https://youtu.be/q2jod360_pi?t=251

He described local recurrence as "recurrence of prostate cancer at the site where the prostate used to be or inside of residual prostate components". I realize your surgical pathology might increase/decrease that 33% chance.

In the PSMA era, is anything different now in my type of situation? If PSMA PET and MRI show nothing, despite the 33% odds, do most men still take the gamble and radiate the prostate bed because it is likely the only chance for a full cure?
Posted 7/12/2024 8:49 PM (GMT -5)
Hey Bob - I ended up with a similar diagnosis as you and decided to go with adjuvant radiation which is radiation to the prostate bed with undetectable (<0.10) PSA within approx. 6 months of surgery. The recurrence odds were statistically improved for my high risk situation by doing this but offset by the possible side effects of ART if the treatment was not needed.

I am not so sure the logic is much different for your situation. Do you want to give up the 33% chance to attack the possible local cancer? The other question becomes whether lymph nodes should be included in the salvage radiation field? Lymph node radiation is not free of additional side effects so it is a decision onto itself.

If you had another PSMA or other scan that provided some indication of the problem location, your RO would be very happy and outline a definitive plan to attack the cancer. Right now, it will probably be like my situation where both my Uro and RO said ART was indicated but it was my decision to make and to consider the negative factors with no positive PSA. Thanks doc’s….

Took me a month or two of studying and soul searching to go for the possible 35% statistical benefit improvement. Others might wait for their PSA to signal the need for RT. PSMA and similar scans have changed the dynamic a bit since PCa can be detected at much lower PSA levels so it may be prudent to wait a little longer, take another PSA, and scan again, still being considered as early SRT with better odds.

Hopefully your RO will guide you through the process and answer all your questions.
Posted 7/13/2024 6:47 AM (GMT -5)
My uro told me that an axumin F18 PET scan would not show tumor locations until my PSA hit 3.0. I already had RARP, adjuvent RT and 2.5 years of Lupron. about 3 years after going off the Lupron my PSA hit 3.0 and I got the PET scan. That showed 3 lymph node mets which I then got zapped, along with internal pelvic lymph nodes.

When the PSA is still very low, there is not enough cancer to show up on the scan as the axumin - an artificial protein - is also taken up by muscle tissue which creates visual 'clutter' that hides the cancer.
Posted 7/13/2024 9:24 AM (GMT -5)
trail - Bob's situation is different as he is evaluating SRT at low PSA, not ART like you and I had.

From an article:
To date there have been multiple meta-analyses assessing the utility of PSMA PET-CT [108,109,110,111,112,113] to detect recurrence. In patients with BCR, the proportion of positive PSMA PET-CT scans consistently increased with higher PSA. For PSA categories 0–0.19, 0.2–0.49, 0.5–0.99, 1–1.99, and >2 ng/mL, the percentages of positive scans were 33%, 45%, 59%, 75%, and 95%, respectively. Significantly, PSMA PET-CT improves the detection of recurrence at low PSA (<0.5 ng/mL), and has high sensitivity (75%) and specificity (99%) on meta-analysis of pooled data (Figure 4) [108].

The problem is that early SRT needs to start at lower PSA values to obtain best recurrence odds where the odds of detection are less so what does one do? Tough decision to make.
Posted 7/13/2024 9:42 AM (GMT -5)
I'll probably be in Bob's position in about a month, at which time I expect my PSA will have risen from my nadir of 0.007 (7 yrs ago--about 6 months after my RP) to just over 0.100 at my next 3-month visit (I was just under 0.100 last test). I, too am a G9 (4+5); however, my pathology was pT2 N0 (16 negative nodes) with negative margins and no adverse findings. My tumor burden was 5% and my Decipher test was low-risk for mets.

The tentative plan with my uro/surgeon was for an R.O. consult at 0.1. My doc thinks this is more likely something left over in the pelvis rather than aggressive G9 metastatic disease. Looking back at my PSA numbers, it seems I've had a very slow progression upwards. (This PSA history is IMO an advantage of the uPSA test.) We'll see what the R.O. thinks. I'll ask my uro for a recommendation for the Duke R.O. with the most experience with PCa.

I watched the video with Dr. Kwon linked above (2 yrs old, if that matters). I don't fully understand his admonition to wait for confirmation of pelvic disease before SRT, or at least if that holds for all situations. I can't see much benefit in waiting, unless my R.O. & uro think there is a good possibility my PSA will plateau (vs. the risk of currently pelvic-confined disease progressing to metastatic PCa). My uro seemed in favor of SRT even if imaging finds nothing.

I'll post again when I know more.
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