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Persistent PSA after RALP

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Posted 3/23/2017 1:48 PM (GMT -5)
Merino, if you had "No sign of cancer in dissected prostate" why did you get it removed?
Posted 3/23/2017 2:49 PM (GMT -5)
Biopsy in March 2012 show one core positive out of 11 samples.Watchful w
aiting for 18 months. Second biopsy then show 2 cores positive out of11.
Urologist told me that some time in the future I have to get some treatment.
I thought the door of clemency for nerve sparing surgery was closing.Urologist told me the chance of more cancer in the dissected prostate is 70%.The biopsy
was like seeking for a needle in a haystek.The report of the dissected prostate revealing no cancer came as a shock.
Posted 3/23/2017 2:56 PM (GMT -5)
So what explanation is there for a PSA of 5.7 after your entire prostate has been removed and no cancer was found? Perhaps you should have the whole-mount pathology re-done by Epstein?
Posted 3/23/2017 5:06 PM (GMT -5)
I am fit and not 60.My urologist has an approach of getting rid of any possible
cancer cell.He explained to me that the spots of cancer on the prostate is like
spots on a rotten apple.I have already explained that nerve sparing surgery was
a priority for me and just for the record I was potent from day 7 after the surgery.The explanation for the 5.7 PSA is that in some cases the prostate grows into the bladderwall.With robotic surgery it is not so noticible as with open surgery.So it happened in my case that the medial lob was left behind
as residue prostate tissue.One must realize that searching for cancer in a dissected prostate is not so absolute process. The pathologist does not search
till he finds cancer,he follows procedure.I suppose he reckons the patient must be glad
If there is no cancer and not angry because of unnecessary surgery.After all the prostate is already out.Just for the record my PSA was 4.13 when diagnosed and 2.39 when surgery.All I want to say is PSA is not the best marker.
Posted 3/23/2017 5:25 PM (GMT -5)
Interesting case, Merino - one for the books. I guess it reinforces what we always tell newbies - get a second opinion on the biopsy slides from Epstein or Bostwick.
Posted 3/23/2017 7:12 PM (GMT -5)
Very interesting Merino, If larger amount of tissue remains then a rise in PSA could be caused by numerous things including cancer. If you get a high quality scan and it finds the cancer is only in the prostate bed/pelvic area you could get Radiation therapy. Go to another Doc and get a second opinion - Good Luck!
Posted 3/24/2017 5:34 AM (GMT -5)
I understand that seperating the prostate from the bladder wall is like pealing an orange.There will always be pieces left behind like the white of an orange.The possible explanation for the psa of 45 at 3weeks post-op was manupilation of the prostate during surgery or that a piece of the prostate fell off into the body cavity.I can assure you that going from 2.39 pre-op to 45 at 3 weeks post-op did not go away unnoticible.It took all my courage to refuse radiotherapy.
Posted 3/25/2017 1:02 PM (GMT -5)
Weightloss,

I can absolutely relate to your anxiety. The idea of having had cancer and the idea of it returning can be overwhelming at times. I have found myself doing hours of research looking for reassurance. What I have found is the research doesn't provide reassurance because it will never provide an absolute answer. I want to know that I will be ok and no research will tell me that.

However, what helps me is that with my specific pathology I have a 88% (Han Tables: John Hopkins) chance of being cured from the cancer (which I think is pretty good but not 100%) and if there is a recurrence there are very effective treatments to address it. I am trying the best I can to focus on what is in front of me versus what my future holds. I have control of now but I dont have control of tomorrow. Now its easy to say that and much harder to implement but I am trying.

Take care.
Posted 3/25/2017 3:52 PM (GMT -5)
In all humbleness I want to seguest the following:
Never get anxious,stay calm
Make sure that you get copies of the psa test results
as well as pathologic reports of biopsies and the dissected prostate
If there is something out of the ordinary questioned every step.
Dont climb on the wagon of Munchagen.I know it feels great if an important doctor pays attention to you.The sicker the doctor said you are the more you brag about it.Beware of this trap
Posted 3/25/2017 4:05 PM (GMT -5)
Adjuvant radiotherapy is ok.Salvage radiotherapy is still ok, but primer radiotherapy after a radical prostatectomy is not ok.My gleason was only (3+3).The one core was only 2mm occupied with cancer the other and the only
remain one was only 1mm occupied.All these facts were
in my possesion only after the prostatectomy.My urologist had only used the terms very small and low grade.
Posted 3/26/2017 4:18 AM (GMT -5)
Let's start with MRI scans.The software for MRI was developed in Holland.a Certain Radiologist specialised in prostate cancer went for a MRI in Holland.The results came back stating aggressive prostate cancer.Biopsy samples (15) was taken from the lesson.Results were all prostatitis.Only 5% of prostatitis is because of infection which is curable by antibiotics.The average time for a bone scan to reveal any sighn of a tumor is 8 years.I am now 5 years away from it.Radical prostatectomy has an advantage over radiotherapy regarding impotence and incontinence .The oncologist told me that due to the benign tissue left behind during surgery, he will have to use primer radiotherapy.The chance of serious side effects is now there because there is no prostate anymore to protect the organs.Remember I started the journey with no symptoms.The highest my PSA score was was with time of the diagnose which was only 4.13.Only 2 cores was positive with my last biopsy.One only 2mm the other only 1mm.The mass of the dissected prostate was only 14.5g.All margins were clear.No cancer was found in the prostate.So why shall I risk what I have now just to ease my mind.I just have as in my language said
VASBYT!! In English hold on.
Posted 4/3/2017 7:10 AM (GMT -5)
The 2 weeks have now passed, and its 8 weeks post RALP, as directed by my Urologist, I had a uPSA done at the same lab that reported 0.050 on March 20th. The result was 0.030

I'm happy at the decline but not ecstatic because PSA is still detectable. My Urologist is now asking me to test in 3 months (i.e., 5 months after RALP). Seems ok to me, but I would really like to see something lower, maybe "undetectable" at the 90 day mark post RALP. Should I request that?

Urologist also says that PSA is produced by extra-prostatic sources such as Cowpers gland and the urethral lining and could be causing the PSA readings. Is there any research on these sources producing PSA of 0.0x?
Posted 4/3/2017 7:52 AM (GMT -5)

WeigthLoss said...
Urologist also says that PSA is produced by extra-prostatic sources such as Cowpers gland and the urethral lining and could be causing the PSA readings. Is there any research on these sources producing PSA of 0.0x?


From Wikipedia we can read:
"It is now clear that the term prostate-specific antigen is a misnomer: it is an antigen but is not specific to the prostate. Although present in large amounts in prostatic tissue and semen, it has been detected in other body fluids and tissues.[19]

In women, PSA is found in female ejaculate at concentrations roughly equal to that found in male semen.[52] Other than semen and female ejaculate, the greatest concentrations of PSA in biological fluids are detected in breast milk and amniotic fluid. Low concentrations of PSA have been identified in the urethral glands, endometrium, normal breast tissue and salivary gland tissue. PSA also is found in the serum of women with breast, lung, or uterine cancer and in some patients with renal cancer.[53]"
Posted 4/3/2017 11:54 AM (GMT -5)
Extraprostatic sources can affect PSA in the next decimal place (0.00x). There are benign prostatic sources (i.e. benign tissue left inside), but those dry up over time. I think your Uro is right to wait 3 months (in fact, it might have spared you some anxiety to have waited 3 months in the first place) -- the benign sources, if any, are likely to dissipate by then and give you a clearer picture. You clearly don't have a pattern of rapid progression, so there is little risk to that approach. I know how anxious you must feel, but the only thing that would cause concern is a steady pattern of increase.
Posted 7/6/2017 5:01 PM (GMT -5)
Hi all, just an update. I'm now five months out from RALP and my PSA reading from my Urologist's hospital lab rose from 0.030 to 0.059 from a Siemens assay about 2 weeks ago. As I mentioned before, two other large teaching hospital labs report <0.03 (unknown) and <0.01 (Beckman Coulter) respectively. I repeated the two hospital labs tests after my 0.059 reading and they came back still undetectable. I also tested at a private independent lab, which used yet another Japanese assay and it came back <0.008

I'm now back to the Philadelphia area for a few months and had a test at Labcorp. They use Roche ECLIA and it came back < 0.006

All this is good, but to make sure there is some issue with the hospital lab, I would like to test on a Siemens assay in the US, which is what the private hospital in Singapore used. Does anyone know of a lab in the Philadelphia, NY, Baltimore area that uses a Siemens assay?
Posted 7/8/2017 9:16 PM (GMT -5)
It seems that Quest uses the Siemens assay and the test code is 14808X. It's called the post prostatectomy PSA. I will be looking for the nearest Quest. From their website:

CPT Code(s)
84153

Methodology
Immunochemiluminometric Assay (ICMA)

Limitations
Heterophil antibodies may produce falsely-elevated results.

Reference Range(s)
<0.10 ng/mL After radical prostatectomy
≤4.0 ng/mL In healthy males without prostatectomy
PSA values obtained with different assay methods or kits cannot be used interchangeably.

Clinical Significance
For post-prostatectomy patients. The lower limit of accurate quantification for this assay is 0.02 ng/mL. PSA values less than 0.02 ng/mL cannot be accurately measured and will be reported as less than 0.02 ng/mL. Specimens with PSA levels below the lower limit of accurate quantification should be considered as negative. In patients with a negative result for post-prostatectomy PSA, serial monitoring of PSA levels at regular intervals, along with physical examinations and other tests, may help to detect recurrent prostate cancer.
Posted 7/10/2017 5:19 PM (GMT -5)
Another update:

I've managed to get a scrip for an Ultrasensitive PSA (Quest calls it "PSA, Post-Prostatectomy" Order # 14808) without seeing a doctor! There are a few online sites that hook up with either LabCorp or Quest. Using directlabs.com seems to have worked. I even found a 10% off coupon online for them. I just entered my details into the website to create an online account. Verified that the test was using Quest labs. The fact sheet on directlabs.com even talks about the issues with heterophil antibodies. After paying for the test, I signed into my directlabs account and was able to print a scrip with a "referring physician". So I'm off to Quest tomorrow for the test. Will update when I get the results online.
Posted 7/10/2017 7:53 PM (GMT -5)
Weightloss, if you're in the Philadelphia neighborhood, I'd like to offer to meet for coffee while you're here. If you click on my name over to the left, you'll get my public profile that includes my email address. Drop me a line, I always enjoy meeting another PC brother.
Posted 7/14/2017 8:18 AM (GMT -5)
It was an exercise in futility. All my research and contact with Quest seemed to indicate that they use a Siemens assay. However, when I got my result, it says Beckman Coulter and it was < 0.02 It seems that if you have a regular PSA test, they do it regionally and use a Siemens, but if you order the ultra sensitive, they send the sample off to California and use the Beckman Coulter.

Am still looking for that Siemens assay, so if anyone knows of a lab with one, please let me know.
Posted 7/19/2017 2:13 PM (GMT -5)
Update: I finally found a lab that used a Siemens Centaur PSA assay. It was Atlantic Diagnostic Laboratories in Bensalem, PA. I went out there to get a standard PSA test as they don't do Ultrasensitive, but their standard PSA test defines <0.01 as undetectable. The result: 0.04

In summary, the tests I have done over the past 2 weeks in the Philadelphia area have been as follows:

Labcorp (Roche Cobas 602) : < 0.006
Quest (Beckman Coulter) <0.02
Atlantic Diagnostic (Siemens Centaur) 0.04

This is exactly the same result as I got in Singapore where the Siemens assay is the only one out of five that gives me a detectable reading (0.059 was the last result in Singapore) and reinforces my suspicion that I have some sort of heterophile antibodies that affect the Siemens assay. Siemens uses both mouse and goat antibodies in their test.
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