Recurrence of Gleason 3 + 3 Prostate Cancer 5 years after Brachytherapy

I had brachytherapy on June 20, 2011 for Gleason 3 + 3 prostate cancer. Within 18 months the PSA dropped from pre-treatment value to 3.4 to 0.1. Then it started rising slowly from 0.1 to 0.4 over 18 months and during the last 12 months it jumped from 0.4 to 1.5. Urologist performed DRE exam and detected a nodule. In fact I felt that his finger is touching a large solid mass. A biopsy was performed on August 31. 12 cores were taken inside the prostate and 2 for the nodule

Today I got a copy of the biopsy. Relevant part of the report appears below:

(A), (B), (C), (D), (E), and (F) Prostate Needle Core Biopsies "Left Base, Left Mid, Left Apex, Right Base, Right Mid, and Right Apex": BENIGN PROSTATE TISSUE WITH RADIATION ATYPIA. NO EVIDENCE OF MALIGNANCY

(N) Prostate Needle Core Biopsies "Right Prostate Mass": RESIDUAL ADENOCARCINOMA EXHIBITING TREATMENT EFFECT. TUMOR NOTED IN 4 OF 7 CORES AND COMPRISES 40% OF THE SUBMITTED TISSUE. SEE COMMENT.

Comments:

(N) "Right Prostate Mass": Specimen Comments: Cancers with significant treatment effect are not assigned a Gleason score, which in this context does not correlate well with prognosis.

Clinical Data: PSA 1.5, DRE Isolated nodule, Prev Bx, Positive.

Obviously, the cancer was not successfully treated. This is quite unusual for Gleason 3 + 3 cancer. Does isolated nodule mean a nodule protruding through the capsule. Or is it an isolated prostate mass?

Suggestions and comments welcome.

Sorry to hear that, and probably as surprised as you are. Maybe some one more expert than me will be here to answer shortly. One of the few real advantages( I suppose some argue it is not an advantage) to surgery, IMO, is the surgical path report, where you occasionally find out your pre-op biopsy was off significantly either in your favor or against you. That's all I can come up with off hand, maybe there was an inaccuracy in your BX or some more aggressive cancer cells were just missed by the Bx needle? Or, even if you really were truly G6 and nothing else, I suppose it is possible that seed placement during BT could just miss some cells? I really do not know, but I hate to hear about it.

Doubling time very slow?
His nearly quadrupled in a year. 0.4 to 1.5, at that rate in another year it will be close to 6.0

Sorry that your first treatment didn't get it all. Sometimes with brachy the seeds don't wind up where they were originally placed and there are "cold spots" of radiation insufficient to kill the cancer. There are several steps you might want to take:

(1) Send those biopsy cores to Epstein for a second opinion. Irradiated tissue is very hard to read, even for an expert. You want to be very sure about this.

(2) Get an advanced PET scan, ideally a PET/MRI, to check two things: (a) are there any distant metastases, and (b) where the cancer is within the prostate, and are there any obvious cold spots where the seeds are sparse. Since you live nearby anyway, you can get this done at NIH in Bethesda (Arm 2) for free. Call the number on the following link - they usually love to hear from patients.

/clinicaltrials.gov/ct2/show/NCT02190279

(3) Read these:

Salvage Low Dose Rate Brachytherapy (LDRBT) after primary LDRBT failure

Salvage SBRT for local recurrence after primary radiation therapy (RT)

Your other salvage options include salvage focal ablation (cryo, FLA, HIFU, IRE, etc.) and salvage focal HDR therapy. Because local-only failures are rare after primary radiation, there aren't a lot of experts at salvage therapy after radiation. But an expert is what you want. One of the best places is Memorial Sloan Kettering in NYC. Michael Zelefsky can do seed salvage and Jonathan Coleman may be able to do focal salvage ablation. I suggest you make appointments with the two of them and discuss it after you have your second opinions and your NIH PET scans. Your other option, salvage surgery, is also best done at MSK, so you may wish to discuss it with Eastham or Scardino while you're there.

Same here. G6 brachy treated morphed to G8 in 5 years. Salvage treatment, no distant mets.

Then 5 years after that a lymph node met, treated with SBRT, 18 months ago.

So sorry to hear about your reoccurence.

Forgive me, but I'm unclear as to whether your most recent biopsy was also 3+3? Or did it possibly progress to another level?