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New - Looking for advice with PSA of 0.41 after RALP

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Posted 9/23/2017 8:44 PM (GMT 0)
My husband just received this PSA result 7 weeks after his prostatectomy and it is 0.41.

Advice was to wait 6 weeks for another PSA test.

Seems like this is fast growing, but hoping some of you could shed light on what all these numbers mean.

Just wondering what to expect in the year to come. I feel like we should be doing SOMETHING over the next 6 weeks.

History:

8/2011 PSA 1.0
7/2013 PSA 1.96
5/2015 PSA 3.51
10/2016 PSA 6.87
5/2017 PSA 8.44
7/2017 PSA 9.56

March 2016 Biospy

December 2015 - Biopsy 15 cores with one core showing 1/2 mm Gleason 6 (3 + 3)
June 2017 - Biopsy 15 cores with 9 had more than 1 mm of Gleason 7 (3+ 4)

March 2016 MRI negative
October 2016 MRI Provided PI-RIDS as a V2

August 2017 RALP
Good recovery: Urinary Incontinence - improving but leaks when moving around
ED: Very good recovery.

Pathology Report:

Tumor Grade Gleason 7 (3+4)
Lymph nodes negative
Seminal Vesicles Negative
Tumor involves right posterior left posterior right anterior and left anterior.
Multi centric foci
Two extra capulsar extensions
Bladder neck left was positive
Other margins negative


September 2017 - Almost 7 weeks PSA post prostatectomy 0.41

Post Edited (scar1919) : 9/28/2017 5:22:54 AM (GMT-6)

Posted 9/23/2017 9:37 PM (GMT 0)
I think it's a good idea to get confirmation that his PSA is that high, perhaps sooner than 6 more weeks. I hope you are meeting with a radiation oncologist about this. If he wants some more time for urinary continence to return, he can start hormone therapy. That will stop any further progression, but then he will have to contend with the side effects of hormone therapy (which he may not need for his salvage radiation).
Posted 9/23/2017 11:44 PM (GMT 0)
SRT is the obvious next step here . As TA said with 3+4, ADT may not be helpful or necessary. I would think that SRT should include lymph nodes. A good RO will verify .
Bob
Posted 9/24/2017 12:30 AM (GMT 0)
Thank you for the replies. I will encourage him to get the PSA retested next week.

If the PSA of 0.41 is correct, would the bladder neck involvement cause that high of a number. Do I understand correctly that this number is unusually high after a RALP?

He has an appointment with a RO in about 10 days. Hopefully he will paint a clearer picture. Waiting this next 6 weeks and doing nothing will be tough.
Posted 9/24/2017 12:59 AM (GMT 0)
Also meant to ask if we should request a bone scan or CT scan at this time.



.
Posted 9/24/2017 1:08 AM (GMT 0)
It is high post RP and suggests that PCa was either left behind or had already escaped the prostate where the ECEs exist. The bladder neck is a typical place for ECE Through which PCa escapes. It happened with me but I was Gleason 9. Standard of care is IMRT once PSA is .2 and assuming his reading is accurate, he's already there. His PCa is likely micrometastatic so unable to be seen even with scans. At this point waiting for it to become visible by MRI or the newer CT pet scans may not be advisable. Be sure you have a RO who has lots if experience treating PCa.
Bob
Posted 9/24/2017 1:52 AM (GMT 0)
If they got it all, his PSA would be undetectable now.

I can't say if the cancer escaped at the bladder neck or any other place. I assume that the surgeon did not spare the bladder neck and he got a negative margin there. The absence of a positive margin anywhere does not really tell you anything. When they give him salvage radiation, it will cover all the places within the prostate bed that it typically migrates to first.

A bone scan isn't likely to show anything - PSA usually has to reach 10 or 20 before anything is big enough to show up. A CT scan of the pelvic area may reveal enlarged lymph nodes, and is a reasonable precaution, but that would be unusual with a Gleason score of 3+4, and coupled with his negative LN dissection, it is likely that he could be spared whole pelvic radiation.
Posted 9/25/2017 1:04 AM (GMT 0)
Thanks again!

Tall Allen, what do you mean " I assume the surgeon did not spare the bladder neck and he got a negative margin there."

The pathology report indictated the bladder neck was positive for PCa. Would the surgeon be able to tell that the bladder neck was compromised when he removed the prostate?

Post Edited (scar1919) : 9/24/2017 7:10:25 PM (GMT-6)

Posted 9/25/2017 1:12 AM (GMT 0)
Surgeon's often try to spare the bladder neck in order to better preserve urinary function. But when cancer is found at the bladder neck, they have to cut it out and connect the anastomosis past that point. Since you said that there were no positive margins, I assume your surgeon did that.
Posted 9/25/2017 2:08 AM (GMT 0)
So- could you please clarify - what exactly did the path report say? Did it say that there was a positive margin left behind at the bladder neck? Or did it say that cancer was found at the excised bladder neck and there was no positive margin left behind? Those are two very different situations. If there was a positive margin, the stage would be R(1).

Yes, surgeons can often see the cancer and 'cut wide' so as not to leave any behind. Sometimes they have a pathologist standing by during the surgery and take progressively wider frozen sections for microscopic inspection if there is any doubt.
Posted 9/25/2017 7:48 AM (GMT 0)
Hi scar.....I'm going to tag along with the fine advise you're getting.

I'm two and a half months post RALP and have a PSA of .32

My surgeon thinks it's OK for me to wait another month for a follow up PSA test. I'm not comfortable with that and have an appointment with an RO next week. I received some similar very good advise here last week.

If I learn more about this "Persistent PSA", I'll post it here, if OK with you.
Posted 9/25/2017 12:16 PM (GMT 0)
Tall Allen, I will look again at the report, but the cut line was positive and I assume some was left behind?

So if the surgeon could see the cancer and tried to "cut wide" can I infer this is why he is still having incontinence problems?

garyi, oh yes, I will follow along your journey as well. All the best to you!

Post Edited (scar1919) : 9/25/2017 6:19:51 AM (GMT-6)

Posted 9/25/2017 1:19 PM (GMT 0)
Sounds good scar. Best of luck to you, too.

A wide cut could be a contributing factor to your husbands incontinence. It's also quite early in his journey.
Posted 9/25/2017 5:22 PM (GMT 0)
OK, then you're saying there was a positive margin - R(1). That augurs well for a cure with salvage radiation. It helps to know for a fact that cancer was left behind in a place where radiation can destroy it. (With no positive margins, it could possibly be micrometastatic.)

There are two urinary sphincters. One - the internal urethral sphincter - is above the base (top) of the prostate at the bladder neck. The other below - the external urethral sphincter - is near the apex (bottom) of the prostate. The one at the top is under autonomic (involuntary) control, meaning it stops urine flow from the bladder without having to think about it. So if he couldn't preserve the bladder neck, that "spigot" is always on. The external sphincter, on the other hand, is under conscious control. He learns to aid its function by tightening skeletal muscles with kegels. So even if he lost the one at the bladder neck, he still has the one at the bottom, and continence can often be regained with practice.
Posted 9/25/2017 5:43 PM (GMT 0)
TA....isn't the internal sphincter always removed with the prostate?

Also, are both SBRT and HDR Brachytherapy approprate salvage treatments for these persistent PSA issue?
Posted 9/25/2017 5:54 PM (GMT 0)
garyi-

If you're looking for research studies on salvage radiation, here are a few that may be of interest:

On the importance of treating while PSA is low:
/pcnrv.blogspot.com/2016/09/very-early-salvage-radiation-has-up-to.html
/pcnrv.blogspot.com/2016/08/how-early-salvage-radiation-therapy-can.html

On the odds that it will be successful:
/pcnrv.blogspot.com/2016/08/probability-of-remaining-recurrence.html

On the benefits of using neoadjuvant ADT to wait longer:
/pcnrv.blogspot.com/2016/10/urinary-and-sexual-healing-improved-by.html
Posted 9/25/2017 5:55 PM (GMT 0)
Scar--Welcome but sorry you and your husband have to join our club. The advice here from TA and Break60 and others is invaluable. Wish I had found it earlier in my journey. Good luck!

Jim
Posted 9/25/2017 7:00 PM (GMT 0)
garyi-

It is called "bladder neck sparing." It's not always possible or a good idea. For urinary continence, they want to spare as much of the urethra as possible. For cancer control, they want to cut wide.

For salvage after surgery, SBRT and HDR brachytherapy are not yet appropriate salvage therapies, although they have been tried experimentally. HDR-BT has been tried as a kind of non-curative focal salvage to slow progression were there is a macroscopic tumor in the prostate bed. SBRT is in a couple of clinical trial - my RO will be starting one soon. A few have tried a hypofractionated protocol:

/pcnrv.blogspot.com/2016/08/can-salvage-radiation-therapy-be-safely.html

There are special radiological challenges to using hypofractionation after the prostate is gone.
Posted 9/26/2017 12:14 AM (GMT 0)
Thank you for the most interesting studies, TA.

It seems treatment options for scars husband and me will be few and problematic. I may need to contact Dr. King about that coming clinical trial.

Nothing seems straightforward with prostate cancer.
Posted 9/26/2017 1:59 AM (GMT 0)

garyi said...
It seems treatment options for scars husband and me will be few and problematic.

I don't know why you say that. Few? Well yes -there is just one standard of care, salvage IMRT, that works very well and has been around for a long time. Problematic? There are many decisions (e.g., ADT or not, how long, when to start, how much radiation, to what area), but these are everyday sort of issues that will get sorted through. It's just a matter of sitting down with an experienced RO (of which there are many) and starting a dialog. It may seem formidable now, but as you discuss them with the RO, it gets clearer. This may seem bewildering to you because it's all new and you're understandably anxious, but that's why we hire professionals.
Posted 9/27/2017 1:24 AM (GMT 0)
How soon after the RP can my husband's radiation treatments begin?

They made an appointment for him to see an RO in December! His surgery was the beginning of August and he just had his 7 week check up that resulted in the 0.4 PSA. Quite concerned at this point. He is going to call tomorrow and find out what's up.
Posted 9/27/2017 1:57 AM (GMT 0)
It can begin anytime after 3 months to allow for healing. But you may want to wait longer to get better recovery. It's a good issue to discuss with the RO.
Posted 9/27/2017 2:03 AM (GMT 0)
Tall Allen, thanks again!
Posted 9/27/2017 12:07 PM (GMT 0)
Scar I had surgery in March and plan on starting SRT in October haven't decided yet on ADT will see what my psa is on October 11

Larry
Posted 9/27/2017 4:44 PM (GMT 0)
SkyPilot, good luck with your treatment. I am quite concerned with my husband's PSA post RALP already at 0.4. I really hate this downtime just waiting for appointments and no plan in place.
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