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PSA Anomaly

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Posted 2/15/2018 8:40 AM (GMT 0)
Hi all,

I just joined the group but have been reading your forum posts for about 6 months. I thank you so much for the wealth of knowledge that you share. I've learned a great deal from your experiences and research.

I'd like to share an experience of my own. I had a RRP a little over 2 years ago. Prior to that I was on AS for about 5 years. My knowledge was limited. I just let the professionals do the thinking for me. That was my first mistake. 3 TRUS biopsies showed indolent 3+3 Pca. At most 3 positive samples @ 5%. Never had (offered) a parametric MRI. The 4th (and last) TRUS biopsy hit a 3+4 @ 20% w/ perineural invasion. That was the game changer for me. I opted for the RRP. Pathology report stayed @ 3+4. Prostate = 60 grams. The shocker was EPE pT3a. Margins were negative but the margin was "focally abutted by malignant glands". As with many Pca patients, I sweat it out every time I wait for my routine PSA results. As you can see on my signature line - my nadir was <.01 - but has generally fluctuated between .01 and .02. However in 01/18 it popped up to .03. I've learned from this forum that is the point to start thinking about a potential post-RRP treatment plan.

But first I decided to go to another lab (02/18) and pay out-of-pocket for a comparative PSA test. A well-known nationally recognized lab that other PCa patients have given excellent reviews. Result? <.006.

Now it comes down to which lab to trust. I realize that when measuring such small quantities of PSA accuracy is questionable. But there is quite a difference between .03 and <.006.

Naturally I'll wait it out and get another test in 2 months or so to monitor trends. But it just goes to show what a difference a lab can make.

Hopefully Lab#2 got it right.
Posted 2/15/2018 9:37 AM (GMT 0)
Others more knowledgeable will chime in but from where I sit there is not much difference between the two readings. Undetectable.
Posted 2/15/2018 2:26 PM (GMT 0)
Exactly what I was thinking.
Posted 2/15/2018 4:41 PM (GMT 0)
TJ123

My journey was somewhat similar to yours. After Surgery PSA was <.005. Eight years out it had risen to .06.
I am 33 months out from SRT and my PSA readings all have been <.006. Seems the outlier PSA of <.006 might not be accurate. Time for retesting for sure.
Posted 2/15/2018 5:44 PM (GMT 0)
You need to see a rising pattern for at least three tests before you start worrying. Keep to one lab. Each lab can have different test methods and sensitivity levels. Comparing the results will just drive you crazy.

Retest and when there is a clear rising trend, you'll need to talk to the docs.

Right now, you've just got weird readings, not much PSA and every reason to go enjoy life to the full.

Andrew
Posted 2/15/2018 6:36 PM (GMT 0)
Thanks for your feedback, fellas.

Some HW posters much more knowledgeable than I about the disease have posted research showing that once a post RRP patient hits PSA .03 chances are very good it's going to continue on a trek upwards and recur. That's the reason I became concerned and got my PSA tested by another independent and reputable lab. So when the latest PSA reported out as a <.006 I was relieved, at least for the time being.

Of course the best and only real option I have at this point is to watch for trends and go where it takes me. I'm scheduled for another one in about 2 months.

In the meantime I'll take it a day at a time and keep on learning.
Posted 2/15/2018 7:27 PM (GMT 0)
Your EPE was only "focal" and you don't say if there was any pattern 4 at that point. There are day-to-day fluctuations in uPSA, so just retest in 3 months. Pick one lab and stick with it, and see if a convincing pattern emerges.
Posted 2/15/2018 8:25 PM (GMT 0)
Thank you, TA.

Perhaps you can explain something to me. No one else has.

My path report says that my tumor involved approx. 5% of examined specimen. It goes on to say there was one dominant focus, 1.5cm.

And the report does not indicate if there was any pattern 4 at the EPE. Perhaps it would be a good idea to have the path labwork sent to Dr. Epstein for his opinion.

What exactly is the significance of "focal" when it comes to Pca?
Posted 2/15/2018 8:54 PM (GMT 0)
"Focal" means that it just barely touched the capsule, usually ≤1 mm from the edge. You might email the pathologist with the question - Was there any pattern 4 found at the EPE focal point? If he didn't look at it, I'm sure Dr Epstein would be happy to.
Posted 2/15/2018 10:45 PM (GMT 0)
TJ123 wrote Margins were negative but the margin was "focally abutted by malignant glands".
Is that where the question about focal came from?
Could it mean that the surgeon cut wide at the EPE but there was a focal positive surgical margin, probably close to the EPE? Both EPE and margins can be focal in pathological reports. confused
Posted 2/15/2018 11:48 PM (GMT 0)
I think a trend is the key.
Posted 2/16/2018 12:04 AM (GMT 0)
Hi Gemlin,

I spoke to the urologist who assisted the surgeon about it. She told me that the margin was close - but still considered negative. Later I learned through independent research that the close margin puts me at a little higher risk for recurrence than someone with margins with more wiggle room. But that research seemed to contradict Patrick Walsh, MD in his Surviving Prostate Cancer book. As I recall Walsh said that patients with close margins generally do as well as those with more cushion between the tumor and the margin. Who knows?
Posted 2/16/2018 1:17 AM (GMT 0)

TJ123 said...

Later I learned through independent research that the close margin puts me at a little higher risk for recurrence than someone with margins with more wiggle room.

Perhaps this will make you feel better - from Epstein himself:

"Dr. Epstein completed a study of patients whose tumors were particularly close (less than two-tenths of a millimeter) from the surgical margin. Even though there wasn't a comfortable cushion of tissue between the tumor and the edge of the prostate, those patients did just as well as patients with more separation between the tumor and the margin."

/www.hopkinsmedicine.org/brady-urology-institute/specialties/conditions-and-treatments/prostate-cancer/prostate-cancer-questions/understanding-surgical-margins-after-radical-prostatectomy

If you can spare a little money (a few hundred I think), Epstein is sure a good source for a 2nd opinion. I did that and am glad because he found my margin was GS 3+3, and the post-prostatectomy pathologist had not bothered to state that. So now with my low-level, but seemingly stable, uPSA, I feel a little better holding off on SRT.

Robert
Posted 2/16/2018 2:34 AM (GMT 0)
Yes, I read Patrick Walsh, MD's book and noted the same information about close surgical margins. And, yes, it did make me feel better until I did further research and found this:

"Cancer that is within 0.1 mm of the surgical margin of a prostatectomy is associated with an increased risk of prostate cancer recurrence."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4428570/

So there seems to be some disagreement in the medical field.

With me, time will tell.

And I may just get a 2nd opinion on path report, as you suggested. Unfortunately I can't contact my pathologist directly. I have to go through my PCP to bounce a question off the pathologist and wait for his answer.

I was surprised that a pathology report wouldn't break down the malignant pattern at the EPE focal point. To a layman that would seem to be pretty important information.
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