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Advice on Liver Mestases - Original Diagnosis Prostate Cancer

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Posted 1/2/2019 10:05 AM (GMT 0)
Any advice welcome. My husband is now a few months shy of 51 years old with likely diagnosis of liver mestastasis (cancer could be stemming from elsewhere), which the MRI done just 2.5 weeks ago seems to indicate. PSA is at 0.3 - and he is on lupron. His background is below. Waiting on the results of the liver biospsy completed a week ago. With the new yer holiday and complicated case as his, the pathology is taking the longer side - as we were told 3-5 business days for results. Requested STAT medical records to be sent to Sloan Kettering for a second opinion. Anyone know turnaround time for second opinions or if there is a better institution for my husband's issue?

Background 2017/Early 2018:
My husband (young 49 years old) was diagnosed in mid-late June 2017 with prostate cancer after all five of the six biopsies came back GS 8 and one at GS 7 (& PSA 24+ in May 2017). He moved to another local hospital, Cleveland Clinic, for a second opinion and a doctor that could perform the robotic RP.

The CT scan and MRI revealed no concerns they could see. Within less than a week after the scans, the doctor was able to find a time (with our request to expedite) for the RP in the first week of July. The RP was completed with one nerve spared (closest to the GS 7 biopsy) - quality of life due to his age.

Post op report/pathology shows:
-GS upgraded to 9
-Positive margins (partially into the seminole vesicles and described as "bulging" to the bladder)
-Lymph nodes clear

External beam radiation - 7 week course completed in Jan-Mar 2018. Lupron started in 9/2018.
Posted 1/2/2019 10:58 AM (GMT 0)
Newhere--

Wow. That's a tough one. A welcome to our crew, for now I'll simply welcome you and trust that some of the guys who know more about the details of high-risk disease come around.

I'll suggest that with the joint teams at Cleveland Clinic and MSKCC involved, you'll get the best minds in the world on the hunt. Besides, they all know each other by first names.

Liver involvement with metastatic prostate cancer is rare-usually PC metastasis in skeletal (bones) or lungs. At this point, it's not really about where the live mets came from--it's what form are they taking, and what can be done about it?

Hang in there, the answers will come. (PS: where in the Cleveland area are you located? I grew up in the southwest suburbs and now live in the Philly area)
Posted 1/2/2019 11:03 AM (GMT 0)
Hi there, based on what you have written about your hubby´s history, the chances for liver mets from PC are really small. I don´t know what MRI is showing, but doubt that it is PC. There are opitions even for liver mets, like resection but let´s first hear the good news.
Posted 1/2/2019 11:15 AM (GMT 0)
Thank you two for replying so quickly! Halbert, we live on the far west side of Cleveland. My husband grew up on the SW side - so you may have been neighbors. You mentioned, "I'll suggest that with the joint teams at Cleveland Clinic and MSKCC involved, you'll get the best minds in the world on the hunt." gives me some comfort.

SpecialLady, yes, the docs at CC agree that it probably morphed into another cancer from another place.

Worried that his billirubin is increasing steadily daily in the past week. Any thoughts here?
Posted 1/2/2019 9:17 PM (GMT 0)
NewHere--I grew up in Berea, my dad was on faculty at B-W. He died of PC in 2004, and I haven't lived in that area since I left in the fall of 1976.
Posted 1/3/2019 2:22 AM (GMT 0)
My son was accepted at BW and we made a trip there together 15 years ago. It's an unusual campus. He ended up choosing Wooster, down around Mansfield. about the liver, yes it is unusual for PCa to metastasize directly to the liver. But it IS possible to have more than one cancer.
Posted 2/3/2019 12:02 PM (GMT 0)
My husband was diagnose with neuroendocrine carcinoma poorly differentiated that may have come from his prostate cancer, which rarely can morph into this cancer. His story is above.

Be aware about treating only for the Pca. My husband had been seeing the radiation oncologist, Dr. Tendulkar at CCF, for 1.5 years post the radical prostatectomy using ETBR for a 7 week period and lupron shots every 6 months. The issue is these docs focus only on the Pca and not looking for metastatic cancers. Dr. T said sometimes these Pca are heterogeneous, and they treat for the Pca but the other cells migrate and morph into a small cell carcinoma. My husband's Pca may have and infiltrated his entire liver. Poorly differentiated is a very aggressive, fast growing NET carcinoma that found a home in an unlikely "primary" spot, the liver, for my husband.

Please make sure you go in for physical or bloodwork or ask for other scans from your doctors (oncologist or general medicine or whomever) especially if you have high Gleason scores and positive margins for the Pca. The doc you may be seeing isn't looking for "other" or mestatic cancer. The CCF definitely has issues with this...too much of a silo for treating patients. Any cancer is the whole person....not just this is my task to treat this one part.

Post Edited (NewHere123) : 2/3/2019 6:00:17 AM (GMT-7)

Posted 2/3/2019 12:55 PM (GMT 0)
Reknowned PCa medical oncologist Mark Scholz has written about his practice and treating PCa that has spread to the liver. He has treated many such cases. In addition to more usual treatments like ADT and chemo, he has been using SIR-Spheres for several years. I have read several articles by him regarding the use dating back to 2015. These are a type of micro radiation in the form of small beads that move to the liver tumor through the blood stream. They are produced by Sirtex. Originally developed to treat liver Mets from colon cancer, Scholz has used them for PCa spread as PCa and colon cancer are relatively similar adenocarcinomas.

Newhere123, many men on this board use Dr. Scholz. He specializes in advanced PCa and has an excellent reputation. I advise that you learn about him and consider a consultation.
Posted 2/3/2019 1:06 PM (GMT 0)
Thank you, will do. His cancer being poorly differentiated means that it looks like just cancer cell and not Pca...meaning it doesn't look like any cell type (such as prostate or liver cells). Does that make a difference? We are seeing NET (neuroendocrine tumor) specialist now at a comprehensive cancer institute.

He has had an undetectable level of PSA.

Post Edited (NewHere123) : 2/3/2019 6:28:39 AM (GMT-7)

Posted 2/3/2019 1:19 PM (GMT 0)
Yes the cell type does make a difference as different types respond to different treatments. I have read several studies about PCa liver Mets. Generally they respond better to chemotherapy than ADT. Some can be surgically removed. Some respond to radiation, but the liver is intolerant of radiation, thus the SIR-spheres approach. NET is another type as well and generally doesn’t respond to ADT. All very confusing and it is important to find the specialists with the actual experience. Good that you are seeing a NET specialist.

In addition the Mark Scholz, Eugene Kwan at Mayo Clinic and Oliver Sartor at Tulane are among the very best with advanced difficult cases. I would reach out to them for consideration as well. Your case is obviously very serious and you will need all the brain power and experience you can find.

Best wishes.
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