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Is it still "Indolent" after Biochemical Recurrence?

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Posted 5/15/2023 4:27 PM (GMT 0)
05/18/2009 - Robot-assisted laparoscopic radical prostatectomy
Surgical Pathology: Prostate gland 51.8 grams; Gleason score 3+3=6; Pathologic stage T2c, N0, Mx; Left/Right Pelvic lymph nodes clear (no tumor present); No presence of extra-capsular invasion; No margin involvement
07/06/2009 - 1st post-surgery PSA <0.1.
PSA started creeping up slowly around 2013 and hit 0.20 in early 2017.
Relatively stable during 2019, 2020 and 2021:
03/15/19 - 0.30
06/22/19 - 0.34
09/10/19 - 0.36
02/24/20 - 0.34
07/17/20 - 0.33
12/22/20 - 0.37
03/08/21 - 0.35
09/03/21 - 0.36
Jumped up in late 2021 but has remained relatively stable since:
11/17/21 - 0.51
03/07/22 - 0.53
10/08/22 - 0.54
01/17/23 - 0.56
05/01/23 - 0.63
PSA doubling time is still 2-3 years on average.
So far, no post-surgery treatment, just periodic PSA monitoring.
3/9/2023 - PSMA PET-CT Ga68 scan:
1. No convincing evidence of distant PSMA-avid metastases.
2. Head/Neck: There is no pathologically enlarged or PSMA-avid lymph node.
3. Chest: Mediastinum, hila and lymph nodes: There is no pathologically enlarged or PSMA-avid lymph node.
4. Abdomen: There is no pathologically enlarged or PSMA-avid lymph node.
5. Pelvis:
a. Lymph nodes: There is no pathologically enlarged or PSMA-avid lymph node.
b. Soft tissue: Status post radical prostatectomy. There is a 0.9 cm focus of intense PSMA uptake in the prostate bed, adjacent to the left posteroinferior bladder wall, corresponding to an ill-defined soft tissue nodule on CT (SUV max 40.5, average Hounsfield units 50, 4:81, 3:47).
4/26/23 - MRI scan:
1. Prostate size: Status post prostatectomy. Corresponding to focus of PSMA avidity in the left prostatectomy bed, there is a 0.9 x 0.4 cm nodule (series 6, image 18), which demonstrates marked diffusion restriction and early enhancement.
2. Seminal vesicles: Unremarkable
3. Neurovascular bundles: Uninvolved.
4. Urethra (including bladder inlet and urogenital diaphragm): Unremarkable
5. Lymph nodes: No lymphadenopathy.
6. Urinary bladder: Underdistention is associated with mild, uniform bladder wall thickening.
7. Bowel and peritoneum: No ascites
8. Osseous structures: No aggressive lesions.
9. Anterior pelvic wall: No inguinal hernia.

All of my statistics point to a non-aggressive, or indolent, cancer. My question is this: if my PSA continues to rise slowly, with a consistent doubling time of over two years, does the cancer ever need to be treated? Does a Gleason 3+3 remain a 3+3 forever, meaning it's something that I never need to worry about? Does the existence of a "nodule" mean that the cancer is no longer indolent? Are the conclusions different when the situation is biochemical recurrence? What if my life expectancy is 120?
Posted 5/15/2023 4:31 PM (GMT 0)
updated profile:
Age 69 (55 when Dx)
05/18/2009 - RALP
Surgical Pathology: Prostate gland 51.8 grams; Gleason score 3+3=6; Pathologic stage T2c, N0, Mx; Left/Right Pelvic lymph nodes clear (no tumor present); No presence of extra-capsular invasion; No margin involvement
2017 - Biochemical Recurrence
PSADT consistently between 2 and 3 years
Most recent PSA 5/1/23 - 0.63
Posted 5/15/2023 10:05 PM (GMT 0)
I’d call Dr. Epstein at JH and talk to him about this.

https://www.hopkinsmedicine.org/profiles/details/jonathan-epstein

Who did the final pathology on the prostate? I wonder if those slides are still available…
Posted 5/16/2023 1:40 AM (GMT 0)
Wild guesses on my part…Since the possible source of the PSA increase is clearly defined in PSMA PET/CT and MRI, can a biopsy be obtained to analyze the “nodule” in the prostate bed?

Your PSA seems to be slowly increasing in rate. The solution seems to be a straight forward salvage radiation situation that could probably be targeted at the nodule area and not the typical general area approach for less treatment. Would need to see an experienced radiation oncologist with some willingness to think outside of the box. I could imagine a 3 treatment targeted SBRT approach.

You are still relatively young so you have many years to live in this PSA purgatory. I would probably not want to risk the PCa becoming a bigger problem some day but that is me.

ps: the nodule could grow and cause functional problems as you get older not related to cancer.
Posted 5/16/2023 4:24 AM (GMT 0)
Hey I am also from NJ, but my story is not as promising as yours.

My advice? Do not take any chances.

Wipe.
it.
out.

You are in the best possible position. Meet with a RO and blast the critters into oblivion.
Posted 5/16/2023 12:25 PM (GMT 0)
55, some thoughts from a non-professional.

At your present PSA you are barely at the threshold of a scan finding anything and only if it was one or very few locations expressing the PSA. If you have 100 different micromets no one may be big enough to find even at multiples of present PSA. General consensus is that true G3 doesn’t advance nor can it live outside the Prostate area as it is so similar to prostatic tissue. G3 is not known to spread. It may be that you had some cancer outside the surgical field that is now growing and perhaps spreading which indicates to me your G3 was contained, but you had something else more advanced that was not detected. Or, you may have true G3 that is still in the area that the surgeon missed that is slowly growing, but not yet large enough to detect by scan. Could have been a bundle of a few hundred cells (micromet) on the bladder neck for example that couldn’t be seen due to the small size. If so, it will be eventually found, but probably won’t spread. Once PCa leaves the area and relocates elsewhere the G is no longer measured even if biopsied due to the multiple mutations/evolutions it takes for the cancer to learn to live elsewhere.

To now treat or not? To radiate (SRT) you should have evidence of location otherwise you are shooting in the dark and may be subjecting yourself to negative side effects that may not bring a cure. Generally the success of SRT decreases with time as the probability of spread outside the radiation field increases with time. You are 10 years out so this is a concern. SRT is most always a wide radiation field. Focal radiation is usually only done when the tumor is defined. SRT often is wide enough to include the pelvic lymph nodes. Generally only one shot at SRT so you go for it strong. Use of ADT appears too early and given the original low risk dx and slow increase would probably not be indicated. Plus it would probably guarantee you would not find the PSA source for a very long time to attempt other treatments.

How to proceed? Very diligently, in my opinion. Continue to monitor and investigate and make sure you are with a specialist that is very experienced with conditions like yours. Looks like nothing really threatening anytime soon and may end up with an easily manageable condition for a very long time with minimal intrusion on a good lifestyle.
Posted 5/18/2023 1:08 AM (GMT 0)
@island time - unfortunately, my prostate gland is no longer available for review, so I can't even get a Decipher score.

@Mumbo - I will be talking to my urologist next week about the viablity of getting a biopsy of the nodule, as well as the possibility of surgical wholesale excision of all of the residual prostatic tissue, to include the nodule. "Salvage surgery" following an incomplete radical prostatectomy, if you will.

@JNF - both the PSMA PET/CT and the MRI scans identified the nodule/lesion at the base of the bladder, which would correlate to the slow-rising PSA. The post-surgery pathology showed no extracapsular extension, and there was nothing in the seminal vesicles nor any lymph nodes. As you say, a G3 is not known to spread. Taking all of these things into account is the reason for my question of whether treatment is called for at this time, where the situation does not appear to be clinically significant.
Posted 5/18/2023 1:29 AM (GMT 0)
Sounds like you have a good handle on this. I would be interested to hear how urologist proposes salvage surgery. I had robotic inguinal hernia surgery after RALP and the process is more difficult due to adhesions and scar tissue from surgery and ART. Maybe they try to access the area from a different direction more like bladder surgery…

Age 64 is still pretty young so living another 20 years is not out of the question at all. No rush to do anything which is the good but it is a weight to carry around for a long time. Wish you luck with this.
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