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Recurrent PC after Radiation

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Posted 12/12/2015 3:34 PM (GMT 0)
Good morning. First Time poster.

In 2011 after several negative biopsies, I was diagnosed with Prostate Cancer (Gleason 3+3=6; PSA 10.5) from a biopsy conducted at NIH by Dr. Pinto. For whatever reason, I did not fit the criteria to be included in the NIH study so I was off to investigate the numerous methods of treating PC including active surveillance. I visited several doctors at Johns Hopkins and Radiation Oncology facilities. For whatever reason, I "assumed" that radiation therapy (RT) would "cure" me. After 42 sessions from Feb - Apr 2012 at the maximum radiation level, my PSA went down to 0.5. After several checkups with no change in PSA, I "assumed" I was in the clear.

Fast forward to December 2013, my PSA went to 1.9. My primary doctor did not mention it and I figured that was still below the 4.0 threshold of concern. I was not aware of the 2.0 increase for recurrent PC. By May of 2015, my PSA went to 3.9. I visited my urologist and a biopsy was recommended. PSA went to 5.4 in September, 6.3 in October and back to 5.5 in November. I went back to NIH for a prostate MRI, CT Scan and Pet Scan. The MRI indicated two nodules that were likely cancerous and the CT and PET Scans indicated no evidence of metastasis. Had a biopsy at NIH on Dec 5th and am awaiting the results.

My wife and I have been investigating our options pending the biopsy results. The information is voluminous and often contradictory. Specialists, naturally, recommend their specialty (SRP, Cryotherapy, Braccia seeds, hormones, etc.) but then they often criticize other methods. One doctor went as far as saying that SRP is unethical for recurrent PC as the cure rate is zero (due to some some micro-metastasis) while others portray SRP as the only realistic option. I've been to Dana Farber in Boston, Johns Hopkins, Chesapeake Urology, NIH in addition to a number of phone discussions with various institutions. It seems the more we read about the various processes, the more confused we get. At the moment, our inclinations are Cryotherapy (less invasive, ability to include prostate margins to reduce possible micro-metastasis, less significant incontinence and ED side effects than SRP)

I'd love to hear about others in similar circumstances (recurrent PC with a positive biopsy and PSA less that 7) and what you experienced as well as choosing a method of treatment. Thank you for reading and thanks in advance for any response.
Posted 12/12/2015 5:09 PM (GMT 0)
Welcome to HW.

This is something we hear a lot about, but it does happen. The information is confusing.

Hopefully, some of the folks that know more about the advanced disease will be along soon with some good info for you,
Andrew
Posted 12/12/2015 6:40 PM (GMT 0)
Wellcome to HW.
FWIW, European Association of Urology give this guideline when RT fails:
High intensity focused ultrasound (HIFU), cryosurgical ablation and salvage brachytherapy
are treatment options for patients without evidence of metastasis and with histologically
proven local recurrence. Patients must be informed about the experimental nature of these
approaches.
Posted 12/12/2015 7:31 PM (GMT 0)
Hello and sorry you find yourself here. I can't offer any direct experience here, but did want to extend a welcome to you. Hopefully some others will weigh in soon. Good luck to you!
Posted 12/12/2015 9:59 PM (GMT 0)
Welcome. I'm sorry to hear that the RT treatment failed. You've certainly availed yourself of the best doctors at top institutions. Just as in primary therapy, every specialist in each kind of salvage therapy thinks his is the only way to go. So it falls to you to figure out which is best for you. Just as with primary therapy, this will involve weighing the probability of cure against the probability of side effects that may adversely impact your quality of life. The probability of success is about the same for all salvage therapies - roughly 50%±25%. That reflects the probability that the cancer may be micrometastatic and systemic already.

I agree that surgical salvage is challenging. There are a few surgeons in the US who are really expert at it. Scardino and Eastham at MSKCC probably have more experience than anyone at it. In case you haven't seen it, here's what they have to say about it:

Salvage Radical Prostatectomy for Radiation-recurrent Prostate Cancer

While SRP is necessarily radical/whole gland, all other salvage treatments can be done as focal, hemi-gland or whole gland. Focal carries the lowest risk of adverse side effects, whole gland the most.

There are three kinds of salvage radiation that have been used after local RT failure: HDR brachytherapy, LDR brachytherapy and whole-gland SBRT. Salvage HDR and LDR brachy salvage has been tried with good results in terms of cancer control and side effects. LDR is more widely available. HDR will be harder to find. I know that UCSF has done some HDR salvage.

SBRT salvage has been reported with good results. I'm only aware of Don Fuller in San Diego doing it. He's reporting 82% control at 2 years with low toxicity, which is encouraging:

High-dose-rate stereotactic body radiation therapy for postradiation therapy locally recurrent prostatic carcinoma: Preliminary prostate-specific antigen response, disease-free survival, and toxicity assessment

As for the salvage ablation therapies, I've seen reports for both cryo and HIFU (I've only seen a single case report for FLA). In either case, whole gland salvage ablation is associated with awful side effects, so I think that only focal or hemi-gland ablation should be considered. HIFU became available in the US last month, and I was very impressed by Dr. Peter Scionti in our on-line interview. You might want to call him to see if he's doing salvage. Aaron Katz in NYC has had good success with salvage cryo.

This doesn't come up a lot in HW, so I'll be interested to hear from you as your move along on this journey.
Posted 12/13/2015 2:58 AM (GMT 0)
Please seriously consider calling the Dattoli Cancer Center in Sarasota which treats ONLY PCa , most of the patients having had recurrence. You owe it to yourself to see how efficient and caring this practice is. State of the art imrt and brachytherapy are offered. I just returned home after 50 sessions of IMRT via DART to pelvic lymph nodes and am now in remission. Guys travel there from worldwide for treatment.
Bob
Posted 12/13/2015 10:54 AM (GMT 0)
First, sorry to hear about the failure of your primary treatment.

Your story is similar to mine. Radiation followed by biochemical failure. I decided to visit Johns Hopkins and put my fate in their hands (didn't mean I wouldn't continue to research and ask probing questions). I enrolled in a clinical trial (Avastin/ADT2) and have been more happy with my progress. I seem to have had a rather unique response to this treatment as I'm only remaining Johns Hopkins patient who has not yet exceeded endpoint.

You can see the history of my progression by clicking the "VIEW IMAGE" link below.

Best of health!
...Jerry

btw: My physician is Dr. Emmanuel Antonarakis. I'm more than pleased.
Posted 12/30/2015 1:22 PM (GMT 0)
Hello and thank you to everyone commenting on my situation with recurrent prostate cancer after radiation.

My biopsy results came in but I was a little disappointed to learn that they did not assign a Gleason Score or stage level where recurrent cancer biopsies are concerned. Apparently the radiation I received several years ago modifies the cells (Benign prostatic tissue with treatment effect). So I am left to fend for myself until I can arrange some appointments for consultations. I have a Multi-Discipline appointment at NIH in late January and I was very fortunate to get an appointment at the Mayo Clinic in February.

I have prostate cancer in three of 16 cores. However, it looks like #5 is stating cancer in "2 of 3 cores". It seems like they are saying there were three cores at the same spot(?). Not sure. I do know that they repeated some cores. There were a total of 24 cores taken. Four went to a couple of "studies" going on at NIH that I agreed to participate in. That leaves four repeated cores which may be good since I am sending samples to various cancer centers.

5. Prostate, right lobe, apex lateral, biopsy: Prostatic
adenocarcinoma, involving 2 of 3 cores; 0.5 mm and tiny focus on one;
1.5 mm of one.

6. Prostate, right lobe, apex medial, biopsy: Prostatic adenocarcinoma,
moderately differentiated, involving 3 mm.

13. Prostate, right lobe, MR mid anterior TZ axial, biopsy: Prostatic
adenocarcinoma, moderately differentiated, involving 2.4 mm

I guess I have another month to get a medical opinion about the state of my cancer so, if anyone has an opinion regarding these results, I'd love to hear it. I know it would only be an opinion based on your own situation or background.

Thanks again for your help, Paul
Posted 12/31/2015 3:36 AM (GMT 0)
Are you still Gleason 6?
Posted 12/31/2015 1:38 PM (GMT 0)
If I have a biochemical re-occurrence, the next therapy for me is back on Lupron (ADT) according to my radiation oncologist.
Posted 12/31/2015 1:42 PM (GMT 0)
My last PSA was %.6 in November.
Posted 2/14/2016 3:26 PM (GMT 0)
Sorry, my last post in December should have been that my PSA at that time was 5.6.

Current PSA is 5.2. My PSA peaked at 6.38 on October 1, 2015 but has shown a steady (but slight) decline since that time (11/3/15 - 6.2; 11/28/15 - 5.5; 1/27/16 - 5.3; 2/9/16 - 5.2). The decline started when I stopped taking Deplin (methylfolate) and then, gradually started a number of supplements.

I've been to, among other urology doctors, NIH, Johns Hopkins and, most recently, was fortunate enough to be seen by doctors at the Mayo Clinic in Rochester, MN (Man, it's cold in Minnesota!)! However, it seems the more I (and my wife) investigate what to do next, the more questions we have. I am very appreciative to those of you who have offered information and provided your own experiences on this website as well as referring me to various websites and articles concerning my situation and PC in general. HW subscribers are very well informed.

Of the big three (NIH, JHU and Mayo), one says that scoring does not work on recurrent PC, one scored my biopsy as a Gleason 6 and another scored my PC as a Gleason 7 (indicated that they have never seen a Gleason 6 in recurrent PC - it's always more aggressive). Two of the three feel that the only potential cure option is a salvage radical prostatectomy (SRP) while the third feels that an SRP is a waste of time due to probable metastacis. The two recommending the SRP indicate that any alternatives have similar or less effectiveness as an SRP with the same, or greater, side effects.

My questions at this point are as follows:
1) Does the location of the tumors in the prostate influence possible alternatives? (From what I can tell, I have three tumors - one at the Apex and two at the base. They are all on the right side as they were my first time around in 2011).
2) Does anyone have a concern that a SRP may result in the PC being re-seeded elsewhere in the body such as the lymph-nodes?
3) I have been cautioned about additional radiation after my first treatment in 2012. Braccia Therapy and SBRT seem to be possible alternatives to SRP. Any input on your experiences with these options would be appreciated.
4) Noticing that some of the posts on HW have indicated that others have been diagnosed with PC at ages about a decade younger than their fathers were diagnosed with PC, I can't help but see a correlation with the requirement in the 90's to add folic acid to all breads in the US to combat other diseases with an increase in PC being diagnosed at younger ages. Any opinions?

Many thanks for your help, RecurrentPB
Posted 2/14/2016 4:04 PM (GMT 0)
Thanks for reporting back in. This isn't an area where I can offer any expertise about next steps, but hopefully others can weigh in. I do know that SRP is supposed to be quite tricky, although there is one occasional poster here that had success in that area.

Regarding question #4, I would think that the most likely reason that guys are being diagnosed younger than their dads is simply because of the advent of PSA testing. I don't have anything to back that up, but it seems quite plausible.

Hope other weigh in with thoughts on your next steps.
Posted 2/14/2016 4:43 PM (GMT 0)
If it were me, salvage surgery and Cryo would be out of the question due to the side effects and less than stellar cancer control results. When you use surgery for advanced cases you pretty well guarantee losing the nerves. We all know that SRP is most difficult and very questionable as to effectiveness, thus so few surgeons attempt it. Cryo has terrible side effects and not all that effective as well.

HDR brachytherapy and SBRT are where I would focus. Both will cover a greater area than the surgical field for better cancer control and have demonstrated much lower levels of side effects. Is anyone discussing radiating the lymph nodes and nor a course of HT? If you are recurrent and possibly systemic, these should be considered. Rarely does radiation fail unless you were systemic to start and cancer was outside the radiation field. That is what I would be assuming. I also agree that you were not a true G6. There had to be some higher grade cells somewhere that the biopsy missed and were outside the radiation field.
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