Too hasty to have Salvage Radiation?

Hi everyone.
My brother and best friend, Larry, informed me that he had prostate cancer over a year ago. He also told me that since it was in our family, that I was more likely to have it as well. His turned to be a very high gleason and stage 4. To shorten the story, I ended up with a very low grade and had my prostate removed on November 11, 2015.
I had some complications due to scar tissure, which were handled with a trip to the Hospital and a scope and laser procedure to remove scar tissue. I then used catheters for a few months to keep the scar tissue from reforming, or to make it form with a wide enough gap to allow urination.
My description of this procedure is penile torture. ( joking)

My first PSA was around 0.35 after that it continued to go down with a low of 0.19.

(Biopsy 10/5/2015
12 cores -2 out of 6 carcinoma - G6 10% - G6 2%
open Radical Prosectomy 11/11/2015 negative margins
Perineural invasion Present - Prostate wt 54.3g – stage PT2c
PSA 8/19/2015 3.31
Post-surgery .35, .23, .19, and now .29
Age 64 )

The last test, it went up to 0.29. I read an article on Salvage Radiation that recommended having it at a much lower PSA level.
I went to see a Radiation Oncologist, and we talked about doing Salvage Radiation to me.
Yesterday, I went to see my Urologist, and he wanted to tell me that if I did SR that it may not effect the outcome of my cancer. We had a fairly good discussion and during it he told me that the PSA bouncing around could possibly be cancer cells in my blood, and not extra prostate cells left in the bed. I have never heard of this.
I had a talk with my brother, and he told me that I might just want to wait and see what the PSA does.
Has anyone ever heard of this? I am re-considering having SR done so quickly. If I do wait and see, what would be the level that I should start moving back towards a SR treatment regimen again?
Thank you for your time. Ned

I assume that your pathology Gleason score was still 3+3. If so, you cannot have metastases, and there must be a piece of cancerous prostate tissue still in there. PSA from benign tissue dissipates within a few months of surgery. What choice do you have but to get the rest of it with salvage radiation?

I think what your urologist means when he says that the cancer is already in your bloodstream is that it may have already metastasized - very tiny cancer cells would be everywhere. In that case, salvage radiation to the prostate bed would be futile. But that would not be possible if your pathology Gleason score were only 3+3.

JNF,
you are correct, the Gleason score remained the same 3 + 3. I was just reading the pathology and 15% of the prostate was found to be cancerous.

Tall Allen,
I just didn't understand how the cells would be in my blood stream, and that it had not gone on to metastasize. The Dr. stated that the cells in my blood stream would be bouncing around and affecting the PSA reading. He also stated that in my case, normally they would not recommend Salvage Radiation. Due to the history of my brother, who had an exceptionally agressive form of Prostate Cancer, I was wanting to get every chance to get rid of the cancer, such as if some small cells were left behind. I am going to check and see if my insurance would cover it if I wanted to get a second opinion - consult from MD Anderson Center.

I am going to read a bunch more on this forum, but I have been relying on my brother's research and knowledge to get answers. I need to understand more on my own. Any help would be appreciated.
Thank everyone for their replies and consideration. Ned.

PCa is very blood borne. It is common for men to have PCa cells in their blood stream. That does not mean they will develop mets. Only the more aggressive cells of G4 and 5 can locate and grow outside of the prostate. So, you can have some cells left behind as TA says, you can have some circulating as your doc suggests, and you can have both.

As TA says, SRT should mop up what was left behind and stop this. But if you are continuing to be G6 then what may be left shouldn't hurt you and you may find you live with a PSA level that is detectable, but stable. Kind of like a low risk man on AS that never progresses. I think the real risk is that some prostate tissue was left behind and from that more PCa could develop to cause a future problem. SRT should alleviate that.

I agree with JNF. After surgery, there are often a lot of cancer cells in the bloodstream, but they are not necessarily cells capable of metastasizing. Eventually those non-viable cells die off and are filtered out. Low grade prostate cancer cells must be within prostatic tissue to survive. Only metastatic cells can survive without prostate tissue to grow in (which is what makes them lethal). If you want to know more about this:

Can invasive procedures spread prostate cancer?

I said...
Cancer cells may be released into systemic circulation by surgery. A study of circulating epithelial tumor cells in breast cancer patients found that the serum-detected cell numbers did increase in some patients following surgery, and the increase was sustained in some, indicating viability. A study of bladder cancer circulating tumor cells using CellSearch® found an increase following transurethral bladder resection. Eschwège et al. found increased numbers of prostate epithelial cells in the serum after surgery, but found no association with metastatic progression or survival. To my knowledge, there has not yet been a study specifically of circulating tumor cells pre- and post-prostatectomy.

But there may be cancerous tissue left behind that can progress to the point where it does metastasize.

I said...
Another difficulty arises where the surgeon must detach the prostate from the urethra, which runs right down the middle. The surgeon scrapes prostate tissue away from the urethra, and cuts it as far away as he can from the bladder neck on top, and the urethral sphincter, on the bottom. He then joins the two ends together, which is called an anastomosis. This procedure may leave cancerous tissue behind. In a recent CT/MRI study of post-prostatectomy tissue, 76% of recurrences after surgery were found to occur at the anastomosis. How many of those were from cancerous tissue that was left behind, and how many from contamination of the surgical blade?

Bob-

Here are two statements:

(1) Metastases are never associated with a GS 6 found at pathology
(2) GS 6 can never lead to metastases

The first statement is true. The second statement is false. See the difference?

Bob,

To add my misunderstanding to what the Tall one is saying, Gleason 6 disease can turn into* a more-aggressive type with a higher Gleason score and that more-aggressive disease can metastasize. But it won't ever metastasize before it changes to Gleason 7 or higher. That means that if there are metastases present then there will be Gleason 7+ cancer present (even if it used to be Gleason 6).

His statement one -- that "Metastases are never associated with a GS 6 found at pathology" -- looks backward in time and is true. Before metastases can form there must be GS 7 or higher that can be found by a pathology. But his statement two -- that "GS 6 can never lead to metastases" -- looks forward in time to falsely deny the possibility that GS 6 will lead to metastasis by the intermediate step of changing to a higher Gleason disease.

We frequently hear the statement "Gleason 6 never metastasizes" which, in a very narrow sense is true for the same reason that "A virgin will never give birth" is true, but it is prudent to remember that a man with Gleason 6 disease can still occasionally get screwed if he doesn't take care.

*One of the more technically dense and indecipherable threads we have had on this forum dealt with whether Gleason 6 disease turns into higher Gleason disease or whether the man simply develops Gleason 7 disease at more or less the same locations. From a patient's point of view it doesn't seem to make much difference but, thankfully, however it happens it doesn't happen that often.

So..since metastasis is never associated with pathological G6 and G6 can lead to metastasis then G6 can lead to pathological G7 if something happens to it....like what ? Similar to sex with a virgin?

How does one "take care" that this "somethiing " doesn't happen ?

There's no way to "take care". If you have high risk PCa and its not detected by bx or scan, so you don't treat it, and it later progresses what else can you do but treat it then or "overtreat it" when it's only determined to be Gleason 6?
That's the dilemma surrounding AS and imperfect detection methodology.
Bob

Sheepguy,

Actually, it does happen that men diagnosed as Gleason 6 "turn into" Gleason 7s. Happens all the time. Something like one quarter of men receiving surgery with biopsy diagnoses of Gleason 6 disease will be upgraded to Gleason 7 or above in their post-surgical pathology reports. Men on AS will be upgraded from one biopsy to the next, although less often.

I'm a bit vague on my sheep-farming terminology but my understanding is that her first pregnancy turns a "gimmer" into a "ewe", particularly in Scotland and the north of England.

When I spoke of "taking care" I was mostly suggesting that men remember the "Active" part of "Active Surveillance." Gleason 6 disease is low risk, not no risk, but if a man diagnosed with Gleason 6 disease follows the guidelines of a successful AS program then his chances of catching the disease after it starts to move but before it metastasizes are really quite good.

I'm not sure what the term "true Gleason 6" means.

There are studies that researched metastatic patients and reported the Gleason score of the included individuals.

Azzam - SBRT: An Opportunity to Improve Quality of Life for Oligometastatic Prostate Cancer
reports in table 1 that they included patients with Gleason score 6 to 10.

Berkovic – SBRT for patients with limited PCa metastases
reports also in table 1 that patients with Gleason score 5 to 10 were included.

Finally Messing - Immediate versus deferred ADT in patients with node-positive PCa …..
reports in the full text that he included quite a number of patients with Gleason 6.

So patients with Gleason 6 can also develop metastases.

George

For all practical purposes then, you can only be confident of not getting metastasis is to have RP and a gleason 6 . But that gleason 6 does not turn into gleason 7 as I understand it. Of course, neither does a biopsy G6...the G7 was simply missed and the biopsy G6 is still a G6

Ned,

I'm not sure we've mentioned it here but most of us on this forum who have had that sort of radiation have had a fairly easy time of it, although there are a few notable exceptions. Most guys come through with fatigue and hemorrhoid flareups as their most significant side effects. The fatigue is generally not particularly debilitating. In my case it mostly involved falling asleep watching television in the evenings. As for the 'rhoids, there are a number of treatments your RO can suggest that will generally get them under control straight away.

But, while it is never acutely horrible, it can get to be something of a grind after a few weeks. What helped me in that regard was to put 39 20oz bottles of diet Gatorade knock-off in the trunk of my car before the first session. I would drink one in transit each time I drove myself to the cancer center. I worked out the proper level in the bottle for each stoplight along the way to pace myself to arrive with a nicely full but not bursting bladder. As well as being handy, the dwindling number of bottles in the trunk provided a visual confirmation that I was making progress and the treatments wouldn't last forever.

Good luck.