15 months post RP PSA

Husband has been on a 3 month PSA schedule since RP 09/2022.
PSA has been <0.04, 0.05, <0.04, 0.05 and this week 0.66.
We saw Dr. today and he will do repeat PSA and then a PSMA.
Our plan would be to have second opinion at Roswell Park Cancer Center.
We went to Roswell in beginning of this journey and really liked the radiation Doctor. He was also the Dr. that said he would not do radiation and that surgery was his best option.
We were expecting this, but it still is not easy for me.
Any advice is much appreciated. Thank you for all the support

Wife#1. If the RO wouldn’t perform radiotherapy as primary treatment with that diagnosis, he would be professionally hypocritical to perform the salvage radiation, in my opinion. Exactly what were the reasons he stated to deny your husband radiotherapy to begin with? Did you seek an assessment with another RO, or just go with the surgery?

I agree with Ed. Find a top notch RO that does a lot of prostate salvage radiation work including pelvic lymph nodes.

Thanks for the excellent explanation. Did removing the prostate resolve the urinary issues?

I still suggest you focus on a RO that can demonstrate to you exceptional experience and volume doing SRT.

Best Wishes.

Here are the results of his PSMA Scan. Our appt. is Friday to discuss. Any advice appreciated. Thank you.

1. Status post prostatectomy. No evidence of local recurrence

2. Lymph nodes: There are 4 radiotracer avid subcentimeter left internal iliac lymph nodes which measure
3-7 mm short axis with SUV max from 4.2-13.7 (series 3, images 212, 213, 216 and 218). No additional
suspicious lymph nodes.

3. Skeleton: Focal intense radiotracer uptake in the T4 vertebral body with SUV max of 8.6 is adjacent to a
Schmorl's node in the inferior endplate, potentially metastatic disease or uptake related to acute Schmorl's
node.

IMPRESSION:
1. Status post prostatectomy. No evidence of local recurrence.
2. There are 4 radiotracer avid subcentimeter left internal iliac prostate cancer lymph node metastases.
3. Focal intense radiotracer uptake in the T4 vertebral body is adjacent to a Schmorl's node which could
be acute. This could be due to prostate cancer metastasis or uptake related to the Schmorl's node. MRI of
the thoracic spine with and without IV contrast may be able to distinguish between these 2 possibilities.

_____________


2. There are 4 radiotracer avid subcentimeter left internal iliac prostate cancer lymph node metastases.

3. Focal intense radiotracer uptake in the T4 vertebral body is adjacent to a Schmorl's node which could
be acute. This could be due to prostate cancer metastasis or uptake related to the Schmorl's node. MRI of
the thoracic spine with and without IV contrast may be able to distinguish between these 2 possibilities.
No additional suspicious bone lesions or areas suspicious for prostate cancer metastases.

_____________

Thank you for the help,

Surgery 09/2022
PSA 11/2022, <0.04
02/2023, 0.05
05/2023 <0.04
08/2023 0.05
11/2023 0.66
12/23 0.7 Dr. wanted it done at a different lab, his lab. I think he wanted to be the one to tell us instead of us
getting it at other lab portal the next day. Just my guess.

I updated my husband’s bio if you want to review it. Praying for your husband.

I finally have the MRI results from his Thoracic spine,

Abnormal T1 hypo-, T2 hyperintense marrow signal within the T4 vertebral body with slight
vertebral body height loss and mild bulging of the posterior wall. There is associated enhancement
postcontrast imaging. These findings are suspicious for metastatic lesion superimposed subacute
pathologic compression deformity with less than 25% vertebral body height loss. The bulging of the left
posterolateral vertebral body cortex of T4 effaces the ventral CSF and abuts the ventral cord resulting in
minimal canal narrowing. No convincing evidence of epidural spread of tumor. The remainder of the
thoracic spine is intact without acute abnormality or aggressive lesion.
Soft tissues: The paraspinous soft tissues are unremarkable. No epidural fluid collection or lesion.
Incidental note of benign-appearing perineural cysts within the T6-T7 and to a lesser degree T7-T8 right
neural foramen.

The short version:
1. Findings suggestive of a T4 vertebral body metastatic lesion with superimposed subacute pathologic
compression deformity resulting in less than 25% vertebral body height loss. There is mild
bulging/retropulsion of the left posterolateral cortex of the T4 vertebral body which effaces the ventral
CSF and abuts the ventral cord resulting in minimal canal narrowing. No convincing evidence of epidural
spread of tumor.
The PSMA scan did show radiotracer avid 4 iliac lymph nodes
We see the RO tomorrow, any advice is much appreciated. Thank you.

Might want to ask if biopsy of spine is possible to confirm “suggestions”? The RO should have a plan for addressing all the scan results, nothing out of control suggested so should be a positive meeting.

If you and/or husband are not comfortable, move on as you appear to be doing. He is past primary treatment so next steps are key for best results. Might want to move biopsy to Roswell Park as well and get things going with them now.

Well. Husband had biopsy of T4 on his spine. So he has Prostate cancer in his Lymph nodes and T4. We will meet with the radiologist at the cancer center first. We are going to Roswell Park for the second opinion, My first choice for treatment.
Brief recap, cancer center has Radiation Dept, but Urologist does injections and Surgeon manages the oral medications. Does not give me confidence .
I appreciate all of your help and I will keep you updated as I value your opinions.
My only wish is, I wish he was more involved in this, but I know enough to present the information and ultimately it is his decision.

.My husband is already responding extremely well to Lupron/Abi/Pred (Started in December and undetectable by January}, By the time he started IMRT to pelvis with extension to para aortal lymph nodes (March 4), his radiation oncologist announced his nodes were almost resolved from the ADT. He also had a suspicious lumbar lesion, but that was not confirmed. By the end of only one week of radiation (70 gys in 39 sessions), his nodes had already resolved. Bottom line is that oligometastatic, hormone sensitive, micrometastatic prostate cancer can respond really well to early aggressive treatment. I hope this helps! Good luck!

Stephanie