No scans before surgery?

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Jerry L.
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Date Joined Feb 2010
Total Posts : 2484
   Posted 8/16/2012 6:27 PM (GMT -7)   
I have a friend with PC and after talking for a bit, I became puzzled...  His biopsy showed G7 10 out of 12.
 
He had robotic surgery and still has some psa after several months.  He has positive margins, no SV, no LN.  They are talking radiation now.
 
I asked if he had any recent scans and he said no.  But, then I was told that he never had any bone scan or ct scan leading up to surgery.  Can this be correct?  Don't all patients get scans to see if surgery is even an option?  I'm confused.
 
Thanks,
Jerry L.
11/09 Dx at Age 44 -------------- 4.03
12/09 DaVinci Surgery
1/10 T3b, G9 --------------------- <.05
2/10 Adj. Radiation -------------- <.05
3/11 PSA Rise/Scans/Spot ------- .09
on Pelvic Bone
4/11 HT / XGEVA ------------------ .06
5/11 Spot Radiation -------------- <.05
12/11 - 6/12 ------------ <.01

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2626
   Posted 8/16/2012 6:50 PM (GMT -7)   
Realistically, with an average per-surgery PSA of 5 to 10, the great majority of scans never show anything. Probably need a PSA of 100 to have detectable mets.

I have often figured it is done as a liability prevention tool for the doctor, I had another set of scans with a PSA of .06 prior to SRT. I figured it couldn't hurt, just in case I had another malady I didn't know about, but was 99.9 % certain it would not show any mets.

I am hopeful the Sand Lake scanning we hear so much about will someday be a widespread technique available to many more guys,

Goodlife

Jerry L.
Veteran Member


Date Joined Feb 2010
Total Posts : 2484
   Posted 8/16/2012 7:00 PM (GMT -7)   
I guess I am just the exception to the rule.... .09 with bone met.
 
The F18 PET/CT Bone Scan is becoming more available.  I just had it done locally.

BOOGEE
Veteran Member


Date Joined Jan 2012
Total Posts : 575
   Posted 8/16/2012 8:08 PM (GMT -7)   
My husband had his isolted met confirmed with the same F-18 pet/ FDG.
The conventional ct's and bone scans are just too unrealiable, so glad to hear these tests are more readaly available.
Now are more insurance company's willing to pay for this test?
By the way my husbands PSA never was over 6. and it's been said with a PSA under 20 mets. aren't usually found!

BOOGEE
Age 53
2010 PSA's 6.3, 4.7 5.6
RP open Oct -2011
Stage T1c
Gleason 4+3 left side Gleason 3+3 right side
11 lymp/ no mets.
Perineural invasion present
neg. marg.
Path staging (pt1): pT2c: bilateral disease
PSA Post -Op
1.2 11/2011
1.8 12/2011
3.5 1/2012
2-12Casodex Lupron PSA .03,
5/12 PSA <0.1, T-12
CT, BONE, MRI Neg. for Mets.
F-18/FDG showed 1 met.,spine T-11

Tigerfan53
Veteran Member


Date Joined Jan 2011
Total Posts : 836
   Posted 8/16/2012 8:31 PM (GMT -7)   
My experience leading up to surgery: I was told by one major cancer center that with my stats (PSA under 6) scans would not be done because they would not reveal anything. At another major cancer center (where I eventually went for treatment) they did a trans rectal MRI.
-
Diagnosed Dec 2010 at age 53
09/2010 PSA 4.8
11/2010 PSA 5.1
11/2010 PSA 5.3 after antibiotics
12/2010 Biopsy: 50% in 1 of 12 cores, PIN, G6, T1c
03/2011 PSA 5.6
06/2011 RALP negative margins, G6, pT2b, PNI
09/2011 PSA < 0.05
12/2011 PSA < 0.05
06/2012 PSA < 0.05

Zimac
Veteran Member


Date Joined Mar 2012
Total Posts : 600
   Posted 8/16/2012 8:56 PM (GMT -7)   
Ouch! That trans rectal MRI as explained by my husband was the most uncomfortable test he's ever had. Would refuse to ever get one again.

My husband had a PSA of 6.8 day of surgery with negative scans. His path showed clear margins. Three months later scans showed spot on the hip with a PSA of 2.9.

Not really sure how accurate the bone and CAT scans are. Maybe we should have had a PET scan before the surgery.

Zimac
Age 60, Dx'd 56 -2008, PSA 6.4
12/2008-open RP, nerve sparing
Path: Gleason - 4+3, clear margins
1/2009 - Bone Mets
7/2009 - Lupron, Zometa
3/11 - Lung Mets confirmed
11/11 - Zytiga, not effective
4/12 - Taxotere, PSA 23
Failed Taxotere
7/23 - starting monoclonal antibody therapy (clinical trial)
Living for the moment

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 5953
   Posted 8/16/2012 9:04 PM (GMT -7)   
Two factors -
 
- scans are notorious for not picking up small lesions, which most relate with a low psa.
 
- Walsh states clearly in his book that you can have a very high psa but not have cancer, or have a very low psa and have very significant cancer.
 
PSA is just one indicator. Scans are often wasted effort, but not always. Doctors prescribe scans as they feel to be useful in each specific case.
Moderator - Prostate Cancer
(Not a medical professional)

DaVinci 10/2009
My adjuvant IGRT journey (2010) -
www.healingwell.com/community/default.aspx?f=35&m=1756808

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 24336
   Posted 8/16/2012 9:08 PM (GMT -7)   
jerry,

sounds like your friend not having scans was more an exception than the rule before his surgery. for most of us, the scans aren't useful, but we are told they make an excellent baseline for any future activity. i had scans both before surgery and before SRT.

david
Age: 60, 56 at PC dx, PSA 16.3
3rd Biopsy: 9/8 7 of 7 Positive, 40-90%, 4+3
open RP: 11/8, Catheter in 63 days
Path Rpt: 3+4, pT2c, 42g, 20% tumor, 1 pos margin
Incont & ED: None
Surgery Failed, recurrence within 9 months
Salvage Radiation 10/9-11/9, SRT failed within 9 months, PSA 4/12 = 37.x
Spent total of 1 ½ years on 21 catheters, Ileal Conduit Surgery 9/10,
7 other PC-related surgeries
Member of Prostate Cancer & Chronic Pain HW Communities since 10/2008
“I live in the weak and the wounded” – Session Nine (Movie)

Steve n Dallas
Veteran Member


Date Joined Mar 2008
Total Posts : 4090
   Posted 8/17/2012 1:26 AM (GMT -7)   
I never had any scans.
Age 57 - 5'11" 215lbs
Overall Heath Condition - Good
PSA - July 2007 & Jan 2008 -> 1.3
Biopsy - 03/04/08 -> Gleason 6
06/25/08 - Da Vinci robotic laparoscopy
07/24/12 - 49 Month PSA -> less then .01
Surgeon - Keith A. Waguespack, M.D.

"Lord, I seek your wisdom and guidance in making me the person my dog thinks I am."

MsWorryWart
Veteran Member


Date Joined Aug 2011
Total Posts : 1367
   Posted 8/17/2012 3:16 AM (GMT -7)   
My husband had lots of scans, MRI, CT, Endorectal Coil, Bone, and one other that I can't remember.

The CT scan did pick up three "morphed" lymph nodes.

After the biopsy of one with a positive return, it helped make the choice for which type of consolidation would be used, once the HT shrunk the tumor enough to even consider consolidation.
Husband DX 49 yr old - T4,n1,m1
2006 - PSA 4.6 (Dr. never told us this!)
07/11 - PSA 57.0-DRE "Normal"(as per ^ doctor)
07/11 - BX -7 of 11 cores positive-80% 4+3-7
8/4 - MDA-G8
8/11 - LN, SV, & Bladder positive BS Clear
8/12 - Degarelix & Casodex
8/25 - PSA 12.
9/8 -1st Lupron - PSA 2.1
10/11- PSA .71
11/11- PSA .44
12/11 -PSA .35
01/5/12 - Tax/Carbo 2nd Lupron Inj
PSA - .1
06/12 IMRT Complete!

Water Guy
Veteran Member


Date Joined Jul 2011
Total Posts : 2404
   Posted 8/17/2012 4:43 AM (GMT -7)   
I asked my URO about scans after my biopsy was positive and he told me with my numbers he didn't want to expose me to the extra radiation of bone scans which he believed would be negative. As it turned out he was right. I did end up having a full nuclear heart stress test the week before surgery, so I didn't need that radiation from needless bone scans.
 
 
Terry
AGE 61 Dx with fam hist of PC
PSA
1.5 5/09
2.5 6/10
3.5 12/10 ref URO
5.25 3/11 DRE Neg
BX 4/13/11 2 of 12 cores diag both sides 15% & 20% GS7(3+4)
RALP nerve-sparing 6/8/11 path G7 pT2C, Marg-Lymph-Sem-Vas-PNI- organ confined 60% tumor involved 69grms 4.3X4X3 cm
100% dry 7/3/11
post PSA
9/11 <0.07
12/11 <0.04
3/12 <0.01
6/11/12 <0.01
TRIMIX injections for 100% ED

BB_Fan
Veteran Member


Date Joined Jan 2010
Total Posts : 977
   Posted 8/17/2012 7:03 AM (GMT -7)   
I also had no pre-surgery scans. Uro said that with a PSA of 3.6 and G7 (3+4), it would be a waste of time.
Dx Dec 2008 at 56, PSA 3.4
Biopsy: T1c, Geason 7 (3+4)
Robotic RP March 2009
Path Report: T2c, G8, organ confined, neg margins, lymph nodes - tumor vol 9%
PSA's < .01, .01, .07, .28, .50. ADT 3 5/10. IMRT 7/10.
PSA's post HT/SRT .01, < .01
End ADT3 5/11
PSA 10/11 < .01, T 103
PSA 1/12 < .01, T 214
PSA 4/12 < .01, T 288
PSA 6/12 < .01, T 380

NewspaperLover
Regular Member


Date Joined Sep 2009
Total Posts : 219
   Posted 8/17/2012 8:16 AM (GMT -7)   
Usually don't do scans before surgery. If salvage radiation is called for after surgery, scans more likely to rule out evidence that cancer has already spread beyond the prostate bed. Best wishes to your friend.

NewspaperLover

Jerry L.
Veteran Member


Date Joined Feb 2010
Total Posts : 2484
   Posted 8/17/2012 9:27 AM (GMT -7)   
I'm always learning things with this disease.  I thought with a G7 or above (and other data) that docs would want to know if it escaped before treatement (surgery vs. radiation)

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 3760
   Posted 8/17/2012 10:18 AM (GMT -7)   
Jerry,

You may be confused as there are two types of scans commonly given before treatment. CT and bone scans are used to identify lymphnode or bone involvement. These are given to high risk patients, especially those with high psa. These types of scans are just about worthless for low risk patients or intermediate risk with low psa as they just can't see small leisions and have a high false positive rate.
The other types of scans are those given to image the prostate only, such as color doppler ultrasound, and various MRIs. These scans are used to locate the tumor inside the prostate to see extra capsular extensions, seminal vessicle invasion or nerve involvement in order to identify surgical problem areas before the actual surgery. These can be useful for all risk catagories, especially those with high volume tumors or those thinking about AS.
66 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, 4 weeks of urinary frequency and urgency; no side affects since then. 3 years of psa's all at 0.1.

Jerry L.
Veteran Member


Date Joined Feb 2010
Total Posts : 2484
   Posted 8/17/2012 10:45 AM (GMT -7)   
My friend has had no scans for any reason. I was just surprised given the number of cores positive.

You'd think the doctor/patient would want all info going into treatment.
11/09 Dx at Age 44 -------------- 4.03
12/09 DaVinci Surgery
1/10 T3b, G9 --------------------- <.05
2/10 Adj. Radiation -------------- <.05
3/11 PSA Rise/Scans/Spot ------- .09
on Pelvic Bone
4/11 HT / XGEVA ------------------ .06
5/11 Spot Radiation -------------- <.05
12/11 - 6/12 ------------ <.01

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 8/17/2012 10:45 AM (GMT -7)   
Jerry L. said...
I'm always learning things with this disease.  I thought with a G7 or above (and other data) that docs would want to know if it escaped before treatement (surgery vs. radiation)
 
 
Hi Jerry L.,
 
I'll try to help clarify...my reply is really no different than an aggregation of what's already been said here, but maybe I can explain more clearly. 
 
Of course the doctor would like to know if cancer has escaped the capsule before surgery (in particular), but this is not precisely possible.  The best available tool for the majority of cases is the Partin Table/nomogram (LINK) which help show the precentage of likelihood of organ confined PC based on clinical case characteristics (pre-treatment PSA, Gleason and Stage) compared to thousands of similar cases from the past. 
 
If PC has escaped and a large tumor has formed, then it would show-up on a whole body scan or bone scan, but those scans simply do not have the resolution capability to show something smaller.  Therefore, the guidance is that scans below particular clinical threasholds are almost never worthwhile.  Different organizations recommend different thresholds, but the organization which I think trumps the others is the American Urological Association.  The AUA's guideline "Prostate Specific Antigen Best Practice Statement -- 2009 Update" has the following:
pg 32 -- Routine radiographic staging, such as with bone scan, computed tomography (CT), or magnetic resonance imaging (MRI), or surgical staging with pelvic lympn node dissection is not necessary in all cases of newly diagnosed prostate cancer.
 
pg 34 -- Routine use of a bone scan is not required for staging asymptomatic men with clinically localized prostate cancer when their PSA level is equal to or less than 20.0 ng/mL.
 
pg 35 -- Computed tomography or megnetic resonance imagning scans may be considered for the staging of men wiht high-risk clinically localized prostate cancer when the PSA is greater than 20.0 ng/mL or when locally advanced or when the Gleason score is greater or equal to 8.
 
Some older urologists may be in the "habit" of prescribing scans as a standard step, but patients from the past (say, 20 years ago) used to typically present with much worse case characteristics than is typical today.  Whereas it would have been much more appropriate 20 years ago to send just about every man with biopsy-confirmed for scans, that is simply not true today...and in fact it is considered a big waste of healthcare resources today.
 
There are always, of course, anecdeotal exceptions.
 
Furthermore, one factor that is changing is that some of the newer scanning techniques—some which have been further refined even since the 2009 AUA Update—are changing the landscape of this guideline.  But most of the replies in this thread are rooted in this AUA recommendation.
 
Does this help?
 
 

Jerry L.
Veteran Member


Date Joined Feb 2010
Total Posts : 2484
   Posted 8/17/2012 10:52 AM (GMT -7)   
Casey - yes, that helps.

Thanks
11/09 Dx at Age 44 -------------- 4.03
12/09 DaVinci Surgery
1/10 T3b, G9 --------------------- <.05
2/10 Adj. Radiation -------------- <.05
3/11 PSA Rise/Scans/Spot ------- .09
on Pelvic Bone
4/11 HT / XGEVA ------------------ .06
5/11 Spot Radiation -------------- <.05
12/11 - 6/12 ------------ <.01

Magaboo
Veteran Member


Date Joined Oct 2006
Total Posts : 1173
   Posted 8/17/2012 11:03 AM (GMT -7)   
FWIW:
Before my open RP I was told that the operation would be terminated if lymph nodes were involved. No scans were done.
The only scan I had done was just before SRT to locate the position of the prostate bed and consequent tattooing.
Not sure if this is common practice here in Canada.
 
Born 1936
PSA 7.9, Gleason Score 3+4=7, 2 of 8 positive
open RP Nov 06, T3a, Gleasons 3+4=7, Seminal vesicles and lymph nodes clear
Catheter out 15 Dec 06, Dry since 11 Feb 07
All PSA tests in 2007 (4) <.04
PSA tests in 2008: Mar.=.04; Jun.=.05; Sept.=.08; at SRT Start=0.1,
Salvage RT completed (33 days-66Gy) 19 Dec 08
PSA: in Jan 09 =.05, all 6 monthly tests to date (Jun 12) <.04

Post Edited (Magaboo) : 8/17/2012 11:36:13 AM (GMT-6)


walkbyfaith
Regular Member


Date Joined Jan 2012
Total Posts : 211
   Posted 8/17/2012 11:09 AM (GMT -7)   
Our Uro decided on ct and bone because Hubby's PSA, 17.2, was close enough to 20. My dad, PSA, 6ish, gleason 6, was not scanned AND he saw the same Uro as Hubby (small dang world).

Casey's post explains it well and is in line with Hubby and Dad's PC profile.
~walkbyfaith~ Hubby, age 45, DX 12/23/11, PSA 17.2
Biopsy, Gleason: RIGHT SIDE: 3+3, (10 or less volume) LEFT SIDE: 3+3, 3+3 (both approx 10% volume or less) 4+3, 4+3 (30% volume)T1C, Bone - Neg, CT - Neg
RALP: 2/2/2012 POST-OP: ORGAN CONFINED: Primary Pattern, Grade 4, Secondary Pattern: Grade 3 = 7 (19% prostate tissue involved) PNI/present, SVI/neg, MARGINS/clear, LN/neg, t2C
PSA, <0.1, 4/2012

Jerry L.
Veteran Member


Date Joined Feb 2010
Total Posts : 2484
   Posted 8/17/2012 12:57 PM (GMT -7)   
Moving forward, my thinking will be that only guys that are within a certain threshold should have scans.  Certainly, I can not compare most guys with my case.
 
What always irks me with my case is that my doc did some type of ct scan back in the day to see if the catheter could come out after surgery.  That was his only purpose.  I don't recall any other information given to me.  I then proceeded with adj. radiation even though psa was undetectable.  It wasn't until I read the scan report (like 2 years later) that there was a 5mm spot noted.  This spot was eventually picked up on scan once psa moved a little and other scans were done.  At that point it was much larger.
 
That first scan showing something would have been very important information before adj. radiation.  For me, more information is better before any treatment.
 
 
 
 
 
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