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Persistent PSA of .32 ten weeks after surgery - update

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Posted 10/6/2017 9:24 PM (GMT -7)

As an update, I met with my RO this week and developed a plan regarding my Persistent PSA. Some others here have it and maybe this will help.

By way of review I've have little leakage over the last three months, my ED symptoms are minimal, G 3+4=7 Grade Group 2, G pattern 4 = 10%, pT2c pN0 pMn/a, carcinoma organ confined in about 15% of the gland, EPE SV LN negative, PNI present, pathology verified by Dr. Epstein at JHMI. I did have one small positive anterior margin 0.1 mm long and limited < .3mm. 

My main concern is I've had ulcerative colitis for 45 years, and have had lower urinary tract symptoms (LUTS), a group of clinical symptoms involving my bladder, urethra, urinary sphincter and prostate for about 7 years. I had a TURP for it one and a half years ago that didn't alleviate the problems at all.

So after two PSA's, both at .32 ng/mL, the alarms went off. I'll have another PSA tomorrow and yet another in 4 weeks. I will also get another Decipher Test; my first one was 15 months ago, and most importantly, I'll get an Axumin PET Scan, also know as a Fluciclovine (18F), or a anti-1-amino-3-18F-fluorocyclobutane-1-carboxylic acid(FACBC). It's specifically for those of us with suspected PCa recurrence based on elevated PSA levels.

 

Then in four weeks, I'll meet with both my RO and my surgeon, so determine our next course of action. This also gives my system about four months to recover from surgery. 

 

My RO thinks I will need SRT and possible ADT. I'm going to investigate SBRT clinical trials for persistent PSA, and what I'd really like is some sort of active surveillance. Those RT side effects may be very daunting.

 

Some articles I found that talk about Persistent PSA include:

 

http://ascopubs.org/doi/full/10.1200/JCO.2005.08.904

http://ascopubs.org/doi/abs/10.1200/jco.2014.32.4_suppl.32

http://ascopubs.org/doi/abs/10.1200/jco.2011.29.15_suppl.e15041

http://ascopubs.org/doi/full/10.1200/JCO.2011.38.2788

http://ascopubs.org/doi/full/10.1200/JCO.2016.67.9647

I hope the above helps some of you in the same boat.

70 years old @ Dx, LUTS for 6 years
PSA's never over 3.0, Now 2.3
Ulcerative Colitis since 1973
TURP 2/16, G3+4 discovered,
3T MRI fusion guided biopsy 6/16
14 cores; G 3+3, one G3+4, Grade T1b
Second 3T MRI 1/17
RALP 7/17 Dr. Gonzaglo The Univ of Miami
G3+4 Organ confined
pT2c pNO pMn/a
Mostly Dry so far
10 week PSA .32
Posted 10/6/2017 11:37 PM (GMT -7)
Thank you, Garyi. Very helpful. Thanks
Posted 10/7/2017 6:23 AM (GMT -7)
Gary, sorry to hear you are dealing with this.

From what I've read, on this forum, the advances in SRT techniques have really lessened the chances of bad side effects. Of course there's always a chance.
Dx Age 64 Nov 2014, 4.3
BX 3 of 12 cores positive original pathologyG6, G6, G8 (3+5)
downgraded to 3+3=6 by tDr Epstein, JH
RALP with Dr Ash Tewari Jan 6, 2015
Post surgical pathology – G7 (3+4), ECE, Margivns, LN, SV all negative
PSA @ 6 weeks 2/15, .<02, remained <0.02 until January 2017, .02, repeat Feb 2017, still .02. May 2017-.033, August 2017- .033
Decipher test, low risk, .37 score
Posted 10/7/2017 6:56 AM (GMT -7)
Good luck Gary. Tough nut to crack.

WB Ken. Looks like your PSA is holding steady.
---------
2014-15: PSA's 9, 12, 20, 25... Neg DRE, Neg TRUS biopsy
6/16: MRI Fusion biopsy, Right Base, 2x40%+2x100% all G8 (4+4)
8/16: DaVinci RP, 6mm EPE, PNI, 25% G4, BL SVI, stage T3B N0M0
1/17: started 18 months Lupron ADT, PSA's ~.03
5/17: AMS800 AUS implanted, revised 5/30
39 tx RapidArc IMRT (70 Gy) Aug-Oct 2017
Age 66, recently retired to Florida 'just in time'
Posted 10/7/2017 7:10 AM (GMT -7)
Hi Gary,

I don't know anything about persistent psa, but I think a .32 psa after surgery with a good pathology report means that something is still down there. The chances are that it's still in the general area, and SRT would have a very good chance of zapping it. I agree with Pratoman, I don't think the SEs should deter you.

I certainly wouldn't opt for AS if my doctors are recommending SRT, but that's just me. You appear to be super informed so I'm sure you'll make the right choice for yourself.

Please keep us informed.
62 yrs
PSA: 2/4/15: 3.5;
1/21/16: 3.8
2/13/17: 5.1
3/27/17: 5.45
3/27/17: 5.5
4/17/17: 2 of 16 pos., 15 and 4 percent. GS 8.
Bone Scan clear.
Robotic RP May 24, 2017, NYU Hospital, Samir Taneja M.D.
Margins clear, SV and LN negative, Focal EPE, GS 4+5
Prostate 44.6 grams, tumor 5% of prostate
1 pad a day after about 3 weeks. ED near total.
7/26/17 PSA <.01
9/7/17 .01
Posted 10/7/2017 8:35 AM (GMT -7)
Thanks Rob. Steady so far, another test coming up early November.
Dx Age 64 Nov 2014, 4.3
BX 3 of 12 cores positive original pathologyG6, G6, G8 (3+5)
downgraded to 3+3=6 by tDr Epstein, JH
RALP with Dr Ash Tewari Jan 6, 2015
Post surgical pathology – G7 (3+4), ECE, Margivns, LN, SV all negative
PSA @ 6 weeks 2/15, .<02, remained <0.02 until January 2017, .02, repeat Feb 2017, still .02. May 2017-.033, August 2017- .033
Decipher test, low risk, .37 score
Posted 10/7/2017 10:40 AM (GMT -7)
Hi Gary -

I too had persistent PSA, but mine was over 2. I went to UCSF for the 68Ga PSMA scan and it found left a few left side lymph nodes and the prostate bed had uptake.

The da Vinci surgeon removed ten nodes - 8 from the right, 2 were positive, and two from the left not positive.

I hope your scan shows where the cancer is, but with such a low PSA not sure it will.

I also had my surgery at U of Miami.

Bobby Mac
Age: 69 at PC dx, PSA 6.7 Biopsy: 2/16 13 of 14 Positive, - RALP 4/16 Path:EPE, 2 + margins, Gleason 4+3=7, 50% of gland, Stage pT3a N1, nodes 2/10,+, 68 Ga PSMA 8/16 left node +, bed +, Lupron 8/16 - 6/17, Firmagon 7/17, uPSA 6/16, 2.41, SRT completed 12/16, PSA 6/2016, 2.6, 7/16, 2.2, 8/16 .6, <0.1. since 10/16, 1/17 T=43 5/17 T=34, 6/17 T=25, 7/17 T=25, 9/17 T=48
Posted 10/7/2017 12:12 PM (GMT -7)
I understand your concern garyi. My bladder neck sutures came loose....which resulted in more scar tissue...which resulted in a stricture. It's been treated once and so far so good.

What I'm thinking of doing....speaking with a urologist to see if it's possible for them to see or to even discern what's going on in there. I want to know what it is...exactly....that we're dealing with....and possibly getting ready to zap.....as compared to others....

That might would tell you more...or not...

Just more data to go with...

sharing the links was thoughtful...thanks
PSA 2010 thru 2014...4.0 +/- .7
Dx 12/14 @ 56 yo...2 cores G6 <5%, 1 core G6 20%, 1 core HGPIN.
RALP 11/25/15...3+4. 3 to 5 mm surgical margin 15% involvement pT2+
2/16-.01...4/16-.00...7/16-.00...10/16-.01...1/17-.01...4/17-.02...7/17-.02

Post Edited (island time) : 10/7/2017 2:32:55 PM (GMT-6)

Posted 10/7/2017 8:24 PM (GMT -7)
My husband has a past history of ulcerative colitis. He met w/ his gastro before he started SRT. He just finished 40 treatments at 76 gy. He was on Lialda 4 times a day to lesson inflamation to the colon. Bob finished on Thursday of last week on Tues. he started noticing some constipation and rectal pain and burning. Oncologist said put Prep. H on it which he did and it's feeling much better. Except for our 4 hour drive every day for 40 days, radiation has so far been a non-event. Bob has been extremely tired but as I stated he's been doing a 4 hour drive every day and he's also on firmagon shots for 6 months. Prat is sending you my email for any further questions or want to talk about anything. ~Miki
I'm Miki husband Bob- age 53 @ DX
Initial PSA 8/14 - 4.1
Biopsy 9-11-14
Results: 9/25/2014 - 6 of 12 cores positive (5 cores G6, 1 core G7)
DaVinci RP 12-03-2014
Gleason 6 -Surgical Path
Stage T2c- 1 positive margin 30% tumor of prostate
1-8-15 .00
4-9-15 .02
7-10-15 .06
9-15-15 .07
12-17-15 .1
1-25-16 .11
4-28-16 .13
6-22-17 .26
8-7-17 SRT Started +Firmagon
8-21-17 .05
Posted 10/7/2017 9:50 PM (GMT -7)
Thanks Miki...I look forward to talking to you. Glad your husband is doing well.

I've been on 2,800 mg of Asacol (mesalamine) for many years to keep my colitis in remission. It works well. I also take a high quality probiotic daily.

SRT will probably be my only option, but I want to actively reduce the probability of rectal and urinary complications as much as possible.

A radiation technician with superb aim should help ;-)
Posted 10/7/2017 9:55 PM (GMT -7)
I don't think SBRT is currently being used for SRT. A good RO and team can get you through with IMRT. The machines now are very good, very accurate.

Just make sure they know your history and complain a lot during treatment. ;)

You'll be fine. It won't be easy, but it can be done.

Hang in there,
Andrew
I'll be in the shop.
Age 57, 52 at DX
PSA:
4.2 10/11, 1.9 6/12, 1.2 12/12, 1.0 5/13, .6 11/13,
.7 5/14, .5 10/14, .5 4/15, .3 10/15, .3 4/16, .4 10/16, .4 5/17
G 3+4
Stage T1C
2 out of 14 cores positive
Treatment IGRT - 2/2012
My latest blog post
Posted 10/7/2017 10:03 PM (GMT -7)
You will be fine. When your doctors tell you it is time- get it done. There is still a lot of living to do.
Diagnosis in August 2007
Age 57
PSA 4.1 Gleason 3+4=7
Robotic Surgery - 10/2007
GS 3+4=7, Stage T3a N0 MX, Margins-, EPE +, PIN+, Nodes-
Post- Surgery PSA .005, Jan. 2015 .06
SRT ended 5/15/15. 35 treatments 70 Gy's 8/1/'15 PSA <.006 11/1/2015 <.006 5/2016 <.006. 12/2016 <.006, 5/2017 <.006
Posted 10/8/2017 9:23 PM (GMT -7)
Thank you all for the support and advise. IMRT is, I know, the RT I'm looking at.

Miki...an email will be headed your way as soon as I recover from a busy weekend.

Bobby Mac...what were your reasons for going to UCSF, a superb PCa hospital, for the 68GA PSMA scan when the Univ of Miami offers the same procedure?

Does anyone know the differences and relative pros and cons between a Axumin PET Scan and a 68GA PSMA one??
Posted 10/9/2017 5:23 AM (GMT -7)
With Pesistent PSA right after RALP, especially one above 0.3, I have read a number of people saying "hit it fast and hit it hard" and "throw the kitchen sink at it".

What is the consensus about the time frame for treatment (HT and RT) after RALP all this should be started? Gary, you are about 10 weeks out now, correct? Does it look like you will begin your treatment at about 4 months after RALP?

Do weeks matter? My husband is 0.4 PSA seven weeks after RALP, I feel weeks do matter if there is still all that PCa floating around in his body.
History:

8/2011 PSA 1.0
7/2013 PSA 1.96
5/2015 PSA 3.51
10/2016 PSA 6.87
5/2017 PSA 8.44
7/2017 PSA 9.56

March 2016 Biospy

December 2015 - Biopsy 15 cores with one core showing 1/2 mm Gleason 6 (3 + 3)
June 2017 - Biopsy 15 cores with 9 had more than 1 mm of Gleason 7 (3+ 4)

March 2016 MRI negative
October 2016 MRI Provided PI-RIDS as a V2

August 2017 RALP
Good recovery: Urinary Incontinence - improving but leaks when moving around
ED: Very good recovery.

Pathology Report:

Tumor Grade Gleason 7 (3+4)
Lymph nodes negative
Seminal Vesicles Negative
Tumor involves right posterior left posterior right anterior and left anterior.
Multi centric foci
Two extra capulsar extensions
Invaded bladder neck
Other margins negative


September 2017 - Almost 7 weeks PSA post prostatectomy 0.41
Posted 10/9/2017 5:50 AM (GMT -7)
Hi scar....neither my uro nor my RO have suggested the 'hitting it hard kitchen sink' approach. I'm about 12 weeks post surgery.

Both want to better understand the why and where for the Current PSA. That's one reason for my question above, about the two types of scans. I'll get the results of my recent blood draw on Wednesday, when I see my surgeon.

I also hope to have the results of a Decipher test within the next four weeks when I see my RO. Then we (I) will have more data, to decide how hard we hit it. RT comes with it's own package of complex and insidious long term side effects that I'm not looking forward to.

With all that's known about PCa, it's maddening how much uncertainty there is about it. Persistent PSA takes it to a higher level eyes

I'll keep you posted.....
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