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    Old 05-26-2020, 01:54 PM   #1
    JustBrandon
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    Dad's cancer may be back

    Hello all. Some of you probably know me from the days back at the other forum before it shut down. For those who dont, or who need a refresher here it is:

    7 years ago dad was diagnosed with prostate cancer following a high PSA test of 4.2 ng/mL. He was subsequently biopsied and found to have 5 of 12 cores + for Gleason 3+3=6 prostate cancer. He had surgery approximately two months after the biopsy and pathology agreed with the Gleason score of 6. It did however mention focal minimal margin involvement at the apex-- though the pathologist noted it was equivocal and not definitive.

    For 6 years post surgery, his PSA was always either <0.04 or undetectable, whichever term the doctor chose to use those particular days. However today on his yearly screen, it was found to be 1.047. Urologist says to not get worried just yet, they will retest in a month and see if perhaps it was a machine or sample error.

    Needless to say I am rather stunned and worried at this development. I was always under the impression Gleason 6 could not survive outside the prostate gland, and therefore should not be capable of recurring post surgery. Perhaps there was a small amount of pattern 4 in it? Though surgical pathology was adamant in confirming the biopsy score of Gleason 6. I read it up, down, sideways, backwards, and with the doctor. There was never any mention of any tertiary area of higher grade cancer.

    Have you ever heard of Gleason 6 recurring?

     
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    Old 05-27-2020, 05:28 AM   #2
    DjinTonic
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    Re: Dad's cancer may be back

    Hi Brandon. Sorry you're having this worry. As you dad's doc said, amy unexpected PSA rise has to be confirmed with a retest. Some possibilities is a rising PSA is confirmed:

    1. A small amount of pattern 4 was missed in the whole-prostate sampling. This could have put tumor cells in circulation (CTC) before diagnosis. It can take years for micromets to grow.

    2. A minute amount of healthy or G6 tissue may have been left behind at the RP.

    3. Even though G6 itself cannot metastasize, it can grow locally outside the prostate, e.g., as an extraprostatic extension or bladder neck invasion. Or there may have been a positive surgical margin. Have another look at your dad's post-RP pathology report to see if any was mentioned.

    A PSA rise can be the result of healthy tissue and/or malignant tissue that was either left behind or newly formed. About 10% of men with prostate-confined G6 are high risk for higher-grade lesions and met formation.

    Advanced scans such as Ga-PSMA-PET or Axumin can help determine the location/source of recurrence. Speak to you dad's docs about these.

    Keep us posted.

    Djin
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    11-10-17 Decipher 0.37 Low Risk; 5-yr met risk 2.4%, 10-yr PCa mortality 3.3%
    LabCorp uPSA: 0.010 (3 mo.)…0.015 (1 yr. 6 mo.)…0.015 (2 yr. 4 mo.)

     
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    Old 05-27-2020, 07:16 AM   #3
    JustBrandon
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    Re: Dad's cancer may be back

    Quote:
    Originally Posted by DjinTonic View Post
    Hi Brandon. Sorry you're having this worry. As you dad's doc said, amy unexpected PSA rise has to be confirmed with a retest. Some possibilities is a rising PSA is confirmed:

    1. A small amount of pattern 4 was missed in the whole-prostate sampling. This could have put tumor cells in circulation (CTC) before diagnosis. It can take years for micromets to grow.

    2. A minute amount of healthy or G6 tissue may have been left behind at the RP.

    3. Even though G6 itself cannot metastasize, it can grow locally outside the prostate, e.g., as an extraprostatic extension or bladder neck invasion. Or there may have been a positive surgical margin. Have another look at your dad's post-RP pathology report to see if any was mentioned.

    A PSA rise can be the result of healthy tissue and/or malignant tissue that was either left behind or newly formed. About 10% of men with prostate-confined G6 are high risk for higher-grade lesions and met formation.

    Advanced scans such as Ga-PSMA-PET or Axumin can help determine the location/source of recurrence. Speak to you dad's docs about these.

    Keep us posted.

    Djin
    Yeah the first point is something I'm certainly worried about. Any quantity of pattern 4 carries a potential risk to spread or return, even if it is a very small portion of what was found overall. That's the first thing I got to thinking soon as I heard the test result, possible pattern 4 that was obscure. The fact that test yesterday came back OVER 1.0 really lends me to think about possible pattern 4.

    As for the second point, that's quite possible as well, though I'm not sure if that would be enough to raise the PSA over 1. Perhaps it could be.

    His pathology report did mention something about "focal minimal margin involvement at the right apex, though this is equivocal and not definitive". All other margins were negative, and extraprostatic extension nor seminal vesicle involvement were present.

    Maybe that focal minimal involvement of the right apex could be where it is returning(if indeed it is). Will definitely have him ask the doc about that. Alas I can't go with him to the next test due to local COVID 19 protocols.

    Thank you so much, your input is greatly appreciated and I will let you know more when I find out.

    Regards.

     
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    Old 05-27-2020, 11:16 AM   #4
    Michael F
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    Re: Dad's cancer may be back

    Hi again Brandon! You have always been extremely vigilant in dealing with your father's PCa from diagnosis, through treatment and now follow up.

    It is baffling to see such a high post RP PSA pop up on his annual test. The very 1st action step is to repeat it to either confirm it or rule it as an error.

    As I've always preached:

    1. "Obtain and Retain Copies of The Original Lab Report Each Time!" This can't rule out a testing error BUT it will prevent any error generated by someone who is either transcribing or reading the result incorrectly.

    2. Always use The Same Lab and Same uPSA Methodology

    What Lab & uPSA Methodolgy has he been using?

    3. Never use an office based uPSA Methodology!

    IMO, such a large PSA increase between post RP years 6 - 7 is shocking. Arithmetically, his PSA level is now 25% of what it was at the time of RP (4.2). It is not likely that this could be the result of regeneration of benign prostate tissue.

    Hoping this is determined to be a testing error!

    I agree with Dj's points and suggestions. If this latest uPSA is correct, getting one of the newer imaging scans should pinpoint locate the recurrent PCa that is confined to a single area.

    Good luck and keep us updated.

    MF
    __________________
    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free =13%)
    Jan '12: Biopsy: 1/12 = G7 (3+4) & 5/12 = G6
    March '12: Robotic RP: Left: PM + EPE => MD excised additional adjacent tissues
    Pathology: Gleason (3+4) pT3a pNO pMX pRO c tertiary pattern 5 / Prostate Size = 32 grams / Tumor = Bilateral: 20% / PNI: present
    uPSA Range: 0.017 - 0.039 at 98 Months Post Op: Mean = 0.023 (n = 24)
    LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%) ED = present

     
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    Old 05-27-2020, 11:16 AM   #5
    Southsider170
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    Re: Dad's cancer may be back

    For your dad's PSA score to go from <0.04 to more than 1, a 25 fold increase in just a year, it sounds like it could be a lab mistake. That's quite a rise , all of a sudden, especially after 6 years of nothing.

     
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    Old 05-27-2020, 04:28 PM   #6
    Prostatefree
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    Re: Dad's cancer may be back

    It seems improbable after 6 years it goes from <0.04 to 1.047 in one year. Those are also different type tests results. Something is amiss.

     
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    Old 05-28-2020, 10:50 AM   #7
    IADT3since2000
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    Re: Dad's cancer may be back

    Hi Just Brandon,

    I too think that test may be a false resort, though it is quite possible for a recurrence to be first noticed at the six year point after excellent prior results in circumstances like your dad's. I am now seven years since a curative attempt at radiation, but despite extraordinarily low PSA results since then, I know that I and others of us must remain vigilant.

    I am puzzled by the last point raised below:

    Quote:
    Originally Posted by Michael F View Post
    3. Never use an office based uPSA Methodology!

    MF
    My own PSA testing has used a practice-wide, collocated lab for a number of years now for my own uPSA testing, and I'm convinced the results have been reliable. There was one proven error in my results during one of my triple intermittent ADT rounds prior to radiation, but I believe my oncologist used an outside lab at the time. There is likely a variation in capabilities among practices. My oncologist is part of a large, well-regarded, long-existing practice with its own collocated lab one floor down.

    Good luck to you and your dad.

    Jim

     
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    Old 06-02-2020, 01:41 AM   #8
    HighlanderCFH
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    Re: Dad's cancer may be back

    I, too, believe it will turn out to be some sort of lab error. If there was absolutely no other grade involved, there should be no real problem.

    And, as has been suggested, it is always possible that some benign prostate tissue was left behind and is beginning to reveal itself. This would be healthy tissue and present no problem.

    But I'm putting my money on a testing error. Hang in there, he is probably just fine.

     
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    Old 06-06-2020, 02:55 PM   #9
    JustBrandon
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    Re: Dad's cancer may be back

    Quote:
    Originally Posted by HighlanderCFH View Post
    I, too, believe it will turn out to be some sort of lab error. If there was absolutely no other grade involved, there should be no real problem.

    And, as has been suggested, it is always possible that some benign prostate tissue was left behind and is beginning to reveal itself. This would be healthy tissue and present no problem.

    But I'm putting my money on a testing error. Hang in there, he is probably just fine.
    Yeah I'm hoping for a lab error, and the Gleason score of 6 both on biopsy and surgical pathology lead me to think the sampling was read read erroneously. I think I remember back on the other board a couple years ago there was a "blip" that appeared like a PSA rise enough to be detected, but that one 3ended up being a. Erroneous reading, as the follow up test on that one went back down to the usual <0.04 the doctor had always called zero.

    Perhaps as you suggested it could be healthy prostate tissue that has just now begun to secrete PSA again.

    One slight concern that does have me a little bit worried is the fact that he is losing weight and appetite somewhat. Of course that could be entirely unrelated to his prostate cancer status.

    We will find out the 30th of this month if this latest reading was another "blip" or if it is a truly ominous sign that we will again have to fight the cancer again. Of course if we do, we still have a lot of options available to us.

     
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    Old 06-07-2020, 07:29 AM   #10
    BlueHeron2020
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    Re: Dad's cancer may be back

    Quote:
    Originally Posted by JustBrandon View Post
    Yeah the first point is something I'm certainly worried about. Any quantity of pattern 4 carries a potential risk to spread or return, even if it is a very small portion of what was found overall. That's the first thing I got to thinking soon as I heard the test result, possible pattern 4 that was obscure. The fact that test yesterday came back OVER 1.0 really lends me to think about possible pattern 4.

    As for the second point, that's quite possible as well, though I'm not sure if that would be enough to raise the PSA over 1. Perhaps it could be.

    His pathology report did mention something about "focal minimal margin involvement at the right apex, though this is equivocal and not definitive". All other margins were negative, and extraprostatic extension nor seminal vesicle involvement were present.

    Maybe that focal minimal involvement of the right apex could be where it is returning(if indeed it is). Will definitely have him ask the doc about that. Alas I can't go with him to the next test due to local COVID 19 protocols.

    Thank you so much, your input is greatly appreciated and I will let you know more when I find out.

    Regards.
    Brandon, have your dad put you on speaker phone when he see’s doc, that’s what my wife and I do when she can’t come in due to Covid restrictions.
    __________________
    64 Yrs old, BMI 23.1, Active and healthy walker, hiker, surfer
    Hope to live 20+ more years
    2012-2019 linear PSA progression 2-6.9
    Oct 2019 3T MRI Two areas pirad 4 identified
    Dec 2019 MRI US fusion biopsy
    4/27 cores positive
    GS 6(3+3) 10% core volume random area
    GS 7(3+4) 30-40% core volume random area
    2/7 cores GS 7(3+4) core vol 10-20% target area
    Urologist recommends prostatectomy
    Radiologist recommends: TBD

     
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    Old 06-09-2020, 11:08 PM   #11
    HighlanderCFH
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    Re: Dad's cancer may be back

    Quote:
    Originally Posted by JustBrandon View Post
    Yeah I'm hoping for a lab error, and the Gleason score of 6 both on biopsy and surgical pathology lead me to think the sampling was read read erroneously. I think I remember back on the other board a couple years ago there was a "blip" that appeared like a PSA rise enough to be detected, but that one 3ended up being a. Erroneous reading, as the follow up test on that one went back down to the usual <0.04 the doctor had always called zero.

    Perhaps as you suggested it could be healthy prostate tissue that has just now begun to secrete PSA again.

    One slight concern that does have me a little bit worried is the fact that he is losing weight and appetite somewhat. Of course that could be entirely unrelated to his prostate cancer status.

    We will find out the 30th of this month if this latest reading was another "blip" or if it is a truly ominous sign that we will again have to fight the cancer again. Of course if we do, we still have a lot of options available to us.

    Yeah, I would not think his weight loss would be part of this. Probably most situations involving metastatic cancer would involve weight loss -- and there is no way his situation would involve something like that.

    Last edited by HighlanderCFH; 06-09-2020 at 11:09 PM.

     
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    Old 06-10-2020, 04:46 AM   #12
    Southsider170
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    Re: Dad's cancer may be back

    Quote:
    Originally Posted by JustBrandon View Post

    One slight concern that does have me a little bit worried is the fact that he is losing weight and appetite somewhat. Of course that could be entirely unrelated to his prostate cancer status.

    We will find out the 30th of this month if this latest reading was another "blip" or if it is a truly ominous sign that we will again have to fight the cancer again. Of course if we do, we still have a lot of options available to us.

    A lot of people are suffering anxiety due to the current Coronavirus Panic and shutdowns, and he also has this burden of this lab result. Anxiety is no joke and causes real symptoms.

    As these matters resolve, especially after he gets the word and the plan from the doctor, so should his anxiety resolve as well.

     
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    Old 06-30-2020, 08:13 AM   #13
    JustBrandon
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    Re: Dad's cancer may be back

    Good news, dad just called with the results of his PSA re-test. His PSA is back to to being <0.04 once again. So no cancer!!

     
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    Old 06-30-2020, 11:08 AM   #14
    DjinTonic
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    Re: Dad's cancer may be back

    Excellent! -- another very good thing to celebrate tomorrow!

    Djin
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    11-10-17 Decipher 0.37 Low Risk; 5-yr met risk 2.4%, 10-yr PCa mortality 3.3%
    LabCorp uPSA: 0.010 (3 mo.)…0.015 (1 yr. 6 mo.)…0.015 (2 yr. 4 mo.)

     
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    Old 07-01-2020, 03:39 AM   #15
    Michael F
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    Re: Dad's cancer may be back

    Quote:
    Originally Posted by JustBrandon View Post
    Good news, dad just called with the results of his PSA re-test. His PSA is back to to being <0.04 once again. So no cancer!!
    Great News Brandon!

    Bottom line is: your father is a victim of Lab Error. I remain a bit surprised that the URO MD did not immediately tell the Lab to re-run the PSA assay.

    Now you should take the time, go back upstream and demand answers to how and why a grossly incorrect value 1.047 was reported. How many other incorrect values has this Lab reported?

    Lastly:

    - What were the total charges for the PSA test?

    - Call the Lab and tell them to reimburse the health insurer and your father's OOP costs for the errant test result.

    - Call the health insurer and inform them of the situation and that you have asked the lab to reimburse the insurer.

    Enjoy The 4th with a confirmed undetectable PSA!

    MF

     
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