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  • BCR of My Protate Cancer - Advice Please

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    Old 01-23-2021, 06:31 PM   #1
    PCBRO
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    BCR of My Protate Cancer - Advice Please

    Surgery Feb. 2016 3.5 PSA Stage T1c Gleason 3+4=7 Confined to prostate / clean margins/nodes/vessels

    Recurrence of PSA .2 after 60 months. Seeing two specialists in the next two weeks.

    I would like anyone who has had a similar experience to describe what their course of action was afterwards and what success have they had with it. (i.e., radiation therapy / other).

     
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    Old 01-23-2021, 07:39 PM   #2
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    Re: BCR of My Protate Cancer - Advice Please

    Quote:
    Originally Posted by PCBRO View Post
    Surgery Feb. 2016 3.5 PSA Stage T1c Gleason 3+4=7 Confined to prostate / clean margins/nodes/vessels

    Recurrence of PSA .2 after 60 months. Seeing two specialists in the next two weeks.

    I would like anyone who has had a similar experience to describe what their course of action was afterwards and what success have they had with it. (i.e., radiation therapy / other).

    Hi,

    Sorry to hear about the change in PSA. With your stats it seems so unlikely to happen. Have you confirmed yet that this was not some lab error?

    I hope this might be the case.

     
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    Old 01-24-2021, 12:49 AM   #3
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    Re: BCR of My Protate Cancer - Advice Please

    Hi PCBRO and Welcome to the Forum! Some more information might help shed light on what may be going on.

    1. Stage T1c was your clinical grade before surgery. Can you look at your post-op path report and tell us your pathological grade? It will start with the letter "p" -- for example pT2a. Also, does the report confirm that your post-op Gleason score also 3+4=7?

    2. Do you have all your post-op PSA readings leading up to your current 0.2?As Highlander said, it's important to establish an accurate PSA and trend with repeat readings.

    BCR can be from benign and/or malignant tissue both local to the prostate bed and/or in metastases. The most common site for metastases are local lymph nodes, which can be irradiated. Not all men with BCR go on to clinical recurrence of their cancer; however, most choose to have further therapy to avoid this, knowing that for a large group of men this therapy will be overtreatment.

    If BCR is confirmed, the next step after RP is usually salvage radiation therapy (SRT). There are advanced scans such as Axumin and Ga-PSMA-PET/CT that help locate the source(s) of any recurrence. These scans can help determine the field of radiation to use, which is often limited to the prostate bed. They are more sensitive at somewhat higher PSA levels, however. One study found "For PSA categories 00.2, 0.21, 12, and >2 ng/ml, PSMA PET/CT were positive in 42%, 58%, 76%, and 95% of patients, respectively."

    You can also inquire about having a Decipher genomics test done on tissue removed at your surgery, which will have been stored at the institution where you had your RP. This test can estimate the risk -- low, average, or high -- of your cancer metastasizing in the 5-yr post-op period.

    With a biopsy of G (3+4), you most likely did not have a bone scan done -- that is something you can discuss with your docs.

    I'm sure others will chime in with their experience with salvage RT.

    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, negative 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
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.020 (3 yr. 7 mo.)

     
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    Old 01-24-2021, 04:44 AM   #4
    PCBRO
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    Re: BCR of My Protate Cancer - Advice Please

    Highlander,

    Thanks for responding. I was hoping it was lab error. Unfortunately, it was confirmed by three different labs. (I went out the same day and had it tested at the same hospital lab and two independent labs.)

    PCBRO

     
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    Old 01-24-2021, 05:07 AM   #5
    PCBRO
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    Re: BCR of My Protate Cancer - Advice Please

    DT,

    Thank you for responding and for providing the great information. To answer your questions: (1) The post path was T2c, Gleason confirmed at 3+4, and no involvement with lymph nodes, seminal vesicles, or prostate margins. (2) PSADT is estimated at around 19 months based on trend data leading up to the .2.

    Based on my research to date, and helpfully confirmed by your information, my next likely course of action will be scans followed by some form of radiation treatment. I am seeing two specialists this coming week.

    Additional question: If there is no lymph, vesicle, or margin involvement, what other paths are there for metastasis to occur? This is a fairly specific/medical question, but I thought I would take a shot!

    Thanks again,

    PCBRO

     
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    Old 01-24-2021, 08:16 AM   #6
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    Re: BCR of My Protate Cancer - Advice Please

    Thanks, OK, so your post-op path staging was pT2c. The 8th edition of the TMN staging guide, which came out after your (and my) RP, did away with the letter subdivisions of pT2 (a, b, and c) according to tumor location, because for prostate-confined disease the location (again within the prostate) has no bearing on future outcomes. The total amount of tumor, however, does appear to be correlated with the risk of BCR. Was there an estimate of the percentage of prostate occupied by tumor?) Also, your path report should report the number of (negative) nodes removed and examined.

    It a small amount of prostate tissue may be left behind after surgery. Also, unfortunately, circulating tumor cells are not unusual long before treatment. These cells usually have a very difficult time establishing themselves outside the prostate, but sometime micromets do form. This is one reason you might discuss a Decipher test at your upcoming consults. Metastasis risk cuts across all Gleason scores and includes G7 (3+4). So even a "perfect" RP result (pT2 with no negative margins), does not mean that no tumor cells were left behind. A Decipher result of low met risk might give you some peace of mind that the recurrence is local; a return of high risk might prompt you to treat sooner.

    The "official" and most common definition of BCR is a PSA of 0.2 that is confirmed as still rising. It is not impossible for one's PSA to plateau (Johns Hopkins originally proposed 0.4 as the definition of the BCR point for this reason). Some men choose very early SRT with a PSA below 0.2 if they have several adverse factors; some choose SRT at higher PSA levels, and these are still considered as "early" SRT.

    The general rule is that the longer one goes from treatment to the start of a PSA rise and the slower the rate of the rise (DT), the better the prognosis. It is certainly possible that RT can zap all remaining tumor cells out of existence.

    Please keep us posted with the advise you get at your consultations.

    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, negative 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
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.020 (3 yr. 7 mo.)

     
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    Old 01-24-2021, 09:45 AM   #7
    PCBRO
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    Re: BCR of My Protate Cancer - Advice Please

    Djin,

    Thanks, again, for the great information. Greatly appreciated. To answer your questions, the tumor volume was estimated at 5% and there were 11 lymph nodes examined with no involvement.

    I will get some background on the Decipher test before having my first doc discussion on Tuesday.

    Best,

    PCBRO

     
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    Old 01-24-2021, 11:25 AM   #8
    IADT3since2000
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    Re: BCR of My Protate Cancer - Advice Please

    Hi PCBRO,

    Building on the other comments, it would also help to know your age and general health status.

    .Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    21 years as a survivor. Doing well. Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low and stable at <0.01; apparently cured (Current PSA as of 12/2/2020). (Current T 93 12/2/2020.) Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs. Barely noticeable side effects from radiation; continuing low T, likely do to long use of ADT, but good energy and adequate strength. I have a lot of School of Hard Knocks knowledge, and have followed research, which has made me an empowered and savvy patient, but I have had no enrolled medical education. What I experienced is not a guarantee for all but shows what is possible.

     
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    Old 01-24-2021, 11:37 AM   #9
    PCBRO
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    Re: BCR of My Protate Cancer - Advice Please

    Hi Jim,

    To your questions: I am 68 and in great health otherwise - no medications, all blood test parameters within range, and I get regular exercise.

    Thanks,

    PCBRO

     
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    Old 01-25-2021, 06:21 AM   #10
    DjinTonic
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    Re: BCR of My Protate Cancer - Advice Please

    Why some G6 (3+3) men are high risk for metastases even though G6 disease cannot metastasize

    I'd like to clarify something I said above: "Metastasis risk cuts across all Gleason scores and includes G7 (3+4)." I will explain that this actually extends to G6 (3+3), but did not say so because this statement requires clarification.

    1. Gleason 6 (3+3) lesions themselves do not metastasize*

    2. Nonetheless, a seminal study of the Decipher genomic test

    Decipher correlation patterns post prostatectomy: initial experience from 2342 prospective patients (2016)

    demonstrated that about 10% of men with prostate-confined G6 disease (confirmed by post-RP exam) had cancer that has a high-risk of forming higher-grade lesions that can lead to metastases within 5 years . If you widen this group to include G6 men whose tumor has grown out of the prostate capsule locally (as G6 can do), this goes up to 17%. If you look at the percentage for intermediate + high risk, this percentage goes up to 36%! (Data in Fig. 2, which demonstrates how metastasis risk cuts across all Gleason scores).

    This is why mention is now usually made of genomic testing for G6 men who are contemplating active surveillance. There is reason to believe that G6 men who are Decipher high risk and thus at risk of developing higher-grade lesions that can metastasize are not good candidates for AS.

    A second reason why a G6 (3+3) biopsy may lead to a false sense of security.

    Setting aside the genetic risk of what I would call "more dangerous" G6 disease, there is the issue of the small sample size of a biopsy. There is really no way of knowing with certainty whether you currently do harbor a higher-grade lesion(s) that was missed on biopsy. This is behind one of the reasons that (1) G6 men with more than a few lesions are not considered good candidates for entering AS; and (2)G6 men in AS programs who develop a higher burden of G6 lesions (size and/or number of lesions), are told they should leave AS and seek treatment: the increased amount of G6 disease statistically increases the chances that they currently harbor higher-grade lesions or are at risk of progression.

    It is true that mpMRI surveillance can help mitigate this problem and identify suspicious lesions that need biopsy investigation, but there is no 100% guarantee that you are truly G6.
    ______________________
    * The single case of G6 metastasizing that I know about was actually a case that proved the rule. A metastases can be genetically traced back to specific PCa lesion in the prostate (and it often turns out that all of one's metastases arise from a single prostate lesion even though PCa typically presents with multiple lesions). This patient had a G6 prostatic lesion that was adjacent to a higher-grade lesion and some G6 cells picked up genetic material from that lesion that conferred it with metastatic potential. So this case was a rare anomaly.

    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, negative 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
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.020 (3 yr. 7 mo.)

     
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    Old 01-25-2021, 06:47 AM   #11
    PCBRO
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    Re: BCR of My Protate Cancer - Advice Please

    Djin,

    Thanks for the additional info on the grading/metastasizing issue. I am having my first doc meeting tomorrow.

    Glenn

     
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    Old 05-03-2021, 08:52 AM   #12
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    Re: BCR of My Protate Cancer - Advice Please

    Hi Djin,

    Do you have any references for your statements about the risks associated with G3+3 at final pathology?

     
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    Old 05-03-2021, 09:34 PM   #13
    HighlanderCFH
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    Re: BCR of My Protate Cancer - Advice Please

    Quote:
    Originally Posted by DjinTonic View Post
    [b]
    * The single case of G6 metastasizing that I know about was actually a case that proved the rule. A metastases can be genetically traced back to specific PCa lesion in the prostate (and it often turns out that all of one's metastases arise from a single prostate lesion even though PCa typically presents with multiple lesions). This patient had a G6 prostatic lesion that was adjacent to a higher-grade lesion and some G6 cells picked up genetic material from that lesion that conferred it with metastatic potential. So this case was a rare anomaly.

    Djin
    If I'm understanding this correctly, the fact that the G6 lesion was adjacent to a higher Gleason grade tumor, rules out this individual case as being a G6 case.

    It is simply a HIGHER Geason case that also happens to include G6 along with it.

    For true G6 patients just starting down the road to treatment, this November 1st will make TEN YEARS since my da Vinci prostatectomy -- and I have had a zero PSA ever since.

    Chuck

     
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    Old 05-04-2021, 04:17 AM   #14
    DjinTonic
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    Re: BCR of My Protate Cancer - Advice Please

    Quote:
    Originally Posted by francij1 View Post
    Hi Djin,

    Do you have any references for your statements about the risks associated with G3+3 at final pathology?
    Hi francij1. I'm not certain which statements you are referring to. If you mean upgrading of the Gleason score at final pathology, this is a basic statistical fact that is well documented in the literature. For example:

    Predictors of adverse pathologic features after radical prostatectomy in low-risk prostate cancer (2019)

    https://bmccancer.biomedcentral.com/articles/10.1186/s12885-018-4416-4
    ________________________________

    Preoperative and Postoperative Gleason Score Correlation of Patients Who Underwent Radical Prostatectomy

    http://cms.galenos.com.tr/Uploads/Article_36897/UOB-19-35-En.pdf

    In this study 178 men where G6 (3+3) at biopsy and 141 were G6 (3+3) after RP. I believe the 141 included some men who were downgraded to G6 after RP; however, this only increases the number of G6 who where upgraded!
    ________________________________

    Risk of Pathological Upgrading and Up Staging among Men with Low Risk Prostate Cancer Varies by Race: Results from the National Cancer Database

    https://pubmed.ncbi.nlm.nih.gov/27582435/

    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, negative 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
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.020 (3 yr. 7 mo.)

     
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    Old 05-04-2021, 04:31 AM   #15
    DjinTonic
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    Re: BCR of My Protate Cancer - Advice Please

    Quote:
    Originally Posted by HighlanderCFH View Post
    If I'm understanding this correctly, the fact that the G6 lesion was adjacent to a higher Gleason grade tumor, rules out this individual case as being a G6 case.

    It is simply a HIGHER Geason case that also happens to include G6 along with it.

    For true G6 patients just starting down the road to treatment, this November 1st will make TEN YEARS since my da Vinci prostatectomy -- and I have had a zero PSA ever since.

    Chuck
    Hi Chuck. Not exactly. First I should say that in all cases where G6 (3+3) men developed metastases, when the entire prostate was re-examined, it was always the case that a higher grade lesion(s) was missed and the men weren't G6 to begin with. So nothing unusual about these cases, except for the shock of mets, that is. None of the mets came from a G6 lesion.

    The case I refer to was written up because it was one-of-a-kind. As I remember it, the man had some G6 lesions and some higher-grade lesions as well. What was unique was that when the mets were examined, they had the architecture of G6 lesions! Since it is known that G6 doesn't metastasize, further genomic studies were done. It was possible to trace all his met(s) to a single prostate lesion, which was, in fact G6. However, this G6 lesion was adjacent to a higher-grade lesion (I don't remember the grade) and it was found that a G6 cell had picked up genetic material from the adjacent, higher-grade lesion that conferred it with metastatic potential. This cell had proliferated into an "altered" G6 lesion that then gave rise to his mets. But yes, this could only happen because he had a lesion >6 to begin with. So the met had the appearance of G6 (3+3), but one that could metastasize.

    IMO, this highly exceptional case actually "proves the rule" that G6 doesn't have the genetic ability to metastasize.

    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, negative 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
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.020 (3 yr. 7 mo.)

     
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