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Biochemical Recurrence and Salvage Prostatectomy

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User
Posted 22 Feb 2018 at 17:52

I have recently been diagnosed with biochemical recurrence of my PCa. I had 3 years of hormone treatment (2009-2012) as well as IMRT in 2009. My PSA has risen from undetectable to 2.4 ng/ml at the last measurement in January of this year hence the diagnosis. A recent PET/CT scan showed the cancer is still confined to my prostate and seminal vesicles.

The options I have been presented with are either standard care of further hormone treatment when my PSA approaches double figures or my PSA doubling time is less than 6 months or salvage prostatectomy.

Salvage prostatectomy as explained to me is still an experimental procedure and has the potential higher risk of side effects including urinary incontinence, bleeding and fistula formation. I have a meeting with the surgeon in two months time to find out more and if I would qualify as a suitable candidate. In the meantime I would like to know if there is any experience or knowledge of the procedure in the community.

Tom

User
Posted 01 May 2021 at 00:34

UCLH and Guildford also have highly rated surgeons who do salvage prostatectomy (who I can't name here - PM me if you want to know).

Edited by member 01 May 2021 at 00:35  | Reason: Not specified

User
Posted 18 Apr 2020 at 19:40

Hi Tom, 

Thank you so much for sharing your story with me.  Although my PSA is much lower at 2.5, the scans are very much pointing my oncologist towards pressing on with surgery soon. I too feel very well now but I don't want this thing spreading further. 

I wish you the smoothest possible journey on your chosen path. 

Best wishes, 

Rob

User
Posted 30 Apr 2021 at 18:40

This is from a NHS website.

Salvage robotic assisted laparoscopic radical prostatectomy

Surgery to remove the prostate after prior treatment such as external beam radiation therapy is known as a 'salvage radical prostatectomy'. Salvage prostatectomy is regarded as a technically demanding procedure. Surgeons at Guy's hospital are highly experienced in the technique of salvage radical prostatectomy and have performed surgery in men who have had a large range of primary prostate cancer treatments including external beam radiation therapy, brachytherapy, High Intensity Focused Ultrasound, cryotherapy, electroporation and combinations of the aforementioned treatments. All salvage prostate surgeries for recurrent prostate cancer are performed using one of two Da'Vinci robotic systems co-located in adjoining robotic theatres on the Guy's hospital campus.

Thanks Chris

User
Posted 30 Apr 2021 at 19:55

Thanks Chris, very helpful info.

 

Shaun

User
Posted 01 May 2021 at 02:14
It was UCLH who recommended me to have HIFU as salvage treatment for failed RT in 2015 saying it would be almost 100% certain that a salvage Prostatectomy would result in permanent incontinence. However, due to there being a very small tumour in my Prostate, it has been agreed that I will have a have another HIFU treatment if the transperineal template Biopsy next month shows I am suitable. (I was previously told I had cancer in an Iliac Lymph Node, although a PSMA scan showed this was not so. If it had been the case HIFU or Prostatectomy would have been ruled out).

I am certainly glad I had HIFU even if it needs to be repeated rather than go for a salvage Prostatectomy and suggest anybody considers this or Cryotherapy before surgery made more difficult due to previous RT. It is so difficult that few surgeons will attempt it, which speaks for itself.

Barry
User
Posted 01 May 2021 at 13:23

My surgeon at Guildford, Professor Whocannotbenamedhere, wrote a recent professional article on the difficulties of performing surgery on a previously irradiated prostate. (It was successful).

I wrote a few words about it, together with a hyper-link to the paper itself, and submitted it to this website. A note came back: ‘submitted to moderators’.

As it has never appeared, I presume the moderators have lost it.

Now I cannot find the bloody article he wrote!

Why do they feel the need to moderate original posts, but not comments on posts?

Best of luck.

Cheers, John.

Edited by member 01 May 2021 at 13:47  | Reason: Not specified

User
Posted 01 May 2021 at 17:33

If it's the same Retzius Sparing robotic surgeon at Guildford I'm thinking of, I interacted with him recently on twitter about salvage prostatectomy following hypofractionated radiotherapy (fewer fractions of higher power each).

From the recent Pelvic Radiation Disease Association 2021 Confenence, it seems hypofractionation is increasing the cases of Pelvic Radiation Disease. Hewhocannotbenamed noted hypofractionation makes salvage prostatectomy more difficult because of significantly more fibrosis present. I said these two observations are probably linked.

Edited by member 01 May 2021 at 17:40  | Reason: Not specified

User
Posted 03 May 2021 at 06:35
Yes, that was it, and the Professor was dreading the day when Dan Dare is proposing to get away with just a single blast of radiation from his ray-gun, instead of multiple fractions, which is apparently mooted for some time in the future!

Cheers, John.

User
Posted 04 May 2021 at 01:36

There are a number of new ways of treating PCa being pursued John. These may work to varying degrees and for men that are suitable candidates. A trial of Interstitial Photodynamic Therapy, 'Specta Cure P18' is one of them. It is open until December of this year. I did enquire about joining it but was ruled out as I had previously had HIFU, although men who have had failed EBRT or HD Brachytherapy are eligible. https://www.cancerresearchuk.org/about-cancer/find-a-clinical-trial/a-trial-looking-at-a-new-way-of-giving-photodynamic-therapy-for-prostate-cancer-spectracure-p18#undefined

 

Barry
User
Posted 04 May 2021 at 17:41

This is from the Royal Marsden website about the surgeon I spoke to regarding salvage prostatectomy. He also practises at Imperial College.

" He regularly performs robotic prostatectomy at The Royal Marsden and is developing a new pathway of care for patients who are eligible for salvage prostatectomy surgery for recurrent disease after other treatments."

I am still holding on without treatment but I'm having a re-staging CT/PET scan on Thursday because my PSA has risen above 5ng/ml. This will be followed-up with a telephone consultation with my oncologist to discuss my options.

I think salvage prostatectomy is still at the bottom of my list.

Tom

 

User
Posted 13 Nov 2021 at 21:32

Hi Tom 

Eventually it was concluded my cancer was inoperable. I am therefore now on a mix of Zoladex and Enzalutamide.  Fortunately I am responding well and my PSA is virtually undetectable. Of course I get all the side effects of no testosterone but hey, I am alive. I just have to live a little differently and hope that I can continue to respond to the treatment for as long as possible but I am very aware that nothing lasts forever. 

I hope you find the best way forward for your situation. 

 

Take care. 

Rob

User
Posted 14 Nov 2021 at 21:04

Zumerset, if you read RCMJ's profile you will see that his original diagnosis some years ago was T3b so surgery was ruled out and he had brachytherapy instead. When he had a recent recurrence, there was talk of salvage surgery but this did not go ahead, probably because the previous brachy would have made it too difficult.

Edited by member 14 Nov 2021 at 21:06  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 16 Nov 2021 at 05:25
Once a T3 is diagnosed it is considered high risk and unlikely to be cured by surgery alone which tips the balance towards radiotherapy. A T3B pushes this even further.

User
Posted 17 Nov 2021 at 22:45
A bit of good news. After 6 months of being back on zoladex with virtually no side effects my psa has gone from 12 ng/ml to 0.12 ng/ml. Enzalutamide being kept in reserve.

Tom

User
Posted 17 Nov 2021 at 23:29

Good result, may it last a long time.

Dave

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User
Posted 23 Feb 2018 at 09:29

Morning Tom

Hmmm. Salvage prostatectomy eh. I would be interested in the answers to that too as I thought it wasn't possible (although as you say it's experimental)

Hopefully, you'll get helpful answers

We can't control the winds - but we can adjust our sails
User
Posted 23 Feb 2018 at 10:18

Some months back I had a referral due to rise in PSA after RT/HT. The options were discussed on what if by the same uro consultant when first diagnosed in 2004 - HIFU not advised, salvage surgery ( nothing was mentioned about experimental) was possible. The uro has a good reputation but I made the point I would decline that. So it was left as IHT for the time being. In the end my PSA took another dip so no action needed at this point.

Ray

User
Posted 23 Feb 2018 at 16:58

Andrew, you are correct that the surgeon screens potential patients as to their suitability for the operation.

I will find out more later but I have already been told that factors like general health, bladder and bowel functionality are taken into consideration. In addition there would be a template biopsy before being selected as suitable for the operation

My first thoughts are that I will stick with standard care but am trying to keep an open mind at present.

Tom

"I'm not afraid of dying, I just don't want to be there when it happens" - Woody Allen

User
Posted 23 Feb 2018 at 17:31

Another option? Member davekirkham initially had RT/HT then later salvage HDR brachy. Might be worth reading his profile.

Ray

User
Posted 07 Mar 2018 at 22:47

Sorry to be late to your chain.  Nearly same story.  I elected for Robotic radical salvation prostatectomy a year ago.  It is not for the faint of heart, but until SPARTAN study, not a lot of options. Suggest something like Mem Sloan Kettering website for good overview.  Will leave incontinent for sure, but varying degrees.   Artificial sphincter a nuisance but works very well.  PSA arising again.  None of us are going to live to be 140 - it is all about extending life as long as quality of life sustainable.

User
Posted 09 Mar 2018 at 13:46

Hi Gary

The artificial sphincter is new to me. Can you say a bit more about it.

Tom

User
Posted 09 Mar 2018 at 23:17

With a Transperineal template showing only one core out of fifty, I was considered suitable for HIFU and subsequent MRI seemed to show this was successful. However, my PSA has since risen and is likely due to a suspect iliac node which HIFU could not reach. The possibility of treating this with more RT may be possible (I await a PSMA scan to help determine this). I am reluctant to fall back on just HT. I am glad I didn't opt for radical surgery - I was told there would be a near 100% chance of incontinence and it would not have dealt with the suspected cancer in the iliac node. I was not offered brachytherapy but doubt this would have reached the suspect ilian node.

Barry
User
Posted 16 Apr 2020 at 19:40

Hi Tom, 

A long time since this post but I am now probably destined for salvage surgery following the return of my PCa, 6 years after treatment by HT, HDR brachytherapy and external beam RT. Your post came up in my search and I wondered if you underwent salvage surgery.  If so what was your treatment and outcome?

Regards 

Rob 

User
Posted 18 Apr 2020 at 16:14

Hi Rob

I haven't had any further treatment yet as my PSA has not reached a trigger point. Just now my PSA is just over 4ng/ml and creeping up slowly. When it goes over 5 I will be re-staged after another PET/CT scan.

However, I have more or less decided not to have the operation. I am nearly 80 and apart from the PCa I am healthy and active and have a good life-style. The potential of being doubly incontinent is not appealing so I am almost certain do go down the standard treatment path of hormone therapy.

Tom

User
Posted 18 Apr 2020 at 19:40

Hi Tom, 

Thank you so much for sharing your story with me.  Although my PSA is much lower at 2.5, the scans are very much pointing my oncologist towards pressing on with surgery soon. I too feel very well now but I don't want this thing spreading further. 

I wish you the smoothest possible journey on your chosen path. 

Best wishes, 

Rob

User
Posted 30 Apr 2021 at 18:33

Can i ask, where do they do the salvage prostatectomy....my onco hasn't mentioned it , just told me no surgeon would do it?

Shaun

User
Posted 30 Apr 2021 at 18:40

This is from a NHS website.

Salvage robotic assisted laparoscopic radical prostatectomy

Surgery to remove the prostate after prior treatment such as external beam radiation therapy is known as a 'salvage radical prostatectomy'. Salvage prostatectomy is regarded as a technically demanding procedure. Surgeons at Guy's hospital are highly experienced in the technique of salvage radical prostatectomy and have performed surgery in men who have had a large range of primary prostate cancer treatments including external beam radiation therapy, brachytherapy, High Intensity Focused Ultrasound, cryotherapy, electroporation and combinations of the aforementioned treatments. All salvage prostate surgeries for recurrent prostate cancer are performed using one of two Da'Vinci robotic systems co-located in adjoining robotic theatres on the Guy's hospital campus.

Thanks Chris

User
Posted 30 Apr 2021 at 19:55

Thanks Chris, very helpful info.

 

Shaun

User
Posted 01 May 2021 at 00:34

UCLH and Guildford also have highly rated surgeons who do salvage prostatectomy (who I can't name here - PM me if you want to know).

Edited by member 01 May 2021 at 00:35  | Reason: Not specified

User
Posted 01 May 2021 at 02:14
It was UCLH who recommended me to have HIFU as salvage treatment for failed RT in 2015 saying it would be almost 100% certain that a salvage Prostatectomy would result in permanent incontinence. However, due to there being a very small tumour in my Prostate, it has been agreed that I will have a have another HIFU treatment if the transperineal template Biopsy next month shows I am suitable. (I was previously told I had cancer in an Iliac Lymph Node, although a PSMA scan showed this was not so. If it had been the case HIFU or Prostatectomy would have been ruled out).

I am certainly glad I had HIFU even if it needs to be repeated rather than go for a salvage Prostatectomy and suggest anybody considers this or Cryotherapy before surgery made more difficult due to previous RT. It is so difficult that few surgeons will attempt it, which speaks for itself.

Barry
User
Posted 01 May 2021 at 13:23

My surgeon at Guildford, Professor Whocannotbenamedhere, wrote a recent professional article on the difficulties of performing surgery on a previously irradiated prostate. (It was successful).

I wrote a few words about it, together with a hyper-link to the paper itself, and submitted it to this website. A note came back: ‘submitted to moderators’.

As it has never appeared, I presume the moderators have lost it.

Now I cannot find the bloody article he wrote!

Why do they feel the need to moderate original posts, but not comments on posts?

Best of luck.

Cheers, John.

Edited by member 01 May 2021 at 13:47  | Reason: Not specified

User
Posted 01 May 2021 at 17:33

If it's the same Retzius Sparing robotic surgeon at Guildford I'm thinking of, I interacted with him recently on twitter about salvage prostatectomy following hypofractionated radiotherapy (fewer fractions of higher power each).

From the recent Pelvic Radiation Disease Association 2021 Confenence, it seems hypofractionation is increasing the cases of Pelvic Radiation Disease. Hewhocannotbenamed noted hypofractionation makes salvage prostatectomy more difficult because of significantly more fibrosis present. I said these two observations are probably linked.

Edited by member 01 May 2021 at 17:40  | Reason: Not specified

User
Posted 03 May 2021 at 06:35
Yes, that was it, and the Professor was dreading the day when Dan Dare is proposing to get away with just a single blast of radiation from his ray-gun, instead of multiple fractions, which is apparently mooted for some time in the future!

Cheers, John.

User
Posted 04 May 2021 at 01:36

There are a number of new ways of treating PCa being pursued John. These may work to varying degrees and for men that are suitable candidates. A trial of Interstitial Photodynamic Therapy, 'Specta Cure P18' is one of them. It is open until December of this year. I did enquire about joining it but was ruled out as I had previously had HIFU, although men who have had failed EBRT or HD Brachytherapy are eligible. https://www.cancerresearchuk.org/about-cancer/find-a-clinical-trial/a-trial-looking-at-a-new-way-of-giving-photodynamic-therapy-for-prostate-cancer-spectracure-p18#undefined

 

Barry
User
Posted 04 May 2021 at 17:41

This is from the Royal Marsden website about the surgeon I spoke to regarding salvage prostatectomy. He also practises at Imperial College.

" He regularly performs robotic prostatectomy at The Royal Marsden and is developing a new pathway of care for patients who are eligible for salvage prostatectomy surgery for recurrent disease after other treatments."

I am still holding on without treatment but I'm having a re-staging CT/PET scan on Thursday because my PSA has risen above 5ng/ml. This will be followed-up with a telephone consultation with my oncologist to discuss my options.

I think salvage prostatectomy is still at the bottom of my list.

Tom

 

User
Posted 01 Jun 2021 at 15:16

I now have the results of the PSMA PET/CT scan that I had on the 6th May. Unfortunately restaging of the disease has shown spread in the lymph nodes in my lumber region as well as a possible lesion on C£3 of my spinal column.

 Previously cancer was confined to my prostate and seminal vesicles.

I am now back on bicalutamide prior to restarting the Zoladex treatment I had 11 years ago. My memory is that I tolerated the Zoladex fairly well with hot flushes being the main problem. Other treatment options e.g. cryo-therapy, brachy-therapy are ruled out because of the location of the tumours

However, side effects of Zoladex are not my main concern. I realise that each individual is different but is there any information out there regarding average survival of people with my diagnosis?

User
Posted 01 Jun 2021 at 23:02
I believe a lot depends on how your PCA responds to the Zoladex ie the bigger the reduction the longer the treatment will work for.

Will they be treating you with ajuvant ABI or Enzo? These seem to be delivering major benefit if taken up front.

User
Posted 02 Jun 2021 at 10:24
My oncologist will decide whether or not to add enzolutamide at my next consultation in late July when he will have the results of my latest PSA as well as the results from a number of other blood tests.

Tom

User
Posted 13 Nov 2021 at 18:23

Hi Rob - what did you go for eventually?

Quote:

Hi Tom, 

Thank you so much for sharing your story with me.  Although my PSA is much lower at 2.5, the scans are very much pointing my oncologist towards pressing on with surgery soon. I too feel very well now but I don't want this thing spreading further. 

I wish you the smoothest possible journey on your chosen path. 

Best wishes, 

Rob

User
Posted 13 Nov 2021 at 21:32

Hi Tom 

Eventually it was concluded my cancer was inoperable. I am therefore now on a mix of Zoladex and Enzalutamide.  Fortunately I am responding well and my PSA is virtually undetectable. Of course I get all the side effects of no testosterone but hey, I am alive. I just have to live a little differently and hope that I can continue to respond to the treatment for as long as possible but I am very aware that nothing lasts forever. 

I hope you find the best way forward for your situation. 

 

Take care. 

Rob

User
Posted 14 Nov 2021 at 20:53

Glad you have responded well to the treatment. Why was the cancer inoperable - had it spread and, if so, where to?

Thanks

 

Originally Posted by: Online Community Member

Hi Tom 

Eventually it was concluded my cancer was inoperable. I am therefore now on a mix of Zoladex and Enzalutamide.  Fortunately I am responding well and my PSA is virtually undetectable. Of course I get all the side effects of no testosterone but hey, I am alive. I just have to live a little differently and hope that I can continue to respond to the treatment for as long as possible but I am very aware that nothing lasts forever. 

I hope you find the best way forward for your situation. 

 

Take care. 

Rob

User
Posted 14 Nov 2021 at 21:04

Zumerset, if you read RCMJ's profile you will see that his original diagnosis some years ago was T3b so surgery was ruled out and he had brachytherapy instead. When he had a recent recurrence, there was talk of salvage surgery but this did not go ahead, probably because the previous brachy would have made it too difficult.

Edited by member 14 Nov 2021 at 21:06  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 15 Nov 2021 at 11:36

Hi Lyn. Yes - but I'm even more confused now. Why was surgery originally ruled out with T3b as I understand that this means the cancer has spread to the seminal vesicles. Don't they usually remove the seminal vesicles when they remove the prostate? I also didn't think that brachy could be used  to cure cancer in the seminal vesicles?

quote=LynEyre;261582]

Quote:

Zumerset, if you read RCMJ's profile you will see that his original diagnosis some years ago was T3b so surgery was ruled out and he had brachytherapy instead. When he had a recent recurrence, there was talk of salvage surgery but this did not go ahead, probably because the previous brachy would have made it too difficult.

User
Posted 16 Nov 2021 at 05:25
Once a T3 is diagnosed it is considered high risk and unlikely to be cured by surgery alone which tips the balance towards radiotherapy. A T3B pushes this even further.

User
Posted 16 Nov 2021 at 17:54

Originally Posted by: Online Community Member
Once a T3 is diagnosed it is considered high risk and unlikely to be cured by surgery alone which tips the balance towards radiotherapy. A T3B pushes this even further.

 

Thanks francij

I am T3b and they intend to remove my prostate and seminal vesicles as salvage therapy and they believe this will cure my cancer (although cure is never guaranteed of course!). However, I'm guessing that this is possibly only done at certain hospitals. It's also possible that they wouldn't do it years ago but surgery has improved.

User
Posted 17 Nov 2021 at 22:45
A bit of good news. After 6 months of being back on zoladex with virtually no side effects my psa has gone from 12 ng/ml to 0.12 ng/ml. Enzalutamide being kept in reserve.

Tom

User
Posted 17 Nov 2021 at 23:29

Good result, may it last a long time.

Dave

User
Posted 04 Jan 2022 at 14:24

Great news rank_bajin.

 

There's some stuff on SRP that I'd like to add to for future googlers. It is an op with a horrible SE profile. I get the general idea of avoiding it but it is not experimental. For those who cannot, there is a Recurrent Cancer team at Guy's that has (IMO) the two guys who will give you the best odds if you go that route. At least one (possibly two) actively takes on these guys despite the hits to his stats on SEs (and Guy's, BTW, tops the country*) because he wants to help the men whom other surgeons cannot or will not. The stats are not great, but they are as good as you are going to get. 

 

* https://www.npca.org.uk/provider-results/trust/guys-and-st-thomas-nhs-foundation-trust/plot/

 
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