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rising PSA post salvage radiotherapy

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User
Posted 14 Jan 2020 at 20:44

Hi, this is my first post.  Looking for some advise on what we should be doing next.


My husband was diagnosed in Dec 18, age 49.


Nov 17 PSA was 3.4, he was tested due to family history.  He had exam, but advised against biopsy, they weren’t concerned. Tested again Sep 18, PSA 4.1, biopsy found 5/5 cores left side only, Gleeson 4+3=7


Feb19, robotic assisted laporoscopic radical prostatectomy, partial nerve sparing.   small positive margin found,


Mar 19, 6 weeks post op, PSA 0.6, Apr 19, PSA 0.7


No PET scan (choline) available in Aberdeen, went on waiting list for Edinburgh.  (6 month wait)


June 19, PSA dropped to 0.3, July 19, had PSMA Pet scan at London bridge (consultant said worth having done – private health paid).  PSMA scan showed nothing.


Sept 19 PSA 0.3, Nov 19 ended 33 sessions of salvage radiotherapy. 


Jan 20, 6 weeks post radiotherapy PSA now up to 1.0.  Consultant “at a loss as what’s going on”.


9 lymph nodes were taken during op – all clear. 


They suggested that another PSMA scan may pick up something now readings are higher, potentially other nodes affected but it would be unusual,  after being discussed at consultants meeting today they want an urgent CT bone scan.   


Is it worth asking for referral for private PSMA scan.  Also why don’t they do a bone scan prior to radiotherapy?


 

User
Posted 14 Jan 2020 at 23:20
I am not sure I would bother with another PSMA at this time as there is no guarantee that it will pick up what it missed so recently. There are alternative tracers available, including choline 11 C and choline 18-F which might be worth asking about but I think I would wait for the bone scan first and then decide.

Did they not put him on hormones alongside the RT?
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 14 Jan 2020 at 23:24
Re bone scan, they probably didn't do one because the PSA was considered to low to have spread.

What was the final pathology from the OP?



User
Posted 14 Jan 2020 at 23:35

L Cook , I will leave the PSMA answers to those who know. 


 In answer to your question about scans before SRT, I was told that if they did a bone scan before SRT and found nothing they would still do SRT to the prostate bed. If they did a scan before SRT and found evidence of Mets SRT would be not be done. When I asked if they were guessing that the cancer was in the prostate bed, I was told it was a very educated guess based in years of experience. I am dipping in and out of BCR, next test in  few weeks will be interesting. I will follow your progress with interest.


Thanks Chris

User
Posted 14 Jan 2020 at 23:57

Originally Posted by: Online Community Member
Re bone scan, they probably didn't do one because the PSA was considered to low to have spread.

What was the final pathology from the OP?




 


He had a positive margin, which is probably why they assumed the rising PSA was remnants in the prostate bed. 

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 15 Jan 2020 at 09:48
thanks for the replies.

copy / paste from consultants referral for the PSMA scan.

His pre-operative characteristics were: PSA 4.1, cT1c, Gleason 3=4=7 prostate cancer on Left lobe only in 5/5 cores (45% vol.); core positivity 50%. Probability of pelvic lymph node involvement: 5.3% (Briganti nomogram). MRI (pre-biopsy): 36cc prostate volume; no obvious tumour seen (PIRADS 2). His prostatectomy pathology was Gleason 3 + 4 = 7 disease involving 50% of the total gland volume, with a small positive margin at the left base measuring 5 mm. There was a single focus of tumour within perineural tissue, and tumour within adipose tissue was identified just at the junction of circumferential margin of the prostate, as it merged with the extra-prostatic tissue. The specimen was cautiously staged as pT2bN0.

The had presumed that cells may still be in prostate bed, therefore SRT.

PET scans not available Aberdeen at the moments - Edinburgh no longer taking people. Due to this they would seek approval for a referal to London or Manchester on NHS if required. but since meeting on Tuesday that changed to the bone scan.

We thought that the PSMA scan was superior to the choline so were happy when nothing showed.

Consultant originally said he wasnt suitable for hormone treatment - but guessing thats because they thought the OP/SRT would do the trick.

User
Posted 15 Jan 2020 at 13:53
the hospital rang today to say there may be another change of plan. If they do a CT bone scan he wont be able to have PSMA scan for some time due to having limit of radiation - they didnt say how long.

I believe the PSMA scan he had last year was PSMA / CT.

will a CT bone scan show more than PSMA ?
User
Posted 15 Jan 2020 at 14:43

I’m very sorry to read about your situation and have to admit I don’t understand what is going on.


I had a prostatectomy.  My post operative PSA was 0.014.  In the space of a year, it had risen to 0.023.  This was still exceptionally low but as I’d had several small rises, my oncologist suspected something was going on.  I paid for a PSMA scan and it picked up cancer cells in some of my lymph nodes.  My SRT therefore targeted these nodes as well as the general prostate bed.  I was put on HT for 18 months which covered pre and post SRT.  PSA is now <0.006.


Even though I’ve been through some of the same things as your husband, i don’t know enough to say what might be going on.  If you haven’t done so, call the specialist nurses from this site.  They are brilliant and will hopefully be able to guide you.

User
Posted 15 Jan 2020 at 20:49
CJ's PSA rose to 80 and still the best scans available came back clear - some men just have micromets in multiple places that are too tiny to see, and some prostate cancers simply don't show up on scans. Cook's OH's mpMRI was clear despite a G7 affecting 50% of his prostate, PNI and positive margins.

Personally, I would still be more inclined to the bone scan than the PSMA scan as the PSMA failed once already. There is also FACBC if Leeds St James would accept a referral for him?
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
 
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