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BCR after robotic prostatectomy and negative PSMA PET scan

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User
Posted 10 Feb 2023 at 04:58

This is a continuation of an earlier post. I am 4 months post prostatectomy, Gleason 7 [4+3], positive surgical margins and capsule penetration. T3a, No, Mo.


My PSA never went to zero. First Post op PSA 0.7 as was the second. 


I finally had a PSMA PET scan Ga-68 completed. The results were negative for PSMA avid recurrence.


I am reading on what this report actually means and how this report will influence treatment decisions.


I am due to have a bone scan and a pelvic MRI in the next month.


Does anyone have comments or experience of this situation.

User
Posted 24 Mar 2023 at 17:06
Hi Stephen

Because you had a positive margin and persistent PSA the RT is probably a no brainer regardless of a negative PSMA scan.

My Onco told me PSMA scans are not ideal for diagnosing prostate bed recurrence due to the bladder masking the PSMA (it will light up regardless because the ligand is excreted via the kidneys).

So the fact you had no indications elsewhere could be good news regardless But you should probably get on with Salvage therapy to deal with the bit the surgeon left behind.
User
Posted 10 Feb 2023 at 16:01

Thanks Jellies for the information. The negative PSMA scan appears to be a good thing, though as you say the risk of spread of micro cancer is present. There is research from Australia [ Louise Emmett, Journal of Nuclear medicine Vol 61, No 6 June 2020 that shows 81% Freedom from Disease Progression in the negative PSMA group if they receive salvage Radiation plus or minus ADT. Men in this group do worse if they receive no further treatment.


I look forward to seeing my radiation oncologist for the first time in April.

User
Posted 12 Feb 2023 at 02:20

persistent-prostate-specific-antigen-after-radical-prostatectomy-and-its-impact-on-oncologic-outcomes.html


Thanks for the replies. francij1 raised an important issue for me. It is reported that 5-10% or more of men have a persistent PSA elevation of >0.1 after prostatectomy, the research in this group is less well developed than for BCR patients. The paper above describes a worse prognosis for patients such as myself as a group. However the negative PSMA may or may not help clarify the next steps for me. I agree that the next question should be what treatments might give me the best chance of a durable remission with the least risk of serious side effects.


 


I am learning this year that I have to live with doubt and uncertainty as does everyone on their journey with PCa.


Thankyou for the support and very helpful comments.

User
Posted 23 Mar 2023 at 07:38

You are 100% correct about going on vacation.  I went on 3 ski holidays during chemo which finished yesterday.  This was a conscious decision to ensure that I didn't look back at the period and say I had no "Quality of  Life" during treatment.  Quite the opposite.  Prostate cancer treatments and diagnosis take a lot of time so as you say, important to keep living life and doing the things you enjoy as best you can. 


Good news on the bone scan and also comforting that your PSA is stable.  Mine was moving upwards so next step for me is 8 weeks pelvic radiation starting in 3 weeks time.  They are also adding a second line drug to my ADT but not sure which one yet (there seem to be a few options).  Interesting to see how your radio onco wants to play it.  Good luck!

User
Posted 24 Mar 2023 at 16:21
I am glad that you are receiving comprehensive treatment with hormones, RT and chemo.

I am fearful of pelvic RT and losing the continence I have regained after my surgery.
My Gleason grade was 7 [4+3] and given the PSA persistence I think that I should push for RT and ADT at the very least.
Like you I had a post op bleed and a first negative PSMA PET paid for privately. I had not thought of doing a second PSMA scan in the future.

There is much uncertainty with the course of treatment and my disease at this time.

I am looking for another window between investigations and treatment to get away hopefully up north in Canada to the Boreal forest to witness the spring warbler migration. Like you I also keep very active inspite of old man aches and pains. Thankyou for your encouragement to keep a positive outlook and move forward.
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User
Posted 10 Feb 2023 at 13:18

My PSMA at similar levels of PSA showed two very small pelvic lymph nodes.  The size was less than half a centimetre which I understand is about the limit for showing up on a PSMA scan. So it is quite possible at those levels of PSA that you have pelvic mets which are just too small to see.  This can be treated with pelvic radiotherapy and ADT.

User
Posted 10 Feb 2023 at 16:01

Thanks Jellies for the information. The negative PSMA scan appears to be a good thing, though as you say the risk of spread of micro cancer is present. There is research from Australia [ Louise Emmett, Journal of Nuclear medicine Vol 61, No 6 June 2020 that shows 81% Freedom from Disease Progression in the negative PSMA group if they receive salvage Radiation plus or minus ADT. Men in this group do worse if they receive no further treatment.


I look forward to seeing my radiation oncologist for the first time in April.

User
Posted 10 Feb 2023 at 17:40

A small number of prostate cancers don't generate the PSMA molecule, and therefore won't show up on PSMA PET scans. There doesn't seem to be good agreement on what percentage of prostate cancer this is, but various studies suggest < 10%, although I have seen a few other figures saying < 20%.

User
Posted 10 Feb 2023 at 17:51

Stephan, does the article say how long the disease is progression free for. Could you perhaps post the link.


Although my scan picked up a single tumor, the onco said it is possible the rising in PSA is being generated from another undetected source. I got my GP to give me a blood form today for an interim PSA test so I can get an idea of what is happening. Hoping the last test was an error.


Thanks Chris 

User
Posted 10 Feb 2023 at 21:43

Here is the link to the article about 3 year disease free progression after a negative PSMA PET scan and SRT. Journal of Nuclear medicine vol 61, no6, June 2020 page 866-872


I understand that more dedifferentiated advanced prostate cancer cells don't generate PSMA molecules and are invisible to the scan. I am going with the thought that my Gleason 7 T3a has not reached that stage. However I will be getting an MRI and Bone scan to see if they show anything. The frustration with PCa  is that every test has a range of different meanings and interpretations.

User
Posted 11 Feb 2023 at 08:42
I don't think That study isn't applicable to you StephenCAN as you have not had a BCR.

I would be asking the surgeon how he managed to leave a chunk of prostate behind that is expressing 0.7 PSA.

I would be asking the oncologist what are the chances of a durable remission with prostate bed versus whole pelvis salvage RT.
User
Posted 11 Feb 2023 at 16:43

Hi,


A couple of fairly basic points Stephen.   


The psa 0.7 seems fairly high, are you sure it isn't 0.07?


What deductions can you make with a psa of 0.7 that isn't rising?  That it's a bit of benign prostate or something else giving off psa?  That you should wait until it rises?   If it does rise could you afford another psma or would you go for a PET scan or just for treatment?


I wouldn't advocate waiting too long at 0.7 and would be looking for radiotherapy with hormones if it was me, but that's me. 


Peter

User
Posted 12 Feb 2023 at 02:20

persistent-prostate-specific-antigen-after-radical-prostatectomy-and-its-impact-on-oncologic-outcomes.html


Thanks for the replies. francij1 raised an important issue for me. It is reported that 5-10% or more of men have a persistent PSA elevation of >0.1 after prostatectomy, the research in this group is less well developed than for BCR patients. The paper above describes a worse prognosis for patients such as myself as a group. However the negative PSMA may or may not help clarify the next steps for me. I agree that the next question should be what treatments might give me the best chance of a durable remission with the least risk of serious side effects.


 


I am learning this year that I have to live with doubt and uncertainty as does everyone on their journey with PCa.


Thankyou for the support and very helpful comments.

User
Posted 12 Feb 2023 at 13:21
PSA does sound a bit high, after it's removal - was it .7 or .07?
But PSA tests, can be inaccurate, if you have had Sex or a tummy upset a day or 4, before the test.
User
Posted 12 Feb 2023 at 14:19

An interesting link Stephen although the statement at the end seems less positive than I'd have thought: 'Salvage radiotherapy may result in a survival benefit in well-selected patients' (for those with persistent psa).   


Also it was published 3yrs ago and I wonder how old its data is and if it takes into account wider spread use of PSMA scanning and improved RT etc.  Your own conclusions are realistic.

Edited by member 12 Feb 2023 at 14:25  | Reason: Not specified

User
Posted 12 Feb 2023 at 14:35
PSA tests at 0.1 and above are considered to be very reliable. Orgasm, bike riding, etc are thought to increase PSA but a very small amount for a very limited time - a few hours maybe - and would not explain a persistent PSA of 0.7

A negative PSMA only tells you that either the patient is not PSMA+ or that the remaining cells are in clusters too small to see. If the post-op pathology had been clear, it might be hard to justify salvage RT as there would be no reason to believe that the PSA generating cells are in the pelvic area. However, many years' & thousands of patients' worth of data indicate that salvage RT to the prostate bed will often be effective following a not-great pathology coupled with detectable post-op PSA.

If you were my brother or Dad, I would still ask about a good old fashioned choline PET scan, just in case you are PSMA-negative.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 12 Feb 2023 at 16:57
I talk to my oncologist in a week, then MRI and Bone scan in March and radiation doc in April. I will ask about a choline PET.
I will let you know how this unfolds.
User
Posted 23 Mar 2023 at 00:02

This is just an update. I completed a Bone Scan this week which was negative for metastases.


My latest PSA "dropped " to 0.6. 


I go for a pelvic MRI with contrast tomorrow morning.


I have just returned from a vacation which did me a whole lot of good. It is surprising how much time it takes up, living with and being treated for cancer. Living with doubt and uncertainty has been very wearing on me, something I did not realize until my vacation.


In 2 weeks I finally get to see the Radiation Oncologist and I will give an update then as to what next.......

User
Posted 23 Mar 2023 at 07:38

You are 100% correct about going on vacation.  I went on 3 ski holidays during chemo which finished yesterday.  This was a conscious decision to ensure that I didn't look back at the period and say I had no "Quality of  Life" during treatment.  Quite the opposite.  Prostate cancer treatments and diagnosis take a lot of time so as you say, important to keep living life and doing the things you enjoy as best you can. 


Good news on the bone scan and also comforting that your PSA is stable.  Mine was moving upwards so next step for me is 8 weeks pelvic radiation starting in 3 weeks time.  They are also adding a second line drug to my ADT but not sure which one yet (there seem to be a few options).  Interesting to see how your radio onco wants to play it.  Good luck!

User
Posted 24 Mar 2023 at 16:21
I am glad that you are receiving comprehensive treatment with hormones, RT and chemo.

I am fearful of pelvic RT and losing the continence I have regained after my surgery.
My Gleason grade was 7 [4+3] and given the PSA persistence I think that I should push for RT and ADT at the very least.
Like you I had a post op bleed and a first negative PSMA PET paid for privately. I had not thought of doing a second PSMA scan in the future.

There is much uncertainty with the course of treatment and my disease at this time.

I am looking for another window between investigations and treatment to get away hopefully up north in Canada to the Boreal forest to witness the spring warbler migration. Like you I also keep very active inspite of old man aches and pains. Thankyou for your encouragement to keep a positive outlook and move forward.
User
Posted 24 Mar 2023 at 17:06
Hi Stephen

Because you had a positive margin and persistent PSA the RT is probably a no brainer regardless of a negative PSMA scan.

My Onco told me PSMA scans are not ideal for diagnosing prostate bed recurrence due to the bladder masking the PSMA (it will light up regardless because the ligand is excreted via the kidneys).

So the fact you had no indications elsewhere could be good news regardless But you should probably get on with Salvage therapy to deal with the bit the surgeon left behind.
 
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