I have a question that has me (and some MDs) stumped.
I was diagnosed with PCa [T4N0M0, Gleason 8, 11 out of 12 cores >60% involvement] in January 2009. My PSA in 2006 was 3.4; in 2007 and 2008 it was 1.5. My PSA at Dx was 1.53. Nuclear bone scan in 2/09 did not indicate any distant metastasis in bone. Treatment was 79 Gys IMRT/IGRT plus 3 years of ADT (Firmagon). My PSA went undetectable in 11/09 and has remained so ever since (<0.015 in 2/16). Even though I stopped ADT in 2/12, I have remained castrate (so much for a hormone holiday!) T =13 ng/dl in 2/16.
It has become increasingly painful for me to walk and in late March as part of a workup for my feet, my podiatrist(!) ordered a nuclear bone scan. I suggested that while we were at it, let's scan my entire body. Lo and behold, a single hot spot was found in a rib. My urologist poo-pooed the idea that it was a met, since my PSA was undetectable, suggesting that I must have cracked it in a fall. (I have had broken ribs before and well remember the pain, so I was skeptical to say the least.)
So, we did a CT scan (without contrast) of my chest. The radiologist wrote "Osteoblastic metastatic disease to the right third anterior rib with non-displaced pathologic fracture." Of course he knew nothing about my PSA status and my urologist remains unconvinced that it's actually a met. My oncologist suggests that the radiologist may be right. I've suggested that since my original Dx of fairly aggressive G8/T4 cancer had not raised my PSA it didn't seem completely unreasonable that a recurrence with metastasis could occur without impacting PSA. [And if it is a recurrence, it's probably CRPC since I'm castrate.] On the other hand, I'm asymptomatic for bone pain and can feel pain only when I press the area of the lesion with my fingers.
I did some further research at scholar.google.com and found a couple of journal articles (including one in Cancer ) that indicated metastatic PCa with undetectable PSA has been observed, albeit rarely. None of the docs involved (including the thoracic surgeon who is well experienced with mets and lung cancer) have offered a reasonable theory—to me, anyway—of what the lesion might be if it's not a PCa met. It certainly doesn't seem like an infection since I've experienced no pain, raised temp, or other classic symptoms.)
After a lot of discussion and a PET scan, (which being standard F18 unsurprisingly showed no hypermetabolism anywhere), we agreed that the next step would be to remove the lesion surgically and have it biopsied. Which will happen next week. (We decided against a needle biopsy since it was likely to be inconclusive.)
So, my question: is anyone here aware of a similar situation having occurred in the past? Or, in the words of my urologist, is this simply "another Craig Pynn anomaly."
I will certainly post the biopsy results here, since if nothing else, it seems like an interesting situation. As they say, every man's journey with this disease is unique. But this journey seems just plain weird.