In a post on Feb. 3, which was incomplete regarding my husband’s 4.5 year history with diagnosed PCa, I replied to George71 (his post entitled, “SABR-COMET-10 trial that radiates up to 10 lesions”) that my husband and I are struggling as George71 is with the decision of how/when to proceed with (husband's salvage) treatment. Tall_Allen questioned why we’re “struggling” since my husband has not had salvage radiation to his prostate. I would really appreciate feedback from as many of you as are willing to reply, so will give his history in as short a form as possible, but also to give complete info. Husband is now 77 yo, skinny (5’10,” 145 lbs.), no meds, teaches 6th grade math in FL.
IF you have the time to read this and respond, THANK YOU!
Husband started yearly PSA testing in 1995
2003, first PSA rise to 7.47, TRUS biopsy 12 cores negative, PSA rise attributed to extreme BPH.
From 2004 to 2009, PSAs up (highest 7.65) and down (lowest 5.43), TRUS biopsies done every other year, 12 cores always negative.
2010, missed PSA due to relocation, new job, house hunting, moving and finding a new urologist.
2011, BPH still worsening, gland estimated to be 100+ grams, PSA 7.74, urologist prescribed Rapaflo (allergic reaction to Finasteride) for BPH, recommended eventual Green Light.
2012 & 2013, urologist did not repeat PSA, pushed hard to do Green Light without further tests or attempts to resolve BPH, so consulted another urologist.
March 25, 2014, new urologist, PSA 11.75, recommended TURP.
April 2014, PSA 14.80. Later in April, TRUS biopsy, all 12 cores negative. Biopsy caused prostate to swell so that husband could not come off of Foley, so he was told now no alternative other than simple prostatectomy. Surgeon could only do open simple prostatectomy and needed an assistant surgeon from Tampa.
My reaction, just NO!
June 2014, consulted with Dr. Vipul Patel, Celebration, FL. Dr. Patel did not repeat PSA nor biopsy, but scheduled robotic simple prostatectomy based on history and latest biopsy results (3 months earlier).
August 14, 2014, laparoscopic robotic simple prostatectomy, Dr. Vipul Patel. Prostatic tissue removed in “simple” was 86 grams. Post-surgical pathology revealed tumor 100% G 3+3 = 6 involving less than 1% of the entire gland, largest tumor focus 4 mm in greatest cross-sectional diameter as measured on the microscopic slide, 100% negative margins, staged pT2c, no report on lymph nodes because it was a “simple,” but no lymphadenopathy.
Sept. 25, 2014, PSA 0.2
Sept. 2014 to Dec. 12, 2016, PSA rose in slow increments, but not continuously, to 1.2. Until PSA reached 1.2, Dr. Patel always advised that rise was normal because the surgery was a simple prostatectomy, and so prostate tissue remained.
December 2016, 3T-MRI revealed “mass” under bladder; PNI was observed.
March 2017, MRI-guided biopsy, 1 of 4 cores positive, G 3+4. Dr. Patel was convinced (and convinced us) that he could do salvage surgery to remove the mass and seminal vesicles. Discounted PNI as unimportant.
July 25, 2017, salvage laparoscopic robotic by Dr. Patel revealed NO mass under the bladder. All tissue analyzed in pathology was 100% negative for disease (despite that 1 positive biopsy core.)
August 23, 2017, PSA 0.6
Nov. 15, 2017, PSA 1.0
Dec. 13, 2017, Axumin PET, No positive identification.
Jan. 4, 2018, PSA 0.8
Jan., 2018, Dr. Patel referred to MO who recommended 2 years of ADT to start at the appointment plus 44-55 days of radiation. Dr. Patel disagreed because of the results of the Axumin and declining PSA.
Jan. 17, 2018, C-11 Acetate at Phoenix Molecular Imaging on advice of Dr. Patel. No positive identification.
March and June, 2018, PSA 0.7 (remained the same)
Sept. 2018, PSA 0.9
Nov. 2018, whole body bone scan. Reported very mild uptake at L4, possibly arthritis. Recommended 3T-MRI follow up to perhaps distinguish early met from arthritis.
Dec. 3, 2018 DCFPyL at Stanford, indicated mild uptake in LEFT prostate bed.
Dec. 4, 2018 68Ga RM2 at Stanford, no positive indication.
Jan. 2019 MO prescribed MRI prostate/pelvis w/contrast and MRI lumbar w/contrast. Lumbar w/contrast MRI was negative. Did not have MRI prostate/pelvis w/ contrast because it was coming up at Mayo Rochester.
Jan. 28, 2019 MRI prostate/pelvis w/ contrast.
Jan. 29, 2019 Consultation with Dr. Kwon, Mayo, Rochester. Advised MRI showed “very mild increased uptake RIGHT prostate bed.” Dr. Kwon recommended 18 months ADT plus 6 to 8 weeks of radiation to the prostate bed. Husband advised he has cognitive impairment; Dr. Kwon revised to “perhaps 6 months of ADT.”
Jan. 29, 2019, C-11 Choline PET. Results:
Status post prostatectomy and lymphadenectomy. Very subtle mild choline uptake
at the right seminal vesicle margin, corresponding to findings at MRI.
Similarly no definite choline uptake corresponding to abnormal findings on the
left seen at PyL PET/CT exam.
No choline avid lymphadenopathy.
Diffuse mild choline uptake throughout the marrow is likely reactive.
Other findings on low-dose noncontrast CT: Vascular calcifications.
Nonobstructing bilateral renal calculi.
IMPRESSION: Very subtle choline uptake at the right seminal vesicle margin
corresponding to area of abnormality at MRI. No choline avid lymphadenopathy or