Rising PSA after RP, how common is this? - Advanced Prostate...

Advanced Prostate Cancer

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Rising PSA after RP, how common is this?


Good evening everyone. It’s been a few months since I’ve updated my status. But back in April I was diagnosed with prostate cancer. I had a Gleason score of 8, 4+4 and a PSA of 11. My bone scan and CAT scan both came back negative, although the bone scan identified a benign lesion on my femur. Neither my surgical oncologist or radiology oncologist feel it’s metastatic (I have no pain or soreness).

As a result I had an RP at the end of July. This past week I had my first follow-up appointment with my surgical oncologist. I didn’t get the news was I hoping to hear, my PSA has elevated to a 24.

My SO doc put me on ADT (bicalutamide). I also have a new bone scan, CAT scan and PSA test scheduled over the next few weeks and then an appointment with a radiology oncologist in early November.

I’m not sure what to expect from from this point on. Any thoughts?

I realize it depends on the test results but I’ve continue to read and follow many of you (Tall Allen, tango, and j-o-h-n, to name a few) and respect everyone’s opinions.

Take care.


18 Replies

What were the pathology findings of your prostatectomy? - positive margins? T stage? Gleason score?

Not a good idea to take Casodex before your bone scan/CT. It may mask what you are looking for. Talk to a radiation oncologist before you do that. You should be able to get an insurance-covered Axumin scan.

Next steps depend on the results of your scans.

Rondief in reply to Tall_Allen

My SO and RO work out of the same facility (Fox Chase Cancer Treatment Center in Philly). I know they talked about ADT.

FWIW, I had an axumin scan by a previous doc but they screwed it up (that’s why he’s a previous doc). My SO ordered a new scan and the results are as follows. I believe it it all good.


1. Left femoral diaphyseal lesion redemonstrated. Based upon constellation of findings this most

likely represents enchondroma; metastatic process less likely to unlikely. Consider short-term

follow-up with at least plain radiography to ensure stability.

2. Abnormality seen involving the left abductor magnus muscle suggestive of a hemangioma.

I know the Gleason is 8, 4+4, but I’m not sure about T-stage or margins. Below are a few of the highlights from the path findings (you may have a better idea on how to interpret them).

And thanks for your insight.



Right posterior base, biopsy:

- Prostatic adenocarcinoma, with perineurial invasion.

Prostate and seminal vesicles, radical prostatectomy:

- Prostatic adenocarcinoma, Gleason's score 8 (4+4) [Grade Group 4].

- Carcinoma involves the right lobe and right apex.

- Lymphovascular invasion is indefinite.

- Prostatic carcinoma is focally present at right posterior superior circumferential surgical resection margin.

- The apex and base resection margins are negative for tumor.

- Right seminal vesicle, involved by tumor.

Right pelvic lymph node packet, excision:

- Metastatic prostatic adenocarcinoma seen in one of five lymph nodes

Synoptic Report:

Procedure: Radical prostatectomy


Histologic Type: Acinar adenocarcinoma

Histologic Grade

Grade Group and Gleason Score: Grade group 4 (Gleason Score 4 + 4 = 8)

Extraprostatic Extension (EPE): Present, focal

Seminal Vesicle Invasion: Present - Right


Margins: Involved by invasive carcinoma - Limited (< 3 mm)

Location of Positive Margin(s): Right posterior

Lymph Nodes

Number of Lymph Nodes Involved: 1

Number of Lymph Nodes Examined: 9

Pathologic Stage Classification (pTNM, AJCC 8th Edition)

Primary Tumor (pT): pT3b

Regional Lymph Nodes (pN): pN1

Tall_Allen in reply to Rondief

You had a PET/CT, but those were the results of the CT - I assume the PET scan also showed nothing?

So your pathology results showed stage T3b (seminal vesicle invasion) and pN1 (cancer in pelvic lymph nodes).

Assuming the new bone scan is also negative, they will want to begin salvage radiation. I'm sure that after about 2 months of ADT, your RO will irradiate the pelvic bed and the pelvic lymph nodes. ADT will continue for at least 18 months.

Rondief in reply to Tall_Allen

Thanks for breaking that down for me. I love my SO, he is as smart as they come but he talks above my my head and I need a simpler explanation.

Hi Ron,

I am a 4+3 and had a rising PSA after RP. I saw the RO and we went with IMRT radiation to the prostate bed which brought the PSA down to undetectable. 14 months later the PSA began to rise again and I decided to get a PSMA scan in addition to a pet and bone scan. I was fortunate to get the scans done on a trial through NIH. The pet and bone scans found nothing but the PSMA scan found involvement in a pelvic lymph node. I started ADT (Lupron) had the entire pelvic lymph area radiated and I am now back to an undetectable PSA. Long story with a short piece of advice to try and get a PSMA scan to find out where to treat and what to treat with.

Best wishes,


GeorgeGlass in reply to Moespy

How definitive were the findings of the PSMA? I did the same PSMA tests at NIH but they said two suspected areas/hot spots but without great confidence. Where did you have the radiation done? What does the entire pelvic lymph area emcompass? How many spots is that? What are the long term risks of that radiation treatment to that area? Just trying to weigh my options.



Moespy in reply to GeorgeGlass

Hi George,

The PSMA lit up 3 spots next to each other in the iliac lymph nodes. I pushed and NIH took a biopsy of the bigger of the 3 LN's and it was positive for PCa. I immediately went on ADT and had the pelvic LNs up to and including your common iliac LNs radiated (IMRT) over 8 weeks. My Radiation Oncologist is Dr. Stephen Greco at Hopkins and I had the radiation sessions done in his Bethesda facility on Rockledge Drive. Still undetectable with 10 months left of ADT and will then go on vacation. Long term side effects from radiation are minimal and not something I have concentrated on, but could include fatigue and future cancer from exposure. I felt fine and have no issues so far.

Hope that helps, happy to provide any other information.

Best wishes,


GeorgeGlass in reply to Moespy

thanks Jim, I had general come beam IMRT for 20 session befpre getting brachytherapy at Bethesda Military hospital. I don't think they targeted the treatment properly. Thus, I have future threats like you but I was always wondering if I should try to target these hot spots I have. I see others radiating them but my Duke doctors dont think its a good idea - the age old comment that there must be microscopic cancer floating around in my lymphatic system. So, I haven't figured out why they must be floating around in my lymphatic system but that's not the thinking when other guys get radiation treatments on their lymph nodes that light up on PSMA scans. Maybe I should contact Greco. I was close to getting prostatectomy from Alan Partin but due to a series of events including coronary artery diagnosis right before scheduled surgery I ended up getting radiation instead. Wish I could go back and do it over differently.

I'm happy to hear that you are doing well now and I hope that the zero PSA stays that way forever.


Moespy in reply to GeorgeGlass

Thanks George.

I am a big fan of Dr. Greco. He is mild, compassionate and very experienced.

My hope is the 2 years on Lupron will clean up the micros and I can be free of this and ADT for a good long vacation. Then if it comes back I still have many tools left to knock it back again.

Best wishes with your treatment!


GeorgeGlass in reply to Moespy

thank Jim! Prayers to you.


I would try to get a PSMA PET/CT scan (Ga 68 or DCpyl) to know were the cancer is located. There are some clinical trials:



If the cancer is located in the pelvis radiation to the prostate fossa, lymph nodes up to aorta bifurcation and ADT could have good control of the cancer:


If there are distant metastases you should discuss the systemic treatment options with your MO.

Rondief in reply to tango65

Thanks, I’ll keep you updated

Rondief in reply to tango65

Thanks tango, that article sound like exactly where I’m at and I’ll mention PSMA to my doc

tango65 in reply to Rondief

Best of luck.

GeorgeGlass in reply to tango65

What does this mean? lymph nodes up to aorta bifurcation


I am very close to your situation, but hopefully still with low PSA.

Your doctors follow the current guidelines.

That is good for them, as they are legally covered, but not good for you as the kind of diagnosis and consequent treatment you are getting is out dated.

If you are to get the already proposed PSMA PET/CT now, there is a high likelihood that your up to now treatment will prove anything but optimum.

For example it may show that a higher number of lymph nodes (9 is minimal, I had 20 and know people that had +30) needed to had been taken out, or at the extreme, that RP was doomed to fail because distant metastases were already there.

Had you had taken this test 6 months earlier, would had been better to know beforehand or not? (rhetorical question to your SO)

In the event you/they decide to radiate your bed (not your crib).

My experience/caution (as I posted today on a previous post):

I've had 39 treatments (8 weeks, 5 days a week minus 1 day). I did NOT have any side effects during the actual "FRYING". However years later it was discovered that my left urinary tract had become scarred/constricted and required many "in and out stents" for my kidney and urine. BTW the in and out of the stents were "a walk in the park". No Pain or discomfort. Rad was done at Memorial Sloan Kettering cancer center in NYC.

Just be wary of the damage that Rad can do (even if it's silent).

P.S. Ask the radiologist for:

SpaceOAR hydrogel is an option for men who undergo radiation treatment for prostate cancer. It acts as a spacer providing space between the rectum and the prostate, making it much less likely that the rectum is exposed to radiation. It is injected into place prior to the start of radiation treatment.

Thank you for reading my posts, hopefully I make you smile..

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 10/15/2019 7:52 PM DST

Rondief in reply to j-o-h-n


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