Blood Test Question

[Murph256]

I have a question for the biochemists on this forum. Since I was first diagnosed in Jan of 2018, my alkaline phosphate numbers have always been a little elevated. Also, my neutrophils have always been elevated and my lymphocytes low. I had a bone scan in April of 2018 and a axumin PET scan in Feb of 2019, both of which turned up nothing. My PSA is currently undetectable after RT and ADT, but I only just stopped the ADT last August and the RT last June.

In my last blood test last Nov, my ALP was 101, my neutrophil was 77.1% and my lymphocyte was 10%. These numbers have all been in a fairly narrow range since my DX two years ago.

My question is, are these numbers an indication of something lurking systemically or nothing to worry about?

[LearnAll]

There is individual variation in ALP numbers for each person (range 45 to 117) Your ALP seems closer to upper end of normal. In this situation, you need to get ALP from last few years and see what has been your average ALP. In my case , years ago before diagnosis, my lowest ALP was 55, so that is what I consider my baseline. You need to find your baseline and compare with current number. Also, healthy liver generates about 40 to 50 points of the ALP. If scans and clinical symptoms are pointing towards remission, that is a very good news.

Remember, dead cancer cells do not produce PSA..they are just dead or in coma.

Next marker is Neutrophil to Lymphocyte Ratio which can give you some idea about how well things are going. N to L ratio should be as low as possible ,preferably below 1.5

N to L ratio higher than 3 is not desirable. Take absolute number of Neutrophils and divide by absolute numbers of Lymphocytes and that's how you get your N to L ratio.

[Murph256 in reply to LearnAll]

Thank you for your prompt response. My average ALP over the last two years has been 98, with a low of 90 at the very end of my RT.

My Abs Neut is 4.7 and my Abs Lymph is .6, still not good.

[LearnAll in reply to Murph256]

So my impression is that your baseline ALP should be 90. Plus minus 10 points are not really significant. It can fluctuate from one lab test to another test by 10 points .

I think you should be fine with 110 BUT make sure it is not rising steadily...Monitoring is still needed.

Same thing with N to L ratio...up to 3 .0 is Ok so its somewhat higher. May be you have some hidden infection somewhere...try to look for that.

[westof in reply to LearnAll]

Hmm... I just received the results of my monthly blood draw. here are some of them:

Alkaline Phosphatase83 U/L

9 - 122 U/L

Alanine

Aminotransferase (ALT)17 U/L

6 - 34 U/L

Aspartate Aminotransferase (AST)22 U/L

11 - 33 U/L

Neutrophils81.3 %

45.0 - 90.0 %

Lymphocytes7.0 %

10.0 - 50.0 %

My dx was 16 months ago: G9,S3,high PSA 28 and no mets.

In April I had HDR Brachey and finished 25 days of IMRT in July.

I take Zytiga, prednisone and Lupron and will continue for another year and a half (my MSK MO says that I'm "slightly anemic and treatment is the culprit".

Should I be concerned about my N to L ratio (11/1)?

Thanks

[Murph256 in reply to westof]

Who is your MSK MO? Do you recommend him?

I was seeing Dr. Min Yuen Teo at MSK, but he disappeared when my clinical trial ended. My next apt is in Feb.

[westof in reply to Murph256]

Dr Richard Frank, formerly of MSK and now heads up the Whittingham Cancer Center @ Norwalk (CT) Hospital. On SUNDAY 8/18 I sent him an email re: anemia and he replied within 4 hours! He is great!

webmd.com/richard-c-frank

MSK has satellite branch there and my MSK RO works there and in NYC. He referred me to Dr Frank.

Best

[Murph256 in reply to westof]

Sounds promising. I am in Wilton, 10 min from the Norwalk Hospital. Thank you for the recommendation.

[westof in reply to Murph256]

Hey neighbor, Easton

[Murph256 in reply to westof]

We just cut our tree there a couple of weeks ago at Maple Row Farm.

[westof in reply to Murph256]

Just a bit more info re: MSK Norwalk:

Dr Daniel Shasha is my MSK RO. He performed Brachy in NYC and IMRT at Norwalk.

When I go to Whittingham, my wait time is usually less than 10-15 minutes and both docs give me all the time I need and answer every question.

However, I come prepared. I have a note book with questions prepared in advance and I get to the point. The consults are fast and efficient!

Best

[Murph256 in reply to westof]

I’m very happy with my RO at MSK. I found him to be smart, well trained, highly skilled and friendly. His wait times are outrageous however.

I’ll speak to your guy, Dr. Frank. And I’m also going to speak with Dr. Daniel Petrylak at Yale New Haven and Greenwich Hospital.

[LearnAll in reply to westof]

A part of high neutrophil count is due to prednisone which causes benign increase in neutrophils. So, if you are taking prednisone the value of N to L ratio as a predictor marker goes down. Your liver appears in good shape based on AST and ALT numbers.

If you are with long bones (you are tall and bone heavy) then, ALP 83 seems pretty acceptable.

Race and size also needs to betaken into consideration when analyzing these numbers.

If you are Asian and 5'2" tall, you have smaller prostate and smaller bones so lower end of normal numbers are more accurate for you.

If you are African/Slavic/German with height of 6;5" , you have larger prostate and longer bones. .in that case upper end of normal range is more accurate in your case

Ethnic medicine is a new but fast growing field...because there are significant differences in dosing of medicines across race and ethnicity. If you give 5 mg of Valium to a 5" feet tall, Chinese woman...she will sleep for 20 hours.. But you give the same dose to a Caucasian or African woman..she will have effect for only a few hours.

[westof in reply to LearnAll]

Thanks! I'm 5'10" and weigh 160. small to medium bones. Few SE's to mention.

Best

[LearnAll in reply to westof]

In that case ...look for middle of the normal range and compare ALP numbers with that midpoint.

[westof in reply to LearnAll]

Again, Many thanks.

[Hidden]

"....The value of 2.494 for NLR was found to be a cut-off value which can be used in order

to distinguish recurrence according to Youden index. According to this, patients with a higher NLR value than 2.494 had higher rates of PSA recurrence with 89.7% sensitivity and 92.6% specificity..."

ncbi.nlm.nih.gov/pubmed/257...

"... Patients were divided into a high-NLR group (NLR 2.36) and a low-NLR group (NLR<2.36) according to the pretreatment NLR...

...Our findings suggest that the pretreatment NLR may be associated with pathological stage and lymph node involvement in PCa patients receiving RP, and that PCa patients with a high NLR may have a higher rate of biochemical recurrence following RP than those with a low NLR..."

ncbi.nlm.nih.gov/pmc/articl...

"....In summary, our meta-analysis demonstrates that an elevated NLR is a strong indicator of poorer prognosis of patients with mCRPC, whereas the NLR is not significantly associated with prognosis of patients with localized PCa...."

ncbi.nlm.nih.gov/pmc/articl...

[depotdoug in reply to Hidden]

This is a whole new arena for me. Time to watch my blood labs extremely close. Got a lot of reading to read.

[Hidden in reply to depotdoug]

There is a whole family of markers apart from the Lymphocytes to Neutrofils Ratio, such as Platelets to Lymphocytes Ratio (PLR), Lymphocytes to Monocytes Ratio (LMR) and the Systemic Inflammation Index (SII) which combines 3 of them.

Also, an increase in Eosinophils signals a mounting defensive by the body.

[depotdoug in reply to Hidden]

Thanks, I'm a start your engines advanced PCa guy now pegged Metastic and Stage4.

Zytiga(Abiraterone) and Prednisone to be started this Wed. I've got my Blood Labs from Sept 10th at 1st Lupron inj and last week Dec 10th 2nd Lupron inj. Is it time to start baselining those results??

[Hidden in reply to depotdoug]

Go further back. I composed an excel with results as old as 1994. Each time series is revealing.

[depotdoug in reply to Hidden]

Yeh I could go back to 2016 ish when PSA started its re-rise. That was 3 years post ADHT Round #1 which ended ~ ~ early 2013.

Do you mean my Blood labs reports with those lymphocytes, platlets, monocytes, type of markets?

[Hidden in reply to depotdoug]

Yes.

[Murph256 in reply to Hidden]

Thank you for your informative response.

So what is the cutoff for platelets/lymphocytes and lymphocytes/monocytes, if I may ask?

Also, are these studies accurate for second recurrences after RT, as well as initial recurrences after RPs? I would assume that they are, if they are predicting lymph node involvement.

[Hidden in reply to Murph256]

Regarding PLR, this meta-analysis examines a number of papers comprising various cutoffs to associated endpoints.

ncbi.nlm.nih.gov/pmc/articl...

My personal retrospective data shows that during my "inocent" years it was 125+/- 25. During the "suspecious" years it surged up to 260 and now after the RP is falling but very slowly (latest one at 198) .

Regarding LMR one study sets the cutoff point to 3.05, but attention here. Higher is good, lower is bad, reciprocaly to the other ratios where less is better.

Equally, from an "inocent" 5.x I have gone down to 2.0 and now very slowly climbing up-hill (latest one 2.3).

My personal view is that, like PSADT, it is the derivative (rate of rise or fall) that signals the trend.

[Murph256 in reply to Hidden]

Thank you.

[Hidden in reply to Murph256]

You are welcome.

[depotdoug in reply to Hidden]

THxs again justfor, I've got some homework to compile starting with when it snows tomorrow, or after my PFT personal fitness training session#3. Anxiety exercising relief is doing me great lately. Really for the last 4 years. Exercising trying to keep my muscles, bones, legs, and especially my Cardio health as good as I can. Do not want a repeat of SCA arrest like May 2011, 12 days in CICU +5 cardiac rehab days.

Let's see I've had 7 older now not-my Urologists, 3 IU Health Urologist now 2, 2 Radiation Onc, 1 past Med Onc, and 1 newest present MO. That's a lot of laboratory testing reports.

Doug