Bone Marrow Involvement?

[j5000]

Hi all, I'm relatively new here. Thank you for reading.

For those of you who have prostate cancer in your bone marrow, what caused your doctor to check for it? My dad has a fracture in his pelvis from the cancer and the pain from that caused him to go get things checked out. They discovered that his PSA went from 3.2 to 185 in 10 months.

He has now had 3 months of degarelix and 1.5 months of Zytiga/prednisone PSA is down to 11. However his hemoglobin has dropped to 10.8 and is RBC is low and 3.68. Furthermore, his Myelocyte Absolute Manual and Automated nRBC Absolute are all a bit high. He had low platelets (70) to start and now they are up to 215. WBC is normal. Doctor wrote in his notes that he 'suspects bone marrow involvement.' Dad currently has little to no pain which is a miracle, I know.

I don't know if any of this will even make sense to anyone. I feel like bone marrow involvement is not a good thing and I'm looking for someone who is/has experiencing this to give me perspective of what is to come.

[Hidden]

The prostate cancer in his bone marrow at diagnosis would have the same high chance of being hormone sensitive as if it were anywhere else in the body. So his numbers could continue to improve with ADT.

Have the blood numbers improved since treatment started? What were the numbers at diagnosis 3 months ago?

Some anemia is common with ADT, although his RBCs are lower than the typical level of anemia from ADT. Hopefully, they will continue to improve.

As far as I know, he should still have a good prognosis as long as the cancer is hormone sensitive and responds well to ADT. Sounds like it is. Wishing him the best for him.

[j5000 in reply to Hidden]

Thanks so much for responding Gregg. I sadly feel like most of his numbers have gotten worse since the very first blood test. Providing just a few of his numbers below, let me know if you were asking about something I didn't list here.

9/23 12/27

PSA- 185 11

Hematocrit- 48.5 35.2

Hemoglobin- 16.2 10.8

MCH 29.3 29.3

MCHC 33.4 30.7

MCV 87.7 95.7

Platelets 123 215

RBC 5.53 3.68

WBC 6.2 5.4

nRBC/100 WBC 0.000 0.90

nRBC absolute 0.000 0.050

[Hidden in reply to j5000]

Have they biopsied the marrow and know for sure the primary is prostate?

[j5000 in reply to Hidden]

He had a bone biopsy on the lesion that was in his pelvis which showed primary as prostate. Is this the same as bone marrow biopsy?

We've just switched over to a larger university hospital this week. The doctor definitely implied that there is some funky things on his bloodwork but said he wants to get another blood test in to check on it, so we are headed back there on 1/21.

[Hidden in reply to j5000]

I would ask, but I don't think they would biospy the bone marrow in a typical biopsy of a bone lesion.

I would definitely want to get that done if they haven't done it since bone marrow invasion is not common in prostate cancer at diagnosis. It's generally a late stage development after prolonged treatment.

[j5000 in reply to Hidden]

Thanks Gregg57, I definitely will ask for it at our next appointment. Would you say it is late stage development DUE TO treatment or just because treatments haven't worked and it's progressed further?

My dad's progressed so incredibly quickly (10 months PSA went from 3.2 to 185). Yet (thank goodness) he has very minimal pain and symptoms.

A couple doctors said that in their experiences they hadn't see anyone else go up that quickly. Really makes me wonder if it is already in the marrow. Appreciate your advice more than words can explain. Wishing you well.

[Hidden in reply to j5000]

It's not that uncommon for PSA to rise that fast before treatment. He had roughly 6 doublings in 10 months so on average, that's a PSA doubling time of 1-2/3 months. PSADT can get as low as 3 weeks in some cases so his is a fairly fast increase, but not extreme.

My PSA was 463 at diagnosis and I had terrible pain, but went down to 12 in one month. You said his PSA is 11 right? That's the important thing. That's a huge improvement in a short time and there's a good chance it will continue to improve.

The late stage development of bone marrow infiltration often happens with successful treatment. We had someone on the forum who had succesfully treated his M1 prostate cancer for 12 years and ended up with bone marrow invasion. The cancer just evolves in different ways. Any cancer that has a survival advantage lives to reproduce. The longer we treat the cancer, the more time it has to evolve into more resistant forms. We are just trying to hold it off for as long as we can.

[j5000 in reply to Hidden]

Thanks Gregg57, it's good to know that his is AS extreme as people make us feel.

Yes, his PSA is now 11. Your drop in one month is incredible.

Thank you so much for this information, puts my mind at peace a bit. This is certainly a rough road to travel and I appreciate you taking the time to offer your knowledge. I am going to talk with his doctor on 1/20.

[LearnAll in reply to j5000]

The blood numbers can fluctuate as treatment starts working. My Hb was 12.5 on the day of diagnosis and now after 7 months it is 14.7. And the other blood numbers also shwed same trajectory. However, I did not have bone marrow invasion.

[j5000 in reply to LearnAll]

Thank you Learnall for responding. So glad that your numbers have gone up. Dad's numbers seem to be trending downward. But we will keep a close eye on it.

[LearnAll in reply to j5000]

J5000, I have been tracking blood parameters every 15 days since the day of my diagnosis. (May15,2019) I chart graphs of each lab reading.

I observed that degree of fluctuation in blood parameters corresponds with degree of disease process. PSA, Al Phos, Albumin, Hb, ..all of them rise and fall in tandem depending on what the status of cancer is at that given point. This is my "one man"

study.

[Zetabow]

PSA was 1386 and blood tests showed I was very Anemic, plus terrible bone pain.

It's been just over a year, my PSA has remained 0.028, Platelets etc have all been good for last 8 months. They said at one point I was producing any Platelets.

I still have lot of pain in Femurs where the most damage was done.

[j5000 in reply to Zetabow]

Thanks Zetabow for taking the time to answer and share your opinion. That is sounds wonderful that your PSA is sow low, I'm sorry about your pain though. May I ask, are you still anemic? My Dad's platelets, PSA and alk phos have improved in the past three months but some of his other bloodwork has not (hemoglobin , RBC etc).

[Zetabow in reply to j5000]

All my blood work is good at the moment, specially things like PSA, Hemoglobin and Platelet count.

Pain is the worst in the early hours where I'm woken by pain and often unable to move my legs for several min, not so much paralyzed, feels more dead, like when you sleep with your arm in wrong position and it's dead for a while until you get it moving. I'm seeing a pain specialist and she has me on Nuerontin, Oxycodine, Oxycondone etc which is helping. I had an MRI before Xmas and hope they can do some radiation treatment on the Femurs to help with the pain. It's tough some days but since they doubled my pain meds I feel a little more on top of the pain for the moment at least.

[Cheerr]

Low blood levels on diagnosis is one way for the MO to think of possible bone marrow invasion.

First find out what type of biopsy was done? Only a bone marrow biopsy can confirm the same. Most MO's may not order for a biopsy again now, since treatment plans/options usually do not change with/without marrow involvement. But you can always ask.

Just like Gregg said, cancer in the bone marrow / or in any part of the body on diagnosis usually hormone-sensitive, so the blood work improves slowly once the treatments begin.

The current bloodwork may be below the normal range but is fortunately not dangerously low where blood transfsions are needed, so thats a good sign.

[j5000 in reply to Cheerr]

Thank you so much Cheerr. I will ask about doing a bone marrow biopsy but I understand what you are saying that they may not as their treatment plan wouldn't change if there was.

I'm hoping that as we continue on some of his numbers come back to normal, however it is comforting to hear that they are not dangerously low. Our oncologist definitely took note of the hemoglobin and said they are going to keep an eye on it. I keep reminding myself that I have to remember the circumstances we are in and that to a certain extent my Dad's numbers may never be fully normal again. Truly appreciate you taking the time to answer.

[Cheerr in reply to j5000]

It’s good that the doctors are monitoring the levels. This is to be sure it’s never falling too low. And with time you’ll be able to see an improvement. And at some point it’ll stabilise a bit. It may not always be perfect (like HB 13-14) but at a point even 11 sounds good when dealing with cancer and it’s numerous treatments.

[j5000 in reply to Cheerr]

This is exactly what our doctor said. When I mentioned my concern about the Hemoglobin being 10.8 they responded with 'that's actually pretty good.' I'm glad they are monitoring though as my Dad's hemoglobin seems to be going down 1 point every month (was 14.2 on 10/15). Hoping that they regulate a bit and don't continue downward.

[LearnAll in reply to Cheerr]

I agree with you on "treatment plan/option donot usually do not change with marroew involvement" The treatment still remains "kill the cancer cells" by any means/all means available. But, if Hemoglobin goes too low (below 9) then, temporary blood transfusion might be needed to replenish Hb.

[Cheerr in reply to LearnAll]

Yes agreed. But most hospitals allow a blood transfusion only if HB < 7.

So tricky part in when blood levels are not too low but are not in the normal range either.

With cancer & it’s treatments levels HB 9-12 are considered okay too at times since not everyone can bounce back to 13-14.

Those with constant low levels should keep monitoring to be on the safe side. It’ll stabilise at some point hopefully.

[Hirsch in reply to Cheerr]

Since when do hospitals make medical decisions. please clarify. Good luck.

[tom67inMA]

My PSA went from 2.0 on a routine screening to 216.0 at diagnosis in 13 months. If I recall correctly, my urologist also said he never saw anybody go up that fast (the first several months after diagnosis are all a blur to me).

Don't know if my marrow was involved at all, and my oncologist doesn't seem to care and generally doesn't like to do any testing beyond blood work unless it will inform a treatment decision. I do have some pain, but it's mostly controlled with Celebrex and I've gone back to work full time and am also walking and running 20+ miles a week. The running greatly helps with side effects including pain but can also aggravate the pain if I overdo it.

Details of my treatment are in my profile, but at last check in early October my PSA was <0.01, ALP was in the low 40s, Hgb low end of normal (13?), white blood cells just below normal, and platelets a bit low (<120k) and dropping slowly.

One thing to keep in mind (and I'm still trying to wrap my head around) is that the "normal" ranges for most blood work is based on the average readings of healthy people. Cancer treatments can affect blood counts both during and after treatment, and since many of us here are on ADT for life, we can expect abnormal blood counts.

[j5000 in reply to tom67inMA]

Can't thank you enough for this response Tom. Although I wish that my Dad and you had something other than this in common, it's good to know that you are doing well now having had a similar story to my dad. Your numbers match my dad's somewhat similarly.

My dad has extensive metastases in his pelvic bone and spine (and some in the ribs and shoulders). He started at PSA 185 and Alk Phos 481 (that went up to 1000 one month into treatment). It is down now to 11 and 381 respectively and we hope that all this continues to work for as long as possible.

As you said, I'm constantly reminding myself to not let the abnormal counts bother me too much, rather to be content that they aren't (and hope that they don't) go dangerously low. I really appreciate you taking the time to respond and share your story. Wishing you well.

[tom67inMA in reply to j5000]

Has your dad had chemo? My Alk Phos was up near 1000, and while it dropped on Lupron it was chemo that really seemed to knock it down into the normal range.

I had lots of mets too. Check out healthunlocked.com/advanced... too see my bone scans. About the only thing good I can say about the before scan is that it didn't qualify me for the "a met in every bone" club.

Good luck to your dad!

[j5000 in reply to tom67inMA]

He has not had chemo. We started out for the past three months with one oncologist (who said dad should do Zytiga) and have just switched over to another at a larger hospital (who usually goes the Taxotere route). It was implied to us that Dad's bloodwork wasn't good enough to do the chemo (platelets were 70 at the time). I often think we maybe should have done Taxotere first, but guess we just have to continue on the path we are on. And the PSA/alk phos are going down so hopefully it will continue to work.

You are so right when you said the first few months are all a fog. Man oh man is that SPOT ON. We are just now sort of coming out of it almost 3 months to the day. I wish that once my dad got diagnosed I had known all I know now as I think we could have made a better decision but obviously that's not possible! So I just try to be as informed as I can and reach out to forums like this, people like all of you and our doctors to learn, learn, learn. I hesitate to say it in terms of jinxing it, but Dad's having some good, minimal pain days and I am hoping they continue. There's nothing better than hearing his life or the lightness in his voice because he's actually feeling ok!

Wishing you well and luck also, Tom! I will be following your story and thank you again for taking the time to write. You have no idea how much it means to caretakers and the people who love those that are going through this!

[LearnAll]

Tom,

Thats an important question. Why our bone marrow is working at lower level ? is it residual cancer OR ADT effect?

For me its too early to tell as my blood parameters have all bounced back to normal levels as they were before diagnosis. I will keep an eye on them as 7 months is too early to make conclusion.

[tom67inMA in reply to LearnAll]

My understanding is it can be "all of the above". If yours have bounced back to normal levels that's fantastic, I'm not sure everybody gets such a bounce. I know my oncologist was greatly amused at how reliably my neutrophils came back at the end of each chemo cycle. "Perfect saw tooth" was how he described the graph. Apparently, many of his patients have comorbidities that complicate things, and there's definitely many stories of people (not just prostate cancer patients) that have to delay chemo while the blood counts recover, or need transfusions, etc.

My blood counts are currently going in all directions. I'm hoping they'll be more normal on the next draw a week from now.

[LearnAll in reply to tom67inMA]

Neutrophil bouncing back quickly is a good sign. Chemo causes temporary neutropenia. If your bone marrow is functioning well, it will respond to neutropenia fast by manufacturing more neutrophils to make level normal again.

[j5000 in reply to LearnAll]

Learning a lot from you all. Thank you.

My dad's Neutrophil percentage and Neutrophil Absolute have been normal thus far, however he has not done Taxotere yet as he is currently doing Zytiga/prednisone. I'm assuming if this treatment plan may not have similar effects on the Neutrophils

[LearnAll in reply to j5000]

j5000,

Its good sign that dad's neutrophils are in normal range. If you want to get even more accurate state of bone marrow , get NLR (neutrophil lymphocyte ratio ) and PLR (platlet lymphocyte ratio)

For NLR, take absolute Neurophil count and divide by absolute lymphocyte count. If the number comes below 2, dad's marrow is still doing well.

For PLR, take platlet count number and divide by abs lymphocyte number , if the figure comes below 120, another indicator that his bone marrow is not in trouble.

If the ratios come abnormal, do not worry as with treatment, these ratios will start improving and hopefully become fully normal as they have done in my case.

[tom67inMA in reply to LearnAll]

I was just reading recently about these ratios in the context of them being markers of inflammation. My ratios are elevated because my lymphocytes have been very low. If they've been improving, it's more because my neutrophils and platelets have been dropping modestly more than the lymphocytes coming back.

[LearnAll in reply to tom67inMA]

It doesnot matter how these ratios are coming towards normal values. Mere correct ratio indicates status of disease and acts as predictive marker besides being inflammatory markers. May be your lymphocytes are getting depleted fighting left over cancer cells.

The best inflammatory markers are C Reactive Protein (should be less than 1) and

LDH (lactic dehydrogenase ) sould be less tha 150.

Keeping bodily inflammation as low as possible ... is a very good intervention to stop progression of prostate cancer. Thats where the role of plant based anti inflammatory foods, spices and herbs comes.

[j5000 in reply to LearnAll]

For those of you here who kindly answered me, I am reaching out again to ask another question. I hope you don't mind.

I've been looking more into Dad's blood counts and saw that his nRBC/100WBC is 0.90% and it should be 0.00% (as it has been for all the weeks leading up to this). I should also mention that the first CT scan he had done showed an enlarged spleen. I'm reading up about the nrbc/100wbc and seeing something called 'Leukoerythroblastosis.'

Have any of you had similar numbers for that count of heard of this? It appears relatively serious to me, but I could just be making myself worried. I am going to contact the doctor on Monday.

[LearnAll in reply to j5000]

j5000

Leukoerythroblastosis is a sign that Dad's bone marrow in not able to produce fully matured blood cells..means there is arrest in development oof cell causing a lot of "blast cells"

This condition happens when bone marrow is affected by (1) cancers such as mProstate cancer or lung cancer (2) chronic inflammatory condition such as tuberculosis or sarcoidosis.

In Dad's case, there is enough reason to suspect that this bone marrow abnormality is coming from invasion of prostate cancer cells in the marrow and disturbing the manufacturing process. Lets hope it turns out to be reversible with treatment. Waiting to hear what his Doctor says on Monday.

[Zetabow in reply to j5000]

Curious I had an enlarged Spleen on my scan results as well

[j5000 in reply to LearnAll]

Thank you LearnAll! I calculated these ratio in all of Dad's blood work since the beginning of all this three months ago. The ratio has been below 2 and 120 respectively until the past month (Dad's platelets have gone up in this time period).

In Dad's most recent blookwork his NLR is 1.75 and PLR is 121. You are so right though we just have to wait to see how the treatments go for him. Thank you!

[LearnAll in reply to j5000]

I am glad to know Dad's beautiful NLR and PLR. That should lower everyones anxiety as things are going well and going in right direction. Also keep an eye on his Hemoglobin level. Congratulations.

[j5000 in reply to LearnAll]

We definitely will be keeping a close eye. Thank you again for replying!

[j-o-h-n]

Give your 70 year old Dad my regards and tell him God is on his side.... (yours too)...

Good Luck, Good Health and Good Humor.

j-o-h-n Sunday 12/29/2019 11:13 PM EST