Rising ALP (alkaline phosphatase) but PSA still undetectable...any thoughts that don’t include bone Mets??!!

[dkingsley]

My husband was diagnosed with Gleason 9, advanced prostate cancer in January 2020, his psa was 5 pre surgery. Had RP 3/20, 9/40 positive lymph nodes. Post surgery PSA was 1.7. Had PSMA done at MSK 5/20 only uptake found was in para aortic lymph node. Started on ADT and Apalutamide. Had whole pelvic radiation with a boost to the lymph node in 11/20. Has been undetectable since starting on meds. His last two blood work ups showed an elevated ALP of 148, then 158. Ruled out liver, know it is coming from bone. Given his low emission of PSA from the start is it possible to have bone Mets and still be undetectable? If not bone metastasis any other ideas as to why his ALP is rising? They are also looking at his para thyroid gland. He works out with weights regularly and runs about 20 miles a week. Has always done cardio but weights are new. Could the new work out routine be the culprit? Would appreciate any insight.

[LearnAll]

The rise in ALP is not big enough to say that there are bone mets growing. ]Some fluctuations in ALP occur in men who work out and lift heavy weights.

You should check his ALP every month to discern a clear trend.

If ALP keeps rising each month then, its something serious. Because some aggressive type of cancer cells do not produce much PSA but they can corrode bones and cause increase in ALP.

Just monitor ALP each month and find out if it is up and down ....or consistently going up. To early to tell anything definite.

[dkingsley in reply to LearnAll]

Thank you! I think if the para thyroid test comes back normal his MO might do some scans. She told us today not to worry as the PSA has remained undetectable but my biggest fear is maybe his cancer doesn’t express PSA so worried that PSA is not a good indicator for him.

[LearnAll in reply to dkingsley]

But bone specific Alk Phosphatase is specific about bone mets.. .irespective of low PSA type or high PSA type prostate cancer cells. Besides ALP, other marker to monitor is Lactate Dehydrogenase (LDH ) (very important) as this enzyme if rising tells about cancer cells turning aggressive.

[dkingsley in reply to LearnAll]

I don’t know if they are testing LDH... I will ask. Thanks again for responding.

[Dett]

For what it’s worth, my husband (Gleason 9 with mets) was diagnosed with hyperparathyroidism about a year ago. There are two types: primary and secondary. Primary hyperparathyroidism is usually caused by a benign tumor on one of the four parathyroid glands. My husband’s PTH and other blood tests weren’t exceptionally abnormal, but a subsequent sonogram revealed that he had a parathyroid tumor. None of his doctors seem especially concerned, and they don’t recommend removing the tumor. Husband’s ALP rose slightly above the normal range at his last bloodwork; I’m hoping it’s just the parathyroid tumor or something trivial. PSA remains undetectable. Please keep us posted.

[dkingsley in reply to Dett]

Thank you for sharing... I will keep you posted

[dkingsley]

Thank you...really hoping it’s the increase in weight lifting! I will check his blood work to see it the others you mentioned have trended up.

[SeosamhM]

Great post to draw out great information! Thanks, Kingsley!

[NecessarilySo]

First I'm not a doctor, but a survivor who has had a lot of time (9 years) to read up on mPC. I have often wondered about what a rise in ALP means. Mine has stayed in normal range. High ALP is associated with cancer metastasis among many other things. There is a good explanation in Elevated ALP Wikipedia. After reviewing that and my own history of ALP the things that stand out to me for your husband's case (slightly elevated ALP but undetectable PSA) are:

1) the extra weight workouts give stress to bones,

2) Vitamin D deficiency possibly caused by winter lower sun exposure,

3) A fractured bone such as too heavy weight lift or running knee joint wear,

4) Hypertension,

5) Recent additional Drugs (Apalidomide?)'

6.) Metastasis spread to colon from aortic lymph node (very initial).

[dkingsley in reply to NecessarilySo]

Thank you... I’m really hoping it’s the weight lifting!

[NecessarilySo in reply to dkingsley]

I do a bit of weightlifting., although very moderately (maximum 40 lbs. (It is supposedly helpful for osteoporosis as it increases bone health). Testosterone-reducing drugs cause calcium loss in bones, (e.g.Lupron), while weightlifting causes increase of calcium in bones. How much does he lift, maximum? Just curious for comparison.

[Wings-of-Eagles]

I'm mis-understanding , I think (brian fog) do you mean that eating yogurt, lentils and chicken and or turkey can raise or does it lower ALK phosphates? Thanks always for all your great info by the way