Are We Out Of The Woods For A While?

[Londear1992]

It has been a roller coaster of a few months. After a hemi-ablation HIFU In Germany (4/11/19) Alan had a great nadir of 0.19. Men with that kind of result have a 96% chance of not having a recurrence within five years of treatment. It stayed like that for a year and then increased to .80 in May of 2020 and had reached 2.13 last month.

A 3TMRI in July indicated two possible lesions - Pirads 3 and Pirads 4 high grade cancer. (Alan's only biopsy before HIFU showed two small cores of Gleason 4+3 with a small amount of Gleason 4+4 pattern. The two small tumors were T1c's.)

With the rising PSA and supected lesions on July's MRI, Alan got scheduled for a PSMA-PET Scan at Dana Farber on 27 September. No sign of metastasis, but there was a small intensity seen in the prostate. All signs pointed to a recurrence. (BTW this was a Pylarify PSMA PET Scan and was fully covered by Alan's Medicare.)

To rule recurrence out, Alan had an in-bore, MRI guided perineural biopsy at Brigham and Women's last Wednesday (with Dr. Tuncali who has done more than 1,500 of these) and miracle of miracles, no cancer was found in the two suspected areas (it was fibromuscular tissue - maybe scar tissue from the lesions he had removed in Germany?) and another six samples were taken from various parts of the prostate to be sure. All were benign!

Many doctors use the Phoenix definition to assess a biochemical recurrence following HIFU, which would be a PSA of 2.00 above nadir, or in Alan's case 2.19. At his present PSA of 2.13, that is awfully close to that limit, but in the absence of any cancer found on his PSMA PET Scans or MRI Guided biopsy, Dana Farber says there is nothing to treat as far as they can discern.

So Alan has been put back on active surveillance. Hooray! But if his PSA continues its rise and hits 4.00, he will need to go back for more testing. We would like to think he is out of the woods for now (maybe re-growth of prostate tissue caused the PSA rise?) but we are not sure what to think. Any ideas? BTW we were very, very happy at Dana Farber. The oncologist, Dr Choudhury, was awesome.

We are seen above with Alan's HIFU doctor (Dr. Stefan Thüroff in Munich.) He practiced HIFU treatments on patients for more than 25 years before retiring last month. He was a wonderful doctor and always considered QOL for his patients.

[Tall_Allen]

It is very hard to use the typical imaging after HIFU - it doesn't look the same. Let's face it, the PSA is coming from somewhere, and biopsies can often miss it. Maybe they can find it with a transperineal mapping biopsy in 6 months.

I am not a fan of HIFU:

prostatecancer.news/2021/03...

[Londear1992 in reply to Tall_Allen]

Thanks. This is the report from the in-bore, MRI Guided transperineal biopsy Alan had last week.

PATHOLOGIC DIAGNOSIS:

A. LEFT ANTERIOR APEX LESION:

Fibromuscular tissue; no prostatic epithelium or carcinoma identified.

B. RIGHT ANTERIOR APEX LESION: Benign prostatic tissue.

C. LEFT APEX:

Benign prostatic tissue.

D. LEFT MID:

Benign prostatic tissue.

E. LEFT BASE:

Fibromuscular tissue; no prostatic epithelium or carcinoma identified.

F. RIGHT APEX:

Benign prostatic tissue.

G. RIGHT MID:

Benign prostatic tissue.

H. RIGHT BASE:

Benign prostatic tissue.

[addicted2cycling in reply to Londear1992]

Tall_Allen wrote --- " ... Maybe they can find it with a transperineal mapping biopsy in 6 months.... "

IMO and it's not even worth 2 cents, T_A is SPOT ON regarding a MAPPING BIOPSY should PSA continue to rise. Employing a Brachy Grid with 5mm spacing and sufficient core needles for prostate tissue remaining can provide 40/50+ biopsy samples for the coverage of virtually all of the remaining prostate.

BEEN THERE AND DONE THAT having had my right half GL-10 HEMI cryoablated (2015) and a recurrence in 2018 within left half (focalled spots of 6/7 in 2015) that were found using Axumin then pinpointed with mapping biopsy by Dr. Gary Onik. Will be having Axumin tomorrow due to rise in PSA as a first step for checking again.

[Currumpaw in reply to addicted2cycling]

Hey addicted2cycling--

The email came at 0130 hours --therefore--Best wishes and hoping your scan is clear!

Currumpaw

[addicted2cycling in reply to Currumpaw]

Thanks 👍 Just like one finally finds that item being searched for in the last place you look, 😀, results will be taken as they come. Expect the worse and go for a FULL MOON midnight bicycle ride on Wednesday!!!

[Tall_Allen in reply to Londear1992]

What I suggested is a MAPPING biopsy (see addicted2cycling).

[tango65]

If you have contacts in Germany , perhaps you could consult about getting a 18F PSMA 1007 PET/CT which is not eliminated by the urine. Ga 68 PSMA and the Pylarify ligands are eliminated by the urine and could make difficult to visualize lesions in the prostate . 18 F PSMA 1007 may be more precise to detect lesions in the prostate since if eliminated by the liver.

jnm.snmjournals.org/content...

Biopsies can miss lesions and PC could be multifocal.

[Spyder54]

Thank you for the complete summary. Fascinating journey. I assume Hemi ablation is half of the prostate-yes? Wouldn’t the other half always put out some PSA?Best to you both,

Mike

[Londear1992 in reply to Spyder54]

Yes, Mike, that is expected. The question is the velocity. A bounce is expected and Alan experienced this at one year. His PSA had gone from 0.19 at three months, 0.21 at six months, then 0.80 at one year out. The bounce is expected as the prostate recovers, but the continued rise is a worry. Still, he had two of the most up-to-date tests and no sign of cancer either from the PSMA PET Scan (Pylarify was used, which is more sensitive when there is not as much PSA) and the in-bore MRI guided guided biopsy (done by a very experienced doctor.) Alan's MO at Dana Farber said you can't treat what you have no evidence for (he was a bit puzzled too.)

For comparison purposes, a friend of ours had the same type of cancer and same treatment (HIFU) as Alan with the same doctor in 2007. Here are his recent PSA numbers:

3/19 = .64

10/19 = 1.03

3/20 = .81

10/20 = .98

3/21 = .72

10/21 = .70

So, yes, the PSA is expected to bounce back with half a prostate left and even increase over time, due to aging and due to re-growth of prostate tissue. Our friend had a nadir of less than 0.10 so his has gone up over time too, but we are talking over 14 years. Alan's has gone from 0.19 to 2.13 in only two-and-a- half years, so that is more concerning.

But his MO has put him back on AS and has told him not to worry until his PSA hits 4.00. With any luck it will have gone down a bit or plateaued when he has his next PSA. Thanks for your response. We will keep you posted!