This situation is a bit abnormal, but wanted to gather some thoughts.
My father was DX'ed last September with Gleason 4+4, tertiary 5. He had his RALP + PLND 2 weeks ago. Pathology showed ECE+, PNI+, SVI+, LVI-, 2/16 small LN mets (unfortunately, poorer than what imaging showed), and close PSM (less than 0.1mm) in right posterior. Final staging was T3BN1M0. Prior to surgery, he did 6-month neoadjuvant ADT (3 month Zoladex + daily bicalutamide) as initial MRI showed tumour too close to the rectum wall. Fortunately, this wasn't the case when they opened him up, so there were no complications.
A week before surgery after another round of imaging, my dad received another 3 month Zoladex injection (was surprised by this). On the day of the surgery, he was told to stop the daily bicalutamide. His PSA one day after RALP was 0.67, which dropped from 2.05 at the time surgery. However, 2-week post-op, we found that his PSA rose to 0.85 instead of dropping, which shocked all of us. He is scheduled to do another PSA test in a month, and was told to go back on daily bicalutamide.
I understand this situation is abnormal, as our urologist (considered one of the top in the country) seems to have his own process of patient monitoring and follow-up (first PSA testing right after RALP, 2nd PSA testing 2-week post RALP etc.), but wanted to gather some thoughts.
My question:
Does this increase from one day post-RALP to 2 weeks post-RALP indicate early CRPC, only after 6-months of ADT (note that he had another shot of Zoladex a week before surgery)? Could the jump be from other causes such as the new round of ADT injection a week prior, or stopping the daily anti-androgen?
I understand PSA rebounds can happen during when you first start hormone therapy or radiation, but I couldn't find any cases on post-RALP, as for most (if not all), standard time to do first post-op PSA test is 4-6 weeks, not 2. Plus, I understand neoadjuvant ADT + ADT post-surgery is uncommon, so really having trouble digesting and interpreting this.
Would love to hear your thoughts on this.
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sixmongoos
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RP dumps large amounts of PSA into his serum. That's why PSA tests are meaningless for 3 months after surgery. But PSA is not the issue - the LN metastases are.
He should be talking to a radiation oncologist about whole pelvic salvage radiation and 2 years of ADT. He might consider the following clinical trial.
I’ll answer in plain English. Without looking up each post surgical ICDM pathological code, What did pet scan show prior to surgery or MRI? You did not say that or what type. My husbands had MRI prior to surg was gleason 4+3. No treatment prior. At surgery, they found it had escaped to pelvic lymph etc. again this was not on MRI. Had they known would not have done surg. It usually is not done here… I fully understand that many try medication first to control the PSA, but sadly does nothing to resolve the problem, it will fail and when cells wake up can become fast moving. Mine was not on meds prior to surg. His PSA did not go below 3 after. It was 5.5 before surg. Got to Mayo where a c11 choline pet scan showed it was in lymph in chest area. It would be interesting to know what his imaging showed prior to surg. The reason post surgical PSA is done more at the 6 week range is that it is often unreliable earlier due to previous antigen circulating and taking time to decompose and be eliminated from the body. That could be the situation in your case. Similiar to the post radiation bounce. If it continues to go up while on the meds which is strange to be on them, he needs a pet scan to determine where it has metastized to so further treatment can be started. Your ICDM codes do indicate there is a possibility. You might want to refer to the PEACE1 study for current thinking in treating metastasis that also includes parts of the CHARRTED and others. There are also immunological avenues etc. I am in the US which each country approaches things a bit differently and each country has their own approved medication. I know, at one time, zytiga was not avail in Canada. Best wishes.
In re reading I see some results of pre surgical imaging. You may need to prepare for further treatment.. bill did start with the chemo, and sorry I don’t do initials for pathways, then 6 mo of zytiga, Lupron and prednisone, then 37 radiation with the same meds,nthen the meds for a year. 6 years non detectable no evidence of disease by pet scan, no meds or treatments 5 years. He had very little side effects during the two years. Our quality of life, which may be different than yours,is better now than when this journey started 8 years ago.
Appreciate the thoughts. I'm sorry to hear that your husband had to go through an unnecessary surgery, but very glad to hear that you guys are doing well. 8 years! That's amazing.
Thank you for your kind words. My dad was already aware from the get-go that his aggressive cancer profile puts him a likely candidate for adjuvant/salvage RT + ADT, so further treatment isn't a big shock to us. My biggest concern however, was more so the likelihood of reaching castration resistant too soon - however, it seems like only time can tell what the results would be.
Out of curious, for your husband's case, did they radiate the whole pelvic area + systematic therapy to kill the cells outside the radiation area (i.e. the LN in the chest)? I wasn't aware they still radiate the pelvic area once distant mets are found.
I had two suspicious iliac LNs 1 1/2 yrs after RP in 2013 and one yr after SRT in 2014 . I was advised to have all pelvic LNs radiated which I did in 50 sessions and 75 grays. Never had a recurrence in soft tissue or other organs but had Met in one bone in 2017, two bones in 2018 and in multiple bones in 2022. Bones are typical place for Pca to travel after pelvic LNs I believe. I was Gleason 9 stage pt3b N0M0 post RP.
His numbers are non-consistent. PSA has a half life of 2.5 to 3.5 days. Even if all his PSA was originating from his removed prostate, which would have been the most favourable case, one day decay of the pre-surgery existing PSA of 2.05 could not have brought it down to 0.67. My assessment is that said 0.67 is a lab error. Also, his 2 weeks 0.85 tells me that even with the longest half life of 3.5 days his 2.05 PSA would had been brought down to 0.13 (4 halvings), which is not the case. Hence, PSA is still produced at other places.
Just wanted to give a quick update - my father had another PSA test after a month, and it has dropped to 0.3. Curious if going back on daily bicalutamide could have helped, or if it was truly PSA dump from RP.
Assuming 30 days of Bicalutamide @ 50mg/day, should lower pre-existing PSA down to 18%* of initial value. 0.85x.18= 0.15 or 0.2 rounded to a single decimal place. Not far off the 0.3 that you wrote, but why on earth don't you use a 2 decimal places reporting lab?
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