Elevated PSA 8 weeks after Robotic Prostatectomy

[OLDSALTY2008]

At the age of 70 my most recent treatment was a Robotic Prostatectomy after which pathology report was Gl 3+4 prostate cancer, pT3a (EPE and bladder neck invasion), N1 (1/15 nodes positive), multiple positive margins.( Prior to that I underwent Cryotherapy for prostate cancer in Mar 2012.)

My PSA level never dropped to undetectable after the prostatectomy. Initial PSA after robotic surgery was 1.25 ( Nov 2022)

Further tests showed mostly steady PSA increases :

Mar 2023 -PSA 1.73 Jun 2023 -PSA 1.95 Sep2023 -PSA 1.70 Nov2023- PSA 2.5

I had 2 subsequent PSMA PEST scans:

DEC 2022 GA68 PSMA PET scan indicated no definite evidence of recurrent or metastatic prostate cancer.

Nov 2023 Plarify PSMA PET scan indicated no definite evidence of recurrent or metastatic prostate cancer.

My urologist/surgeon recommended intensified ADT (LUPRON + ENZY) after the initial PSA of 1.25. I have since declined up to now.

I have consulted 3 radiation oncologists in the last two weeks, all whom recommend salvage radiation (35 IMRT treatments) to the prostate bed and to the pelvic lymph nodes along with 6 months of ADT (Lupron).

Their collective theory is that microscopic disease is prevalent in the prostate bed with one concluding that my cancer is PSMA negative resulting in the negative pet scans.

From what I understand the radiation will be more of a means of keeping future PSA levels at undetectable rather than providing a cure which would most likely require additional ADT.

I am wondering is it worth risking the GI and GU side effects related to radiation or would the intensified ADT be the better option? Has anyone else experienced this situation?

Thanks so much for this wonderful forum

Guy

[Tall_Allen]

Whole pelvic radiation is potentially curative. You will need 3 years of ADT and 2 years of abiraterone, as in the STAMPEDE trial, however.

Or, you can sign up for the following trial with 2 years of ADT+apalutamide:

clinicaltrials.gov/study/NC...

[OLDSALTY2008 in reply to Tall_Allen]

Good to hear " potentially curative" from an unbiased source. Thanks for the quick response. I will investigate the clinical trial which you mentioned. I have signed up for a clinical trial related to conventional (35) vs hypofractionated (23) radiation treatments at MD Anderson and was chosen for the conventional treatment.

[Justfor_]

What about your "bladder neck invasion"? Will it be irradiated as well, or not?

[OLDSALTY2008 in reply to Justfor_]

Yes, I was told that area will be specifically targeted with high dose radiation as it has a high likely hood of presence of cancer cells. This is worrisome because the urethra is completely exposed with the prostate having been removed. I am very concerned about GU side effects particularly late term. My main reason to question radiation is that no evidence of any cancer showed up on either pet scan . It is being assumed microscopic cancer is in the pelvic bed and lymph nodes. Seems like an awful lot of microscopic cells to result in a 2.5 PSA> I believe a .2 PSA is considered a biochemical relapse when PSA is undetectable and mine was 1.25 right after surgery (never undetectable). I am thinking there is something other than microscopic cells someplace and pelvic radiation is just a shot in the dark.

[Justfor_ in reply to OLDSALTY2008]

You have an excellent appreciation of the situation you are in. In your shoes, I would waited a bit more before deciding on further treatment as your PSADT is in the gray intermediate range for aggressiveness (approx 1 year). My reasoning is that your PSA -moreover your PSADT- numbers are not compatible with two negative PSMA PET scans. The argument that your cancer isn't PSMA avid, yet scores high PSA expression is in the realm of a very long shot IMO.

[OLDSALTY2008 in reply to Justfor_]

The PSADT is my main reason for delaying treatment for a year so far. My urologist infers the same.

Can you define "long shot IMO" for me as I am not familiar with the phrase.

Thanks

[Justfor_ in reply to OLDSALTY2008]

Attributing a very low probability for such a combination being your case.

[Grandpa4]

ADT is never curative. You may well have local residual disease in lymph nodes or pelvis. I think radiation gives you 20-30 chance of cure. I think longer and more aggressive anti-testosterone therapy increases your odds slightly. I took the radiation and 2 years of ADT and Abiraterone. I got bilateral sacral fractures from it but they healed well and I am doing well now. I had no urinary side effects. Did have a lot of gas and had to change my diet for a while to minimize it. It is a personal choice, but I would not wait too long.

[OLDSALTY2008 in reply to Grandpa4]

I agree ADT is not curative. I am leaning to radiation. My oncologist team is associated with a Center of Excellence with regards to cancer and I do have faith in them. They did mention that ADT after the radiation is to be considered and will likely be part of the regimen.

[Rocketman1960]

Salvage radiation is/was not a picnic for sure. But, it offers some long term benefits that you won't get with ADT alone.

[OLDSALTY2008 in reply to Rocketman1960]

Yes, the thought of the benefits is what encouraged me to seek multiple opinions, I realize I am my own best advocate.

[Rocketman1960 in reply to OLDSALTY2008]

Bingo. Yes you are. Good luck to you on your decisions going forward.

[j-o-h-n]

Greetings OLDSALTY,

Radiation - I've posted this before so to those people who have already seen this please forgive me.

I had 8 weeks of salvage radiation to "the bed". 5 days a week (not weekends) for 8 weeks minus 1 day for a total of 39 sessions at MSKcc. The actual radiation was like getting an x-ray by my dentist. I never had any side effects during the whole 39 sessions. However, 2 years later my left urinary tract was "fried" as per my urologist (or from passing prior kidney stones he was not sure). So, I had to have a urinary stent placed up my urinary tract (through my willy which is really nothing - sounds terrible but it's nothing) to aid in passing my urine (which was never a problem anyway). So I had stents in and out every three months for many years and now I'm stent free, However today 15% of urine from left kidney and 85% from right kidney, but not a problem. So make sure you get a good radiologist. Also, I don't know if this would apply to you but guys here recommend SPACEOAR HYDROGEL to be inserted for protection of parts of your body. Make sure you ask your R.O. about the space oar and make sure you ask here on this forum before getting fried.

Good Luck, Good Health and Good Humor.

j-o-h-n Sunday 12/03/2023 6:11 PM EST

[OLDSALTY2008 in reply to j-o-h-n]

Hi j-o-h-n, your unfortunate experience and the like is what is causing my hesitancy. None the less glad to hear you were able to recover from such an ordeal.

(* Space Oar is not an option for me)