Thoughts and suggestions please

[LowT]

83 YO male with complex medical history detailed in previous posts including hormone abnormalities of hypothyroid, marked elevation of FSH and LH, mild elevation of PRL, markedly low free testosterone, osteopenia/osteoporosis, and statin intolerance.

RARP Oct 2016 for 3+4 PCa. Gland 78 gm. SV negative as was ePLND #24. Cancer unusual location, posterior midline surrounding ejaculatory duct with extensive EPE which had not been detected on two prior MRIs. Recent Decipher on earlier surgical specimen 0.68, high risk. Standard 12 core biopsy would have completely missed the cancer.

Low dose TRT for two years beginning nine months after surgery due to low T symptoms which later were determined to be due to intolerance to high dose statin. December 2018 uPSA first became detectable at 0.015. All TRT been discontinued since September 2019.

Sept 2022 uPSA reached 0.1, MRI found a new enhancing nodule in L prostate bed abutting the rectal wall. Further investigation included three negative PSMA PETs and a repeat MRI was essentially unchanged. Have been offered SR and +/- ADT by two ROs. One of the ROs indicated absent the longevity in my family history and good physical status, he probably would not suggest treatment. Grandmother and great grandmother both died at 96 from broken hips and uncles lived into late 80s early 90s.

Presently in good health. Swim 1/2 mile three times a week. Have had 4 episodes of AFib over past ten years but well controlled on anti-arrhythmic and Mg and K.

October 2023 uPSA reached 0.35. Subsequently has fallen to 0.25 perhaps as a result of various treatments including low dose statin, 5 ARIs, supplements, etc.

Bilateral lymph edema from the ePLND is controlled with support stocking and a concern of making that worse with SR along with proximity of nodule to rectal wall.

Recent BMD reported osteoporosis of both femoral necks. So ADT a concern.

Currently in a holding pattern or what could be called AS.

In addition to AS monitoring including further imaging, I’m considering a needle biopsy to confirm recurrence using that information in risk assessment regarding further treatment considering the multiple interconnected issues.

Any thoughts or suggestions greatly appreciated.

[Tall_Allen]

The rectal wall lesion is the one I'd keep an eye on. Can you get an FDG PET/CT?

[LowT in reply to Tall_Allen]

Why (FDG) PET/CT scan? I didn’t think glucose is an energy source for prostate.

Both Ga68 and 18F PSMA PET/CT scans were negative.

From ChatGPT:

1. FDG PET/CT Scan:

- FDG PET/CT scan is used to detect cancerous cells in the body by measuring the uptake of a radioactive glucose analog called FDG.

- It is commonly used for staging, restaging, and monitoring the response to treatment in various types of cancer, such as lung cancer, lymphoma, and breast cancer.

- FDG PET/CT scan is not specific to prostate cancer and is used for imaging a wide range of cancers.

2. PSMA PET/CT Prostate Scan:

- PSMA PET/CT scan is specifically used for imaging prostate cancer by targeting the Prostate-Specific Membrane Antigen (PSMA) that is overexpressed in prostate cancer cells.

- It is highly sensitive in detecting prostate cancer lesions, especially in cases of biochemical recurrence and metastatic disease.

- PSMA PET/CT scan is more specific to prostate cancer and helps in accurate staging and localization of prostate cancer lesions.

[Tall_Allen in reply to LowT]

FDG might be able to find metastases that don't express PSMA.

[SteveTheJ]

I can comment only on low thyroid. I had that before cancer but the medications made it worse. For me increasing synthroid and adding cytomel brought it back to normal.

[j-o-h-n]

If you think yours is complex, you should see mine.....

Good Luck, Good Health and Good Humor.

j-o-h-n

[LowT]

My present approach is to remain conservative with comprehensive AS and try to outlive the cancer while maintaining QOL

Risks of RT include rectal wall damage and potential of worsening lymph edema as well as possible ureter/bladder damage, esp long term.

Risks of ADT in addition to all the usual would be to worsen osteoporosis of femoral necks and increasing fracture risks.

The hormone issues I can live with unless they maybe adversely impacting neoplasm growth rate or aggressiveness.

FSH, LH and PRL are known to promote angiogenesis but endocrinologists can’t seem to explain their elevations and they are not oncologists, etc.

I’m slowly reducing levothyroxine dose with reasoning that euthyroid levels or slightly elevated levels may encourage tumor growth rate.

I’ve also added both DUT and FIN which appears to have lowered the PSA on two occasions. Most recently from 0.35 to 0.25. I know that is not supposed to happen but in my study of n =1 that may be having effect. Stay tuned!

I’ll try to post a graph showing this if I can figure how to do that.

Lastly, is any info gained from Bx worth the risk and what useful additional information would change this conservative approach?