My PSA has risen over nearly 5.5 years since my prostatectomy from Undetectable to 0.3. I was referred to an RO who, after reviewing my test results and prior history, indicated that there were some "cells left behind" near the prostate bed, even though they tried to get at them unsuccessfully during the surgery. He said this was not uncommon. I had a good surgery in that I went with an undetectable PSA for several years. However, it was interesting and a bit disconcerting to hear the comment about cells left behind. My assumption is that it is those cells, which gradually contribute to rising PSA.
Given my intermediate risk level (Gleason 7_4+3), the fact that I had a prostatectomy five years earlier, but now I have a rising PSA which has reached 0.3, they recommended both a PSMA PET Scan and a Pelvic MRI. The proposed treatment plan is a course of 34 radiation treatments plus six months of Orgovyx.
Nothing was found in the PSMA PET Scan. In the Pelvic MRI, the finding reads "The prostate and seminal vesicles are absent secondary to known prostatectomy, there is no residual prostatic tissue."
How could there have been some cells left behind, but yet the MRI states ''no residual prostatic tissue''? Are we dealing with microscopic cells? Is the principal driver for taking action now the rising PSA? Does this MRI inform the scope and length of the treatments?
Thank you in advance.
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brilliant17
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eager for TA’s read in this. Seems like psa of .3 is too low to detect mets in a PSMA pet scan. I understand that psa of 2.0+ is when the pet scan might show lesions.
My husband is in the same situation They didn't find anything on the pet scan either but they still wanted him to go ahead with ADT and salvage radiation but my husband refused the ADT and wanted to wait for any mets to be revealed before he would have any radiation
I just turned 79 and the side effects of the 6 months of ADT and 25 sessions of radiation were relatively minor. Doing great one year out of treatment.
When I had my initial radiation consult my RO and I discussed doing the pelvic area even though no cancer was on the scans. She felt that based on her experience and training there was cancer that the scans were unable to pick up. So while they did the radiation to the prostrate they also did the pelvic area.
Time will tell if it helped got the cancer. My thinking was that even if it bought 5 or so more years it would be a benefit. Once you hit the 80 plus mark it is a crap shoot.
Good luck to you for many years. Do you know what made your doctor decide that only 6 months of ADT was good? Also did you opt for injections or pill form? Thanks.
I had the shot of Lupron in 3 month intervals. I was put on Lupron by the Urologist not the radiation or medical oncologist. Neither medical nor the radiation oncologist did not offer to expand the Lupron time past 6 months.
The length of time on Lupron is really a function of the cancer staging based on Gleason score, biopsy, scans, and other tests, etc. It can run anywhere from 4 to 6 months to life time or until it stops working.
I forgot to add that that there is some evidence that adding Lupron prior to and after radiation actually enhance the ability the the ability of the radiation to kill the cancer.
Without getting in the technical weeds it is because of the Beta valve of this type of cancer and how it interacts with the radiation.
Thanks. Okay in my case so far my RO says that based on my Gleason 7 (4+3) and because I had some seminal invasion at the time of my prostatectomy, I need to do something similar to you- six months of ADT and 34 radiation treatments. Your post is reassuring.
The doctor said that he will also analyze my prostatectomy pathology slides to see if there is anything more aggressive which would justify a second HT medicine plus extending the HT time frame beyond 6 months. But so far he does not think that will be the case especially with a negative PSMA and MRI. BTW, I started out with Orgovyx pill form for 2 weeks but then switched to a 3-month injection and I will plan on getting a 2nd one when the time comes. By the time the radiation starts I will be almost 6-7 weeks on HT. I was surprised to learn that the injection was Lupron but I guess that is still being used and there is no injection form for Orgovyx.
Cells "left behind"? In my case, with a post RP nadir of 0.050, eight years ago, we accepted that my 4+3 had already spread outside the gland. I chose to rely on <0.010 and dismissed the IMO misleading term 'undetectable'. (also IMO, the 'diagnosis' of cells left behind is unfortunate at best).
If I had a do-over today, with your findings, and as my focus is to defer ADT/CR/chemo for as long as possible, I would first seek second opinions of the PSMA and MRI (I have mine done in London, England; I now know UCLA and Mayo offer second opinion services). If the results confirmed the original findings, I would seek out fluciclovine or Choline PETS for comparison. I would also get a blood biopsy - recently I had the GUARDANT360 CDx (there are others now). And I would have genetic testing as well.
Less than a year after my RP nadir of 0.050, when my usPSA was up to 0.1, I tried salvage RT to prostate bed, no imaging, and refused drugs. I did not do imaging as I was not accepted into PSMA trials and was (wrongly) discouraged to try fluciclovine or Choline. The RT failed to get all the remaining cancer; post salvage RT nadir was 0.075.
I then learned imaging in Europe begins as low as 0.030. When my usPSA was again back up to 0.11 I went to Europe for imaging and suspicious lymph nodes were identified. I had salvage extended pelvic lymph node surgery and six cancerous nodes were confirmed, including the para-aortic. Today, six years later, usPSA holding very low stable 0.03X range, no ADT.
I’m beginning to think that we need a new group “ Prostate CA on a shoestring”……so many here speak of travelling to far off places to obtain advanced treatment that is well outside the pocketbook of many others I presume…..IS it that advantageous to go far afield for specialized txs and scans in other countries?
Like you there are a fairly large group that do the best we can with Medicare and local/regional resources available.
Remember even people with money to burn die. The key in my humble opinion was to find it early at a low grade. After that it is a crap shoot even with all of the money in the world.
Well, I certainly think so. As I was working and living in England at the time of my diagnosis, it was easier for me. I did have my RP and salvage RT in US. Medicare has paid for two PSMA PETs, blood biopsy, and a few other things my former private health insurance would likely have denied - based on my experiences. Note, I have given up driving a Corvette in my retirement.
I concur with Mgtd, the key is to find this beast early. Although I began screening in my 40's, my doc and I missed the very thing we were screening for, prostate cancer.
All the best to all of us fighting this beast! Keith
Hi anony2020. No, I don't mind sharing As mentioned earlier, I delayed my response to give this some thought for having taken bicalutamide for a year, I am most grateful I have not (yet) had to continue on ADT, and I have great respect those that are. (I have taken from and added to my response to chat regarding my use of usPSA).
Back when I was recommended the STAMPEDE Trial I feared the harsh impacts on my otherwise very healthy and active lifestyle. For the long term I feared the impacts on my very healthy and strong heart, bone and muscular structures. And my thinking has been and continues, the sooner one starts ADT the sooner one may realize the onset of castration resistance.
Yes I am taking a lesser path, but today, still consulting with RO and MO, ADT/chemo is not recommended at this time.
"How could there have been some cells left behind, but yet the MRI states ''no residual prostatic tissue''? Are we dealing with microscopic cells? Is the principal driver for taking action now the rising PSA? Does this MRI inform the scope and length of the treatments?"
MRIs can't detect tumors smaller than about 5 mm, and PSMA PET scans are highly PSA-dependent and often can't see tumors when PSA is below 0.5. So you have to treat what you can't see.
The standard treatment for men in your situation was determined by the SPPORT trial:
As you see, your PSA is just about at the point (the point is just a median and not a clear separation) where more intensive therapy can make a difference, so it is a judgment call.
Thank you Tall_Allen. So do you mean more intense than the proposed treatment plan of 7 weeks of photon radiation treatments and six months of hormone therapy in this case Orgovyx? And if so, how so? Thanks.
At lower PSA (≤ 0.35), Group 3 did no better than Group 2, so widening the treatment area had no effect. Both groups did better than Group1, so ADT had a significant effect.
At higher PSA (> 0.35), Group 3 was better than Group 2, but the difference was not statistically significant. Both groups did better than Group 1, indicating ADT effectiveness.
Where:
Group1: PBRT (prostate-bed radiation only)
Group 2: PBRT + STADT (prostate-bed radiation + short-term ADT)
Group 3: sWPRT + STADT (salvage whole pelvic radiation + short-term ADT)
Your case is puzzling but without identifying where the cancer is exactly, radiation is like usming a shotgun to kill ants. I would wait till you know where to attack the cancer and not just guess. And yes, get as many second opinions as you can.
I had a PSA of 5.9. I did RALP but my PSA hardly went down afterwards. Failed surgery (post psa 2.9) yet my pathology was great, negative margins, etc and fully contained less than 5 percent of total prostate mass. Surgeon was puzzled and sent me to the radiation oncologist. 6 months lupron and radiation. Kept it down for 12 years until this year PSA 1.5 PSMA scan shows 3 small areas in the pelvic lymph nodes. My medical oncologist said it was probably there since surgery but got knocked down by ADT and Radiation overlap. (No nodes removed at time of surgery nor radiated). I am presently on ADT awaiting Proton Beam to the offending nodes. Keeping my fingers crossed. I still wonder if nodes had cancer in them at time of surgery or something happened during surgery that seeded cancer cells. I recently read this on the subject that shocked me: urologyweb.com/robotic-pros...
Yet today, most doctors are still adamant that cancer does not with surgery alone. Their point is that even if the cancer cell had bedded, it would not grow until something had happened to them. Well, the question is how do we determine whether it has or not?
Brilliant if it helps, my situation the same (.34). Elected for "group 3" treatment 2018,. All good , fingers crossed 6 years later. Radiation treatment not a big deal. The ADT shots lasted about one year before T returned. Annoying but over with.
Marlins1, good to hear! By group 3, do you mean whole pelvic radiation versus prostate bed radiation? Any side effects to your bladder or urination patterns? Are you a baseball Marlins fan?
I was in a similar situation. surgery, ADT and a slow increase in psa. Scans negative. The psa of 0.1 had to be coming from a few cells. I had pelvic radiation and now PSA is .006 for two years. Some diarrhea side effects, but I would have the radiation again blindfolded. I read Tall Allan's work. My belief is to kill every last cell, then forget about it. (But keep one eye open.)
Got both bed and Pelvic field. No bladder or bowel lasting problem. Mild incontinence no better to maybe worse. Hard to tell as getting older ........... Maybe Marlins fan soon, moving to FL. I would definitely do the Salvage. Can be last chance for cure.
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As mentioned earlier, I delayed my response to give this some thought for having taken bicalutamide for a year, I am most grateful I have not (yet) had to continue on ADT, and I have great respect those that are. (I have taken from and added to my response to chat regarding my use of usPSA). 
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