Looking for advice on next steps...

[Daveofnj]

Hello,

I am looking for opinions about what to do next. Here's my situation:

I had focal laser ablation in 2017 after having been diagnosed with Gleason 3+4. My pre-op PSA was 6.6. The ERG and PTEN test was low risk. About 1/4 of my prostate was ablated and the remainder of my prostate measures about 40cc.

Although several post op MRIs (the most recent in Nov. 2020) show no residual disease, for the past two years my PSA has been creeping up and I am wondering what to do about it. The scores have been:

March 2019 2.5

July 2019 2.9

Sept 2019 2.4

July 2020 1.7 (after starting Dutasteride and transdermal TRT)

Nov 2020 2.0

Dec 2020 2.7

Discontinued the testosterone TRT

Jan. 2021 2.0

Since Dutasteride reduces PSA by 50%, my current score is the equivalent of 4.0, which is a 60% increase since Sept 2019.

Wondering what to do next. The MRI shows nothing that could be biopsied. Any suggestions?

Thanks for any ideas.

Dave

[Magnus1964]

I am surprised that you were starting with Dutasteride? Why not Lupron and casodex or abiratorone before going on to the newer drugs.

[Daveofnj in reply to Magnus1964]

For the past 3+ years all of my MRIs showed NED, so I have assumed everything was OK. I started the Dutasteride to reduce DHT and shrink the prostate, not necessarily as a cancer treatment (although I know some men may use it to prevent prostate cancer.)

[Tall_Allen]

My third biggest issue with focal ablation is that one doesn't know how to use PSA afterwards to monitor it. (My first biggest issue is incomplete eradication of the tumor in the ablation zone; my second biggest issue is that prostate cancer is almost always multifocal, and the small foci of higher grade cancer, too small to see on an MRI, are left to grow)

mpMRIs only show higher grade foci of cancer that are larger than 4 mm.

Your PSA is pretty stable (fluctuations are expected). The "multiply by 2" only applies if you have BPH. The reason is that dutasteride decreases the PSA due to BPH, but not the PSA due to prostate cancer. If you do not have BPH, dutasteride will not cut your PSA.

So, if there were anything big and high grade, an mpMRI would probably pick it up. I think the best way to look at it is that you are on active surveillance. That means periodic systemic biopsies are necessary to monitor progression. I think you should consider a random 12-core biopsy with an extra 4 cores from the ablation zone. This is not easy to read - be sure to send it to Epstein's lab at Johns Hopkins for a second opinion.

[Daveofnj in reply to Tall_Allen]

Thanks. I was thinking of getting a PSMA PET/MRI before deciding to do a biopsy. If it shows nothing I would not do the biopsy. What do you think about that?

[Tall_Allen in reply to Daveofnj]

You have the same size limitation, and PSMA is not much expressed early on. I'm afraid that there is no substitute yet for a biopsy.