Post Prostate very high PSA

[medicineradman]

Ive got a guy who had the Robot for intermediate risk prostate cancer (Gleason 4+3 in 2 cores, 3+3 in 2 cores) PSA 10.5. Path showed ECE+, negative margins, 2 nodes were negative. He had a post prostatectomy PSA of 1.0. 1 month later his PSA is 1.14. Final Gleason was 4+3 with tumor occupying 20% of the prostate is noted. He did happen to have a bone scan pre-op which was negative

Hes got 6 pads incontinence right now. It seems weird to that his margins are negative. I feel like that is wrong and the robot probably just missed some of the prostate. What should I do now? I thought I should get an MRI see if there is tissue in prostate bed and also if there are any suspicious nodes. If there is tissue then I can just treat with RT and boost that area, probably without hormones since its clear where the PSA is coming from. If there is no tissue and no suspicious nodes I guess I could get a bone scan (?) but it was negative pre-op. If that is negative I would treat his prostate bed and give hormones. Thoughts about this plan? Other strategies?

Couple questions: will a pelvic MRI show prostate tissue (this way I can see the nodes too) or do I need to get a endorectal? Im giving him another month to improve his continence otherwise we have a whole other headache to deal with to meet reasonable constraint. How urgent is it to get this started?

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[Palex80]

1. Do you think you can get a C11-PET-CT? If yes, do it.
Otherwise, restage him with MRI and another bone scan or consider a whole body MRI for his possible bone disease extension, also check for paraaortal nodes with CT or MRI.
Whole body MRI for bone disease is becoming popular and may be superior to bone scan.

2. If staging is negative or only shows disease in prostate bed, then start with bicalutamide and treat with RT when his incontinence is better. You can do that and it may even be better according to RTOG 9610.

 

[RadOncDoc21]

I'm with the C-11 PET... That thing works!

 

[NotBeyonce]

Talk to surgeon to see if he/she could have left prostate behind. It's less common in a university setting (typically with good surgeons) vs. the community. MRI probably wont help detect local recurrence if it's a good surgeon. Prostate LN mets are relatively uncommon compared to other cancers -- if you see 1.1 cm LNs, what do you do? (Probably just include them in your post-RP volume, dont chase after them otherwise). If you saw gross disease, what would you boost too? (70-80?)

I would recheck PSA and wait for his urinary function to improve (a few months). once you start RT, his urinary function will be "locked in." plus, if he has micrometastatic disease, it's probably already there.

C11 PET great option. Some more options:
https://www.researchgate.net/public...in_the_detection_of_recurrent_prostate_cancer

 

[medicineradman]

Thanks for the helpful responses. I'll see if I can get c11 pet. Also I thought the latest data was showing that RT doesn't lock in the inontinence issues? That's based on what I recall hearing from a 2014 spring refresher from the mskcc guy whose name I can't remember. But I think following psa and holding off so long as it remains relatively stable is a good option.

 

[Celestia]

Thanks for the helpful responses. I'll see if I can get c11 pet. Also I thought the latest data was showing that RT doesn't lock in the inontinence issues? That's based on what I recall hearing from a 2014 spring refresher from the mskcc guy whose name I can't remember. But I think following psa and holding off so long as it remains relatively stable is a good option.

Last I heard, the only place to get this was at Mayo. Has it changed?

 

[NotBeyonce]

Talk to surgeon to see if he/she could have left prostate behind. It's less common in a university setting (typically with good surgeons) vs. the community. MRI probably wont help detect local recurrence if it's a good surgeon. Prostate LN mets are relatively uncommon compared to other cancers -- if you see 1.1 cm LNs, what do you do? (Probably just include them in your post-RP volume, dont chase after them otherwise). If you saw gross disease, what would you boost too? (70-80?)

I would recheck PSA and wait for his urinary function to improve (a few months). once you start RT, his urinary function will be "locked in." plus, if he has micrometastatic disease, it's probably already there.

C11 PET great option. Some more options:
https://www.researchgate.net/public...in_the_detection_of_recurrent_prostate_cancer

Here is another relevant article by the same group: https://www.researchgate.net/public...Local_Therapy_What_Are_Our_Options?ev=prf_pub
Right now, we dont know if he has local residual disease/recurrence and/or distant mets. Factors suggesting micromets are non-GS6, relatively high PSA right after RP(assuming it is a good surgeon), and negative SMs. We don't know his PSA-DT yet (1 month time span is kind of short). Also, his burden of distant mets may be higher than that of local recurrence. You don't want to commit him to post-RP RT, then check the PSA in 6 months, only to find that it is way higher than now (by that time, you would have given him a useless therapy with all of the toxicity). So, I would probably get some more blood markers and images before you commit him to treatment.

What do you think?

 

[Phantom1]

I would talk with the surgeon regarding the resection and what he thinks about the post-op PSA. I would then restage the patient with a bone scan and a MRI of the pelvis. Did you look at the pre-op bone scan yourself? Sometimes there are equivocal calls, you could followup anything questionable with CT/MRI of that area. Yes this seems a little suspicious, you should nail down whether there is any distant disease prior to initiating adjuvant XRT. If there is something outside of prostate bed then he would be receiving all the toxicity with no benefit. He should receive hormones with any prostate bed radiation, it doesn't have to be bicalutimide (as that causes gynocomastia), could use casodex and lupron..

 

[medgator]

I would talk with the surgeon regarding the resection and what he thinks about the post-op PSA. I would then restage the patient with a bone scan and a MRI of the pelvis. Did you look at the pre-op bone scan yourself? Sometimes there are equivocal calls, you could followup anything questionable with CT/MRI of that area. Yes this seems a little suspicious, you should nail down whether there is any distant disease prior to initiating adjuvant XRT. If there is something outside of prostate bed then he would be receiving all the toxicity with no benefit. He should receive hormones with any prostate bed radiation, it doesn't have to be bicalutimide (as that causes gynocomastia), could use casodex and lupron..

I like firmagon/degarelix for 1-3 months before switching to lupron/eligard. No need for casodex to suppress flair and you get a quick drop in psa/immediate GnRH suppression.

I'm a believer in using it with post op xrt in high risk situations although it's currently undergoing study in the rtog

 

[medicineradman]

This is a different patient but the sort of thinking that creates the above situations. The surgeon wrote this and I have no clue what he is trying to argue. What I think he is saying is that because there is a retrospective study that shows in guys who recur after RP + ADT have higher PCSM then we should start with surgery [ignoring the fact that the study doesnt account for patient differences in who is selected for surgery vs ADT to start with.] Does this justify taking a high risk guy for trimodality therapy. Am I missing something?


....However, studies emerging over the last few years suggest that RP is not only appropriate for this population [high risk] but also may be a more optimal initial treatment, given that many of these patients require multimodal therapy to manage their disease. PSA progression?free survival is problematic as a comparative endpoint, given that criteria for recurrence differ greatly between RP and RT. Despite similar risks of BCR, the risk of prostate cancer specific mortality (PCSM) was significantly higher in the EBRT cohort, suggesting that these patients have more advanced disease at the time of recurrence. More specifically, examination of the very-highest-risk men, with progression-free probability of >25%, revealed that the 10-year PCSM was 21.2% for RP compared with 26.6% for RT. (Lee B, Eur Urol. 2015;67:204-9.) There's also evidence to the converse, in favor of EBRT+ADT. In a series of > 1,500 patients comparing BFFS for treatment with RP vs treatment with EBRT in patients with high-risk disease, 10-year BFFS was superior for EBRT (54% vs 47%), with the benefit confirmed on multivariate analysis. Comparisons of different subgroups showed that the benefit existed in all but the lower-risk population (with Gleason 8 disease and prostate-specific antigen [PSA] levels < 10 ng/mL). (Stephans KL, Int J Radiat Oncol Biol Phys. 2013;87). Given conflicting evidence for treatment of high-risk disease we also discussed the side effects of both treatment modalities and their effect on QOL. I believe *patient* understands the need for multimodal therapy. At this point he is leaning towards surgery, but wants to think about it for another week before making a decision.

 

[Palex80]

How about this:
http://www.ncbi.nlm.nih.gov/pubmed/22373045
Graph:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4124597/figure/F1/

Less than 5% of patients with "unfavorable histology": pT3b or pN1 or GS8-10 will experience no biochemical relapse after 10 years, when treated with surgery.

 

[Haybrant]

treated a guy for high risk prostate cancer gleason 8 in 10 cores, PSA was 15 ng/ml. ADT then did whole pelvic RT + ADT which completed over a year ago. He has been on ADT for a total of 1.5 years. He is due for another Lupron injection tomorrow (6 month injection). His PSA's have all been 0.2 or less since he was on ADT. He got a PSA drawn 1 month ago it was 3 ng/ml and another one today and its 5 ng/ml. Testosterone is pending

What does this mean now; I understand the Lupron could wear off early on a 6 month formulation or maybe they mistakenly gave him a 3 month. But despite that he has had definitive therapy so I suspect this constitutes a recurrence? What would you do at this point. Hes a 68 yo man, KPS is 70-80 not a great candidate for other invasive therapies. Thank you

 

[seper]

Sounds like a relapse. Chemo?

 

[Haybrant]

Sounds like a relapse. Chemo?

youd get bone scan now? and if this is negative?

 

[evilbooyaa]

treated a guy for high risk prostate cancer gleason 8 in 10 cores, PSA was 15 ng/ml. ADT then did whole pelvic RT + ADT which completed over a year ago. He has been on ADT for a total of 1.5 years. He is due for another Lupron injection tomorrow (6 month injection). His PSA's have all been 0.2 or less since he was on ADT. He got a PSA drawn 1 month ago it was 3 ng/ml and another one today and its 5 ng/ml. Testosterone is pending

What does this mean now; I understand the Lupron could wear off early on a 6 month formulation or maybe they mistakenly gave him a 3 month. But despite that he has had definitive therapy so I suspect this constitutes a recurrence? What would you do at this point. Hes a 68 yo man, KPS is 70-80 not a great candidate for other invasive therapies. Thank you

Re-stage him. Strong chance, IMO, that he's now become castrate-resistant, barring mix-ups in Lupron dosing.

If he's metastatic, then chemo/clinical trials. If it's negative and he's completely asymptomatic I suppose you could discuss observation, but it's probably not going to change your treatment down the line. Even if this was a mix-up, I don't think the PSA bounce would be this high, but I can't say that I've treated a ton of prostate cancers (and thus seen the PSA bounce in clinical practice).

 

[Chartreuse Wombat]

treated a guy for high risk prostate cancer gleason 8 in 10 cores, PSA was 15 ng/ml. ADT then did whole pelvic RT + ADT which completed over a year ago. He has been on ADT for a total of 1.5 years. He is due for another Lupron injection tomorrow (6 month injection). His PSA's have all been 0.2 or less since he was on ADT. He got a PSA drawn 1 month ago it was 3 ng/ml and another one today and its 5 ng/ml. Testosterone is pending

What does this mean now; I understand the Lupron could wear off early on a 6 month formulation or maybe they mistakenly gave him a 3 month. But despite that he has had definitive therapy so I suspect this constitutes a recurrence? What would you do at this point. Hes a 68 yo man, KPS is 70-80 not a great candidate for other invasive therapies. Thank you

Cannot make a judgement unless testosterone is known. Bad news either way.

 

[mavrik13]

treated a guy for high risk prostate cancer gleason 8 in 10 cores, PSA was 15 ng/ml. ADT then did whole pelvic RT + ADT which completed over a year ago. He has been on ADT for a total of 1.5 years. He is due for another Lupron injection tomorrow (6 month injection). His PSA's have all been 0.2 or less since he was on ADT. He got a PSA drawn 1 month ago it was 3 ng/ml and another one today and its 5 ng/ml. Testosterone is pending

What does this mean now; I understand the Lupron could wear off early on a 6 month formulation or maybe they mistakenly gave him a 3 month. But despite that he has had definitive therapy so I suspect this constitutes a recurrence? What would you do at this point. Hes a 68 yo man, KPS is 70-80 not a great candidate for other invasive therapies. Thank you

Unless the testosterone is normal (extremely unlikely) this has declared itself bad news disease. Typically testosterone takes longer than 6 months to recover, though if the injection was totally botched then he could be 1 year out from hormones and have a semi-normal testosterone and rising PSA.

I'd consider restaging now with CT A/P +/- Chest, MR prostate and bone scan. We have a trial open with PSMA-PET which has been useful, but I wouldn't have a patient travel hours to get one.

If local disease only, could consider salvage treatments (HDR brachy, HIFU, cryo). Otherwise usual total androgen blockade, withdrawal of ADT (not sure I've ever seen this work), followed by appointment with med onc.

 

[nkmiami]

How about this:
http://www.ncbi.nlm.nih.gov/pubmed/22373045
Graph:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4124597/figure/F1/

Less than 5% of patients with "unfavorable histology": pT3b or pN1 or GS8-10 will experience no biochemical relapse after 10 years, when treated with surgery.

From this data, even the "favorable" Gleason 8 have a 30% BFS at 10 years in the hands of a Hopkins surgeon. The just of the article is that they can tease out the favorable patients for surgery to obtain a 30% BFS. I never realized control was so horrendous? Why is it even part of the NCCN guidelines for G8?

 

[medgator]

From this data, even the "favorable" Gleason 8 have a 30% BFS at 10 years in the hands of a Hopkins surgeon. The just of the article is that they can tease out the favorable patients for surgery to obtain a 30% BFS. I never realized control was so horrendous? Why is it even part of the NCCN guidelines for G8?

Why is surgery part of the guidelines for stage IIIA nsclc?

Neither is a category 1 rec, the way radiation is, but I imagine they survive because you can "salvage" with xrt afterwards, and in some surgeon's mind, two therapies is better than one

 

[evilbooyaa]

Why is surgery part of the guidelines for stage IIIA nsclc?

Neither is a category 1 rec, the way radiation is, but I imagine they survive because you can "salvage" with xrt afterwards, and in some surgeon's mind, two therapies is better than one

Stage IIIA NSCLC is a heterogenous population:
For N1 disease, if there's no pathologic mediastinal involvement, you get to omit radiation therapy.
For N2 disease, if you can get people through neoadjuvant chemoRT and get them to a point where a lobectomy can be performed, they seem to do better than those getting definitive chemoRT, per intergroup 0139.

I'm all on board slamming urologists and the NCCN prostate guidelines, but I think the NSCLC guidelines are reasonable as written.

 

[nkmiami]

With high risk prostate cancer, I doubt any patient (or many surgeons) goes into surgery knowing that there is a 70-95% chance the surgery will fail.

 

[seper]

Welcome to standard Urology practices in the US. It's really annoying. With very high risk prostate Ca, like I said before, surgery is, IMHO, plain mutilation.

 

[medgator]

Stage IIIA NSCLC is a heterogenous population:
For N1 disease, if there's no pathologic mediastinal involvement, you get to omit radiation therapy.
For N2 disease, if you can get people through neoadjuvant chemoRT and get them to a point where a lobectomy can be performed, they seem to do better than those getting definitive chemoRT, per intergroup 0139.

I'm all on board slamming urologists and the NCCN prostate guidelines, but I think the NSCLC guidelines are reasonable as written.

The data supporting surgery is pretty weak imo, not really an OS benefit, and there clearly is morbidity in patients who require pnuemonectomy.

The preferred/category 1 approach is definitive chemoradiation therapy in stage IIIA nsclc. Just like the category 1 approach in high risk prostate is EBRT+2-3 years of ADT.

I will agree, however, that the data supporting surgery in IIIA lung, as weak as it is, is still stronger that the data supporting surgery in high risk prostate ca.

It's just that lung ca lends itself better to multidisciplinary management than does prostate ca. I will routinely get referrals directly from pulm and/or med onc in stage III patients without them even seeing a surgeon, and often these patients are presented at our tumor board.

High-risk prostate patients will sometimes come my way if they are too big for cryo, too old for surgery, too educated on their disease, have an educated pcp etc

 

[evilbooyaa]

The data supporting surgery is pretty weak imo, not really an OS benefit, and there clearly is morbidity in patients who require pnuemonectomy.

The preferred/category 1 approach is definitive chemoradiation therapy in stage IIIA nsclc. Just like the category 1 approach in high risk prostate is EBRT+2-3 years of ADT.

I will agree, however, that the data supporting surgery in IIIA lung, as weak as it is, is still stronger that the data supporting surgery in high risk prostate ca.

It's just that lung ca lends itself better to multidisciplinary management than does prostate ca. I will routinely get referrals directly from pulm and/or med onc in stage III patients without them even seeing a surgeon, and often these patients are presented at our tumor board.

High prostate patients will sometimes come my way if they are too big for cryo, too old for surgery, too educated on their disease, have an educated pcp etc

It's not an OS benefit, but there is PFS (and not just like better LRR or something without as much clinical value) improvement. Granted it's on a subset analysis, but those who got a lobectomy seem to do better.

Like I said, IIIA disease usually does get definitive chemoRT at my institution given the logistical issues of trying to actually pull it off.

Completely agree with you on the rest. Bolded gave me a laugh, but it's certainly true.