Rising PSA years after radical prostatectomy

Posted by olanordman @olanordman, Feb 22, 2021

I am 60 years and I had radical prostatectomy on 23rd Nov 2018. I was told out of the 15 lymph nodes taken only one was affected less than a millimetre. It was Gleason score 7B with PSA around 13 at time of surgery but 11 at time of diagnosis in June 2018.

The PSA been fluctuating between 0.09 and 0.18 since surgery on 23rd November 2018
I have no incontinence as well as Erectile dysfunction. I take hypertension medication – Norvask Amlodipine 5mg daily and Cetirizine 5mg for allergy. Below are some of the test results. I have many of these test results – a few below
Jan 2019: 0.11
April 2019: 0.11
June 2019: 0.09
August 2019: 0.12
December 2019: 0.12
April 2020: 0.12
August 2020: 0.11
October 2020: 0.17
December 2020: 0.15
February 2021: 0.18

I am worried the cancer may be returning or might have spread. I met my doctor today and expressed my concerns. He has agreed to refer me to the hospital where I had the surgery. Any suggestions based on this brief history?

Interested in more discussions like this? Go to the Prostate Cancer Support Group.

@swdg

Hi - I am not a doctor. My situation has some similarities to yours. My PSA has gone up and down over the last 4 years or so after a RALP. You may want to check this out: https://prostatecancerinfolink.net/2015/01/14/low-detectable-psa-after-prostatectomy-watch-or-treat/

My most recent PSA was .07. It had been rising to .11, then it has been coming down since then. I have decided that if it does start rising and does so steadily, I will probably wait until it is .5 or so and then get a PSMA or similar scan to see if anything is found.

Best Regards

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I find it interesting that the PSA varies in individuals from very low (such as yours at .07 to .11) to extremely high in the hundreds (and even thousands). Also there is always a qualifier in medical literature that the PSA is not a reliable indicator yet it is used (almost arbitrarily) to start down a path of many tests and precedures looking for prostate cancer. Now it is recommended that it not even be looked at after a certain age (I think around 50). Very confusing and questionable.

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@zj69

Hi
I underwent a Robotic-assisted Radical Prostatectomy on 15-Feb-2022 at UHN Canada. Surgical pathology on 15-Feb-2022 revealed adenocarcinoma, Gleason: 8 (3 + 5), and negative surgical margin involvement status. The disease was pathologically staged as T3a N1.

PSA RESULT
- PSA on 01-Apr-2022 (Total PSA is 0.017 ug/L).
- PSA on 12-Oct-2022 (Total PSA is 0.075 ug/L).

My Pathology report after surgery shows as under. My PSMA -PET test did not detect the Lymph node before surgery.

DIAGNOSIS
1. Soft-Tissue: periprostatic tissue: Mature adipose tissue, no lymph nodes identified. Negative for malignancy

2. Right external iliac artery node: Three reactive lymph nodes, negative for malignancy

3. Right pelvic lymph node: Four reactive lymph nodes, negative for malignancy

4. Left pelvic lymph node: Metastatic adenocarcinoma (diam < 1 mm) in one of six lymph nodes.

5. Prostate and seminal vesicles, weight 28 grams:
- Predominantly right posterior peripheral zone localization of adenocarcinoma, Gleason score 8 (3 + 5) with a high-grade component, comprising 60% of the carcinoma
- Positive for intraductal carcinoma
- Positive for (focal) extraprostatic extension, negative for bladder neck invasion or seminal vesical invasion (pT3a)
- Surgical margins negative for malignancy
- About 9% of the prostate volume involved by carcinoma

COMMENT
Immunostaining performed to exclude neuroendocrine carcinoma component: Both chromogranin A and synaptophysin are negative, while the androgen receptor is intense nuclear positive. The basal cell staining (HMWCK) highlights the intraductal carcinoma
component.

SYNOPTIC DATA

Procedure: Radical prostatectomy:
Prostate Size
Prostate Weight (g): 28 g
TUMOR
Histologic Type: Acinar adenocarcinoma
Histologic Grade
Grade Group and Gleason Score: Grade Group 4 (Gleason Score 3 + 5 = 8)
Tertiary Pattern 5 (less than 5%) in Overall Gleason Score 7:
Present
Percentage of Pattern 4: 40 %
Percentage of Pattern 5: 20 %
Intraductal Carcinoma (IDC): Present
Cribriform Pattern: Present
Tumor Quantitation: Estimated percentage of prostate involved by tumor: 9 %
Extraprostatic Extension (EPE): Present, focal
Location of Extraprostatic Extension: Right posterior
Urinary Bladder Neck Invasion: Not identified
Seminal Vesicle Invasion: Not identified
Treatment Effect: No known presurgical therapy
Lymphovascular Invasion: Not Identified
Perineural Invasion: Present:
MARGINS
Margins: Uninvolved by invasive carcinoma
LYMPH NODES
Regional Lymph Nodes:
The number of Lymph Nodes Involved:
Number of Lymph Nodes Involved: 1
Size of Largest Metastatic Deposit (Centimeters):
0.1 cm
Number of Lymph Nodes Examined: 13
PATHOLOGIC STAGE CLASSIFICATION (pTNM, AJCC 8th Edition)
Primary Tumor (pT): pT3a
Regional Lymph Nodes (pN): pN1
ADDITIONAL FINDINGS
Additional Findings: None identified
SPECIAL STUDIES
Ancillary Studies: NGS prostate

Please can you tell me about the following?

1. is it curable after reoccurring?
2. Life expectancy rate: How many years can you survive?

Thanks

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Welcome, @zj69. Rising PSA is a common concern among members here. For that reason, I moved your questions to this existing discussion so you can read previous posts and connect with members easily:
- Rising PSA years after radical prostatectomy https://connect.mayoclinic.org/discussion/rising-psa-2years-after-radical-prostatectomy/

I agree with @web265 that interpreting your pathology results is out of the league of fellow prostate cancer survivors. I also agree with the tips he shared with you here: https://connect.mayoclinic.org/comment/772319/

You ask the questions on everyone's lips:
1. is it curable after reoccurring?
2. Life expectancy rate: How many years can you survive?

I hate to be the one to tell you that you'll never get direct answers to those questions. Oncologist rarely use the word "cure". Cancer goes into remission. You can live with it. These are more likely the responses you'll hear.
While some might give you a statistical response to your query about how many years, but that is a population-based answer. Your doctor may have a better guesstimate based on your diagnosis, personal health status and existence or absence of other conditions. But it is only that - a guesstimate.

You are in good hands at UHN in Toronto. What treatments, if any, are being recommended after surgery?

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@colleenyoung

Welcome, @zj69. Rising PSA is a common concern among members here. For that reason, I moved your questions to this existing discussion so you can read previous posts and connect with members easily:
- Rising PSA years after radical prostatectomy https://connect.mayoclinic.org/discussion/rising-psa-2years-after-radical-prostatectomy/

I agree with @web265 that interpreting your pathology results is out of the league of fellow prostate cancer survivors. I also agree with the tips he shared with you here: https://connect.mayoclinic.org/comment/772319/

You ask the questions on everyone's lips:
1. is it curable after reoccurring?
2. Life expectancy rate: How many years can you survive?

I hate to be the one to tell you that you'll never get direct answers to those questions. Oncologist rarely use the word "cure". Cancer goes into remission. You can live with it. These are more likely the responses you'll hear.
While some might give you a statistical response to your query about how many years, but that is a population-based answer. Your doctor may have a better guesstimate based on your diagnosis, personal health status and existence or absence of other conditions. But it is only that - a guesstimate.

You are in good hands at UHN in Toronto. What treatments, if any, are being recommended after surgery?

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Thanks, Colleen, for your response. I was asked to go for a PSA test every three months next test will be on Jan-23. If it is >0.2, I will go for a PSMA test to see if they can find it. They are expecting near the prostate bed. My surgical margin was negative. But I had one regional pelvic left lymph node and EPE in my pathology. So I do not know yet but sure going for RT.

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Get on Zolodex to stop testosterone the fertilizer of PC

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@olanordman

Good information. Have you had radical prostatectomy - postrate removed? I thought without a prostate the bench marck was 0.2 for salvage treatment.

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You are correct. PSA .20 or more x 2, after a prostatectomy, is considered a biochemical recurrance. That is exactly what happened to me 8 yrs post op. I had a PSMA PET Scan that lite up 3 areas in my lung (lymph nodes). I had a bronchoscopy/biopsy but all 3 areas were negative. Nothing else lite up, not even the prostate bed. So, don't know why my PSA is climbing or where the recurrence is. Might have to have a repeat PSMA PET Scan as my PSA get's higher. Might be able to pick up something at that point. Have appointment's with my Pulmonologist and Urologist in a week.

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Hi, where exactly are they radiating? Did you have a PSMA PET Scan to locate the recurrence?

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Removed 2009 so 13 years ago yesterday. Now almost 80 years old. 5 years ago PSA slowing rising and went to .72 a year ago slowly over 5 years and Vanderbilt prostate oncologist said just check each 6 mo. Now to 1.02. Still says watch at my age. No symptoms and had scan and he says watch?

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@jic811

Removed 2009 so 13 years ago yesterday. Now almost 80 years old. 5 years ago PSA slowing rising and went to .72 a year ago slowly over 5 years and Vanderbilt prostate oncologist said just check each 6 mo. Now to 1.02. Still says watch at my age. No symptoms and had scan and he says watch?

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Did 40 rads 5 years ago, then Zolodex fot 3 yrs. L2 nuked 1 inch out PSA was 1.2 on Zolodex for 2 years PSA up 4.22, 5.23 and now 6.6 in 4 months
Doing bone scan Monday PET nuclear than CT scan week after. Feel great Weak spine if I stand to long or walk long distance.

What you think I'm stage 4 metastatic castrate sensitive My testosterone levels are <.o4 so Zolodex works, but why PSA up to 6.6? Am I going resistive, then what?

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I started with radiation therapy (25 doses) in Sept. 2021 alongside 150mg biculatimide daily. I had radition of the breast and staryed with 150mg a week before the radiation.

PSA values
Dec. 2021 - less than 0.1
Jan, Feb, April, May, Aug, Sept, Oct.
All less than 0.1
I asked the urologist and he said that these values mean psa is not detectable. I am stil on the 150mg and will stop in end of March 2023

I am told Biculatimide is same as Casodex.
There are side effects but I have managed them - decrease in urge for sex and AT TIMES weak erection , constipation, tiredness, pains in my breast and burning sensation on toes, intermittent back and side pains, at times pelvic pains.
I train in the gym 3 - 4 times weekly.

I have been told to check psa twice a year from March 2023 but I have opted for 3 times. I am told the bench mark for further treatment after this is 0.4. I am yet to confirm from the urologist on 12th Dec. Any idea?

I thank all of you for your ideas. This forum has helped me a lot.

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What is the benchmark of PSA value for further treatment after man has gone through radical prostatectomy and combined radiation and hormone therapy. I have been through radical prostatectomy. I am currently on biculatamide 150mg which I started with radiation (25 does) for 5 weeks. he biculatamide is to be taken up to 31st March 2023 (18 months). Currently my PSA is not detectable.

I am yet to contact my urologist on 12th th Dec.

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