Recent Diagnosed - Gleason 4+4=8

[Eightydeuce]

Initial diagnosis in February with PSA 4.38. Biopsy shows highest Gleason 8. CT scan found 3 lung nodules, in both lower lobes with largest approx 5mm, but undetermined. Bone scan clear as well as rest of CT scan. Surgery (DaVinci) scheduled April 5th. Any thoughts or experiences based on this much appreciated and great to find this group. Age 65 and non-smoker all my life.

[GP24]

After surgery you should get a PSMA PET/CT to check the lung nodules or if the cancer has already spread. If the lung nodules are cancer, a chemo will usually provide good results.

[TylexGP]

I agree with others. Get the CT. Prior to my DX I had a CT in prep for a cardiac ablation where I had several sub centimeter nodules. They have remained stable for 2 years and are likely an incidental finding.

[addicted2cycling]

Eightydeuce wrote -- " ... CT scan found 3 lung nodules, in both lower lobes with largest approx 5mm, but undetermined ... "

Without biopsy of nodules is not *undetermined* the operative word? Would not a PYLARIFY PSMA PET pick up on the nodules if they are expressing PSA and not if something else?

[Eightydeuce]

Thanks for response. I have appt. with pulmonologist for later in April.

[tango65]

PET/CT scans can be requested with diagnostic CTs. All the PSMA PET/CTs I had at UCLA were done with diagnostic CTs including contrast and intestinal contrast.

The usual lower resolution of the PET/CT scans try to reduce radiation to the patients. Most doctors do no request diagnostic CT along with the a PET/CT .

[tango65]

He has a high risk cancer.

Try to get a PSMA PET/CT before doing any treatment.

If there are nodules in the lungs which are really prostate cancer he has a hematogenous dissemination of the cancer. The cancer could be anywhere.

Ct scan and bone scan have a significant lower detection rate of metastases when compared to PSMA PET/CTs.

Using PSMA PET/CTs before treatments leads to change in treatment plans in most of the patients.

[Tall_Allen]

Surgery will be a waste of time if those lung nodules are prostate cancer, and it is not your best therapy anyway. Cancel the surgery.

The first step is to get a bone scan/CT. That will probably be negative. Then get a PSMA PET/CT scan. If that is also negative, you can go ahead with prostate therapy.

The kind of prostate therapy with the best record of success is in situations like yours is called brachy boost therapy. This entails external beam radiation to a wider area + a brachytherapy boost to the prostate + 1 year of hormone therapy. You will have to meet with a brachytherapy specialist to get this. Where are you located?

[Eightydeuce in reply to Tall_Allen]

Thanks for your response. I chose the path of surgery using Dr. Patrick Walsh's "Guide To Surviving Prostate Cancer" and the Mayo Clinic support group. Am actually seeing pulmonologist today. Appreciate your thoughts.

[addicted2cycling in reply to Eightydeuce]

Eightydeuce wrote -- " Thanks for your response. I chose the path of surgery using Dr. Patrick Walsh's "Guide To Surviving Prostate Cancer" and the Mayo Clinic support group... "

Fightinghard wrote -- " please get the scans asap... "

In total agreement with Fightinghard no matter what any book information was given.

Having been treated 8 years ago for GL10, my 2cents is Fightinghard, Tony666 and others have hands on experience for their own PCa treatment and lives lived.

Good LUCK. 👍

[pakb in reply to Eightydeuce]

Did an oncologist recommend the surgery ? Or urologist? I'd have the scans then meet with a radiation oncologist and medical oncologist who specializes in prostate cancer. Agree that surgery may not be your best option if lung nodules are cancer. There are so many other options available since Patrick Walsh's book was published in 2012 for advanced disease.

[pe43 in reply to pakb]

I see on Amazon that there's a 4th edition of Walsh's book published in 2018, and a 5th edition will be available in October 2023.

[London441 in reply to Eightydeuce]

I chose surgery based on that book as well. It’s archaic. If you want a thinner, shorter penis, highly probable ED and a high chance of recurrence (necessitating further treatment) go right ahead. I’m not even listing all the consequences I had from surgery, and would never do it if I had the choice again.

Radiation has completely changed since that book was written. Don’t be fooled by the existence of newer editions.

Surgery is an increasingly worse choice for all but certain early stage, organ confined, low volume disease and even then it’s not the best option. Do your homework.

[pakb in reply to London441]

Agree. Sorry for your surgery issues.

[doc1947g in reply to London441]

When people decided to bee BLIND and stay BLIND, it is sad.

You described the SEs of other therapies but you passed over the surgery' SEs.

[London441 in reply to doc1947g]

My major consequence of surgery besides the sexual sides I mentioned was heavy incontinence which never recovered, despite dedicated pelvic floor exercises. It was finally solved (gratefully) by a artificial urinary sphincter. Although admittedly this was another surgery and will have to be redone after 5-15 years, it was a great solution for me.

Keeping in mind always that lasting incontinence from surgery is statistically less than 5% so I was lucky-unlucky that is.

The big problem with surgery is it's an easy sell to the layman. He wants 'one and done' and it seems logical to remove the prostate and take the cancer with it, as if it were that simple. Too often as we know it is not.

Sensitive scans not available to me at time of treatment (along with not buying into Walsh's book as being some sort of bible) would have very likely led to me changing my mind about surgery.

There is much they can't know until they get in there. 'The information you can only get via surgery' is a common selling point, but it's precisely because of PSMA pet etc that this is no longer the case.

Much is also made of 'nerve sparing' (to preserve erectile function) by urologic surgeons. At least part of the time this is wishful thinking at best. Of course the skill of the surgeon is a big factor in all of this, as is the proximity of the cancer to the nerve bundles.

Surgeons are often faced with the choice during RP of how much nerve sparing they want to attempt vs removing all the cancer they can find. It's challenging and sometimes murky. Added to this is the fact that some surgeons only start the procedure and then turn over the remainder to less skilled assistants to complete it, increasing their volume of surgeries, and of course profits. Quality inevitably suffers. Things like this are a major reason why there are so many detectable PSA's post op-an adverse feature to say the least.

Interestingly many men would opt for preserving their erectile function over attempting to remove all the cancer. I don't understand it and don't want to understand it, but to each his own.

All said, I am totally at peace with my decision, even though I chose aggressive additional treatment post op via a clinical trial featuring plenty of additional side effects. Partly because I have no evidence of disease so far (2 1/2 years post ADT) but mainly because there is obviously nothing I can do to change the past. I went with the first information and took it as truth. An easy mistake to make.

Onward!

[Tall_Allen in reply to Eightydeuce]

Patrick Walsh is, of course, very biased towards surgery. Karnes has a similar influence at Mayo. Books are quickly outdated, and support groups can't be counted on to supply good info. Your best alternative is to meet with specialists and to make up your mind afterward.

For high risk patients, you can see that the odds are that surgery will not be successful:

mskcc.org/nomograms/prostat...

For very high risk patients, brachy boost therapy has results far exceeding surgery:

prostatecancer.news/2018/03...

Due diligence demands that you meet with a brachytherapist before making such an important decision. I think the best brachytherapist in the Midwest is Alvaro Martinez in Detroit.

[Tony666]

on the lung nodules, I had a similar 5mm lung nodule show up on my ct scan. What they do is to wait a year to see if there is any change. If not, it is likely benign which is my case. I went ahead with prostate cancer treatment and then a year later got another ct scan to check the lung nodule.

on treatment, my question to you is how many cores/percentage was cancer? In my case, I also had high risk cancer (gleason 9) but only 5% of the prostate (only 3 of 12 cores and within cores only 20 percent). 5 % was also confirmed by an mri. If you have a lot of Gleason 8, tall Allen is correct that radiation+brachy+adt is best. Since I had high Gleason but just small amount, I went with a trial of intensive ADT (4 drugs) for six months (to get any stray escaped cancer cells) followed by prostatectomy. My trial was at NIH but UC San Diego has a similar trial. Now almost 3 years since surgery with no recurrence. So far, so good .

[Junenight]

After I was initially diagnosed with prostate cancer in 2021, I had an MRI and a conventional CT scan which showed no spread beyond my prostate. Fortunately, I also had a PMSA/CT scan that showed spread to several distant bones and lymph nodes. The detects were all relatively small, which is why they didn’t show up with the MRI and CT scan. Based on the MRI and conventional CT scan my treatment would likely have been surgery to remove my prostate, which would have done nothing to address my systemic disease.. Instead, I’ve had the triplet therapy you can read all about on this site that has become standard of care in the US for people in my situation. I think you really should get a PMSA scan before proceeding with treatment to determine the best treatment for you. Hopefully the PMSA rules out further spread.

[Junenight in reply to Junenight]

p..s. My Gleason score was also 8. Also, prostate cancer is slow growing so, if it hasn’t spread yet, taking a bit more time to get a PMSA scan before surgery, even if it means pushing the surgery back a bit, shouldn’t be a problem.

[doc1947g in reply to Junenight]

NOT all PCa are SLOW.

Mine had a tumour doubling size in less than 2 months. So even my urologist agreed with the RO treatments which were started 2 weeks post diagnostic.

ADT (Lupron Depot 45mg/6months) and VMAT-RT 20fx(3Gy)=60Gy.

So the treatments chosen were perfect.

3 years later, PSA= 0.02μg/L and Testosterone = 2.1 nmol/L - 60.57 ng/dL

[Fightinghard]

please get the scans asap. After that your drs can determine best treatment options. TA explained it perfectly. Surgery might not be the best option for you. It WILL result in many side effects later on. Maybe need a second opinion dr to help you decide

[Eightydeuce in reply to Fightinghard]

Thank you! Nodules are benign!

[Concerned-wife]

from our experience, they will watch to see if lung nodules increase in size. There are many non cancerous nodules that can show up in scans

[Grandpa4]

get scans because if it is prostate cancer in the lungs surgery will not be necessary.

[Eightydeuce in reply to Grandpa4]

Thanks! Nodules benign!

[maley2711]

LARGE numbers of scanned folks show lung nodules....for nodules smaller than a cutoff size, they track any growth with quarterly or semiannual scans for a year to watch for any significant ? growth. Non-smokers can have lung cancer, just a lower risk. My wife's sister fell victim to lung cancer......non-smoker. It is a fact that more men diagnosed with PCa die from other cancers than from PCa....same for heart problems of course. Odds are great your nodules are benign...if they see a certain amunt of growth over next 1-2 years, then a biopsy.....ugh!!!

[SteveTheJ]

Best wishes. Get the best advice (including from here) and if at any point your doctors become unresponsive, find other doctors. If you go on androgen deprivation therapy (ADT) be aware that different men respond very differently.

I was Gleason 8 with prostate removal about 6 months after diagnosis. ADT has not been an issue for me so far, just some fatigue.

A man can live a long time with prostate cancer; hopefully you're one of those.

[Eightydeuce in reply to SteveTheJ]

Thanks !

[reb77]

In 2019, a CT scan showed bones clear but suspicious nodules in my lungs and lymph nodes. A lung biospy indicated it was Pc. Lungs and lymph nodes clear (undetected) after 3.5 years of treatment with Orgovyx and Zytiga.

[anonymoose2]

Sounds almost identical to my prognosis in 2017. Other than I went with radiation. If I had to do it all over again I would go the surgery as it was contained in the prostate. My nodules are from being sick with flu and pneumonia in my past. We keep an eye on it but nothing changes year after year. Just recently got back on Xtandi after a year vacation. Living with cancer with success and QOL. So not complaining.

[Eightydeuce in reply to anonymoose2]

Thanks! Nodules are benign!

[Arrayscout]

I was 4+4 going in and coming out of surgery. This was 2011. I did have recurrence in 2012 and did salvage whole pelvic radiation with hormonal therapy for 18 months, and today my PSA is not detectable. Do your research, talk to urologic, radiation, and even medical oncologist if needed but make it your decision. You have time. You should rule out those lung nodules which are probably not related to your prostate cancer. Good luck.

[Eightydeuce in reply to Arrayscout]

Thanks! Had appt with Pulmonology yesterday. Nodules benign!