Hi everyone. Hoping to get some input from the collective experience and knowledge of the helpful people on this forum in making a decision on course of treatment. I apologize for length of post, but, with two issues (prostate and kidney) it took a bit to accurately explain. Newly diagnosed with Prostate Cancer as of Nov 1 2023. 59 years old, physically fit. I live in Southern Virginia. I Met with Multi Discipline team at Inova Schar Cancer Institute in Fairfax VA on 7 Dec 2023 and have a 2nd opinion meeting with Multi Discipline team at Duke Cancer Center in Durham NC on 5 January 2024.
A quick back story to add context.
Summer of 2023 began having issues beginning the urine stream and then stopping mid stream without completely draining bladder. Dull pain in lower pelvic area and lower left side of back. Primary Care Dr ordered PSA test and CT scan of pelvis. PSA came back 5.3 (August 2023) CT scan (1 Sep 23) revealed 13mm x 15mm tumor in left kidney. No other abnormalities. Referred to Urologist for prostate/kidney. Oct 5 2023 met with Urologist (Inova Urology Fairfax VA) who performed DRE for prostate (abnormal) and pointed out on CT scan that kidney tumor was problematic due to location (near artery) and referred me to head of Urologic Oncology at Inova Schar Cancer Institute in Fairfax VA as she had more experience with complicated surgeries and offered the best opportunity to save most of the kidney (partial nephrectomy).
9 Oct 2023 Appointment with head of Department went well and she ordered MRI of pelvic area as well as prostate. MRI of Pelvic area confirmed Kidney tumor, but, showed no other abnormalities of sign of spread to other organs. MRI of prostate resulted in PI-Rad 5 Score for 1 suspicious lesion, Seminal Vesticles (within normal limits, Neurovascular bundles (within normal limits), Lymph nodes (no enlarged nodes), bladder (within normal limits) Bone Marrow (No suspicious bone lesion confirmed). Impression from MRI was:
1. Focal area suspicious for clinically significant prostate tumor, centered at the midline, extending bilaterally at the apical peripheral zone. 2. Prostate Volume 33cc 3. No evidence for extracapsular extension.
Based on this MRI a Transperineal MRI assisted biopsy was schedule for 1 Nov 2023
Results of biopsy on Nov 1 2023 were Gleason 3+4=7 on 8 of 15 cores, Grade group 2. Gleason 3+3=6 on two cores and the remaining cores benign. All positive cores 5%, or Less than 5%. Pattern 4 lacks large cribriform morphology.
PSA had increased from 5.3 (August) to 5.9 (Nov)
Bone Scan on Nov 24 2023 showed No evidence of osseous metastatic disease.
Decipher Test .49
Intermediate Risk Factors of T2C and greater than 50% of cores positive put me in Intermediate Unfavorable category.
Met with MO, RO and urologic Surgeon at Inova Schar on Dec 7 2023. Their recommendation was:
Primary recommendation due to my age of 59 and overall good health and best option to get rid of cancer was for Robotic Assisted Laparoscopic Prostatectomy (Nerve sparing)
• Based on my research I came into meeting leaning heavily toward radiation with only advantages I see for RP over RT being an accurate assessment of true nature of cancer via post surgery pathology, No more BPH, and PSA becoming a better barometer of cancer spread. Otherwise, all studies I have read indicate far fewer odds of SE via RT.
Secondary recommendation was for RT
• EBRT with 6 months of ADT plus Brachy boost (This seems like the best option to me for potential cure, although HDR Brachytherapy as monotherapy appeals to me as well)
• RO said if I didn’t want to do the above Radiation due to ADT then he would consider HDR Brachytherapy as a monotherapy, but, said that the EBRT+ ADT+ BT would be best treatment from his point of view.
o RO also said due to my taking Tamsulosin (which works great for me) for urination issues would recommend procedure to ablate the urethra with 2 month wait after that to begin radiation.
I would welcome any input on pros/cons I haven’t considered of either RP or RT. My specific questions:
1. Anyone had The tri modal RT above after having Urethra ablation for BPH? My primary concern with RT is if I don’t have ablation procedure will have SE of Urinary retention. Or, If I do have the ablation procedure run risk of incontinence if RT done too soon after procedure.
2. Going to Duke for 2nd opinion Jan 5. Anyone with experience with Duke or other Institution on east coast for Tri modal RT that you would recommend?
3. Any stories of Success with above RT?
As for the Kidney. Due to small size of tumor and slow growing nature of kidney cancer the recommendation is to handle the Prostate first then deal with kidney after healed from Prostate treatment. Probably by use of SBRT in order to try and save the kidney. They think due to location of tumor a successful surgery for partial nephrectomy is unlikely and entire kidney would have to go.
Thanks in advance for advice and help.