Which Treatment for These Biopsy Results?

[Nordman]

I now have my biopsy results

Gleason 3 + 4 ie 90% of 3 and 10% of 4

Grade 2 The consultant said it was Intermediate but at one point used the term Low intermediate. Is this latter term valid given the stats?

T2a NO MO - but I am puzzled about this because although it was mostly all on the left side 1 core of 6 on the right was 3+3 but only 1%. I thought that was T2c but the consultant said it was only a "tiny amount" so T2a. Should I query this further?

6 out of the 15 cores had PCa. 3 out of the 6 cores were on the left side and were 1.3mm, 5mm, and 9mm. 1 out of 6 cores was on the left. I can't account for 3 of the 15 cores! Will have to ask.

Cells - Adenocarcinoma - micro acinar

No cribriform features

No EPE or Perineural Invasion

DRE - normal palpation

PSA before biopsy was 14.32

MRI indicated a 14mm tumour on the left lower quadrant and an indeterminate echo on the right side.

Prostate volume 36cc on MRI

Prostate density at MRI 0.39

PIRADS 4 on MRI

The consultant mentioned Active Surveillance - possibly due to my age (approaching 78) The T2c question mark bothers me. I also read somewhere that AS should not be considered with samples above 5mm. He also mentioned RT + HT, (IMRT) but I want to avoid HT. I am considering LDR Brachytherapy, but my HOLEP 12 years ago might preclude BT.

VMAT IMRT + HT, VMAT IMRT without HT, possibly LDR Brachytherapy, Active Surveillance

are the only treatments available to me in my neck of the woods. Which would you recommend given my stats.

Was there anything I missed out or should clarify in the biopsy stats?

Any other input on the above stats and treatments?

Nordman

[Tall_Allen]

T stage is based on DRE, so you are probably T1a.

Your NCCN risk category is "unfavorable intermediate risk" because your PSA is greater than 10.

Here are some relevant stats for each therapy:

prostatecancer.news/2018/10...

Can you get SBRT?

[maley2711 in reply to Tall_Allen]

from cancer.org....

" The clinical T category (written as cT) is your doctor’s best estimate of the extent of your cancer, based on the results of the physical exam (including a digital rectal exam) and prostate biopsy, and any imaging tests you have had. "

incorrect?

[Tall_Allen in reply to maley2711]

Yes, incorrect. For clinical stages, the T stage is only based on DRE findings, according to AJCC v.8. "Assigning the clinical T category (cT) is accomplished using information from the DRE of the prostate and should always reflect DRE findings only."

acsjournals.onlinelibrary.w...

[maley2711 in reply to Tall_Allen]

and from Hopkins......

" The clinical stage is based on the results of the urologist's physical examination of the patient's prostate (including a digital rectal exam (DRE)) and any other tests done prior to definitive treatment (i.e., surgery or radiation). " ???????????

So, prior to treatment would have been TRUS , and just recently MRI. When Hopkins gives a man his clinical stage, this or the more limited DRE-only result? hmmm??

[Tall_Allen in reply to maley2711]

JH follows AJCC v.8 as does everyone else. T stage is by DRE-only as I showed you.

[maley2711 in reply to Tall_Allen]

why that on Hopkins webpage?????

[Tall_Allen in reply to maley2711]

Why ask me? Ask them. Perhaps it is an outdated webpage.

[maley2711 in reply to Tall_Allen]

More into the weeds......

staging.seer.cancer.gov/tnm...

May be used?

[Tall_Allen in reply to maley2711]

I don't understand why you care what SEER uses for its database. The only manual that is used by clinicians in the US, Canada, and Australia (and often in Europe) is AJCC v8. It is the only manual used for the NCCN risk categories and the Cancer Prognostic Stage Grouping. There are many other staging systems but none are as widely used. Here's my article about it:

prostatecancer.news/2017/03...

[maley2711 in reply to Tall_Allen]

Because my T stage is different, depending on the definitions. Actually, no Doc has even mentioned T stage.

[Tall_Allen in reply to maley2711]

Most men are T stage T1c - nothing is felt. So for most men, T stage is inconsequential. But if something is felt, it raises the riskiness. It is used to put you into an NCCN risk category. The starting point for your preferred treatment is based on your NCCN risk category.

Judgment plays a role too. Some doctors will lower a patient's risk level if there are few positive cores, mostly pattern 3, low Decipher score, a history of prostatitis and BPH elevating PSA, and no family history. They may raise a patient's risk level if MRI shows more than focal penetration of the capsule, there is PNI, there are many positive cores, mostly pattern 4 or 5, aberrant morphology, high decipher score, family history, or very low PSA for the amount of cancer.

[maley2711 in reply to Tall_Allen]

This ?

hopkinsmedicine.org/health/...

[Nordman in reply to Tall_Allen]

Many thanks for that info and the ref Tall_Allen

It looks like my elevated PSA has screwed up a more favourable diagnosis. This has taken me down a notch.

Unfortunately my regional hospital is not at the cutting edge of PCa treatment and SBRT is not available to me, only VMAT IMRT.

I note from the ref you provided that conventional IMRT is still a good option and Brachy boost therapy probably the best for unfavourable intermediate risk PCa. However, I have decided not to go with Brachytherapy because of potential difficulties of seed placement due to HOLEP

It therefore looks like it will be conventional IMRT.

I currently don't plan to have HT because I have an under performing solitary kidney with eGFR of 42. HT carries a not inconsiderable risk of AKI even for those with healthy kidneys.

[NanoMRI]

Hopefully my input will help (I have read the others). I was 57 when diagnosed, 67 is coming up soon. 78+ is very appealing to me

My input is to focus on your current overall health and longevity outlook and balance these with treatment risks and potential outcomes.

As I delved into my diagnosis I moved away from focusing on the biopsy findings as I accepted my cancer was not indolent and there was reason to believe it had spread.

My attention shifted to what was my intent/hope for my first treatment attempt outcome and also the long haul, given my age. I wanted the best shot at getting all the cancer and if I was to face ADT/chemo, to delay this as long as possible. After many consultations with focus on mpMRI findings, the unanimous consensus for my circumstances was surgery. (IMPORTANT - I am not at all recommending surgery to you or anyone else; I just want to be clear this was my choice for my overall circumstances given there are a few strong anti-surgery voices in his group).

Note, my RP did not get it all, neither did the salvage RT. It remains unclear whether my third treatment attempt, salvage lymph node surgery got it all, but six years since that third attempt, my outlook continues very favorable and as of yet, no multi-year ADT and no chemo.

Hope this helps. All the best!