My dad had an MRI and biopsy done in February of this year. Some samples show Gleason 7 and 8 and then there’s also Gleason 9. There is also slight invasion into the seminal vesicles. PSMA shows no metastasis. Back in 2022, he was Gleason 6 and was on active surveillance.
We are going to Memorial Sloan Kettering in NY for treatment. Because of the Gleason 9, they want to treat it aggressively. We have met with the radiation oncologist who has proposed the combination of brachytherapy and external beam radiation (EBRT) along with 18-24 months of ADT + abiraterone.
We then met with the medical oncologist who agreed that this is the preferred approach at MSK but that we should still meet with the surgeon. Based off of my own research and things that I have read (I am no doctor of course) it does seem like this would be the more suitable option. Why do the surgery if you’re going to need radiation regardless.
The surgeon proposed hormone therapy, RP, and radiation. Because the cancer is already invading the seminal vesicles, he said surgery alone wouldn’t get all of the cancer, as there are more than likely microscopic cells. So radiation would be inevitable. My surprise was adding in the hormone therapy with surgery. When we spoke with the radiation oncologist and medical oncologist, my understanding was that the hormone therapy would only be with radiation. The surgeon said this would be a very aggressive approach.
My dad already has his mind set on the hormonal therapy with radiation but we obviously want to do whatever is going to give the best success rate. Also don’t want to have to go through unnecessary treatment options. Am I wrong for thinking the best approach for Gleason 9 with seminal vesicle invasion is hormone therapy with brachy and external?
Thanks everyone! I’ve been reading so many posts the past two months and it’s been really helpful navigating this journey. Finally got the courage to post.
Written by
Lnsilva09
To view profiles and participate in discussions please or .
I agree with you - kind of crazy to add hormone therapy to surgery and to do it knowing he will need radiation anyway. The side effects are always worse from salvage radiation than from primary radiation.
Another plus is that if you avoid surgery you avoid anesthesia, which has its own cumulative degrading effects. This from Dr. G00gle : "Anesthesia use in the elderly can lead to accumulated effects, including a higher risk of postoperative delirium and cognitive dysfunction. Elderly patients are more susceptible to these complications, which can persist for weeks, months, or even years after surgery. "
because your dad may have seminal invasion, I agree the brachy boost at MSK may be the best course of action.
I only wanted to object to tall Allen’s comment that adding hormone treatment to surgery for high risk prostate cancer is “crazy”. It is in fact a cutting edge experimental approach that is currently being trialed in California (the proteus trial) and in Canada (the guns trial). Your surgeon is actually on top of his game by suggesting it. I did a similar NIH trial with Gleason 9 and now 4.5 years later am still undetectable. Still, I did not have seminal invasion which suggests to me that the brachy boost at MSK may be best for your father. Nevertheless rest assured your surgeon is not “crazy” but is actually suggesting a smart way forward if you did not for any reason want to go the radiation route.
In your bio you say " Result: complete response - no cancer seen on disection" do you mean, after surgery, they didn't see any cancer in .. what? what dissection are you talking about? its great that you are undetectable 4.5 years later - may that continue.
Yes. At diagnosis I had Gleason 9 (5+4) in 2 cores. FYI the trial protocol required a second MRI guided biopsy that confirmed the cancer. After 6 months of intensive ADT (goserilin + enza + abi ) they removed my prostate and about 15 glands. NIH dissected my removed prostate and glands and found no cancer. I still get tested every six months though in case any cancer cells escaped and had gone dormant.
TA can answer for himself, but the way I interpreted his comment was that, given that the OP has seminal vessel invasion (and the urologist didn't seem to take that into account), it was "crazy."
The statement touches on a nuanced debate in prostate cancer management, particularly regarding treatment strategies for high-risk, locally advanced disease. Here's a breakdown of the key considerations:
### 1. **Gleason 9 (G9) Prostate Cancer with Seminal Vesicle Invasion (SVI):**
- **Gleason 9 (Grade Group 5):** Indicates aggressive disease with a high risk of progression and metastasis.
- **Seminal Vesicle Invasion (SVI; pT3b):** A marker of locally advanced disease, associated with poorer outcomes and higher recurrence rates after surgery.
### 2. **Surgery (Radical Prostatectomy) in This Context:**
- **Controversy:** While surgery is standard for localized prostate cancer, its role in G9 with SVI is debated. Studies show higher rates of positive surgical margins, recurrence, and the need for additional therapies (e.g., radiation or androgen deprivation therapy (ADT)) post-surgery.
- **Criticism of Surgery Alone:** Performing surgery *without* a multimodal plan (e.g., adjuvant radiation/ADT) may be insufficient, as micrometastases or residual disease are likely. Some argue that surgery in this setting offers limited survival benefit compared to radiation-based approaches.
### 3. **Hormone Therapy (ADT) as an Adjunct:**
- **Rationale:** Adding ADT to surgery (neoadjuvant or adjuvant) may reduce tumor burden, improve surgical outcomes, or delay recurrence. However, evidence for survival benefit in this specific context is mixed.
- **Multimodal Approach:** ADT is more strongly supported when combined with radiation therapy (RT) for locally advanced disease. Trials like SPORT/SPCG-15 show superior outcomes with RT + ADT compared to surgery alone.
### 4. **Preferred Alternatives to Surgery:**
- **Radiation Therapy (EBRT) + ADT:** Considered first-line for locally advanced prostate cancer with SVI. Long-term ADT (18–36 months) with radiation improves survival in high-risk cases.
- **Triple Therapy:** Emerging data support combining RT, ADT, and novel agents (e.g., abiraterone) for very high-risk disease.
### 5. **When Might Surgery Still Be Considered?**
- **Select Cases:** Younger patients with limited SVI or those who strongly prefer surgery may benefit if combined with adjuvant therapies (e.g., salvage RT + ADT). Shared decision-making is critical.
- **Staging Accuracy:** Preoperative MRI/PSMA-PET may better define SVI extent, guiding surgical planning.
### 6. **Key Guidelines:**
- **NCCN Guidelines:** For pT3b disease, recommend adjuvant RT ± ADT if adverse features (e.g., positive margins) are present post-surgery. However, primary RT + ADT is often preferred over surgery for upfront SVI.
- **EAU Guidelines:** Favor radiation + ADT for locally advanced disease, noting surgery should only be offered in a multimodal setting.
### Conclusion:
The assertion that "surgery for G9 with SVI is crazy" reflects the growing consensus that radiation-based therapies (+ ADT) are more effective for locally advanced disease. Surgery may still play a role in select cases but requires careful patient selection and integration with adjuvant treatments. Hormone therapy alone is insufficient, but its combination with other modalities (surgery or radiation) is evidence-based. Multidisciplinary evaluation is essential to tailor therapy.
If we know RP fails at a rate of 20-40% overall, how often does it fail for G9’s with SVI?
This is why I think RP for such cases is yes, crazy. RP has a high likelihood of side effects no man wants, particularly ED and loss of penis length and girth.
Many surgeons sell RP to younger men especially because their (presumably) robust health makes them more likely to tolerate it well. Robust health that includes more likely to be sexually active.
I also had SV involvement, only one was visible on the PSMA pet scan and the MRI Linac specialist radiated bought of the Seminal vesicles.
I really not sure if it is a common practice to radiate the seminal vesicles or do they only radiate them if there is a recurrence because radiating seminal vesicles could be very toxic to the bowel?
Your question touches on important considerations in prostate cancer radiation therapy, particularly regarding **seminal vesicle (SV) targeting** and **toxicity risks**. Here’s a breakdown of current practices and rationale:
---
### **1. When Are Seminal Vesicles (SVs) Targeted with Radiation?**
#### **Primary (Initial) Radiation Therapy:**
- **High-Risk/Locally Advanced Disease:**
- If imaging (MRI, PSMA-PET) or biopsies show **SV invasion (SVI)**, radiation to the SVs is standard. This includes both the involved SV and often the contralateral (opposite) SV, even if imaging appears normal, due to risk of microscopic spread.
- For **high-risk cases without visible SVI** (e.g., Gleason 9, PSA >20), guidelines (NCCN/EAU) still recommend prophylactic SV irradiation because microscopic involvement is common.
- **Intermediate-Risk Disease:**
- SV radiation is more debated. Some protocols irradiate the proximal SVs (closer to the prostate), while others avoid them to reduce toxicity.
#### **Salvage (Recurrence) Radiation:**
- If SVs were **not treated initially** and recurrence occurs in the SVs (detected via PSMA-PET/biopsy), they would be targeted in salvage therapy.
- If SVs were **already irradiated**, repeat radiation is usually avoided due to cumulative toxicity risks.
---
### **2. Why Your SVs Were Likely Targeted Upfront**
- **Visible SVI on Imaging:** Your PSMA-PET/MRI showed involvement in one SV. Even if the other appeared normal, microscopic disease is possible, so treating both is precautionary.
- **MRI-Linac systems** (like yours) allow real-time tracking of the prostate/SVs and motion adaptation (e.g., accounting for rectal filling), which spares the bowel.
- **Dose Constraints:** Radiation oncologists prioritize limiting bowel exposure. For example, the volume of rectum receiving high-dose radiation is tightly controlled (e.g., V70 <5–10%).
---
### **3. Toxicity Concerns: How Safe Is SV Radiation?**
- **Bowel Toxicity:** The SVs sit near the rectum, so irradiating them *can* increase risks of:
- Acute: Diarrhea, urgency.
- Late: Proctitis, bleeding, rare fistulas (<2% with modern techniques).
- **Mitigation Strategies:**
- **Advanced Delivery:** Intensity-modulated radiation therapy (IMRT), volumetric arc therapy (VMAT), and MRI-guided systems (e.g., MR-Linac) sculpt dose away from the bowel.
- **Hydrogel Spacers:** Sometimes placed between the prostate/SVs and rectum to physically separate them.
- **Bladder/Rectal Preparation:** Emptying the rectum/filling the bladder before treatment reduces organ motion and exposure.
Studies show that with modern techniques, severe bowel toxicity from SV radiation is **<5%** in experienced centers.
---
### **4. Is This Common Practice?**
- **Yes**, for high-risk/visible SVI:
- Trials like **RTOG 9413** and **PROFIT** support elective SV irradiation in high-risk cases to improve cancer control.
- Omission of SV radiation is more common in low/intermediate-risk cases or when toxicity risks outweigh benefits (e.g., pre-existing bowel disease).
---
### **5. Your Case: Key Takeaways**
- **Rationale for Treating Both SVs:** Even with unilateral SVI on imaging, microscopic spread to the contralateral SV is possible. Your team likely opted for comprehensive coverage to minimize recurrence risk.
- **Toxicity vs. Benefit:** While SV radiation carries risks, untreated SVI has a much higher risk of recurrence/metastasis. With MRI-Linac precision, your team likely optimized safety.
- **Follow-Up:** If you’re experiencing bowel symptoms, discuss mitigation strategies (e.g., dietary changes, medications) with your care team.
---
### **Bottom Line**
Radiation to the seminal vesicles **is standard in high-risk cases** (especially with visible SVI) to maximize cure chances. Modern techniques like MRI-Linac have significantly reduced toxicity risks, making this approach both safe and effective. Your treatment aligns with current guidelines, but always share any toxicity concerns with your radiation oncologist—they can adjust supportive care or future monitoring.
Totally agree. There are some cutting edge treatments by leaders in the field that have not yet made their way through the long and arduous process of a Phase 3 trial, which can take years.
"... invasion into the seminal vesicles... My surprise was adding in the hormone therapy with surgery. When we spoke with the radiation oncologist and medical oncologist, my understanding was that the hormone therapy would only be with radiation..."
IMO, a PCa diagnosis with any invasion, seminal or perineural, likely means microscopic metastases for which you should have systemic hormone therapy. Regardless of whether the prostate is removed or radiated. I had PNI, was radiated without hormone therapy, and got metastasis to one or more nodes.
Your experience and perspective highlight critical nuances in prostate cancer (PCa) management, particularly the debate about when systemic therapy (e.g., hormone therapy/ADT) should be combined with local treatment (surgery or radiation). Here’s a breakdown of the key issues:
- **SVI (pT3b):** A marker of locally advanced disease, strongly associated with higher rates of metastasis and recurrence. Guidelines consistently recommend combining ADT with radiation (or surgery + adjuvant therapy) for SVI.
- **PNI:** Common in PCa, but its prognostic significance is debated. While PNI alone may not always warrant systemic therapy, it can signal aggressive biology when combined with other high-risk features (e.g., high Gleason score, PSA >20). Your case—PNI followed by nodal metastasis—suggests PNI may have been a marker of occult systemic spread.
---
### **2. When Is ADT Recommended?**
- **With Radiation:** ADT is standard for intermediate/high-risk localized PCa. For example:
- **High-risk (including SVI):** Long-term ADT (18–36 months) + radiation is strongly supported by trials (e.g., RTOG 9202, DART01/05).
- **With Surgery:** ADT is less commonly used upfront. It’s typically reserved for adjuvant/salvage settings if recurrence occurs (e.g., rising PSA, nodal/metastatic disease). However, some argue for earlier systemic therapy in high-risk cases (e.g., G9, SVI).
---
### **3. Your Case: PNI and Omission of ADT**
- **Why ADT Might Have Been Excluded:**
- PNI alone, without other high-risk features (e.g., Gleason ≤7, low PSA), might have been classified as "intermediate-risk," where some clinicians omit ADT.
- Variability in practice: Not all providers agree on PNI’s significance, and guidelines (NCCN, EAU) don’t uniformly mandate ADT for isolated PNI.
- **The Metastasis Risk:** Your progression to nodal disease underscores that PNI *can* indicate aggressive biology, even without other obvious risk factors. This aligns with studies showing PNI is associated with higher biochemical recurrence rates, though its independent impact on metastasis remains unclear.
---
### **4. The Case for Systemic Therapy in Invasive Disease**
- **Microscopic Metastases:** Invasion (SVI, PNI, or extracapsular extension) suggests the tumor has acquired migratory potential. Even with successful local treatment, micrometastases may already exist.
- **ADT’s Role:**
- **Radiation + ADT:** Reduces local recurrence *and* systemic spread by targeting androgen-dependent cells.
- **Surgery + ADT:** Less evidence for survival benefit, but adjuvant ADT may delay recurrence in very high-risk cases (e.g., G9, SVI, positive margins). Trials like SPCG-12 show mixed results.
- **Emerging Trends:** For high-risk localized PCa, combining local therapy with **intensified systemic therapy** (e.g., ADT + abiraterone/docetaxel) is being explored to address micrometastases earlier.
---
### **5. Guidelines vs. Personalized Care**
- **NCCN/EAU Guidelines:**
- For SVI: Favor radiation + long-term ADT over surgery alone.
- For PNI: ADT is not routinely recommended unless other high-risk features are present.
- **Your Experience:** Highlights gaps in risk stratification. Biomarkers (e.g., Decipher, Prolaris) or advanced imaging (PSMA-PET) might better identify patients needing earlier systemic therapy, even with "lower-risk" features like isolated PNI.
---
### **Key Takeaways**
1. **SVI vs. PNI:** SVI is a stronger prognosticator, but PNI *can* indicate aggressive disease, especially with other risk factors.
2. **ADT Omission Risks:** Skipping ADT in invasive disease (even with local treatment) may leave micrometastases untreated. Your case exemplifies this.
3. **Multimodal Therapy:** For high-risk features (G9, SVI, extensive PNI), combining local treatment (surgery/radiation) with systemic therapy (ADT ± novel agents) is increasingly justified.
4. **Advocating for Yourself:** Your experience reinforces the need for shared decision-making and seeking second opinions in borderline cases.
---
### **Bottom Line**
While guidelines provide a framework, prostate cancer’s heterogeneity demands personalized care. Your story underscores that invasion (seminal or perineural) should prompt careful consideration of systemic therapy, even if guidelines are ambiguous. For patients with aggressive biology, erring on the side of overtreatment may sometimes be preferable to risking metastasis.
I opted to have the prostate removed along with a bilateral lymphadenectomy.
Frankly, the cancer was progressing quickly and for me to spin up a RO would have taken months.
So, I proceeded to have the RAPL.
All margins clear, Gleason 9 (4+5)
Of course PSA dropped from pre op of 6.8 to 1.2(IIRC).
After surgery, I moved my care to a Cancer center of excellence in Boston.
PSMA/PET scan showed cancer in tissues of prostate bed and the left para aortic node.
So, then I was immediately put on Lupron which further dropped PSA to .6, it was then decided to add Abiraterone, which dropped PSA to <0.10… undetectable.
After 4 months, PSMA/PET scan showed that the para aortic node was no longer “avid” the ADT and Abiraterone had shrunk the cancer to about 1/3 of what it was… 2 months later, consoldative radiation was done.
During radiation, I was glad to have had the RAPL as this negated any urinary blockages due to effects of RT. Some mild leakage but nothing much.
Abiraterone started giving me liver problems and I was switched to Nubeqa (Darolutimide)
So far, so good.
I made the choices with the information I had available at the time and after reading that patients with high volume cancer may benefit from prostate removal.
Whether or not this increases my survival rate… who knows.
Just read your bio, my dad’s biopsy results are very similar. The PSMA-pet showed the cancer in the tissue and the node after your surgery? That’s my concern about the surgery is having to have the radiation done anyway.
Yes, I still had some “avid uptake” in several nodes, one was the left para aortic node… but, it was not responding to uptake on th pre Radiation therapy PSMA PET scan after 6-7 months of Lupron + 5 months of those on Lupron+ Abiraterone. Adding Abiraterone was amazing.
Don’t fear radiation, for me it wasn’t much of a bother and I’m in a very good place right now for a Stage 4A patient. My treatment was curative in intent and won’t know for another 2 years when I get a break from ADT… if it becomes resistant in that time period and my PSA rises, then we’ll have to try other options.
It is imperative to get treatment at a cancer center of excellence if cancer is metastatic, the volume of patients, experience, latest imaging and targeting technology and software WILL save his life.
In my case, we will see if removal was beneficial or, not… only time will tell.
As a note, ADT is more difficult for me than either the surgery or, radiation.
At age 68 I had RP for what turned out to to be a G9 with seminal invasion. Six months later I had evidence of oligo metastatic disease (T8) on PSMA PET treated with SBRT. The nasty little bugger was systemic and was doubling quickly (on 3 month PSA follow up), so I elected to get aggressive treatment at Johns Hopkins. Triple therapy followed by whole pelvic radiation. Chemo and Darolutamide for only 3 months and Lupron for a year. PSA went undetectable after 2nd chemo cycle and has stayed there. My T never recovered so my very experienced MO at Hopkins put me on TRT with supervision of an endocrinologist. It's been a game changer for me and PSA remains undetectable 5 months later. He said their treatment has killed all of the aggressive clones and if the cancer returns it will be indolent and manageable. I completely trust his opinion. They have a large data base with similarly treated men.
my dad was treated in the same way..started pamorelin injections and surgery in jan 2020..he had seminal vesical and bladder neck invasion..approx 5 years on pamorelin till it failed and 2 days back had done psma scan ..reports awaited..psa 4
Content on HealthUnlocked does not replace the relationship between you and doctors or other healthcare professionals nor the advice you receive from them.
Never delay seeking advice or dialling emergency services because of something that you have read on HealthUnlocked.
When is Medical Oncologist Appropriate?
Medical oncologist and radiology oncologist
Prostate cancer gleason 9; 88 years of age
42 yr old prostate cancer
Dad's advanced Gleason 9 PCa
