MRI results not promising ...need advice

[gordee09]

I've been on AS for over a year after being diagnosed with low grade (Gleason 3+3) in Feb of 2016 but had a biopsy in 2013 with negative results but continued to have an increasing PSA (4 in 2010, 8 2013, 12 2016 and now 15)...Just had an MRI and have to make a decision. Another biopsy targeted to the area that the MRI suggests there might be cancer in the anterior part of the prostate.

Looking for advice based on their finding....

Peripheral zone;

An area of markedly hypo intense signal on ADC map/hyperintensity on high b value DWI straddling on the anterior horn of the left apical peripheral zone and the anterior fibromuscular storm measuring 1.9 x .9 cm on axial image 25 series 8 (PI-Rads DWI score of 5). Corresponding masslike T2 signal abnormality and early enhancement measuring about 1.5 cm cephalocaudad. The mass abuts and bulges the outer prostate contour. In the middle this bulge abuts the cephalic aspect of the sphincter urethrae muscle. To the left of midline the tumour signal takes the angular shape of the space between the left side of the sphincter urethrae muscle and the elevator and, abutting the surface of these muscle but not visibly invading their substance. Anteriorly, the step-off between the right side tumour mass and the outer prostate contour is about .3 to.4 cm.

Elsewhere the prostate has indistinct hypo intensity on the ADC map and the striated T2 hypo intensity (PI-Rads DWI/T-2 score of 2)

Transitional zone: Heterogenous without focal finding of note.

Extraprostatic extension:

Elsewhere the outer prostate contour smooth. Neurovascular bundles appear symmetric. Seminal vesicles do not appear involved. No enlarged pelvic lymph nodes identified. A non-specific focus of decreased T1 signal with the left femoral head.

Questions

Do I get a biopsy to determine the grade of cancer?

Radiology or Prosatectomy?

Suggestions?

[Burnett1948]

Burnett1948. I am not as knowledgable as others. My story. Because my PSA was 7.6 in 2005 I had a biopsy; the 6 cores were all positive: my Gleason was 3+3. My first Urologist suggested radiation. I got a second opinion. The first thing the second Urologist did was to check the Gleason score which was revised to 3+4. He suggested surgery: I had a Robotic RP in 2005, then radiation in 2009 after recurrence which I am still dealing with. Because they cut my Urethra which runs through your prostate and then had to rejoin it; I like everybody else lost penis length. I don't know what happens when you have radiation. But if your nerves are not successfully spared with surgery you need to use a needle to have sex with a shorter penis. Now I'm no expert and I hope others will correct me if I am incorrect. But I picked up some Urologists (the majority probably) favour surgery and some favour external radiation. I believe there are other methods to check out now in 2017.

[AlanMeyer Moderator]

Gordee,

In general, they used to say that, all other things being equal, PSA < 10 is considered low risk, PSA >=10 and <20 is intermediate risk, PSA > 20 is high risk. It looks to me that on both PSA score and on the MRI description, the time is past for active surveillance. I think it's time for treatment.

Find the best urologist you can find and talk to him or her about surgery. Find the best radiation oncologist you can find and talk to him or her about radiation. In the U.S., I think a good place to find good doctors is at the teaching and research hospitals. See: cancer.gov/research/nci-rol...

My impression is that most patients want desperately to believe that they made the right treatment choice. Even if their treatment failed, they'll recommend the same treatment to others. It's a problem that most of us are prone to. The same thing holds for doctors. It can be hard to find a urologist who doesn't think surgery is the best treatment, or a rad onc who doesn't think radiation is best. They even have biases in the type of surgery or radiation. You'll find articles (almost always written by surgeons) that say surgery is superior and even that radiation doesn't work at all, and also articles by rad oncs that tout radiation over other treatments. And if they work at a center offering proton beam radiation, some of them will tell you you're committing suicide if you choose any other treatment.

In my personal and admittedly inexpert view, among the standard treatments, the caliber of the doctor means more than the modality of the treatment. I think you're better off with an outstanding rad onc than an average surgeon, or an outstanding surgeon than an average rad onc.

Side effects from the two kinds of treatment are different, but significant. I've heard one patient after another say he had no side effects from his surgery or radiation. Don't believe it. Maybe there are lucky patients, but a lot of us like to fool ourselves. There will likely be some loss of potency from either treatment and likely urinary effects (of opposite types) from the two treatments. Surgery affects continence. Radiation can make it hard to urinate. Either treatment can result in a fiasco if done by an incompetent doctor.

Best of luck.

Alan

[AlanMeyer Moderator in reply to AlanMeyer]

When you talk to the doctors, ask about the specifics of your case. For example, how will they treat the extraprostatic extension?

I had a couple of those and they were treated as part of my primary radiation treatment. I don't know whether a surgeon would have tried to treat them or whether he would say that you should have surgery, then have radiation. If so, I think I might prefer to have it all done at once, but ONLY if I had a good rad onc.

Alan

[Hidden in reply to AlanMeyer]

Alan, not a knock on you, but it is so typical that treatment discussions present only two options -- surgery (cutting) or radiation. There is now a third option that the medical establishment isn't keen on acknowledging -- High Intensity Focused Ultrasound (HIFU). Yes I had it and yes that is my bias. And no, incontinence and impotence are not problems 7 months post HIFU 'surgery'. I couldn't be happier with my treatment choice, although I certainly am poorer, having paid out of pocket. The establishment view: "there hasn't been 10 years of results in for HIFU, therefore we shun it". They will likely be saying the same exact thing five and ten years from now.

[AlanMeyer Moderator in reply to Hidden]

Yes, there are other local treatments besides surgery and radiation. These include HIFU and cryosurgery (freezing the prostate tissue.) Proton beam radiation, a different kind of radiation that doesn't use x-rays, has also been touted as newer and better than surgery or x-rays. "Cyberknife" is a relatively new x-ray treatment that has a lot of hype around it. HDR brachytherapy is another technique that was touted for a while (and which I had.)

One of the problems in medicine is that we naturally imagine that the latest techniques are better than earlier techniques, the way the latest computers are faster than the earlier ones. After all, why would someone introduce a new technique if it weren't better than the old ones? In practice however it's often the other way around. The latest techniques are neither as well proven nor as well explored. We often don't know how good they are, what the best way to use them is, or what patients are most likely to benefit from them.

I don't deny that they might be good, but I have seen so much hype surrounding each new treatment that I avoid recommending them unless and until clinical trials clearly show that they work as well as the well as the established treatments.

Having said that, I'll also say that I hope your HIFU treatment works perfectly and that you come out of it both cancer and side-effect free.

Alan

[Hidden in reply to AlanMeyer]

I am side effect free and my PSA is undetectable. The quality of life promises were delivered for this patient. Time will tell as to whether I get a 'durable remission'. I remain active in this forum to prepare for when things might go against me.

[gordee09 in reply to Hidden]

I had surgery planned and last minute opted for HIFU by Dr Stephen Scionti in Sarasota. That was 3 weeks ago. Everything working, walked out after 2 1/2 hour surgery and eating an hour later. Obviously don't have any long term results yet but I believe this was the best decision for me considering my age. Feared the incontinence and erectile dysfunction issues... Positive moving forward... (golfed on Sunday, worked out Mon, Tues and Wed this week.....just wearing the depends while taking the Flomax.

[gordee09 in reply to gordee09]

3 months later my PSA is 1.2 ...ED perfect with slight incontinence but improving weekly...

[skillmk in reply to AlanMeyer]

Excellent and truthful advice!

[James789]

it would depend on what you want, plus your age and if you are young or old

[Dr_WHO]

It sounds like it is time to move from AS to treatment. Please know that what the scans did not show is as important as what they did. It looks like the cancer is confined to the prostate. While that sucks, it is a lot better than if it was found in your lymph nodes or bones. There is every reason to believe that your cancer can be totally cured.

Definitely find yourself a good urologist and get a biopsy. Research the positives and negatives of radiation, surgery, cryo and ultrasound. Once you have the results from the biopsy then discuss your options with your cancer team.

We are all pulling for you!

[evreca]

Hi Gordon, I don't know if this is a repeat answer, but here is some info for you- If you get another biopsy, insist on the MRI-ultrasound fusion method - not available at all locations. This method merges your prior MRI with an ultrasound controlled by your urologist (special equipment needed) in order for the urologist to take the sample at the most significant or index lesion for a pathology report. Certainly the analysis provided by your MRI would be excellent in guiding the biopsy needle. Normally, perhaps only 4-6 samples would be required as compared to the "blind" transrectal ultrasound biopsy of 12-15 samples. The conventional biopsy is like shooting in the dark. If you are going to get a grade or Gleason score, get a second opinion of the pathology report, such as at Johns Hopkins- this is the most critical informational item that will drive your treatment and likelihood of recurrence.

You may also need a high grade PET scan to determine if the prostate cancer has metastasized. For this you need to go to Mayo Clinic for C-11 choline PET/CT or to the Phoenix Molecular Imaging Center for C-11 acetate. At your current Gleason 15, you have no problem in qualifying for detection. The radionuclide tracers are especially good at detecting where the prostate cancer has migrated and this information may affect your future treatment. There is another radionuclide on market approved by FDA, Axumin but not sure where it is offered. Other conventional CT scans are not sensitive enough. While you are at it, get the Sodium Fluoride PET/CT scan for the rest of your body- much better than the conventional Technitium 99 scans.

The treatment form can be decided upon after getting more information on your condition. Get as much knowledge as possible from the internet or support groups. Above all, do not panic.

[evreca]

Gordon, Sorry, in my next to last paragraph, meant PSA =15

[MelbourneDavid]

I think you need a biopsy to identify the Gleason score of the lesion. There's a huge difference in prognosis and treatment of a fast growing Gleason 6 (prognostic group 1)and a Gleason 9 (prognostic group 5)

I'd tend towards external beam radiation because of the likelihood of local tissue invasion, based on that MRI - surgery seems likly to leave positive margins behind and need adjuvant radiotherapy and why have both sets of side effects, but you need that biopsy.

I had one PIRADS 5 lesion with PIRADS 5 extracapsular extension that was just a patch of tiny indolent Gleason 6 lesion with no extension.

Your experience does show the value of MRI. TRUS biopsy (trans-rectal ultrasound guided untargetted) is poor at sampling the anterior region where your MRI lesion is.

[Hidden]

You need the biopsy to get a definitive assessment of the aggressiveness of the cancer. It isn't that bad.