Perineurial invasion with stage 2 prostate cancer

[Hondo555]

I am 67 and just received my path report. Stage 2, Gleason 3+4=7 and says perineurial invasion present. I know that invasion could allow reoccurrence and spread outside of prostate. First meeting with Dr. tomorrow. Not sure his recommendations but I think the radical prostatectomy would be my best option. Any thoughts?

[Tall_Allen]

Here is some info on PNI:

pcnrv.blogspot.com/2018/03/...

I have no idea why you think RP is your best option. I think that active surveillance or focal therapy are probably not good options for you, but all other therapies have the same cure rates - the side effects are different, though. You are just at the beginning of your process. At this point, your best stance is to decide not to decide. Just gather information and meet with experts in all the therapies that have been known to work well for men with your diagnosis - including experts in SBRT, low dose rate brachytherapy, and high dose rate brachytherapy.

Here are some questions to ask (and not to ask) tomorrow:

pcnrv.blogspot.com/2017/12/...

Also, it's a very good practice to ask your urologist to send the biopsy slides to Epstein's lab at Johns Hopkins for a second opinion (cost $275).

[Hondo555 in reply to Tall_Allen]

Thanks. At this point, I’m just not sure what I need. I am just being my own doctor which is not a good thing, but having to wait two weeks to see gives you time to self treat in your own mind from the plethora of information out there . My main concern now is the perineurial nerve fiber in the prostate that goes to the bones. The cancer is on that. To what extent, I don’t know. I will certainly read the info in the links you sent and that is much appreciated.

[Tall_Allen in reply to Hondo555]

If it's any comfort, we've all been through the panicky stage you are now experiencing, and have all thought "just cut it out!" I used psychotherapy and learned to practice mindfulness to qwell the racing thoughts.

[Schwah in reply to Hondo555]

One step at a time is the key. And your first step is a proper diagnosis. Part of that is the great suggestions from tall Alan. Get the second opinion on your biopsy from Epstein. You will learn that there is much disagreement on all subjects prostate cancer. But the one thing that seems universal is that Epstein is the best and often his reading will be different then your first.

Schwah

[jaybojammer]

I am 63 and was diagnosed in September with 3+4=7 in two of fourteen cores and 3+3=6 in three cores (positive on both sides). There was PNI detected on the two higher score cores. Urologist said he was not that concerned. Second opinion urologist said basically the same thing but ordered an MRI which showed invasion into the left seminal vesicle. Unfortunately, nerve sparing is not an option for the left side. The recommendation changed from RP only to RP with follow up external beam 3-4 months later.

I have chosen RP and am scheduled for surgery next week. I'm not sure the MRI changes the surgery any as they both said they would remove both seminal vesicles during the RP. They are just adding radiation and convinced me I want a bone scan to see if it has metastasized.

Best of luck to you.

[Hondo555 in reply to jaybojammer]

Thanks for sharing. I see the urologist tomorrow to get treatment options. Did your urologist suggest RP or did you just want to get it out. That is where I am now. I want the cancer gone and with the PNI I am afraid of just the seeds or just radiation.

Good luck

[dentaltwin in reply to Hondo555]

The bulk of what I've read agrees with what Tall_Allen said--you've got options. My situation was similar to yours, diagnosed last year at 66, PNI, Gleason 3+4. MRI was "suspicious" for extracapsular extension , no seminal vesicle involvement. Opted for RP/PND. You might want to speak with a radiation oncologist.

[jaybojammer in reply to Hondo555]

I saw two urologist/surgeons and one radiation oncologist. All three recommended RP. The second urologist recommended RP then radiation after the MRI indicated seminal vesicle invasion.

[Schwah in reply to Hondo555]

By the way, do not let your urologist rush you into a prostatectomy. If you decide to go that way, your best option is at a major teaching hospital or other center of excellence with a Doctor Who has done hundreds if not thousands of the procedures. I’m guessing your urologist does 10 or 15 year. Not even a tough choice. Also check out all the other options.

Schwah

[Bruins11]

I was in your shoes in July 2018. Gleason score 3/4. Had RP in September 2018 which was successful. PSA .01 since. However, 3 pad incontinence resulted from RP unfortunately which I’m still dealing with. So, I would suggest you talk with both a surgeon and a Rad. Specialist before you make final decision. Good luck,

[Magnus1964]

I don't know what your weight and general health is but at your age you might consider radiation therapy.

[Adf2529]

Good advice on this thread. All treatments have a risk profile. Understand your tolerance for risk re side effects; short and long-term. It takes a while to sort out. Consult with experts. Be cautious of urologists with general practices. For low land intermediate prostate ca, there are four routes: 1) RP, 2) radiation and 3) focal or whole gland therapies involving ultrasound, heat or freezing, and 4) active surveillance.

It was hard for me to be on active surveillance after an annual biopsy moved me from 3+3 to 3+4. I was mostly asymptotic except for long term BPH symptoms. I took nine months to learn and ask questions and to challenge myself to assess risks. I put myself in the position of being post-treatment: could I live with my treatment choice if things did not go well.

A couple of doc comments, during my voyage, stuck with me. A surgeon, who had done or been involved with thousands of RP’s, said the goal for the remainder of his career to reduce the volume of operations in his practice by 40%. That made a big impression on me. Another highly qualified surgeon said: I cannot predict, after doing thousands of operations, which patient will emerge without long-term symptoms and which will have urinary and sex function problems.

RP is major surgery. In the end, I decide to go with SBRT, with a highly qualified and experienced program at a major institution where the patient volume is high enough that the staff is also highly educated.

Good luck on the voyage!

[dadzone43]

Take your time. This FEELS urgent but is not urgent. Anxiety can drive to bad decision-making.