Hi everyone (including the redoubtable Tall Allen),
I'm leaning toward having RALP but am wondering if I am making a mistake. Is surgery, in my case, over-medicalization? Overly aggressive? Should I do AS instead?
I am Gleason 3+4, but only 2 out of 12 needles had cancer and the % of cancer in those 2 cores was only 40%. And under 5% was Gleason 4.
My father died at age 85 of PCa (I'm 73 now and very much like him) and my PSA has been slowly inching up and is now 7.3.
My prostate is enlarged: 80 cc.
My stage is T1c and I am a "favorable intermediate risk."
I've found a highly experienced and capable surgeon to do the surgery (Dr. Jonathan Hwang from the Washington Hospital Center in Washington DC.) and I am inclined to do it.
If I were to have surgery, do you think I would be making a big mistake?
I'm eager to hear your answers. Thank you!
Best, Chris Palmer (retired professor)
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Cory_777
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Yes indeed. If you don't have any comorbidities elevating the risks of surgery, it will be prudent to go along now that you can. My book says that up to 70 you can have RP. Yet, at the center where I had mine (70yo) one of my neighbours was 73 and another78! Both were looking fine.
Your case has many similarities to mine. Diagnosed at age 75 with 78 cc gland. PSAs in 5-7 range. MRIs (2) were read as contained within prostate. Percent free PSAs 16-23. My cancer was in unusual location so 7 additional "crossfire" cores were taken under MRI guidance. The standard 12 cores only showed one small area (<5%) of 3+3. However all seven of the crossfire cores were 3+4 up to 90% in some of those cores. Bx read as no EPE. My story is a little complicated and you can read my previous postings. I chose to have RRP. Final report showed extensive EPE but negative SM. You are approaching an age where you soon may not be a surgical candidate. I assume you are in good physical health since surgery is offered as an option. Did you have a second read on your slides by someone like Epstein? Yours' is difficult call (aren't they all when we have skin in the game?) Looks like you are doing all necessary homework and your decision will be the right one.
Again, my case was rather unusual as I was also diagnose with late onset hypogonadism. See my earlier posts. I felt more confident by getting the gland out. Experts agreed I needed whole gland treatment. Every case is unique for each of us which is why it is so important to educate oneself. No one knows us like we know ourselves and we are the one that has live with the choices we make. Lot to learn but you have the time and you will be better off for it.
That is a new one> sounds like you had a 2nd biopsy? If so, another TRUS, or transperineal ( maybe what you mean by crossfire cores)? Were those 3+4 cores taken from the same area as had been sampled in 1st biopsy, or were they taken from a lesion found on mRI? Your case is intrriguing, and somewhat scary as you almost walked away with a bogus diagnosis. Credit to you urologist for doing additional testing?
Thank you LowT. So, I understand that you had 2 MRIs. Then you had only one biopsy, which included 12 standard cores, and also 7 "crossfire" cores. Were those crossfire cores taken from a PIRADS 3 or greater found on your mRI? Also, was the MRI-targeted done while you were in an MRI machine, or was it a fusion biopsy> why specifically called a crossfire core? I think that is a new term for most of us? Sorry for all the questions.....just trying to learn more before my biopsy!!
Slow down and master some of the basics before signing up for theory of equations. You won’t be able to comprehend what your making a decision about until taking some time for undergraduate courses. No one can do that for you. Every PCa case is unique and you are your best advocate. You have plenty of time and a bunch of the top world “experts” on this forum. It’s a process game with a changing context. You do your homework and then place your bet and feel confident you make the best call as only you will live with the result and none of us are in total control of that. Same as with most things in life.
What is it the day “$hit happens”.
I did my homeWork, selected surgeon with great reputation (over 8,000 prostatectomies, etc. etc., etc.). I was the unfortunate one with complications of internal bleeding, one week hospital stay rather than over night, 2 units of blood and a body that looked like a piece of road kill.
However even though I had extensive EPE my surgical margins were negative and I’m still here and have dry pants with excellent ironed control. Who knows if I’d chosen a different path??
I asked you this...mainly about your use of "crossfire cores" .......
" Thank you LowT. So, I understand that you had 2 MRIs. Then you had only one biopsy, which included 12 standard cores, and also 7 "crossfire" cores. Were those crossfire cores taken from a PIRADS 3 or greater found on your mRI? Also, was the MRI-targeted done while you were in an MRI machine, or was it a fusion biopsy> why specifically called a crossfire core? I think that is a new term for most of us? Sorry for all the questions.....just trying to learn more before my biopsy!! "
Yor reply basically admonished me ...you didn't reply to my simple question re "crossfire cores". Hopefull you will let us uneducateds know what is meant by "crossfire cores".
BTW, I have been educating myself for 2 years now..but "crossfire cores" is something I have missed eveidently.
No admonishing here. This is all the info I can provide. As you can see they called it PIRADS 3 and other areas PIRADS 2. But neither one of those related to my 3+4 cancer as it was not identified by the radiologist because of the atypical appearance.
The cross fire technique I assume was approaching the suspected lesion from a sideways angle due to the atypical location of my cancer. Here is the initial reading of my first MRI:
1. The prostate measures 5.9 x 5.1 x 5.1 cm, which corresponds to a volume of 78 g and a PSA density of 0.1 ng/mL/g.
2. A 1 x 0.7 cm right medial mid transition zone lesion is indeterminate (PI RADS 3 = Indeterminate). This lesion does not show early enhancement relative to the remainder of the prostate on dynamic contrast-enhanced sequences.
3. Benign prostatic hypertrophy within the transition zone and foci of chronic prostatitis within the peripheral zone (PI RADS 2 = Low likelihood of clinically significant cancer).
4. The central zone is unremarkable.
--
As you can see the cancerous lesion was completely missed due to the unusual location but was identified by another radiologist after I sent images for a second read as my untrained eyes thought this area looked suspicious.
The cancer surrounded the ejaculatory ducts and was posterior mid-line.
The second read said this:
1. Prostate volume: 78 cc. Triangular lesion on T2-weighted imaging posteriorly in the midline extending from the base down to the mid gland demonstrates marked restricted diffusion. This can be seen as an uncommon variant of extension of central zone and/or posterior midline fibrosis. However, there is also markedly abnormal hyper-enhancement with this, which is very atypical for either of those benign differential considerations.
2. No extra prostatic extension, seminal vesicle invasion, or neurovascular bundle involvement.
3. No suspicious lymph nodes. No suspicious osseous findings.
Thank you LowT. I guess "crossfire" was the term used by your urologist. My lesion has been described as located in a more challenging area to sample...perhaps why that area is not normally sampled in a standard non-MRI biopsy. To me , it does look like your 1st radiologist did identify at least one PIRADS 3 to be sampled.....I can't determine if the 2nd radiologist was referring to the same area. He doesn't mention a PIRADS number? Kaiser here in Oregon is now referring all MRIs and subsequent MRI-directed biopsies to our local OHSU med school facilities......too many differences between Kaiser radiology readings and readings by OHSU radiology. My Kaiser Doc suspicious of the whole PIRADS system? well, IMHO, far from perfect, but better than nothing. without it, a standard biopsy would not sample the area of my lesion!!!! You may have heard about the newer microultrasound TRUS equipment that may accomplish much of what prostate MRI does now......without need for radiology to be involved. Other than $$, I believe all urolgy clinics would be switching to this ASAP. Studies I have seen indicate this new microultrasound equals or comes very close to providing the extra degree of cancer detection provided by MRI. And, of course, combining the micro with MRI an even higher detection rate...though only to a small extent. To me, the most important step in this whole PCa system is obtaining the most accurate diagnosis..with the fewest number of biopsies!!!!
Kaiser reported as right transistion zone......OHSU said anterior area.....my Doc said both referred to same area. The nerve block injection for pain control is often ineffective for that area....increasing my dread about having this 16 core biopsy!! What was your experience? I have also read that many men consider the nerve block injection the worst part of the whole procedure?
Because of the location of my lesion, and perhaps the need to do more 'aggressive' biopsy, mine was done under general anesthesia in the operating room utilizing image fusion technology.
Sounds like your location is in anterior prostate. Mine was posterior midline, around ejaculatory duct, which probably explains difficulty in reaching it with traditional six and six cores on each side. Even though the Bx showed no EPE the final pathology report from the surgery identified extensive EPE. Thankfully the SMs were clear.
I was also told mine is more difficult to reach.....on the opposite side of prostate from where needle enters prostate......I think, not sure, on the upper anterior.....as I said, Kaiser Doc used term "right transition zone". Kaiser agreed to do biopsy under deep sedation, but not GA(no breathing tube), in an operatory. However, Kaiser does not have fusion equipment! So, Kaiser Doc referred me to OHSU med school, which has the fusion equipment but wouldn't agree to sedation! I consulter with Kaiser uro re this dilemma ...he said , for the best confidence in the results, if it were he, he would have the biopsy done at OHSU. So, much as I'm fearing the experience without sedation, I will have the biopsy at OHSU. It took a 100 page appeal/treatise of Kaiser's initial denial of the referral to OHSU ...just to be covered for the fusion biopsy there!!
What type of insurance covered your fusion biopsy with sedation/GA? From all my reading, most insurers, like Kaiser, do not cover a pre-biopsy MRI and subsequennt first biopsy, unless the patient has 1st undergone the standard "blind" 12 needle biopsy. With the success of my appeal, I am the exception to the rule at Kaiser!!! Though, they did agree to Kaiser MRI before the biopsy...just not to the fusion biopsy with an outside institution. They did refuse an outside MRI using 3T MRI....Kaiser machine is 1.5T.
The biggest mistake you can make is in not thoroughly investigating all your options. You have plenty of time to decide and to meet with a variety of experts.
(1) I'd recommend you meet with the head of an AS program at a top institution. Johns Hopkins (Ballentine Carter) has one of the strictest AS programs anywhere, but even they have been relaxing their criteria because of the remarkable success of AS. With your low volume cancer and your pattern 4 at only 5%, many programs would accept you now. If you decide to go with AS, most will require an mpMRI-targeted confirmation biopsy within a year. Getting a genomic test of the biopsy cores (Decipher or Prolaris) is also prudent.
(2) At Georgetown, I'd recommend you talk to Sean Collins about SBRT.
(4) I've never heard of the surgeon you mentioned, but with Misop Han nearby at Johns Hopkins, it would be hard to beat the likes of his experience anywhere. Experience counts in surgery. Here are some questions to ask when you talk to him (adapt as necessary):
You should take your time and seriously consider active surveillance. I have been in Johns Hopkins’ AS program since 2009, with no changes in my pathology. My personal threshold for leaving AS would be two or more biopsy cores with more than 10 percent Gleason 4 pattern. You are below that criteria.
I read comments that only five percent of men have serious issues with incontinence or impotence a year after RP. If that is to be believed, then every one of those is on the internet every day publicizing their plight. Not impressed with the side effects of surgery.
The non-recurrence rates reported for SBRT/Cyberknife and for proton beam therapy are very impressive. If my pathology changed, I would have TULSA-PRO with Dr. Pavlovich at Johns Hopkins. But, that is not yet covered by Medicare or insurance, so that may not be an option (yet) for many men.
Time is on your side. I recommend you buy Dr. Mark Scholz’ The Key to Prostate Cancer. He interviewed thirty prostate cancer experts and presents their descriptions of the treatments that they provide for men at the different risk levels.
In my view you should look into HIFU (high intensity focused ultrasound) and TULSA (transurethral ultrasound ablation). I live in Charlotte, NC and had HIFU done Aug 14, 2020 by Dr. Samuel Peretsman. I had a single lesion as revealed by 3T mpMRI, 13mm in the apex, and the focused biopsy evaluated by the local pathologist showed 4+3=7 in 2 cores in the lesion. I had a second opinion of the slides done at Johns Hopkins - they said I had 3+4= 7 (a better outcome), with 30% cancer and no cribriform morphology. The local pathologist provided none of this detail.
I had planned to have TULSA, done by Dr. Scionti in Florida, but Covid-19 got in the way - the risk for travel was too great to me.
Dr. Peretsman and Dr. Scionti do HIFU on cancer patients from all over the country. Dr. Peretsman does RALP as well - because of this, he knows who is a good candidate for HIFU. Urinary incontinence is much less likely with HIFU. Dr. Scionti in Sarasota Florida is very well recognized for HIFU as well, and has more experience with TULSA than many other urologists.
HIFU is a similar treatment option to TULSA-PRO but Chris P your prostate size seems too big and beyond the reach of HIFU (high intensity focused ultrasound) i.e. it can't focus out beyond a 40 cc prostate or so. Not a doctor, I just play one on the internet. I did opt for HIFU in 2016.
HIFU can be performed on a prostate >40cc, if a TURP is done first. However, TURP isn't always required.
My prostate was 51cc. It wasn't required that I have a TURP, since I had a focal treatment and the location of the cancer allowed the sound waves to reach it. But I had a TURP done first to remove calcifications in the prostate, which can interfere with the ultrasound waves from either HIFU or TULSA. A standard 10 minute ultrasound of your prostate in your urologist's office will reveal if there are calcifications that could interfere. Those pictures can be FEDEXed (better than trying to send scans) to the HIFU or TULSA treating urologist to determine if you are a good candidate for HIFU or TULSA, and if a TURP would be needed to remove calcifications or reduce the size of the prostate.
Please note that nerve sparing procedures, or methods used to reduce side effects, done with either HIFU, or TULSA may have a greater chance of cancer recurrence. This is because the margins treated around the cancer are less. Current info about nerve sparing RALP indicates this is no longer a concern:
Dr. Peretsman has a reputation for being more aggressive in treating the margins, if his patient is comfortable with it. I liked this as I wanted the greatest chance of getting all of the cancer with a focal treatment (only the cancer + a wide margin was treated), and I was comfortable with the chance of ED, with less chance of incontinence via HIFU. But Dr. Peretsman lets you decide how aggressive of treatment you are comfortable with, within his judgement of how much treatment is needed. Because of the size and location of my cancer, and my request for him to be as aggressive as needed to have the greatest chance of getting all of the cancer, Dr. Peretsman advised my recovery would be longer, since he would treat very close to my urethra, and it would be affected. That was OK with me, too. He said his favorite patients are those who are willing to put up with 6 months more recovery due to wider margins, which result in a corresponding much lower chance of cancer returning.
Here is some info about my journey: My PSA was 1.5 for awhile. I waited 6 yrs (dumb) before having it tested again at age 64 in Dec. 2020 . It had risen to 34. I had HIFU in Aug 2020....it took 6 months to figure out how I wanted to get treated, and that HIFU and TULSA existed. Today I received my first post-HIFU PSA result: 0.01.
That 40 cc limit is what I remember my HIFU surgeon saying. I had full gland HIFU despite the tumor presence on only one side. I had TURP surgery 10 years prior, for BPH.
I agree with the several posts to investigate thoroughly so you are comfortable with your decision whatever it is.
At this stage it appears you are curable.
IMO the above statement overrides all your decision making. Most importantly it gives you time to make a decision.
Your age makes the question of you being a future surgical candidate a prominent question.
The fact your father died of PCa at 85 (12 years senior to you) will likely be a prominent factor in your decision-making.
You may get some conflicting advice and you might consider deciding ahead of time what your decision might be in the face of roughly equal conflicting advice.
I know what my decision would be but I am not you and am not a MO nor am well versed in ALL the CURRENT research or ALL the details of your individual history & family history. You have to be comfortable with down-stream effects of whatever decision you might make is.
Get the surgery and kill it dead. Your Dad died from this and now your early detection could prevent this from happening to you. That said, there is a difference between surgeons and their outcomes so (if you decide to get surgery), be sure to research each surgeons outcome statistics.
Just an opinion without complete knowledge of all the details of your individual case and without a specialty in the field (MO, RO or Urology).
You are almost exactly where I was two years ago. I had 1 .5 cm node in my prostate. Which I didn't know until I got the RALP. The bad news was I was upgraded from 3+4 to 4+3 (75%). The good news was there were negative margins and no other nodes. My point is a 1.5 cm piece of PCa is only 5% of the prostate. Getting a needle to get to the worst of the PCa is unlikely. There is probably more hiding in the worst area.
Some very good advice, here. Please read and process it thoroughly before making ANY decision to do surgery. I was intermediate favorable risk, with a similar profile to yours. After a year of investigation, decided on SBRT over RP.
You never mentioned what was your late Dad's option(s)....What did he opt for? There are 3 things to remember when we are told that we have the beast. Research, Research and Research.
Are you affiliated with the late comedian Professor Irwin Corey by any chance?
My father opted for a hormone pill that might have given him a year or two extra, who knows. He didn't know he had PCa until it metastasized and spread lethally to his bones. This was the late 1970s in England and I don't think the PSA test was in use back then.
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