Make or Break

[Atlantic77]

ok guys it seems I may have waited a bit too long.. latest MRI shows 9mm lesion, 1.5mm EPE certain, right apex..

Last biopsy Oct 2019 G3+4=7 (30% 4)

I would imagine a biopsy at this stage will indicate increased agressiveness so I plan to move straight to treatment.

This moves me into stage T3a and high risk.

What are your thoughts on best course of action?

Is ADT now inevitable as an adjunct with both surgery and radiation treatment?

I have access to a well respected surgeon and also SBRT technology (not sure of the ROs skill and no way of checking up his success rates etc.)

[Tall_Allen]

I think you are jumping the gun in thinking that the MRI can correctly detect a 1.5 mm EPE. MRIs are very bad at that. What is your PSA? Please read this before you overtreat yourself:

prostatecancer.news/2020/04...

[Atlantic77 in reply to Tall_Allen]

PSA 7.6 Dec 2020

[Tall_Allen in reply to Atlantic77]

So your only possible "high risk" factor is the supposed focal EPE. I'd want more evidence before treating as high risk. Maybe get a Decipher test if insurance will cover it.

[Atlantic77 in reply to Tall_Allen]

So far yes, but given the fast progression thus far from G6 to G7 in one year, and it being over one year since last biopsy, and % of G4 detected in 2019, it seems inevitable that at the least it will now be a G4+3 ( size has increased from 5mm(2018) to 7mm(2019) to 9mm(2020).I will ask about Decipher or Polaris but just want to treat now without another biopsy and waiting, anxiety etc...

Ideally without ADT but if need be would a 3 month shot suffice?

I had the top radiologist in France who specialises in prostate cancer mpMRIs to undertake scan and interpret results.. He seems pretty certain and he used that Likert scale referred to in the article you posted (he specifically noted a 5, hence EPE certain).

[Tall_Allen in reply to Atlantic77]

I think you may be confusing detection with progression.

[Atlantic77 in reply to Tall_Allen]

Detected lesions (with MRI or biopsy) is all we have to go on to estimate progression the way I see it?

In any case I'll see what the urologist and RO recommend and post before casting the die

[OldTiredSailor in reply to Atlantic77]

You are rushing to grim conclusions with scant facts!

Many men experience G7 biopsy results and then the same biopsy slides are down graded by a 2nd pathologist. This is due to the ambiguous and subjective nature of the grading. Betting the future on a single score by a single pathologist might be ambitious.

MRI readings of prostate cancer are notoriously inaccurate. In my case the tumor size was off by a factor of 20, the prostate size was 100% off, and the EPE was not detected.

If I were you I would want a 2nd biopsy read by at least two different pathologists, and another reading of the MRI data by a pathologist who specializes in PCa readings.

I would also want a DeCipher Biopsy genomic analysis.

You don't mention how many cores were taken, how many were positive for PCa, and where those PCa cores were found.

What is the PIRADs score?

What is the Free PSA %?

What is the PSA density?

[Atlantic77 in reply to OldTiredSailor]

You don't mention how many cores were taken, how many were positive for PCa, and where those PCa cores were found. - 2 cores out of 4 TRUS guided targetted biopsy positive G3+4=7 with 30% of 4 in Oct 2019)

What is the PIRADs score? - PIRADS Score = 5

What is the PSA density? - 0.33

What is the Free PSA %? - No free PSA % measurement

[rscic]

Consulting with the Urologist & RO before coming to a treatment conclusion is a good idea. If there is EPE with Gleason score increase, options might include surgery or radiation treatment of the Prostate as well as pelvic radiation ..... but see what the Urologist & RO say.

[JuliesHusband]

Don't worry about short term ADT if it is in your program. For your situation they may recommend 4 to 6 months ADT with radiation.

ADT will give you menopausal symptoms, but women all deal with it. It will probably cause you to have no interest in sex, but if you find you can, make sure to ignore the lack of sexual interest and be active anyway.

[Atlantic77]

Update

Met with urologist and RO over the last few days

RO:

SBRT is no longer possible for me anywhere in France due to the MRI reading of Very probable EPE of 1.5mm at right apex, PSA = 7.5 (rising consistently), last biopsy Oct 2019 G3+4=7 with 30% of 4.. (% of 4 progession likely since this biopsy)

Option of IMRT (20 sessions) with 6 months adjuvant ADT

Uro:

DaVinci nerve sparing RP with lymph node removal (no ADT) and monitor PSA following surgery

I contacted UCLA about a clinical trial using SBRT for high risk but I got a response from a Mr Basehart informing me that this trial was no longer recruiting.

However, he did suggest I set up a remote consult with Dr Kishan in relation to the MIRAGE study comparing CT-SBRT with MRI-SBRT.

Was wondering would that be worth a shot and would there be any significant risks should I be selected for the CT arm?