Thank you so much for your inputs. My father finally had his MRI Fusion TRUS biopsy and below are the results. I am doing all the background work on what the course of treatment would be (leaning towards radiation). Your input would be highly valuable when meeting with the RO.
Quick History : My Father is 74 years old and has been having urinary issues in the night and he was on Tamsulusin and Dutasteride, the PSA increased from 4.6 to 10 over the course of 5 years. This year he got his MpMRI and it showed a Pirads 4 leasion (the biopsy showed nothing in the MpMRI pointed location) Below are the biopsy results. The urologist has been very open to options and suggested men in the 70s prefer radiation to surgery but my dad can undergo surgery if he chooses to do so since he is physically very fit. He asked us to talk to the RO. Additionally he said he wanted to do a cystoscopy before to check for blockage and help with it before radiation. So he won't have urinary issues during / post radiation.
Below are the results
Left
A Base : Adenocarcinoma (Gleason 6 (3+3)) Tumor length percent 40%
Long term Dutasteride is known to limit the PSA to almost by half. If so, your father's PSA of 10 is in reality somewhere close to 20. Such a PSA value, by itself, places him in the high risk category. There are ongoing trials (Australia was first with it, other parts of the world followed) where a PSMA PET/CT is given to high risk patients before any radical treatment (prostatectomy or irradiation). Something to consider if you can undertake the cost.
Thanks Justfor_ his PSA has never reduced on Dutasteride , so the doctor consider his PSA as an absolute value 11 instead of 22. I don’t think they allow for PSMA PET here in the US but will verify.
I think he should think of that as "unfavorable intermediate risk" because of the high percentage of cores with cancer, the high PSA (doubled because of the dutasteride), and the PNI.
It is also a good idea to rule out metastases using a PSMA PET scan. It is now covered by Medicare. He is at borderline risk for lymph node invasion, and the PSMA PET scan can help decide whether the pelvic lymph nodes should be treated as well. A Decipher test on his biopsy cores can help decide whether ADT is needed with it.
Assuming there are no distant metastases, there are several curative options - SBRT, HDR brachytherapy or LDR brachytherapy. But the decision about monotherapy to the prostate vs a wider field with a boost to the prostate will depend on those other tests.
Tall_Allen We spoke with a radiation oncologist at Memorial Sloan Kettering, as you mentioned since a PSA wasn't repeated when it was at 11, they said he is the at the border of favorable and unfavorable. The only additional treatment with unfavorable would be the addition of ADT therapy. He went over all the options and thought with his IBS , he would benefit with Proton Beam Therapy. He mentioned all SBRT, EBRT would yield the same results. Additionally, if my father can tolerate it, he thinks surgery is also a good option.
Where and how can I request PSMA PET in New Jersey? As mentioned before his insurance is valid only in NJ.
@Tall_Allen, I am stuck gain. I was able to offer a site that offers the PSMA PET scan. However both the radiologist and his urologist have told me he isn't eligible because this is his first time with Prostate Cancer and he is Intermediate Favorable, so the insurance will reject it and the centers won't even take him in even if you are paying out of pocket. Is this correct? They want him to do the Bone Scan and CT scan. I am confused yet again. Any suggestions would be highly helpful.
He is really not on the borderline, he is in the unfavorable risk category, and if you double the PSA (to 20) as one is supposed to do when taking dutasteride, he is officially "high risk." IF your insurance rejects pre-authorization, appeal it on that basis. Ask why they would do a bone scan/CT if he is favorable risk.
Tall_Allen Happy New Year! I am back again, I couldn't convince the urologist with the PSMA PET though I had all the information. He said to complete the PET CT / Bone Scan and then he can write up the prescription for my father.
In the meanwhile, MSKCC asked us to transfer the slides for them to review the biopsy. We met with two radiation oncologists one at MSKCC Bergen and One at the local hospital. The one at the local hospital isn't favorable with SBRT because he says it will be high intensity and he wants my father to be able to manage the side effects at 75 so the regular IMRT or IGRT (45 sessions) would be best, he didn't offer spacer gel until I asked.
I am waiting for MSKCC at Bergen to confirm the pathology and suggest a treatment. It has been two months since diagnosis and things are so slow, I am quite concerned. However, the urologist performed a cystoscopy to look for any bladder obstruction, he thinks it will help to do a Green Laser prior to radiation because the prostate obstructs the bladder. I don't know if it is very necessary considering the side effects and that aggravating during radiation.
I am still going to push for the PSMA PET. Do you have any suggestions on SBRT vs Hypofractionated vs EBRT?
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Here we go.......
Followup on friend I mentioned. 
Treatment Options
Gleason score change from 3+4 to 3+3 with perineural invasion noted under Active Surveillance 
