Question for the Brain Trust, what am I missing!

[frankie08033]

I want to thank everybody who replied to my earlier question regarding a treatment decision. I got my PSMA results back today and it showed no spread or evidence of distant metastic disease. All seems contaimed to the Prostate. No nodal or bone spread.

However I do have Gleason 8 ( 3+5) and "likely" SVI according to earlier MRI. WIth this in mind i would think there is a 50/50 chance of a rising PSA after RALP. This was the path I was originally thinking of doing. If there is a 50/50 change I would need radiation after surgery, why not just go with radiation to start? That is my question. I am a veryhealthy and active 66 year old with no health issue but the PC.

My RO suggest 18-24 months of ADT, HDT Brachy and 5 weeks of beam radiation ( Proton or Photon). He said the results would be the same as doing surgery plus radiation. The Radiation route seems so much less invasive with lower SE.

Here is my initial MRI scan results below.

frankie08033

PROSTATE:

Size (AP x TRV x CC): 3.2 x 5.0 x 4.0 cm = 33.5 mL.

Post-biopsy hemorrhage: Not applicable.

Central gland enlargement (BPH): None.

Focal lesions - localization as follows:

Lesion: 1

Size: 1.8 x 1.2 x 1.5 cm (AP x TRV x CC), 5/23 and 9/16.

Location: Right base to midgland posterolateral peripheral zone

T2-weighted images: Score 5: Circumscribed, homogeneous moderate hypointense focus/mass greater than or equal to 1.5 cm in greatest dimension or definite extraprostatic extension/invasive behavior.

Diffusion-weighted images: Score 5: Focal markedly hypointense on ADC and markedly hyperintense on high b-value DWI, but greater than or equal to 1.5 cm in greatest dimension or definite extraprostatic extension/invasive behavior.

Dynamic post-contrast images: (+) Focal,and, earlier than or contemporaneous with enhancement of adjacent normal prostatic tissues, and, corresponds to a finding on T2-weighted and/or DWI.

PI-RADS Assessment Category: 5, Very high (clinically significant cancer highly likely).

Extra-prostatic extension (EPE): Overlying capsular bulging and mild irregularity with prominence of the neurovascular bundles (5/21 and 9/17).

Lesion: 2

Size: 5 x 5 x 8 mm (AP x TRV x CC), 9/16 and 5/23.

Location: Left base, lateral peripheral zone.

T2-weighted images: Score 4: Circumscribed, homogeneous moderate hypointense focus/mass confined to prostate and less than 1.5 cm in greatest dimension.

Diffusion-weighted images: Score 4: Focal markedly hypointense on ADC and markedly hyperintense on high b-value DWI; less than 1.5 cm in greatest dimension.

Dynamic post-contrast images: (+) Focal,and, earlier than or contemporaneous with enhancement of adjacent normal prostatic tissues, and, corresponds to a finding on T2-weighted and/or DWI.

PI-RADS Assessment Category: 4, High (clinically significant cancer likely).

Extra-prostatic extension (EPE): Overlying capsular irregularity without gross EPE.

Seminal vesicles: Ill-defined soft tissue along the course of the right seminal vesicles is concerning for tumoral invasion (4/15).

URINARY BLADDER: Trabeculated bladder with bladder diverticula measuring up to 3.2 x 1.7 cm in the left posterolateral bladder wall, suggestive of chronic bladder outlet obstruction.

LYMPH NODES: No pelvic lymphadenopathy.

BONES: No suspicious osseous lesion.

OTHER: Small fat-containing inguinal hernias bilaterally.

Note: Clinically significant cancer is defined on pathology/histology as Gleason score greater than or equal to 7, and/or volume of greater than or equal to 0.5 mL, and/or extraprostatic extension.

DynaCAD segmentation of the prostate and dominant nodule(s) was deferred as the patient has known clinically significant tumor. [DC0]

IMPRESSION:

1. Known clinically significant prostate cancer, with dominant peripheral zone PI-RADS 5 lesion in the right base-mid gland and PI-RADS 4 lesion in the left base.

2. Mild extraprostatic tumor extension on the right with likely neurovascular and invasion and mild right seminal vesicle invasion. Mild capsular irregularity on the left without gross extraprostatic extension. No pelvic lymphadenopathy or pelvic osseous metastatic disease.

3. Calculated prostate volume of 34 mL.

[Tall_Allen]

Congratulations on no distant metastases!

Look at these curative results recently obtained even without brachytherapy boost therapy (although brachy boost therapy is a good choice too). It brings up topics to discuss with your RO:

prostatecancer.news/2021/06...

[Stellabell]

I had a very similar diagnosis, same Gleason's and two tumors found on the MRI, one of which had invaded the seminal vesicle. I consulted a team at Duke medical, who reviewed all the tests and slides. The radiation oncologist and surgeon both said it was a 50-50 choice between surgery and radiation, but radiation would be necessary, even with surgery, because of the extent of the positive samples (17 to the 20 were 8 or 9) and the tumor which extended beyond the prostate. Neither would give a firm opinion. The medical oncologist was more forthcoming. She said since I would have to endure radiation anyway, why add the extra risk and side effects of surgery, since the long term success rate for either treatment was about the same. I would add as a personal recommendation, to avoid any long term ADT if possible, or at least keep limited if you can. Much worse side effects than the radiation itself.

[frankie08033 in reply to Stellabell]

Thanks so much for your reply Stellabell. I’ve been back and forth but finally decided on Surgery. The 2 plus years of ADT basically swayed me to Surgery. Will have a 50-50 chance to get it so willing to take the chance with idea of needing radiation afterwards but with less ADT.Happy Thanksgiving and all the best to you.

[Teacherdude72]

The choice is yours to make and the right one for you. Never second guess of have doubts. I had G9 but otherwise similar to you. Now in my 8th year after all the radiations. My RO has stated I will die with it not of it. MO agrees. B positive and life your life well.

[frankie08033 in reply to Teacherdude72]

Thanks,

Words well said. I do have a great outlook even with this issue facing me.

All the best.

[Scout4answers]

if sexual function is at all important I would choose radiation. ADT side effect can be minimal with exercise program.

Radiation after RO will be 44 sessions vs 20 if done alone.

There is so much they don’t tell you upfront.

[frankie08033 in reply to Scout4answers]

Thanks so much for your words.

All the best.

[Teacherdude72 in reply to Scout4answers]

True but if you ask direct, pointed questions you will get answers. If not ask why or switch doctors. You have to like your doctor's in order to trust them What I have found is high dose radiation quicker has better results and getting her brachytherapy, boost, often can improve results.

[frankie08033 in reply to Teacherdude72]

Hello Teacherdude 72,

Was this reply suppose to go to Scout4answers?

[Teacherdude72 in reply to frankie08033]

Yup. Sory

[HopingForTheBest1]

Get genetic testing, which can provide viable treatment options.

[conbio]

Hey Frankie -

We're pretty similar - 66 yo, Gleason 4+5, no spread outside prostate. I talked to the surgeon and oncologist and went with the 3-legged stool treatment of EBRT, brachy, and ADT. I had some long discussions with the radiation guy and once he found out I was a scientist he sent me a pile of papers from the Journal of Radiation Oncology. The ASCENT studies out of Canada, and others, show the best results regarding re-occurrence and longevity were associated with this 3-legged approach.

I started on Lupron 9/21 and just had my last shot yesterday - that would be an 18 month regime. Libido in the toilet but we manage, annoying hot flashes, particularly in the summer. And I picked up a trainer for weight lifting once a week, lift on my own a second time, and climb, bike, ski as I can. My aerobic capacity is down a bit because my red blood cell count is down - but all in all, I'm good.

I had 24 beam sessions in Feb-March this year, a 2 week rest, and then those 68 brachy seeds implanted. Was tired from the cumulative radiation but missed only a couple workouts. There was a couple months of annoying excess getting up at night to pee, but now I am slowly weening off Flowmax.

I was worried about the long-term effects of surgery and 2 folks I know that had RP had to go back for radiation anyway. My oncologist just yesterday say the goal of stomping hard on this cancer was to cure it. Good luck with you decision and treatment.

[frankie08033]

Hello Connie,

Thanks for your input and words of encouragement . I was there 2 days ago and switched back to surgery yesterday. Very hard decision for me as I’m sure it is for most people. Wishing you the best and will update and monitor this forum going forward.

[Justfor_]

I had the same dilemma like yours, but finally went for RP when I understood that there is no cure for PCa, only management, i.e. buying time by sequencing treatments all of which bearing life changing implications. With surgery you get the "bill" the next day, while with irradiation it can take a number of years, concomitant ADT playing a role in it. I got 2.5 years out of RALP, plus one year (and counting) out of Bicalutamide, yet salvage RT is no doubt the next step.

[frankie08033]

Thanks and wishing you the best on your journey.

[cancerfox]

There are no good decisions with this lousy disease, only least bad ones as perceived by the decision maker at the time of the decision. Future outcomes are unknowable. Good luck on whatever you decide and just move forward. 🦊

[frankie08033]

yes, agree but feeling better about moving forward.

All the best.

[Tony666]

Frankie - One option you could consider if you want to do surgery is a trial of 6 months of “intensive” ADT followed by surgery. This is what I did and had good results. 3 years ago I was diagnosed with Gleason 9 (5+4), 2 small lesions but no indications from scans that it was outside. The SOC leans towards radiation +2 years ADT but I was concerned with long term impacts of this. At the same time, with Gleason 9 there is a reasonable chance that some micro cells may have already escaped even if they don’t yet show up on scans.

NIH has a trial of 6 months “intensive” ADT to get rid of any escaped micro cancer cells followed by surgery to get rid of the mother ship. Since it was only 6 months of intensive ADT my T was able to fully recover. 2 and a half years later no recurrence, no incontenance. Some ED but manageable. If you are on the east coast the NIH trial is awesome (no payments, no insurance needed, lots of top docs). If on the west coast, I believe UC San Diego has a similar trial. There is of coarse no guarantee it would work as well for you, but if you have decided to do surgery anyway, then this just adds an extra layer of protection against any cancer cell escapees without adding much in terms of long term impacts.

[frankie08033]

Thanks Tony

I’m surprised that is not an option offered before or right after surgery. Maybe it will be the new SOC

[frankie08033]

Just an update. Had RALP yesterday at PennMed in Philadelphia by Dr. Thomas Guzzo. The worst part was removing a drainage line from the side of my stomach today. Big ouch!

Dr. though everything looked good but will wait a week or so to confirm. I was very happy with all the Staff at Penn Med, both radiation and urology. Both thought either way would be a good choice and no one was pushing too hard from their perspective.

Thanks for all the input from everybody here. This a great forum with many caring and intelligent people. I’ll keep looking, posting and replying in the future.

frankie08033

[frankie08033]

Week after RALP

Has not been too bad since surgery last week. Getting the Catheter removed was a big relief. Urinary issue has been ok with improvement some control, maybe 25% back already. I'll take that as a good sign. Not worrying about ED for a while.

Received the pathology report today and everything was clear with no disease anywhere! I am a realist and am aware there could still be cells floating about but don't think I could have asked for a better report. Also noted, originally I was thought to have Gleason 8 (3+5) from biopsy but after the pathology report today that was shown to be a 7 (4+3), so not quite as high risk as first thought. PSA scheduled for mid March. Time to celebrate at least for the moment. Thanks to all who contribute to this forum. I can't tell you how much it has and will continue to help.