ECE and CRIBRIFORM FOUND IN PATH REVIEW OF MSK BIOPSY BY UCSF

[JWS13]

I am scheduled for SBRT at UCLA for 1/12/ 2023. However , UCSF did a path review of MSK's Biopsy report, and indicated that UCSF found additionally :

1. the presence of "expansile cribriform subtype"

2. the "possible identification of extracapsular extension" described below:

"Tumor is in loose fibrous tissue immediately next to adipose tissue, that while NOT DEFINITE ,is HIGHLY SUSPICIOUS for EXTRAPROSTATIC EXTENSION".

MSK had neither of those findings in their original report.

The Chief RO of UCSD said that she is concerned that the SBRT might miss this ECE which may result in a recurrence for which they couldn't retreat and I would be stuck on Hormone therapy for life.

She highly suggested IMRT and 4 months of ADT. (I can't have adt due to cardiac conditions)

She wanted me to personally confirm with the MSK Pathologist that there was no ECE. Please give me your thoughts.

.(The ECE was just a possibility from path report not from an MRI.)

1.Is the RO right about you have one chance to treat the prostate bed w SBRT, IMRT, BRACHY and if you miss the ECE you can't retreat the recurrence from the miss? and then Hormones?

2 Is IMRT maybe the better treatment because its longer and covers more territory of the prostate bed.

3. Will the pathologists talk to you directly? has anyone talked to a pathologist that reviewed or did their biopsy?

4. The ECE is not even clearly indicated , it is NOT DEFINITE & HIGHLY SUSPICIOUS FOR EXTRACAPSULAR EXTENSION should it be an important consideration?

5. Sloan Kettering says their pathologist says NO CRIBIFORM and they say Pathology is Subjective , difference of opinions?????

6. Should I get a third Review from Dr. Epstein at Hopkins, or will that confuse things more..

Sorry , for the long post but their continually changing the playing field with choices that may injure you QOL forever..and you really don't know who to believe ,there all centers of excellence.

ALL RESPONSES & THOUGHTS APPRECIATED AND WELCOMED!

TALL ALLEN WOULD APPRECIATE YOUR SAGE COMMENTS!

Gleason 7...4-3..62...

[Tall_Allen]

Usually, MSK is among the best. I'd certainly get an opinion from Epstein. He is the Gold Standard - it won't confuse things - what he says is definitive. He or someone on his staff will talk to you. I suggest sending him both reports.

It sounds like one core went through the capsule and found cancer there. You may want to read this:

prostatecancer.news/2020/04...

Note that Epstein wrote these:

bjui-journals.onlinelibrary...

sciencedirect.com/science/a...

I can't see why SBRT would miss anything that IMRT hits. If anything, SBRT has more precise image guidance than IMRT because it is intrafractional.

[JWS13 in reply to Tall_Allen]

Tall Allen....thank you ...you really are responsive with a dearth of information...I have one question for you...Is the RO right about you have one chance to treat the prostate bed w SBRT, IMRT, BRACHY and if you miss the ECE you can't retreat the recurrence from the missed opportunity? One of the posters said that you CAN treat it again if their is a recurrence with Cyberknife, or cryoblation?

Can you retreat after a recurrence?? if so how ? same options (i.e . sbrt, cyberknife, etc.)

[Tall_Allen in reply to JWS13]

As I said, there is no problem treating the ECE with SBRT, IMRT or anything else. I don't know what the RO is talking about. Recurrences i n the prostate are rare with modern doses of radiation, but there are plenty of options if it does occur:

prostatecancer.news/2017/09...

[Yearofthecow in reply to JWS13]

JWS, I had SBRT with Dr Kashan at UCLA, and I asked him if salvage treatment was possible after SBRT, and he said yes. They could do brachytherapy, cryoblation, etc.

Things have changed when I started on AS 10 years ago, because at that time I was led to believe from a urologist at a different place that only after surgery you had salvage options, not after radiation.

That is why you are doing the right thing JWS, getting as much information as possible to make informed decisions.

John

[Yearofthecow]

If it were me, I would definitely get a read from John Hopkins, and request the Epstein read the slides if that is at all possible.

I would also ask the radiologist oncologist at UCLA what they thought, after the read from Hopkins

Wishing you all the best

[JWS13 in reply to Yearofthecow]

thank you ..

[StayingOptimistic]

My past experience is: I was treated at MSK. I had ECE. I did the IMRT. The SR didn’t work and got recurring disease.

[JWS13 in reply to StayingOptimistic]

How long ago? Why did you choose IMRT over SBRT? Was your ECE clearly defined in your path report or just "highly suspicious" ,What did you use to treat the recurrence? what was your gleason please...where and when did you have your IMRT done? how are you now? thanks for responding buddy..

[StayingOptimistic in reply to JWS13]

RP(2012), SRT(2017), the radiation didn’t work at all. Psa kept going up as you can see from my bio. So, it took about 4 years after RP to have the psa reaches .07. Then I did the radiation at psa=.07. It did not work and psa started going up untill it reached 1.5 or so on 2020 where I had a psma that showed metastasis in the pelvic and abdomen. I started a clinical trial at MSK (2020) with ADT only for one year and have been off the ADT for about a year now. Yes, the ECE was stated clearly on the biopsy report. I did the radiation in Commack MSK facility, Long Island.

[maley2711 in reply to StayingOptimistic]

As you comment , your recurrence was discovered later in your pelvic/abdominal area. Were those areas thoroughly radiated? if so, i Guess it would be fair to say that the RT didn't work.

[StayingOptimistic in reply to maley2711]

only the prostate bed was radiated. The problem for me was, how to discover recurrent disease at a psa of .05-.07? I didn’t think there was a way. They didn’t offer to radiate the pelvic area. They thought it was not necessary. I still have the same issue now, how do I monitor the disease when my psa is .02?

[maley2711 in reply to StayingOptimistic]

I see that you were diagnosed Gleason 3+4...did you have any other findings that put you in a higher risk group.? If not, yes they wouldn't advise pelvic area radiation.

Seems your only marker at this point is PSA progression.... then PSMA PET but no earlier than PSA 0.5, preferably 1.0 or higher for more accurate results. I assume you have asked your Doc(s) this question..answering is their job!!! Problem with relying on PSMA PET is too low PSa plus size limitation of approx 1/6" spot or larger for detection.

[StayingOptimistic in reply to JWS13]

SBRT was not offered to me by MSK on January of 2017. May be they didn’t do then, not sure.

[NotDFL in reply to StayingOptimistic]

Patient Ahk1 had his prostate removed first; a different scenario.

[JWS13 in reply to NotDFL]

thanks