I have been on AS followed by Behfar Ehdaie at MSK since 2020. PSA has been trending up with most recent being 6.1 Prior biopsy (2021) was G7 (3+4) with 3 positive cores out of ten. Two G6 and 1 G7 3+4 (with G4 in 2% of the core).
MRI in January 2023 showed two lesions with PIRADS 3 (no EPE, no SV involvement ). This was a slight change from initial MRI (2020) with two lesions, one with PIRADS 2 and the other with PIRADS 3.
New biopsy on April 17, 2023. Four of 10 cores with tumors. Two G6 cores (30% and 5% of the cores with carcinoma). Two G7 (4+3) cores. 40 and 45% of the cores with carcinoma. Both cores had 90% with G4. One of the G7 cores perineural invasion is identified.
I believe the change in Gleason score (from one core with 3+4 with low percent of G4 to two cores with 4+3 and a high percent of G4) moves me from grade group 2 (favorable intermediate risk) to grade group 3 (unfavorable intermediate risk).
Trying to schedule a call with Dr. Ehdaie in the next couple weeks to discuss the pathology and next steps.
What is the recommended treatment going forward? I am eager for opinions (Tall Allen especially) about optimal radiation approach (IMRT/SBRT/Brachy LDR or HDR, etc.) and whether ADT will be needed.
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rosenjpj
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Brachytherapy worked for me and my biopsy results were similar to yours. I’m 2 years out and did adt. Wanted to be aggressive in treatment and went with MSK. Dr.Zelesfki and said he was looking at a cure and I would most likely die from something else, other than PC. Adt was a bit ruff and cost me my relationship in the end but I have no regrets as it was not the only issue with my partner. I hear of some not so great outcomes with surgery and at first that was my choice. But after considerable research I chose differently. I have no regrets and erection are the same as pre-radiation and I still ejaculate over 2 years later and that’s a great thing. Up until this year I was still having wet dreams and at 56 years old that has returned, which by the way, I love. Do your research and make a wise choice as there is no going back once done. Best wishes Eric
I initially saw Dr Edhaie and liked him. He is a surgeon and if you choose surgery he is probably a very good choice.
I'd recommend you see Dr Jeremy Setton for a consultation for radiation. He spent at least an hour with me answering my exhaustive list of questions thoroughly and honestly. Do some research and have a list of questions.
I ended up having MRI guided radiation as part of a study with Dr Zelefsky and at four months after treatment I'm very pleased with the results. I've had minimal side effects and PSA has gone from 19.6 to 3.9.
I think their "Precise" is slightly different from the MRI guided radiation. I had to be part of the study to get the MRI guided which is preferred as they can track any movement in real time and stop the radiation if your prostate moves, as mine did, to minimize any damage to adjacent tissue.
You have "unfavorable intermediate risk" PCa. MSK has a lot of great doctors to choose from. I suggest you start with Sean McBride - he does SBRT. They can also provide HDR brachytherapy (Michael Zelefsky) as a monotherapy. Whichever you choose, 4-6 months of ADT with it will probably increase the chances that the therapy is curative.
I don't think you are a good candidate for prostatectomy because of the PNI, and because at your risk level, the odds of a cure are not as good:
Gleason 7 (4+3) and a PSA of 14 at the time of surgery. I had my RP at MSKCC in Manhattan with Dr Eastham. Excellent surgeon and a surprisingly issue free experience. His golden hands preserved my erection. Two years later, with my PSA rising steadily, I inquired into radiation treatment at MSKCC Monmouth. Not the same level of quality, IMHO. I ultimately went with Dr Sim Sang, who moved from MSKCC to Monmouth Medical in Long Branch. 39 IMRT daily treatments with very strict urinary and bowel requirements on my part. Issue free, no SE and I feel great. MSKCC also dug their heels in on Lupron, whereas I insisted on Orgovyx. All good, no SE, and my PSA remains at <.05
thanks much TA. Thats what I anticipated due in large part to following you. Its good to have the validation. You have taught us well 🙌. Appreciate the names for me to check into at MSK. I will keep you posted.
I did MSK Precise coming up on a year and a half ago. No ADT or hormone treatment of any type. This was decided after a favorable decipher score. Worked with Dr. Zelefsky, he also said I have a 90% chance of never seeing this again. PSA is every six months, last was down to 1.35. So far so good. I wouldn’t consider going anywhere other than MSK, outstanding, caring people and facility. The deciding factor for me to have radiation over surgery is the outcomes are statistically equal, and the MSK Precise is obviously non- invasive. And the plumbing is working really well. Best of luck
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