Pure intraductal carcinoma, surgery or SBRT

[KikiBoo]

I posted here before about my dad, aged 76 was diagnosed with intraductal carcinoma with no invasive carcinoma found from MRI-guided fused biopsy. PSMA PET scan is clear, only mild uptake inside prostate matching previous MRI lesion finding. More detailed summary on bios.

Urology oncologist who did his biopsy suggest RARP and said IDC-P might not respond well to radiation or hormone therapy. He also stated since lesion is close to the apex of the prostate, so higher chance of long term incontinence. Of course all the general risks and recovery that come along with surgery and his older age are all concerning too.

Radiation oncologist suggest SBRT which he successfully treated patients with localized PCa with IDC-P. He never treated patients with pure IDC-P like my dad though. However, he feels confidence that SBRT would work for my dad. He also suggest adding 2 years of hormone therapy afterwards regardless he pick surgery or SBRT.

Both options have its pros and cons. SBRT seem much less invasive and suitable for his age and other side effects in consideration. He does not really want to consider hormone therapy due to all the side effects and he already on a mediation that causing high blood pressure. Anyway, it still very difficult to make a decision of what is the best treatment.

Any advice or comment here would be greatly appreciated. Thank you.

[Tall_Allen]

UTSW knows how to give a more intensive dose of SBRT (Neil Desai at UTSW is excellent). I suspect he should get whole pelvic radiation too.

" He does not really want to consider hormone therapy due to all the side effects" Which side effects? If he refuses ADT, I doubt he will get any benefit from the treatment.

"...he already on a mediation that causing high blood pressure."What has that to do with ADT?

[KikiBoo in reply to Tall_Allen]

Tall Allen, thank you for your reply. We think SBRT might be better option for him because of his age and other concerns about surgery. But at the same time, we find it not easy to make a decision.

My dad is referred to Dr. Hannan at UTSW and hope he is also good.

I think he worried about the ADT side effects and it might cause more heart issues other than the high blood pressure and dilated aorta that they are monitoring from ADT.

[Tall_Allen in reply to KikiBoo]

Heart issues are rare with ADT. It does not cause high BP.

[KikiBoo in reply to Tall_Allen]

Thanks. Did you have any suggestions/feedback between surgery and SBRT in this very uncommon case?

[Tall_Allen in reply to KikiBoo]

I suspect whole pelvic radiation is necessary, so surgery is precluded.

[KikiBoo in reply to Tall_Allen]

We set up another appt with RO, so he can ask more questions. I will ask about is the SBRT is whole prostate gland and include pelvic area or not.

What is your take about the UO mentioned IDC-P might not respond well to radiation and/or ADT?

[Tall_Allen in reply to KikiBoo]

What would a urologist know about it?

[KikiBoo in reply to Tall_Allen]

Thank you Tall_Allen. I think you are right. I guess his saying is just based on other articles out there.

[KikiBoo in reply to Tall_Allen]

Tall_Allen, UO replied with this site to explain his saying about IDC-P not respond well to radiation.

redjournal.org/article/S036...

I came across this myself too which I think cases in the article should be normal PCa with ICD-P. I guess in a way, doctors think we won’t know exactly if he has pure ICD-P or not. However, we are trying to balance everything with my dad’s age, potential risks, and everything. My dad is thinking he is almost 77 and not want to endure the surgery and any SEs or complications that might come along if he does not have to.

[Tall_Allen in reply to KikiBoo]

Thanks for showing me that SEER database analysis. Such analyses are often misleading because of selection bias -- patients who got RP were given it because they were thought to have good odds of surviving surgery. I doubt there were many 77 year olds in their analysis.

OTOH, in a retrospective study, men who got adjuvant radiation had improved BCR:

ro-journal.biomedcentral.co...

This suggests that IDC-P does indeed respond to radiation + hormone therapy, It is a retrospective study, however.

[KikiBoo in reply to Tall_Allen]

Thank you and good explanation!

The RO did say he successfully treat the localized PCa with IDC-P. Just never treated anyone with IDC-P only like my dad. But he thinks it will still work for his case. In the first appt, we also asked if the size of the lesion (26mm from apex to top on the left peri zone) and location (close to apex which might affect incontinence risk if surgery) will be a concern for radiation, he did not think those are issues for SBRT at all.

[Gabby643 in reply to Tall_Allen]

Thanks T-A!

[Mgtd]

You might want to consider the pill form of ADT. It can be stopped within a week or so if necessary.

I was slightly older when I did ADT. Honestly please do not let the side effects determine if he does it. Some like myself sail through it.

Other factor to consider is how long will he be on ADT. If he is looking for a remission then ADT is required.

[KikiBoo in reply to Mgtd]

The RO suggested 2 years of ADT after either SBRT or surgery. You said you are slightly older when you did ADT, would you mind me asking how old you are when you have radiation and ADT? How's your experience with both? My dad is taking Ibrutinib for waldenstrom's macroglobulemia, so besides concerning about ADT side effects, they will also have to select one that will not interact with Ibrutinib.

Hope you have a fun day skiing and be safe.

[Mgtd in reply to KikiBoo]

Sure I was 78 when I did ADT and radiation. I will 80 in 2 months.

Some minor rough spots with radiation and ADT but nothing I would not do again with the hope of remission. As you can see I am back to normal doing all the things I love to do and even things I hate.

I can not speak to your dad’s other medical issues those need to be addressed by his doctors. I guess it boils down to whether he wants the chance at a remission.

Chair lift is ending need to get ready to get off. Bye!

[Mgtd in reply to KikiBoo]

One thing I forgot to mention. Have him discuss 12 months of ADT. There is some differences in how various MO prescribe ADT.

What was his Gleason score?

[KikiBoo in reply to Mgtd]

All it says on the biopsy report is intraductal carcinoma, and they don't even grade it. Total of 15 cores. 6 on the right are all benign, and all 9 on the left are all intraductal carcinoma. Here's the 3 cores taken from the area of interest from MRI, and the rest of the other 6 cores of the left side are basically the same thing, but different % and mm.

G. Prostate, Left PZ MRI Lesion #1 x3, biopsy:- Intraductal carcinoma involving 3 of 3 cores (11 mm, 80%; 12 mm, 80%; 4 mm, 60%)

Other than that, there's an ancillary studies section to point out immunohistochemical stains with appropriate controls were performed for PIN4 cocktail on block D and G. The atypical glands show the following reactivity: p63-Focal positive in basal cells, High molecular weight keratin-Focal positive in basal cells, racemase-positive, INSM1-negative, and GATA3-negative. This immunohistochemical profile, along with the morphology supports the above diagnosis. No definite invasive carcinoma was identified in the current specimen. Definitive treatment is recommended by some for intraductal carcinoma even in the absence of invasion. Repeat biopsy to assess invasion is recommended by others.

[Don717]

Do the ADT Kiki!!!...if things are going bad he can always stop.

[Mgtd]

As TA mentioned I also had the pelvic area at the same time. He might want to consider that so it all gets done at one time.

By the way we just had 12” of new snow so I am heading off for a half day of down hill skiing. Honestly at my age half day is more then enough.

[Laguy01]

i can give you my experience. I am turning 60 in six months. I had PC gleson 8 with cancer spread to lymph node. I was given proton radiation with ADT. The radiation was not bad . The ADT causes hot flashes, muscle loss. Added fat around waste line. It has possible side effects of heart and calcium issues . My last check up, I had a Psa of .06 with testosterone level of 10ng. The doctor was happy with out come. I thought he was going to do more scans after the treatment but he said it was not necessary and would not show anything. Not sure if i agree with that but he is the professional. So For your Dad, i would consider the treatments available.

[Mgtd]

You might search on this site for Intraductal Carcinoma. I found 3 or 4 listing. Apparently rare and no standard defined treatment like other forms of prostrate cancer. You may need to go to a cancer center of excellence to get the best treatment for your dad.

[KikiBoo in reply to Mgtd]

Thank you Mgtd. Yes, he is currently going to UT Southwestern which it's a cancer center of excellence since we are in the Dallas, TX area. I also did search around a lot about ICD-P, but his case is very uncommon. Doctors basically treat it as high-risk case at UTSW.

[Mgtd in reply to KikiBoo]

Sorry i can not be more help! You are doing the best you can. Because it is so rare the best thing to do is to follow the prescription of your doctor. They are the experts.

I would also suggest you talk with your dad and ask him does he want to fight this hard or refuse ADT. This is his call and the family needs to respect that.

In either case all the legal and medical powers of attorney, wills, and medical decisions like DNR need to be in writing. Not easy discussions but critical.

[sofirose]

Hello,I am no expert,but my husband had this choice to make some years ago. He was age 70with grade2 prostate cancer. The surgeon advised he could have the surgery but at his age the risk of incontinence and recovery slower. He decided to go with the radiotherapy and had 20 sessions over 4 weeks,he had hormone treatment before but not after. He is now 80 and has a psa yearly which has remained stable up to now. We are in the UK and treatment may have improved or changed, have to say we don't regret our joint decision. As they say everyone's different,wish you all the best.

[KikiBoo in reply to sofirose]

Thank you for your reply sofirose. We are also worried about what will come along with surgery. Tougher recovery, incontinence and potential complication with his age? That is the reason after we met the radiation oncologist and got offered the SBRT option, my dad is more leaning towards this much less invasive option. After all, he has to balance treatment SE along with his QoL and his other condition that's on treatement. No decision is easy. At times, it is also very frustrating to get answers from doctor or make apppointments. A lot of delay and wait time. It's very difficult for my parents.