Mostly Decided on SBRT Treatment

[Chrisopopolis]

I am going forward with recommendations for treatment of my prostate cancer. Actually I have been given 4 options: Continue Active Surveillance; Focal ablation of the Gleason 3/4 tumor; Radical Prostatectomy; SBRT radiation of prostate gland.

I would appreciate any feedback on my decision to go with SBRT.

My details:

Prostate cancer (CMS code)

Staging form: Prostate, AJCC 8th Edition

- Clinical stage from 2/6/2025: Stage IIB (cT2a, cN0, cM0, PSA: 3.6, Grade Group: 2) - Unsigned

Histopathologic type: Adenocarcinoma, NOS

Prostate specific antigen (PSA) range: Less than 10

Gleason primary pattern: 3

Gleason secondary pattern: 4

Gleason score: 7

Histologic grading system: 5 grade system

70 y.o. year-old male with initially clinically localized prostate cancer (pre-treatment PSA 3.5, Gleason 3+3 with 1/14 cores positive, CAPRA 1, Oncotype 25 – low risk, Decipher 0.4 – low risk), monitored on active surveillance with subsequent prostate biopsy on 10/18/21 showing Gleason 3+4 prostate cancer (5% pattern 4 with total 6/7 positive MRI-targeted lesion, otherwise benign systematic cores) with transrectal ultrasound on 2/6/25 consistent with US T2a disease (Dr. Shinohara).

Recommendation: Either SBRT 38 Gy in 4 fraction to the prostate, radical prostatectomy (surgery), focal ablation, or continued active surveillance with Dr. Shinohara.

 

Plan:

[1] Re-referral for Dr. Shinohara for biopsy, GSM placement, hydrogel spacing

[2] Follow-up with Dr. Gottschalk after [1].

 

Tentative recommendation for Cyberknife 38Gy in 4 fractions EOD

- RT authorization will be obtained

- CT and MRI simulation will be scheduled

[Tall_Allen]

I think AS sounds like the best option, at least for a while. UCSF has a good AS program. Remember, Until 2005, your pattern 4 would have been ignored. It is negligible and can be watched.

I had SBRT.

[Chrisopopolis in reply to Tall_Allen]

Thanks for that feedback. UCSF was recommending AS too. But they want to continue to do biopsies as a part of that treatment (of course) and I have not done well with biopsies in the past. After my last one in 2021 I decided that I would probably go for SBRT when and if some sort of treatment other than AS was recommended. Dr. Shinohara noted that “Focal Ablation was feasible” for the lesion that has 5% pattern 4. I took that to mean we were at the point of some other treatment being recommended but that is not what he was saying. The lesion which Dr. Shinohara thought focal ablation is feasible is on the rear/bottom of the prostate and can be felt because it bulges out a bit against the rectum. I didn’t like the fact that it is so near the surface but I understand that most lesions are? Anyway, I have read here about focal ablation and will not go that route, but I thought if they are going to do another biopsy, they may as well place the gold seeds at the same time and do the SBRT.

Reading your comment about the negligible amount of pattern 4 makes me lean back toward AS and I may just go ahead with biopsy only for now.

[Tall_Allen in reply to Chrisopopolis]

"can be felt because it bulges out a bit against the rectum." You left out that very important bit of information -- it changes everything!

That is called Stage T3a and puts him in the high risk category. He is not a candidate for AS. He should have a PSMA PET/CT - preferably using Posluma. Assuming that no distant metastases are detected, he should have boost therapy - either with HDR brachy or SBRT. He should not have SpaceOAR, as that might protect any cancer that has grown against the rectal wall.

[Chrisopopolis in reply to Tall_Allen]

I’m probably giving bad information…

Here is the latest ultrasound notes that I probably misunderstood:

On digital rectal exam, the prostate is estimated at 40 grams, with nodularity at the right midgland.

FINDINGS and IMPRESSION:

1. The prostate gland was estimated to be 27cc and transition zone 6cc.

2. PSA density is 0.13148148

3. A hypoechoic area, measuring 0.32 cc at the right mid and right base, with possible ECE and no SVI, is noted.

4. Right base hypervascularity was noted on Doppler exam.

5. Findings consistent with cT2a disease.

6. Focal ablation feasible.

Sketches of Ultrasound Findings

[Chrisopopolis in reply to Chrisopopolis]

And from MRI:

MRI Screenshot

[Derf4223]

Hope you get at least doublet treatment

[Chrisopopolis in reply to Derf4223]

I have not heard of doublet treatment. Can you tell me a bit more?

[Derf4223 in reply to Chrisopopolis]

Put the word "doublet" into the Search HealthUnlocked space above. You should get over 300 hits.

[j-o-h-n]

Elenas? Yiasou...

Good Luck, Good Health and Good Humor.

j-o-h-n