Gleason 3+4 incidental to turp

[Bj1069]

less than 1% of tissue. Urologist recommended IMRT. PSA pre Turp 12.2. Had been elevatec between 11 and 22 for over a year. My original doc passed in 2015. New doc never did DRE or ordered a biopsy. Radiation doc introduced me to a new doc who did a DRE and a six core unguided biopsy that was neg, no PSA test, and told me to come back in a year. My GP ordered a PSA which was 5.1 and told me to go to UC Cancer Center in Denver where they did bone scan and whole body CT. CT showed nothing at all.Bone scan showed increased uptake in wrists, elbows, ankles, maxilla, lumbar spine, and hips. Radiologist chalked all but maxillary up to degenerative disease, and said the maxillary was due to inflammation. Urological oncologist called and said see your GP for the arthritis and then come to see me. In the meantimme our pathology lab will retest your samples. Retest shows gleason 4+4. Xrays show no degenerative process and my sinuses are clear. Is this how PCa is treated? Seems crazy to me.

[YostConner]

If you are going to do watchful waiting, it seems your next appointment would be sooner than a year. The urological oncologist seems to be paying most attention—especially with the request you come back in. To you like/trust him/her?

[Bj1069 in reply to YostConner]

He's really very good. He's a researcher working mostly on higher sensitivity and specificity imaging and focal treatments like interstitial laser and cryo with real time mri imaging. I'm not a big fan of any of the definitive treatments, but 4+4 would likely change my mind. Assuming the pathology reports arent completely wrong, I would like to at least find to tumor. I'm going to discuss with my urological oncologist and see what conclusion we can reach. If I decide to do RP, I'll probably go to MSK so I can be a burden to my kid for a change. I'm really leary of high dose radiation. I've had a lot of exposure to radiation already and that's a bear I don't want to poke any further.

[Tall_Allen]

No, that's not how it's treated. Have your samples from both the TURP and the 6-core biopsy retest sent to Epstein's lab at Johns Hopkins for a definitive opinion:

pathology.jhu.edu/departmen...

If it's confirmed as GS 4+4 (high risk), your most curative option is brachy boost therapy. However, your TURP may cause urinary issues when combined with radiation doses that high. Other options for you to explore are external beam radiotherapy (IMRT) or surgery. you have to take the initiative to go seek out experts in all of those procedures and you will have to make the decision as a trade-off between expected cure rate and possible urinary side effects.

Here's an article about how to find the right doctors:

pcnrv.blogspot.com/2017/12/...

[Bj1069 in reply to Tall_Allen]

Wow. Thanks a lot. You've been a great help

[JoelT in reply to Tall_Allen]

Hi Allan,

I agree 100% that the tissue samples should be reviewed by the Epstein lab.

I would like to know what makes you make the statement that "your most curative option is brachy boost therapy." Where does your data come from?

Joel

CancerABCs.org

[Tall_Allen in reply to JoelT]

While we do not have, and probably never will have, a randomized clinical trial (RCT) comparing surgery, brachy boost, and IMRT in high risk patients, we have 4 randomized trials comparing brachy boost to IMRT only (one using LDR brachy and 3 using HDR brachy). Brachy boost was significantly better than EBRT alone in all of those. This constitutes Level 1a evidence. Based on those, ASCO/CCO revised their guidelines such that EBRT alone is no longer a recommended option for high risk patients. Here are some articles about those RCTs:

pcnrv.blogspot.com/2017/03/...

pcnrv.blogspot.com/2016/08/...

For comparisons with surgery, we have Level 2a evidence. Both metastasis-free survival and prostate cancer specific survival were much better among high risk patients treated with a brachy boost. (They updated that to n=1809 at ASTRO, but the results are much the same):

pcnrv.blogspot.com/2017/02/...

There was a similar analysis from the University of Alabama at Birmingham that was smaller and shorter term, but I mention it because the patients were predominantly Gleason 8:

pcnrv.blogspot.com/2016/08/...

[Bj1069 in reply to Tall_Allen]

So I went to MD Anderson. 1.5 t imaging showing .4 x .4 cm lesion in right transitional zone , symmetrical seminal vesicals, no extracapsular protrusion, DRE (Normal), CBC , normal, electrolytes normal, urinalysis positive for white cells and protein, urine culture normal, STD panel neg, HEP neg, HIV neg, 3DFusion biopsy (neg for cancer, scar tissue from previous infection) pathology showed Gleason 3+4 in 1% of tissue from original TURP. PSA prior to Fusion biopsy 0.8. So, apparently I had a very small tumor which was completely removed during the TURP. I'll have a DRE and a PSA in six months to allow for healing (TURP and 3 biopsies in 4 months) due to trauma. So, that is my saga. Had someone ordered the MRI prior to the TURP, it would have been a much shorter, less worrisome, and much, much cheaper story. But I like the ending.