Should Perineural Invasion (PNI) change my Radiation Treatment Plan

[Seminole0412]

Hi everyone. A quick background. Age 59. Was diagnosed in Nov 2023 with Gleason 3+4=7 Intermediate Unfavorable (10 of 15 cores positive) and tumor in both side of prostate.

PSA 5.9

Decipher .49

Bone Scan showed no metastasis

Met with Multi Discipline team at Inova Schar Cancer Institute in Fairfax VA on 5 Dec 2023

Inova Schar Cancer Institute

1. RP was primary Recommendation

2. RT Recommendation was 6 mo ADT/EBRT/HDR BT

Scheduled 2nd opinion from Duke Cancer Center Multi Discipline Team for 5 Jan 2024

1. RT was primary recommendation with 6 mo ADT (orgovyx)/SBRT 5 sessions (once per week for 5 weeks)

2. SBRT to prostate only. Not lymph nodes or SV. The RT opinion was the Inova RT recommendation was an overtreatment based on my staging. But, if I wanted to include the Lymph and SV he could do so, but, did not think necessary.

For me RT makes more sense than RP and I want to get best chance of cure while balancing SE. Therefore, I decided that the Duke approach seemed reasonable and have elected to proceed. The ADT is schedule to begin in 10 days, 28 Jan 2024. Thankfully, Insurance picked up cost of Orgovyx with $50 per/mo copay.

Duke did a 2nd opinion on Inova Pathology report from November biopsy (Should have done this earlier from Johns Hopkins). Duke pathology report was almost identical with the exception of downgraded one core from 3+4=7 to 3+3=6. BUT, added Perineural Invasion (PNI) to 1 of the 3+4=7 cores.

I read an article linked by Tall Allen from another post on PNI that said PNI is not always reported by all pathologists, so, perhaps it was simply omitted by the Inova pathologist.

Regardless, I’m not sure whether this report in 1 core alone should change the treatment option and if so what to request. Initial thought would be to simply include lymph nodes and SV in the RT plan. Would love to hear any opinions or someone who had similar circumstances as what treatment was decided upon and outcome.

Thanks for the help.

[Tall_Allen]

I think Duke already took it into account by treating you as unfavorable intermediate risk by adding some ADT.

[Seminole0412 in reply to Tall_Allen]

Thanks TA. Spoke to RO about 2 hours after I posted this and he essentially said the same thing. So I'm going to proceed with ADT/SBRT will let everyone know how it works out.

[timotur]

I would ask for a PSMA scan to see if any LN's are involved. Otherwise ADT/EBRT/HDR BT is a good option. I would definitely want pelvic radiation with PNI.

[Explorer08]

I had PNI which was discovered in the pathology study post-RRP in 2011. My cancer load was very low with no evidence of escape anywhere….except the probability that cancer cells escaped via the PNI. That came to pass ten years later and now I’m on continuous ADT. I was Gleason 9, however, so it was inevitable at some point I guess. I am oligometastatic with one lymph node.

[caltexboy]

With a decipher score of 49 you are just above low risk for prostate cancer aggressiveness in the future. RT plus six months of ADT is a reasonable approach.

[j-o-h-n]

Tally ho......... hope you do fine...... BTW maybe a good idea to cut and paste your post into your bio. Helps you and Helps crew....

Good Luck, Good Health and Good Humor.

j-o-h-n Saturday 01/20/2024 3:45 PM EST

[Seminole0412 in reply to j-o-h-n]

John, Thanks I will do that.

[TJGuy]

I would get a PSMA pet scan right away to see what it finds and add that into the determination what your treatment should be.

No sense in getting just SBRT to the prostate if the pet scan finds any other mets, then you likely looking at much more inclusive Radiation and Therapy.

Or they may just be progressing one step at a time as you go along the way, and then adding in future RT if or as you need it.

[paige20180]

I third a PSMA scan for all the reasons mentioned. Or the best PET scan that works for you. I wouldn’t treat without the best information and picture I could have.