Gleason score 9: treatment options

Hello all,

I have been recently diagnosed with prostate cancer.

* my Gleason score is 9.

*I do not have any seminal vesicle invasion nor lymphovascular invasion as per my prostate gland biopsy; but there is Perineural invasion.

*My PSA is 40. 

* Whole body bone scintigraphy shows "mild focal metabolically active focus in the right 11th rib that is of unknown significance".

* CT scan of lower abdeomen shows normal kydney, bladder, bowel loops; BUT "enlarged Pelvic nodes in right external iliac, right obturator group measuring up to 15 millemeters short axis diameter"

I was wondering what does the above mean in terms of whether the cancer has significantly spread or not, what further tests do I need, and what are the treatment options.

Thank you in advance for any reply that can help me to understand my situations.

Best wishes to all of you,

mmbagehi

Welcome to this site -- sorry you have to be here, but glad you found it. This is a complex disease, and fortunately there are a lot of smart, experience people here who can help you. My situation is different from your so I don't have direct experience with your situation but maybe I can give you a little help until some of the others with more similar stats can weigh in. A gleason 9 is aggressive, and a PSA of 40 suggests that it's been underway for awhile. However the reports you got are not clear cut. They suggest that there is at least the possibility that it has spread. The rib notation is ambiguous because a bruise from an earlier sports injury or traffic accident or similar can be hard to distinguish from an early met. Your lymph nodes are enlarged but again this is not proof of spread, but it is possible.

Because of the high PSA and high Gleason you are in line for aggressive treatment. I suggest you read Walsh's book on surviving prostate cancer for an overview of your options. There are three basic modes of treatment: surgery, radiation, hormones. Given that there is some indication that it may have spread they would not treat it with surgery -- and definitely not treat it with surgery alone -- but would mostly likely treat it with a combination of radiation and hormones. There are several different forms of radiation to consider as well.

If you are not near one of the top cancer centers in the U.S. (and even if you were) I would encourage getting a second opinion. You have an aggressive cancer not a slow growing mild one, and you will want to be treated by someone who specializes in PC and has seen a lot of different cases, if you can. Here's a list of major cancer centers:
http://en.wikipedia.org/wiki/NCI-designated_Cancer_Center#Comprehensive_cancer_centers. Hopefully you are close to one of them.

They might do some more advanced imaging to see if the cancer has spread. It's hard to say without knowing exactly what scans they did.

I hope you realize they cannot predict with excellent accuracy if you have 'micro mets' or cells that spread beyond the gland. Biopsies can not define precisely escape of micro mets, biopsies are even tainted by factors of defining: gleason score properly, what about many types of variants in PCa (they are not always understood, especially by average pathologists), you have DNA ploidy of the PCa cells that could be tested for but usually aren't, you have missed biopsy areas that could in fact harbor a different Gleason score and even a different variant type of PCa (this has been proven).

The docs run nomograms and partin tables or s.w.a.g. as to what they think your situation actually is, they have been proven wrong numerous times and biased. We have guys herein with low stats and post surgery clear margins and the all good signal and some of them yet failed to be cured even within a couple years BCR (failure of psa) happened. With PNI (perinueral invasion) it is possible for PCa cells to escape, doesn't mean they did even if known in your few biopsies analyzed, but could have just via this method.....will not show up on any scans known until you have a pretty measurable mass of it, in order to show up on a scan. So, we are dealing with plenty of unknowns in PCa and this helps account for a large percentage of failures in surgery or other treatments. Try running your own stats in a nomogram as atleast an averages comparative thing, still won't tell you how you would do individually. Just trying to shed light on the reality in PCa, we used to be told years ago that scans were definitive and .20 or higher was the defined failure psa level (post treatments), we know this is not the truth today. Based upon that beautiful history and much more I could site, best to question everything and all the time....(perhaps). Best to your decisions.

Test that could be done (some like these):  PAP, UnTx or Pyrilinks urine testing for bone breakdown (defines mets), other markers on blood tests as seen in Dr. Strum's book A Primer on Prostate Cancer and there are others, like CTC (circulating tumor cells blood testing), lymphnode biopsies are even a separate concept (not often done). There are some scans that appear to be better than standard ct and bone scans.

Post Edited (zufus) : 10/2/2012 8:23:12 AM (GMT-6)

I will add my situation. My psa is 5.6 and my prostate feels normal. But my recent biopsy results (5 of 12 samples) show a gleason of 9. I have colitis, but it has been in remission for over a year. I get a CT and bone scan next week. If there is no spreading, the doctor wants to perform robotic surgery. He studied at the Mayo Clinic. He said radiation will damage my intestinal wall. Can the prostate be saved?

Hi mmbagehi,

I'm sorry to welcome you to this board. That's a pretty lousy diagnosis you got there, but you still have lots of options. I hope you are already working with a urologic oncologist. On top of that, a consult with a radiation oncologist (RO) is probably a good idea.

As for the spot on your rib... It sounds too small to biopsy, but a sure way of telling if it is a met is to start you on ADT. If it shrinks, it was a met.

As for your pelvic LN mets, those and your prostate and prostate bed can be treated with radiation. Some may disagree and I'm not an RO, but my hope would be that it will at least slow the cancer down. And if it turns out that the spot on your rib is a met, 3-5 zaps of SBRT may be able to eradicate it.

- Allen

D'Oh! Thanks Billybob - a thread kidnapper! LOL

Meenakshi,
So sorry to hear about your husband's dx. There are a lot of tx options out there to treat G 9 cancers, and I assume you are now seeing an oncologist. I would suggest you star a new thread about your husband to get the most responses, because this is an old thread that many won't look at.
Go to the button Post New Topic and give it a title. A lot of knowledgeable guys and gals will reply.
Best wishes!
Beth