Small prostate Tumor...should I try Focal Laser Ablation.

I have a small prostate tumor. Have had a fusion biopsy....several radiologists have said that in my particular case I would be an ideal candidate for Focal Laser Ablation for PCa. Dr. Sperling said the tumor can easily be seen in the MRI and it would be a very smooth procedure. I am posting my biopsy results and if you can please take a look and confirm this. Does anyone have experience with Dr. Sperling or know of other doctors in NYC that do this. They say NYU hospital and Sloan Kettering does this but they may not use the same method. Does anyone know if insurance is covering this treatment in any cases?...I do have good out of network benefits.

It's confusing. Currently my Dr.....Dr. Tenaja from the Smilow prostate center suggested that this therapy is too new and suggested I go on the watchful waiting program...which means another biopsy next year and mri every year after that.
Any input would be greatly appreciated.

here are my biopsy results:
2/16/2016
1. Left lateral base prostate: Biopsy
-Benign prostatic tissue
2.Left lateral apex prostate:biopsy
Left Lateral Mid prostate biopsy:
- Adenocarinoma of the prostate, Gleason score 3+3=6 involving one core (1mm,10%)
3.Left lateral Apex prostate: biopsy
-prostatic tissue with small focus of atypical glands prostate:
4. Left medial base prostate: biopsy-benign prostatic tissue with portion of benign seminal vesicle/ejaculatory ducts.

I'm having trouble inserting the images of the biopsy report. I will edit it soon and post the full results. Though as far as I know the tumor with the 3+3 score is the only area they are talking about using the FLA on.

Thanks for any input.

Dr Tenaja's advise sounds good to me too...Don't sign up for ANY treatment until you have pre-approval from your insurance company..

I would ask how old you are, what your psa history has been, and if close relatives have had PCa?

But, even with what you have provided so far, you have a minimal amount of low grade cancer, and don't need to have any treatment, unless you demand it.

Please try to provide answers to the above questions, and as much detail about your physician consultations as you can.

In my humble opinion, a formal Active Surveillance program is all that you need with that biopsy pathology.

Please research the AS programs at Johns Hopkins and other major prostate cancer centers. Good luck.

Maybe you are a person that embraces new technology before most other people do? Focal laser ablation of prostate cancer is currently investigational because long-term outcomes are as yet unknown. A more conservative approach would be AS until treatment is needed.

I should have listed my psa history and other factors. I posted them before but this is a new thread.

I'm 62. My father had PC but didn't die from it.... brother had aggressive PC at 57 and was successfully treated with the kitchen sink of therapies.

PSA history: PSA has been around 2.3 on finesteride for years........ then over the last 4 years its at 3.25. I think it rose a bit under one point last year. The last test was a few months ago, four months after the biopsy and it was 2.9...so it actually went down after the biopsy....I know it goes up for a while after the biopsy...but maybe the 2.9 is a good sign.

In the research to FLA that I have done I can't see where people are worried about side effects ten years later. Since it seems to have such minimal bad side effects that only last a week and seem to be the most benign way of eradicating a tumor I think common sense would suggest that if a good amount of people who have had this procedure and show no bad results 3 years out (and there are quite a few) I find something horrible developing 5 years after unlikely.

But the cost...the insurance coverage is part of the issue as well.

The Dr. who performs the FLA is kind of making it seem like I might be missing a window of opportunity to be able to use the FLA if the tumor goes from 6 to seven. Its a game of odds and waiting and making choices....things we all have to deal with....and we all have that in common.

All input is really appreciated and would love to hear from more of those who have the FLA.

Thanks all and be well!

Hi Fuzzboxman. FLA/SBRT/CRYO/HIFU are all pretty cool things from where I sit, and if they are getting that good now at identifying and mapping the tumor, then by all means I would take advantage of early sniper/surgical interventions to stop the train before the locomotive is even manufactured.

BUT, I would need to point out that at this point, your targetted biopsy shows one core of Gleason 6 only, which in terms of all I have read in here and online, would make you a wonderful candidate for DO NOTHING.

I'm not suggesting you ignore the obvious hereditary implications, but unless I'm missing something, I'm just saying that in your case so far, it's the best bad information a guy can get if he has to have PCa.

Here's a thread you can read from a satisfied customer:

www.healingwell.com/community/default.aspx?f=35&p=1&m=3533447#m3643084

Here are a few points of caution, however:

• PC is rarely unifocal. After RP pathology, there is a only a single tumor in less than 1 in 5 men who were diagnosed with a single tumor. There are almost always small sites of cancer missed by MRIs or biopsies that are found later.

• All forms of thermal ablation suffer from the heat sink effect. That means heat flows away from the ablation site into surrounding tissue. Because of this there may be incomplete tumor destruction in the ablation zone and there can be thermal injury to other organs, depending on the site.

• Because of the two points above, there is a 20-30% "re-do" rate for focal ablation. I suspect increased risk to surrounding tissues with more re-dos.

• There is a theory, called the Index Tumor Theory, that speculates that all tumors spring from a mother tumor called the Index Tumor. This theory is highly suspect. There is evidence on both sides of the question. My guess is that it occurs in some but not all cases.

• Multiparametric MRIs, even when read by expert radiologists, are far from perfect. They are actually pretty bad at detecting Gleason 6, and can sometimes miss high grade cancer. It is unclear how well it works in ablated tissue. While Wolfster feels safe just monitoring that way, I think careful practitioners would not depend only on that, but would have you undergo periodic follow-up biopsies, possibly saturation biopsies.

• There is no validated was to monitor success using PSA. What is a "good" nadir? What kind of rise is indicative of biochemical recurrence?

• Given that there is lifetime monitoring of PSA and probably should have follow-up biopsies, what is the advantage of focal ablation over active surveillance for the low risk patient? Mark Emberton, one of the foremost practitioners (in the UK), recommends focal ablation only for intermediate risk patients for this reason.

• Unless you have really high end insurance, they will not cover the treatment or the re-dos. They may balk at serial mpMRIs as well.

I'm not against it, and I'm actually glad that it is being tried, although I hope it is tried very cautiously and with very careful monitoring. I raise these points so that you have your eyes open and so that you don't only hear the voice of its advocates. It's also because of patients like you who are willing to be the guinea pigs that we make any advances.

ASAdvocate said...
I have read that the chance of a G3 cell mutating into a G4 is almost non-existent. Only two such possible cases were noted after thousands of men were followed for over ten years at Johns Hopkins.

This is often misunderstood. What JH showed was actually the other way around. They showed that in men in whom metastases were detected, those men always had higher grade (than GS 3+3) prostate tumors. That does not at all imply that a GS 3+3 tumor will not someday become a higher grade tumor, which may then metastasize. In fact, we know they do in about half of men eventually, which is why active surveillance must remain active. The other half may never need treatment of their indolent cancer.

- Allen

I also read that PCa cell do not progress, e.g. in www.ncbi.nlm.nih.gov/pmc/articles/PMC3775342/

"Although we cannot rule out the possibility that Gleason grade progresses within an individual, we conclude that it is not a major feature of prostate cancer."

"The Gleason grade of a tumor typically does not progress."

Is it so that the G3 and G4 (and G5) cancerous growth starts out separate and independent?

We know from Klotz's AS study that after 20 years of f/u (and we can be reasonably certain that higher grade cancers weren't missed in every biopsy over 20 years), about half of low risk tumors progressed to require treatment, and about half were indolent. This was affirmed by a JH study that found that "The estimated likelihood of grade progression within 10 years of study entry ranges from 12% to 24% depending on the prior."

onlinelibrary.wiley.com/doi/10.1002/sim.6003/abstract

And a study at Harvard found that some men originally biopsied as GS 6 did eventually die of PC:

Clinical predictors of survival in men with castration-resistant prostate cancer: Evidence That Gleason Score 6 Cancer Can Evolve to Lethal Disease

Were you referring to the following JH study? It found, as I said, that "Out of over 14,000 totally embedded RPs from multiple institutions, there was not a single case of a GS≤6 tumor with LN metastases." Which is different from saying that GS6 tumors never progress.

DO ADENOCARCINOMAS OF THE PROSTATE WITH GLEASON SCORE (GS) ≤6 HAVE THE POTENTIAL TO METASTASIZE TO LYMPH NODES?

This was corroborated in several studies:

Gleason 6 Prostate Tumors Diagnosed in the PSA Era Do Not Demonstrate the Capacity for Metastatic Spread at the Time of Radical Prostatectomy

Nationwide prevalence of lymph node metastases in Gleason score 3 + 3 = 6 prostate cancer.

Now, it may be that G4 and G3 progress from a common precursor, or they may progress from one to the other, or via both mechanisms. Either way, grade progression does occur which is why it's so important to have those repeat biopsies on active surveillance or focal therapy.

Clonal Progression of Prostate Cancers from Gleason Grade 3 to Grade 4

Tracking the clonal origin of lethal prostate cancer

- Allen

If you can live with it….do so…and to answer your question {Parapharased}…if the focal thing does get the one tumor can't I get pca again any way? Yes you can and yes you will have to watch it any way…Si you have asked the right questions…answered them well yourself…say you can live with it… whats the problem?…live your life according to your own template…and well…. you know the rest..

I am in the same boat with Gl 6 and only one core with 10%, so for time being my uro recommends AS,
I am also researching FLA and read 4500 posts at Inspire on this topic, consulted my MRI with Dr.Walser and Dr.Bush and for now I feel no reason to rush, I am sure DR.Sperling will be happy to do FLA at $30K but check with two other names what they think, and with time passing by we get better data on outcome from FLA

I too have considered FLA for my low grade localized PC. For me , it is not quite time yet as my g6 PC is very small (only 1 core, 1% of that core and only 1mm in size).

This is a safe procedure, although it is still considered investigational for prostate. So, chances are you would not be able to have this covered by your health insurance.

However it is already successfully used in minimally invasive neurosurgery for brain tumors and is covered under most health plans. It's the exact same device for the neurosurgical application. So, if it's used in brain surgery, you can rest assured that it is safe for the prostate. It's best application is in Neuorsurgery for a hypothalamic hamartoma tumor. This is a deep seeded lesion NEXT TO THE BRAIN STEM THAT IS TRADITIONALLY THOUGHT TO BE NON OPERABLE until this technology became FDA approved.

So, thermal damage as described by another poster here is highly unlikely. You don't ablate next to the brain stem unless you can do it safely. The system has temperature controls that automatically shut down the laser if too much heat is generated. It's extremely controlled. The ablation, due to these temperature control settings, will not spread to unwanted tissue unless the operator (radiologist) is unskilled in this procedure.

Here is an analogy that I believe to be fitting. Let's say you have a gun to kill prostate cancer with 4 bullets. Unfortunately some PC is aggressive and may need more than one bullet to kill it. So, the first and biggest bullet is RALP, second bullet is radiation, 3rd hormone therapy and 4th chemo. Well think of FLA as a 5th bullet that can be used before any of the other 4 bullets. Even if it doesn't work and additional prostate cancer pops up elsewhere in the prostate, the other 4 bullets are still available whenever you need them.

FLA will destroy your one lesion if the procedure is done by a skilled interventional radiologist. This will not however prevent additional lesions from potentially forming at a later date in the prostate.

The "redo" rate mentioned by another poster would be more related to other lesions popping up at a later date, not so much that the original lesion is not fully cooked.

The real issue here is the cost. If you can afford $30k with no reimbursement than it may be a fantastic option for you. I would recommend getting a full consult from a specialist doing this treatment. The centers mentioned earlier in this thread successfully do this procedure in their clinics several times a week.

When or if my PC ever progresses and I need some form of treatment, I will be choosing FLA as a first line of defense versus my PC.

Good luck.