Advice on action plan

Well, I don't see a re-reading of your biopsy slides on the list--that has the potential to tell you way more than the MRI can and it's a heck of a lot easier. Other than, I think you might be expecting a tad too much from the MRI. For example, it won't tell you if there are other tumors and it certainly can't tell you what grade they are.

I'm glad your investigating FLA, which I don't know much about but could be very appropriate with your diagnosis. Have you ruled out AS? Also, have you ruled out radiation, such as HDR brachy or SBRT?

robot - Have I missed something? Couldn't you also be considering Active Surveillance? I can understand focal treatments, if your one core is all there is, but radical treatment so soon?

Really, your pathology wouldn't be taking me to immediate action, and I'm an admitted control freak. I'd be doing even more research on treatment options, while in Active Surveillance - at least for a while. Your PCa was caught even earlier than mine.

We each have to find our own way of reaching a decision. I am supportive of your well thought out method, but agree that you might be looking for too much from the MRI.

I do suggest that you determine the best practitioners in your area and meet with them. Surgeon, seeds, HDR, SBRT, FLA, and AS. Get their individual assessments while you are getting the MRI and slides re-read. I do think you have time on your side in making a decision, but would be frequently monitoring the PSA. G4 can have a way of getting out of hand quickly.

Jim (Tudpock18),
Your story is inspiring. I saw an RO yesterday who specializes in seed implants, and he also recommended that I get the mpMRI for planning purposes, whether it be surgery or BT. I did not think I would be open to LDR BT but after yesterday, it's moved up on the list. If I had to pull the trigger today, it would probably be HDR BT, with LDR a very close second. Surgery continues to scare me due to avoiding ED being very important for me. MRI scheduled for 1/5, so no decision before that, just more anxiety and research!

Good point - added to plan.

Post Edited (robotguy) : 12/15/2016 10:35:56 AM (GMT-7)

Just saw your post and my reactions, FWIW

0. Yes of course, get confirmation from Epstein

1-2. Your treatment decision should not depend on the MRI. I think you are thinking about it backwards.

Surgery:
If you decide on surgery, the surgeon may ask for an MRI to help plan, but usually not. It would be incredibly rare for someone with who is otherwise favorable intermediate risk to evince EPE on an MRI (and it does not require an mpMRI for that - just a T1 or T2 MRI). Unless a lump was felt on DRE or something suspicious showed up on your TRUS, there is no reason to probe further. This should be requested by a urologist if he wants one. You cannot reliably judge from any MRI whether there is cancer near the NVB - only frozen sections during the RP can do that. There is nothing that you are likely to learn from an MRI that will help you make a decision. You are profoundly overestimating what an MRI can tell you.

Radiation
ROs need an MRI for planning. But again, not an mpMRI - just a T1 or T2 MRI. (which is probably what Martinez ordered) Once again, the MRI is not useful for making the decision, but it is necessary for planning.

AS
Probably not. While favorable intermediate risk guys can elect AS, it probably won't be for long. If you decide you want/need say a couple of more years before treatment, then you should get an mpMRI-targeted biopsy within a year. Better yet, a template mapping biopsy. Once again, the doctor should be calling the shots.

3. FLA
You didn't say how many cores were positive and which core was the GS 3+4 one. Most reputable ablation therapists won't do any kind of ablation if there are more than 2-3 positive cores or if they are in different lobes. Please read:

/pcnrv.blogspot.com/2016/12/focal-ablation-unresolved-issues.html

Endorectal coils are typically only used with 1.5T MRI, not 3T. There are reasons not to use them - they alter your anatomy and make subsequent location difficult. If you are convinced you need an mpMRI, make sure you have a very experienced radiologist who will be interpreting it - it is not straightforward. And be sure to get pre-approval from your insurance.

Wolfster - I sent you a friend request on inspire.com
Tall Allen - thanks for the input. I'm finding that conflicting information is the norm rather than the exception with regard to PCa. I've been told by 2 ROs that the mpMRI can be helpful in deciding a treatment option. They claim certain anatomy features may be more suitable for surgery vs. others for BT. Martinez ordered the 3T mpMRI specifically for this purpose. He uses it to ensure the urethra is shaped such that radiation damage will be minimal. He said he rejects up to 20% due to incompatible anatomy. The LDR RO told me he would be able to use it to tell if the NVBs and urethra are favorably located/shaped for surgery. Also, at least one poster commented that a coil with 3T gave a very clear picture.
I have no idea if there is actually some scientific data behind all these claims, or if it's all just opinion, or if it's all just to make me feel better. It's certainly all very overwhelming. Regardless, I'm the type who needs to do my research before making a decision, so I appreciate all the feedback and info. Maybe in the end my decision will be the same treatment option had I just taken the first urologist's direction (RALP), but I think I will feel like I at least tried to make a good choice.
Thanks to all for the support, I'm sure I'll need more as we go. Hope we can all help each other get through this very difficult situation.

TA,
Thanks again for all the time and info you put into this forum, it is greatly appreciated! Martinez did order the mpMRI, I'll have to get clarification at my appointment next week as to why he requested the mp.
I'm leaning towards HDR BT. I have been reading all the HW posts on 1 vs. 2 vs. 6 fractions. I believe he said he would do 2 fractions 1-2 weeks apart. I will ask his opinions on each option.
I am still hanging on to the possibility of AS, delaying treatment for as long as reasonably possible. I am waiting on the 2nd opinion from JH on the slides. If the reading is the same, what do you think about AS for my very small showing of G4 (see signature)? Thank you again!

robot - I'm sure TA has the scientific guidance regarding your thoughts about AS, but I can tell you that my biopsy was a bit worse than yours (in addition to the single small G3+4 core, I had 3 G3+3's), and my uro (trusted source) told me that I could probably qualify for one of the AS programs. I didn't ask which one, as I quickly told him that I would prefer to go right to treatment. At your young age, I'd probably have felt more attracted to AS, to delay the treatment side effects as long as possible.

What good news is that! Yes it happens often, in my experience, which is why we always recommend it.

That should get rid of your reservations about AS. I think it is always a good idea to get a f/u mpMRI-targeted biopsy within a year of the first one. Again, this is often part of an AS program, so your doctor will order it. I think it's a good idea to do AS as part of an established program.

If you do decide you want to go ahead with HDRBT, the schedule doesn't seem to matter much:
/pcnrv.blogspot.com/2016/08/is-there-optimal-treatment-schedule-for.html

I know they've even tried a single dose of 19 Gy, but that is experimental and I have some reservations about it. Coincidentally, I just met with Dr. Demanes yesterday (Martinez's colleague at UCLA), and they are also moving to 2 implantations a week apart of 13.5 Gy each.

Robot, I'm curious. Why do you -- and others -- assume the downgrade is the correct reading? Why is JH necessarily correct and the first pathologist not? What possibly unwarranted assumptions are being made?

When I faced a similar situation, I went to Dr. David Bostwick for a tiebreaking third reading. His reading was the most concerning at all -- he found a PCa variant -- so I opted for a template mapping biopsy, something Tall Allen wisely suggested you might consider.

That 5 mm mapping biopsy, much, much more thorough than the three-core biopsy taken after the 3T mpMRI scan I had, revealed a couple of (tiny) GL10 tumors. It took four months of effort, but I finally had the information I needed to make an informed treatment decision.

Good luck to you -- and to us all. My lesson learned: trust but verify.

Post Edited (Boon1) : 1/4/2017 4:20:27 PM (GMT-7)

Time for an update. Here's my situation:
I'm 47
April 2015 PSA 2.22 (first one, ok, a little high, check again next year)
August 2016 PSA 4.56 (this is the alarm bell that set everything in motion)
September 2016 PSA 3.78 (still too high) Urologist suggests Bx
October - thinking
November 21, 2016 TRUS 12 core
December 5, 2016 bad news - 1 core 20% G(3+4) urologist recommends surgery
Johns Hopkins pathology 2nd opinion says 10% G(3+3)
RO appointment with HDR and LDR specialists
January 5, 2017 mpMRI to determine anatomy for HDR and to stage and locate tumor.
N0, M0, organ confined, near wall at right base PI-RADS 4, 9mm lesion. 6mm PI-RADS 3 right apex.
LDR guy says LDR + Beam, HDR guy says HDR mono, urologist says surgery.

Now I am heavily into researching Focal Laser Ablation. Seems better than HIFU, just because of real time 3T MRI monitoring for better accuracy. Seems like a good choice. EXCEPT for the $20k bill. Also, my wife is very against it since it is considered experimental by the insurance companies.

My opinions:
LDR + Beam = overkill and unnecessary radiation risk
HDR mono = pretty good option, except for fewer salvage options, slight risk of secondary cancer
surgery = probably would be the best option except that preserving potency is VERY high on my list
FLA = I think this is the best route except for the cost and my wife is scared of the lack of long term data

Any thoughts or words of wisdom?

Thanks!