Gleason score 9 just found out today

I had biopsy at Mayo Clinic on Tuesday. Got call today Gleason score 9, 5+4 left, 5+3 right side, 6-7 samples high rate, remainder samples 7. Looked confined to prostate. PSA score 6.1. MRI done at Mayo did not show any nerve bundle or spread. They are suggesting bone scan, and surgery. 57 year old guy. Any suggestions on course of treatment and Docter recommendation for Mayo in Rochester MN.

Post Edited (Polaris1!) : 1/12/2017 7:07:55 PM (GMT-7)

Welcome to our club and sorry to hear about your diagnosis. Your diagnosis is actually similar to mine and I'm also in my 50s. When I was diagnosed, it took me several days before I could even get my mind in gear to figure out what to do. Not sure about your current state of mind, but here are some thoughts to get started.

First off, get a second opinion on your biopsy slides. You clearly had your biopsy at a world-class institution, but there's still a significant benefit to sending your slides to Dr Epstein at Johns Hopkins where they do nothing but read prostate biopsy slides. The newly diagnosed sticky at the top explains how to do that. FYI, the 5+3 core is a very atypical reading (5+4 or 4+5 would be more common) and it would be good to get a handle on that.

Results from your scans are significant since they will show if there is any spread to your bones. You didn't say what your PSA was (that would be important for us to know), but if it's under 20 it's unlikely anything will show up on the scan. If there's no spread, you can begin to look at surgery and the various kinds of radiation.

Urologists are surgeons and typically recommend surgery. You should also talk to at least one radiation oncologist to check into radiation treatments--since there are several kinds of radiation and you might need to talk to more than one RO for this.

FYI, for many high-risk guys surgery isn't always the way to go since being a G9 means that it's more likely that the cancer is beyond the prostate. If it is, it means having follow-up radiation. In my case, I just cut to the chase and started with radiation rather than risking the SEs of BOTH surgery and radiation.

Lastly, as a G9 you likely have hormone therapy in your future. For most guys, HT puts an immediate hold on your cancer, which is great. It also makes radiation more effective. Unfortunately, the SEs aren't particularly fun.

Even though you have a serious diagnosis, you can do well. I had what some people call the "triple play": brachytherapy, external radiation and hormone therapy. I'm coming up on four years post treatment and I'm doing very well with minimal lasting SEs. Good luck to you and let us know how we can help!

Welcome to HW, sorry you need to be here.

Glad to hear you're being seen at Mayo. Good place.

At G9 you need to be agressive. Doing surgery is a reasonable choice as you'll get a detail pathology report and if it's truly confined to the prostate - you're done. If not you have options like HT/RT.

Radiation treatment with HT might be a reasonable option too and likely just as effective as surgery while avoiding the trauma of surgery.

I would recommend talking to a radiation oncologist as well as a surgeon.

Hang in there and keep us updated on your progress.
Andrew

Sorry to have you join our club with a G9 but there's good treatment available. The only advantage for surgery that I can see is the surgeon can pull out a bunch of lymph nodes and then can be examined for the presence of cancerous cells. If the cancer is really organ confined, that is an excellent outcome. You are in a world-class facility, good choice.

I wince every time I hear of a high-risk case being recommended for surgery (by a surgeon, of course). I don't think, generally, that it is the best overall treatment strategy, but your work-up is not yet complete, so let's get all the info.

Some of the evidence to back-up my stated belief includes THIS (full paper) 2016 publication by Baker et al.

The results in favor of initial radiation therapy are particularly impressive because radiation patients in this study had disease that had progressed further at the time of treatment. They had higher Gleason scores, higher stage, and higher risk of lymph node involvement. The results are all the more impressive because the amount of radiation given was low by today’s best practice standards, and because combination therapies of external beam radiation with a brachytherapy boost to the prostate have been proven superior to external beam monotherapy in randomized clinical trials.

Regarding John_TX's comment that "...the surgeon can pull out a bunch of lymph nodes and then can be examined for the presence of cancerous cells," there is limited value in to this in high-risk cases because it has been demonstrated that the limited pelvic lymph node dissection of surgery patients is typically inadequate to detect the full extent of involvement. One needs to more carefully differentiate between the very wide spectrum of PC cases before selecting a treatment strategy.

best wishes...

You have world class expertise at Mayo. Listen to them. But, that being said, Epstein at Johns Hopkins is a world class pathologist specializing only in PC. I would absolutely look at getting a second opinion on your slides. Then you will have more confidence knowing where you stand.

At Mayo, be sure to at least consult with radiation specialists. Each treatment, radiation and surgery, has advantages and disadvantages. Mayo has your information and they will soon have bone scan results too (high probability that will be negative).

The folks here are very knowledgeable, but use the suggestions to engender further consultations with the real experts at Mayo

Mel

My numbers are very similar to yours. I turned 57, August 2015 and had prostate surgery October 13, 2015. Initial path had me at a G10, Doctors could not feel anything in the DRE and second opinion of the Slides downgraded me to a G9 (4+5).

I was given a 50/50 chance of surgery curing me so I took that route, but ended up having to do adjuvant radiation in early 2016. Do your home work and prepare lists of questions for your doctors. Ask the surgeon what happens if surgery does not work and ask the radiation people what happens if the radiation doesn’t work. I typed out my questions and then wrote down all of the doctor’s answers and made my treatment choice. I decided that surgery would give me the best path report for my progonisis

Good luck with you treatment decision and I pray for your peace of mind with the choice you make. Keep us posted on your journey here

The initial path GS from the 12 core biopsy:
2 of 2 were benign
2 of 2 had <0.3mm foci present
5+5=10, in 1 of 2 cores and 1 was less than 0.2mm
4+5=9, in 2 of 2 cores
4+4=8, in 2 of 2 cores
4+5=9, in 2 of 2 cores, with perineural space invasion identified
Weight 40 grams

Second opinion of the slides, GS 9

Final Path:
All 17 lymph nodes were negative.

Prostate size: 4.1 x 3.7 x 4.9 cm

Prostate weight: 53 grams

Total GS 9 (4+5=9)

40% of the prostate involved

Seminal vesicles invasion: Identified

Margins: Minute focus of left posterior margin involved by the tumor. In the right and left apex there is focus approaching the edge, but due to the absence of ink in the portion, it cannot be definitively said that it is a true margin

Perineural invasion: Present, extensive

Path staging: pT3bNO

Hello Polaris1,

Wishing you well, as you begin your medical journey and treatment pathway ...

You mentioned Mayo Clinic --- I just returned from Mayo Clinic in Rochester, Minnesota --- this was my fourth visit there --- my treatment history is shown below my signature.

I decided to add Dr. Eugene KWON to my medical team --- he is a noted urology oncologist at Mayo Clinic, and he specializes in advanced cases with complexities. I just consulted with Dr. Kwon again yesterday at the famous Gonda Building located on the medical campus at Mayo Clinic.

Over the course of time, I have undergone additional tests and scans at Mayo Clinic such as detailed MRIs of the prostate, the abdomen, the pelvis, and the PET-choline scan --- to stay on top of my case.

Interesting to note ... Mayo Clinic treats one million patients from all over the globe, each and every year ... from all 50 states, plus 250 countries from around the world. Several of us here on this website have visited Mayo Clinic over the course of time ...

I just wanted to extend my BEST WISHES to you, Polaris1 ---
"Cyclone Team Fan" ~ Iowa State University

Handshake of support, from across the miles,