Active Surveilance Continued from 2011 Requesting Advice

My first post in several years. I'm gratefull for being a member of our group. Being treated at UTSW, Dallas, TX. DX 2011 PSA 5.49, 3+3=6 in 2 of 32 core sedation biopsy. Prostate 55cc. Current 2017 PSA 6.88 stable.

2013 Biopsy = F. Left middle #1, biopsy:
- Prostatic adenocarcinoma, Gleason score 6 (3 + 3) 1.0 and 0.5 mm foci
involving two of four cores (2% total core volume)

2017 = Had first MRI last week, results below. I'm not sure what to do next.

DR recommends follow up with an in-clinic biopsy maybe 6 core guided by MRI image to target Lesion #1 or sedation biopsy with 20 core samples. I've avoided the in-clinic adventures twice with sedation biopsy. Any thoughts ?

June 2017 EXAM: MULTIPARAMETRIC MRI OF THE PROSTATE W AND WO IV CONTRAST

INDICATION: 67 years old man with known prostate cancer for active surveillance; Gleason 6 cancer at left base on prior biopsy from 2011.; Elevated PSA up to 6.8 ng/mL, stable.

TECHNIQUE: Using a phased-array coil, multiplanar T1-, T2-, and diffusion-weighted imaging of the pelvis were performed on a 3 Tesla scanner. Axial T1-weighted images were obtained before, during and after the intravenous administration of 10 cc of Gadavist and were analyzed on a dedicated post-processing workstation (DynaCAD).

The patient deferred the use of an endorectal coil.

FINDINGS:
Prostate:
Measurement: 5.0 x 6.1 x 4.9 cm; estimated volume: 78 cc;
Focal lesion(s):
Lesion # 1 (index lesion):
- Key image: series 301; image 27;
- Size: 14 mm;
- location: left; mid; anterior peripheral zone;
- T2WI: 3 ; DWI: 4; DCE (early and focal enhancement): positive;
- Mean ADC value: 0.451 x 10-3 mm2/s;
- PI-RADS v2 score: 4 - High (clinically significant cancer is likely to be present);
- Likelihood of extraprostatic extension: 3 - Indeterminate; the lesion is seen to abut the prostatic pseudocapsule at places with associated mildly irregular margins.
- Likelihood of seminal vesical invasion: 1 - Highly unlikely;

Diffuse abnormalities: None;
Bladder: Trabeculated appearance.
Adenopathy: No pathologically enlarged lymph nodes.
Bones: No aggressive bony lesions.
Other: No significant pelvic free fluid.

I'm not sure exactly what to do next, if I need to think about radiation or surgery.

Thank you very much!
Suttersmill

Post Edited (suttersmill) : 6/18/2017 10:54:56 AM (GMT-6)

I think 4 years without a biopsy is long enough. The 30-core one is, of course, preferable.

The MRI report says the positive cores in 2011 were in the left base, in 2013 were in the left middle, and now, the suspicious area is in the anterior. So far, all the cancer found has been in very small amounts and is the lowest grade. A suspicious area does NOT mean there is cancer there, just that it needs to be explored. Hopefully, you'll be able to stay on Active Surveillance. I would think you'd want the assurance you will only get from a 30 core biopsy.

Your prostate has been rapidly growing in size due to BPH, and you have signs of urethral obstruction from it - it also may explain the suspicious area in the anterior which often gets compressed by BPH-related tissue growth in the transition zone. I would think you are experiencing problems with urinary retention. I think you should discuss starting on Proscar or Avodart to shrink your prostate.

Getting up 3x at night to pee is too much. Hopefully, some medication can correct that.

SBRT is done in 5 treatments, IMRT in about 40 (click in my signature for references). Timmerman at UTSW does a lot of SBRT, if it comes to that. Your prostate is too big for seeds, but there is another kind of brachytherapy - high dose rate brachytherapy - that may be appropriate. But let's first see what the biopsy says.