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Posted 8/4/2017 2:59 AM (GMT 0)
My MRI Ultrasound Fusion Guided Biopsy results just came out: 1 out of 14 cores was found to be cancerous:

• Right Lateral Base: Prostatic Adenocarcinoma (PC), GS 7 (4+3, Grade Group 3) involving 55% of one core. Perineural invasion (PNI) identified.
• Right Lateral Mid: Benign fibromuscular tissue and adipose tissue.
• Right Lateral Apex: Benign prostatic tissue with focal chronic inflammation.
• Left Lateral Base: Benign prostatic tissue with focal atrophy.
• Left Lateral Mid: Benign prostatic tissue with focal mild chronic inflammation.
• All the rest cores are benign prostatic tissues.

Before biopsy, my MRI has identified two lesions (4mm and 8mm PI-RADS 4) in prostate. The biopsy core which contains cancer is from the 8mm lesion. The lesion is in contact with prostatic capsule, but no definite extraprostatic disease is seen. No evidence for seminal vesicle invasion.

The bx results have been sent to Myriad Genetics for a genetic testing to find out the aggressiveness of the PC before making treatment decisions.

My questions are:

1. Is PNI a significant factor in my decisions to choose treatments among surgery, non-surgery and AS options?
2. Should I deal with the two inflamed areas first through medication before doing any non-surgery treatment on the cancer? I am thinking of dealing with the inflammation first to see how this part has contributed to my increased PSA.
3. With my Gleason scores and other factors listed above, would EBRT or SBRT be a viable option?

I thank you in advance for your advice.

_______________________________
Age: 55, active and in excellent health
PSA: 4.8 - 11.5 (9/2014 - 6/2017)

Post Edited (dafight) : 8/3/2017 10:33:56 PM (GMT-6)

Posted 8/4/2017 4:22 AM (GMT 0)
dafight, welcome to the club where nobody wants to belong. But, there are very informed and experienced people here who can offer you great advice.

You mentioned AS? No way is that an option for you...and I am a big supporter of AS. With that pathology, you cannot spend too many months deliberating. A treatment plan should be chosen.

The current form of EBRT is IMRT, which is about 44 sessions. But, SBRT(Cyberknife) is reporting equal or better results from only 5 sessions. That would be my choice if my indolent status ever becomes more dangerous. And, yes, that is a viable option for you.

PNI is not a major factor in choosing treatment. Inflammation is more a noticed anomaly than a real concern once cancer has been detected.

Others will be along with their honest and sincere opinions. Please read them all carefully. Good luck to you.
Posted 8/4/2017 5:12 AM (GMT 0)
It really sucks you have to be here, but welcome to HW! I have learnt a ton here and you should definitely spend some time reading up.

I am not knowledgeable enough to give treatment advise but it's pretty surprising that with a very high PSA - 11.5 , you just had one core positive. I'm wondering if they may have missed some areas.

I've learnt from reading some of TA (Tall Allen) threads that if they found PNI during biopsy , it's generally more concerning than finding PNI during pathology ( found in most ) and that should go in as a factor while considering treatment decision.

On a positive note , I can tell you that my path report was downgraded after RALP from 4+3 to a 3+4 and based on this article from Johns Hopkins - there is 50% chance of this downgrade happening , but you would only find that out if you went the surgery route.
urology.jhu.edu/newsletter/prostate_cancer_discovery_96.php

Post Edited (ddyss) : 8/4/2017 7:46:48 AM (GMT-6)

Posted 8/4/2017 12:17 PM (GMT 0)
Hi, dafight,
As the others have said, I will echo - welcome to this club of ours that nobody volunteered to join. Sorry to find you here, but glad you've found us. At this site, I believe you will find some of the best, balanced information and advice on your PCa journey.

With your G4+3=7 and your moderately high PSA, I believe that they would consider you to be "unfavorable intermediate risk." Don't panic at the "unfavorable" as that merely differentiates your case from guys with the less-aggressive G3+4=7 variety of PCa and/or mildly elevated PSA. That said, I think that your next steps should be to learn about the various treatment options and choose yours. I agree with ASAdvocate - your G4+3 definitely should be treated, not watched.

At your age they may offer you either surgery or radiation. Both have about the same efficacy, and either can potentially be curative. I would advise you to investigate the options (I personally would look into surgery, brachytherapy (either permanent seeds or temporary), SBRT (super-hypofractionated external radiation, typically only 5 treatments) or hypofractionated EBRT (external radiation, but far fewer than the old-school 40 treatments). I strongly advise you to look into not only the efficacy of the treatments, but also their side effects. Whichever treatment you choose, there will be side effects, and you will live with them for a long time. In my case, I chose my treatment based upon the side effects profiles. I wanted to choose one that wouldn't leave me wishing I had taken another direction.

Whatever you do, do not let any doctor rush you from a consultation right into scheduling treatment. You don't want to wait a long time, but a month or two to decide will not affect your long-term prognosis. Gather your thoughts about treatments and come on back to discuss. We'll be here for you.
Posted 8/4/2017 12:53 PM (GMT 0)
Hello, Dafight and welcome. Sorry you have to be here. May I suggest you red the sticky thread at the top of our forum that is designed for new patients. That will give you a good start on the education you need. I would also suggest you you have your slides sent to Dr. Epstein at JHU for a second opinion. Getting an expert opinion on your biopsy pathology is essential in making an educated treatment decision.

You have already received some excellent advice so I'll not repeat it. Take your time, search out multiple opinions from experienced doctors and you'll be fine.

Good luck and let us know how we can help.

Jim
Posted 8/4/2017 3:10 PM (GMT 0)
Thank you all so much for your kind replies and great advice. I will get the slides sent for second option. I am thinking about Cyberknife as some of you have suggested. I want to get some validation and confirmation from you veterans before going to a RO. I am glad that you think I might be a candidate for it.
Posted 8/4/2017 3:27 PM (GMT 0)
Dafight...good luck on your treatment decision. Since I was a low volume G6 my decision was treatment or AS. Once I made the decision to elect treatment I quickly ruled out surgery (over kill for my Dx) and I it came down to what type of radiation treatment to get. I chose SBRT at Cleveland Clinic since it appeared to offer slightly better outcomes with slightly less side effects than the other options. The five vs forty five treatments was a bonus. I also liked that they would also treat the area around the prostate and could very accurately shape and modify the dose to mnimze the damage to all the important stuff I wanted to keep working. It was comforting to see my treatment plan took into account treating the areas around my prostate just in case my Bx had missed something.

I'm six weeks post treatment and had almost zero side effects. Some minor burning on urinating that lasted about 10 days. No medication, no restrictions with my grandchildren, no catheter, no pads, no ED and my wife says we still have a little wet spot. That said I'm only a data point of one.
Posted 8/4/2017 4:12 PM (GMT 0)
Sorry about your diagnosis, but glad you're working on making an informed treatment decision--including getting the second opinion on your biopsy slides. All good advice upthread and you should know that no matter what treatment you choose, your chances of a cure are excellent.

Good luck to you and let us know how we can help.
Posted 8/4/2017 5:36 PM (GMT 0)
1. Is PNI a significant factor in my decisions to choose treatments among surgery, non-surgery and AS options?

No. It is a risk factor, but compared to the GS 4+3, it is less important.

2. Should I deal with the two inflamed areas first through medication before doing any non-surgery treatment on the cancer? I am thinking of dealing with the inflammation first to see how this part has contributed to my increased PSA.

At this point, it doesn't really matter what the sources of your elevated PSA were. You are intermediate risk no matter what. And there are no really good ways to reduce the chronic inflammation anyway. Just keep in mind, if you pursue radiation, that it may continue to keep your PSA elevated. That can be psychologically frustrating.

3. With my Gleason scores and other factors listed above, would EBRT or SBRT be a viable option?

Yes, certainly they are good options. SBRT is a kind of external beam radiation therapy (EBRT). Other kinds are conventional IMRT, hypofractionated IMRT, and proton therapy. Other kinds of radiation comprise two kinds of brachytherapy (high dose rate or low dose rate). I had SBRT, so I'm a fan of that.
Posted 8/4/2017 7:19 PM (GMT 0)
This forum is awesome. Tall Allen's one by one answer to my questions is such a blessing to me. thank you.

Tall Allen, to the second question, the doctor said they have medicine to cure the inflammation, but it will take several months to do it. I am not sure I have that much time to wait before I start treatment. If I pick SBRT it would be a problem to tell the effectiveness of the treatment since we don't know the PSA number will be contributed by cancer or inflammation, assuming I still have inflammation by that time.
Posted 8/4/2017 7:32 PM (GMT 0)
The frustrating thing about chronic prostatitis is that it's usually impervious to antibiotics and anti-inflammatories. The other frustrating thing is that it is usually relapsing and remitting. Even if you reduce it now there's no guarantee that it won't come back. Radiation may set off a recurrence. It is frustrating when you're trying to track PSA.
Posted 8/4/2017 11:47 PM (GMT 0)
Dafight,

I had a similar tumor profile to you, but with significantly higher PSA. My combination of tumor and PSA put me in Unfavorable Intermediate Risk. In addition, I had urinary difficulties which led a couple of my physicians to assume prostatitis. Numerous antibiotic cycles didn't affect my PSA much and didn't help my symptoms. Based on my experience, I wouldn’t recommend putting time and effort into trying to improve the inflammation and causing delay to treating a 4+3 and double digit PSA.

Two months in advance of my SBRT treatments, my RO started me on lupron and casodex to slow down the cancer cells and improve the cancer control, and to potentially shrink the prostate a bit. Given your intermediate risk you may want to ask your RO about potential needs and benefits to you of a treatment cycle of androgen deprivation. I'm very happy with the cancer control outcome so far, and I’m more than a year past treatment.

Regarding urinary difficulties, most of my physicians felt my symptoms would not improve with SBRT, and to expect a notch or two of worsening. So I had realistic expectations following my treatment, and my urinary symptoms did worsen about eight months after completing treatment. Here on HW, some guys advised me that their difficulties improved after radiation, so there’s at least some chance!

Best of luck,
Jim
Posted 8/7/2017 3:58 PM (GMT 0)
Thanks all for your sharing information and experience here. I am in the process of selecting a SBRT treatment doctor/location/center. My questions are:

1. Since SBRT is completely controlled by computer, do the treatment doctor/RO expertise and skills play an important role in selecting the treatment center/location?
2. Is Cyberknife the most recommended SBRT?
3. Do you have any recommendations for a particular doctor/treatment center based on your own experience?

Looking forward to your suggestions and advice.
Posted 8/7/2017 4:31 PM (GMT 0)
1. Since SBRT is completely controlled by computer, do the treatment doctor/RO expertise and skills play an important role in selecting the treatment center/location?

The computer is just a dumb tool that doesn't know what to do on its own. The RO and physicist have to tell it what to do.

2. Is Cyberknife the most recommended SBRT?

It's the most popular brand. I was treated using Truebeam with Rapidarc, which is faster, but not necessarily better. Several brands are in use.

3. Do you have any recommendations for a particular doctor/treatment center based on your own experience?

Where are you?
Posted 8/7/2017 5:20 PM (GMT 0)
Thanks Tall Allen. I live in central TX. I can come to other areas for treatments if RO and physicists make big difference in treatment results. Because SBRT is only 5 sessions in 5 days, I would like to find a proven treatment center and doctors for the treatments. Of course, if there is excellent on close to home, it would be better.
Posted 8/7/2017 5:27 PM (GMT 0)
dafight,

I'm not sure if they do it there, but in Texas you can't go too far wrong with MD Anderson in Houston. I realize Texas is a big state, and "central Texas" might be a long way from Houston.....
Posted 8/7/2017 8:38 PM (GMT 0)
Timmerman at UTSouthwestern in Dallas has been doing SBRT for a long time.
Posted 8/8/2017 3:23 AM (GMT 0)
Hi dafight,

I live in Houston Tx and was recently diagnosed with Pca - see my signature. After a fair amount of learning I have decided I am most interested in pursuing SBRT treatment. In Houston it seems that only one location uses SBRT to treat Prostate Cancer and that is at St Lukes/Baylor - a Dr. Steven Carpenter heads the Radiation Section there and I met with him about a week ago. They have had the SBRT machine (Cyberknife) for a few years but he told me they only treated 30 prostate cancers cases and he had no records that he could share with me about successes and feedbacks from those patients. So, I decided to look elsewhere. And it seems as Tall Allen indicated that UT Southwestern in Dallas does a lot of work with SBRT treating prostate cancer and I got an appointment there this week. You can look at their website and they have published some great results also from the SBRT (Cyberknife) treatment. Note that M D Anderson in Houston had SBRT but does not use it to treat Prostate Cancer.
Posted 8/8/2017 4:13 AM (GMT 0)
Hi Busman, thanks for your reply. I checked UT southwestern as well after Tall Allen recommended. They do seem to have great expertise in SBRT, and many different advanced equipment including Cyberknife and TrueBeam. I am glad you have made an appointment with them. I will also try to make an appointment with them in the near future.
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