Recceived Bx Results

Hi

I had a biopsy last week, and got the bad news this afternoon by phone, have follow up meeting to discuss the results in more detail next week.

Anyhow this has been a long drawn out episode for me, since in initial PSA test late June.

I had local blood draw for PSA and resulted in 12.4 done by lab at local hospital, Mid-Coast hospital.
Saw Urologist on Aug 15th and we repeated the test, also requesting free PSA. Since local hospital couldnt perform free PSA they sent to Mayo clinic. Results 8.1 and 5%free. DRE showed slight firmness on right apex. Scheduled biopsy for 10/11.

I was hoping maybe some prostitis because of PSA readings, since have had some discomfort down in perenium area.

From conversation this afternoonover phone, to inform me, I was told the staging is T2A, 12 core biopsy,6 cores had cancer less than 50% of cancer in them and all were Gleason 3+4, all on right side. I will ask for the individual % in each of the cores with cancer, I hope they didnt just report <50% when I would think the actual % would be available.

Also dont understand how it could be staged T2A when the 6 cores on right side lobe contained the cancer, maybe he grouped the Bx cores close since on the DRE he felt sight firmness on right side.

In any case I requested he send the slides to Dr Epstein at John Hopkins for 2nd opinion and I hope the Gleason 3+4 stays the same or goes down and hope the provide more detail on % in each core.

So I guess since I have gleason 7, by NCCN guidelines I am intermediate risk.

I plugged into the MSK nomogram and it gave 33% chance of organ confined and 66% chance of ECE, 7% chance of SVI and 6% for lymph nodes.

Looking at those results, I would be hesitant to go with surgery since 2/3 chance of ECE??

What if any further testing would be useful?

I see many get MRI's but do these test after bx results tell anything? can the MRI show ECE or lymph node involvement?


Do CT scan or bone scans tell anything with my grading? NCCN doesnt seem to think they are useful with Gleason 7 , and PSA <10


Any question I should ask at follow up meeting for the biopsy results?

will ask for pathology report done by Maine Medical Center.


Since I have had time to research treatments, I have asked local patient navigator for prostate cancer at Maine Medical Center (largest Hospital up here) for information.

They have the DaVinci RP, seems the surgeons of which my Urologist is one, each perform 40 or so a year, some have 600 under their belt, doing them since 2003.

on the RT side they have HD Brachy either as mono therapy , 4 fractions 38 gy in 3 days as mono therapy, overnight 2 evenings 3 days total or 2 fractions 19 gy 2 days 1 over night, with IMRT 45 gy, guess it depends on risk. I guess they stopped LDR Brachy and have gone HD. also use ADT depending on risk.

per the IMRT they have Varian equipped with Rapid Arc, and use cone beam CT prior to each treatment,

they use the 80gy 40 fractions 2 gy per fraction and slightly modified for lower risk 70 gy 28 fractions, 2.5 gy per fraction.

I will have to look into the SBRT in the area, I guess Beth Isreal in Boston offers it.

I will set up some consultations once I iron out what imaging tests are needed.

Sure I will have plenty of questions.

Have learned a lot just reading posts here.

One thing for sure, you are certainly doing your homework...Staging at this point is pure guesswork so don't worry about that too much..How old are you?

Turboz-

That's the kind of news no one wants to hear. I'm sorry you have to deal with it.

Turboz said...
Also don't understand how it could be staged T2A when the 6 cores on right side lobe contained the cancer, maybe he grouped the Bx cores close since on the DRE he felt sight firmness on right side.

Biopsy cores are not used to stage the cancer - only the DRE is used for that. He felt a small lump on the right side, so it's T2a.

I agree with you completely that no further scans of any kind are necessary right now. Multiparametric MRIs are only useful to guide a second biopsy if you were a candidate for active surveillance, which you are not. A normal MRI (T1 or T2) might be useful to a surgeon planning his surgery or a radiation oncologist planning his radiotherapy, but you can have that at their request after you make a treatment decision. MRIs are not at all very good at finding small EPE - not much better than a coin toss. I think it's a reasonable assumption that you probably have some.

I also agree with you that a bone scan isn't likely to show anything with your low PSA and grade. However, given the high involvement on the right, and the lump, a pelvic CT may be a good idea to check if any lymph nodes seem to be enlarged.

I think the HDR brachy monotherapy is a great idea if they have a good amount of experience with it.

Irving Kaplan at Beth Israel has a good rep for SBRT.

I can't think of a single reason to do 80 fractions of IMRT. In fact, the Assoc of Radiation Oncologists (ASTRO) will soon issue guidelines recommending hypofractionation for all risk categories.

LN involvement (N1) puts one into a much higher risk category. It's very unlikely with GS 3+4 and a low PSA - I only mention it because you seem to have a lot of it and there's a lump. There are some indicators that whole pelvic treatment in that case might be beneficial, but it's far from proven. There are less than a handful of doctors using SBRT for that - a few do it as a monotherapy, a few as a boost to the prostate with whole pelvic IMRT. Brachy boost would be a more conventional way of doing it. But cross that bridge if you come to it.

I would think that something in the 75-100 range would be enough to get up to speed for HDR brachy monotherapy. Ask about outcomes and toxicity results.

Sorry for your news. My doc at Yale is doing a second MRI to see if any changes in 4 months to determine the urgency of treatment. We don't expect changes and will then treat in May if there are changes sooner. I wish you well. Denis

Halbert

I live 20 minutes from Portland in Brunswick.

My game plan is to do the follow up on the biopsy results, get the results from hopkins on the pathology. See what other tests i need.

Then schedule the consults with a surgeon here, a RO here who does the HDR Brachy, and set something up in Boston for SBRT.

I think that will cover my bases.

QUestion on HDR Brachy(Will have to research this), is there any info on salvage, my thinking being you could have more HDR brachy since in theory your other organs local havent been exposed to as much radiation unlike conventional EBRT in any mode.

Turboz,
You my friend have answered TA's question on the earlier thread "Is Patient Empowerment a Myth?". Your doing a great job on the empowerment side. Whatever your choice of treatment is I have no doubt your choice will be one without regret. Keep posting and good luck.

Just want to offer another welcome to our club. And as others have noted kudos on your pre-treatment homework. I've had excellent treatment over the years at my regional medical center (UMass Medical Center), as you probably can get in Portland other than for newer or less widely-used treatments (e.g., SBRT). I've transferred my care to Dana Farber since my recent recurrence. I'm a bit closer to Boston than you are, but it is worth the trip and the traffic if you are looking at treatments not available locally or not offered by specialists with similar high-caseload experience. Best of luck sorting through your treatment options and coming to a decision on what to do next.
Jim

Had the meeting this morning with the Urologist per my biopsy results.

He confirmed my staging, gave me the pathology report, went over the report.

He answered most of my questions but some still have a couple questions


My PSA is 8.1, stage cT2a, All Gleason 3+4 RA 50% Inv 85%GL 3,15%GL 4 ;Rmid 20%InV 75%GL 3 25% GL4; R Apex 30% Inv 90% GL3 10% Gl4, 6/12 cores pos, no perineural invasion in any of the cores.

The MSK nomogram gave me a prediction of 33% organ confined and 66% EPE, 6% + Lymph nodes, 7% for the SVI+. He showed me the Johns Hopkins which gave me 58% organ confined, EPE 36%, 4% SVI+, 2% for Lymph nodes. he said the MSK always is higher and result probably in between.

Why the difference?


I may also be naïve, but I asked him if you have EPE, cancer thru the capsule, how far into the surrounding tissue does the cancer grow? I was asking either how much wider in mm (1mm -10mm) would a surgeon have to cut or how much wider would a Radiation Oncologist add to the volume outside the prostate to treat?

He kind of didn't understand why I was asking. I just want to get a feel for EPE and how it impacts decision for treatment.

He said it is microscopic and is often difficult to see and measure.


If the DRE shows rock hard lobe, he would suspect gross ECE and plan the surgery accordingly, probably not spare the nerve on that side and cut wide. I didn't get hung up on this, I will ask at my consult for surgery.

I took this to mean my right side would be a maybe for nerve sparing. I feel for these surgeons, sounds like they have to make a judgement call before or during the surgery to decide. Guess if they tell you up front one can decide if they want surgery.


He said with my PSA, Gleason 3+4 I was Intermediate Risk per NCCN and I need to have treatment. He said I didn't need any bone scans or CT/MRI for clinical since NCCN guildlines indicate very low chance of metastasis and lymph nodes.

He said my cancer probably is multifocal, I asked if there might be a more aggressive cancer either in the anterior portion of the gland or in the transition area. He said they tend not to see it and it would unlikely make a difference in terms of treatment.

We did talk a little about the surgical aspect.

I asked to compare the clinical staging/biopsy results to post pathology, he said they find 25-30% either more cancer or different Gleason score, finds maybe 25% with more cancer than suspected and 5% with less.

I asked about the lymph nodes, he said if the nomogram predicts 2% likelihood of involvement they remove a couple to check.

I asked what do the Radiation Oncologist do, ie do they treat the lymph nodes, he said they probably depends on the Gleason Score and risk class and to ask that question during the consult.

Anyone know what guidelines RO's use from nomograms as far as lymph node treatment if needed?

Per the seminal vessels, surgeons remove and he said the RO's generally treat in the plan, but if they suspect gross involvement they may fine tune. From my DRE he didn't suspect large involvement if any.

I asked about HDR Brachy and pubic arch and need to have image to determine if it would be an option or the anatomy would preclude that option. he said I have an avg 32cc and in all probability it wouldn't be a issue, he said people with large prostates might have an anatomy which could be an issue but ask the RO.


He indicated he has about 250 RALP's . The practice he is with, tracks the outcomes, and he claims that all the surgeons in the group have basically the same results. he indicated 16% Pos margin rate and 85 on the urinary incontinence rate. he didn't mention the sexual side effects or how they rate on that front. I asked about how many people he operated on required salvage radiation, he didn't know off the top of his head but stated you have to track the pos margin rate, because you don't know the patient mix, one surgeon could have great results but treating patient with lower grade less involved cancer. He said they dont reveal the
survival outcomes if I understood him correctly.

I told him I would prefer to set up a consultation for surgery with another surgeon who has been with MMC since they started the robot program in 2003, guessing this person has many more procedures. although I am leaning toward radiation treatment.


He said the JH nomogram indicated for someone with my stage/ gleason, PSA, I had 93% BCF from their nomogram at 5yrs, vs 78% from MSK? I couldn't find the means to calculate this at Hopkins site?


In the general discussion he said the most technically challenging part was the surgical plane at the bladder neck and likelihood of pos margin is possibility there.

I asked him how long to go thru the rest of the process to get the consultations completed and choose. He indicated you want to get that done and treatment done in 6 months or less, so he wasn't pushing for an immediate decisions, told me to do the consultations and think about it over the next few months and get something scheduled.

Once I get the 2nd opinion on my slides, I will set up the consultations.

I did find out from the Clinical navigator they have been doing HDR Brachy either as mono therapy or with IMRT as a boost since 2005. Sounds like they have treated 200 or so patients, about 2 per month. Will discuss with the RO when I talk to him.

I would echo that sounds like a very good post-biopsy consult. Of course, a lot of that was because of how well prepared you were. I went into mine like a blank slate.