New Member looking for help

My name is Keith Nice to meet all of you I have read quite few of your comments and I am grateful for your responses to people in need ! Here is my background

I am 59 excellent physical shape my PSA . 4.6 . My Father had prostate cancer 14 years ago had his prostrate removed and lived for many years after ( died of a series of strokes )

I had 12 biopsies done on 6/5/18 . 8 out of 12 showed cancer involvement

Here is Pathology Report

Right Base Needle Biopsy

1.)Adenocarcinoma of Prostrate Gleason Score of 7 . (3+4) . involving 40 % of tissue

comment: Perineural Invasion is identified (from what I can tell this is not good)

Right Mid Needle Biopsy

2.) .

Adenocarcinoma of Prostrate Gleason Score of 6 . (3+3) . involving 50 % of tissue

comment 2 out of 4 cores involved by Tumor

High Grade Prostatic Intraepithelial neoplasia (HGPIN) is also present . ??

Right Apex Needle Biopsy

3.)

Adenocarcinoma of Prostrate Gleason Score of 6 . (3+3) . involving 75 % of tissue

Left Base Needle Biopsy

4.)

Adenocarcinoma of Prostrate Gleason Score of 6 . (3+3) . involving less than 5 % of tissue

Left Mid

Adenocarcinoma of Prostrate Gleason Score of 6 . (3+3) . involving less than 5 % of tissue 2 out of 4 cores involved by Tumor

comment a rare atypical gland is seen in a third core . ??

Left Apex Needle Biopsy

6.)

Adenocarcinoma of Prostrate Gleason Score of 6 . (3+3) . involving 10 % of tissue

My questions are . What does this mean ? especially the comment Perinueral invasion is identified ? I am leaning towards Removing my Prostrate but do not have any leads for a qualified Surgeon in the NYC area or possibly Yale in New Haven Ct Anyone had good experience with surgeons in these areas ?

My next move is an MRI at a center that specializes in PC MRI's ??

Very Grateful for your help and input

Thank You . Keith

Keith,

Welcome, and sorry you have to be here.

The earlier advice to send your slides to Dr. Epstein is good.

I wouldn't get too alarmed over the finding of perineural invasion. From a Q&A by Dr. Epstein:
“Perineural invasion” means that cancer cells were seen surrounding or tracking along a nerve fiber within the prostate. When this is found on a biopsy, it means that there is a slightly higher chance that the cancer has spread along the nerves outside the prostate. Still, perineural invasion doesn’t necessarily mean that the cancer has spread outside the gland. Actually, other factors, such as the Gleason score and amount of cancer in the cores, are better indicators of cancer spread outside the gland. And even when tumor has microscopically spread out of the edge of the prostate, the majority of men are still cured.

It looks like you're headed toward treatment with that pathology report. What comes next is taking time to learn about the treatment options available to you, and talking with multiple doctors about them.

Keith: Welcome.
You have some time before you must treat. Sooner rather than later but certainly a few months will not be a problem. Take that time to talk to at least one Doc in each of the specialty fields. SBRT Doc knows SBRT but not surgery. Surgeon knows RP but does not know HDR and on it goes. Talk to the Doc who specializes in each field. Once you have the info and spent a little time with it then make a decision.

Remember that your decision will be for life so look long and hard at potential SE's and cure rates.

Roger

Keith,
You have one of the best places for cancer treatment in the country at Sloan Kettering in Manhattan. That was where I started. I first met with a surgeon and then a radiation doc. They work very closely as a team. On my second visit with the surgeon, he said the team felt the best treatment plan for me was radiation. My point is, you want the best, and you want a team that works together to find the best treatment plan for your particular condition. When you make an appointment with a doctor, try to have someone accompany you and bring a note pad and ask all the questions you can. At the top of the forum page, there is a sticky for the newly diagnosed. Give it a look. Feel free to ask all the questions you want here. There are a lot of folks here and they have been through every different scenario in this battle.
Good choice on sending the slides to Epstein.
Best of luck

Keith,

I was diagnosed at about the same age as you and also had a father who had prostate cancer.

I also recommend you check out the different procedures. While I eventually elected to go with HDR Brachytherapy for what I thought would be less likelihood of side effects, I had met with Dr. Tewari at Mt. Sinai and was sufficiently impressed with him that I would have gone with him if I had decided on surgery.

Good luck,

We have a similar diagnosis and what those above have said is great advice. I do suggest strongly that you learn about all your options and take your time. I took nearly 6 months to get treated and for me, that was the right amount of time. I needed to learn and get comfortable with my choice. And keep asking questions here and to your docs. I developed a binder with all my records, contacts, and a list of questions. Hang in there! Denis

Upgraded to GS 4+3 but no change in your unfavorable intermediate risk category. With 90% pattern 4 in one core, you are close to the border of "high risk." (If it were 95%, it would have been GS 4+4). I think you should discuss treating it that way, especially with the PNI and the high volume. That would make brachy boost (and not surgery) your best therapy.Michael Zelefsky would be my top choice.

I think you'll want to read this:

/pcnrv.blogspot.com/2018/03/brachy-boost-therapy-and-surgery-extend.html

Let me know if I can explain anything (I use a lot of abbreviations sometimes).

I could have told you Epstein would say that. You have to be VERY skeptical about doctors in one specialty offering opinions about other specialties that they have absolutely no knowledge of. Note "the questions NOT to ask" in the list below:

/pcnrv.blogspot.com/2017/12/questions-to-ask-and-not-ask-on-first.html

• Age should have no impact on your decision

• There are many local salvage options after radiation - surgery is not one of them. Moreover, if you read the link I gave you, among high risk patients, the 10 year rate of distant metastases is only 13% for brachy boost vs 46% for RP, even with many having salvage radiation. So you will likely never need salvage if you have brachy boost and you almost assuredly will if you have surgery first.

Here's a nomogram to give you a feel for whether surgery is likely to be successful for you:
/www.mskcc.org/nomograms/prostate/pre_op

You can compare that to the numbers for brachy boost for unfavorable intermediate risk:
/pcnrv.blogspot.com/2017/05/brachy-boost-therapy-should-be-reserved.html

If you don't mind a trip to a somewhat seedy neighborhood in Flushing, Alan Katz is well worth talking to (see links in my signature).

Tall Allen said...
I could have told you Epstein would say that. You have to be VERY skeptical about doctors in one specialty offering opinions about other specialties that they have absolutely no knowledge of. Note "the questions NOT to ask" in the list below:

TA, its surprising to me that someone with Dr Epstein's education, experience, and broad knowledge of prostate cancer and mainstream treatments and not being a surgeon, would be biased. When I talked with him and said I was having radiation he offered that he thought that was a mistake since my seminal vesicle was close to the tumor. He said surgery was the way to go. I ignored his advice, but have always wondered why he was so quick to dismiss radiation.

hrpufnstuf-

Walsh has dominated Johns Hopkins. They are very strong on surgery and medical oncology, but very weak at radiation oncology. Epstein regularly works with surgeons there, but since there is no pathology after radiation, he has little to add to that subject. Doctors are specialists and only have time to keep up with what it is there business to know about. It's on the patient if he gets misinformed by asking questions that the doctor would have no reason to know the answers to. I've met only one doctor who absolutely refuses to answer questions outside of his specialty. his standard answer is , "I can refer you to a specialist who can answer that for you."

Hello Sharpcut,
A bit late to this string, but wanted to weigh in as my husband sounds very similar to you. He is 55.

We started with the MRI up at Yale-New Haven. That came back PI RADS 4 (likely cancerous lesion). We then proceeded with the biopsy, which came back with multiple cores of Gleason 6 Adenoca. I also had his tissue samples sent to JH, where he was upgraded to Gleason 4+3 / 7, with Grade group 4+3 in 4 of 8 samples (The others were 3+4), placing him in the higher risk intermediate category. His cancer is mostly at the left apex and he also has perineural invasion on the left side.

My hubby is scheduled for Robotic prostatectomy on June 29th, with Dr. Laudone at MSK. If you have access to New York, you have access to some of the best in the field.

We had a last minute panic this week as we read and learned more about Brachytherapy (prostatecancerfree.org) online. We are feeling like we were steered right to surgery from the very beginning and honestly, I don't feel like we did our due diligence. We talked with some people about the Brachy and have decided to stay on our current path and not postpone the surgery. We are settled now and need to move forward as you can make yourself crazy if you keep second-guessing your decision.

HOWEVER, I would advise you to take your time. Do not rush. Check all of your options. Meet with Surgeons, a radiation oncologist, and a medical oncologist to learn firsthand about the options you have.
The most difficult thing for me was not having access to DATA on outcomes and side effects. It's frustrating but for now, that is something that is not available to laypersons.

Best of luck to you~

Sharp cut, good on ya for doing your due diligence.

And I have to say about Tewari, I think he’s great, even though I’m recurring, not his fault, it’s medicine. And I’ve always felt like he cares. But your comment about keeping up his nimbers is interesting. Because, here I am, at a critical juncture, and I called to set up my next appointment. They told me, nothing till September. Only after I got one of the NP’s on the phone and asked her to intervene, did I get an earlier appointment, but still not till August 3rd.
And here you are, a new patient, getting an appointment in July.

I’m glad you got in soon.
It does make me think maybe he’s more interested in getting more notches on his belt than helping guys like me make decisions when we recur. Also makes me think what the motivation is behind the advice to wait until I get to .2, or even .4, before acting on SRT.
I was not planning on taking that advice anyway, in the absence of some earth shattering evidence for doing so. But your comment certainly gives me pause.
To be clear, I’m not dissing his ability as a great surgeon, which I think he is. It’s just I wonder about the focus and priorities of a practice

I’m glad you got the early appointment and I’m glad you posted about it. It tells me a lot. 🤔🤔🤔