Gleason 8 - now what to do?

I just got a Gleason 8 diagnosis (mpMRI guided, 3 of 16 cores, left base mid and peripheral). The previous biopsy from January of this year only found PIN in 1 of 26 cores, also pmMRI guided. I assume it was there but missed the first time. Or could it have developed in the 9 months?

I’m 67 and otherwise healthy. I assume a radical prostatectomy is an option. There is some ECE but my urologist believes there is no lymph node or seminal vesicles spread. I have a CAT scan and bone scan scheduled.

I will speak to a radiation oncologist next week. I’m going to speak to a surgeon this Friday at another institution. I’m also being considered for two clinical trials: (1) 6mo of ADT before surgery followed by 4mo of ADT or (2) 3mo before 5 days of stereotactic radiation followed by 3mo of ADT.

This is all overwhelming. I’m not sure how to choose. My instinct is to do RP ASAP.
Any thoughts welcomed. I appreciate the response on the other threads.
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9/14/18 Gleason 8 PSA 7.2 T2a Age 67
mpMRI 7/18 PIRAD-5 size 90cc lesion 17x16mm posterolateral base peripheral zone with ECE; no change from mpMRI of 12/17
PSA hist 9/18 7.2; 7/18 7.2; 12/17 7.02; 11/17 6.2; 11/16 5.2
Biopsy hist Jan ’18 24 cores no PCa but 1 with PIN;
Sept ’18 16 cores 3 with Gleason 8 left base

Do not "rush " into any treatment. You have one shot to get this right. You want a cure with the least chance of permanent side effects. Please educate yourself to what's available

Sorry to meet you here. Tons of support here. First thing you might want to do is get your slides examined by Dr. Epstein. Ten more people after me will tell you that too. You don't need surgery (or any other treatment) next month. I remember the fear and anxiety at diagnosis. You are way ahead of me b/c you found this site earlier. Do take the time to read the posts on top. You have time to do a lot of research and a lot of research to do. Best of luck and keep posting.

Hi, Jim--

I'm also G8, so I know where you're coming from. It's a hard pill to swallow.

I agree with all the advice you've gotten already from forum members. The only thing I might tweak is that though you shouldn't rush and should explore all options thoroughly, don't drag your feet either. G8's no joke. It sounds like you're on top of things, though.

Instinct may be worth listening to when selecting among doctors or medical centers -- it's important you feel comfortable with the people who are caring for you -- but not when choosing the type of treatment, imo. Do your research. Think about what's most important to you in terms of outcomes, quality of life, etc., and which side effects concern you the most.

I'm not sure on what basis your urologist is betting there's no SVI or LN involvement. If it's just his gut feeling based on experience and he can't point you to a particular test result, I wouldn't put too much stock in it. Hopefully he's right, but who knows.

Feel free to contact me privately anytime if you wish. My email address is in my profile.

Best wishes,

SP.

Thanks everyone for the sane and calming advice. Even Gleason 8, while aggressive, is still slow growing enough to explore the options.

Thanks, Andrew, for the suggestions. Brachy may not be suitable for someone like me who has had two TURPs for BPH. Is that right? But SBRT is interesting. I talk to a RO next week at MSKCC. One of the things that worries me about radiation is that you can’t have it twice. If you have RP, you still keep radiation in reserve if the PCa comes back. Is that a concern?

SP, I believe they think there’s no SVI or LN from the location of the lesion on the MRI. Although the MRI suggests there might be ECE. The surgeon who did the 1st biopsy wrote there is “no clinical evidence of ECE or SVI.”

I got a second opinion on the 1st biopsy. It’s good to advice and thanks for the reminder.

There are plenty of salvage options if primary RT fails. If you've have brachy seed, you can follow up with beam radiation. If you've have beam you can do seeds.

There are also focal methods as AS said.

Surgeons always say that, event when it's not true.

Andrew

Jimmy, sorry you have to deal with this. I would recommend when you do your consults to bring up the TURPs especially to surgeons. Your T3MRI will show any scaring. Generally, this will make surgery are little more complicated and you will want a surgeon experienced with these. I consulted with the best PC surgeon in my state. He said he would not recommend surgery for me due to the bladder neck scarring. That left radiation, although I considered SBRT with or without Brac. (seeds) this was again not recommended for me by three radiation oncologists including one at MD Anderson's Proton Center. So I was left with hormone therapy and RT. In this article, the various RT is described https://www.hindawi.com/journals/bmri/2016/6829875/ In the recent March 2018 JAMA article a mega-review of the RT treatment was reported which found that survival rates were not improved using higher dose radiation, however, the higher does reduce reoccurrence according to the review.https://www.sciencedaily.com/releases/2018/03/180323121752.htm A higher number of lower dose patients had salvage surgeries or other interventions later. So I went with 44 at 79.2 rather than 39 at 70.2. Since this may increase my side effects I also did the SpaceOar and had a colonoscopy prior to treatment which started this week. My prep was done at the MD Anderson Proton Center that recommended a lot of the diagnostics, which I appreciated. I thought my two genetic tests also added some good information. I ended up doing the RT at my local cancer center just for my own convenience. It is nice and quiet. Appointments are at 10 AM and 15 minutes away. I would also recommend the new book by Mark Schultz The Key To Prostate Cancer. It is well written and covers a lot. Take your time. Good Luck!
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68 yrs., marathon runner, PSA .012, 8.12.18, 1.42 June 18, 2018 (Lupron 5.21.18 & 8.15.18), 12.7 May 2018, 13.7 Jan. 2018, 2.1 May 2012. SpaceOar 9.6.18, testosterone <.7, 8.15.18, Tot Mayo 19 ng .17 testosterone Free 6.18.18, Gleason 3+4=7 involving 15% of the right apex and 15% of the right mid, 3+3=6 prostate cancer involving 5% of the left base. Pathology interpretations by John Hopkins, UNM Cancer, and SF Path 3+4=7 or 4+3=7 MD Anderson Proton Center w/o %. T3 MRI 1.8 lesion left side 5P, Neg. Bone Scan. Prolaris test 3.5 consistent with intermediate and a PTEN test negative. Father PC age 78 RT & ADT now 93 yrs. Neurogenic bladder due to lumbar disk disease and recurrent bladder neck contracture with urinary retention man. 20 years doing catheterizations. TURP & scaring 2003, Finasteride 5 milligrams daily since 2002.

Post Edited (SantaZia) : 9/27/2018 6:04:57 AM (GMT-6)