Epstein path report finally recieved

Hi everyone

I have recieved my path report 2opinion from Dr epstien at john hopkins . His opinion is i have gleason 7 in several core samples. All but one core is 3+4 with a single core 4+3. A few cores of gleason 6.

9 of 12 cores have cancer and i was diagnosed at stage T2c .

I am looking for 1st treatment cure . Is it resonable to think surgery could cure me.
Does the volume of cancer Put me at hifhet risk of bcr . My research to date show better results of no bcr with seeds and EBRT vs surgery. I want to minimize side effects but want to do what it take to get cured. If cancer is OC what is rate of bcr with surgery vs radiation. Also if i choose seeds and eBRt as intial treatment i avoid the surgery side effects if more treatment is required post surgery. Is cuberknife or prton therapy an option with seeds instead of EBRT ?

Newbie,

OK, with your G7, and one core 4+3, then you are definitely intermediate risk, so treatment is in your future. The good news is, that any of the mainline treatments can be curative. My own case in point: I was G6 in 3 cores, all on one side at diagnosis--and G7 in all 4 quadrants after surgery. I'm coming up on the 5 year mark on Feb 17, and all indications are that I can call myself cured.

Surgery could cure you. Any of the standard radiation protocols could cure you (SBRT, LDR, HDR, EBRT). It comes down to your personal assessment of the risk profiles, how much time you want to spend getting treated and recuperating, where you are going to get treated--and how location (both you and the facility) affects things.

There will be the forever debate in here about side effects (immediate or potentially long term), how severe and how common they are, etc. The important thing is to talk to the treatment teams where you are, and decide from there.

Proton is new enough that it's track record with PCa is not well defined. Some will say (that aren't the business of selling it) that it's really no better than the more established treatments for prostate cancer.

The key points, IMO, to weigh are:
1. How important is it for you to know for certain what your pathology is? Surgery is the only way to actually KNOW that.
2. How easy or hard is it for you to get to the treatment site for multiple visits? Radiation in all flavors requires more back and forth to the treatment location that Surgery does.
3. What is your personal risk assessment of the potential side effects?
4. What is your comfort level with your treatment team? If you have good rapport with the team, then it does make a difference.

Good luck--now the time for digging into the options really begins. Get informed, ask questions--take notes! And then, when you feel you've done your due diligence, make the decision and be at peace.

Newbie,
I m glad you’re doing your home work. Please keep researching your options. If you’ve not already found it www.prostatecancerfree.org is another excellent site for information on comparing treatment success. Some treatments like SBRT and proton are relatively new and it’s a little harder to find information. Every treatment will have side effects. Since I was low risk and all the treatments offered had a high success percentage I focused on side effects. Once I determined the best fit for me I focused on finding the very best practitioner and team to do it. In total I was able to complete treatment in seven day trips to Cleveland Clinic for SBRT. All of my follow up is by virtual visit. Good luck on finding the best fit for your situation.

I just ran the MKSCC nomograms based on your signature and Epstein by and found using RP surgery and no radiation or hormone therapy:

Survival at 10 years....99%. At 15 years.....98%.

Progression free probability. At 5 years...41%. At 10 years...27%

Organ confined probability.....13%

Extra-capsular Extension........84%

Lymph Node involvement........32%

Seminal Vesicles Invasion........34%

Based on these probabilities most men, similar to you your diagnosis, treated at this leading institute were not cured by surgery alone. These probabilities should mean you would statistically expect to pursue SRT in the near future. This would indicate to you to avoid the surgery and use the combination of brachytherapy (either seeds or HDR) and EBRT (IMRT/IGRT).

The caveat is that a nomogram will not predict your situation. Neither can any surgeon. Pursue some of the other nomograms from JH and others to measure the consistency. You have said you want to avoid the uncertainty of surgical and the high probably or negative treatment side effects. This would point your toward the use of radiation therapy as the primary initial treatment.

Given that about one third of diagnosis are upgraded when one has a full gland pathology that adds risk to the unfavorable-intermediate. about a third will be upgraded to high risk and that means surgery most often fails. I was a lot like you, a whole lot of G4. That is the kicker.

For you one pathologist found a teeny bit of 4+4 for G8. The best pathologist found a good amount of 3+4 and 4+3 for a majority of G7. I’m not sure I see a real difference. A whole gland pathology may show G8 after all, but it is certainly not going to show a G6.

My urologist says to treat to the worst G score. His many years of experience have shown him that the reality is most often worse than the biopsy. That means to evaluate the amount of the G4 and determine whether you want to go for a cure based on percentages, which would point to the combination of brachytherapy and external beam. This would cover the areas surgery can not reach and could include the lymph nodes if you are concerned. Or you could take the risk that you will be cured by surgery and are fine with the surgical side effects and SRT in addition, if the dice roll the wrong way, as they often do at your risk level. This approach would significantly would downplay the nomogram and bet you are in the small minority that surgery alone cured. To me, one seems more of a sure thing and the other is more of a gamble, based on the nomograms and studies that we are all aware of.

If you are not ruling out surgery, i would wait for the results of imaging and not judge by the nomograms alone. Your chances for any given adverse feature, e.g. seminal vesicle invasion, are not the same if imaging suggests SVI+ and if it suggests SVI-.

Djin

I have a cousin with the same pathology.

He is doing IMRT with a high dose brachytherapy boost.

That combo, with or without ADT, appears to have very good non-recurrence results compared to other treatments.

No

It's impossible to say what the odds are that surgery alone could cure you, although JNF's nomogram info suggests that there's a decent chance that it wouldn't. So to me what this comes down to is are you okay with SRT in the event that surgery doesn't do the trick?

I faced the same question as you, although as a G9 it was less likely that surgery alone wouldn't work for me, so I went with the brachy + IMRT treatment. But one thing I've learned here over the years is that everyone has different criteria for evaluating their decisions. (To that point, I'm also one who didn't see the value in getting a full path report from surgery, but I know it's important to some guys.)

Michael_T said...
It's impossible to say what the odds are that surgery alone could cure you, although JNF's nomogram info suggests that there's a decent chance that it wouldn't. So to me what this comes down to is are you okay with SRT in the event that surgery doesn't do the trick?

I faced the same question as you, although as a G9 it was less likely that surgery alone wouldn't work for me, so I went with the brachy + IMRT treatment. But one thing I've learned here over the years is that everyone has different criteria for evaluating their decisions. (To that point, I'm also one who didn't see the value in getting a full path report from surgery, but I know it's important to some guys.)

Perhaps the standard of care has changed since your RP, Michael, but for my RP results, G9 (4+5) with no persistent PSA, whether or not adjuvant therapy would be advised (as per NCNN guidelines) was totally dependent on whether or not there was one or more major adverse findings in my path report. The path report served its purpose, and now my PSA will be the factor determining if savage therapy is in my future.

Chatting with my uro/surgeon at a recent visit, as I like to do to increase my PCa knowledge, I asked if a finding of lymphovascular invasion alone in my report would have been enough to make ART advisable in my case, and he said yes. That's an important report.

Djin

If the MRI shows lesion(s) and location then that is pretty good data to work from. If it doesn’t, it does not mean as much since a lesion can be there but not detectable by MRI. A MRI can also detect a lesion and miss another lesion so there is not a 100% diagnosis from a MRI. It just becomes another piece of data that helps make decisions.

If a MRI sees something, the radiologist can see or infer that it may have escaped the gland. The urologist can guess whether a nerve can be spared based on lesion location but will not know for sure until they are actually in there and can observe the conditions. Only the pathologist can actually tell if a lesion escaped the removed prostate by microscopic examination since it is not visible in many cases.