Biopsy report today

Hi Willie. Sorry the results weren't better.

It's always a good idea to have prostate biopsy slides sent for a 2nd option. You can ask the doc who did your biopsy to send them to Dr. J. Epstein at Johns Hopkins for review.

On one hand, perineural invasion identified at the time of biopsy (when it can be seen in the tiny amount of tissue sampled and inferred to be more established/extensive) is statistically correlated with a higher risk of adverse findings such as growth extending out from the prostate, e.g. through the capsule or into the seminal vesicles. Your imaging workup should provide clues to either back up or refute this.

On the other hand, more than 50% of Gleason G8 (4+4) disease is downgraded to G7 (3+4) or (4+3) based on men who go on to have surgery. This is because, by convention, the biopsy grade is that of the worst core found and the amount of pattern 3 can be correctly estimated only if the whole prostate can be sampled. (Since half your positive cores had pattern 3, my guess is that you may well be a G7.)

Of course both of the above remain more theoretical considerations if you opt for RT as your primary treatment, but they should be kept in mind.

You might discuss with your docs what the benefit would be of a having a genomics test (e.g. OncotypeDx or Decipher) to determine the genetic propensity of your cancer to metastasize. This could play a role in determining if and when ADT might be used as well as the prostate volume to irradiate (prostate bed or whole pelvis) with external RT. A Genomic testing is less reliable when done on biopsied tissue compared to a removed prostate, but it can be beneficial when the test result could influence the treatment choice or if RT has been chosen and there will be no RP tissue to test.

I'm sure other Forum Brothers will chime in with treatment recommendations. If you are considering surgery, ask any surgeons you interview, based on your lesion location and clinical/imaging workup, how likely it appears that one or both neurovascular bundles can be spared. Also ask their outcome statistics for continence and potency for their patients with similar disease status. Your choice of a highly experienced surgeon is the most important factor in ensuring the best possible outcome!

I home your imaging points to prostate-confined disease.

Djin

One of the challenges of this disease is the fact we have so many treatment options available to most men. Both surgery, radiation and combinations are considerations that offer a likely cure. Unfortunately each treatment option comes with side effects and some of those can significantly effect the quality of life. That’s why it so important to know exactly what you’re trying to treat. A second opinion on the slides can have a big impact on treatment options. Although the scans are a great idea and help sometimes they are not exactly definitive.

You’re in the right place to begin learning everything you can about this disease. Another good source of information would be prostatecancerfree.org. You can find a lot of good information regarding the success rate of various treatment options. Like most stuff in life you get out of it based on what you’re willing to put into it. This site and the one I pointed out do require a bit of a learning curve but if you’re willing they can return very valuable information and help you successfully treat this beast.

The more information you’re willing to share will also be helpful. Important things to know Is your PSA history, the size of you’re prostate etc. Those things can be shared in a signature and you can look at other signatures for ideas.

I hope you keep asking, learning and sharing. It’s the best way to get through this and we’ve all been where you are now.

wewillie, that's a lot of PSA for your age at this point. Where are you located?

A short soapbox speech for newbies and friends of newbies. Some researchers advocate that the upper end of the normal PSA range should be 3 and not 4. It is true that conditions other than PCa can raise your PSA, but you can have any of those conditions in addition to PCa. Listen to a uro who wants to investigate your high PSA with an MRI or a biopsy, especially if you have never had a biopsy. If you do have PCa, the higher your pre-treatment PSA, the greater the statistical risk for recurrence after treatment.

Most cases of PCa are low-grade, and some men can delay and even avoid treatment. But about 20-25% of cases are serious, and the most powerful weapon in the war against metastatic PCa is early diagnosis.

Djin (stepping off my soapbox)

Willie, Dr. Freeman is the expert in your area. With your high PSA you need start treatment sooner than later. Your prostate size is a little larger than normal unless you have other urinary issues (BPH) I would focus on a combination of therapy. One is often called the ‘Triple Play’. It combines radiation techniques with ADT. Although the ADT is not pleasant it is tolerated much better in men who are active, fit, and ready to fight this beast. The ADT will immediately take away your testosterone that feeds the PC and make any remaining cancer cells much more sensitive to the radiation. I’m sure Dr. Freeman is up to date on the latest SBRT.

Another option is seeking out second and third opinions from any the major centers of Cancer Excellence including Johns Hopkins, Cleveland Clinic, MD Anderson, Mayo, etc. All these places offer virtual visits which eliminates the travel and you’re talking with the very best practitioners in the world. Although I made a total of eight visits to Cleveland Clinic for my treatment all of my follow up has been virtually. Five of my eight visits (the actual treatment days) could have been combined with a week long stay using their facilities. I’m a firm believer in that seeking out the very best makes a big difference in outcome.