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Posted 2/17/2022 9:21 PM (GMT 0)
Got Path Labs from my Biopsy last Wednesday today. Follow up with URO (whom I like a lot) on 2/23.

Numbers in signature. My cousin who had GS8 PC 12 years ago suggested I seriously consider RP.

What say ye all?
Posted 2/17/2022 9:24 PM (GMT 0)
sorry you have to be here but welcome! see my signature for my feelings on surgery! if i read your numbers correctly there's a good chance surgery alone may not be curative. with that knowledge why would you risk the life-changing side effects?
Posted 2/17/2022 9:34 PM (GMT 0)
Hi BB and welcome. Sorry you have to be here but we will help as much as we can. With the number of positive cores and the cancer load you probably need treatment sooner rather than later even though our cancer is generally slow growing. Re the Gleason score, is it 4 + 3 or 3 + 4 or a combination? Obviously the 4 + 3 is worse.

Anyway, I have a few suggestions:

1. Send your biopsy slides to Dr. Epstein at Johns Hopkins. He is "the" expert on prostate pathology and it will be good to get the best info possible re your diagnosis. Info on how to do that is in the sticky thread for newly diagnosed patients that is located at the top of our forum threads.

2. Get yourself educated on our disease. You can start with the sticky thread and then start reading some great books. "Guide to Surviving Prostate Cancer" by Dr. Walsh and Dr. Scholz, "Invasion of the Prostate Snatchers" and "The Key to Prostate Cancer". Between these three you will have a pretty full look including some balance and nuance.

3. Start thinking about the treatment options. The good news and bad news is that we do have options. It's interesting that your cuz had RP a dozen years ago but things have dramatically improved in the radiation world in that interim. You probably want to visit doctors who specialize in HDR Brachytherapy, SBRT and a "triple play" of IMRT, seeds and ADT if it looks like your cancer has escaped. LDR Brachy alone is probably off the table based on your situation. Your urologist is likely to recommend surgery because...well...he is likely a surgeon.

Good luck. Ask any and all questions...our members have a great deal of knowledge and are willing to share -- and support.

Jim
Posted 2/17/2022 9:35 PM (GMT 0)

F8 said...
sorry you have to be here but welcome! see my signature for my feelings on surgery! if i read your numbers correctly there's a good chance surgery alone may not be curative. ?

Hi F8, what is it about my numbers that makes you think it'll take more than that? Still very much a newbie here.

Thanks!
Posted 2/17/2022 9:37 PM (GMT 0)

Tudpock18 said...
Re the Gleason score, is it 4 + 3 or 3 + 4 or a combination?

Combination of 3+4 and 4+3 in those 7 Cores
Posted 2/17/2022 9:42 PM (GMT 0)
You'll discover that the majority of respondents here are radiation centric. You'll have to assess your own circumstances and make your own choices. I wish you well.
Posted 2/17/2022 10:02 PM (GMT 0)
G4 can get problematic. When you enter the intermediate risk arena a significant number of surgeries fail and have to be salvaged by radiation. A combination that often induces the worst negative side effects that should be avoided. If you haven’t done so, I suggest you run some monograms to see some of the probabilities. The one at Memorial Sloan Kettering can be useful.

Rather than jump to a treatment conclusion based on your cousin’s good results I suggest you get educated about the treatment options and start interviewing different practitioners regarding their specific assessments. I saw three surgeons and three different radiation oncologists before deciding. It was the best thing I did.
Posted 2/18/2022 1:31 AM (GMT 0)

BBinSC said...

F8 said...
sorry you have to be here but welcome! see my signature for my feelings on surgery! if i read your numbers correctly there's a good chance surgery alone may not be curative. ?

Hi F8, what is it about my numbers that makes you think it'll take more than that? Still very much a newbie here.

Thanks!

########

hey BB -- psa 10 + high volume cancer. you are high risk and you need to act quickly! i'd strongly recommend seeing a radiation oncologist and getting a shot of lupron while setting up your treatment plan. good luck man. stick around and ask lots of questions!
Posted 2/18/2022 1:37 AM (GMT 0)
BB - there are basically three patterns of prostate cancer that define the Gleason score which typically presents the primary and secondary cell patterns noted. My layman’s description would be:

Pattern 3 - Cells that may be cancer when they grow up
Pattern 4 - Cells that are cancer
Pattern 5 - Special Forces organized cancer cells ready to do some damage

When you get a G7 (3+4) classification, the majority of cells observed in the sample are Pattern 3. When you get a G7 (4+3), the majority are Pattern 4. This is why the G7(4+3) is more concerning and of higher risk.

The surgery vs. radiation debate is endless and rarely will you find people arguing for surgery if something else will work. No one wants prostate cancer nor treatment but alas, here you are.

Surgery is the default treatment since that is what urologists do. It either makes sense to you or it doesn’t but in any case, study the options in depth, meet with a few different doctors to get their professional opinions and offerings, then make a decision and move on.

You are relatively young so surgery may not be as daunting as with the older folks and may affect your decision making. I think some of the newer radiation schemes (SBRT/cyberknife, HD Brachytherapy, hypofractionated IMRT) are “better” than the standard IMRT radiation or LD Brachytherapy seeding and may be perfectly suitable for your situation. Check them out with the doctors then see where your thinking goes.

Not sure about your local resources but lots in Atlanta if you need to find specialists. Good luck
Posted 2/18/2022 1:49 AM (GMT 0)
Welcome to our club that none of really wanted to join, but here we are.

I'd second the other thoughts...as you get more G4 cells in your samples, you're moving towards high risk disease, with increased risk of the little beasties getting out of the prostate and into other parts. Because of that, the chances of a good surgical CANCER result go down.

Where are you located? I'd agree that you need to find a well regarded regional cancer center that has a multitude of treatments available, and go there. A Urologist will recommend surgery 90% of the time--because they are surgeons, it's what they do. They won't know a lot about the radiation options--because that's not their thing. A good one will recommend radiation therapists if you ask.

Your first task, however, is education. Start looking at the different options. Ask questions here. Lots of lay person knowledge. Learn the vocabulary and the abbreviations. It's a lot to take in. Hang in there, the answers will come.
Posted 2/18/2022 1:53 AM (GMT 0)
Hi BB. A question for you. How many (negative) biopsies did you have before your last, positive one?

Your imaging will help your docs evaluate the chances of your cancer being prostate-confined and met-free. If your chances of coming through a RP with a "perfect" path outcome (pT2 plus no positive margins) are low, RT would be all the more attractive, IMO. If you do choose RP, remember that the choice of a highly experienced surgeon who has excellent outcome stats is the most important thing you can do to help ensure success.

Djin
Posted 2/18/2022 2:08 AM (GMT 0)

DjinTonic said...
Hi BB. A question for you. How many (negative) biopsies did you have before your last, positive one?

Djin

This was my first biopsy.
Posted 2/18/2022 2:11 AM (GMT 0)
For those who asked, I'm in Greenville SC and we have several major healthcare providers. My Primary care doc and Urologist are part of the Bon Secours system. They treated my dad back 15 years or so ago when he had PC. We also have Prisma, which due to past experiences I don't like. Not cancer related
Posted 2/18/2022 2:16 AM (GMT 0)

Mumbo said...


When you get a G7 (3+4) classification, the majority of cells observed in the sample are Pattern 3. When you get a G7 (4+3), the majority are Pattern 4. This is why the G7(4+3) is more concerning and of higher risk.

Here's the list of all the right side samples:

G: "PROSTATE, RIGHT BASE, BIOPSY": PROSTATIC ADENOCARCINOMA, GLEASON
SCORE
4 + 3 = 7 (GRADE GROUP 3) INVOLVING 75% OF BIOPSY. HIGH GRADE PROSTATIC
INTRAEPITHELIAL NEOPLASIA.

H: "PROSTATE, RIGHT MID, BIOPSY": PROSTATIC ADENOCARCINOMA, GLEASON
SCORE
4 + 3 = 7 (GRADE GROUP 3) INVOLVING 75% OF BIOPSY.

I: "PROSTATE, RIGHT APEX, BIOPSY": PROSTATIC ADENOCARCINOMA, GLEASON
SCORE
3 + 4 = 7 (GRADE GROUP 2) INVOLVING 70% OF BIOPSY.

J: "PROSTATE, RIGHT LATERAL BASE, BIOPSY": PROSTATIC ADENOCARCINOMA,
GLEASON SCORE 4 + 3 = 7 (GRADE GROUP 3) INVOLVING 95% OF BIOPSY.

K: "PROSTATE, RIGHT LATERAL MID, BIOPSY": PROSTATIC ADENOCARCINOMA,
GLEASON SCORE 4 + 3 = 7 (GRADE GROUP 3) INVOLVING 95% OF BIOPSY.

L: "PROSTATE, RIGHT LATERAL APEX, BIOPSY": PROSTATIC ADENOCARCINOMA,
GLEASON SCORE 3 + 4 = 7 (GRADE GROUP 2) INVOLVING 90% OF BIOPSY. HIGH
GRADE PROSTATIC INTRAEPITHELIAL NEOPLASIA.

M: "PROSTATE, ROI #1, BIOPSY": PROSTATIC ADENOCARCINOMA, GLEASON SCORE
4 + 3 = 7 (GRADE GROUP 3) INVOLVING 95% OF BIOPSY.

That's kinda ugly, ain't it?
Posted 2/18/2022 2:21 AM (GMT 0)
BB, was your PSA monitored during the 5 years between the 4.0 and 7.4?
Posted 2/18/2022 2:41 AM (GMT 0)
"K: "PROSTATE, RIGHT LATERAL MID, BIOPSY": PROSTATIC ADENOCARCINOMA,
GLEASON SCORE 4 + 3 = 7 (GRADE GROUP 3) INVOLVING 95% OF BIOPSY."

this is not good but you have a shot at beating it! your biopsy strongly suggests that cancer is out of the capsule. see a radiation oncologist and get lupron shot ASAP!

good luck man!
Posted 2/18/2022 2:43 AM (GMT 0)

DjinTonic said...
BB, was your PSA monitored during the 5 years between the 4.0 and 7.4?

No, it wasn't.
Posted 2/18/2022 2:51 AM (GMT 0)
What F8 said.
Posted 2/18/2022 3:19 AM (GMT 0)
BB - your biopsy pathology was not much different than mine, maybe a tad worse given the high percentages. My story is below which shows that it can be worse when the entire prostate is analyzed so keep that in mind.

Anyways, it is the real deal and you have prostate cancer thus time to keep things moving along as it does not get better while you wait. It is also great that PCa tends to be slow growing so you can analyze treatment options then get it taken care of after some study and learning. Start making your second opinion appointments after your Uro visit next week (ask for referrals and find your own) and get ‘er done.
Posted 2/18/2022 7:49 AM (GMT 0)
You are clearly high risk, as F8 stated. Based on the PSA at 10 plus a G7. What is most concerning to me is the extent of the G7 in many cores of 80-95%. That indicates that capsular escape is much more likely as the cancer is already at the edges. You could have escape that is not detected by any scan and could result in positive margins with surgery that would probably also require salvage radiation. Not a desired combination from a negative treatment side effect perspective.

I agree with F8 and Fauntleroy, as I was in a similar position at diagnosis. Get started on treatment with ADT and favor a combination of HDR brachytherapy and IMRT with coverage of the pelvic lymph nodes.
Posted 2/18/2022 12:44 PM (GMT 0)
Good morning BB-so sorry you are here. It would seem like time is of the essence. - psa of 10- the very high percentages of cancer load - 4+3 Gleason scores. This Bad Boy is serious. It is time to get a shot of ADT while you decide where you are going to get treated. Triple play radiation plan aligns as an appropriate battle plan to kick this mass of cancer surrounded by some prostate tissue. As most have written here, you need to ask questions and seek answers. You want the best outcome. That might not be available locally. Your particular best provider might be out of your region. I get it, no one likes to travel for treatment but everyone wants the best outcome. If I would have continued in “the neighborhood”, my outcome would not have been desired. I had salvage radiation at M.D. Anderson in Houston. My psa has been <.006 for seven years. It has been nearly 15 years since surgery. You can self refer on line for M. D. Anderson for consultation. Surgery is probably not the best option in your situation. I encourage you not to limit your treatment choices or institutions. Get the best treatment you can afford- time, effort, inconvenience, money. Big responsibility but it can and must be done.
Posted 2/18/2022 1:30 PM (GMT 0)
Hi, good to meet you.

My case was similar to yours - lumpy gland, PSA 11.1, G7(4+3). After biopsy it became urgent to deal with. I was informed that: if you start with surgery and that doesn't work, you can still try "salvage" radiation to try and effect a 'cure' while holding the beast at bay with Firmagon, Lupron, Eligard etc.. On the flip side, if you start with radiation you cannot then use surgery as a back-up option.

PSA in your blood has a half life of 2-3 days. If your PSA is 10 before surgery, 3 days after it will be 5, 6 days after surgery it will be 2.5 and so on. I got surgery, 2 weeks later PSA was 0.2 (bad number). Firmagon started immediately, then Lupron. 3 & 1/2 months after the RARP I began 40 rounds of salvage radiation (72 Grey). I was on leuprolide chemotherapy (injection every 6 months) for 2 & 1/2 years.

That didn't work, eventually. When my PSA rose to 3, I got put back on Eligard + Xtandi. Had a PET scan that found 3 metastatic lymph nodes. I got radiation to my pelvic lymph nodes and serious spot radiation treatment to the 3 hot ones (106 Grey). That finished last March. I quit Eligard this past Dec. PSA less than 0.1. Will be getting blood tests every 3 months for the next 2 years. With a bit of luck the PCa won't come back again. If it does I will get it zapped again if needed/possible. If it does return again, it may be "indolent".

Not telling you what to do here, just sharing my experience and reasoning as well as a bit of cheer-leading. There are a lot of alternatives available to us, we can use those to extend our healthy lives and perhaps to get rid of this nasty little inconvenience....fingers crossed. IMHO, as long as I have options, I have hope. smile

Having a team - Uro, MO, RO - is beneficial for balanced opinion.
Posted 2/18/2022 1:33 PM (GMT 0)
Thanks to everyone for their input. This was truly an eye opener. Had no idea it would be this pervasive. As far as local resources, where I live here in Greenville, SC (metro area 1MM+) we have multiple world class healthcare organizations and cancer centers.

So far have had no insurance issues and I'm now at the max out of pocket for the year. I'll let you all know how my URO appt goes.
Posted 2/18/2022 1:56 PM (GMT 0)
Important that you do not allow the uro to speak for the other specialties. The uro needs to stay in the specific lane he/she is board certified for. Getting an assessment for radiotherapy from an urologist is like allowing your electrician to give you plumbing advice…….and vice-versa. Only the board certified radiation oncologist can assess the specific type of radiotherapy they practice. You should expect to interview several different doctors regarding their specific specialty. Also be prepared that too many of all specialists generally underplay the significance of treatment induced negative side effects particularly regarding surgery.

I wouldn’t wait on the uro appointment to start the search for radiation oncologists in your area that practice external beam IMRT and those that practice High Dose Rate brachytherapy. A few minutes with Mr. Google can tell you a lot about the availability of different methods. I also suggest you run your dx numbers through one of the nomograms. They can provide another data point regarding the probability of outcomes for different treatment methods. One of the best is at Memorial Sloan Kettering Cancer Center. Go to www.mskcc.org and look for prostate cancer nomogram.
Posted 2/18/2022 1:57 PM (GMT 0)
If anyone can recommend a RO and or MO in the Greenville SC area, It would be appreciated.
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