New: 55yo, 4+5=9, PSA 7.6->5.2, ECE SVE(?) what treatment ?

I have been reading this forum for a couple of weeks and finally decided to ask you for some advice. Here goes my brief story.

I am 55 yo, without other major health concerns or bad lifestyle habits. I have teenage kids and am happily married. My diet used to be low on simple carbs, mostly mediterranean, with daily consumption of cheese; I used to eat red meat about once a month or two. Height 6’0. Weight 220 pounds.

Day 1: PSA 7.6

Day 3: PSA 7.4; Free PSA 10%. Palpable cT0.
I switched to a veggies, legumes and seeds/nuts diet hoping to loose weight and lower my PSA.

Day 10: Multiparametric MRI has identified PI-RADS 4 in an area of about 15 mm located in the peripheral zone, left lobe, mid-apical sector, posterior segment. The report noted moderate probability of extracapsular extension 3/5 ESUR and some findings compatible with prostatitis. Seminal vesicles and differential ampullae present and symmetrical. The prostate size is 18 cc.

Day 27: PSA 6.3; Free PSA 10%. Palpable cT2.

Day 29: Biopsy
Right Side Area: 0/6 cylinders have anything of significance
Left Side Area: 3/6 cylinders have Gleason 4+5=9 with 20% occupying 10 mm
PI-RADS Area: 3/3 cylinders have Gleason 4+5=9 with 75% occupying 19 mm
Conclusion: very high risk, Grade 5

Day 50: PSA 5.5; Free PSA 9%. Weight 195 pounds.

Day 52: PET/CT 68Ga-PSMA-11
Heterogeneous distribution of 68Ga-PSMA-11 in the peripheral zone, the middle sector of BOTH lobes, with the largest uptake at the point of the extracapsular extension in the left lobe (SUVmax 5.7). There is infiltration of the left seminal vesicle (SUVmax 7.5). No other foci of lymph node uptake with overexpression of PSMA receptors compatible with pelvic or distant tumor infiltration are identified. T3bN0M0

The urologists propose Robotic-Assisted Laparoscopic Prostatectomy with Extended pelvic Lymph Node Dissection (ePLND). Also, they gently explain a possible necessity of a follow-up Multimodal Treatment that includes radiotherapy, ADT, etc. They point out that extracapsular extension sometimes can be removed without any positive margin and that the left seminal vesicle infiltration could be a false positive result of the recent biopsy (3 weeks prior to PET/CT 68Ga-PSMA-11).

The radiation oncologists point out that there is also an option to do iMRT or iGRT or VMAT with a temporary HDR brachytherapy boost and 18-24 months of hormones. They say that the extra capsular extension and the seminal vesicle infiltration are highly likely to be real based on PET PSMA. Some concerns about a temporary HDR brachytherapy: a small size prostate (18 cc) and a relative complexity to reach seminal vesicles with the brachy seeds.

So far, I have found only medical experts with a high degree of specialization in each treatment. I have not found anyone who would look at all the treatment options available given my case and help me to prioritize those treatments.

I appreciate any ideas, personal experiences, article references or anything that you feel would be useful in order to make my decision about the right treatment or a sequence of treatments.

Thanks, Mumbo! I guess I did not have enough time to make the story shorter ;)

Given Gleason 9, ECE and likely SVI, I suppose I am very likely to have positive margins. What bothers me with the Surgery-first approach is that I will let those bad cells grow quietly for another 3-6 months, while I am recovering after the surgery and preparing for the RT.


Also, I did see some opinions here that in similar situations at least some of the Gleason 9 and 10 Crew are against the double side effects from both Surgery and RT given a very likely Multimodal Treatment after the surgery. Perhaps, I have misunderstood the context of those discussions.

Dear Michael_T, your kind words mean so much for me and my wife since your diagnosis was similar to mine.
I am in the process of collecting radiologists' opinions about the scans. I did read a book by Marc Scholz that made me question the Surgery-first approach. I believe he is a part of the same Prostate Oncology Specialists in LA that you used. Do you think they would be open to a phone consultation?

quietleaf said...

Given Gleason 9, ECE and likely SVI, I suppose I am very likely to have positive margins. What bothers me with the Surgery-first approach is that I will let those bad cells grow quietly for another 3-6 months, while I am recovering after the surgery and preparing for the RT.

Also, I did see some opinions here that in similar situations at least some of the Gleason 9 and 10 Crew are against the double side effects from both Surgery and RT given a very likely Multimodal Treatment after the surgery. Perhaps, I have misunderstood the context of those discussions.

Comparing surgery and radiation is apple and oranges to some degree. Surgery is methodical and information is acquired along the way to define the next action(s) required. Post-op PSA testing is the yard stick, pass/fail for the most part. Radiation requires all assumptions at treatment time and it is usually a long time before you know that the treatment was effective since HT beats the PSA down with most men and is not worth measuring until you get months or years down the road. Just depends on how you like your anxiety served to you.

Other than PSA and Gleason score, the additional risk factors are EPE, surgical/positive margin, lymph nodes, and seminal vesicle invasion which you have a couple so far per the imaging, not including any genetic or genomic factors. The G9 diagnosis makes you more likely to have positive margin(s) if you had surgery but that is the nature of your high risk status. I might suggest you get genomic testing done on the biopsy cancer and see where those factors line up (Decipher et. al).

I think if I had your hand (mine was close enough), I might be thinking hard about the maximum radiation option "triple play" with the hope that you get everything possible by the multiple radiation modes and HT for a couple of years. Radiation might want to include the lymph nodes as well. Always keep in mind, neither surgery or radiation solves the problem of the PCa outside of the local treatment area which is what you hope the PSMA scan is correctly telling you.

I am a fan of getting all the info I can to help make a tough decision. Most of the items I mentioned can be taken care of fairly quickly if one can get the doctors to start the process rolling.

As you can see from my signature, I had a similar high risk and significant tumor volume diagnosis. Three different surgeons said no surgery as it would not be curable in my situation and they did not want to subject me to the risks and probable negative treatment side effects of combining surgery and subsequent radiation. The radiation treatment side effects are very different when there is no prostate to absorb 80-90% of the radiation.

Thus, I used HDR-BT, IMRT and three years of ADT (Lupron, Eligard, Casodex and Avodart). The pelvic lymph nodes were included in the IMRT. Now some twelve years later I continue to be both cancer free and negative treatment side effect free. Everything works just fine.

As to knowing more about the cancer with a surgical pathology versus a biopsy, with your risk factors it would probably be meaningless when it comes to your prognosis and treatment. You are very high risk and need to be aggressive with treatment, but also need to be mindful of the probable side effects of surgery. Hopefully you knock this out and can look forward to another 40 years of life.

I would suggest contacting Decipher in California and ask them how it would be accomplished in Europe. Also the cost would be something to discuss as it is typically covered by US insurance.

https://decipherbio.com/

My guess is they are trying to license companies in Europe given their success. The tough part is that a small sample of the biopsy cancer has to be sent to them since they are testing the cancer's characteristics.

The smaller the prostate the better the radiation target for both external beam and interstitial. That is why the best radiation oncologists insist on 4-8 weeks of ADT before radiation. Large prostates bring more of the bladder and rectum in play which you want to avoid in radiation for toxicity reasons. And with HDR-BT the seminal vesicles are a piece of cake. That is another reason it is so good.

My 1st dx was GS8 but a 2nd opinion from J Hopkins upgraded it to GS9. PSMA PET indicated involvement in one lymph node. My urologist still tried to "sell me" on RP but knowing I'd still require RT I skipped the RP (and those SE) and sought out proton radiation therapy and, after first denying it my insurance agreed on the appeal. Received 44 treatments (M-F) for 9 weeks, along with ADT. Eligard injections and later Zytiga oral added to the mix. In a couple weeks I'm getting my 6-month review since beginning treatment. So far, PSA is undetectable, Test is "5", Libido is "zero" (one of those unfortunate SE), and I am moderately fatigued, have lost much muscle mass and replaced it will a jelly-belly roll (adding 1 pants size), and there really is that "brain fog" that I've heard mentioned. No bladder or bowel SE from the proton RT. I'll be on ADT for another 18 months, so I expect the PSA to remain undetectable for at least that long. The book by Robert Marckini was instrumental in my choice of treatment, "You Can Beat Prostate Cancer". Worth the few bucks on Amazon.

If I were you age I would go to Mayo Clinic and see Dr Eugene Kwon and do what he says.

Quietleaf, Sorry for your tough diagnosis. As I was weighing treatment options I found a site (prostatecancerfree.org) that offered some comparison of treatment options by risk type. You can click on ‘high risk’ and find a very busy chart with many circles comparing many treatment options. Just unselect the majority and add back those you maybe interested in. The data points on the chart can be selected to reveal the source of data. I would caution you that some of the data maybe years old and it does take some personal evaluation. Best wishes for a cure. Terry

Thank you for all of the suggestions!
I have opted for a triple play of ADT + HDR Brachy + EBRT.
Some Brachy doctors expressed concern about the prostate size < 20 cc. I was told it requires a special skill to not undertreat the small prostate.