Questions for dr and decision criteria for high volume G6

I think my signature, created just now, will show the relevant data, except that I couldn't fit as much as I wanted into it.  My DRE has always been negative, and my prostate is sized "normally" for a 58 year old.  My dad was diagnosed with PCa at age 60, treated with seeds, and then on recurrence initiated a long-term course of Lupron, which didn't do much for his QOL.  He was on Lupron 15 years or so, and died last year (a couple of years after ceasing Lupron) of other causes at age 89.  The JHU reading of my biopsy noted a left side showing "small focus of atypical glands, suspicious for carcinoma...Separate high-grade prostatic intraepithelial neoplasia."

My urologist here told me the volume makes me intermediate risk, but I can't find how to differentiate between low level and high level intermediate.

My MSKCC nomogram notes a 66% probabililty of the cancer being contained.  Other risk index values are more favorable.

I've scheduled RALP with Dr. James Porter at Swedish in Seattle next month, and he comes highly recommended both on this board and by personal acquaintances.  He told me he suspects one nerve bundle must go, and that he should take out the local lymph nodes--two, as I recall--even though the nomogram suggests a 3% risk of spread to the nodes. I'm wondering, based on readings, a number of questions:

1)  Given my apparent risk of escape outside the capsule, how should I weigh SBRT or another RT vs surgery, open or robotic, by a highly skilled surgeon?

2)  Should I request an MRI and nerve mapping?

3)  Are there other aspects to low grade, high-volume Gleason 6 (which seems a little unusual) that I need to make a sound decision?

I certainly want to live a full life, but continence and erectile function are important to me. I'm in good shape, physically active, and have no current problems in those departments.

Thanks so much.  This is a remarkable group!  I've had one previous post but lurk quite a bit and admire the culture and ethos here.

JockMT: Welcomr to a place that will help. I am not sure why your Doc considers you an intermediate with only a G6. Normally G7 guys come under that description. G 3 + 4 = low or favorable intermediate while G 4 + 3 = upper intermediate. A multiparmetricMRI is a decision that you and your Docs must make. I can tell you from experience that a very good radiologist who teams up with your docs are in order.

Did I read that your are already scheduled for Ralp? If so, than the very best of luck and have confidence in your team. If you have not made up your mind than by all means make an appointment with Dr. Peter Grimm who is in Seattle.
Dr Grimm is one of the very best Brachy Theaapists in the business and has cure rates equal to and in some cases better that Ralp.

Also consider SBRT and HDR procedures because you have time with your stats.

Other gentlemen will no doubt give you more advice. Talk to as many guys asossible who have gone through this, continue your research, and remember that surgeons know a lot about RALP and ROs know a lot about RT. hear them all out and make a choice that determines the rest of your life. Best wishes and keep us posted,

browntrout and Tall Allen, thanks so much for your thoughts and those names. Those 5 100% cores scare the bejeepers out of me, whether G6 or not.

Tall Allen, I always look for your posts. Thanks for sharing your knowledge and research.

I've only seen the sentiment once or twice that you only get to have so much radiation in your life, and that that's one reason for surgery. I've been exposed to way too many ag chemicals and far too much sun, with the latter leading to some pretty aggressive surgeries. I don't know if that larger concern is a real issue or not.

Im not so sure that is necessarily high volume. They hit a bulls eye on a small tumour or 2…maybe! Just be cause it filled up 6 out 0f 7 very slender needles to the top does not make your big old prostate hi volume and you can tell your doc I said so. It certainly isn't intermediate risk and why are you at so hi a risk for escape? What indicates that?? nomograms? there right as much as thther'e wrong.Your psa has doubled in 8 years to a relatively low number. You need to talk to an AS expert…and run don't walk from this forum until you might need some help in 10 or 15 years. The responses you have received are to your fear not your condition. Yikes the panic goes on as OT rides the train. I don't think you will follow my advice, as all the prep you are doing, probably created , first your fear, a normal reaction for a newbie with the c word, then hook up with healing well as a lurker get more information with the group thinkers.. Now you have crossed the Rubicon{must save face internally..it really is good money after good and not after bad} You will get it treated soon, when the odds are very high you will never need treatment for 10-15 years …if then. Good luck with your journey. You should think hard on this post.

I will be leaving the forum for good and this will be my last post…watch me! Its to hard for me to see so many being they own worst enemy and getting support for doing so. I got too much on my plate also… So tah tah… I love ya all and the people I will remember most know who they are. So JockMt You take care of yourself and at the least get a second opinion from a AS spec. What do you have to lose and it could save you years of tx. anyway something had to break the camels back. Your thread just tied up all the data points for me. Please no responses from this adios. Aloha…Pono…Mana. If you ever get to Maui…check me out at the south shore Kihei… Im the tall good looking guy with a big smile and a pretty girl in the vicinity… Oh My wife knows and walks tall because of it. Damm How did I get so blessed ….. As the crowd looks at each other in bewilderment…scratch their heads and say: Who was that Masked Man So much fun…so much fun...

I had both HDR Brachytherapy and IMRT to the prostate area and pelvic lymph nodes. My docs said I could have additional radiation to the area and that other areas could be radiated if needed.

The amount of radiation also depends on the passage of time. My wife had radiation for breast cancer in 1996 and had a second cancer in the same breast in 2010. Again radiation was used after determining she had likely overcome the effects of the first radiation due to the passage of 14 years and the specifics of the first and second doses.

It appears there is no actual absolute as it all depends on the amount, the type, the locations, and the time. With prostate cancer, there is essentially no need for salvage radiation following radiation as the initial primary treatment, thus there really shouldn't be much concern over subsequent radiation. Men who use radiation as a primary treatment that require subsequent radiation due to recurrence are usually to treat mets outside the area that had been radiated.