gleason 7 (4+3) post RP, advice needed

Hi everyone, first off i would like to say thank you for all of the valuable information on this site as i have been a lurker for quite some time. Unfortunately, the time has come to start asking question instead of just searching for answers. sorry for the long post

My father (58 years old) was diagnosed with pca in Jan 2016. Biopsy revealed 7 positive cores, 5 gleason 8 on the right and 2 gleason 6 on the left. Biopsy was prompted by a rise in psa from 3.5 to 5.2 within 8 months. following diagnosis he had a CT and Bone scan which were both negative and an MRI which did not show any extraprostatic extension. Given this information, he chose to have surgery which was done in march. Unfortunately he had some adverse pathology, Gleason was now 4+3, focal extraprostatic extension at the left apex and 3 focal positive margins. no SV or LN involvement.

He has had relatively good recovery from surgery and is now about 95% continent.

His first psa done at 10 weeks came back at .22 subsequent test 3 weeks later was .28 and then .32. The urologist put him on casodex 50mg to halt progression while we got the ball rolling with Radiation Oncologists.

We chose to see Dr Michael Zelefsky at Memorial Sloan Kettering. Prior to our first consultation with him they requested an MRI W/WO contrast. those results came back as follows :

No suspicious findings within the prostatectomy bed.
Nonenhancing markedly low T2 signal nodularity measuring 0.7 cm probably
representing scar tissue.

PELVIC NODES: No adenopathy.

BONES: No suspicious bone lesion.

OTHER: Nonspecific subcentimeter low T1
iliac bone lesion, at the level of the left SI joint.

Given these results Dr Zelefsky felt that due to the positive margins that the site of the residual psa was likely still in the prostate bed or possibly in a lymph node. The plan was 40 treatments of IMRT a 72 Gry to the prostate bed and lymph nodes and likely hormone therapy (he advised us to stop taking the casodex for now)

In regards to the non specific bone lesion, he felt that it was likely nothing to worry about, but to be safe requested a full body MRI. There was also some discussion about possibly enrolling him in a new PSMA scan being conducted at MSKCC.

My dad had the full body MRI done the following day (9 days after the mri for the pelvis) and those results are not as encouraging.. everything unremarkable except for that left iliac bone lesion..

"Left posterior iliac lesion with imaging features probably
representing metastasis. Degenerative change is a possibility as well."

This radiologist seems to think that the lesion is a met while the initial radiologist termed it as "non specific and not suspicious"

We have an appointment with Dr Zelefsky on Thursday to discuss this latest scan and next possible steps.

I am scared, confused and quite honestly - emotionally drained. I cant even begin to imagine how he is feeling/ handling all of this. I am assuming that the next step is a biopsy of the bone lesion?

any advice or input would be helpful. Thank you in advance!

Is 0.7 cm too small to biopsy? This is particularly troubling because he was on Casodex, which would have shrunk the lesion. If it's too small to biopsy, can MSK still do that PET scan?

If it's a met, I think Howard Scher is an excellent medical oncologist.

- Allen

Elena, welcome to our club...and your father as well. If he's consulting with Zelefsky and the team at MSK, that's as good at it gets, anywhere on the planet. He has every chance of living long enough to die of something else, a long time in the future.

Breathe deeply, he's in good hands.

No - if Zelefsky isn't worried, I'm certainly not. I misread that - I thought that was the size of the iliac lesion, but re-reading, I see no mention of its size. So my question is the same - How big is the iliac lesion, and can they biopsy the iliac lesion? How long was he taking Casodex before the MRI that found it? Did it seem to shrink between the time of the bone scan and the subsequent MRI?

If he has to give up on curative therapy, it's really important to know for sure that it's a met.


- Allen

Elana, you're asking the right questions, and the team at MSK has the experience to give specific answers about your father's case. Let us know what they say after the next visit.