My Strange Journey with Gleason 3 + 3 Prostate Cancer

I call it a strange journey because 5 years after brachytherapy my prostate is cancer free, at least that is what appears to be in a biopsy and MRI, but I have cancer in peri-prostatic mass emanating from the capsule.

In March of 2011 I was diagnosed with T1C prostate cancer with Gleason score of 3 + 3. Only 2 of the 12 core were cancerous, only only 15% and the other 5%. The urologist suggested seed implant and I had that on June 20, 2011.

Within 18 months from the seed implant my PSA dropped from pretreatment number of 3.4 to 0.1. During the next one year I had PSA bounce from 0.1 to 0.2 and back to 0.1. It was two and half years after the treatment. I was very happy with virtually no side effect. Then the PSA started climbing. In the next one and half year it went up from 0.1 to 0.4. Finally from July 2015 to July 2016 it jumped from 0.4 to 1.5.

I became very concerned and called my RO. He was out of the country. His nurse contacted him. The nurse then called me to tell me that the RO thinks it is PSA bounce and gave me a prescription for PSA test in January 2017 and a follow up appointment with the RO. I was little surprised, a bounce after 5 years?

Luckily, I had an annual appointment with my uro. His initial reaction was that I should have more frequent PSA test (I was having one a year). But he was surprised when he gave me a DRE. He felt a hard nodule. As a matter of I felt that his finger was against a hard object between my rectum and my prostate. So he ordered a biopsy.

The 12 needle biopsy inside the prostate found nothing. But he had 2 needles going into what he described as an isolated nodule. Cancer was found in this isolated nodule. But because of effects of radiation treatment no Gleaso score can be assigned The uro said he did discuss that the result with my RO and was told that the RO can do external radiation that might cure the cancer. Uro also told me that if I want he can start hormone treatment. The RO wanted an MRI and so an MRI was ordered.

The result of the MRI is what surprised me most. I quote part of it here:

"There are brachytherapy seed implants seen within the prostate parenchyma. Along the posterior rightward aspect of the mid gland and the base, there is a heterogeneous mass emanating from the peripheral zone measuring 24 mm anterior to posterior, 25 mm transverse, and approximately 22 mm superior to inferior. The superior aspect of the mass abuts the base of the right seminal vesicle and along the inferolateral aspect projects into the rectal prostate angle causing mass effect over the rectal wall. The lateral margin of the mass causes outward bulge of the levator and and the puborectals sling but does not extend through the muscle to the pelvic sidewall. Following gadolinium administration, there is early heterogeneous enhancement and the lesion is noted to restrict diffusion. Although the mass abuts the undersurface of the right seminal vesicle, do definite evidence of seminal vessel invasion is seen."

What surprised me is the large size of the mass 0.94 in x 0.98 in x 0.87 in and that it is pressing against the rectum.

Two days ago I saw an MO at Fox Chase Cancer Center. Her comment was it is a very unusual case. She is going to present it in her weekly meeting with radiation oncologists and urologists. She did also talk with an urologist and the urologist said it is possible to remove the mass surgically. Once the MO calls me after her meeting, I will probably have an appointment with an uro at the Cancer Center.

My strange situation tells me that we should not tell anybody to take Gleason 3 + 3 cancer lightly. An MRI should be done to make sure that there is no cancer (probably of higher grade) on the capsule or outside it, like it happened in my case.

Two years ago, just when my PSA was gradually creeping up, my RO told me that my cancer is cured and I don't have to see him anymore. I told him what does he mean by cured. Did he mean in remission?

I have an appointment with the RO on Monday. I want to hear what treatment he recommends. And I want to ask him why my rising PSA over the last two years did not ring a bell for him and the uro. Just imagine during this two years or more the cancerous mass outside the prostate was growing. Such a large mass does not grow overnight.

I will keep my treatment process posted. I am also curious to know whether anybody has similar case like mine.

Prostate cancer is a strange beast. Some of us are very lucky to be cancer free for many years after the initial treatment. In many posts we hear from men in their forties, fifties and sixties battling very courageously with vey aggressive cancers.

Very unusual kind of recurrence.

I don't think you will get any benefit from playing a blame game - least of all for yourself. It sounds like your doctors gave you standard of care.There is a reason biochemical recurrence is defined as nadir+2 -- it's because PSAs tend to bounce around. You showed nothing that would have raised a red flag for anyone, until the DRE. I assume they checked your seed placement a month after your brachytherapy and the seed distribution looked fine then (otherwise they would have re-seeded any cold spots). Neither does your case provide a model for how other cases ought to be handled. I'm sure the tumor board will be fascinated. They will probably write it up as an odd case study that doctors will read it and say "hmm."

What is important is what you will do about it. It is large, but it is a single isolated mass. So the question is whether it can be surgically removed easily (with clear margins), and, given its location, what the risks are. This is much more like a common tumor on the kidney or other organs rather than the typical multifocal prostate cancer. The question I would have for the RO is that given its size, and possible hypoxic environment within the tumor, is radiation likely to be effective. Also, does it make sense to shrink it with hormone therapy before surgery or radiation. If you decide on a surgical lumpectomy, it would seem to be important to take frozen sections until a clear margin is obtained.

I think Fox Chase has a lot of expertise that can help you.

Standard LDR brachy protocol is to do a CT about 30 days after seed placement to insure the placement of seeds was good. I assume that was done, right? Why would they do an MRI? What would it tell them that the CT did not?

Actually, for someone with your diagnosis, it would be almost unheard of to have a bone scan, and unless there is something like a lump growing into surrounding tissue, it would be very rare to have an MRI. Some surgeons and external beam ROs use them for planning studies (not diagnostics). mpMRIs (not ordinary ones) can sometimes show areas suspicious for high grade cancer, which is why they are used on follow-up biopsies by men on active surveillance - they are not a part of normal diagnostics for a man like you. Your doctor is correct that it probably would have showed nothing at the time, and would have made no difference in your treatment.