MRI shows capsular irregularity/ "Likely" Extracapsular Extension

Hello, Thanks everyone for your previous replies which helped me narrow down my treatment options to HDR brachy and SBRT. I'm zeroing in on HDR because I had a good meeting with Dr. Demanes at UCLA who feels like I'm a lock for HDR monotherapy. He believes I have a 95% cure possibility on all the information I'm sharing with you below -- he also did an ultrasound and DRE. He has staged me at t2a although - he said he was being true to the DRE and not using the MRI which shows t2b.

Apologies for the extra detail but I'm in the home stretch of making a decision and will have to take the bull by the horns once I'm fully informed.

I have found a former resident of Dr. Demanes -- trained by Demanes in HDR. Demanes helped me find him. He is Dr. Michael Wong up in Santa Clara operating out of Kaiser -- my health care provider. He comes highly recommended by others and I had a great phone consult with him. This saves me a lot of money not having to go out of my health care system. Otherwise I'd be going with Demanes and I'd have none of these new questions.

Dr. Wong is quite adamant about adding an additional treatment for the reasons of my MRI results. He wants to do HDR in one session and follow with 3 weeks of beam -- I understand this adds toxicity and extra side effects. He says because I'm 50 years old that I should be extra sure. Then again, because I'm young I have to weigh in quality of life vs. side effects. There also seem to be plenty of studies that show that adding beam to brachy doesn't improve effectiveness. However, when looking at t3 treatment which I'll get at below, the beam or hormone does show (through a number of studies) more effectiveness in tandem with brachy or SBRT/Beam

The wrinkle, I think, is my MRI showing capsular irregularity (I've pasted all the findings at bottom) and a 4 out of 5 suspicion for extra capsular extension, or ECE being "likely." This has 3 out of 5 doctors that I've consulted with getting kind of nervous. As a result, it appears that all these doctors want to add some sort of extra treatment (I'm assuming this is for the possibility of T3, what I understand would be ECE, please correct me if I'm wrong). That said, the MRI is pasted below and there is capsular "irregularity". All doctors are agreeing that it could be nothing, or that if there is ECE it would be microscopic. I don't know what that means because cancer is a microscopic disease so if there's a microscopic extension it's still an extension right? And if there is an extension does it always mean its broken through? And if it's broken through what's that mean?

The concern with Dr. King, SBRT pioneer who I saw at UCLA for SBRT (and why he wants to add hormone treatment) is the presence of 3+ 4 in 4 cores (5 % 3+4 in 2 cores / 10% 3+4 in 2 cores) plus the fact I have 3+3 or greater in 6 out of 12 cores with 60-90 percent involvement. He also mentioned PNI on my pathology being another concern. He is concerned with the large quantity of cancer, which he admitted is an important factor, as well as, I'm thinking, possible extracapsular extension (I didn't ask King about whether ECE is another reason he is recommending hormones with SBRT).

Dr. Wong is concerned with ECE and making sure that, if there has been anything happening with the seminal vesicles, that the beam would help there. Dr. Goy out of Kaiser Hollywood is doing brachy seeds therapy and has been running his own studies for years showing that monotherapy is more effective than adding beam for both intermediate high risk and intermediate low risk.

You can understand why now I'm totally unsure which way to go - I can tell Wong to do HDR monotherapy. I can do SBRT and say no to the hormone. But when doctors are saying 5-10% more effectiveness with an additional treatment, it's hard to go against that judgement.

I appreciate any input or experience here -- I have pieced together that the MRI is good at reading my lymph nodes. These glands are clear, according to the report, but that maybe I can't be sure about the seminal vesicles being clear, even though the MRI says its highly unlikely there is seminal vesicle involvement:

location: right posterolateral peripheral apical midgland
Clock-face axial location: 7-9 o'clock
Cranio-caudal location: 30-60% of distance from apex to base
Longest diameter: 1.4 cm
Capsular involvement: adjacent capsule is irregular
T2 signal: oval moderately hypointense signal with circumscribed margins, 4/5 suspicion
Diffusion-weighted imaging: focal very markedly hyperintense high B-value DWI and markedly hypointense ADC, 699 square microns/second, 5/5 suspicion
Dynamic contrast-enhanced perfusion: focal early and intense enhancement with plateau, positive 3/5 suspicion
Enhancement kinetics: Ktrans 1.489, Kep 2.990, iAUC 6.01 O
Suspicion for extracapsular extension: 4 (1 = very low suspicion, 2 = unlikely, 3 = intermediate suspicion, 4 = likely, 5 = definite)
Suspicion for neurovascular bundle involvement: 2 (1 = none, 2 = possible, 3 = highly likely)
Suspicion for seminal vesicle invasion: 1 (1 = very low suspicion, 2 = unlikely, 3 = intermediate suspicion, 4 = likely, 5 = definite)
Overall level of suspicion: 5/5 (1=very low suspicion, 5=very highly suspicious, by UCLA and ACR-ESUR Pl-RADS v2)
Limited views of the pelvis reveal no enlarged lymph nodes.

Appreciate your help everyone!


Richard Morgan
Diagnosed 2/19/18
Gleason 3+3 majority --minority presence of 3+ 4 (5 % 3+4 in 2 cores / 10% 3+4 in 2 cores).
3+3 or greater in 6 out of 12 cores with 60-90 percent involvement. PNI showing on two cores.
PSA 5.1 . t2a (or t2b -- depending on which Dr's report you are reading)
First HDR treatment scheduled 7/25/18

Hello Richard...I'm not nearly knowledgable enough to have a good opinion, although I will say that you're talking to some good docs. So if I'm correctly reading your post, your choices are:

-HDR brachy mono (Demanes recommendation, but Wong will do it if you ask)
-HDR brachy plus IMRT (Wong recommendation)
-SBRT, but with a nice helping of ADT on the side (King)

I had the HDR/IMRT combo, but unlike the regimen that Wong is recommending I had five weeks IMRT. I also had four fractions of HDR brachy over two sessions a week apart. On face value, Wong's regimen seems like a dialed down version of what I had as a G9, but then again it's quite possible there are more factors here than just the number of sessions.

Hard call since you're balancing the line between being safe and over-treating. Hopefully, one of the smart guys here will be along soon...

Is Demanes still taking patients? He keeps retiring and coming back. He said he wanted to spend more time pole vaulting.

MRIs are notoriously bad at detecting EPE. There are lots of false positives - it's not much better than a coin toss, especially when it's microscopic. (They're pretty good at finding SVI, but you don't have that.) If it is microscopic there is little danger of growing into surrounding tissue, but that risk increases with size.

ADT radiosensitizes the cancer, which can be important if it is large and dense and not well supplied with blood vessels (this is called "hypoxic"). Another way of radiosensitizing it is to have a hyperthermia treatment right before your radiation.

5-10% is not a huge factor when the probability of a cure is about 85-90% anyway - but that is your call to make.

Thanks Allen, If you ask to meet with Demanes specifically he will meet with you and he will also still do a treatment if he is requested. Semi retirement, I guess. You can tell he's a guy that loves being there and is not really retired. That's funny about the pole vaulting. Come to think of it he is wiry like a track and field guy. Ha ha.

What did you mean about the risk increasing with size when referring to ECE -- are you talking about the size of the tumor (mine is 6 cores out of 12 / 60-90% cancerous) or the size of the extension (mine said to be microscopic if it's even there)?

I would also tend to think that a microscopic ECE that's an aggressive grade it might be of concern
(I do have some G4 in my biopsy)??

What have you found on your studies of SBRT in terms of its effectiveness on not just intermediate risk but also intermediate risk / unfavorable. Because really the big issue that keeps coming up is that
doctors can't seem to get off the fact that I'm borderline intermediate risk and
intermediate unfavorable (or high risk intermediate). They come to this conclusion due to the quantity of my cancer (60-90%) in those six cores (out of 12) and the fact that there is some 3+4 in 4 of 6 cores.Not to mention now the capsular irregularity and that ECE is likely.

I will end on the fact that Demanes (who has apparently won awards for his diagnostic capabilities) places me firmly in intermediate (as opposed to\ unfavorable intermediate). If I were going to have him do the treatment, I'd be doing HDR monotherapy and we wouldn't be having this conversation.

I'm still considering SBRT. But don't think I'd do the hormone based on this study -- have you seen it?
https://www.frontiersin.org/articles/10.3389/fonc.2014.00240/full

Thanks again for all of your time and support to date!

Best, Richard

Tall Allen said...
Is Demanes still taking patients? He keeps retiring and coming back. He said he wanted to spend more time pole vaulting.

MRIs are notoriously bad at detecting EPE. There are lots of false positives - it's not much better than a coin toss, especially when it's microscopic. (They're pretty good at finding SVI, but you don't have that.) If it is microscopic there is little danger of growing into surrounding tissue, but that risk increases with size.

ADT radiosensitizes the cancer, which can be important if it is large and dense and not well supplied with blood vessels (this is called "hypoxic"). Another way of radiosensitizing it is to have a hyperthermia treatment right before your radiation.

5-10% is not a huge factor when the probability of a cure is about 85-90% anyway - but that is your call to make.

Appreciate it Michael -- this is helpful. How were the SE of the HDR and beam combo ? Did you notice some ED issues over time from 2-5 years -- and if so, were they treatable with ED medication.
Curious as to why IMRT vs. EBRT.

And when did you do the hormone and for how long? That has its own set of side effects -- and how long after completing did you get back your regular self -- or did you not get your regular self back to some degree? Lastly, how did the triple play seem to feel overall once you got through it.

I guess my big choice here is dual therapy versus a monotherapy. Adding a second treatment is the thing that gets me concerned being that I'm 50 years old, healthy and fit and I'm not wanting to mess with my quality of life if I can avoid it.

For me, HDR monotherapy would be 2 sessions 2 weeks apart -- or 1 HDR session with the 3 weeks of EBRT (I think it's EBRT) to follow.

Did you do one treatment of HDR or multiple?

Thanks again!

Best, Richard

How are you doing now --

Michael_T said...
Hello Richard...I'm not nearly knowledgable enough to have a good opinion, although I will say that you're talking to some good docs. So if I'm correctly reading your post, your choices are:

-HDR brachy mono (Demanes recommendation, but Wong will do it if you ask)
-HDR brachy plus IMRT (Wong recommendation)
-SBRT, but with a nice helping of ADT on the side (King)

I had the HDR/IMRT combo, but unlike the regimen that Wong is recommending I had five weeks IMRT. I also had four fractions of HDR brachy over two sessions a week apart. On face value, Wong's regimen seems like a dialed down version of what I had as a G9, but then again it's quite possible there are more factors here than just the number of sessions.

Hard call since you're balancing the line between being safe and over-treating. Hopefully, one of the smart guys here will be along soon...

RM said...
What did you mean about the risk increasing with size when referring to ECE -- are you talking about the size of the tumor (mine is 6 cores out of 12 / 60-90% cancerous) or the size of the extension (mine said to be microscopic if it's even there)?

The size of the extension.

RM said...
What have you found on your studies of SBRT in terms of its effectiveness on not just intermediate risk but also intermediate risk / unfavorable.

As you might imagine, the incidence of higher risk types is lower than lower risk types, so it is difficult to get adequate sample size to draw conclusion. Breaking intermediate risk into favorable vs unfavorable intermediate risk has only gained traction in the least couple of years, so between the low incidence and the lack of subgroup analysis, there is little data. Alan Katz made a stab at it and so did a group in Philadelphia but sample sizes are way too small:
/www.frontiersin.org/articles/10.3389/fonc.2014.00312/full

Almost all studies (SBRT, HDRBT, ImRt, etc.) just lump all intermediate risk together, understanding that most such patients are in the favorable intermediate risk category.

No one has yet detected a benefit to ADT with ADT or HDRBT in unfavorable risk situations, but that doesn't mean there is no effect. Trials of this situation are only small and non-randomized. I know Dr King makes 9 months of ADT optional for high risk cancers, and Demanes often uses it too for high risk cases receiving brachy boost. Lacking info, it is good insurance. For unfavorable intermediate risk, I imagine the duration would be less.

If you feel you can't endure short-term ADT, other options are hyperthermia and simultaneous integrated boost to the dominant index lesion.

Margolis is the best. I was sad when he moved from UCLA to Weill Cornell.