Determining what to do after AS

At a crossroad I think.

Although the doctors I saw suggested I should get treated instead of doing AS I chose to go the AS route to start. I have been doing AS for the past 2 years. I have been able to keep my PSA down from a higher point I had just before the 1st biopsy. (I was careful to change my diet and increased my exercise and have benefited greatly there. ) With my last MRI imaging my doctor has suggested to forego the biopsy and actually start a treatment option. Looking for input and thoughts. (surgery VS. combo brachy/IMRT were the main options I was suggested to choose from when I first started this journey)

My last MRI was as follows:

MRI shows multiple lesions consistent with significant prostate cancer as well as suspicion of extension beyond the prostate. Dr. recommends treatment versus repeat biopsy.

Study Result
Narrative
MRI PROSTATE WWO;

CLINICAL INFORMATION: Reason: prostate cancer on active surveillance History: above

TECHNIQUE: Multiplanar, multisequence MRI of the prostate. Pre and post contrast sequences
were obtained following intravenous administration of 17 mL of Dotarem.; Endorectal coil
was used.

COMPARISON: MR prostate with and without contrast on 9/4/2018

FINDINGS:

PELVIS:

PROSTATE:

Prostate Size: 4.3 x 2.8 x 3.1 cm

Peripheral Zone: Heterogeneous intermediate low T2 signal throughout the peripheral zone,
likely sequela of previous prostatitis.

There is a T2 hypointense PI-RADS 3 lesion in the left apex that measures 0.6 x 0.4 cm
without corresponding low ADC signal, possibly corresponding to the previously seen
PI-RADS 4 lesion. On today's examination, this lesion appears as mild capsular thickening
and may be external to the prostate gland (image 15, series 501).

There is a PI-RADS 5 lesion in the right mid gland with extension to the base measuring
2.3 x 1.1 x 0.5 cm. There is broad interface with the capsule as well as focal capsular
discontinuity with ill-defined T2 hypointense signal extending beyond the capsule that is
suspicious for extracapsular extension, particularly at the level of the neurovascular
bundle (image 11, series 701).

There is a PI-RADS 4 lesion at the midline apex of the gland that measures 0.6 x 0.7 cm
and demonstrates low T2 and ADC signal with associated hypervascularity.

Central Gland: BPH with circumscribed nodules.

Seminal Vesicles: Mildly fluid distended

Extracapsular Extension: Possible extracapsular extension associated with a right-sided
mid gland lesion that extends to the base.

BLADDER: No significant abnormality noted.

LYMPH NODES: No significant abnormality noted.

BONES, SOFT TISSUES: Degenerative changes involving the bilateral hips.

OTHER: No significant abnormality noted.

IMPRESSION: Multiple lesions in the bilateral peripheral zones with a PI-RADS 5 lesion
noted in the right midgland with extension to the base. This lesion demonstrates features
suspicious for extracapsular extension. See above for additional details.

So last biopsy was a year ago and you were a G7? But no plans to do another biopsy and you're going off the MRI? If that's the case, at the very least I would get a second opinion on the 2018 biopsy from Epstein's lab at JHU. You want to confirm the G7 is actually a G7 and that it's a 3+4 instead of 4+3.

Assuming you're a G7 and want to treat, you'd likely have pretty much every option open to you. Unless I'm misunderstanding something about the severity of your diagnosis, brachytherapy would typically be given as a mono therapy and not in conjunction with IMRT. I think you'd likely be pursuing surgery, SBRT and brachytherapy (seeds or HDR).

Send them to Epstein, he signs off on all and will speak to you about his findings either on the phone or email.. He is very accessible and on top of every read.

Agree with F8, if you need to treat you have great brachytherapy options without using surgery and its more significant negative treatment side effects. Though I prefer and used HDR brachytherapy, you have one of the best seeds radiation oncologist in the world with Dr. Moran in Chicago. I would call him first thing Monday morning.

Yup, you need to get treated. IMRT/brachy is a good option, so would be SBRT.

Yes, find out as soon as you can if brachy and IMRT combo is still an option....To me, that MRI report suggests the horse may have left the barn but I'm not a doctor..

Atom, I agree with the others that surgery doesn't make much sense at this point. I think going back to Dr. Moran and getting his assessment is your best bet. He is one of the best.

Good luck.

Jim

IMHO, and experiences, Dr. Moran and Bicalutamine (Casodex) ONLY is the way to go, If your Uro is good, he should agree. BTW, lifetime remissions are possible, but "cure" isn't. No matter what, constant vigil is part of the diagnosis.

Good luck.....move fast!