New here: Husband has very high risk localized PCa

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Comments

  • Thank you VGama!

    Thanks for sharing this knowledge VGama. 

    So is a PET scan better than an MRI for finding localized spread? It seems everyone in the PCa world gets an MRI but here, they are very difficult to get. We have asked many times. 

    The good news is that we saw a Rad Onc at one of the best cancer facilities in the country. She was amazing. It was the first specialist we met on this journey that actually seemed to care and to want to do everything to give my husband the best outcome possible. She said she wanted to review the scans and also the pathology. She said that typically for very high risk cases, she'd do ADT followed by high dose brachytherapy followed by EBRT. She examined my husband and said that the prostate was quite mobile and that she didn't feel any nodules. In her estimation, it was a T2. (music to our ears)

    Today, she called and said she'd been thinking about my husband. (how I love this doctor!!) and was concered by what appeared to be a bladder neck extension. She said if this was the case, surgery would be the better option. She was having their radiologist review the films and was going to discuss the case in their group meeting today. 

    As you wrote VGama, this doc said ADT has a "sensitizing" effect on RT and that's why they're used in combination. Also as you wrote, in her call today she said she wanted my husband to start ADT right away- regardless of the ultimate choice that is made. In fact, my husband did begin ADT with the other urologist, mainly as a means of buying a bit of time, reducing significant stress and hopefully stopping cancer growth. We realize that there is no evidence that neoadjuvant improves outcomes but there is no negative effect either. 

    Another thing this doctor said was that it was not exactly correct that failed RP can be fixed by RT but not the other way around. She said it was important to know why there was biochemical re-occurrence and to find the source. She said rarely is the source the prostate if there is a failure after RT but in the rare case that it was, surgery could still be done at their center. 

    I can't tell you how much it means to find a doctor who sees my husband as an individual and wants to do her best for him. 

    Thanks again for your contribution!

     

     

     

     

     

  • Old Salt
    Old Salt Member Posts: 899 Member
    This all makes sense

    As I wrote earlier, a triple attack is appropriate: ADT + radiation + boost radiation.

    Whereas I got ADT + SBRT + IMRT, the SBRT 'boost' (apparently not available to your husband) can be replaced by brachytherapy. This is what my urologist originally recommended. I decided to substitute SBRT for brachy (see my earlier post), but the fact is that the dosing for SBRT is based on what the radiation oncologists learned from (HT) brachytherapy.

  • VascodaGama
    VascodaGama Member Posts: 3,495 Member
    Insist in a reliable image study for final decision

    Hope,

    I call you now Hope because you may be, by now, less desperate and more confident due to the knowledge you have already acquired.

    Unfortunately to your husband and many young fellas, GP doctors rarely do screening for prostate cancer. Cancer is mostly found when symptoms arise. Treatment follows typically the same pattern so that men should know a little the basis and demand screening (PSA) starting at their 45 years old. However, rare are those that know the meaning of the word "PSA".
    The guidelines provided by the Urologists' Associations should be blamed not only for not recommending the screening earlier but also for their recommendations regarding diagnosis. As you comment above, most doctors get image studies with equipment and techniques that are only feasible to those cases already advanced (probably with apparent symptoms). Traditional CT or MRI cannot detect cancer of small sizes. Most urologists know about this but they follow their institutions recommendations, get the tradition CT plus bone scan and deliver diagnosis with false negatives.

    My lay opinion on your husband's aggressive case is that he should check for any metastases in close lymph nodes. This information would weigh in the type of preferred treatment. Exams using techniques that fuse data in 3T-MRImp, using choline based contrast agents, or (still better) in a PSMA PET exam, are the best choice. However, I am not sure if the PSMA PET is viable for HT patients (ADT influence). You need to inquire with the radiologist.
     Another point to consider is that these exams are usually not covered by NHS system (Canada and Europe) so that one must do the exam under his insurance policy or go privately at his own expense (about 2,500 Euros).

    The doctor you met seems to be good in both aspects. He/She is up-to-date with newer techniques and therapies, and spends time with the patient explaining details and discussing openly. Trusting our doctor is very important when we know little on the matter.
    I wonder about the doctors' comment on the bladder neck extension. Is she referring to cancer? Usually an extension at the base of the prostate (near the sphincter) relates to hyperplasia and it is usually accompanied with urination problems/symptoms (urgency, etc). The protuberance (upwards) can also press the seminal vesicles that could lead to a lack of ejaculation. Can you tell if your husband have had any similar experiences?

    A reliable image study is highly recommended to verify if T2 is the proper clinical stage for the choice of surgery. It will also check for such extensions and the results can be used to "map" the proper field for a radiation treatment (solo or adjuvant). Investigate on the possibilities.

    Best wishes,

    VGama

     

  • Insist in a reliable image study for final decision

    Hope,

    I call you now Hope because you may be, by now, less desperate and more confident due to the knowledge you have already acquired.

    Unfortunately to your husband and many young fellas, GP doctors rarely do screening for prostate cancer. Cancer is mostly found when symptoms arise. Treatment follows typically the same pattern so that men should know a little the basis and demand screening (PSA) starting at their 45 years old. However, rare are those that know the meaning of the word "PSA".
    The guidelines provided by the Urologists' Associations should be blamed not only for not recommending the screening earlier but also for their recommendations regarding diagnosis. As you comment above, most doctors get image studies with equipment and techniques that are only feasible to those cases already advanced (probably with apparent symptoms). Traditional CT or MRI cannot detect cancer of small sizes. Most urologists know about this but they follow their institutions recommendations, get the tradition CT plus bone scan and deliver diagnosis with false negatives.

    My lay opinion on your husband's aggressive case is that he should check for any metastases in close lymph nodes. This information would weigh in the type of preferred treatment. Exams using techniques that fuse data in 3T-MRImp, using choline based contrast agents, or (still better) in a PSMA PET exam, are the best choice. However, I am not sure if the PSMA PET is viable for HT patients (ADT influence). You need to inquire with the radiologist.
     Another point to consider is that these exams are usually not covered by NHS system (Canada and Europe) so that one must do the exam under his insurance policy or go privately at his own expense (about 2,500 Euros).

    The doctor you met seems to be good in both aspects. He/She is up-to-date with newer techniques and therapies, and spends time with the patient explaining details and discussing openly. Trusting our doctor is very important when we know little on the matter.
    I wonder about the doctors' comment on the bladder neck extension. Is she referring to cancer? Usually an extension at the base of the prostate (near the sphincter) relates to hyperplasia and it is usually accompanied with urination problems/symptoms (urgency, etc). The protuberance (upwards) can also press the seminal vesicles that could lead to a lack of ejaculation. Can you tell if your husband have had any similar experiences?

    A reliable image study is highly recommended to verify if T2 is the proper clinical stage for the choice of surgery. It will also check for such extensions and the results can be used to "map" the proper field for a radiation treatment (solo or adjuvant). Investigate on the possibilities.

    Best wishes,

    VGama

     

    doctor called again!

    My family has suffered in the worst way with the system as my daughter died from medical error many years ago. It has meant that trust for us is a huge issue. We used to trust physicians automatically but we don't any more. So this wonderful young, very smart doctor is a real God-send to us. 

    She called again, on Friday evenning (imagine that!) to tell me that she was concerned about the bladder neck extension. The radiologist for the TRUS wrote that there appears to be a BPH extension into the base of the bladder and that bladder cancer should be ruled out. She presented my husband's case to the team and there were divided views. She said that if the extension is cancer then surgery would be the better option because she wouldn't want to radiate so close to the bladder. She has spoken to the surgeon and moved up the date of the appt to sometime in the next 2 weeks. She said she'd leave it to the surgeon to do more imagine and/or a cystoscopy. 

    The reason I was concerned about the extension was because a publication about very high risk PCa by Mayo included this:  

    Our preoperative evaluation for patients with high-risk PC at Mayo Clinic includes bone scan as well as cross-sectional imaging, most frequently with prostate MRI. MRI may be used not only to assess for pelvic lymphadenopathy but also to evaluate local tumor extension, for example, into the neurovascular bundle, seminal vesicle, urethral sphincter, and bladder neck. Such information may then assist with operative planning, for example, as a component of the decision regarding the extent of nerve sparing. As well, if there is a suspicion for bladder neck invasion with cancer based on this evaluation, we perform preoperative cystoscopy.

    So I asked the first urologist about this and he kind of shrugged and said he'd "cut wide". I wasn't pacified by that response. We are so very fortunate to have a specialist who cares who is at the top academic, high volume cancer center. 

    The doctor told me that there is a very small chance that the prostate cancer has invaded the bladder which could mean removal of bladder but not to worry about that. I told her our greatest worry would be not to have trust or faith in our medical care and we can't thank her enough for being so thorough. She said, "just doing my job". 

    My husband experienced urinary problems in the weeks preceding his PSA, which is what prompted him to go to the doctor. His prostate is actually not that enlarged. (45 cc) I researched and found that transition zone PCa can egress into the bladder. Also of note is that he had no external nodes, further suggesting transition as opposed to peripheral PCa. His biopsy numbers are not suggestive of transition zone PCa but I don't think it can be ruled out. 

    Thank you again for your comments- I'll tell the surgeon that if there is an image that it not available here, we would pay and go to another country if necessary. 

     

     

     

     

  • desperate for hope
    desperate for hope Member Posts: 44
    edited October 2016 #26

    Insist in a reliable image study for final decision

    Hope,

    I call you now Hope because you may be, by now, less desperate and more confident due to the knowledge you have already acquired.

    Unfortunately to your husband and many young fellas, GP doctors rarely do screening for prostate cancer. Cancer is mostly found when symptoms arise. Treatment follows typically the same pattern so that men should know a little the basis and demand screening (PSA) starting at their 45 years old. However, rare are those that know the meaning of the word "PSA".
    The guidelines provided by the Urologists' Associations should be blamed not only for not recommending the screening earlier but also for their recommendations regarding diagnosis. As you comment above, most doctors get image studies with equipment and techniques that are only feasible to those cases already advanced (probably with apparent symptoms). Traditional CT or MRI cannot detect cancer of small sizes. Most urologists know about this but they follow their institutions recommendations, get the tradition CT plus bone scan and deliver diagnosis with false negatives.

    My lay opinion on your husband's aggressive case is that he should check for any metastases in close lymph nodes. This information would weigh in the type of preferred treatment. Exams using techniques that fuse data in 3T-MRImp, using choline based contrast agents, or (still better) in a PSMA PET exam, are the best choice. However, I am not sure if the PSMA PET is viable for HT patients (ADT influence). You need to inquire with the radiologist.
     Another point to consider is that these exams are usually not covered by NHS system (Canada and Europe) so that one must do the exam under his insurance policy or go privately at his own expense (about 2,500 Euros).

    The doctor you met seems to be good in both aspects. He/She is up-to-date with newer techniques and therapies, and spends time with the patient explaining details and discussing openly. Trusting our doctor is very important when we know little on the matter.
    I wonder about the doctors' comment on the bladder neck extension. Is she referring to cancer? Usually an extension at the base of the prostate (near the sphincter) relates to hyperplasia and it is usually accompanied with urination problems/symptoms (urgency, etc). The protuberance (upwards) can also press the seminal vesicles that could lead to a lack of ejaculation. Can you tell if your husband have had any similar experiences?

    A reliable image study is highly recommended to verify if T2 is the proper clinical stage for the choice of surgery. It will also check for such extensions and the results can be used to "map" the proper field for a radiation treatment (solo or adjuvant). Investigate on the possibilities.

    Best wishes,

    VGama

     

    PS: you're correct- i'm just hope now and not so desperate!

    Thanks again!

  • hopeful and optimistic
    hopeful and optimistic Member Posts: 2,333 Member
    pet scan

    I don't know where you live in Canada, but in Arizona, there is a high tech pet scan, better than the vast majority of PET Scans that is available, I think for about $3,000.00. You could probably call Dr. Almeida or his staff for more information

    Here is information about this pet scan. I live in CA. and I know many who have gone here for imaging.

    http://paact.help/update-c11-acetate-petct-in-prostate-cancer-fabio-almeida-md-2015/

    There are other locations in the US that offer high tech PET SCANS. Another location is the Mayo Clinic. I personally do not know anyone who has used this facility, but here is information from them. Note that they use choline instead of acetate....for some reason I remember reading that the acetate is better.

    http://www.mayoclinic.org/tests-procedures/choline-c-11-pet-scan/details/mayo-clinic-approach/orc-20157001

     

     

  • VascodaGama
    VascodaGama Member Posts: 3,495 Member
    edited October 2016 #28
    Clinical Trials for image study

    Hi Hope,

    My comments above match what the doctor told you regarding the enlargement of the prostate upwards. This is the missing information for your she-doctor to decide on the RT protocol.

    I think you should request her to help you in procuring/obtaining the proper image exam, not just a suggestion. Tell her about the 68ga PSMA PET or the Mayo’s fusion 3T-MRI mp (multi parametric) using choline (C11 or F18 flurocholine). I believe she (a radiologist) knows about these tests and their efficacy in clear doubts, including the info on lymph nodes “infestation”.
    Please note that she might think difficult the access to those clinics making the studies out of Canada. Her referral will be required (just my guess). Do your best investigating possibilities. Use diplomacy when talking with her.

    Prostate (base) protuberance upwards is typically benign hyperplasia. TRUS done will color (Doppler) may identify if there is any probability of being cancerous, but it wouldn’t provide a clue on other localized tissues. A cystoscopy will provide a view of the inner bladder walls and neck (sphincter) but cannot identify cancer. It will just confirm the anomaly.

    Regarding your comment on the transition as opposed to peripheral PCa, please note that the negative DRE cannot access the whole capsule. I think that the biopsy does not provide info of the particular area so that she has demanded further investigation by the urologist. In any case, being all cores positive it means that cancer is found at all zones including peripheral. The prostate size of 45cc is above normal (25 to 30cc); the increase is part due to hyperplasia, inflammation and cancer. The pathologist may have included in the report such findings, but only from the sample tissues. The urologist can opt for an image study or an extra needle biopsy of the tissue in question.

    I would recommend you to take notes of the conversations as the volume of information increases and may become confused.

    Waiting two weeks for the appointment is comprehensive. Meanwhile you can continue your good work investigating if there are clinical trials for sophisticated image studies running in Canada. Many of this exams are only available in trials. You could contact in advance some clinics (in Canada or outside) and gather info for the next meeting with her.

    Best wishes.

     

    VG

  • Clinical Trials for image study

    Hi Hope,

    My comments above match what the doctor told you regarding the enlargement of the prostate upwards. This is the missing information for your she-doctor to decide on the RT protocol.

    I think you should request her to help you in procuring/obtaining the proper image exam, not just a suggestion. Tell her about the 68ga PSMA PET or the Mayo’s fusion 3T-MRI mp (multi parametric) using choline (C11 or F18 flurocholine). I believe she (a radiologist) knows about these tests and their efficacy in clear doubts, including the info on lymph nodes “infestation”.
    Please note that she might think difficult the access to those clinics making the studies out of Canada. Her referral will be required (just my guess). Do your best investigating possibilities. Use diplomacy when talking with her.

    Prostate (base) protuberance upwards is typically benign hyperplasia. TRUS done will color (Doppler) may identify if there is any probability of being cancerous, but it wouldn’t provide a clue on other localized tissues. A cystoscopy will provide a view of the inner bladder walls and neck (sphincter) but cannot identify cancer. It will just confirm the anomaly.

    Regarding your comment on the transition as opposed to peripheral PCa, please note that the negative DRE cannot access the whole capsule. I think that the biopsy does not provide info of the particular area so that she has demanded further investigation by the urologist. In any case, being all cores positive it means that cancer is found at all zones including peripheral. The prostate size of 45cc is above normal (25 to 30cc); the increase is part due to hyperplasia, inflammation and cancer. The pathologist may have included in the report such findings, but only from the sample tissues. The urologist can opt for an image study or an extra needle biopsy of the tissue in question.

    I would recommend you to take notes of the conversations as the volume of information increases and may become confused.

    Waiting two weeks for the appointment is comprehensive. Meanwhile you can continue your good work investigating if there are clinical trials for sophisticated image studies running in Canada. Many of this exams are only available in trials. You could contact in advance some clinics (in Canada or outside) and gather info for the next meeting with her.

    Best wishes.

     

    VG

    Wise advice!

    Thank you VG. 

    I don't suppose the TRUS was done in color or the radiologist would not have written that cancer needed to be ruled out. I realize that the prostate is larger than normal but based on the calculated volume, the predicted PSA was 6 which was much smaller than the actual of 28. I know that low volume (for PSA) is not a good indicator. 

    The hospital has a 3T-MRI mp and PET  but not PSMA PET. I googled to find out more and low and behold I found an newsletter article by the urologist we will soon see and just as you wrote, he stated that the only way to get a PSMA PET is through a clinical trial. (How do you know so much VG?) He concluded by writing that if you are interested in a trial ask your doctor for guideance. 

    I did find a clinical trial - https://www.cancer.gov/about-cancer/treatment/clinical-trials/search/view?cdrid=761748&version=HealthProfessional&protocolsearchid=6411918

     Are these new PET scans not available even if a patient pays?

    The urologist spent a few years at Sloan-Kettering so he's on current with all that's new. Is the patient generally responsible to pay for transportation to the clinical trial? 

    Regarding transition vs peripheral, is it not possible for the tumor to start in the TZ and spread outwards such that all cores would be positive? 

    So much to learn! I can only read publications on "very high risk" for so long before it becomes depressing. I know it could be worse but the fact that GPs didn't mention PSA twice in the last 5 years during physicals makes it difficult not to be consumed in anger. 

    Thanks again VG. 

     

     

     

     

     

  • Swingshiftworker
    Swingshiftworker Member Posts: 1,013 Member
    edited October 2016 #30

    refer to above

    Me too!

    Did it to me too in another thread.  Save the message but haven't tried to resend it yet.

  • VascodaGama
    VascodaGama Member Posts: 3,495 Member
    edited October 2016 #31
    About techniques and newer Image exams

    Hope,

    I like to read your posts. You have advanced a lot in the diagnosis investigations touching the wound. Now you need to look about the treatment, their risks and the side effects.
    My wife and I went crazy reading everything with two piles one foot high of internet outputs and two books that lead to a final decision. It took us two months of investigation and second opinions. Diagnosed in May and surgery in August 15, 2000. You can do it. Your husband is fortunate for having you so involved in his care.

    Your guessing in regards to the PSA is correct. Gleason pattern of 4 and 5 cells produce lesser amounts of the serum. They are poorly differentiated and deformed without any healthy cell characteristics. The nucleus may not exist already. The excess PSA (above 6) could be from those cancerous cells of lower Gleason patterns, also existent. The pathologist only indicates the two most voluminous and aggressive types he found. The high PSA is very indicative of extra capsular extensions that could have colonized in the travelling route used by PCa. First stop: the Lymph nodes.

    The biopsy needle bores a piece of tissue about 2.5 cm long (the diameter of the prostate not only half of it), therefore includes all zones. However, 12 needles (planned strategically) extract only a tiny portion (in percentage) of the prostate. The in between tissues could be benign or of different Gleason rates. The pathologist report (I hope you have filed a copy for use in second opinions) indicates findings by percentage of each needle, including their location.

    In the past 5 years there have been huge jumps in the “discovery” of newer image study techniques and compounds (contrast agents and radiotracers), more reliable than the traditional exams. The equipment capabilities also have improved a lot in regards to better image resolution and software (creating images as close as the real setting), in terms of sensitivity and specificity. These have been put into trials (solo or combined) for checking safety and outcomes. Typically, clinical trials pass three phases till obtaining its approval for the use in the open. Some guys luckily find clinics doing the exams “off-label”.

    In any case there are already exams that have finished phase III trials, now in practice. The data is reliable and many can have them at particular clinics where they accept insurances or private payments. Clinical trials are free of charge and safe but are conditional. The trial link you provide above is the phase 1 still confirming doses. It also requires two years of surveillance that may prohibit any earlier treatment. Surely one can have the picture and give up in the middle of the trial to pursue what one most wants or needs.

    Results in images differ among used contrast agents, but these newer image exams are all much better than the traditional. You can find articles in the net regarding the trials together with notes comparing the results, therefore providing ideas from where to choose. We have discussed the matter here before in these links;

    https://csn.cancer.org/comment/1544651

    https://csn.cancer.org/node/305239

    https://www.ncbi.nlm.nih.gov/pubmed/26112024

    https://www.ncbi.nlm.nih.gov/pubmed/26795286

    http://cancerforum.org.au/forum/2015/november/advances-in-the-imaging-of-the-prostate-in-the-setting-of-elevated-psa-levels/

    https://clinicaltrials.gov/ct2/show/NCT02611882?term=thomas+hope&rank=1

    C11 and F18 choline are widely in use already. The F18Sodium Fluoride PET is the best for scanning bone metastases but the PSMA PET with radiotracers, such the 68 Ga (Gallium) and the LU-177 (Lutetium) can do the job in both; bone and soft tissues. There are several other radiotracers on the drawingboards, being one of them the DCFPyL of the trial you indicated above. These tracers combined with one positron-emitting isotope, such as the fluorine F 18, provide accurate location of prostatic cells. ProstaScint is the oldest in the market of image studies. There initial techniques provided may false negatives or false positives. They have launched a newer radiotracer with success but I have no details.

    Lu-177 traces and kills the cancer on the spot. I expect Lu therapies to be the future in cancer treatments. There are several clinics doing this expensive therapy in Germany. Here are locations and prices just for reference;
    https://bookinghealth.com/programs/treatment/urology/prostate-cancer-with-metastasis-lutetium-177-psma-therapie/germany?gclid=CLWtzsPf4c8CFUE_GwodKIAN5A

     

    Sorry for the extensive and confusing information that may cause you more stress. Go slowly.

    Best wishes.

    VGama

  • VascodaGama
    VascodaGama Member Posts: 3,495 Member
    edited October 2016 #32

    refer to above

  • oldcoach
    oldcoach Member Posts: 3
    edited October 2016 #33

    Cases all different

    Desperate,

    Sorry to hear of your husband's diagnosis.  All of our cases are different.  My case was simular to what Rooster02 stated. However my  PSA was 69, with a Gleason 3 + 4 =7.  I went to oncologists and weighed the options.  Decided on Robotic Assisted Surgery and had that Dec 2013.  Post surgery pathology showed one very small spot in one lymph node.  I was listed as a Stage pT3bN1.  Doctors said they were going to be very aggresive and they were.  I was treated as though I was a Stage 4.   After surgery, I started ADT and two months later started Radiation on the area where the Prostate had been , as clean up.  In two months time my PSA dropped to <0.010. I had 8 weeks of radiation 5 days per week, and two years on Lupron.   They had my Testosterone knocked down to 17.  Normal is 250 - 1,100.  My PSA has remaied undetectable since.  It had been holding at <0.010 for almost three years.  I've been off  the ADT (Lupron) for 9 months now, and my Testosterone is back up in the normal range .  It's now at 320.   With the "T" levels up, my PSA has come up a little bit to 0.035. They still call the undectable.  My doctors say that is OK for now.  If My PSA goes up to 2, then I will have to ga back on some form of ADT.  However we might have to start that sooner if we/they feel I'm in danger of Bone Involvement starting, or other spread.  I've had the same results as Rooster02 stated with followup MRI's.  I have Arthritis in my hips but my bones are otherwise fine, at this point.  I did have some bone density loss from the radiation and am currently on Prolia to help that situation.

    Make sure and research as much as you can on side effects, from all kinds of treatment.  As I said and as others have said what works for one of us is not always what will work for everyone.  I've told you what I've been through and how that has worked to this point. That way if your Husband is given these options you may know that I have had sucess from these treatments, so far.  I was originally told that If I did nothing, I'd probaly have two years to live.  After all I've been through I'm 3 years past diagnosis.  My doctors are now talking 10+ years down the road and talking what the next treatments might be, if needed.  However I'm not saying what I did  is the only way to be treated.  Thats' why it's very important to get all the opinions you can and study all the options. 

    Know that You and your Husband are in my thoughts and prayers.

    Love, Peace and God Bless

    Will

    cases different

    Will::: i have a similar situation.  After RP in January they found 1 millamenter in one node.  I was staged Pt2C N1  PSA has been undetectable for 9 months.  Dr. Said no further treatment.  all margins clear.  I had periniul invasion but all else ok.   Curious.  how much of a tiny spot did they find in your node.. Also, has anyone on this board know of getting a second opinion after the surgery from the pathology report.  Thanks  old coach

  • About techniques and newer Image exams

    Hope,

    I like to read your posts. You have advanced a lot in the diagnosis investigations touching the wound. Now you need to look about the treatment, their risks and the side effects.
    My wife and I went crazy reading everything with two piles one foot high of internet outputs and two books that lead to a final decision. It took us two months of investigation and second opinions. Diagnosed in May and surgery in August 15, 2000. You can do it. Your husband is fortunate for having you so involved in his care.

    Your guessing in regards to the PSA is correct. Gleason pattern of 4 and 5 cells produce lesser amounts of the serum. They are poorly differentiated and deformed without any healthy cell characteristics. The nucleus may not exist already. The excess PSA (above 6) could be from those cancerous cells of lower Gleason patterns, also existent. The pathologist only indicates the two most voluminous and aggressive types he found. The high PSA is very indicative of extra capsular extensions that could have colonized in the travelling route used by PCa. First stop: the Lymph nodes.

    The biopsy needle bores a piece of tissue about 2.5 cm long (the diameter of the prostate not only half of it), therefore includes all zones. However, 12 needles (planned strategically) extract only a tiny portion (in percentage) of the prostate. The in between tissues could be benign or of different Gleason rates. The pathologist report (I hope you have filed a copy for use in second opinions) indicates findings by percentage of each needle, including their location.

    In the past 5 years there have been huge jumps in the “discovery” of newer image study techniques and compounds (contrast agents and radiotracers), more reliable than the traditional exams. The equipment capabilities also have improved a lot in regards to better image resolution and software (creating images as close as the real setting), in terms of sensitivity and specificity. These have been put into trials (solo or combined) for checking safety and outcomes. Typically, clinical trials pass three phases till obtaining its approval for the use in the open. Some guys luckily find clinics doing the exams “off-label”.

    In any case there are already exams that have finished phase III trials, now in practice. The data is reliable and many can have them at particular clinics where they accept insurances or private payments. Clinical trials are free of charge and safe but are conditional. The trial link you provide above is the phase 1 still confirming doses. It also requires two years of surveillance that may prohibit any earlier treatment. Surely one can have the picture and give up in the middle of the trial to pursue what one most wants or needs.

    Results in images differ among used contrast agents, but these newer image exams are all much better than the traditional. You can find articles in the net regarding the trials together with notes comparing the results, therefore providing ideas from where to choose. We have discussed the matter here before in these links;

    https://csn.cancer.org/comment/1544651

    https://csn.cancer.org/node/305239

    https://www.ncbi.nlm.nih.gov/pubmed/26112024

    https://www.ncbi.nlm.nih.gov/pubmed/26795286

    http://cancerforum.org.au/forum/2015/november/advances-in-the-imaging-of-the-prostate-in-the-setting-of-elevated-psa-levels/

    https://clinicaltrials.gov/ct2/show/NCT02611882?term=thomas+hope&rank=1

    C11 and F18 choline are widely in use already. The F18Sodium Fluoride PET is the best for scanning bone metastases but the PSMA PET with radiotracers, such the 68 Ga (Gallium) and the LU-177 (Lutetium) can do the job in both; bone and soft tissues. There are several other radiotracers on the drawingboards, being one of them the DCFPyL of the trial you indicated above. These tracers combined with one positron-emitting isotope, such as the fluorine F 18, provide accurate location of prostatic cells. ProstaScint is the oldest in the market of image studies. There initial techniques provided may false negatives or false positives. They have launched a newer radiotracer with success but I have no details.

    Lu-177 traces and kills the cancer on the spot. I expect Lu therapies to be the future in cancer treatments. There are several clinics doing this expensive therapy in Germany. Here are locations and prices just for reference;
    https://bookinghealth.com/programs/treatment/urology/prostate-cancer-with-metastasis-lutetium-177-psma-therapie/germany?gclid=CLWtzsPf4c8CFUE_GwodKIAN5A

     

    Sorry for the extensive and confusing information that may cause you more stress. Go slowly.

    Best wishes.

    VGama

    always grateful for info.

    Thank  you. So much to absorb. Fortunately, I have access to journal articles. Today we had a new curve thrown at us. I'll start a new post