need advice please

kanudua

I am hereby mentioning the case as under for your Expert Opinion Patient Name S. Satinderpal Singh (My Father age 63 at Present) diabetic but under control with insulin ( mild dosage )

Brief History

A) In 2008 PSA was 55.3ng/ml ,biopsy suggestive of poorly differentiated adenocarcinoma ,Gleason Score 5+5, Bone scan was negative for metastasis ,He was prescribed LHRH analogues , and was referred to External Beam Radiotherapy ( As MRI revealed Focal peripostatic infilitration in the right side ,Bilateral seminal vesicles also reveal diffuse hypointensity,subcentimeter bilateral external iliac and inginual nodes were seen - Doctor Said Not fit for Radical Prostectomy - Stage cT3bN0/2M0)

in 2010 Patient received 3rd dose of (every 6 months one ) adjuvant hormonal therapy but PSA is rising Serum Psa was 5.86 ng/ml ,MRI Study shows prostate with Altered intensity thickening along the right basal region ,also thickening is noted along the posterior and adjoining right lateral wall of urinary bladder , Doctor Has done HIFU ( High intensity Focus Ultrasound ) as a Salvage therapy for prostate after 3 months waiting as PSA has risen to 18ng/ml

C)After HIFU of ProstatePSA dropped from 18 ng/ml gradually to 0.25 ng/ml upto 2012 , in Early 2013 Psa Starts Rising and risen upto 1.63ng/ml , and recurrence in urinary bladder ,PET CT suggestive of focal wall thickening in the right posterolateral wall of urinary bladder , Doctor did Bladder Tumor Excision by Robotic Surgery 29/7/13

Findings of Histopath Report

Microscopic Examination - Prostatic aciar adenocarcinoma with signet ring cell morphology , Gleason score 5+5

Extent of Invasion : Tumor involves whole Bladder wall with involvement of muscularis proparia and extension into perineural :present while lymphovascular invasion not seen

Margins : the nearest margin of excison is involved by tumor

D) PSA dropped to 0.06 but start rising after only 3 months and has reached 1.67 on 22/2/14 , PET CT indicated Focal wall thickening (2.5X1 .1 Cm in transverse dimension ) with unremarkable FDG uptake in the right posterolateral wall of urinary bladder involving the right VUJ ,with resultant mild to moderate right sided hydronephrosis

MRI on 26/2/14 shows On comparison with Previous MRI Pelvis ( 11/7/13 Before Tumor Excision ) ,there is regression of the wall thickening along posterior superior wall but there is still seen thickening with enhancement in the region .

Patient Condition is Fine and Medically Fit , however having Urinary incotinence after Bladder Tumor Excision and earlier experienced same when HIFU was done

It would be great help to Our Family if you please suggest what should we do now as we met 2 doctors and what they suggest are as under

 

Treatment Options (Suggested after Consultation )

 

1,One Doctor Suggest for repeat removal of tumor only with excision ,following with joining of ureter with bladder but after gap of 6 weeks

2. Second Doctor suggest Bladder tumor excision is no solution as it will recur in other 3 -4 months and only good option is Bilateral Orchidectomy or Repeat LHRH agonist/antagonist as more than 3 years have passed in hormonal treatment also he told operation is only successful in case full bladder ,prostate is taken out which is very complicated considering it might stick with rectal wall .

Sir, as a hope please tell as I am only son of my father and I love my father a lot , pls tell solution in which we can extend his life and is better for him considering his age at present 63 and other complication involved in the treatment , in case if you pls suggest some good doctor in India where we get opinion or treatments .I will be thankful from my heart for this kind gesture and helping us in our difficult times .

God Bless You and ur Family , Awaiting your reply eagerly , In case you require any more test reports pls tell I will send you instantly

Many Thanks

Kanwardeep Singh Dua

Mobile 00919650788007

Gurgaon

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

hopeful and optimistic

Dear Kanwardeep Singh Dua

I am sorry to read of your Father's condition. Aside from wishing your Father well, I am unprepared to comment on your Father's case. Hopefully others here will be able to help you with valid suggestions.

As you may be aware those with a family history of prostate cancer such as yourself are more likely to be diagnosed with prostate cancer. Early dectection is critical to treatment. It is important for you and others with a family history to be screened for this disease. I would guess that a baseline PSA test at about age 35 is appropriate, and then an annual PSA and Digital Rectal Test at age 40 .

Many of us here at this board have changed our life styles to be heart healthy, that is having lots of veggies, no meat or dairy and regular exercises. There have been epidemiological studies in various countries that have shown a correlation between diet and diagnosis of disease. There is a book that you may wish to read "The China Study" by T. Colin Cambell. Additionally there is a DVD "FORKSoverKNIVES"

There is a drug Avodart, that you may wish investigate with relation to taking as a preventive for developing prostate cancer. There have been recent studies done to this drug and also another one Proscar.

 

tarhoosier

Sir:

This is a complete synoposis of a serious case of prostate cancer. Thank you for the details. This is NOT a site for experts or medical advice from professionals. We are at best educated patients. All that I can provide is opinion and suggestions. No medical training or medical advice.

Your father has a serious case of prostate cancer and he has had significant treatment so far. What he has had is more than would be likely here in the US. The fact that he has had radiation and HIFU in the prostate region makes any subsequent surgery a difficult task. It would be unlikely most surgeons here in the US would attempt to remove the prostate and surrounding tissue for a patient of this type with this previous treatment. Plus this would be attempted in an area already treated surgically.

I am concerned for the hydronephrosis, meaning the ureters are not working properly to deliver urine to the bladder. Perhaps the issue is at the bladder. Nonetheless hydronephrosis must be addressed one way or another.

For a man with advanced cancer of Gleason 10 from six years ago he has fought well and hard. Your doctors have given the most complete treatment possible to the local area. It may be time to consider systemic treatments such as orchiectomy or perhaps the use of Honvan, an estrogen analogue which serves similar purposes. The LHRH agonist also serves this same purpose. Then use surgery only for those issues which cannot be addressed any other way.

Your father has faced a difficult diagnosis bravely and submitted to serious treatment at several points. His current health is good, you say, but his age and several of these conditions suggest to me that doctors must be completely convinced that further surgical interventions are necessary. I hope that the doctors are looking at your father as a person and not just as a host of disease.

 

VascodaGama

Consulting a Medical Oncologist is a better choice

Kanudua

Welcome to the board. I am sorry for what your father has been through.

You have received good advices already. I also think that your dad’s case is precarious and that his best choice will be a less invasive treatment less that may assure better quality of life. His cancer (Prostatic Acinar adenocarcinoma with signet ring cell morphology) is a very aggressive type and it can be judged for the aggressive spread along his six years of survivorship. Apart from these risky types of cells, the Gleason grade 5 is the highest and difficult to treat. The rates of survival in signet ring cell carcinomas are short with a median period of5 years from diagnosis. Please read this paper written by an highly experienced PCa pathologist;
http://www.propath.com/newsletters-urologic-pathology-177/500-variants-of-prostate-carcinoma

I am not a doctor but from what I have learn along my 14 years as a survivor and from all the cases I have read and listen, I think that your second doctor’s advice is proper. He suggests a palliative way to control the disease with hormonal manipulations, instead of looking for cure on PCa.     The bladder problem must be addressed separately.

In any case, you need to consider the other aspects of your father’s health. Being diabetic imposes some restrictions on medications. This is a matter that can be better addressed consulting a medical oncologist with experience in treating advanced cases of prostate cancer. They are doctors prepared to look into the “overall” conditions of your father and recommend due protocols. I do not know if there is any specialist in India but your dad may get a consultation overseas and use a local oncologist to follow treatment and tests close to your place. A survivor named Traveler from Australia in this forum is consulting Dr. Steven Tucker, in Singapore. This doctor is famous for the several researches he has done and published papers about the PCa subject. You may contact him by e-mail to request for a phone consultation. Here are links to reach him;

http://65doctor.com/doctor/steven-tucker-1/
http://www.tuckermedical.com/

 

Castration is the main principle in hormonal treatments. The status can be obtained with bilateral orchiectomy alone, therefore avoiding any possible interaction between a LHRH agonist with other medications. This is a simple procedure but permanent. Your dad may also discuss with his doctor about the possibility in entering into a clinical trial for similar cases. Zytiga or Jetvana (chemo) may be something to look for. Here is a list of newer drugs for PCa advanced cases;
http://prostatecanceruk.org/information/prostate-cancer/treatment/treatment-choices/new-treatments

A good book about hormonal treatment is “Beating Prostate Cancer: Hormonal Therapy & Diet” by Dr. Charles “Snuffy” Myers. You may order a copy via the net from Amazon.

I hope your dad recuperates from the surgeries.

Wishing peace of mind for your family.

VGama 

Kongo

Good Advice

Kanuda,

Others here, particularly tarhoosier, have provided excellent advice.  A Gleason 10 diagnosis for these many years suggests a strong possibility that this cancer has spread to other parts of your father's body.  Removal of the prostate at this point will do nothing to curb the growth of cancer elsewhere and it is unlikely that this procedure would do anything except adversely impact your father's quality of life.

It is not uncommon for HIFU to fail, particularly in a case as advanced as a Gleason 10.  HIFU only addresses cancer in the prostate gland and not elsewhere in the body which could well be causing the rise in PSA.  

The hormone treatments your father is receiving will help slow the growth of prostate cancer but it is not a curative treatment. Eventually the cancer will become resistant to the drug therapy and other drugs will be necessary but they too will fail with time.  As you may know by now, HT can also have significant effects on a man's quality of life.

I would encourage you to work with your father and his medical teams to seek a solution that preserves his quality of life for as long as possible.

As tarhoosier pointed out there are not doctors or "experts" here.  We can only share what we have learned during our individual journeys with this disease.  

Best to you and your father,

 

K