Pathology report in - should we commend with HT?

VascodaGama

We all confront the same dilemma at front

We all confront the same dilemma at front. Which therapy is the best to treat?

In the end, the one we chosen is the best. Though, you need courage to find that ultimate comfort for deciding.

Cowboybob is correct. Nobody here has “invited” you to choose surgery. It seems that the family in China has set their minds in surgery and given you the task in proving that such is in fact the best. You are looking for a decision and now worried that your comment against the initial thoughts are unaccepted, or even worse, not proper. You feel responsible.

As commented above, his status would not alter if the treatment (surgery or radiation) is done in three months. The cancer would not “runaway”, it will be there to get the blow when that is done (now or in three months). In such regards, the Tesla 3 MRI result could be your trigger threshold to start the treatment. This is acting fast. You do not need to rush anything.

3T MRI is more reliable as image study. You can request for them in China to include measurement of the gland. You also can request them to provide the results on a CD/DVD which copy you can use in the USA (at a PCa specialist radiologist) to obtain a second opinion. This is your great chance to feel accomplished and to get a REAL decision.

Back to the year 2000, in my times, surgery used to be considered the golden standard of treatment for prostate cancer. At present times such is not correct. The newer RT equipment and modalities can provide results at the same level, to reach the ultimate goal of cure. The choice is now done regarding the details of patient status. The risks and the side effects from treatment are different and that also contribute in the final decision. Incontinence and Erection dysfunction (ED) are prevalent in surgery interventions. Radiation is more linked to colitis, proctitis, libido and damage to semen. Both may prohibit fathering a child.
These should be at the choice of the patient not at the decision of family members.

Just for your information:
Surgery is done open (the traditional) taking approximately 5 hours and requiring blood transfusion; The robotic is faster taking approximately two hours; A similar modality not using a robot is the Laparoscopic done by experienced surgeons but both are more linked to incontinence cases. Radiation is administered from outside non invasive using special equipment that can differ in dose modalities (large dose at many fractions: IMRT or fewer number of fractions hyper fractionated: Cyber Knife); Invasive modalities include Brachytherapy (localized seeds implanted) and High Dose Brachytherapy (with radiation rods).
In contained cases, CK has the best performance status. For localized cases IMRT delivers better outcomes. RT can also be done in combination; eg: CK+IMRT or Brachy + IMRT, etc

The prostate gland is considered too large for surgery or radiation when that extrudes into the bladder. This is accompanied of problems in urination (difficulty, pain, frequency, etc), so that surgeons prefer to do TURP instead of removing the whole gland. The normal size is approximately 30cc but many do surgery when this is 50cc. Some guys have glands at the 80 cc level and still manage to be treated. Hormonal therapy to reduce the size of a gland is done over six months, and even that will not assure a significant reduction in size. HT leads to a reduction of the PSA starting approximately 1.5 months from the first injection of a LHRH agonist. Castration is seen at the two weeks point but the body takes another two weeks (or more) to clean circulating serum. The comment of his Interim doctor makes no sense.

VGama

 

Pathfinder

Wow, this is really helpful.
Wow, this is really helpful.

To put things in perspective from this side, it hasn't been anyone's decision to chase surgery per se, we're just only now becoming educated in what we're facing. The issue is that the doctor post biopsy instructed us that there would be 3 months HT prior to surgery. When questioned has the cancer left the gland, the answer was "we don't believe so", and all this based on a Tesla 1.5 MRI and the biopsy results posted above. That and an incredible vagueness when it came to the details of the condition where staging was concerned.

I suppose what we thought was, if the cancer is indeed contained within the gland, surgical removal of said gland is the most practical step. And because we're worried about the PSA doubling rate and aggressiveness of the cancer, we are trying to quickly figure out if this surgery can be done sooner rather than later.

However talking to you guys has been both educational, and in a nice way, provided an additional dilemma! Because nobody here told us Gleason 8 is "assumed" to have left the gland, and indeed they told us they believe in this case that that hasn't happened.

However we are all aware of the risks involved in surgery. We know nobody can make this decision for my father in-law. If radiation therapy is the better option for him, we will explain that in full.

Here's the thing that I didn't understand previously:

"The newer RT equipment and modalities can provide results at the same level, to reach the ultimate goal of cure."

We were under the impression that there couldn't actually be a cure with radiation therapy! We were thinking that by choosing RT over surgery it would simply be a case of fighting until the very end through a variety of treatments.

We kind of saw it this way: based on the information given here (Gleason 8 = likelyhood of leaving the gland) that surgery would have a 20% success rate of removing all the cancer, and an 80% chance of failure due to cancer having escaped. The 20% would be a cure, and that's the gamble.

We thought RT and HT would be less damaging in terms of side effects, but would only control rather than destroy the cancer. Kind of like extending life expectancy, but conceding to defeat eventually.

If RT can actually cure PC, then we need to reassess everything.

I'm really sorry if this sounds uneducated! We are learning as fast as we can, and there's a lot of ground to cover. The biggest issue has been not being able to understand the seriousness of my Father in-law's PC. We don't know the definite stage, we don't definitely know if it's contained in the gland, and up to now, we're not sure when and how to act regarding treatment options. It's often frustrating and generally concerning.

We will begin looking into the details of RT over surgery now, but if anyone has any more input, every little helps, because I'm getting more from you than I think I ever will from the domestic doctors here.

Thanks again for your support!

Swingshiftworker

Cure for PCa?

It's hard to talk about a "cure" for any cancer because there's always a chance of recurrence regardless of the method of treatment used -- be it surgery or radiation -- BUT there have been many men (me, included) who have achieved total remission of their prostate cancer by means of radiation treatment.

My situation was much different than your father's.  I had an early stage cancer w/only a Gleason 6.  There was no doubt that the cancer was fully contained and I was treated with a method called CyberKnife which is a form of SBRT - stereotactic body radiation therapy.  It is the MOST precise and accurate method of radiation delivery currently available.  It is not only used to treat prostate cancer but is also used for brain, lung, liver and spinal cord, where precision is especially needed and where surgery would be a much more detrimental alternative.

Given that your father's cancer is at Gleason 8 and no one knows for certain whether it has spread beyond the prostate, it is not clear that CyberKnife would be the better choice of radiation treatment BUT if the location of the cancer can be specifically determined through the use of a MRSI (magnetic resonance spectroscopic imaging), which is a specialized version of an MRI that pinpoints the location of choline (which is a marker for cancer) in the body, CK (or any other means of radiation delivery, such as IMRT which is more commonly available) should be very effective in entirely eliminating the cancer w/o need for surgery.

PS: You say that you are fully aware of the risks of prostate surgery but you don't say exactly what you know.  The risks of prostate surgery are not just those common to surgery -- like the risk of infection.  The risks of prostate surgery for a man are MUCH greater than that.  There is the risk of impotence (no erections) and urinary incontinence (have to wear a diaper) which is generally temporary (usually 1 year) BUT can become PERMANENT requiring further surgery to install a penile implant and/or urinary sphincter (if that's what the patient need/wants).  There is also the risk of collateral tissue damage to the rectum and/or bladder which can have other consequences.  

These are risks that NO man should have to accept if there is a better and potentially less damaging alternative.  Radiation treatment by CK or some other means would be that alternative.  It all depends on whether or not the cancer is sufficiently localized or not to justify such treatment.  BTW, the same consideration applies to surgery as well.

Good luck!

 

 

Pathfinder

Thank you for your input

Thank you for your input Swingshiftworker,

Yes, the ED and incontinence are the main things we're aware of and concerned about regarding surgery. Thanks for the info regarding MRSI and Cyberknife surgery. 

It feels like although we now have a lot of information available thanks to you guys, we're really just at a wall with regard to the ultimate question: is the cancer contained or isn't it.

As you said, CK is better for PC contained within the gland (and if we could be totally sure that's the case, I'd probably leap on the first hospital that could offer it!)

I think since the HT is in effect, and many here have said that that affords us some time, that our next step should be to seek out better imaging software wherever it can be found. We have located a Tesla 3.0 locally, and I'll add the MRSI to the search list. Even if it's in another city, it will be worth the trip. 

I think being as sure as we can as to whether the cancer is contained in the gland will help a lot, although I've heard even the very best imaging software isn't ever 100% and can still miss things.

Thanks again guys.

 

Max Former Hodgkins Stage 3

"Bullets"

Pathfinder,

Any decision regarding your dad's treatments is most likely pending on the T 3.0 scan outcome. While it is not perfect imaging, it is the best available. 

I am a guy who had DaVinci surgical removal, and who studied options extensively in advance. MY case was mild and incipient, very unlike your father's biopsy suggests his is.  Initially, and now, he seems to me like a patient for whom radiation would be the preferred approach.   IF the 3.0 shows capsular escape, there is no way I would allow surgery (if you are making the decisions).

The type of radiation employed would very likely be IMRT or IGRT.  Approximately 50% of all new PCa cases in the US are treated first-line with radiation, the other 50% with surgical removal.  Curative-effect rates for the two, for NON-METASTATIC disease are statistically identical.  Side-effects do vary significantly.

For disease known to be metastatic before treatments are begun, surgry is almost never suggested, even by surgeons. There are LIMITED, rare exceptions.

Investigate available radiation modalities where he is located.  Cyberknife, while wonderful for PCa in side the gland, is usually not recommended for disease that has spread, as noted.

IGRT radiation in a heavy case like his would use at least 76, and possibly as much as 80, Gray of radiation.

I have summarily listed these items for simplicty and ease of reference. Everything I have written here has been posted to you already by one or more of the guys, in narrative, paragraph form.

max

hopeful and optimistic

sbrt

is an effective treatment for patients with a Gleason 8. Machines using SBRT are very precise and the permiter of treatment can be adjusted.

I know a man with a Gleason 8 and a high PSA who has had this treatment about a year ago. He first had a course of Lupron, a first line hormone, for a couple of months so the radiation would be more effective. He then had five sessions of Novalis, one the machines that deliver SBRT. He is continuing with Lupron now. His PSA has significantly declined

By the way he did not have an MRI

Pathfinder

Prostate size information from MRI

Before someone asked about the prostate size. Here is the best translation of the report we can manage:

"Prostate size not see definite volume increase, size 4.8cmx2.9cmx3.4cm (Transverse diameter, anteroposterior diameter, vertical diameter). Intermediate area saw small nodule T1 slightly T2 signal, DWI showed no signs of restricted diffusion, dynamic enhanced scan showed gradual strengthening; Around Prostate left rear see a nodular T1 short T2 signals, approx 1.8x1.6cm, DWI showed slightly higher signal, ADC map showed low signal"

And there are some additional comments regarding lymph nodes:

"no seen lymph node in pelvic, no liquid in pelvic, pelvic is normal"

 

 

Pathfinder

Once again, I'm really

Once again, I'm really grateful for this information guys.

Max, you've really spelled it out nicely there, very black and white, which is really helping me to understand our position, and hopeful, knowing he did radiaton without an MRI is surprising but useful!

We believe there may be a Cyberknife available locally, although this is dependent on the 3.0 MRI. I heard Cyberknife was relatively old tech - is this true, or is the best recommendation for prostate removal (in your opinion?)

Although our course of action currently is to persevere for a more detailed MRI or MRSI to be more sure about the PC containment, apparently he can't have those scans until 6 weeks post biopsy due to scarring or healing affecting the imaging results. Does this sound correct?

Secondly, and although we're definitely going to have the MRI before making a decision, our bigger concern is Chinese doctors not seeming to know much about radiation therapy! It's really bothering us, because they all seem to just say "surgery". That may be because, based on the current MRI, they believe the PC to be contained and therefore operable, but we have a sneaking suspicion that they don't commonly practice radiation for PC.

I know that sounds crazy, and we're hoping we're completely wrong. Max's suggestions of IMRT or IGRT give me something to read up on, but is there anything else we should know about modern radiation therapy that we can pursue with the local hospitals? For example, what is the latest and preferred method of radiotherapy done in the west - is it by rod, pellet, etc? We're not sure what we should be asking for.

Thanks once again!

Pathfinder

Further updates

Today we've been given a lot of conflicting information. Many domestic people who have either had, or have had PC in their family, say that in most cases doctors in China recommend surgical removal of the gland, even when cancer has left the gland. 

The reality is that they don't seem to practice radiation therapy as much, meaning that the technology is limited.

Regarding Cyber Knife - and this is rather impressive - one of the only Hospitals in the whole of China that has Cyber Knife is right on our doorstep. That's kind of amazing, since it's a pretty big country! 

We were told that CK is usually used on brain cancer and other organs, but not so much on the prostate. I don't know if that's true, you need to remember western medical practices are certainly ahead of the game. A person whose father underwent CK surgery to remove the prostate who had cancer contained within the gland, still ended up with bone metastases later and the cancer running wild. When querying this somebody said that CK is fairly powerful and it likely didn't just destroy a portion of the cancer within the prostate, but the "good fighting cells" around the outer rim. By killing the natural defence in the tissue the cancer was inadvertantly set free. 

Does this sound possible? I know two people have used CK here with no probems, but apparently it's a method reserved for patients in an earlier stage, rather than Gleason 8.

Any information would be appreciated.

Finally, my father in-law has mentioned testicular pain the last two days. He has been on hormone therapy a week (beginning with an injection, and then daily pills) and I suggested that this was probably a side effect of the drugs affecting the testicles. He is worried it's a spreading of the cancer from the prostate to the testicular region. 

Can anyone confirm if HT will cause testicular pain?

Thank you!

Max Former Hodgkins Stage 3

Various

Path,

You asked a variety of questions since anyone else has written. I will respond to a few of them.  Cyberknofe is one form of SBRT radiation.  Traditionally, radiation is delivered in "fractionated " form,  meaning in comparatively low applications over a period of weeks , to even around two months. But the total number of Gr (Gray, a measure of radiation) is in the end about the same for both. IGRT is a form of very precise fractionated therapeutic radiation.  Cyberknife has benefited from very slick, professional marketing. My radiation oncologist was not a fan, although his group does SBRT as well as fractionated. But SBRT does have widespread acceptance today.

SBRT is in routine use for prostate cancer, in no sense is it new,  although overall SBRT began more forr difficult to access tumors, especially in the brain and lung.

The idea behind SBRT is to deliver the radiation in much stronger individual doses, usually doing in a week or so what otherwise might have taken two months with fractionated delivery. Added to this is extremely accurate delivery.   The efficacy of fractionated and SBRT are about the same, as determined by the long-term studies done so far, but this question is far from resolved yet.  It will be another decade or so before a definitive answer comparing the two can be derived.  It often takes decades for these sorts of data to accumulate, because radiation can have side-effects on cell health that only appear after decades.

"Cyberknife" is a proprietary, company name. Other companies also provide SBRT radiation, primarily Varian.

From the continuing issues you are having with your relative, I think I would try to take him to a Western nation, or Japan, for treatment, if that is an option. 

 

 

VascodaGama

Increased activity of the testis in the first two weeks on HT

Testicular pain is not in the list of prime side effects from hormonal treatments but it is possible to occur, in particular, in the initial two weeks since starting LHRH agonist treatment. These agonists cause a flush in the FSH signaling which will "order" the testicles to produce testosterone continuously. From the third week on the pituitary stops the orders and the testicles enter into stoppage. The increased activity of the testis leads to increased flow of blood in local veins that could cause pain.

In any case I would strongly suggest your relative to inform his doctor on the matter and on any other symptom he will experience. Here are typical side effects from HT;

http://prostatecanceruk.org/prostate-information/living-with-prostate-cancer/how-hormone-therapy-affects-you

VG

 

Pathfinder

Thanks Max for that

Thanks Max for that information regarding radiation treatment. We used that today when speaking to the original doctor who handled the biopsy, and he said radiation treatment was an option, which is good, but because they believe the cancer is still within the gland, surgery is still reccommended. 

Our plan is still to get the MRI again with a 3.0 machine to be more confident about that, however. 

What he didn't give us time for is to ask detailed questions regaridng radiation surgery. Time is extraordinarily limited here. If you get 10 minutes you've done well. I'm considering going abroad as per your suggestions, but that's later down the road. One step at a time.

VGama, appreciate that! To be detailed, it seems to be the right testicle that's aching. We informed the doctor today and he did an inspection of the rectum using his finger. He concluded it was an unrelated infection in the testicles and prescribed over $50 worth of medication and sent us out the door.

In my opinion it is not related to infection whatsoever and he made a nice commission on the prescription - as they do - and now my father in-law is taking meds (about 7 boxes worth) that he doesn't need. In my estimation it must be related to the HT or the PC, because that makes a lot more sense than a sudden 'testicle infection' considering the circumstances.

Which leads me to ask two pertinent questions: 

1: Is there an increased liklihood of testicle infection with PC or accompanying HT?

2: Is such testicle aching a possible sign of the cancer spreading to the area?

We're obviously very concerned about the latter.

Thank you again, your information is invaluable.

 

VascodaGama

Busy doctors or those that prefer to avoid educated patients

I understand the difficulty your relative is having in getting comments from his doctor. Urologists do not like to discuss with "educated" patients when subjected to questioning. Apart of that, hospitals are so crowded and busy that they regulate limits in the time of consultations spent with each patient.

To answer your question; I never read reports about prostate cancer metastases to the testicles. In advanced cases (I think not your relative's) prostate cancer tends to invade firstly the localized lymph nodes and from there it goes to the lungs, liver and bladder. It travels via the blood vessels so that it is caught in the lymph nodes (the filters of our circulatory system). However, even those that pass these filters do not adapt and survive that easily at the newer environment (home). These cells will be targeted by our immune system that see them as "foreigners" to that local. Unfortunately some may survive.

In any case, I have heard of guys reporting about testicle pain, ingrowing pain and lower abdomen pain, by the occasion of being diagnosed with prostate cancer, though the pain seem to be a neurologic matter. Our mind plays tricks on us and fakes us in feeling pain down there every were, with no particular reason. Even the slightest feel becomes a huge worry making us to relate it to the cancer.
As I commented before HT drugs do not cause infection or pain.

Regarding your above information on the MRI, It says that the size of the prostate is normal. They also could not verify lymph nodes involvement. But they point out about a nodule at the back left tissue surrounding the gland. Could this mean extra-capsular extensions?
This is an area out of reach for the finger touch.

I still recommend you to do the T3 MRI and get a second opinion on its results from an independent radiologist. You can do it in the USA with a copy of the MRI film. Upon that you will have the confidence in deciding to advance with surgery or radiation.

Wishing you peace of mind.

VG

  

Pathfinder

Brief follow up: the testicle

Brief follow up: the testicle discomfort hasn't subsided with the prescribed medication, which is exactly as I suspected - they just threw $50 worth of pills his way for the commission. 

He says he doesn't want to take them any more (and I'm wondering personally if such medication can adversely affect the HT treatment in some way) but I told him to keep on them for at least a week just in-case to see if there's any result.

A shame when doctors are also vultures, but that's the way of the world in countries with no national health services. You're a customer, not a patient.

Pathfinder

Need your advice on surgery types

Hello all,

We've been busy. Seen many doctors and visited many hospitals. In the end we came to the conclusion that surgery is the right option for now. The reasons in brief:

- China's radiotherapy isn't as advanced as the west, and the radiologists aren't as experienced in treating prostate cancer. 

- In all consultations regarding the diagnosis, the case is considered to be 'mid-high risk', a T2c with a possiblity of a T3a. Because of this, and because the MRI concluded that the cancer was contained within the gland, we've decided to take a chance on surgery in the event that the cancer is actually contained, and that if not, the surgeon can clean up anything that appears outside the region. There is then an option of salvage radiotherapy later.

- We were given an option of Brachytherapy by one hospital, but they have only treated a handful of cases, and according to information obtained, Brachytherapy is more for low risk patients (and the findings of its efficacy are not conclusive yet).

The question now is what type of surgery to have. We're not sure what to do.

- There is an option in Shanghai, a surgeon with a lot of experience in open type surgery. He favours this kind because of his experience and because he feels it is more thorough than the other options. Unfortunately this is the most costly option for us (by far - 70% more expensive than a local operation). 

- There is an option for local treatment in the city's best hospital using Laparoscopic surgery (4 holes) but they only treated 8 cases of PC last year, hence, less experience in terms of case numbers. They don't offer open surgery. This option is considerably cheaper because some subsidies are available (70% cheaper than Shanghai).

I know money shouldn't really an issue, although whether we like it or not, it will certainly be an issue later. For now I was hoping to get your input regarding Laparoscopic over open surgery types. I understand the latter is less common these days, but we're worried Laparoscopic may be less thorough. 

Would you go for the open type with the experienced surgeon in Shanghai, or Laparoscopic locally in a well respected hospital, but with a lesser case history?

Do cleanup results usually vary a lot between these two surgery types?

Thank you for your advice! 

 

Max Former Hodgkins Stage 3

Pathfinder said:

Need your advice on surgery types

Hello all,

We've been busy. Seen many doctors and visited many hospitals. In the end we came to the conclusion that surgery is the right option for now. The reasons in brief:

- China's radiotherapy isn't as advanced as the west, and the radiologists aren't as experienced in treating prostate cancer. 

- In all consultations regarding the diagnosis, the case is considered to be 'mid-high risk', a T2c with a possiblity of a T3a. Because of this, and because the MRI concluded that the cancer was contained within the gland, we've decided to take a chance on surgery in the event that the cancer is actually contained, and that if not, the surgeon can clean up anything that appears outside the region. There is then an option of salvage radiotherapy later.

- We were given an option of Brachytherapy by one hospital, but they have only treated a handful of cases, and according to information obtained, Brachytherapy is more for low risk patients (and the findings of its efficacy are not conclusive yet).

The question now is what type of surgery to have. We're not sure what to do.

- There is an option in Shanghai, a surgeon with a lot of experience in open type surgery. He favours this kind because of his experience and because he feels it is more thorough than the other options. Unfortunately this is the most costly option for us (by far - 70% more expensive than a local operation). 

- There is an option for local treatment in the city's best hospital using Laparoscopic surgery (4 holes) but they only treated 8 cases of PC last year, hence, less experience in terms of case numbers. They don't offer open surgery. This option is considerably cheaper because some subsidies are available (70% cheaper than Shanghai).

I know money shouldn't really an issue, although whether we like it or not, it will certainly be an issue later. For now I was hoping to get your input regarding Laparoscopic over open surgery types. I understand the latter is less common these days, but we're worried Laparoscopic may be less thorough. 

Would you go for the open type with the experienced surgeon in Shanghai, or Laparoscopic locally in a well respected hospital, but with a lesser case history?

Do cleanup results usually vary a lot between these two surgery types?

Thank you for your advice! 

 

Surgery

Pathfinder,

I will give opinions on several of the questions you posited.

First, while radiation therapy is often a better choice, if current, advanced deliveries of radiation are not available, then indeed it comes off the table as a good option.

You are correct that Brach ("seeding") is usually reserved for mild cases. I cannot imagine that he is such a case.

In the US for surgical removal of PCa, DaVinci Robotic is now the most common, but open incision is not uncommon.  DaVinci is a form of laproscopic, but I am not versed in non-DaVinci laproscopic technology for RP, and can't comment.

If the open-incision doctor is "a lot more experienced," that is what I would go with.  Open-incision is still a technique of choice even in the US for complex and problematic surgeries, and makes "node mining" (checking sentintal nodes for involvement) much easier.  Dr. Peter Scardino, Chief of Surgery at Sloan-Kettering Cancer Center in NYC, himself prefers open incision.

I had DaVinci removal myself, 1.5 years ago.  Open-incision surgery is reportedly slower to recover from, but it seems other issues in his case are more determinitive than recovery time or ease.

Regardless of method used, demand that the seminal vesicles be removed.  This is universal now in the US, and there is virtually never a reason to not remove them.

Liker the other guys, I am not a doctor, and have no medical training whatsoever.  We relate opinions, not medical advice.

I hope this is of assistance,

max

Old Salt

Agreed

Here in the US, it is generally agreed that a surgeon needs to do at least 100 procedures (open, laparoscopic, or DaVinci) to become expert. Therefore, I also recommend the Shanghai (open surgery) option. Recovery will take longer, unfortunately. On the other hand, open surgery gives the surgeon a few options that are unavailable otherwise.

Just like Max, I am not an MD, but  I have read quite a bit about prostate cancer, as a patient.

VascodaGama

Open for me too

I did open surgery 16 years ago, so that I would recommend open instead of the laparoscopic. Both are good but the experience of the surgeon should be the subject to consider in the decision. Open takes longer to perform but the doctor can disect lymph nodes at the iliac which is proper when we have no conclusive image study.  Laparoscopic has lesser cutting therefore faster healing with shorter period of staying in the hospital (cheaper therefore) but the important in the treatment is the outcome, so that the facilities, experience of physicians and after care are important matters to consider.

Best,

VG

Pathfinder

Just to say thank you all for

Just to say thank you all for the responses, it's been extremely helpful in making our decisions. At the moment we're trying to work out some kind of possible subsidy for the cost of the surgery. It's unlikley but worth a shot. My father in law is just now month 2 of diagnosis and is getting the second HT injection and more pills today, but we're hoping to get the surgery done ASAP. 

Will update ASAP. 

Will Doran

DaVinci for me

Pathfinder,

As I have stated, I was a PSA of 69 with a Gleason 7, when diagnosed.  According to my MRI's the cancer was confined to the gland. So, surgery was my best option at the time (3 years ago-next week). So, I , like Max, had DaVinci assisted surgery.  The surgery took 5 1/2 hours becasue of a birth defect and complications caused by a double abdominal hernia rerpair.  I was home the next day after the 5 1/2 hours of surgery.  Back on a treadmill in three days and back on my spinner bike in 6 weeks (two weeks ahead of what I was told to expect).  As VG said, the recovery is much faster from the Robotic assisted surgery.  I didn't even have stitches on the outside.  My surgeon is a firm believer in using some kind of glue.  Not sure what it is called.  But there was no follow up stitch removal.  I had some incontinence problems at first, but that is improving.  I was an Aggressive Stage 3, but was treated as a Stage 4, because in the followup Pathology I had one very small spot in one lymph node.  As Max said, demand that the seminal vesicles be removed. That was done in my surgery and all was well.  It was good to get that report back.  So, I was started on, follow up, with 2 years of Lupron.   And,  then after the Lupron was started first,  8 weeks of RT.  My doctors told me they were going to be very aggresive and they were.  So, far that has all worked out OK in my case.  Like Max and Old Salt have said, I am not an MD.  I can only tell you what has worked in my case.  Our cases are all different. 

In an earlier post from you, you mentioned that your Father-in-law was experiencing testicular pain when he started Lupron.  I had that as well.  I was told that that might happen, because the Lupron causes the testicles to kick into "high gear"(my doctors words) at first and that pain can happen.  Right now, after I've been off the Lupron for 5 months, at this point, My Testosterone is coming back up.  It's still low and I still have a few hot flashes, but my "T" level has come up from 17 to 134 as of my last blood work. Normal is 250 - 1,000.  At this point I am having some testicular pain again as they are starting to function again.  I have more blood work in two weeks and will have my check up and will ask about this at that time.  My doctor told me at my last check up that, again, this pain might occur.  My doctors have been very good at warning me ahead of time of what to expect, all the side effects, etc. 

Best of luck

Tell your Father-in-law, to be strong and fight like the devil

Peace and God Bless

Will