Borderline case?

Lunaone,

I admire your way confronting the situation. You are doing it well in investigating and getting second opinions from several sources before deciding.

The Gleason 6 (3+3) is the lowest in aggressivity but the voluminous aspect found in all the six cores and the positive DRE (tumor is detectable on DRE) may limit your choices in treatment, probably turning AS not suitable. Your doctor’s comment regarding the gland’s ”adhesion“ is related to its shrunk size of 18cc (cause of TURP interventions). I think you should get a proper image exam to certify on extra prostatic extensions.
Common CT or MRI or Bone scans may not be proper to you and I would suggest you to find out on the possibility in having an exam done with the latest techniques and contrast agents in image studies.

Your 10 years long case with BPH, and the negative analysis for cancer till the present sextant biopsy, makes me think that the Gleason pattern is lower than 3. This is an important element that could lead you to better diagnosis and decisions. I mean that a pattern 3 could in fact be a pattern 2 (such classification has been abolished since 2006) which would down grade the aggressivity of your case. However, if EPE is found to exist then you could be confronting a case of micrometastases (a series of colonies of tiny sizes, difficult to be detected by CT and MRI). In such cases PET works better. Another fact is that the viable Partin Tables may also not be proper to predict any EPE involvement, due to the present size of the prostate.

Once proper diagnosis is in hand then you have the possibility in choosing AS if EPE is negative; or, otherwise, choosing a palliative treatment with HT (hormonal manipulations proper for low Gleason patterns of 3 and lower) or have an extensive radical treatment involving the gland, its surroundings and the lymph nodes as far as at the iliac. Your age and your health (any other existing illness, etc) and considerations to the quality of living (side effects of treatments) will count in the final decision.

In your request for the review of the pathological report at Johns Hopkins you can ask for analysis of the Gleason pattern as it used to be done before 2006 (lower than Gr3). The Prolaris genetics testing will also verify cancer’s aggressivity but it will also help to verify if the cancerous cells will do well with a palliative therapy (certain types of genes provide this information).

Take along a list of questions when visiting the doctors. Here is an example to help you;

http://www.cancer.net/navigating-cancer-care/diagnosing-cancer/questions-ask-doctor

Welcome to the board.

Best wishes,

VGama

Lunaone said:

Lots of good input!

Thanks, VGama!

You offer lots of good thoughts here.  I will especially check out the possibility of contrast agents for imaging studies.  A university hospital here in my state has a trial running, apparently, to look at new imaging techniques.  I might do well to check that out.

Cheers!

Lunaone,

Welcome. With Hopeful, I would encourage you to seek out the imaging he recommended, if it is available.  

As you yourself alluded to, conventional CTs will not detect tumors smaller than ~ 5mm, although advancements are being made in CT imaging, as is also the case with MRIs.   I was first made aware of this by my pulmonologist, who is following a node my right lung (most likely benign; if not, my thrid type of cancer).  I have absolutely no medical training; I tell people instead that I have learned stuff by having had everything !  

Imaging technology has new announcements almost monthly, but there is huge lag time between what a device or technology suggests it might do, verses it's availability, both in the insurance and geographic senses of the term 'availability.'  New developements posted here are ordinarily links to a recent study, and they are frequently little more than press releases distributed by the marketing departments of the men who wrote the studies.  Other links are to government assessments, etc., and these are usually more substantive.  I oversimplify, and am absolutely NOT referring to anything on this thread, or any other recent sharings, which are nonetheless valuable and may help a patient in dire straights.  

The writers here tend to be wealthier than most patients -- better connected, better informed, more studious.  If you can travel the nation for the latest and greatest, wonderful, but most cancer patients are lucky to get in to the local clinic for basic services.  I have had several friends and aquaintances over the decades who were at the end of known treatments (some were PCa, most were not) who travelled to Sloan-K and M.D. Anderson, etc.  In every case that was shared with me, they were told that these world-class,  leading institutions would have done what they received at home, at their regional medical center.  And, all of them died shortly thereafter.  There are occasionally very rare situations that only some world-renowned expert with be proficient at treating, but this is extraordinary.  I just am not a believer in the idea that a guy with routine cancer has to travel long distances in the US for care that is probably as good as he would receive in virtually any local medical center.

As a man who had surgical removal last year at the age of 58, I would just like to add that I could never recommend surgery as a first line treatment for PCa in a 72 year old man.  Yes, it is feasible, and men even older have gone the surgical route with good results, but it commonly has the most, and worst, side-effects.   If there is no detectable escape from the gland, SBRT or IGRT are great choices; if escape is confirmed or very likely, IGRT is what I read doctors most commonly recommending.

Do speak to several doctors -- some urologists, some radiation oncologists. Sloan-Kettering Cancer Center in NYC, online at their prostate cancer page, has printable matrices into which you can plug all known diagnostic information variables, to determine probable outcomes from various treatments. These matrices are called by SKCC "nomograms." These are based upon statistical reviews of a huge volume of patients.

Nomograms description from their Prostate Cancer site: https://www.mskcc.org/nomograms/prostate

As everyone has mentioned, your specifics sound like a readily beatable case of PCa.

max

Lunaone said:

MRI and active surveillance

Thanks to "Hopeful..." for the 3T MRI suggestion.  I have been told so far that I'm not likely to get good input from MRI or from CT scan.  Apparently because tumors need to be more advanced than mine are likely to be at this stage before they can show up on most (or all?) imaging exams.  But I will look much more carefully at this since it is so obviously important to know about any ECE and especially about any possible metastasis.'

I meant to say PSA density instead of prostate density in my previous post, by the way.  Since that is the more relevant standard variable.  I'm confused at this stage, however, just what the prognostic value (ECE or no ECE?! tumor aggressiveness level?) of PSA density may be.  It does not seem to be used in Partin tables.  Similar question regarding the 6 of 6 biopsy core involvement, and the 50 to 90% levels of cancer in all of those cores.  Do these facts strongly suggest ECE and/or higher levels of aggressiveness?  Or am I just fine to mostly ignore those things and just use the Partin predictions unaltered?

"Hopeful...'s" remarks about my possibly not qualifying for AS would point to one answer (as does his mention of my low % of free PSA) and it does seem to agree with the sense of things I'm getting from my urologist.

What hopeful is suggesting is a type of spectroscopic scan that is more advanced than an MRI or CT scan.

The 3T MRI is also called an MRI/MRSI or multiparametric MRI that screens for choline which is a marker for cancer.  In the case of prostate cance,r you are given a dye injection and then you're placed in an MRI machine w/a Tesla coil inserted in your rectum.  Any choline found in the scanned region is clearly shown and can giveyou a complete map of the location of any cancer, regardless of the size of the source.  It is simply the BEST test for cancer detection available for PCa.

Here's a link to a UCSF paper on the subject: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1578527/

Only problem is that it's a VERY expensive procedure that isn't commonly approved for payment unless there is already some indication of the exisence of cancer that prior treatment has failed to reach.  In my case, there was an indicatino of a recurrence of cancer (3 rising PSA tests after treatment) which gave my RO a basis to request and receive approval for the scan. 

Not sure you would be able to get approval for such a scan in your case at this time BUT it doesn't hurt to ask for it.  Good luck!

Lunaone said:

Good to hear that PCRI is respectable.

There are so many things out there and I didn't find these guys until about page 3 of some Google search or other I was doing.  So I'm glad you were able to tell me more.  I tried to follow some of the leads from the PCRI pages I was looking at and was not able to open things.  Their SHADES risk assessment tool, for instance, is still a mystery.  Can you provide a link for getting into that?  My problem may be that I'm doing all my work from an iPad.  I have occasionally run into compatibility difficulties in the past.

 

again,

Thanks!

I don't frequent that site.

In the United States one can use a computer free of charge at the public library that can resolve the compatibility issues that you experience, or you can contact the PCRI people for direction or information.

Best,