Pathology report in - should we commend with HT?

Pathfinder,

Others here are much better informed in aggressive and advanced treatments, but I have read that a Gleason of 8 is ordinarily ASSUMED to have escaped the gland. It constitutes very aggressive disease. 

Many doctors, when treating aggressive cancer that has escaped, would recommend that prostectomy not be done at all, now or later. The argument ""for" surgery is toward debulking, the argument "against" is that RPt will not remove all of the disease, and the side-effects are more dibilitating for the patient than they are worth.

He probably needs to be more precisely staged, which would require advanced imaging that perhaps is or is not readily available in China.    Regardless, beginning with HT does not seem unreasonable to me, but as I said, I am not well versed in aggressive or late-stage treatments given first-line.

Do get the additonal opinions.

max

Max Former Hodgkins Stage 3 said:

Impression

Pathfinder,

Others here are much better informed in aggressive and advanced treatments, but I have read that a Gleason of 8 is ordinarily ASSUMED to have escaped the gland. It constitutes very aggressive disease. 

Many doctors, when treating aggressive cancer that has escaped, would recommend that prostectomy not be done at all, now or later. The argument ""for" surgery is toward debulking, the argument "against" is that RPt will not remove all of the disease, and the side-effects are more dibilitating for the patient than they are worth.

He probably needs to be more precisely staged, which would require advanced imaging that perhaps is or is not readily available in China.    Regardless, beginning with HT does not seem unreasonable to me, but as I said, I am not well versed in aggressive or late-stage treatments given first-line.

Do get the additonal opinions.

max

Prostate Cancer is a very slow growing disease, so it best for your father in-law to make an educated decision and not panic as you are. It is counter productive.

Max gave excellent advice.

What is the patients age? Surgery can have major side effects, the older one is the more likely the side effects 

How many cores were taken. Of these how many were positive. What was the Gleason of these positive cores. What percent of each Core was positive. 

Many men with a Gleason eight, first have hormone treatment. The results of radiation treatment is Better when radiation follows hormone. In addition radiation treatment includes a greater range outside the Prostate so there is a better chance of cure.

Keep on asking questions, we can help.

Pathfinder,

From the comments and info you share it seems that you are suspicious of his doctor’s suggestion. I agree that the combination therapy made of HT plus Surgery is weird but it could be suggested due to a reason you have not at hand. For instance, if your family in China has requested for early means of intervention to hold the advancement of the cancer while deciding on a treatment (They may have adopted this to gain time for receiving your comment from the USA); or if his gland is too big in size that would not be feaseble for radiation or earlier surgery intervention; etc.

My opinion is that his case is not at the verge of becoming a night mare overnight. The high PSA of 24 signify the presence of a voluminous cancer (producing the serum) which could be composed of several independent tiny colonies of tumors of different Gleason patterns that could be contained in the gland or already have spread. It is a fact that aggressive Gleason patterns of 4 and 5 are commonly found in cases of extra prostatic extensions, but according to the biopsy info you provided, lower Gleason exists which could be the ones producing the high levels of PSA. Gleason 8 cancers are more for the type of cells that produce lesser amounts of PSA.

I wonder about the Clinical stage his doctor has provided. This typically provides a clue on the data they have in hands. Was there any image study (MRI, CT, bone scan, x-ray, etc). Do you have any report?

Physicians are aware of the limitations in these exams that quite often provide false negatives but when classifying a case they would not disregard the data collected. They tend to follow the guidelines provided by their association (Urology, radiology, oncology, etc), and only a few number follow their instincts based on past experiences. Naturally, a urologist most probably would recommend surgery as much as a radiologist would recommend radiotherapy.

I would think that his doctor is following his trade principles. The suggestion for the HT (hormonal treatment) may have nothing to do with the surgery. In any case, when the prostate size is too big some surgeons (in particular those performing robot assisted surgery=Davinci) recommend diminishing the size of the gland firstly (with hormonal drugs), before operating on it. Robotic surgeries use small holes so that big glands could not be take out into one piece, it should be cut inside the abdomen which procedure raises the probability of leaving behind a tiny piece of “contaminated” tissue (microscopic) that could later cause recurrence.
Such could be his argument of “… making the surgery safer”, as you describe in your post above.

I agree that waiting would be better, even in spite of the risky doubling, if surgery is found to be the best choice, but is it surgery the only and better way to treat this patient? There are other options to be checked about.

One note regarding the hormonal treatment is that this is palliative and does not cure. It manages to pin down the cancer so that the PSA gets lower; however, a lower PSA due to hormonal manipulations masks the results/outcomes of a radical treatment. Accordingly, the success of the surgery done while on the effects of the hormonal therapy cannot be verified at once. One should wait till the effect vanishes, taking about 6 months after the end of the effectiveness of the HT drug.

You doing it well in getting second opinions but you should have in hand a copy of all tests and exams so that proper advice is obtained.

Best wishes,

VGama

Pathfinder,

As Hopeful & Optomistic stated, things like bike seats will raise PSA.  I was a road cyclist and was on a bike seat up to three hours per day, riding with the Penn State cycling club, at times..  I had a PSA that showed 1/2 point above what was acceptable.  I had  DRE and was told that my prostate was "the smallest prostate" the doctor had ever examined.  He wanted to do a biopsy, but my GP said it was all from the bike seat and therefore didn't recommend doing the biopsy, since my prostate was so small. So there were no real signs of a problem.  I had no symptoms.   However 5 years later I had a PSA of 69.  If only I had done the biopsy 5 years earlier.  But that's the way it goes.  My cancer was found, by sort of accident, when I had an internal bleed and it showed up in blood work and MRI's.  At that point my prostate showed up bright red in the MRI (with contrast imaging) pictures.  So, we proceeded.  So as stated it's very important to look at all kinds of tests and the results. 

Now, with the prostate gone, I'm on a spinner bike for 80 - 100 minutes per day and all is well (so far).

Good luck

Peace and God Bless

Will

It is disturbing indeed when doctors do not explain details or pass over the data at their hands. I do understand that they are not teachers and we (the pupils) should get educated on the illness before visiting them. Preparing a “list of questions to the doctor” in advance of each consultation is reasonable.

In the descriptions above, one missing piece of data is the size of the prostate (it should be written in the MRI report or Biopsy), in any case, your indication of existing hyperplasia (“..Benign prostatic hyperplasia, in glands and smooth muscle hyperplasia..”), leads to think that your Father-in-law could have a larger than normal gland. Larger sizes glands and Hyperplasia also justify existing high PSA of which a greater portion may be produced by benign cells.

The term “smooth muscle hyperplasia” may signify PIN (prostatic intraepithelial neoplasia). They do not make any reference to the matter so that we wouldn’t judge it as high grade PIN, which would turn the case more aggressive, with the right side of the gland involved. The other information regards the cancer in the left side with Gleason pattern 5 found in two cores 8% each. They do not comment on a tertiary grade so that the score 8 (3+5) stands. From the data shared, his clinical stage is T2b but the PIN on the right side could upgrade it to T2c. The grade 5 provides the possibility for a T3a.

I wonder about another comment pointed by you that the doctor has recommended “Neoadjuvant chemotherapy prior to surgery “. Does he recommend chemotherapy or hormonal therapy?
Chemo and hormonal are two different treatments. Isn’t it a mere translation mistake?

Bicalutamide (Casodex) and Zoladex (LHRH agonist similar to Lupron) are traditional hormonal drugs. Abiraterone (Zytiga) is also a drug of the hormonal arsenal, usually taken as a second-line drug when the patient becomes refractory to the initial HT drugs. I wonder if his doctor has recommended chemotherapy instead of the hormonal, but either way, both would be meaningless for an adjuvant surgery approach.
One note goes to the possibility that his doctor is running a clinical trial similar to the one run at USA, below. Participants in trials have usually free treatment. You should investigate if he has been offered the inclusion;

https://clinicaltrials.gov/ct2/show/NCT00002633

Max above says it all. Give preferences to a radical therapy (surgery or radiation) and add a palliative that may improve the primer. In such aspect, radiation (RT) seems proper when the case includes information regarding high risk for metastases.

Here are some reading materials that may help you:

A compendium on Prostate cancer and care;
http://www.lef.org/Protocols/Cancer/Prostate-Cancer-Prevention/Page-01

Booklet about biopsy;

http://www.harvardprostateknowledge.org/understanding-your-prostate-pathology-report

Please note that I have no medical enrolment. I have a keen interest and enthusiasm in anything related to prostate cancer, which took me into researching and studying the matter since 2000 when I become a survivor and continuing patient.

Best wishes,

VGama

Path,

From the info you have shared, I cannot understand the reason for doctors at that hospital recommending hormonal therapy before surgery. They seem to be out of focus, treating the PSA not the cancer.
The biopsy report indicates cancer in left lobe and benign tissue in the right. Hyperplasia may exist allover. The number of positive cores is not well specified but one could think that only a fewer percentage involves Gleason pattern 5. You can request a second opinion on the biopsy slides from another pathologist laboratory. You could request your family to DHL them to you and then send it to JH laboratory for an opinion on the findings.

Regarding the treatment, surgery is recommended to contained cases (the whole cancer inside the gland). This is what surgery does, dissect the whole gland. Radiation can also treat at the same level as the surgery to a contained case but it can also cover a wider field including the gland, its bed and the localized lymph nodes. Radiation, therefore, is better when one has doubts about the location of the cancer. 

The hormonal treatment can be done any time. It is paliative so that it only controls the advancement of the cancer. Three months HT is too short for any significant benefit. Usually HT treatments are done for 18 months or just 6 months when its purposes are to "improve" the results of the prime radiation treatment.

You can find details of my comments googling the senrtences.

Best wishes,

VG

The side effects from surgery are severe more so than other active treatment types. Additionally surgery is a localized treatment. So if the cancer has  escaped the prostate, of which there is there is a good chance of in your father's case the cancet will still exist and and salvage radiation treatment will be required. The side effects of each of these treatments are cumulative.

Hormone treatment before radiation increases the success rate of the radiation. 

 still exist.

That is why radiation would be preferred treatment and your father's case. Not only will the prostate be treated but the surrounding areas around the prostate will be treated. It is more likely that they will be better treatment success with less side effects

Having hormone therapy before radiation increases the effectiveness of the radiation