Pathology report in - should we commend with HT?

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

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,

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

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

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

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.