Biopsy Results Back - Not Good - GC5 - Gleason 9 (4+5)

Hi again,

Sorry for the bad results. Gleason rate 5 is the highest in aggressiveness but it can be treated.

You need to discuss the matter with your urologist but the most important will be the judgment on extraprostatic extensions. Gs9 cases got the risk for spread and that limits the options on therapies.

I wonder the location of the positive cores and the percentage of cancer in each one. Can you describe other elements reported by the pathologist. Did they report about seminal vesicles involvement?

How about existing extraprostatic extensions?

In your shoes I would request a bone scan (or still better a PSMA PET) before deciding on a treatment. The previous MRI is limited to detection of volumes and mass but you need to verify spread in lymph nodes (macroscopic) and bone.

Typically, contained cases are treated with surgery or radiation but non contained cases (extraprostatic involvement) are recommended to radiotherapy.

In multimodal approaches in risk cases, some doctors recommend combination treatments involving surgery for debulking purposes plus radiation of surrounding areas (including close lymph nodes) and adding hormonal treatment (ADT).

Multi therapies signifies multi side effects which would deteriorate to certain extent your quality of life.

Here is your story. I think it better that you keep inquiring in the same thread;

I recommend you to have your wife accompanying you for the next meeting. Prepare a list of question and take notes of the conversation. Here is a link for an idea on a list of questions;

Best wishes,

VGama

Hi again,

From the report, there are 7 positive out of 14 cores. They also identified perineural invasion (nerve bundle running lateraly but within the outer shell) which usually is related to bad prognosis in contained judgments.

The nerves is one of the routes for cancer spread.

The two extra needles (LA) may have aimed the lesion identified in the MRI. I wonder their location.

Though the positive cores are all from the left lobe, in my lay opinion, choosing radiation therapy may be the best shot. The apex seems to be the most affected area which also includes the identified perineural invasion.

It will be wise to get second opinions on the comments obtained in your next meeting with the urologist, probably from a radiotherapist.

Here is a link about treatments and the risks involved;

Best wishes and luck in this journey.

VG

Hey @marco1910 sorry to hear of your biopsy results, though glad you found out.

I would consider getting a consultation with a radonc now, or at least scheduling one now. Goal is to discuss possible results and potential plans of action while you wait for a PSMA. Also, to see if they are someone you would want to work with, so a job interview. No need to do everything in serial.

Hi,

Good advice from the survivors above. Might want to get started looking at the various treatments available for agressive cancer so you can have questions ready to ask your team(Urologist + Oncologist). Don’t know if a month is too long to wait but being prepared to make a treatment decision once your PET scan is complete will help move things along. Sometimes you need to be your own advocate to help things moving along. I feel being educated on the various treatment protocols will only help with the dialogue between you and your doctor team. I have included a link to get you started on your homework.

Dave 3+4

Hi again,

I understand your worry on spread while waiting for added tests, but the cancer would not spread in a way that it would alter the present situation or alter the options to treat, in one month.

The data collected from additional tests can influence in the choice of treatment if far metastasis (in bone, or at chest lymph nodes) are identified.

You need the opinion from a specialist not from a PA or GP. Take the lead and contact the hospital.

As I commented above, you have a high risk case for the type of Gleason rates and voluminous (7 out of 14 positive) meaning that there is a high probability for existing extraprostatic extensions, which would classify your case as "not contained".

In such condition surgery alone would not be practical, being radiation prefered. However, in high risk cases some doctors recommend surgery, not aiming cure but with the intent of debulking the chuck of cancer (the whole gland). Radiation would be added to treat the surrounding tissues.

Surely, one can choose radiation alone that would cover the whole gland plus the surrounding areas, avoiding the typical side effects from surgeries.

If the appointment with the surgeon is late then you can start with an appointment with a radiotherapist to discuss on radiation modalities, procedures involved, risks and options.

Survivors in similar status as that of yours have reported in IMRT alone, or combination radiotherapy with Cyberknife plus IMRT, or HDR brachytherapy plus IMRT.

Some doctors recommend starting with hormonal treatment (ADT) but you should get the tests done firstly as the drugs can influence the test outcome.

I recommend you to do some research on the types of radiation on Dr. Google, preparing a list of questions for the appointment, while waiting for the PET or bone scan.

Best wishes.

VGama

Maybe if you see a radiologist he will put you on Casodex or something similar before doing radiation.....at least you are doing something in the meantime and gaining some time.....I am not a Dr by the way so maybe I should not be saying this.....if I was you I would be really not happy at all......you don't want to wait so much if your Gleason score is high.

With a high Gleason score probably all the fancy new treatments like HIFU, Criotherapy, Nanoknife, etc, etc, are out of the question.....

so probably surgery or hormone therapy with radiation are the better options.....

Why do you have to wait so much? You don't want the thing to get out of the prostate.

Hi again,

No detection of far metastasis is great news. I think that now you have a complete set of data to make a decision and proceed. Why do you imply "2-3 months of wait" ?

Is there a problem with the insurer? or is the hospital that busy?

Radiation (RT) is advisable even if you choose surgery. The hormonal treatment becomes secondary but pairing it with radiaton improves the odds of success.

Regarding your questions;

1) The period on ADT of two years is reported to have "generally" better outcomes in G9 cases but my lay opinion is that 6 to 12 months would be sufficient. This period pairs the life cycle of prostate cells that lasts about 6 months to be certain of the death of such cell.

Some G9 guys in this board reported periods of 12 to 18 months.

2) The combination of surgery (RP) and ADT is not common. There is no studies showing long term survival for this kind of combi. But there are good survival outcomes in G9 cases with the combination of RP plus RT.

ADT is palliative and doesn't kill the bandit. It improves the work of radiation (the assassine) in killing cells.

In other words, if in doubt then choosing the "mother of all treatments", RP+RT+ADT could be a choice.

3) I question above your comment on the 2-3 months wait. Surely the cancer is multiplying every day so treating it within one month is advisable.

The PSMA scan result (image film) is usually blared at the surrounding closest area of the gland. This is caused by the excretion of the isotope via the urine that will be present in the bladder at the time when the picture is taken. The "ALL CLEAR" means that metastases were not found in close and far lymph nodes and bone. This verifies a localized case that could be or not to be contained.

It is true that ADT manages to hold the progress of the bandit. In fact some guys managed to postpone radical treatments for 5 years in ADT3 intermittent modalities.

In such cases, one needs to be followed by medical oncologists specialized in combination of drugs.

ADT3 is a combination of three blockades. Antiandrogens plus agonists plus 5α-reductase inhibitors (anti-DHT "dihydrotestosterone).

Not all Gleason rate 5 cells react equally to the same drug. Moderate cases manage to accomplish the same period in holding the bandit on just two blockades. For instance; an agonist (Lupron) plus xtandi.

in all, you need the advice of a doctor that you trust.

Diets or vitamins are good for the overall health but it wouldn't change your present situation.

Get second opinions always.

Best wishes,

VGama

Once you are on ADT, you have some time to decide on further treatment.