Latest on IRE Nanoknife Focal experience
Thought I'd start a new post and update my Pca journey.
Condensed history: First diagnosed November 2023 with 4+3=7 tumor within gland. Confirmed by 2 biopsies, bone scan, and PSMA PET scan. No metastasis. After local urologist suggested surgery or radiation I got a second opinion from Fox Chase Cancer Center in Philadelphia. They too suggested surgery or radiation, but also offered a third option of focal therapy which due to tumor location and other factors I was a good candidate for. I choose this option due to it's having much lower risk of side effects. IRE Nanoknife ablation was performed May 2024. Procedure went well with the exception of a few days of urinary retention after catheter removal. (Do it yourself intermittent catheters is something I would not wish on anyone.) Anyhow, at time of procedure my PSA was 5.6. Three months post procedure it had dropped to 4.6. Everything was functioning as before with exception of no more ejaculate fluid. Now at 6 months post procedure PSA has risen to 9.3 😪 which my surgeon immediately suggested an MRI. Results below:
Narrative & Impression |
|---|
Study: MRI of the Pelvis, with and without intravenous gadolinium, with attention to the prostate gland Indication: Prostate cancer status post by IRE Comparison: MRI 10/6/2023, PSMA PET/CT dated 3/28/2024 Technique: Multiplanar, multisequence MRI of the pelvis was performed before and after the intravenous administration of 17ml of Dotarem with attention to the prostate gland. Findings:PROSTATE SIZE: 2.9 x 3.9 x 4 cm (AP x Trv x CC)CALCULATED PROSTATE VOLUME: 24 mL. FOCAL LESIONS: T2 hypointense nodular area in the right lateral peripheral zone at the mid gland measuring 9 x 11 mm (series 5, image 16), with absent enhancement in keeping with nonviable ablation zone. No additional suspicious lesions by PI-RADS criteria. Remainder of the prostate appears similar to previous examination on 10/6/2023, with prominent rounded the pH nodule at the left base and patchy fibrosis throughout the peripheral zone. PROSTATIC CAPSULE: Intact SEMINAL VESICLES: Normal. URINARY BLADDER: Normal.LYMPHADENOPATHY: No enlarged pelvic lymph nodes are identified. BONES: No suspicious osseous lesion. Impression: 1.Nonviable ablation zone in the right peripheral zone mid gland.2.No additional new suspicious lesions by PI-RADS criteria. |
My surgeons response:
"The MRI looks like there is no evidence of any viable tissue in the ablation zone. There are also no new concerning lesions. Although these findings are encouraging, I still think we should move with the biopsy. We are working on getting the biopsy scheduled next week."
I'm wondering if this latest MRI might not have been able to visualize into the ablated area which might be hiding some cancer growth? Perhaps another PSMA PET scan is in order? I have been experiencing some minor discomfort in the lower right groin which I must admit is kicking in my paranoia as hard as attempt to not let it. I'm disappointed this did not turn out a one and done experience, but I don't regret having tried the Nanoknife procedure. A redo or all other options are likely still available to me. Biopsy is scheduled for Dec. 20th. My journey continues. Whoopee!
Comments
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I have an appointment Wednesday to discuss further. I was thinking about prostatitis or bladder infection, but I really don't have any definitive symptoms of those. I have been experiencing some very minor pain in the lower right abdomen and feeling fatigued which is adding to my worry level. Thanks for your hope. I could not agree more.
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Had appointment today at Fox Chase. Doctor showed me the MRI images and explained they do not see any new areas of concern within the ablated zone or anywhere else in the gland. The ablated tumor area appears to be completely toasted. He will be performing a biopsy (#3 for me 😫) next Friday and has written an order for a PSMA PET scan after the first of the new year. He said that he and other urological oncologists have on occasion seen PSA spikes that resolve without any definitive explanations. Being a pessimist, I think that's wishful thinking? 😕 I will meet with him again in January to discuss findings of biopsy and PSMA PET scan. I must admit that I'm second guessing my decision to go Focal. He also informed me that the ablated areas can sometimes cause difficulties when salvage prostatectomies are performed, but is dependent on where the ablated area is. In my case was not an issue. Of course, I'm still hoping that if he finds cancer it's still within the gland.
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Again I am sorry you have to go through this merry go round again. I am like you and just had focal and this is a big bet….But I chose focal because it leaves ALL options on the table and you probably have the entire arsenal available. Also I remember reading that very high PSA (not sure about the range if above 20 or 100) could indicate that it escapes the gland. Your PSA level is still low but this is stressful…always wondering what the heck is going. May the force be with you !
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Hi,
A lot of you survivors are thinking the correct way, always have at least one backup plan. I chose surgery knowing that I would have at least a couple of paths to go down if my cancer returned. Whether its at the office, travel or what ever, I always try to look down the road I may never travel with backup plan A and B and maybe C. It has served me well over my 72 yrs, good luck.
Dave 3+4
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Below are results from my latest biopsy on 12/20/2024. It appears that the IRE Nanoknife ablation procedure has worked efficiently. No sign of cancer in the ablated area. Of the 14 samples there is only one 3+3 finding in the left side of my prostate which we knew was there prior to ablation.
My surgeons comments: "All the samples taken from the right side were negative for persistent cancer.
There is a single core that was + for Gleason 6 prostate cancer that does not require treatment.
This is excellent news, lets see what the PET scan shows"
Although this is welcome news, my rapid increase in PSA from 4.6 in August to 9.3 in December is stressful. If the PSMA PET scan I'm having this coming Friday is clear like the first one I had 9 months ago I imagine it to be more perplexing to explain. If the PSMA PET indicates there is spread somewhere outside of the gland, I can only guess at which treatments will be offered? Even though, I have been having some second thoughts, I'm still a firm believer that the Focal ablation technologies have definitive merit when applied to select patients that qualify for it. Although still deemed "investigational", I'm certain in the coming years it will be offered more routinely as an option for those that qualify, giving some Pca patients a chance of avoiding the known side effects of RP or RT. My saga continues….
Location: Fox Chase OPERATING ROOM
Date Reported: 12/26/2024
Clinical History/Diagnosis:
Malignant neoplasm of orostate (CMS/HCC) (C61)Source of Specimen(s):
A: Right posterior medial #1
B: Right posterior medial #2
C: Right posterior lateral #1
D: Right posterior lateral #2
E: Right lateral wing #1
F: Right lateral wing #2
G: Left posterior medial #1
H: Left posterior medial #2
I: Left posterior lateral #1
J: Left posterior lateral #2
K: Left lateral wing #1
L: Left lateral wing #2
M: Right anterior zone
N: Right extraprostatic regionFinal Diagnosis:
A. Prostate, right posterior medial #1, biopsy:
- Benign prostate tissue.
B. Prostate, right posterior medial #2, biopsy:
- Benign prostate tissue.
C. Prostate, right posterior lateral #1, biopsy:
- Benign prostate tissue.
D. Prostate, right posterior lateral #2, biopsy:
- Benign prostate tissue.
E. Prostate, right lateral wing #1, biopsy:
- Benign prostate tissue.
F. Prostate, right lateral wing #2, biopsy:
- Benign prostate tissue.
G. Prostate, left posterior medial #1, biopsy:
- Benign prostate tissue.
H. Prostate, left posterior medial #2, biopsy:
- Benign prostate tissue.
I. Prostate, left posterior lateral #1, biopsy:
- Benign prostate tissue.
J. Prostate, left posterior lateral #2, biopsy:
- Benign prostate tissue.
K. Prostate, left lateral wing #1, biopsy:
- Benign prostate tissue.
L. Prostate, left lateral wing #2, biopsy:
- Adenocarcinoma, Gleason patterns 3+3.
- There is 18% tissue involvement.
- Linear tumor extent = 0.9 mm.
- Grade Group 1.
M. Prostate, right anterior zone, biopsy:
- Prostate tissue with extensive necrosis.
- No viable tumor identified.
N. Soft t
issue, right extraprostatic region, biopsy:- Benign fibrovascular stroma and skeletal muscle.
Gross Description:
Received in 14 partsA. Received in formalin
"right posterior medial #1", is a single tan-white soft tissue core
measuring 1.5 cm in length x 0.1 cm in diameter. Entirely submitted in one
cassette labeled A1.B. Received in formalin
"right posterior medial #2", is a single tan-white soft tissue core
measuring 1.2 cm in length x 0.1 cm in diameter. Entirely submitted in one
cassette labeled B1.C. Received in formalin
"right posterior lateral #1", is a single tan-white soft tissue core
measuring 1.3 cm in length x 0.1 cm in diameter. Entirely submitted in one
cassette labeled C1.D. Received in formalin
"right posterior lateral #2", is a single tan-white soft tissue core
measuring 1.7 cm in length x 0.1 cm in diameter. Entirely submitted in one
cassette labeled D1.E. Received in formalin
"right lateral wing #1", is a single tan-white soft tissue core measuring
0.6 cm in length x 0.1 cm in diameter. Entirely submitted in one cassette
labeled E1.F. Received in formalin
"right lateral wing #2", is a single tan-white soft tissue core measuring
0.3 cm in length x 0.1 cm in diameter. Entirely submitted in one cassette
labeled F1.G. Received in formalin
"left posterior medial #1", is a single tan-white soft tissue core
measuring 1.2 cm in length x 0.1 cm in diameter. Entirely submitted in one
cassette labeled G1.H. Received in formalin
"left posterior medial #2", is a single tan-white
soft tissue core
measuring 1.3 cm in length x 0.1 cm in diameter. Entirely submitted in one
cassette labeled H1.I. Received in formalin
"left posterior lateral #1", is a single tan-white soft tissue core
measuring 0.8 cm in length x 0.1 cm in diameter. Entirely submitted in one
cassette labeled I1.J. Received in formalin
"left posterior lateral #2", is a single tan-white soft tissue core
measuring 0.5 cm in length x 0.1 cm in diameter. Entirely submitted in one
cassette labeled J1.K. Received in formalin
"left lateral wing #1", is a single tan-white soft tissue core measuring
0.6 cm in length x 0.1 cm in diameter. Entirely submitted in one cassette
labeled K1.L. Received in formalin
"left lateral wing #2", is a single tan-white soft tissue core measuring
0.5 cm in length
x 0.1 cm in diameter. Entirely submitted in one cassette
labeled L1.M. Received in formalin
"right anterior zone", are multiple tan-white soft tissue cores ranging
from 0.5 cm up to 1.5 cm in length x 0.1 cm in diameter. Entirely
submitted in two cassettes labeled M1-M2.N. Received in formalin
"right extraprostatic region", are two tan-white soft tissue cores
measuring 0.5 cm and 0.8 cm in length x 0.1 cm in diameter. Entirely
submitted in one cassette labeled N1.0 -
swl1956, thanks for sharing your story.
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Hi,
I was wondering before your latest PSA test did you have sex or too much time on the exercise bike which could have risen your PSA? Just going to have to keep an eye on your PSA over the following months to see what trend develops. I must agree the jump from 4.6 to 9.3 is disturbing. As the 3+3 slowly grows your PSA will increase, check with your Urologist to see what he would suspect your rate of climb should be. Good luck…………
Dave 3+4
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Thanks Dave!
Sex! What's that? Lols! Nothing I've been doing would explain a 4 point jump. According to what I've read and Doctors confirming 3+3 low volume tumors are unlikely to turn more aggressive. Not to say it can't happen, but current medical consensus is that 3+3 does not need to be treated. Just actively surveilled.
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The idea behind Focal is to just treat the primary lesion to avoid or reduce any side effects associated with RP or RT. Focal technologies (IRE, Cryo, FLA, Hifu, etc.) are typically not good for whole gland ablations due to damaging side effects. I had a tumor clearly identified on MRI in the right side of my prostate with some cores 4+3. The doctor at Fox Chase offered Focal to me because of my concerns of the side effects of traditional treatments and that I was a good candidate. It's only applicable for some individuals. It's very important that the tumor is located where the ablation zone won't damage any important structures such as urethra and nerve bundles. The thing that sold me was that all other options are still available to me. Focal therapies are sometimes done more than once, but rarely done on more than one lesion at a time.
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UPDATE: Below are results from latest PSMA PET scan I had on Friday. Haven't spoken with Doctor yet, but even with my limited knowledge, this report doesn't look good for me. I was not expecting "active nodes" which leads me to believe metastasis is occurring? Was hoping any recurrence would be within prostate gland which I think could be treated more definitively. Will be interesting what my surgeon recommends when I speak with him in a couple days.
FINDINGS:
Brain: There is no focal increased activity in the brain parenchyma, the underlying structures are unremarkable in CT scan.
In the head neck region, there is physiological activity noted in the lacrimal glands, and salivary glands in relatively symmetrical distribution, the largest gland is left parotid, SUV is 19.7, which was 20.4.
There is no axillary adenopathy bilaterally, degenerative changes in shoulders.
In the thorax, there is no pulmonary nodule, soft tissue lesion or consolidation. No pleural effusion bilaterally, no apparent hilar or mediastinal adenopathy. No abnormal metabolic activity above the background, mediastinal blood pool SUV is 1.8, which was 1.4.
Below the diaphragm, there is physiological activity in the liver with SUV of 9.1, which was 6.5, spleen with SUV of 4.7, which was 4.1, and both kidneys in the same range of 40s.
There are new small active nodes in the aortocaval caval region with the highest lesion at level of L4 with SUV of 9.4. Since last subcentimeter size: a small lesion posterior to the right common iliac vessel with SUV of 7; presacral lesion has SUV of 7.7.
In the pelvis, there is reported ablation in the right periphery zone mid gland. There is a focal increased activity in the right periphery zone near apex with SUV of 4.7. This is worrisome for viable tumor in the region.
In prior scan, the focal activity is in the right mid gland with SUV of 6.7, current activity is SUV of 3.8.
There is a focus of increased activity in the proximal urethra and could be urine in the region. SUV is 6.5, which was 4.5.
There is no significant active node in the iliac or inguinal regions bilaterally. No ascites.
Musculoskeletal, no apparent lytic or blastic lesion in CT bone window, the activity is unremarkable in marrow space.
IMPRESSION:- This scan utilized a F-18 PSMA - Pylarify tracer, typically used for evaluating prostate cancer.
- The patient has reported ablation in the right periphery zone mid gland, the activity is lower than prior scan in this area.
- Higher activity is noted in right periphery zone near apex, worrisome for viable tumor.
- Multiple foci of increased activity along the right iliac chain up to aortocaval at the level of L2, worrisome for nodal metastases.
- Compared to prior PET/CT scan, there is partial response to therapy for the treated lesion, activity focus in right periphery zone near apex with new nodal disease. No additional active lesion above the diaphragm and no bone lesions.
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