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Borderline case?

Lunaone
Posts: 8
Joined: Mar 2016

Hi folks:

I'm new here so I'll keep this fist one brief just to be sure it's working, ok?  I'm 73 in general good health but recently diagnosed with stage T2 Prostate cancer.  6 core biopsy showed tumor in all 6 cores with 50 to 90% involvement but a Gleason score of just 6 (How unusual is that?).  My reading of Partin tables seems to indicate pretty high probability of success with total prostatectomy but age and low Gleason might support Active Survaillance or open radiation.  Your thoughts?  I'll add more detail and other questions once I'm sure this is getting me started.

Swingshiftworker
Posts: 1013
Joined: Mar 2010

While you are older than most, it is very common for men with early PSA testing to be diagnoses at Gleason 6 and Stage T2, which is very treatable.

The 50-90% invovlement of one of the cores is a bit concerning but considering your age, I think it certainly reasonable to undertake active surveillance before electing any other method of treatment.  On the other hand, if you don't want to be bothered by the continual vigilance, you could seek treatment with radiation with excellent prospects for success w/o undue risk or concern about side effects.  

IMO, the best method of radiation currently available is Cyberknife (generically SBRT -- stereotactic body radiation therapy) which can deliver radiation to the sub-mm level and also account for body and organ movement during treatment, which minimizes the likelihood of collateral tissue damage that can cause side effects such as ED and incontinence.  Only 3-4 treatments every other day over a week is all that is needed and CK is now usually availble for insurance coverage.

The most common method of radiation treatment for PCA is IMRT or IGRT.  This is the treatment commonly used after failed surgeries (estimated as being as much as 30% of the time) and it's one of the various reason why I always recommend AGAINST surgery.  Why bother w/surgery if it's going to fail and caue all kinds of KNOWN problems when you're probably going to have to be treated w/radiation anyway, especially given the virtual CERTAINTY of ED and incontiencne for as long as 1 year following treatment?  Not so the case w/radiation.

In any event, IMRT and IGRT (as the primary form of treatment) is about (but not quite) as effective as CK but it is more commonly available and is least likely to be a problem in terms of getting insurance coverage for it.  However, IMRT or IGRT usually takes 25-40 treatments over 5-8 weeks to be completed, which is much longer than for CK.

Given your diagnosis, there's no need to rush into deciding what form of treatment you should choose or, if you start w/active surveillance, whether any treatment will ever be necessary of not.   Just take the time to do the research necessary to familiarize yourself with the various techniques so that when the time comes, you can make the best choice for you when and if the time comes.

Good luck!

Lunaone
Posts: 8
Joined: Mar 2016

Thanks to swingshiftworker!

Here are some more details:  I'm probably at T2c given that each of my 6 cores showed tumor cells.  And tumor is detectable on DRE.  Hopefully I'm not yet T3 since DRE does not indicate any adhesions (i.e. the urologist says it doesn't feel like the prostate is connected to its surrounding anatomy [my interpretation of his explanation]).  I've had two TURPs in the past.  At age 49 and again at 59 (again, I'm now 73).  Both of these were for BPH and no cancer was found in those cases.  PSA has shown gradual increase over last 10 years or so and is currently at 4.3 with approx. 10% free.  Prostate is small (around 18cc) which means greater "prostate density".  Biopsy was done by taking just 6 cores.  "Because the prostate was so small," according to the uroligist.  Every one of those cores showed positive for adenocarcenoma.  Each also had Gleason 6 (3/3).  Lowest % involvement was 50%.  Highest was 90%.  The other 4 were at 60%, 65%, 70%, and 70%.  I'd like to know more about what such widespread involvement may mean.  And does my higher prostate density mean that I should really be assuming a rather higher PSA equivalency?  The Partin tables seem only to use an unadjusted PSA number and the Gleason score.

I'm having the pathology report redone at Johns Hopkins and also Prolaris genetics testing.  Those results should be back later this week.  Any other suggestions as to getting a better picture?  

Once I do have as clear a picture as possible I will move toward a treatment or AS decision.  The Cyberknife suggestion from Swimgshiftworker is much appreciated and will definitely be a candidate.  Since I'm still early in the process I'll be getting additional medical opinions, of course, but I very much look forward to any input from CSN participants.

Thanks!

hopeful and opt...
Posts: 2226
Joined: Apr 2009

lunoane

Suggest that you get a T3 MRI which may indicated extra capsular extension; that is, if the cancer has escaped the capsule. (click my name to the left to read a short discussion of the MRI , what  procedures I have undertaken, in my Active Surveilance during the last 7 years.) Additionally this MRI will examine the prostate itself and will identify any suspicious lesions, and the amount of  involvement within the prostate.

Generally the Active Surveillance protocols are more relaxed for men over 70.However in you case  of large volumes of cancer and a  low free PSA of  10, you may not qualify for Active Surveilance. I believe that it is very important for you to see what the important 3T MRI test will indicate. To be honest I think that a  Prolaris test is of secondary importance, since it is simply analyzing what has been found; not the extent of the cancer, which in my laymans opinion is of most concern, and the reason for the MRI.

 

Lunaone
Posts: 8
Joined: Mar 2016

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.

hopeful and opt...
Posts: 2226
Joined: Apr 2009

Vasco Da Gama posted this site, that provides an estimates of the chances for

OC: organ confined;
EPE: extraprostatic extension;
SV + : seminal vesicle involvement;
LN + : lymph node involvement

http://urology.jhu.edu/prostate/partintables.php

so for your case, inputing PSA of 4.3; Gleason 6 and T2c the results are oc 64%, epe 32%, SV 2% and LN 1%

..........

.........................

When I was diagnosed with two cores out of 12 with less than 5 percent involvement, PSA 2.2 at T1, I was asked to take 1.5 MRI/MS. The 3.0 was not readily available in 2009. I had to pay an additional $900 for the spectroscopy, that was done in conjunction at the same time, since it is considered investigational. I was and am treated at a major university center of excellence in LA. I had medicare and a ppo.

Now there are HMO's where the institution saves money by not offering MRI, and guesses at where the patient stands.  I don't know where you are being treated? It may be possible that your doctor has a bias of this type organization.

I know that I would want to KNOW where I stand. Unfortunately, men who receive localized treatment may have extracapsular extension, but not be aware because they were not tested, and suffer consequences after insufficient treatment.

You said, ' 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. "

The t3 MRI provides a very fine definition. One can also have a spectroscopy in conjunction with the MRI...which provides even finer definition....This is called an MRI/MRSI

http://www.cancernetwork.com/review-article/spectroscopy-prostate-cancer-hope-or-hype-0

Vasco, who is in my opinion, an experts expert about prostate cancer, made some comments to you that is important for you to  consider. He suggested that you may need to also consider a PET scan.

You asked about PSA density...I think that you are referring to the relationship between PSA and Prostate size....one  looks for a favorable  ratio to be 0.15 or less.

You need to look at all of the diagnostic tests that you have had ...they are all a pieces of the puzzle, for possible treatments.

Swingshiftworker
Posts: 1013
Joined: Mar 2010

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
Posts: 8
Joined: Mar 2016

Thanks, Swing... for these further details.  I'm busy working on some other things right now but wanted you to know that I was getting your input ... and appreciating it.  I'll post more again fairly soon.

VascodaGama's picture
VascodaGama
Posts: 3032
Joined: Nov 2010

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
Posts: 8
Joined: Mar 2016

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!

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3309
Joined: May 2012

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
Posts: 8
Joined: Mar 2016

Thanks again, folks!  All of this is helpful.  I will continue to check all my options for imaging input.  And definitely run all of my data through any of the predictor models ("Nomograms," Partin Tables, etc.) so especially thanks for all your input along those lines.

I recently ran across the website for something called the Prostate Cancer Research Institute, PCRI.  They have quite a bit to say about risk assessment and they do include, in that connection, some mention of the number of cores with involvement and the % of cancer in the cores.  Have any of you heard of this "Institute" and know of its reliability/reputation?

I will follow a few of your good leads and then get back to all of you.

Again, thanks!

hopeful and opt...
Posts: 2226
Joined: Apr 2009

There are only  about 30 Medical Oncologists in the United States that specialize only in prostate cancer. PCRI is a group of I think three Medical Oncologists that specialize. This group is in Marina Del Rey, CA. The group is world renown.

http://www.prostateoncology.com/
 
Dr. Scholtz and the other doctors in the group, fortunately are local to me; I have attended several lectures by these doctors.
 
Dr. Scholtz started PCRI, that sponsors conferences featuring world class  doctors who specialize in various aspects of  prostate cancer. PCRI also has a website and pubishes information. In fact there is a mimi conference that will take place in June. It will be in the LA area. The conferences are open to the lay person, and many travel distances to attend.
 
http://pcri.org/#welcome
 
 
 
 
Lunaone
Posts: 8
Joined: Mar 2016

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!

hopeful and opt...
Posts: 2226
Joined: Apr 2009

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,

Lunaone
Posts: 8
Joined: Mar 2016

Yes, thanks.  I do have those library privileges and have used them.  And they have that phone number, as well.  I've also now found some more direct links to the Johns Hopkins Partin materials so I'll explore those.  What I continue to miss is any risk assessment tool that tries to factor in small prostate (hence higher PSA density) and high percent of cores with involvement plus high percent involvement in each core.  That's what seems still pretty unusual in my case.

Thanks again for all your ongoing help!

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