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New MRI Results

mcin777
Posts: 66
Joined: Feb 2013

I have been on active surveillance for five years and just completed a fusion mri.  My Dr is out of town and I would like to know the meaning of some of the results in terms of how serious they are.

Anatomic findings: There is a small focus of altered signal typical of tumor in

the left posterior lateral peripheral zone in the lower one third of the gland.

This has an approximate volume of 0.7 cc with a maximum in plane measurement of

1.3 x 0.8 cm. It is clearly low signal on T2 and ADC sequences and very high

signal on the diffusion sequence. It abuts the posterior capsule where there is

a mild bulge, and the capsular margin is indistinct. No gross spread of tumor

into the periprostatic fat is shown.

 

A second area of potential tumor is in the midline of the peripheral zone at the

base. It has approximate measurements of 0.5 cc with a maximum in plane

measurement of 1.3 x 0.6 cm. It has high diffusion signal and low ADC and T2

signal. It is relatively sharply defined. The adjacent capsule appears normal.

 

IMPRESSION: 

 

1.  Left lateral inferior abnormality consistent with tumor, possibly with focal

capsular disruption. PI-RADS 5.

 

2.  Midline peripheral zone base abnormality with signal characteristics of

tumor but morphologically equivocal. PI-RADS 3.

 

3.  No evidence for extraprostatic tumor.

 

 

PI-RADS Assessment Categories (ver. 2):

 

PI-RADS 1: Clinically significant cancer highly unlikely.

 

PI-RADS 2: Clinically significant cancer unlikely.

 

PI-RADS 3: Clinically significant cancer risk equivocal.

 

PI-RADS 4: Clinically significant cancer  likely.

 

PI-RADs 5: Clinically significant cancer highly likely.

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

An image defined as Pi Rad 2 means that the likelihood of finding a significant cancer with a targeted biopsy , that is 3+4 or greater in unlikely.

The left lateral , where there is a pi-rad 5 indicates a high likelihood of finding a significant cancer with a targeted biopsy.

....

Everything is based on the biopsy......at this point they are only talking about "likelihood" . The tumors can be in truth be cancerous or not.

Additionally, evrn if a significant cancer is found, ie a 3+4, the volume may be small enough for you to continue in the Active Surveillance program............this it true in my case where I have a small  volume of 3+4............(that area need to be monitored)

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

A targeted biopsy is indicated in your case...does your doc have a three dimensional biopsy machine, such as an Artemis at his disposal?

 

mcin777
Posts: 66
Joined: Feb 2013

Thank you for responding.  Yes, I believe that the Dr does have a three dimensional machine.  Even if I am still a candidate for active surveiliance I may opt for the latest lazer ablation treatment which is an outpatient procedure and simply kills the cancer in the area it is located.  Have you given much research into this?

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

You might want to call your doctors office to check what biopsy machine is used. When I receive a biopsy, there is a screen that I can view. It shows locking into the MRI when the biopsy cores are taken. I am treated at a center of excellence. These machines are very expensive.  These three dimensional machines are only available at limited facilities. The Artemis machine is used at well machines by  other manufacturers

As far as zapping the canceous cores, I looked into this type procedure...in my opinion, and this is only my laymans opinion, therorectically this makes sense, however I feel that the current technology is not advanced enough at this time for "best"results. I strongly suggest that you do your own research to determine if this will be best for you. Several months ago I followed a thread at USTOO discussion site, where you can get input...several of these men did this procedure and were happy with the results......anyway you need to research......I hope that you or others will be able to share the results of your research investigation at this thread. 

mcin777
Posts: 66
Joined: Feb 2013

I am back from a fusion biopsy that occurred about two hours ago.  Brutal! - 19 samples.

From the MRI I had, Dr said two lesions, each about the size of a sugar cube,,,1 centimeter.  What ever happened to inches?

When the Dr was prepariing for the biopsy, I mentioned just as I did two weeks ago when when met, that I was interested in 

targeted treatment -  thermal or cryoablation.  He acted surprised and was not anticipating that he would have to take so many samples.  The Dr either does not take good notes or failed to read them.  When I was in his office and told him what I wanted he suggested the biopsy I just had.  Should I look elsewhere for another Doctor.    When I told him that I was surprised about the new findings from the MRI, his response was, "well previous MRI technology wasn't that good".  Hello?  We are talking about my life here.  I have been on active survailance and he did not suggest prior to now another biopsy????   There is a very good chance that I should not have been on active survailance.  Would you change doctors?  

SubDenis's picture
SubDenis
Posts: 130
Joined: Jul 2017

Sorry, your doc was not attentive.  I am all for changing when docs do not make us a priority.  I just did that. keep us posted. Thanks, Denis

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

As I understand the purpose of this visit was to have a fusion biopsy, which you did. You need to wait for the results of this biopsy before determining the best treatment for you.

I hope that your recovery from the biopsy goes well, without complications.  

I was not aware that cryoablation can provide refined targeting. Cryoablation is not generally used for those having first treatment. Generally there is 100 ED among those who have cryoablation of the prostate.

https://www.cancer.org/cancer/prostate-cancer/treating/cryosurgery.html

To be honest I believe that it is best to discuss potential treatment after the biopsy,  not before. You need to wait for the results before deciding on what to do.

I know exactly what you are going through now...I had a biopsy on Friday, and am also waiting for my results. At that time I will decide what active treatment I might do, , or continue with Active Surveillance.

mcin777
Posts: 66
Joined: Feb 2013

Thank you SubDenis and Hopeful.  Worst thiing from the biopsy is the bleeding now.  Have a call into the Dr.  Will let you know outcome.

 

GeorgeG
Posts: 127
Joined: May 2017

A fusion biopsy is the best way to go at this point and that information is needed before any treatment options are decided. Depending on the reults you may also have some more scans in your future and/or some blood test trends to be monitored.

If your doctor id not being serious enough about your case then by all means find a better one but he will not be able to have a productive conversation about treatment until you both have more information.

All the best.

George

 

VascodaGama's picture
VascodaGama
Posts: 3029
Joined: Nov 2010

Jim,

From you comment in the initial post I think that you have decided not to treat 5 years ago and instead gave preferences for AS. Your initial diagnosis indicated two positive cores (Gs 6. The last MRI identified again two regions that may be cancerous. These occupy a vast area so that the affected number of cores taken from the zones may be more numerous than the one from 5 years ago.

I wonder why you have decided this time to treat instead of continuing with AS. Surely, a treatment may provide you peace of mind but it could go the other way and leave you with a nasty quality of life. You should discuss the matter with several doctor and know details of the risks each treatment involves before deciding.

Your initial thread is here;

https://csn.cancer.org/node/255309

Hope for the best,

VG

mcin777
Posts: 66
Joined: Feb 2013

 

Hi VascidaGama

I don't know what my clinical stage is.  I had a biopsy last week and should hear the results in a few days.  Once I find the results of the biopsy where they took 19 snips, I will make a decision as to what I will do.  Before the biopsy, I discovered that there is a treatment called MRI-Guided Focal Laser Ablation.  It is an outpatient treatment that lasts for a short period of time.  They fry the cancerous portion of the prostrate.  No collateral damage.  I thought it best to proceed instead of risking that the cancer has left the prostate.

CowboyBob
Posts: 31
Joined: Oct 2013

Prostate cancer tends to be a multifocal disease (occuring at multiple sites in the gland), as shown in your own clinical course. Although it has been a little while since I reviewed information on focal ablation, I am not aware that there is good information on long term control of prostate cancer with this modality. The way your post reads, I get the impression you believe that your prostate cancer will be eradicated by the ablation procedure. I would spend some time researching this option carefully and get opinions from people who don't have a vested interest in focal ablation.

mcin777
Posts: 66
Joined: Feb 2013

Thank you Cowboy Bob.  Yes, I will do more research especially in light of my new biopsy results.

 

mcin777
Posts: 66
Joined: Feb 2013

My most recent biopsy leads me perhaps in new a direction of treatment, all of which are undesirable to me but necessary if I want to live into my 90s and beyond. :0)

     Diagnosis After Microscopic Examination:

       1.  Prostate right lateral base, biopsy:

        -  Benign prostate tissue.

       2.  Prostate right medial base, biopsy:

        -  Benign prostate tissue.

       3.  Prostate left medial base, biopsy:

        -  Benign prostate tissue.

       4.  Prostate left lateral base, biopsy:

        -  Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1),

involving 75% of tissue (1 of 1 cores; 3 mm of 4 mm total).

        -  Perineural invasion not identified.

        -  See comments.

       5.  Prostate right lateral middle, biopsy:

        -  Benign prostate tissue.

       6.  Prostate right medial middle, biopsy:

        -  Benign prostate tissue.

       7.  Prostate left medial middle, biopsy:

        -  Benign prostate tissue.

       8.  Prostate left lateral middle, biopsy:

        -  Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1),

involving 25% of tissue (1

        of 2 cores; 2 mm of 8 mm total).

        -  Perineural invasion not identified.

 

        -  See comments.

       9.  Prostate right lateral apex, biopsy:

        -  Benign prostate tissue.

       10. Prostate right medial apex, biopsy:

        -  Prostatic adenocarcinoma, Gleason score 3+3=6 (Grade Group 1),

involving 45% of tissue (2

        of 3 cores; 7 mm of 16 mm total).

        -  Perineural invasion not identified.

        -  See comments.

 

11. Prostate left medial apex, biopsy:

        -  Benign prostate tissue.

       12. Prostate left lateral apex, biopsy:

        -  Benign prostate tissue.

       13. Prostate target No. 1, ultrasound-guided fusion biopsy:

        -  Benign prostate tissue.

       14. Prostate target No. 2, ultrasound-guided fusion biopsy:

        -  Benign prostate tissue.

 

Microscopic

Sections from the left and right side of the prostate gland show prostatic

adenocarcinoma, Gleason

 score 3+3=6, (grade group 1).  The neoplastic glands are small, back-to-back

with an infiltrative pattern.  The nuclei are enlarged with prominent nucleoli.  No evidence of perineural invasion seen.

 

Prognostic/Outcome

Prostate Cancer: Pre-Radical Prostatectomy Prediction Nomograms

 

Gleason Score:  3+3=6

Clinical Stage:  T1c

PSA:  6.7 ng/mL

 

Extent Of Disease Probability       %

Organ confined Disease              72

Extracapsular Extension              27

Lymph Node Involvement              1

Seminal Vesicle Invasion               1

 

Primary Treatment Outcomes

                                        10 year(%)  15 year(%)

     Probability of Cancer-Specific           99             99

     Survival after Radical Prostatectomy

   

 

                                           5 year(%)   10 year(%)

  Progression-Free Probability             96              93

 

 

 

Clevelandguy
Posts: 461
Joined: Jun 2015

Hi,

I think if it was me I would talk with the doctor(s) and find out how close the Pca is to the outer wall of your prostate.  If it's close you might want to do something soon(radiation or surgery), if not then you could still do AS for a while longer.  3+3 is not not agressive but it's still cancer.  Extracapsular Extension  27% probability is something to look into.

Dave 3+4

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

mcin777

 

 

Another, probably better way of reading the results of the cores are to look at the actual size of the core tht is positive.....

core #4, 3mm (left lateral base)......(75% of the tissue)

core #8, 2mm (left lateral middle)......(25% of the tissue)

core #10, 7mm(right medial apex)......(45% of the tissue).....if I  understand correctly, two of three cores have this this number

As I understand, the targeted cores (#'s 13 & 14) were not positive, but the random ones above were positive)

I am not knowledgeable, so I cannot make a comment on this statement, "The neoplastic glands are small, back-to-back with an infiltrative pattern.  The nuclei are enlarged with prominent nucleoli"

There were 17 cores taken, so if I understand right 4 out of 17 were positive)...(24%)

There was no perineural invasion identified in your pathology.

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

So what are the next steps in figuring out what is going on?

What is your age? The criteria for AS is relaxed among those who are older.

First, I would consider a second opinion on your pathology. I think that you used Johhs Hopkins in the past.

I would also ask your doctor about having a gene test. I had an genomic health oncotype dx. There are other ones, prolaris, decipher, etc. At this time, if you are of medicare age, these tests are free....medicare wants these companies to do a bunch of them before they are approved.

I would consult with your doctor for his input.....I would also consider having a second opinion by another doctor who specializes in active surveillance........(I wonder, where do you live...we at this forum might recommend an expert in your area).

It is very possible that you can continue with active surveillance, however I feel that a medical professional that you have confidence in is best to provide guidance.

Best

 

 

 

 

 

mcin777
Posts: 66
Joined: Feb 2013

Thank you hopeful.  I am 74 and live in Portland, OR.  I will take your advice and seek other opinions.  I sure hope there is a safe (?) way around not haviing invasve treatment.  I appreciate yours and others responses.   My bleeding still has not stopped completely from the Biopsy.  My Urologist says it is normal.  10 days have gone by.  Four or five times a day I urinate a little blood at the beginning of a stream.  It is usually the color of tomato soup.

Grinder
Posts: 441
Joined: Mar 2017

You're not on blood thinning medication or aspirin therapy are you? Just checking.

I was dealing with a lot of clotting after the biopsy... That creates its own problems.

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

I'm the same age as you.

John Hopkins relaxed the requirements for patients over 70, I think allowing amounts of 3+4.

I list the following contacts, where there can be doctors expert in recommending a course of action based on your numbers.

The Artemis machine is used at several teaching hospitals. You may wish to contact Eigen, the manufacturer of this equipment to find out which facilities use the Artemis machine, that you may wish to visit.. 

Eigen  
 
Medical supply store in Nevada County, California
 
Address: 13366 Grass Valley Ave # A, Grass Valley, CA 95945
Hours
Closed today 
   
   
   
   
   
   
   
 
 
If you are so inclined, UCSF has fusion biopsy equipment since 2014. They are a high volume center
https://urology.ucsf.edu/news/all/201407/mri-ultrasound-fusion-adds-precision-prostate-cancer-care#.WaOEg5Klw2w
You may wish to check other centers of excellence closer to your home.
US News and World report ranks hospitals by speciality.
http://health.usnews.com/best-hospitals/rankings/urology
hopeful and opt...
Posts: 2226
Joined: Apr 2009

In my last biopsy I had blood for about 6 or seven days....there was less each day.....the first day ,  I also had clots, which stiopped my stream..I drank extra water to eliminate these clots......Mine was the color of borsht.......Jim, ...is this what we have come to at age 74; can't wait until we get a little older (lol)

VascodaGama's picture
VascodaGama
Posts: 3029
Joined: Nov 2010

I also counted only 17 cores not the 19 number you commented above but if those exist and were misreported they may have been negative. The findings correlate to the above MRI report and with your initial JH findings on 2013. It seems to be a contained case (negative PIN) with cancer found in 4 cores, on both lobes, classifying a clinical stage of T2c.

My lay opinion is equal to Hopeful's above. You may try getting a second opinion from a specialist on AS but I believe that at your age and with the status verified this time that you could continue with AS and avoid the risks of a radical treatment. You indicate to be interested in a less invasive therapy like thermal or cryoablation, or laser treatment, but these all are associated with risks and side effects apart from less than optimal outcomes.

Another 5 years on AS will turn you into the 80th which time would narrow the options on a radical but these years would be spent with quality of life. At that time if treatment becomes inevitable then you could opt for radiation or a palliative hormonal therapy (ADT) that is typical in aged patients. ADT has a wide range of interchangeable drugs that can be used together or solo in sequential and intermittently, providing many years of life to the patient. Statistics confirm that low Gleason rates (3) cancers provide more than 15 years of survival since diagnosis. For the moment, the only way to avoid the risks, like urine or stool incontinence, damage to local nerve bundles, colitis and proctitis, etc, is to follow AS.

Best,

VGama

 

 

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

Jim,

At one point you mentioned interest in a partial gland ablation. Here is a study that I came across that addresses this. As you can see, the outcomes were not the best.

https://www.urotoday.com/recent-abstracts/urologic-oncology/prostate-cancer/98184-partial-gland-ablation-versus-radical-prostatectomy-comparative-analysis-of-partial-gland-ablation-and-radical-prostatectomy-to-treat-low-and-intermediate-risk-prostate-cancer-oncologic-and-functional-outcomes.html

Intermediate-risk Prostate Cancer: Oncologic and Functional Outcomes.

To analyze oncologic and functional outcomes of partial gland ablation (PGA) compared with robot-assisted radical prostatectomy (RARP) for patients with low-and intermediate-risk prostate cancer.

From July 2009 to September 2015, 1883 patients underwent RARP and 373 had PGA. From those, we selected 1458 participants (1222 RARP and 236 PGA) who have Gleason score 3+3 or 3+4, clinical stage ≤T2b, prostate-specific antigen(PSA) ≤15ng/dl, unilateral disease and life expectancy >10 years. Propensity score matching analysis 1:2 was applied on the overall RARP sample selecting 472 patients for between comparison. As PGA, 188 men underwent high-intensity focused ultrasound (HIFU) and 48 had cryotherapy. Oncologic outcomes were analyzed in terms of the need for salvage treatment. PGA failure was defined as any positive control biopsy after treatment. Functional outcomes were assessed with validated questionnaires.

Matching was successful across the two groups, althought men treated with PGA were older (p <0.001). Mean follow-up in PGA group was 38.44 months. PGA failure was observed in 68 (28.8%) patients, 53 (28.1%) with HIFU and 15(31.2%) with cryotherapy. PGA was associated with higher risk of salvage treatments (HR 6.06; p <0.001) and complications were comparables between groups (p=0.06). RARP was associated with less continence recovery and lower potency rates at 3, 6, and 12 mo after surgery (p <0.001).

For selected patients with organ-confined prostate cancer, PGA offered good oncological control with fewer adverse effects requiring more additional treatments. Potency and continence appear to be better preserved with PGA.

The Journal of urology. 2017 Aug 17 [Epub ahead of print]

Silvia Garcia-Barreras, Rafael Sanchez-Salas, Arjun Sivaraman, Eric Barret, Fernando Secin, Igor Nunes-Silva, Estefania Linares-Espinós, François Rozet, Marc Galiano, Xavier Cathelineau

Department of Urology, Institut Mutualiste Montsouris, Université Paris-Descartes, Paris, France., Department of Urology, Institut Mutualiste Montsouris, Université Paris-Descartes, Paris, France. Electronic address: raersas@gmail.com., Memorial Sloan Kettering Cancer Center, New York, USA., CEMIC University Hospital, Buenos Aires, Argentina., Hospital Universitario La Paz, Madrid, Spain.

mcin777
Posts: 66
Joined: Feb 2013

I consulted with a HIFU specialist and here is what he said:

"The MRI and Biopsy conflict because they do not correlate with each other. The biopsy shows cancer in the left lateral base and mid, as well as the right medial apex sections. The MRI shows lesions in the left lateral inferior ( or apex) and the midline base peripheral zone. So where do we focus our HIFU treatment? How do I choose where to target since the MRI and biopsy don't match. HIFU can only treat about a 40-45 gram prostate. Yours is 109 cc on the MRI. "

 

I have met with three Urologists and they are all concerned that I do something NOW. I have a Left lateral inferior abnormality consistent with tumor, possibly with focal ncapsular disruption. PI-RADS 5.  Seminal Vesicles: Normal. There are no findings of adenopathy. Pelvic bone marrow signal is normal.  The biopsy did not find any cancer with the area classified by the MRI as PI-RADS 5.  However two of the Urologists think that the biopsy missed the cancer and that i am at a high risk of the cancer leaving the prostate.

 

I am more than nervous and confused about what treatment will be the most successful in getting rid of ALL cancer.  There is no guarantee that cancer hasn't already left the prostate. At this point I feel like I have been a fool doing active surveillance.  

 

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

Jim,

Thank you for finding and updating this thread.

You did your due diligence and researched the ability to continue with Active Surveillance. The medical professionals that you contacted feel that now is the time to select an active treatment. One a specialist in HIFU, did not believe that you are a candidate for HIFU.

You have had 3T MRI which did not show extracapsular extension, however the prediction nomogram estimates a 27 percent chance of extracapsular extension.

The two major active treatments that are available are surgery and various forms of radiation.

Surgery is a localized treatment option that can have major side effects. The side effects in fact are age related, so at age 74 or 75 as you are, this would be a very poor choice since a doctor can perform surgery on a patient that is 50 and have excellent results and then perform the same surgery on a man of 75 with poor results; greater chance of erectile dysfuncion and incontinence. Additionally if the cancer is somewhat outside the prostate, additional treatment will be necessary. Surgery does not cure any cancer that is outside the prostate.

Radiation....can treatment the prostate itself, and the perimeter of the treatment can be expanded to go outside the prostate so any cancer immediately outside the prostate will be treated as well. Not say that the radiologist will think that it is necessary to extend the perimeter of the treatment since the radiologist may feel that it is contained...you will have to discuss this with the radiologist.

One form of radiation, is SBRT. This treatment is done in 4 or 5 sessions with minimal side effects. SBRT is very precise, more so than other radiation treatment modalities. SBRT offers comparable cure to surgery without the major side effects. This will be my choice if and when I will need to seek an active treatment. ....as any other treatment, I strongly suggest that you find and "artist" who can provide this treatment..find a high volume center with lots of experience.

Here is a nine year study for your evaluation.

https://prostatecancerinfolink.net/2016/01/06/nine-year-outcomes-after-treatment-with-sbrt/

Best

 

 

 

Old Salt
Posts: 720
Joined: Aug 2014

Please reread Cowboy Bob's comment.

Radiation of the whole prostate (and its environment, if necessary) seems to be the approach that I would recommend. And as far as technologies is concerned, SBRT would be the preferred one. See the above comment (by hopeful) for the argument. More in general, you have ample time to consider all modalities. 

mcin777
Posts: 66
Joined: Feb 2013

Thank you old Salt.  You suggest that I have ample time to consider all modalities.  The three Urologists that I have met with all seem to think that I am a ticking time bomb or that the bomb may have already gone off.  This is based on the prognosis of left lateral inferior abnormality consistent with tumor, possibly with focal capsular disruption. PI-RADS 5.   If I knew for sure that i was okay for a little longer (4-5) months, I would have another biopsy of the T5 tumor to see if it is infact benign or cancerous.  If is was benign then I would opt for HIFU by having my prostate roter rooterd, and then wait it shrinks to the size it needs to be at for a successful HIFU procedure.

Because the MRI and Biopsy were in conflict with each other, I get the real sense from the Urologists that I should not wait any longer to get treatment.  

Old Salt
Posts: 720
Joined: Aug 2014

It's been stated over and over on this and other prostate cancer forums, Urologists are surgeons and they typically recommend removal of the prostate. But one major point to consider is that you are over the 'typical' age limit for surgery (70). 

Like several others who have posted in this thread, I highly recommend that you discuss your options with a good radiation oncologist. 

SubDenis's picture
SubDenis
Posts: 130
Joined: Jul 2017

I cannot suggest which treatment is right for you.  However, I can strongly encourage you to find a doc you can talk to and trust.  So go doctor shopping.  The more I lean into the decision process, I am on the verge of decision making, probably on 11/13 when I meet with my rad oncologist and Uro Oncologist.  For me it is critical I have faith in their opinions, their expertise and their ability to communicate with me.  I am not a medical doctor, so at some point I need to trust the one I choose. a trust is a powerful tool.  As to AS, water under the bridge.  Stay in today and focus on finding the right doc!   Be well, Denis

mcin777
Posts: 66
Joined: Feb 2013

Thank you SubDenis.  What brought you to the place where you have decided on radiation?  How old are you?  Are you in good health for the most part?  I am 74 and in good health.  My Urologist said that radiation is a second choice next to   RP which is his specialty.  For long term benefits RP scores the best.  What kind of radiation treament are you getting?

Thank you for responding. 

CC52
Posts: 103
Joined: Nov 2013

"My Urologist said that radiation is a second choice next to   RP which is his specialty.  For long term benefits RP scores the best."

We come here for support, advice, discernment, sharing our stories...all sorts of reasons. Your experience with AS has taken a serious turn away from what you had hoped for. But that is the risk/reward element of making that decision. Now, you must move forward to something you had hoped to avoid. 

I highlighted your quote above for you to reconsider your Urologist's statement. I don't mean to sound critical or condescending toward you in any way - but remember - that is how he pays the bills. Of course he would suggest any other treatment option comes in second to RP. You do have time to relax (a little) and meet with other specialists before deciding on a treatment that YOU have determined is best for you. Unfortunately, as you have found out with AS, there are no guarantees.

My sincere best wishes - CC

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