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A Minor Victory

MudMan's picture
MudMan
Posts: 23
Joined: Jul 2018

I have made it 48 hours since my second biopsy and do not have a fever.  This may sound minor and insignificant but having had Sepsis from my first prostate biopsy I am ecstatic.  This second 3T MRI Fusion biopsy was deemed needed enough to risk a second bout of sepsis by my Uro team lead....  Now the wait for results and treatment options.

I am new to this thread but have made a few posts on the kidney thread.  The second biopsy was to aid my two uro surgeons to decide to treat the prostate or kidney cancer first and treatment options for my prostate. I have been diagnosed with 3+4=7 from my first biopsy with 3 cores of 12 positive.  Up to the last biopsy my prostate cancer appears to be within the prostate.

The short version of my story is I am 67, active, exercise regularly, 30% BMI, being treated for CAD, have a 2.6 cm Bosniak 4 tumor on my right kidney and was diagnosed with prostate cancer this past April.  My last PSA was 7.2.  One differentiating item that I bring to this forum is that I have a hip replacement that could limit some treatment options for me and others with metal body parts in the pelvic area.

I believe I am past the absolute panic stage and making progress on staying positive.  I have a couple tall hills in front of me and all help is appreciated.

Old Salt
Posts: 720
Joined: Aug 2014

but good news about the biopsy. 

I hope we can be of assistance; please do not hesitate to ask or vent.

 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3329
Joined: May 2012

Welcome, Mudman.

I guess if I were you one of the first things I would want the biopsies to confirm is that the two cancers are not one or the other metastatic to the other site.  This is pretty easy for the pathologist to do, since each type of cancer has different cell types.

I've had ortho surgery around my hip area, and it did not have any bearing on my surgical removal (RP -- radical prostectomy).  I doubt it would effect radiation therapy (RT) either, unless there is metal very close to the gland.

I hope you see fit to share your progress, since your story is a little more complex than most here,

max

VascodaGama's picture
VascodaGama
Posts: 3050
Joined: Nov 2010

MudMan,

I am sorry for the health hazards you are confronting. I hope the last MRI provides you reliable information on the cancer location. If found contained then you have high possibilities in eradicating it for good. This can be achieved with a radical (surgery or radiation). If they find probabilities for existing extra capsular extensions (positive DRE or nodules at the prostate shell or cancer at the nerve bundle, etc) then radiation may be a better option for the achievement. Both therapies have risks and are linked to side effects which could be in conflict with the treatment for the kidney issue.

I wonder if the 30% BMI is all accumulated at the belly. This could restrict surgery to open approaches which type requires more hours in operation and longer period for recuperation post RP. It may also influence the sequence of the two treatments (kidney and prostate) as well any issue regarding your cardio case.

I recommend you to prepare a list of questions for your next meeting with the doctor, and get second opinions from the various specialists before deciding on what is proposed. You need to find details on the risks involved in each treatment and expected consequences.

The more you know about PCa the more confident you become. You will bit it for sure. Please let us know the results of the MRI, DRE and any other evident data on cancer location.

Best wishes and luck in your journey.

(I like your bow tie)

VGama

MudMan's picture
MudMan
Posts: 23
Joined: Jul 2018

Thanks for the replies, personal experiences and guidance thus far.  If allowed, I will do a data dump on my prostate test results when I get the pathology report from the third T3 MRI biopsy.  The first and second were 1.5T. 

The kidney cyst was first seen in 2007 as a simple cyst and was 2.2 cm.  I was not made aware of this information until this past April.  To be blunt, I dumped that Urologist and went to MD Anderson - Houston for a second opinion and confident I will stay there.

Yes, I do have a beer gut from my previous sins of 20 years ago.  I was turned down by the Proton Group at MD Anderson due to the metal hip, but they got me with the current Urology team which includes the Renal surgeon. 

Notes from 2nd of three MRI’s:

Gleason score: 7 (3+4).

Indication: Prostate cancer staging.

Technique: Prostate MRI with endorectal coil acquired at 1.5T. Three-plane localizer, axial T1W FSPGR, and axial DWI of the pelvis was performed. With an endorectal coil, three plane T2WI, axial DWI with ADC reconstruction and DCE sequences were performed focused on the prostate.
Motion artifact: Mild

Findings:

Prostate measurement (3-plane): 5.0 x 3.2 x 5.9 cm (transverse by AP by craniocaudal).

Hemorrhage: Mild

Benign prostatic hypertrophy: Moderate

Dominant lesion is ill-defined and measures 2.2 x 1.2 and is located in the midline central zone extending from the mid gland to apex:
Location: 10-2 o'clock
Moderate low T2 signal
ADC signal is reduced.
Suspicious focal enhancement is seen.
Qualitative suspicion of clinically significant disease: 4. Likely.

Extra-prostatic extension (EPE): The dominant lesion abuts the anterior fibromuscular stroma.

Neurovascular bundle invasion (NVI): not found

Seminal vesicle invasion (SVI): not found

No clear involvement of the bladder neck, distal sphincter, or rectum.

Lymphadenopathy: not found. A nonspecific 0.7 cm left internal iliac lymph node (13, image 12).

Bone metastasis: not found . Evaluation of the left pelvis is limited secondary to blooming artifact from the left hip arthroplasty.

Other: Advanced diverticulosis of the sigmoid colon.

Kidney notes:

Multiseptated right kidney complex cystic mass with hypervascular soft tissue components arises from the lateral cortex of the interpolar region of the right kidney. The left kidney is normal. Bilateral single renal arteries. Incidental circumaortic left renal vein. Bilateral renal veins and the inferior vena cava are patent. Subcentimeter retroperitoneal lymph nodes are seen.

Incidental cholelithiasis. The liver, pancreas, both adrenals and the spleen are normal. The stomach and visualized small bowel loops are normal. Incidental colonic diverticulosis. No significant mesenteric lymphadenopathy. There is no ascites. Atherosclerotic changes of the abdominal aorta and its branches. Multilevel degenerative changes of the visualized axial skeleton.

No mass or consolidation in the visualized lung bases. No pleural or pericardial effusion.

From my very limited knowledge of these matters, I see some good news along with the very scary news.  I should have the latest path report within a week.

Thanks again!!

JJO
Posts: 10
Joined: Sep 2017

I don't have any specific advice, but 13 or so years ago I had a kidney tumor.  It was removed through a partial nephrectomy, so I've still got the kidney.  Haven't had any problems since.

I was diagnosed with prostate cancer a couple of years ago and am on active surveillance.  

So no specific advice, but I've had the same two cancers, and I live a great life.  

MudMan's picture
MudMan
Posts: 23
Joined: Jul 2018

The second biopsy results are in. My lead Uro called me yesterday to set two appointments for this Friday. He is suggesting surgey and/or radiation as treatment options.  I will meet with a RO and a surgeon (team lead).  I do not have the pathology report yet, but was told the three new cores were directed in the most suspicious area that was not sampled in the first biopsy. Still G7, 3+4 and higher volume of cancer on the second biopsy. I am hoping that radiation as an option translates into localized disease.  I am still having trouble thinking logically and forgot to ask what stage I am in.

The kidney will have to wait until I heal from prostate treatment and strong enough for the neph. I am currently trying to write down questions to ask. I feel like I am cramming for finals. 

 

EDIT:  Additional info from 2nd biopsy.  The three needle cores were 9, 14, and 15 mm of cancer, but still 3+4 in all three new samples.  "A.  REGIION of INTEREST #1 VOL 3.37, LEFT MEDIAL APEX ANTERIOR, HYPOECHOIC. HIGH RISK X3 CORES."  Stage 2A.

I was given three options of treatment today, External-Beam (IMRT) with 6 months of Lupron, Brachy and Surgery.  Kidney surgery 4 months or so later.  The three prostate treatment options all have their advantages and not so good side effects or risks.  2 of the 3 require anesthesia while the third doesn't give me the feeling of "best effort to get it all."  It is the second surgery so close that is keeping me form committing to surgery.  The potential of the cancer outside the prostate is keeping me from committing to radiation.  All the respect in the world to those that had to make similar decisions, I don't know how you did it.

Than you for letting me vent and type out loud.

VascodaGama's picture
VascodaGama
Posts: 3050
Joined: Nov 2010

MudMan,

Please vent out as much as you like. We like to vent together with you.

I think that this last report is provided by the MDA urologist based on the results of the last MRI Fusion biopsy which made them to judge your stage as clinical 2A. I believe that he has staged you taking into account your overall diagnosis provided by your initial urologist, including the data of the 1.5T MRI.

It is difficult for us survivors here to opinion on your status as the information on your initial biopsy is missing. I wonder if you can provide a copy of the pathologist report on your initial 12 needles biopsy informing the areas of the positive cores, the results on a DRE and information from additional image exams such as a CT and Bone scan, if any.

In any case, the previous MRI (reported in your above post Jul 30) did identify a possible extraprostatic extension (hypoechoic mass) at the anterior fibromuscular stroma, which was checked in your last 3T MRI that added three more positive cores to the other three found in your first biopsy. We could think this finding to be therefore an extraprostatic extension that would classify you with a T3a stage. However, the anterior tumors rarely are judged as risks for metastases. The typical routes taken by the bandit to spread are via the seminal vesicles and neurovascular bundles that were reported negative at above MRI results. This reasoning makes us think that you got a contained case. In your shoes I would inquire the urologist that provided the cT2a stage if the extension leads in fact to a possibility of spread to adjacent tissues. What makes me suspicious is the identified 0.7 cm left internal iliac lymph node which stands at the same area.

As I have commented in my previous post, contained cases can be successfully treated with surgery alone. The IMRT approach can also achieve the same result and go further by radiating the regional lymph nodes. Brachytherapy can be done alone too but the seeds should be displaced to cover the anterior zone which would probably affect your urethra (just running at the anterior of the prostate). Brachy can also be done in combo with IMRT, treating the areas inner of the prostate, attacking the localized surrounding tissues with a shorter dose delivered by IMRT.

Please read this in regards to staging;

https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/staging.html

http://emedicine.medscape.com/article/2007051-overview

 

If I read it well you had 6 positive needles, 3 out of 12 from the first biopsy and additional 3 from EPE identified in the MRI. The Gleason score is 7 and the prostate is bigger than normal (5.0 x 3.2 x 5.9 cm) probably due to hyperplasia (BPH). I would think that you had urination issues in the past. I wonder if brachytherapy would worsen the case.

Here are ideas to help you formulating your List of Questions to the doctors;

http://csn.cancer.org/node/224280

http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-talking-with-doctor

http://www.cancer.net/patient/All+About+Cancer/Newly+Diagnosed/Questions+to+Ask+the+Doctor

http://www.mayoclinic.org/diseases-conditions/prostate-cancer/basics/preparing-for-your-appointment/con-20029597

 

Do not rush to a decision without gathering information on the case as well information on the risks associated with the therapy. Discuss the contents with your family and go for it.

Please note that I have no medical enrolment. I have a keen interest and enthusiasm in anything related to prostate cancer, which took me into researching and studying the matter since 2000 when I become a survivor and continuing patient.

 

Best wishes and luck.

VGama 

MudMan's picture
MudMan
Posts: 23
Joined: Jul 2018

1st Biopsy Report

1st Biopsy Report

EDIT:  Additional information added 8/5/18 0753 CDT.  The above biopsy report was done by my first urologist and hospital (not MDA). Gleason scoring was upgraded by MDA to 3+4=7.  There was an Oncotype DX Genomic Prostate Score® test performedby the first uro and my GPS score was 33 and in the Low Intermediate risk category.

CT Scan and MRI comments below:

2017 MRI -

FINDINGS: 
1. There is again large blooming artifact from left hip metallic hardware obscuring significant portions of the prostate on several the sequences, in particular diffusion-weighted imaging. 
2. The prostate gland measures 5.2 x 4.7 x 4.6 cm. Estimated prostatic volume is 59 cc calculated by ellipsoid formula.  
3. Central gland: There is a 2.5 x 2.1 cm poorly circumscribed and fairly homogeneous T2 hypointense area throughout the apex with some extension anteriorly to the midgland near the midline. This is moderately increased in size (previously approximately  
   2.0 x 1.4 cm). Though DWI sequences are largely obscured by artifact, relatively preserved ADC map in this area shows diffusion restriction. 
4. Peripheral zone: Scattered bilateral linear and wedge-shaped T2 hypointensities without definite diffusion abnormality within limitations of described artifact and similar to prior (PIRADS 2). 
5. Seminal vesicles: Normal. 
6. Extracapsular extension: None 
7: Bladder: Normal. 
8. Lymph nodes: No suspicious lymph nodes. 
9. Bones: No focal marrow replacing abnormality. 
IMPRESSION: 
Study is again limited by artifact from left hip hardware. 
2.5 cm central gland abnormality throughout the apex and anterior midgland highly suspicious for malignancy (PI-RADS 5). 
No definite extra-prostatic extension or regional adenopathy.

Narrative

EXAMINATION: CT ABDOMEN PELVIS W CONTRAST

CLINICAL HISTORY: ABD PAIN FEVER NO RECENT SURGERY, sepsis after prostate biopsy rule out abscess

TECHNIQUE: Multiple axial images of the abdomen and pelvis were obtained following intravenous administration of iodinated contrast. Sagittal and coronal computerized reformatted images were also obtained. CT images were obtained using low-dose technique
with automated exposure control.

April 2018 CT -

COMPARISON: CT from 9/13/2007

EXAMINATION: CT ABDOMEN PELVIS W CONTRAST CLINICAL HISTORY: ABD PAIN FEVER NO RECENT SURGERY, sepsis after prostate biopsy rule out abscess

TECHNIQUE: Multiple axial images of the abdomen and pelvis were obtained following intravenous administration of iodinated contrast. Sagittal and coronal computerized reformatted images were also obtained. CT images were obtained using low-dose technique
with automated exposure control.

IMPRESSION:
1. Liver, spleen, pancreas, adrenal glands and left kidney are normal.
2. There is a 1.6 x 1.6 x 2.2 cm complex appearing cystic area in the posterolateral aspect of the mid right kidney (series 2 image 62 and series 300 image 51). Appearance on the current examination is indeterminate. A cystic-appearing area was seen in
this location on prior unenhanced CT from 2007. This may reflect a complex cyst. Further evaluation with abdominal MRI suggested.
3. There is cholelithiasis. There is no biliary duct dilation.
4. There is moderate sigmoid diverticulosis and a few diverticula seen in the more proximal colon. There is no evidence of diverticulitis. Appendix is normal.
5. There is no abdominal or pelvic adenopathy or ascites. Aorta is normal in caliber.
6. Prostate slightly enlarged. There is mild fascial edema. There is no pelvic collection or abscess. Bladder is unremarkable.
7. Left hip arthroplasty present. There are degenerative changes in the spine. Trace pleural effusions and minimal dependent atelectasis present.

 

You are correct on the worsening urination problems and your reading/understanding of my data is correct. DRE's - most of those performing the tests reported verbally that the prostate is slightly enlarged and a nodule was felt by some. I agree that Brachy could and probably would completely block urination and I am not sure if Brachy would get the regional lymph nodes. My lead Uro and surgeon said a couple times during our meeting yesterday he and the team "think" and "believe" my cancer is contained.  He also said of the three options presented there were no bad choices.  I recorded our meeting and will listen again and again.  I'm leaning towards the Robotic Assisted Radical Prostatectomy due to the potential side effects of radiation, but sure I will change my mind several times.  Currently, I am under the impression surgery affords me the best chance of winning the fight and going into extra rounds if needed.  A lot more to read and study.

I truly appreciate the feedback, links to very useful information which complements the book I am carrying around, Prostate & Cancer by Sheldon Marks, MD.

 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3329
Joined: May 2012

Mudman,

I'm responding here primarily just to your summation and the biopsy report.

You are leaning twoard DaVinci surgery after a good bit of medical advice.  Probably a good choice. With a Gleason of only 6 and relataively low PSA, the probability of no glandular escape is high.  Surgery is best in cases of containment, and also when stricture (urinary blockage or other restriction) is present.  Radiation at times will worsen such blockages. I also agree with your assessment that Brachytherapy might worsen the blockage.

Do speak to a radiation oncologist before making a final decision.

One other thing:  You put in quotation marks that the doctors qualified what they "think" and "believe" about your situation.  No doctor can speak otherwise.  There is no certitude in these matters, for anyone, with any cancer. The doctors give the best test result assessments they can, but these are never perfect, for any cancer, for any individual.  They make the best medical judgements the available evidence will allow.

Good luck with everything,

max

VascodaGama's picture
VascodaGama
Posts: 3050
Joined: Nov 2010

Thanks for sharing the data. The initial biopsy is consistent with my previous comments. You need to read about the risks of each treatment that may affect your present quality of life.

Do your preparations before starting the treatment.

This is a difficult moment for you but you will achieve the best.

Best wishes,

VG

Old Salt
Posts: 720
Joined: Aug 2014

for an outsider, the presentation of the biopsy report is just super.

As has been pointed out repeatedly above, you have all options available and time to decide which treatment is the best fit for you.

Speak to the best (!) practitioners before making a decision. If you feel overwhelmed, which is perfectly normal right now, take some time to do your 'due diligence'.

MudMan's picture
MudMan
Posts: 23
Joined: Jul 2018

"MyChart" was updated with the Oncologist and Surgeon comments from my appointments last week.  The tumor was rated Stage IIB (cT2c, cN0, cM0, PSA: 5.5 ((as high as 8.5)), Grade Group: 2).  Oncologist will order a biopsy for the lymph node mentioned above to make sure it does or does not need to be included in External-Beam field of treatment.  This biopsy is contingent on my decision to go with radiation+ HT therapy.  The Surgeon has already said he would remove the LN.

Additional info from DRE examination: "digital rectal exam revealed bilateral induration at the apices of the prostate. An MRI was performed to get a better idea of the internal architecture of the prostate given that the rectal exam was disproportionately abnormal given the amount of disease noted on biopsy. The MRI revealed a 49 mL prostate with a dominant central zone lesion extending from mid gland to apex with reduced diffusion."

I didn't like seeing that word biopsy again as that would be my third in the last 3 months.  I called the Oncologist to ask why as I was prepared to decide to go with surgery.  He explained this biopsy is not a through rectum procedure and Sepsis should not be an issue.  So now I am back to Surgery or External-Beam + 6 months of Lupron.  I have eliminated Brachy due to my current weak urination stream.  

RP and greater chance of incontinence has me leaning toward the RT now.  Plus, the overhanging cloud of the nephrectomy that awaits.  I really did not want to spend my first year of retirement venting on a cancer discussion board, but here I am and thanks for listening.

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