Decision Time RP or ADT/HDR/EBRT

CMO2021
CMO2021 Member Posts: 53 Member
edited March 3 in Prostate Cancer #1

After waiting  8 weeks for my MRI Fusion biopsy the results are in and not great mostly Gleason 9 (4+9) and one Gleason 9 (5+4).  Have Bone Scan and CT Thursday and Friday of this week.  Hoping it hasn't metastasized but concerned.  I have appointments set  up at Memorial Sloan Kettering with Medical Oncologis, Radiaiton Oncologist and Surgical Oncologist.   Trying to stay level headed and make the best decision, but need CT and Bone Scan results before I can really move forward but need to make a timely decision due to the agressiveness of the PCA. Any others here treated at MSKCC. 

PSA = 4.1

 

Gland ~ 4.0 x 2.7 x 5.0 cm.

 

Volume = 28.0 gms.

 

PSAD = 0.14

 

PSA2 = 20%

DIAGNOSIS

A PROSTATE, LL APEX; CORE BIOPSY: INVASIVE PROSTATIC ADENOCARCINOMA, GLEASON
SCORE 3 + 4 = 7, GRADE GROUP 2, (5% CRIBRIFORM GLANDS), INVOLVING ONE OF ONE
CORE; 9 MM TUMOR LENGTH (80% OF PROSTATE CORE); PERINEURAL INVASION PRESENT.

B PROSTATE, L APEX; CORE BIOPSY: INVASIVE PROSTATIC ADENOCARCINOMA, GLEASON
SCORE 3 + 4 = 7, GRADE GROUP 2, (5% CRIBRIFORM GLANDS), INVOLVING ONE OF ONE
CORE; 12 MM TUMOR LENGTH (90% OF PROSTATE CORE).

C PROSTATE, LL MID; CORE BIOPSY: INVASIVE PROSTATIC ADENOCARCINOMA, GLEASON
SCORE 4 + 5 = 9, GRADE GROUP 5, WITH INTRADUCTAL CARCINOMA, INVOLVING ONE OF ONE
CORE; 12 MM TUMOR LENGTH (85% OF PROSTATE CORE).

D PROSTATE,
L MID; CORE BIOPSY: INVASIVE PROSTATIC ADENOCARCINOMA, GLEASON
SCORE 4 + 5 = 9, GRADE GROUP 5, WITH INTRADUCTAL CARCINOMA, INVOLVING ONE OF ONE
CORE; 13 MM TUMOR LENGTH (90% OF PROSTATE CORE).

E PROSTATE, LL BASE; CORE BIOPSY: INVASIVE PROSTATIC ADENOCARCINOMA, GLEASON
SCORE 4 + 5 = 9, GRADE GROUP 5, WITH INTRADUCTAL CARCINOMA, INVOLVING ONE OF ONE
CORE; 12 MM TUMOR LENGTH (80% OF PROSTATE CORE).

F PROSTATE, L BASE; CORE BIOPSY: INVASIVE PROSTATIC ADENOCARCINOMA, GLEASON
SCORE 4 + 5 = 9, GRADE GROUP 5, WITH INTRADUCTAL CARCINOMA, INVOLVING ONE OF ONE
CORE; 13 MM TUMOR LENGTH (90% OF PROSTATE CORE).

G PROSTATE, RL APEX; CORE BIOPSY: INVASIVE PROSTATIC ADENOCARCINOMA, GLEASON
SCORE 3 + 3 = 6, GRADE GROUP 1, INVOLVING ONE OF ONE CORE; 1 MM TUMOR LENGTH
(10% OF PROSTATE CORE); PERINEURAL INVASION PRESENT.

H PROSTATE, R APEX; CORE BIOPSY: INVASIVE PROSTATIC ADENOCARCINOMA, GLEASON
SCORE 4 + 5 = 9, GRADE GROUP 5, WITH INTRADUCTAL CARCINOMA, INVOLVING ONE OF ONE

CORE; 3 MM TUMOR LENGTH (20% OF PROSTATE CORE); PERINEURAL INVASION PRESENT.

I PROSTATE, RL MID; CORE BIOPSY: BENIGN PROSTATIC TISSUE.

J PROSTATE, R MID; CORE BIOPSY: BENIGN PROSTATIC TISSUE.

K PROSTATE, RL BASE; CORE BIOPSY: BENIGN PROSTATIC TISSUE.

L PROSTATE, R BASE; CORE BIOPSY: BENIGN PROSTATIC TISSUE.

M PROSTATE, RO1 #1 LM AXIAL; CORE BIOPSY: INVASIVE PROSTATIC ADENOCARCINOMA,
GLEASON SCORE 4 + 5 = 9, GRADE GROUP 5, WITH INTRADUCTAL CARCINOMA, INVOLVING
TWO OF TWO CORES; AGGREGATE TUMOR LENGTH 20 MM (95% OF PROSTATE CORES).

N PROSTATE, RO1 #1 LM SAG BASE; CORE BIOPSY: INVASIVE PROSTATIC
ADENOCARCINOMA, GLEASON SCORE 5 + 4 = 9, GRADE GROUP 5, WITH INTRADUCTAL
CARCINOMA, INVOLVING TWO OF TWO CORES; AGGREGATE TUMOR LENGTH 22 MM (95% OF
PROSTATE CORES).

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Comments

  • Max Former Hodgkins Stage 3
    Max Former Hodgkins Stage 3 Member Posts: 3,721 Member
    edited April 2021 #2
    S-K

    CMO,

    Sloan Kettering is as good as any other facility in the world for PCa.   I'm sure several guys here have utilized them.  It is a good place for you to be at the moment.  DO demand a lead oncologist with serious, specific focus with advanced PCa....not the new kid just showing up out of Residency. 

    There is probably around a 0% chance that you do not have some metastasis, although it may not show in the bone, or on CT/PET.   I base this upon the perineural invasion and essentially 90% volume occupied by Gleason 9 tumors throughout the gland.   No responder here writes with medical training or certifications of any sort.  With HT, RT, and possibly other treatments, your prognosis still might be good, to possibly quite good.   Hoping for the best results possible from your further tests,

    max

  • CMO2021
    CMO2021 Member Posts: 53 Member
    edited April 2021 #3

    S-K

    CMO,

    Sloan Kettering is as good as any other facility in the world for PCa.   I'm sure several guys here have utilized them.  It is a good place for you to be at the moment.  DO demand a lead oncologist with serious, specific focus with advanced PCa....not the new kid just showing up out of Residency. 

    There is probably around a 0% chance that you do not have some metastasis, although it may not show in the bone, or on CT/PET.   I base this upon the perineural invasion and essentially 90% volume occupied by Gleason 9 tumors throughout the gland.   No responder here writes with medical training or certifications of any sort.  With HT, RT, and possibly other treatments, your prognosis still might be good, to possibly quite good.   Hoping for the best results possible from your further tests,

    max

    Hi Max,

    Hi Max,

    I agree  the mets regardless of what shows on the CT or Bone scan. Once I have the results I will push for  genetic testing to see the potential of using a PARP inhibitor in addition of  some of the other treatment options of HT and RT.  I appreciate your reply. I am trying to keep positive attitude and worry about the things I have control over. I will continue to post as I  move through this journey.

     

    Chris

  • eonore
    eonore Member Posts: 118 Member
    edited April 2021 #4
    CMO2021 said:

    Hi Max,

    Hi Max,

    I agree  the mets regardless of what shows on the CT or Bone scan. Once I have the results I will push for  genetic testing to see the potential of using a PARP inhibitor in addition of  some of the other treatment options of HT and RT.  I appreciate your reply. I am trying to keep positive attitude and worry about the things I have control over. I will continue to post as I  move through this journey.

     

    Chris

    New diagnosis

    Dear Chris,

    I echo everything Max stated.  Let's hope that if the cancer has escaped the prostate, that it is still localized so that it can be zapped successfully with radiation.  In the meantime you are doing everything you can, and Sloan Kettering is as good as it gets.

    I wasn't aware that a Parp inhibitor has been approved for prostate cancer.

  • VascodaGama
    VascodaGama Member Posts: 3,491 Member
    Multimodal therapy

    CM,

    I think you doing well in investigating multimodal approaches. Many guys with Gleason score 9 are doing well with protocols involving combination therapies. There have been reports on aggressive surgeries followed by radiation in voluminous cancer treatment in young guys, dissecting the whole gland for the solo intent in diminishing the burden of the cancer. Surely more therapies means more risks and side effects to which you should give consideration (some consequences cannot be avoided). Your present quality of life will be affected. Get your family involved in all decisions.

    I hope that you get good news from the scans but the previous MRI can already provide you details on closer malignancies. In your next meeting with the radiotherapist try obtaining details of the extent of RT protocol he proposes to a voluminous Gleason score 9 cases.

    Will wait to read your next update.

    Best,

    VG 

  • CMO2021
    CMO2021 Member Posts: 53 Member
    edited April 2021 #6
    VG and Eonore,

    VG and Eonore,

    Thanks you for your comments.  My CT scans and Bone Scans did not show any metastatic disease.  I know that there are likely micro mets hanging out somewhere but will take the positive new that gross mets were not seen.  I spoke with RO at MSK today and his approach would be HDR- Brachy then IG-IMRT for 5 weeks and ADT for 18 months.  He was very informative but not pushy just trying to give me a balanced view of the treatment.  I meet with the Medical Oncologist this coming Tuesday and then the Surgeon the last week in April. I will keep you all posted and I appreciate you insight and your support.

    CMO

  • Max Former Hodgkins Stage 3
    Max Former Hodgkins Stage 3 Member Posts: 3,721 Member
    CMO2021 said:

    VG and Eonore,

    VG and Eonore,

    Thanks you for your comments.  My CT scans and Bone Scans did not show any metastatic disease.  I know that there are likely micro mets hanging out somewhere but will take the positive new that gross mets were not seen.  I spoke with RO at MSK today and his approach would be HDR- Brachy then IG-IMRT for 5 weeks and ADT for 18 months.  He was very informative but not pushy just trying to give me a balanced view of the treatment.  I meet with the Medical Oncologist this coming Tuesday and then the Surgeon the last week in April. I will keep you all posted and I appreciate you insight and your support.

    CMO

    Aggregate

    CMO, it seems that you have numerous particulars going for you:  You are well-informed, realistic, calm, and in excellent medical hands.  The Brach with long-term IGRT/IMRT is potentially curative, with the HT helping the radiation do its thing.   I hope all goes well, and that you decide to continue sharing your interesting but challanging case,

  • GeorgeG
    GeorgeG Member Posts: 152
    edited April 2021 #8
    I spoke with multiple people

    I spoke with multiple people at MSK when I was doing my research and of course you see them as a leader throughout the literature. You are in good hands particularly as it relates to radiation therapies, they are at the leading edge. You have taken the best first step by choosing your medical team well. Stay positive brother.

     

    George

     

  • CMO2021
    CMO2021 Member Posts: 53 Member
    GeorgeG said:

    I spoke with multiple people

    I spoke with multiple people at MSK when I was doing my research and of course you see them as a leader throughout the literature. You are in good hands particularly as it relates to radiation therapies, they are at the leading edge. You have taken the best first step by choosing your medical team well. Stay positive brother.

     

    George

     

    Thank you Max and George,

    Thank you Max and George,

    I will keep the group posted as I move through this Journey.  

    CMO

  • CMO2021
    CMO2021 Member Posts: 53 Member
    I met with the Medical

    I met with the Medical Oncologist at MSK today he provided a balanced risk benefit for both RT and Surgery.  In addition he will run the MSK-Impact testing on my biopsy samples and a blood sample. Due to being Gleason 9 I was eligible to have the test run as part of their ongoing clinical studies with MSK-Impact.  I meet with the surgeion in  two weeks and will make a form a decision on initial treatment.  I will continue to post as I continue on this journey.

     

    CMO

  • VascodaGama
    VascodaGama Member Posts: 3,491 Member
    edited April 2021 #11
    Give a chance to the quality of life in the decision process

    CM,

    The approach involving HDR + IMRT covers a wider area than a single surgery (RP) and it is less invasive than an approach involving RP + IMRT, both typicalin Gleason 9 therapies. I believe that the medical oncologist has informed you on the side effects attached to each treatment. 

    I recommend you to decide on a option only after clearing all doubts and discussing the details (pros and cons) with your family.  This is a difficult moment in your life so that take all the time you need to reach to a conclusion. 

    I would like to know the results of the "impact test" but you need to consider that these nomograms are informative only. These are based on data collected from cases with similar characteristics not exactly your situation.  They do not consider the age of the patient (life expectancy) or the deterioration of the quality of life.

    You doing well in gathering the needed details.

    Best wishes. 

    VG 

     

  • CMO2021
    CMO2021 Member Posts: 53 Member
    edited April 2021 #12
    Meeting with Surgical Oncologist

    I met with the surgical oncologist at MSK.  The one discouraging finding was on MSK rereading the CT and MRI from my local hospital they found a suspect node (right external iliac) that was possibly "metastatic" spread to the LN. Despite this he felt with everything considered I would be a good candidate for surgery if that is what I chose. He was informative and did not push surgery over RT.  He said  I could not make a bad decision by choosing RT or Surgery it was just what potential side effects I was more comfortable with.  He also stated that sometime within the next 5 years I would need RT.  He was clear that Surgery was very unlikely to be curative. He also noted that I should think about my PCA as  managing a chronic illness. Given the results from the ASCENDE-RT trial  I am leaning toward RT with ADT and HDR Brachy Boost. I am concerned about the ADT side effects but given my G9  PCA which is likely locally advanced node positive, I think the multimodal RT treatment makes the most sense to me.  I have appreciated all the input and insight for the member on this list.  Still working to make a final decision on treatment.

    CMO

    Gleason 9 Prostate cancer

  • Georges Calvez
    Georges Calvez Member Posts: 545 Member
    edited April 2021 #13
    RP + ADT + RT

    Hi there,

    You could go down the route that I took which was a prostatectomy to remove the gland plus the lymph nodes, etc then ADT plus radiotherapy to clean up any last bits in the prostate bed, etc.
    It is possible with your diagnosis that you will have a measurable PSA post RP, so you could well face salvage radiation with ADT immediately post RP, so you will effectively face what I voluntarily signed up for.
    Initial treatment has three possible outcomes; you could be cured, this is unlikely but possible, you could go into remission, you will be free of prostate cancer for some years, this is quite possible, you will need further treatment for life, this is possible and maybe more probable than an outright cure.
    You are a sample size of one so don't read too much into nomograms and the like.

    Best wishes,

    Georges

  • CMO2021
    CMO2021 Member Posts: 53 Member
    Georges,  Thank you for

    Georges,  Thank you for sharing your experience with me.  What was your Gleason Score prior to surgery. Every physician I met with RT, MO and Surgeon all stated with G9 that I would need RT down the road even with surgery unless I was one of the outliers that was cured.   So my current plan is to go with the ADT/HDR/RT.  I am realistic that my best hope is for a durable remission.  This group helps keep me grounded and sane so I truly appreciate you sharing you experience.

    Best regards,

    CMO

  • VascodaGama
    VascodaGama Member Posts: 3,491 Member
    Taking the right step

    Hi again, 

    I do not know what lead you to decide in the combi treatment ADT/HDR/RT but this doesn't make part in the Ascend-RT trial you mentioned above.

    The combination of HDR brachy plus IMRT has been a typical treatment in risky voluminous PCa cases showing high successful outcomes,  but it is connected to higher RT side-effects, similar to the results obtained in the Ascend trial. In other words, brachy assures better outcomes (longer period of free survival) but at the cost of higher genitourinary, gastrointestinal and erection dysfunction consequences (also typical in RP/RT/ADT combi treatment). In fact,  this is probably what the surgeon told you in your consultation.

    Ascend trial shows that EBRT, in terms of the killing process, is better if delivered in higher radiation doses (81 Gy) than if delivered at lower doses (50Gy). This fact can be extended to the typical radiation volume used in RT protocols (68 Gy) in the combi RP/RT or in SRT.

    The quality of life is in jeopardy. One can try to eliminate the bandit for good in one goal risking the cumulative side effects  or try to eliminate it setp by step in a sequential type of treatment. 

    Probably one more consultation with the MO is advisable to discuss about the details  of your chosen option. I think that you doing well in investigating the details involved to reach to that final decision. 

    I wish you the best. 

    VGama

  • CMO2021
    CMO2021 Member Posts: 53 Member
    edited May 2021 #16
    VG,

    VG,

     

    Thank you for your thoughts and inputs. I appreciate your experience and knowledge With aggressive G9 (multiple cores) with perineural invasion, cribiform cells and MRI suggestng EPE with extension to seminal vessicles and the suspect node.  The chances the PCA is confined to the prostate is small and the liklihood of needing RT and ADT down the road is real.  Therefore I am looking to take an aggressive approach. I think what your suggesting is  my quality of life might be better with Surgery then RT if needed due to  being unable to achieve margins then go to RT and likely ADT.   MO put it like this you deal with side effects upfront with surgery or a farther down the road with the RT/HDR/ADT. I am meeting with the MO on Tuesday.  Thank you for raising additional points I should  consider.

     

    Best regards,

    CMO

  • Georges Calvez
    Georges Calvez Member Posts: 545 Member
    Experiences
    Hi there,
    You can read about my experiences here;
    https://csn.cancer.org/node/318066
    I doubt that you are looking at RP and RT plus ADT somewhere down the road. I suspect that you will have a significant PSA reading after the RP so they will swing you straight onto ADT, eighteen months worth at least, plus 66 Gy of radiation.
    So your choice is RT/HDR/ADT or RP/RT/ADT.
    One of the things about radiation is that it has significant cumulative effects, the first week or two is OK, then gradually you notice the effects of being toasted.
    I was quite lucky but by the end of the 66 Gy I could feel that the inside of my bowel had significant irritation and my urine was ever so slightly pink if I put a few drops on some toilet paper.
    You really do not know how you will respond in terms of effects, you might breeze through it relatively speaking, or it might turn into what will seem to be a medieval trial.
    RP is not a picnic either, in your case I would guess that you are looking at erectile dysfunction, the chance of incontinence is higher when you couple RP with RT.
    I was lucky insofar as I have the first but dodged the second.

    Best wishes,

    Georges
  • VascodaGama
    VascodaGama Member Posts: 3,491 Member
    Preparedness for a final decision

    CMO,

    Please note that I am not a doctor and do not intend to disturb your thoughts in therapies. I think that you researched well so you will decide on the best option.

    In my case, I gave preferences to quality of life but I did it because of the type of cancer I was confronting. Yours shows to be more aggressive and the type of cells described in the pathologist report got particulars known to be more resistant to certain treatments. RT in cribriform type of cancer seems to be lesser effective, so I recommend you to discuss this sort of matters with the MO in your next consultation. I wonder if HDR brachy works better in this sort of cases.

    Here is one article on the issue to help you in formulating a list of questions;

    https://pubmed.ncbi.nlm.nih.gov/31059665/

    We need luck in confronting this disease.  Let's hope that things work in your favor. 

    Best

    VG

  • Max Former Hodgkins Stage 3
    Max Former Hodgkins Stage 3 Member Posts: 3,721 Member
    Update

    I have been following your discussion here following your doctor imputs.   Impressionistically, I would think that surgery would not add much curatively, but imposes significant recovery.   I am not familiar with the trial protocols Vasco discussed, but in general, Trials are a good way to secure the newest treatmens, with excellent follow-up.  Old School, a case like yours would receive IMRT and HT, almost every time.

  • Georges Calvez
    Georges Calvez Member Posts: 545 Member
    Tough call

    Hi there,

    I think it is a tough choice between HDR/RT/ADT and RP/RT/ADT for advanced cases.
    In the former you are trying to destroy the cancer in the prostate and the surrounding tissue with HDR and then adding pelvic radiation to knock out any satellites.
    The amount of radiation that you are using will have side effects that may be more or less manageable.
    The latter choice uses surgery to remove the prostate, surrounding tissues and lymph glands, so hopefully you get the bulk of the tumours, then you use additional radiation to clean up any stragglers.
    In both cases you are looking at extended ADT of between eighteen months and three years depending on individual circumstances, the opinion of the medical team, how lucky you feel, etc.
    If the cancer is locally advanced then both methods have a good chance of a cure or long remission, they may give a significant extension to the time without heavy drugs or life for cases with cancer outside the local area.
    But they both carry the risk and certainty of significant side effects.
    It is Solomon's choice, but we are not Solomon and neither are the doctors.

    Best wishes,

    Georges

  • CMO2021
    CMO2021 Member Posts: 53 Member
    VG, Max and George,

    VG, Max and George,

     

    Thank you for your thoughts, suggestions and impressions.  I have taken a little time away to process information.  I agree with  VG  regarding the study he referenced which shows the challenges when cribiform and/or intraductal carcinoma are seen on biopsy  which show increased risk of poorer outcome. My research show this also holds true for RP.   I am disappointed that the study didn't do separate analysis for the patients that received RT + ADT. Though if you look at journal articles  there is a mixed response with the combination. There is some evidence that ADT that includes abiaterone does provide some improvement in outcome with RT.  There are also clinical trial enrolling subjects with neoadjuvant Abiaterone with RP.  MSK does ADT with Abiraterone with their HDR and follow-up IMRT.  I meet with the Brachy therapy RO on Wednesday.  I met with the MO again this week  and after talking I am still leaning toward the ADT (firmagon) with Abiaterone and the  HDR Brachytherapy and the IMRT.  That is what my gut is telling me (I know not terribly scientific).  Having a place to get different insights and put my thoughts down in writing has really been helpful as I formulate my final decision.   Thank you!