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Thread: New diagnosis - Gleason 9, psa 20

  1. #11
    Top User
    Join Date
    Aug 2016
    Posts
    1,340
    Good point. Equipment specifications is only one aspect. The technicians and the radiologists and their training in using the equipment for specific diseases is invaluable.
    Last edited by Another; 12-01-2018 at 02:44 PM.

  2. #12
    A minor detail but may become important if this is truly an aggressive PCa that has been given to much time to progress.

    There seems to be considerable professional debate about a reasonable or safe elapsed time from Biopsy to surgery (prostatectomy). My highly experienced team (thousands of open prostatectomies, thousands of RALPs, and a total of 45-years experience as urological oncologists) all agreed my RALP could be safely done just 20-days after the TRUS 12-core biopsy. They did not want to wait any longer.

    Both the surgeon and the urological oncologist (retired urological surgeon) specifically told me that new guidance found no reason to wait more than a "couple weeks" after the biopsy to do the surgery.

    As it turned out in my case - there was NO reason to rush the surgery. What appeared to be a very high PSA density (~0.57 ng/ml/ml) was an artifact of a inaccurate prostate size measurements in the DRE, MRI, and TRUS biopsy.
    DOB: July 1947
    PSA: 2.0/2004 4.0/2010 5.8/2010 4.5/2012 5.6/2013 ALL Normal DRE
    5/18 PSA: 9.2
    6/18 PSA: 10.2 & 8.4% Free
    DRE small soft prostate w/no abnormalities
    6/28 3T mpMRI PIRADS 3
    18 cc gland=PSD 0.57 ng/cc
    0.32 cc lesion in apical PZ with subtle T2 signal hypointensity
    mild restricted diffusion of contrast into lesion prostate unremarkable intact capsule
    7/18 4KScore 34% Probability Gleason =>7

    8/03/18 Bx: Adenocarcinoma 6 of 13 cores ONLY L lobe
    T1c / Grade II / unfavorable intermediate
    extent of G3-G4 tissue far greater than indicated by MRI
    G6 (3+3) 70% LL Base 50% L Lateral Mid 20% L Base
    G7 (3 +4) 100% LL Apex 20% L Mid 60% L Apex
    8/15/18 Clear CT scan and Bone Scan
    RALP 8/23/18 pT3a, G7 (3+4), 20% involvement, SM+ (Focal 2mm G6), EPE(Focal G6)+, PNI+, LNI-, SVI-, LVI-
    7g Tumor 20x size in MRI & biopsy report & in BOTH lobes not just L as biopsy reported

    PSA Post Surgery
    10/3/18 0.021
    01/4/19 0.018
    04/03/19 0.022

  3. #13
    Regular User
    Join Date
    Dec 2018
    Posts
    21
    Yes! His doctor said he would have to wait a bit after biopsy to even run the studies. I let him know this concerned me, given the dr’s comment that it was an aggressive cancer and how rapidly his psa increased. Complicating things is that he’s had an infection with 102+ temp, so he is on antibiotics for a month! The doc also noted that it could be my husband had a slight infection before the biopsy which could have increased his psa quicker, but that Gleason score alone meant it was aggressive.
    This encourages me to get as early an appointment as possible with MD Anderson. Perhaps they can at least start the assessment process.
    Thank you so much for this information.
    January 18 2019 PSA 60.8
    November 2018 PSA 22.5
    October 2018 PSA 10
    March 2018 PSA 5.65
    Biopsy Nov 27, 2018
    Gleason score 9; Right prostate - negative; Left prostate - prostate adenocarcinoma 4+5=9/10; percent involved 35%
    Biopsy noted chronic prostatitis
    MD Anderson on Jan. 7, 2019 - Dr. Suduhi
    MRI of spine negative
    bone scan negative
    CT body scan findings - 1/23/2019
    Retroperitoneal, left common iliac and left internal iliac adenopathy.
    Nodule in the prostate gland, consistent with the known primary malignancy
    Hormone therapy planned

  4. #14
    The infection issue is important. My biopsy was delayed two weeks because I cut my ankle while cleaning the roof a week after the MRI. The darn wound would not heal and required several visits with my internist and two different antibiotic treatments. I tried hard to get the biopsy done sooner but none of the doctors would cooperate. Finally, after waiting a few more weeks the biopsy was done and then my urological oncologist was suddenly in a hurry.

    I guess when three different doctors tell you the same thing over a period of two weeks it is a good idea to listen to them?
    DOB: July 1947
    PSA: 2.0/2004 4.0/2010 5.8/2010 4.5/2012 5.6/2013 ALL Normal DRE
    5/18 PSA: 9.2
    6/18 PSA: 10.2 & 8.4% Free
    DRE small soft prostate w/no abnormalities
    6/28 3T mpMRI PIRADS 3
    18 cc gland=PSD 0.57 ng/cc
    0.32 cc lesion in apical PZ with subtle T2 signal hypointensity
    mild restricted diffusion of contrast into lesion prostate unremarkable intact capsule
    7/18 4KScore 34% Probability Gleason =>7

    8/03/18 Bx: Adenocarcinoma 6 of 13 cores ONLY L lobe
    T1c / Grade II / unfavorable intermediate
    extent of G3-G4 tissue far greater than indicated by MRI
    G6 (3+3) 70% LL Base 50% L Lateral Mid 20% L Base
    G7 (3 +4) 100% LL Apex 20% L Mid 60% L Apex
    8/15/18 Clear CT scan and Bone Scan
    RALP 8/23/18 pT3a, G7 (3+4), 20% involvement, SM+ (Focal 2mm G6), EPE(Focal G6)+, PNI+, LNI-, SVI-, LVI-
    7g Tumor 20x size in MRI & biopsy report & in BOTH lobes not just L as biopsy reported

    PSA Post Surgery
    10/3/18 0.021
    01/4/19 0.018
    04/03/19 0.022

  5. #15
    Experienced User
    Join Date
    Mar 2018
    Posts
    58
    If you live in LA the 3 best surgeons are Reiter, Wilson, and Ahlering. Make sure your surgeon has done at least 1500 surgeries.

  6. #16
    Quote Originally Posted by Southsider View Post
    ...BTW, X-rays are read-- MRI's are "interpreted".
    As a one-time, part-time translator of papers into English, I am still interested in such things and did a search. It appears that both are used for MRIs, sometimes in the same paper or even title. As an example:

    Magnetic Resonance Imaging Interpretation in Patients With Symptomatic Lumbar Spine Disc Herniations
    Comparison of Clinician and Radiologist Readings


    ...
    Objective
    To compare the interpretation of lumbar spine magnetic resonance imaging (MRIs) by clinical spine specialists and radiologists in patients with lumbar disc herniation.
    ...
    Agreement between MRI readings by clinical spine specialists and radiologists was excellent
    ...
    These images were read by both the clinician caring for the patient as part of the inclusion criteria for SPORT, as well as a radiologist
    ...
    Each study was thus read by 1 clinician and 1 radiologist whose interpretations were compared.
    ...
    For MRI readings on patients with lumbar disc herniation, agreement between clinical spine specialists completing a data form ...
    Last edited by DjinTonic; 12-01-2018 at 11:40 PM.

  7. #17
    Regular User
    Join Date
    Mar 2013
    Posts
    13
    Hi. Another G9 person here.

    It's often recommended to get a 2nd opinion on the biopsy slides, if you haven't done so yet. Johns Hopkins is a preferred place to do that, and your urologist's office can arrange it. There may be an out of pocket cost if your insurance won't cover it, around $250 or so. It's worth it, since the treatment options depend so heavily on exactly what the biopsy reveals.

    G9 is indeed significant, and merits quite aggressive treatment. Multiple modes will probably be recommended, like radiation plus hormone therapy ("ADT", or Androgen Deprivation Therapy). There has been a trend in the last year or two to add chemo after that combo for G9 cases. Or, surgery plus radiation plus ADT.

    I had an MRI within a couple weeks of the biopsy, mostly because my uro didn't want to wait either. The residual bleeding from the biopsy lasts a long time, and it interferes with the MRI results to some degree. Waiting 3 or 4 weeks for the MRI would yield clearer results. The bone scan isn't affected, and with a PSA of 20 it is likely to show metastases if there are any.

    Finally, if you do end up with radiation therapy, they'll likely start ADT right away with a Lupron shot or something similar. That will immediately begin treating the PCa. They'll wait about 2 months to start radiation, since the ADT sensitizes the cancer cells further to radiation. There are many protocols now for radiation; there's a lot to learn.

  8. #18
    Regular User
    Join Date
    Dec 2018
    Posts
    21
    Thank you for sharing your experience and giving us an idea of what to expect. Did the radiation treatments last long? Did you have any difficulty with the ADT?
    We will definitely request a second opinion on the biopsy slides. We plan to go to MD Anderson, so they may want to see the slides.
    Thank you so much for your input.
    January 18 2019 PSA 60.8
    November 2018 PSA 22.5
    October 2018 PSA 10
    March 2018 PSA 5.65
    Biopsy Nov 27, 2018
    Gleason score 9; Right prostate - negative; Left prostate - prostate adenocarcinoma 4+5=9/10; percent involved 35%
    Biopsy noted chronic prostatitis
    MD Anderson on Jan. 7, 2019 - Dr. Suduhi
    MRI of spine negative
    bone scan negative
    CT body scan findings - 1/23/2019
    Retroperitoneal, left common iliac and left internal iliac adenopathy.
    Nodule in the prostate gland, consistent with the known primary malignancy
    Hormone therapy planned

  9. #19
    Regular User
    Join Date
    Dec 2018
    Posts
    21
    Thanks. No, we live outside San Antonio.
    January 18 2019 PSA 60.8
    November 2018 PSA 22.5
    October 2018 PSA 10
    March 2018 PSA 5.65
    Biopsy Nov 27, 2018
    Gleason score 9; Right prostate - negative; Left prostate - prostate adenocarcinoma 4+5=9/10; percent involved 35%
    Biopsy noted chronic prostatitis
    MD Anderson on Jan. 7, 2019 - Dr. Suduhi
    MRI of spine negative
    bone scan negative
    CT body scan findings - 1/23/2019
    Retroperitoneal, left common iliac and left internal iliac adenopathy.
    Nodule in the prostate gland, consistent with the known primary malignancy
    Hormone therapy planned

  10. #20
    Regular User
    Join Date
    Mar 2013
    Posts
    13
    Quote Originally Posted by Garden View Post
    Thank you for sharing your experience and giving us an idea of what to expect. Did the radiation treatments last long? Did you have any difficulty with the ADT?
    We will definitely request a second opinion on the biopsy slides. We plan to go to MD Anderson, so they may want to see the slides.
    Thank you so much for your input.
    There are various radiation protocols. Mine was rather traditional, 54 Gy to pelvic lymph nodes with boost to 79.2 Gy to prostate. Done in 44 fractions of 1.8 Gy each, over 9 long weeks, each session only lasted about 15 minutes. There has been a lot of work evaluating higher doses in fewer sessions; studies show this works well for many types though I'm not as sure about the G9 types. Definitely look into that, since fewer sessions will make life easier! Also, a brachytherapy boost has shown effectiveness, though at an increased risk of urinary strictures. Your RO should be able to discuss these options.

    Some have also added a chemo series after radiation. There's some evidence the G9 cases may benefit from aggressive systemic therapies due to the higher probability that microscopic metastases may already be lurking out in the system, though undetectable.

    Oh, and ADT? Everyone struggles with that to varying degrees. The main side effects seem to be hot flashes and fatigue, loss of libido and sexual ability, with weight gain also a common problem. There are many others, including loss of bone density, mental "fog", fun things like that. ADT is effective according to a great may studies, but it's no picnic.
    Last edited by redwing57; 12-03-2018 at 12:17 PM. Reason: tweaked brachy comment
    [email protected] on 4/16/13. PSA 5.2, G9(5+4), PNI+, cT3a by MRI.
    IGRT - 44 sessions (79.2 Gy, 50.4 Gy pelvic)
    ADT2 - Lupron+Casodex (5/13-3/16)

    PSA:
    8/13-5/16 <0.1 (ADT2)
    5/16-3/17 recovering from ADT2
    3/17-7/18 ~ 0.6 - 0.8 (no TX)
    10/18 = 1.0

 

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