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Thread: Undecided

  1. #21
    Welcome to The Forum Ducky! As expected, you are receiving lots of suggestions and support. At this point, your diagnosis with Gleason (3+3) PCa places you in a low risk category relative to higher Gleason Stage findings. This places you in a non-crisis situation with time as your ally to get things sorted out.

    It would make no sense to treat if treatment is unnecessary. Simultaneously, it could be a tragic error to not treat if, in fact, treatment is necessary. This is where the skills of expert URO MDs are most important to make the determination.

    Since you will be undergoing another biopsy, having an MP 3T MRI (as ASAdvocate & DjinTonic have pointed out) in advance should be discussed. This can/will identify any other areas of suspicion that may have been missed on biopsy. These can be targeted on your next biopsy. Also, if you end up on long term Active Surveillance (AS), having the MRI now will provide a "baseline" against which any future changes/developments can be compared.

    The biggest difference between a TRUS and TP biopsies is they approach the prostate gland from opposite sides. Each may access areas of the prostate that the other can not.

    You are taking all of the correct steps by asking questions and seeking knowledge. Good job! Continue to do so and base your decisions on the clinical findings and advice of expert MDs.

    Remain vigilant and optimistic.

    Your new Forum Friends are here for you!

    MF
    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free = 0.39ng/ml, % PSA Free = 13%)
    Referred to URO MD
    Jan '12: DRE = Positive: "Left induration"
    Jan '12: Biopsy = 6 of 12 Cores were Positive: 1 = G7 (3+4) and 5 = Gleason 6
    Referred to URO Surgeon
    March '12: Robotic RP: Left: PM + EPE. MD waited in surgery for preliminary Path Report then excised substantial left adjacent tissue(s) down to negative margins and placed 2 Ti clips for SR guidance, if needed in future.
    Pathology: Gleason (3+4) pT3a pNO pMX pRO c tertiary pattern 5 / Prostate Size = 32 grams / Tumor = Bilateral: 20% / PNI: present
    3 month Post Op standard PSA = <0.1 ng/ml
    1st uPSA at 7 months Post Op = 0.018 ng/ml
    uPSA remains "stable" at 84 Months Post Op: Mean = 0.021 (20x uPSAs: Range 0.017 - 0.026) LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%)
    ED = present

  2. #22
    Experienced User
    Join Date
    Oct 2018
    Posts
    87
    Ducky, your situation is very similar to mine - the only difference being 4 positive cores vs. 3. And, notably, that you have both a uro and an oncologist offering AS as an option (btw, was that a MO or a RO?). My own primary uro tells me that I need treatment and why I'm going for a second uro's opinion next week.

    The Scholz book is indeed informative. If you're able to do the trip, his Prostate Cancer Research Institute has its yearly conference in LA in September. I attended the mid-year event last month and it was great. (easy for me to say of course, I live here) The Walsh book is also good, though as ASA says, biased toward surgery; but it's good for general knowledge of this nasty business. Be sure and get the 4th edition.

    Finally, I just read about an Italian study linking consumption of curcumin, aka turmeric, with artificially-heightened PSA levels. Interesting. Especially for someone like me who's been taking a teaspoonful daily for a few years now. Maybe that explains my strangely-low PSA...

    https://www.pagepressjournals.org/in...iua.2018.2.107

    Good luck and keep us posted!

    SC
    Born 1953. All care at Kaiser in LA.

    10/11/18: 2 pos G6 cores of 12. Pros vol 33g.
    12/6/18: MRI finds 15.5mm diameter mass, labeled PI-RADS 5.
    1/4/19: G6 tumor 10% in 1 of 6 cores; uro recs treatment
    2/27/19: Dr. Epstein - G6 on that single guided core; 20%
    3/26/19: Color Doppler with Dr. Bahn; recs AS.
    5/6/19: 2nd Kaiser uro recs AS.
    6/7/19: Dr. Clayton Lau at City of Hope recs AS.
    7/8/19: 3rd Kaiser uro: AS.
    7/15/19: Dr. Leonard Marks at UCLA: AS. UCLA rad finds nothing abnormal in MRI.
    8/23/19: Another Kaiser rad finds nothing abnormal.
    Changing docs to 3rd uro.

    PSA
    8/2/18: 1.2
    3/26/19: 1.8
    6/14/19: 2.2

  3. #23
    Top User
    Join Date
    Aug 2016
    Posts
    1,653
    Another factoid, the larger your prostate the higher the false negative on biopsies. If your prostate is small the more likely it is to hit something. The larger it is the more likely it is to miss something. They take a standard of 12 cores unless they have reason to take more. The larger the haystack the harder it is to find the needle. So, the false negative can range from 50 to 75%. This drops with each additional biopsy.

  4. #24
    Regular User
    Join Date
    Apr 2019
    Posts
    14
    Skipper that was a RO that I went to. Was wondering if anyone here has been seen at the Cleveland Clinic and would recommend one if the top urologist there?

  5. #25
    Somewhat related, I had questions on the logic of PCa primary treatment rarely being urgent. Looking at stats, like 10Y post-RP BCR probability, or 15Y post-RP post-BCR metastatic disease and survival probabilities, invariably those number turn less favourable the higher grade the cancer. Also I think PCa never gets better off its own, it's pretty much guaranteed to progress and with AS the hope is the advance will be slow enough to never matter. In short, we're looking at slowly shifting probabilities.

    On the other hand metastatic disease is quite binary. You either have it, or you don't. When you have it, it's never good news. And I imagine there will have been the week or month where supposedly treatment wasn't urgent, but the cancer crept out?
    --------------
    DOB 1965
    PM me for PSA graphing service & detailed story
    PSA 6.8 11/17
    PSA 7.5 04/18
    MRI 05/18 inconclusive, PI-RADS3?
    PSA 11.8 01/19
    PSA 10.1 02/19
    12 core random biopsy 02/19 (4+3)=7 suspicion of vascular invasion, grade 4 cribriform pattern, no PTEN loss
    Bone scan negative 04/19
    PSA 13.3 04/01/19 pre-surgery significant urinal symptoms and some ED
    RRP 04/04/19
    pT2c pN0 (0 of 7 lymph nodes positive) pL0 pV0 R0(local) Pn1
    Perineural growth predominantly on right hand side, tumour diameter 15mm 90% G4 10% G3
    Prostatic parenchyma with glandular hyperplasia and chronic granular, partly purulent inflammation.
    PSA 0.14 04/30/19
    PSA 0.02 05/13/19
    PSA 0.008 06/04/19

  6. #26
    Senior User
    Join Date
    Jan 2019
    Posts
    479
    I believe the reason is most PCa is slow growing. What everyone will tell you is there is no science to determine when cancer leaves the prostate. In the high risk cases, the cancer can be systemic before a diagnosis.
    DOB 5/1957

    PSA - 11/2010=1.9, 6/12=2.3, 12/13=2.19, 12/14=2.64, 3/17=5.29, 3/17=3.91, 6/17=3.47, 12/17=4.50, 12/17=3.80, free PSA low risk (local (Uro, “My opinion you don’t have cancer), 8/18=5.13, 10/18=5.1, 10/19 ISO PSA 56% risk cancer. All DREs negative.

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM <5%, Right side negative, (Uro opinion “This has been going on for a year”.... ah, more like 2 years ). Bone scan/CT negative

    2/25/19 R-LESS (Robotic Laparoendoscopic Single Site Surgery) outpatient Cleveland Clinic,

    3/6/19. Pathology - Grade Group 4 with Intraductal Carinoma
    T3aNO, GS8, 21 mm unifocal tumor 10%. -7 Nodes, - SV, - Margins, - PNI,
    - bladder neck neg., +LVI, + EPE non focal apex/mid lateral 1mm max extension, Cribriform pattern present. Decipher .86 High Risk.

    PSA 3/27/19 .03. (29 days)
    4/25/19 <.03. (58 days)
    5/25/19 <.02. (88 days)

    ADT - 6/3/19
    ART - 8/5/19

  7. #27
    Quote Originally Posted by KarlEmagne View Post
    Somewhat related, I had questions on the logic of PCa primary treatment rarely being urgent. Looking at stats, like 10Y post-RP BCR probability, or 15Y post-RP post-BCR metastatic disease and survival probabilities, invariably those number turn less favourable the higher grade the cancer. Also I think PCa never gets better off its own, it's pretty much guaranteed to progress and with AS the hope is the advance will be slow enough to never matter. In short, we're looking at slowly shifting probabilities.

    On the other hand metastatic disease is quite binary. You either have it, or you don't. When you have it, it's never good news. And I imagine there will have been the week or month where supposedly treatment wasn't urgent, but the cancer crept out?
    Does time from diagnosis to treatment of high or very high risk prostate cancer affect outcome? [2019]

    Results
    The median (interquartile range [IQR]) time from biopsy to RP was 68 (50–94) days. The median (IQR) follow‐up was 31 (12.1–55.7) months. The cumulative incidence of BCR (P = 0.14), metastasis (P = 0.15), and PCSM (P = 0.69) did not differ amongst time‐to‐treatment tertiles of VHR patients. Also, Kaplan–Meier estimates of ACM (P = 0.53) did not differ amongst time‐to‐treatment tertiles. Similarly, BCR, metastasis, PCSM, and ACM did not significantly differ amongst time‐to‐treatment tertiles in multivariable modelling.

    Conclusion
    In this pooled meta‐dataset of patients with high‐risk or VHR prostate cancer, time from diagnosis to RP did not appear to significantly contribute to differences in clinical outcomes. This finding supports the safety of enrollment of such patients into neoadjuvant clinical trials.
    I believe it isn't a question of a malignant cell or two escaping from the prostate. Many men already have circulating tumor cells (CTCs) in their bloodstream before diagnosis. These vary in number and in their ability to form metastases. They are a focus of "liquid biopsies" research and also are being looked at to identify those men who will go on to castrate-resistant disease. Fortunately, in many men with PCa, CTCs can't establish themselves outside the prostate. For an idea, see this search.

    Djin
    Last edited by DjinTonic; 04-30-2019 at 01:47 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3 -
    2013 TURP (90→30 g) path neg. then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day check)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015

  8. #28
    Quote Originally Posted by Ducky View Post
    Skipper that was a RO that I went to. Was wondering if anyone here has been seen at the Cleveland Clinic and would recommend one if the top urologist there?
    Hi Ducky! There are several RP Graduates from The CC involved in The Forum. Touch base with:

    - wtdedula

    - Duck2 (post #s 6, 10 & 26 in this Thread)

    A consultation at The CC will outline all of your best options and action steps.

    Good luck!

    MF
    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free = 0.39ng/ml, % PSA Free = 13%)
    Referred to URO MD
    Jan '12: DRE = Positive: "Left induration"
    Jan '12: Biopsy = 6 of 12 Cores were Positive: 1 = G7 (3+4) and 5 = Gleason 6
    Referred to URO Surgeon
    March '12: Robotic RP: Left: PM + EPE. MD waited in surgery for preliminary Path Report then excised substantial left adjacent tissue(s) down to negative margins and placed 2 Ti clips for SR guidance, if needed in future.
    Pathology: Gleason (3+4) pT3a pNO pMX pRO c tertiary pattern 5 / Prostate Size = 32 grams / Tumor = Bilateral: 20% / PNI: present
    3 month Post Op standard PSA = <0.1 ng/ml
    1st uPSA at 7 months Post Op = 0.018 ng/ml
    uPSA remains "stable" at 84 Months Post Op: Mean = 0.021 (20x uPSAs: Range 0.017 - 0.026) LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%)
    ED = present

  9. #29
    Thanks Djin. And I get the point of this and similar articles. If cancer developed over many years up to a high risk situation, then 1.5 months (time from biopsy to treatment in an interval of [1.5, 3.0] months) will be statistical noise.

    But I'm still somewhat in doubt. Take my case of PSADT 15 months. Then the PSA might increase from 4.0 to 64 in 5 years, which might on average be the difference of Gleason 6 to Gleason 9, or say a 70% higher probability of BCR in 5 years after RP. If 5 years increase the risk by 70%, then 1.5 months will amount to roughly 1.75%. Compared to 70%, 1.75% may seem insignificant. However, if you had an electrical device with a 1.75% probability of burning your house down, would you feel fine leaving it plugged in whilst out on 6 week vacation?

    I think it's all psychology. Yes, an additional wait of 6 weeks will 98.25% most probably not make a difference. Still, a 1.75% chance of seeing one's house burn down will make most of us feel ill at ease. If it's considered rational to buy fire insurance, why should I not care about the risks of a 6 weeks wait on cancer surgery?
    --------------
    DOB 1965
    PM me for PSA graphing service & detailed story
    PSA 6.8 11/17
    PSA 7.5 04/18
    MRI 05/18 inconclusive, PI-RADS3?
    PSA 11.8 01/19
    PSA 10.1 02/19
    12 core random biopsy 02/19 (4+3)=7 suspicion of vascular invasion, grade 4 cribriform pattern, no PTEN loss
    Bone scan negative 04/19
    PSA 13.3 04/01/19 pre-surgery significant urinal symptoms and some ED
    RRP 04/04/19
    pT2c pN0 (0 of 7 lymph nodes positive) pL0 pV0 R0(local) Pn1
    Perineural growth predominantly on right hand side, tumour diameter 15mm 90% G4 10% G3
    Prostatic parenchyma with glandular hyperplasia and chronic granular, partly purulent inflammation.
    PSA 0.14 04/30/19
    PSA 0.02 05/13/19
    PSA 0.008 06/04/19

  10. #30
    Top User garyi's Avatar
    Join Date
    Apr 2017
    Posts
    1,293
    I had my radiation at Cleveland Clinic -Weston, FL. They are first rate. Their RO's all follow the same protocol. It's the techs that handle you every day.
    72...LUTS for the past 7 years
    TURP 2/16,
    G3+4 discovered
    3T MRI 5/16
    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    CIPRO antibiotic = C. Diff infection 7/16
    Cured with Vanco for 14 days
    Second 3T MRI 1/17
    Worsened bulging of posterior capsule
    Oncotype DX GPS 3/17, LFP risk 63%, Likelihood of Low
    Grade Disease 81%, Likelihood of Organ Confined 80%
    RALP 7/13/17 Dr. Gonzaglo @ Univ of Miami
    G3+4 Confirmed, Organ confined
    pT2 pNO pMn/a Grade Group 2
    PSA 0.32 to .54 over 3 months
    DCFPyl PET & ercMRI Scans - 11/17
    A one inch tumor still in prostate bed = failed surgery
    All met scans clear
    SRT, 2ADT, IMGT 70.2 Gys @1.8 per, completed 5/18
    Radiation Procitis, and Ulcerative Colitis flaired after 20 years
    PSA <.006 9/18, .054 11/18, .070 12/18, .067 2/19, .078 5/19, .074 7/19
    We'll see....what is not known dwarfs what is thought to be fact

 

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