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Thread: Having second thoughts about post op RT

  1. #1
    Senior User
    Join Date
    May 2017
    Posts
    175

    Having second thoughts about post op RT

    I'm scheduled to start HT and SRT in a few weeks but I'm having second thoughts about the radiation. After surgery I had the following combination:

    1) Positive surgical margins (LVI) at three or four places.
    2) Cribriform growth pattern
    3) Persistent PSA at 0.1 and six months later .183

    I believe the cancer is already outside the prostate bed due to the fact that cribriform cancer is highly prognostic for distant metastasis AND it's probably been outside the prostate for quite a while already. My expectations are that if I have radiation my PSA will not go down to undetectable. Sure, it will drop but I sincerely believe it will come right back. I'm not a gambling man and I see radiation as a gamble with low odds of winning. My RO said a scan probably wouldn't show anything and there is no way to know if it's outside the pelvic area. This is basically a gamble. I just see radiation as another insult to the pelvic area. Another co-insurance charge (Cha-Ching) and more down time. On the other hand, if my RO is correct that there is a low chance of secondary cancers, why not take a chance? I can't decide. Two days ago I was leaning towards HT and radiation. Now I'm leaning towards just HT and skip the radiation.

    One question I did not ask the RO was this, if the cancer is already outside the pelvic area, is there any advantage to doing radiation? Is there any advantage to killing some of the cancer even if you can't get it all? I'm really getting tired of this.

    By the way, I also read a paper that described cribriform cancer as genetically closer to pattern 5. I'm wondering of cribriform will eventually get bumped from pattern 4 to 5.

    "Several studies have reported on genetic abnormalities related to CR/IDC growth. Qian et al found gain of chromosome 7, 12, and Y, loss of chromosome 8, and extra copies of c-MYC in both cribriform HGPIN and invasive cribriform carcinoma, suggesting that these growth patterns are genetically more alike to Gleason grade 5 than Gleason grade 3 or 4 prostate cancer."

    Above quote taken from https://www.erspc.org/wp-content/uploads/614.pdf

    EDIT: I've read papers and watched videos about the effectiveness of ART and SRT but I have never seen any info on the effectiveness where cribriform cancer is noted. That is the reason I won't go on pure stats from these articles. They did not separate out the cribriform patients. Maybe I will go back and look to see if there is any data on patients with gleason 9/10.
    Last edited by Busby; 08-15-2019 at 03:48 AM.
    DOB 1961
    2010-05 2.42
    2015-07 7.0
    2015-08 5.4
    2016-02 6.2
    2016-09 7.86
    2017-02 7.2
    2017-05 5.65
    2017-06 biopsy 7 of 13 cores G6
    2017-10 7.11
    2018-04 7.47
    2018-11 11.80

    2019-01 Da Vinci RALP
    Pathology report:
    Final stage pT2C
    Histologic type: Acinar adenocarcinoma with focal mucinous features
    Grade: 3+4=7 35% pattern 4
    23% of prostate involved
    EPE-
    BNI-
    SVI-
    PNI+
    LVI+
    Margins focally positive [1-3 mm] 4 locations
    Cribriform pattern noted

    Roche ECLIA uPSA
    2019-03 0.133
    2019-04 0.116
    2019-05 0.143
    2019-06 0.140
    2019-07 0.183
    2019-08 0.197

    2019-08 Start Lupron/Casodex

    2019-09 Decipher score .49

  2. #2
    Your signature says you are <65 and had RALP in January. You have likely met your private insurance out of pocket for 2019 and the radiation and ADT will cost you $0.

    If the treatment buys you a year or two more of quality life I would ask your family if they want you around another year or two. At 15 years, 47% of those G8s were still alive. Maybe more with ART/ADT.
    Last edited by Duck2; 08-15-2019 at 12:28 PM.
    YOB 1957

    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.

    2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic,

    3/6/19. Pathology - Grade Group 4 with Intraductal Carcinoma
    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)
    9/10/2019. <.02. (198 days)

    ADT - 6/19 - 6/21
    ART - 78Gy 8/19 - 9/19

  3. #3
    Top User
    Join Date
    Aug 2016
    Posts
    1,708
    I have no experience except what I've read here. HT sounds like it's the tougher of the two. What's the risk in adding in radiation?
    Last edited by Another; 08-15-2019 at 01:38 PM.

  4. #4
    Hi Busby,

    Your LVI+ refers to Lymphovascular Invasion. This is an adverse predictive finding within the examined prostate that the cancer was seen in the blood and lymph networks there. The risk is that if the prostate lesions had metastatic potential, cancer may have found its way out via the bloodstream or lymphatic system. This is an adverse finding separate from the SM+ (positive Surgical Margins) you also had in multiple locations. Cribriform architecture is an aggravating risk factor, but it is distinct from Gleason grades 3-5. Cribriform tissue itself doesn't metastasize.

    HT can halt PCa and control growth, especially of metastases, for as long as it works, but if your remaining cancer *IS* currently limited to the prostate bed and a nearby node(s), ART offers a chance at a cure and, if not, could prevent additional distant mets.

    Why don't you have the Decipher test done on your removed prostate tissue to learn the risk of metastasis of your particular cancer? This goes directly to the question you are asking. Decipher low, average, and high met risk has proven to be independent of Gleason score, and, I belive cribriform findings also. If you email the company, GenomeDx, they can give you a definite answer. They were very good about answering my questions (I am a Gleason 9 with a low-risk Decipher score).

    If your docs agree on ART+ADT, wouldn't you want to give significant weight to their expertise? I think HT alone would be advised in cases where either (1) scans have ruled out any involvement of prostate-bed and pelvic-nodes, or (2) advanced metastatic cancer has been established with confirmed distant mets.

    Djin
    Last edited by DjinTonic; 08-15-2019 at 12:54 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (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
    08-28-19 (2 yr. ) 0.016
    Avg. = 0.013

  5. #5
    Senior User
    Join Date
    Jan 2016
    Posts
    100
    I had RALP followed by SRT. It seems to have done a pretty good job on my fairly serious diagnosis. Check out my signature.
    DOB: 2/28/1963 Grandfather died of PC
    DRE: 10/15 Urologist exact words "Uh Oh, your prostate is as hard as a rock"
    Biopsy: 11/15 12 of 12 cores positive
    Gleason: 7 (4+3)
    RALP: 12/29/15
    Gleason upgraded to 9 (4+5)
    EPI (+) SVl (+) Margin (+) PNl (+)
    PT3b
    Continence=99%
    ED=present
    Finished 40 rounds of radiation 5/25/16
    PSA 12/29/15 3.5
    PSA 2/22/16 0.15
    PSA 4/4/16 0.12
    PSA 8/8/16 0.13
    PSA 12/9/16 0.07
    PSA 6/8/17 0.04
    PSA 1/11/18 0.01
    PSA 7/9/18 0.01
    PSA 2/4/19 0.01
    PSA 8/5/19 0.01

  6. #6
    Senior User
    Join Date
    May 2017
    Posts
    175
    My RO said he would be happy to order the genomic test. I'll move forward with that. I guess my problem is with the term "distant metastasis." To me, that term means outside the prostate bed. I may be wrong. I will see what I can find out about this.
    DOB 1961
    2010-05 2.42
    2015-07 7.0
    2015-08 5.4
    2016-02 6.2
    2016-09 7.86
    2017-02 7.2
    2017-05 5.65
    2017-06 biopsy 7 of 13 cores G6
    2017-10 7.11
    2018-04 7.47
    2018-11 11.80

    2019-01 Da Vinci RALP
    Pathology report:
    Final stage pT2C
    Histologic type: Acinar adenocarcinoma with focal mucinous features
    Grade: 3+4=7 35% pattern 4
    23% of prostate involved
    EPE-
    BNI-
    SVI-
    PNI+
    LVI+
    Margins focally positive [1-3 mm] 4 locations
    Cribriform pattern noted

    Roche ECLIA uPSA
    2019-03 0.133
    2019-04 0.116
    2019-05 0.143
    2019-06 0.140
    2019-07 0.183
    2019-08 0.197

    2019-08 Start Lupron/Casodex

    2019-09 Decipher score .49

  7. #7
    Quote Originally Posted by Busby View Post
    My RO said he would be happy to order the genomic test. I'll move forward with that. I guess my problem is with the term "distant metastasis." To me, that term means outside the prostate bed. I may be wrong. I will see what I can find out about this.
    Yes, distant metastases are those outside the pelvis. They can be treated with HT; depending on the location, some can be irradiated.

    Multiple positive surgical margins, however, is an indication that cancer was left behind right there, in the prostate bed.

    IMO, the Decipher results may be able to help you with the decision whether to add ADT; it doesn't address the question of what remains. In the absence of evidence not to, I would think that ART to the prostate bed is a standard treatment for persistent PSA.

  8. #8
    Top User
    Join Date
    Aug 2016
    Posts
    1,708
    Quote Originally Posted by Busby View Post
    My RO said he would be happy to order the genomic test. I'll move forward with that. I guess my problem is with the term "distant metastasis." To me, that term means outside the prostate bed. I may be wrong. I will see what I can find out about this.
    You're right about the possibility, but not a forgone conclusion its happened yet. It's a two part problem. Cleaning up the bed, if you can, is part one. Dealing with distant metastasis is part two, IF you have to. While RT now helps both now (if it exists), its main purpose is to clean up your localized bed issues left over from the surgery. You want to take care of those.

    If you don't finish this and hit the bed with all you got, it may be a problem again later. Do what you can now, imo. It's way too early to throw in the towel.

    Consider getting an assesment and possible help with depression. It is a very real side effect of this journey. It is treatable, and by all means, not necessarily chronic unless you ignore it. Considering less than standard healthcare protocol is one sign.

    Hang in there.
    Born 1953
    family w/PCa; grandfather, 3 brothers
    07-12-04 PSA 1.90
    07-10-06 PSA 2.02
    08-30-07 PSA 3.20
    12-01-11 PSA 5.69 Internist recommends urologist, I say no
    05-16-12 PSA 4.76 manipulate w/diet & supplements
    12-11-12 PSA 5.20, Health system changes to 3 years on testing
    03-07-16 PSA 7.20 Internist adamant on urologist
    DRE smooth, enlarged
    03-14-16 TRUS biopsy-prostatic adenocarcinoma 1%-60% across 8 of 12 samples, Gleason 3+3=6
    03-31-16 MRI pelvis w/o dye
    05-04-16 DaVinci prostatectomy, nerve sparing, Dr. Kent Adkins - recommend
    Final Path; weight 65g, lymph nodes, seminal vesicles, capsule, margin all negative, Gleason 3+4=7, Tumor volume 35%, +pT2c
    Catheter out - 16 days
    Incontinence at 6mos is minimal – no pad
    Cialis 3x/wk & Viagra on occasion
    Begin self-injection needle therapy for erections, stop after 6 due to onset of Peyronie’s
    Erections 100% - 14 months
    5-21-19 PSA <0.02, Zero Club 3.5 years

  9. #9
    Senior User
    Join Date
    May 2017
    Posts
    175
    I'm at the airport heading out for my annual vacation. Going to the Oregon coast for a week. My doc wanted to start Lupron last Tuesday but I told him I didn't want to take it just before leaving for vacation. Being out of town and not knowing what side effects I might encounter. We agreed on a date that was two days after I get back in town. Just got my monthly PSA at 0.196 so now I wonder if I made the right choice to wait. Doc didn't think it would be a big deal to wait ten days. Now I'm second guessing. BTW I can't edit profile from phone.

  10. #10
    Quote Originally Posted by Busby View Post
    I'm at the airport heading out for my annual vacation. Going to the Oregon coast for a week. My doc wanted to start Lupron last Tuesday but I told him I didn't want to take it just before leaving for vacation. Being out of town and not knowing what side effects I might encounter. We agreed on a date that was two days after I get back in town. Just got my monthly PSA at 0.196 so now I wonder if I made the right choice to wait. Doc didn't think it would be a big deal to wait ten days. Now I'm second guessing. BTW I can't edit profile from phone.
    Do not worry about the 10 days, Busby, just enjoy them!

    Djin

 

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