Results are in—what now?

Recent pathology shows MRI targeted biopsy Gleason 4+3 with PNI identified. Gleason 4 is 70%. Carcinoma involves 3 of 4 core fragments. The systematic 12 cores and seminal vesicles were all negative. Grade Group 3.

Recent PSMA reports no PSMA-avid nodal visceral or osseous metastatic disease.

Recent PSA 5.59

I have meeting with my MO on October 17 to review these recent tests. It’ll be interesting to see what he has to say. I’m sure it’ll be a big contrast from our meeting in March when my PSA was 3.66 and I hadn’t had a mpMRI or biopsy. My PSMA then was the same as now. At that time he considered me as having low risk disease with 24 months PSADT and local disease. With this updated information he’ll probably recommend systemic treatment starting immediately but since I’m pursuing cryotherapy of brachytherapy salvage treatment, hopefully in December, I’ll need to know if taking ADT before will impact the treatment protocol for either of these salvage treatments.

I have next meeting with my Duke Cancer Urologist on October 28. I assume we’ll discuss the biopsy results as well as my candidacy for salvage cryotherapy and ADT issues.

I have begun the preliminary process with Dr Zelefsky’s office to have my medical records sent for evaluation for my candidacy for salvage brachytherapy. I hope to meet with him ASAP but probably wont have the evaluation done before early November. I’d certainly like to talk with his office in the meantime about ADT before brachytherapy but doubt they will let me talk with anyone until my initial consultation.

So, this is a gut punch. The 4+3 alone puts me into a risk category calling for ADT and the PNI finding just worsens my case. I see no way around ADT either before or during and after salvage, at least for maybe 12 months. Without salvage I’m on ADT for life, maybe with intermittent pauses.

Just how bad is the PNI finding?

Wow, this is a kick in the teeth for sure. All we can say is the same thing: Get with the experts (sounds like you're already there), make a plan, and get with it.

Hang in there dude. You've got this!

HRPuff,
I would have to admit that I didn’t know that Brachy was even used as a Salvage therapy following Proton or traditional Radiation therapy. I would have thought the entire prostate and local area would have been so “cooked” by the proton beam that it would have been nearly impossible to get a good biopsy, let alone the placement of the seeds. It’s also hard for me to visual the PSMA ligand binding efficiently for a scan. My view of treated area as a shrunken, hard and sticky mess must be way off. I don’t recall anyone before you on the forum having this type salvage. From what I have seen on the internet it does sound like it can work well for you.

I too was surprised that an MO is in the mix, but that doesn’t mean the ROs won’t recommend ADT, and as stated they are the ones who should know in your situation.

The only bit of advice I have is that if you are given the option of ADT to give it careful consideration. You don’t want to be second guessing yourself down the road.

Good luck!

I think the ROs, in this particular situation, should have the final call whether or not to use ADT. If the RO says a year of ADT could help towards a “cure", or at least kicking the recurrence down the road several years, I think it could be well worth the discomfort. Orgovx, which is a pill form of ADT that clears the system fast, could be tried and discontinued if it doesn't work out for you. Your situation seems to be fairly complex with uncertainty for when and where ADT might fit in.

Yes, what I meant by the second guessing is making sure you feel as though you gave it your best shot to stop the cancer. Is a year of ADT discomfort now good enough insurance for possibly preventing a lifetime of ADT down the road? I believe you touched on this in your post. Hard decisions.

Mattam, I agree that the RO may recommend ADT in combination with salvage brachytherapy. I wouldn't like it but knowing it may be a year or so would make it more tolerable, especially since it might improve my odds for a cure.

It's a risk to try salvage for sure. If it fails then its on to ADT for life as 80% of the men who fail salvage are metastatic at failure. Plus I may have side effects from the salvage to add to the ADT side effects.

Tough call, but my gut tells me to try for the cure.

No one at this stage can tell you if there is PNI or not and a PSMA scan isn’t going to tell you if you have micro Mets anywhere.

I agree with the cure crowd, with in the RT world would be full pelvic RT so you have lymph nodes in the field and 18 months ADT and at least Casodex.

All that may sound like over treatment, but the first shot is the best shot. Don’t under estimate 4+3. The is a very small difference in BCR rates between 4+3 and 8.