Gleason 6 with PNI

I was just diagnosed with prostate cancer. I had 2 cores out of 12 that had cancer present: T2A, Gleason 6 (3+3) (80%, 60%) on right mid prostate. There is also perineural invasion. My urologist said that he could not do a prostatectomy, because I have a very large hiatal hernia. Therefore, he is recommending radiation therapy, because he feels that with PNI, that I would not be a good candidate for AS.


We are in the process of moving to San Diego, but will probably not be down there for a few months or more. I would prefer to have the treatment done at UCSD Moores Cancer Center. But. I probably will not be living down there until May or June.

Can I safely wait that long for treatment?

PNI is a minor risk factor. There is absolutely no harm in waiting a few months; in fact, many would consider you a good candidate for active surveillance. PNI (and the relatively high % cancer in those cores, which are related risk factors) may mean you won't be able to stay on AS quite as long as some other guys. Epstein says, "patients with PNI who meet criteria for AS should not be excluded from this treatment option." However, you have 2 cores with greater than 50% cancer, which Epstein would exclude, but others would not.

Perineural Invasion in Prostate Cancer Patients Who Are Potential Candidates for Active Surveillance Urology

As you can see, there is a lot of controversy over the risk factors that should preclude AS. Many programs would take you, especially with the excellent long-term results that have been reported among all low risk patients (like yourself).

I've heard really good things about UCSD and I think you should definitely hear what they have to say. In particular, they have a really interesting new kind of imaging there, called RSI-MRI, that may be useful to you if you decide to go with AS.

I've heard they have a good radiation oncology department.

Welcome Greg. Sorry you are a member of our 'club.' You should consider a second opinion and get your slides reread by a PCa specialist like Epstein just to validate you are indeed a 3+3. I was originally staged as a 3+3 and when MD Anderson read the slides they upped me to a 3+4. Pathology of the prostate upped me again to a 4+3.

Greg,

As you reconsider, you can also investigate non-surgical treatment options. Particularly High Dose Rate brachytherapy and SBRT external beam radiation. These are the two most technologicaly advanced forms of radiation therapy providing you with equal cancer control as surgery and the minimum of side effects.

For HDRBT see wwwcetmc.com the website of Dr. Jeffrey Demanes. He is recognized as the father of HDRBT having used it since 1981. He is also the head of the department at the UCLA Medical Center. You appear to be a candidate for mono-therapy and it would be delivered in two procedures. I successfully used HDRBT more than six years ago.

SBRT is the more modern form of IMRT/IGRT and reduces the number of treatments from 35-40 down to 5 or 6. TallAllen successfully used SBRT more than six years ago and is an excellent reference source.

Greg S –

I'm going to weigh in and add a comment here because my numbers at diagnosis (Dx in 2011) are similar to the ones you have now. (Ballparkish similar, anyway).

You now:

Age 66
G6(3+3)
T2a
2 cores out of 12 (80%, 60%)

Me then:

Age 65
G6(3+3)
T1c
3 cores out of 12 (90%, 70%, 5%)

As for treatment, in my case I did ultimately have radiation (IMRT, 9 weeks, 45 sessions, topping out at 81 Grays).

The point I want to make is that, as the numbers in my signature below indicate, it looks like treatment with IMRT was successful for me, and I'm still good after close to five years following it.

(But it's also true that I was given HT (Lupron) during the RT treatment. Has anyone said anything to you about taking that at the same time?)

Of course individuals vary, and the results I got with RT don't guarantee what yours might turn out to be. But I simply offer my experience as one example of how treatment with radiation (if you go that route), for a roughly similar PCa situation, appears to have been successful. You are welcome to take that for what it is worth.

But I also do wholeheartedly concur with the other good advice others here are giving you, namely, that you indeed consider all reasonable treatment options before choosing one.

When it comes to treating this disease, we really need to take our best shot first, whatever we decide that it will be, so it's essential to take the time to make sure that the decision on what that best shot will be for us is the best decision that we can make.

At G6, waiting isn't a problem and AS should be high on your list. the "c" is an anxiety generator, but PC is a bit of a different animal and cancers are much more treatable these days.

I wouldn't think you'd need to consider RT with lupron, you're on the lower risk side of things.

Andrew