Urologist says HT only

New guy impressed with the quality of information and links here -- thanks.

Urologist eager to do RP at time of DRE, biopsy and initial report on it, but now, I think because of the CT comment below, urologist rejected RP, did not even mention RT, and wanted to start HT quickly. He had not seen the report from JHU (G7) so based his recommendation on local path (G8), especially the CT radiologist's. Nonnogram is different for G7 vs. G8, as you all know.

Anybody able to help me interpret? I see the advice not to discuss RT with uro or RP with radiation docs.



Age 75, excellent health
PSA 23.8? (Blood drawn 45 minutes after vigorous Nordictrac skiier workout with impact on pubic bone/bladder)
Gleason 4+3 from Johns Hopkins (4+4 from nearby regional hospital),
6 cores on left negative, 5/6 on right positive
Stage at DRE 7/20 was T2A but JHU pathology said EPE AND PNI on right midgland only
Bone scan negative for metastases
CT radiologist said 5 mm sclerotic focus on head of right femur, "too small to be detected by upcoming bone scan, statistically should be a bone island but because of PCa worrying"

Tall Allen said...
It would rule out surgery for me, but others may differ.

I don't think we know which treatment gives the lowest mortality.
The clinical trial /clinicaltrials.gov/ct2/show/NCT02102477
Surgery Versus Radiotherapy for Locally Advanced Prostate Cancer (SPCG-15),
seeks to study whether radical prostatectomy (with or without the combination of external radiation) improves prostate-cancer specific survival in comparison with primary radiation treatment and hormonal treatment.

Progressing - welcome to the forum.

I hope the bone island is benign and not a bone metastasis.

Hi Progressing and welcome to our community. Not sure if this came up in your discussion with your uro, but although there's not a hard rule on age for surgery, you're probably on the older side for RP. (Although based on your Nordictrac workout, you could probably kick my 56-year-old rear end.)

Good luck on your next steps...

Progressing-

MSK has some great doctors. Howard Scher (MO) is certainly among the best MOs anywhere, and Michael Zelefsky is among the best ROs anywhere.

MSK is part of the OSPREY trial of the DCFPyL PET scan, but to qualify, you will have to agree to a prostatectomy, and as I said, based on early studies, I would be wary of that in your case. Fortunately, NIH is running two clinical trials of the DCFPyL PET scan that you may qualify for:

/clinicaltrials.gov/ct2/show/NCT03181867
/clinicaltrials.gov/ct2/show/NCT03173924

The contact person is the same for both:Yolanda McKinney, R.N. (301) 443-6913 ymckinney@mail.nih.gov
They are delighted to hear directly from patients. The nice thing about clinical trials at NIH is that all costs are covered, including travel and accommodations in D.C.

If you're are able to rule out that the femur lesion is a metastasis, Zelefsky would be a great choice as your RO to perform curative therapy for you.

I doubt you could go far wrong with any of the MOs at MSK. The really critical thing is the PET scan. If that is negative, you can move onto a potentially curative radiation therapy and you won't have to live with cancer.

New information from MSKCC re-evaluation of CT scan and biopsy slides:
"No suspicious osseous lesion
No abdominal or pelvic lymphadenopathy."
Still Gleason 4+3 and PNI; pathologist at MSKCC added "high grade PIN" but did not report EPE.
Cautious about "low attenuation hepatic focus, possibly focal fat, metastasis less lilely (25%)." Full liver blood workup,showed all normal except elevated prostatic acid phosphatase (2.8 vs desirable upper limit of 1.5 ng/mL).
MRIs of pelvis and liver on 9/20 and 9/22.

Good news -- Memorial Sloan Kettering did MRI and reviewed original CT scan. No metastases, no seminal vesicles, no lymph nodes involved but "broad capsular abutment and focal bulge," "suspicion" (75%) of EPE.
Options to consider are surgery, Lupron plus radiation, or clinical trial with Lupron, ARN-509, Zytiga for 3 months, then SBRT, then three more months of the three hormone drugs.
Appointments with RO 9/27 and URO 9/29.

Suggestions welcome!