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  • Surgical removal vs. EBRT

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    Old 12-03-2020, 08:24 AM   #16
    Terry G
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    Re: Surgical removal vs. EBRT

    KPJ1, I wish more men would do as you’re doing. I believe there would be far less regret in their choice of treatment. A good source of PC treatment options if you’ve not already found it is prostatecancerfree.org. I found it very helpful in comparing different choices especially after spending some time with the different graphs showing success results by risk level. It helps if you ‘clear’ the choices and then start adding treatment options. Each data point is the result of a study and by hovering the mouse over the data point it will lead you to the specific study. From there you can get information about the date of the study etc.
    I’m glad to see you check out the credentials for the Dr.’s your considering. The differences between the very best and the rest of the field can be the difference between a cure and recurrence. Keep posting and sharing since it helps all of us on the journey.
    Terry
    __________________
    Rising PSA:
    11/13 1.95; 9/15 3.28; 10/16 5.94
    TRUS 1/17
    Bx: Three of twelve cores adenocarcinoma Gleason 6 (3+3) all on left side, no pni.
    DOB 7/21/47; good health; age 69 @ Dx
    Treated 6/17 SBRT @ Cleveland Clinic by Dr. Tendulkar
    Reduced ejaculate only side effect; everything works
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    PSA’s post.SBRT 1.1, 1.1, .9, 1.8, 2.7, 1.0, 0.3, 0.6, 0.8

     
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    Old 12-03-2020, 07:38 PM   #17
    GuyBMeredith
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    Re: Surgical removal vs. EBRT

    KPJ1,

    You will probably note that men who do IMRT plus ADT have a higher incidence of ED than with radiation alone. I contend that this is due to general ignorance on the part of doctors about men's sexual function while on ADT (castrate).

    Of the two books suggested I've read only Dr. Walsh's book. He offers quite a bit of good information, but is very much incorrect in saying men are not able to function sexually while on ADT. He says that a certain percentage of men on ADT can have erections, but none can have orgasm with the absence of testosterone. None of the male sexual functions require testosterone. (See article extract below.) From my experience and that of others, I can tell you he is wrong up to three times a week.

    Why is this important? Erectile tissue in the penis requires frequent oxygenated blood from erections to remain healthy. Lack of oxygenated blood can cause development of fibrous tissue in the penis rather than spongy erectile tissue. Surgery patients are encouraged to have erections as soon after surgery as possible to keep up the supply of oxygenated blood (vacuum pump blood does not work as it is not oxygenated) to maintain healthy erectile tissue.

    Patients on ADT usually have no automatic libido and not enough interest to attempt erections so, over the typical short run of 4 to 6 months, erectile health can decline. Doctors should be encouraging ADT patients to attempt sexual activity, but are setting the opposite expectation as they are generally ignorant that this is possible.

    ________________________________________ _____________________

    Vasoactive intestinal polypeptide (VIP) is not an androgendependent
    neuromediator of penile erection

    L Cormio1*, L Gesualdo2, E Maiorano3, C Bettocchi2, F Palumbo2, ATraficante1, FP Schena2 and FP Selvaggi21Department of Urology, Di Venere Hospital, Bari-Carbonara, Italy; 2Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy; and 3Department of Pathology, University of Bari, Bari, Italy

    The effects of castration on vasoactive intestinal polypeptide (VIP) immunostaining in human corpus cavernosum (CC) and the relationship between VIP immunostaining and erectile function.were studied in patients with localised prostate cancer who had (Group 1¼castrated) or had not.(Group 2¼control) undergone 3-month neoadjuvant chemical castration before radical prostatectomy. Evaluation of erectile function included medical and sexual history, physical examination, and measurement of total serum testosterone. CC biopsies were taken at the end of radical prostatectomy and samples immunostained with anti-human VIP antibody. Specific staining was quantified by image analysis and expressed in arbitrary units (AU). Chemical castration induced erectile function deterioration in 70% of patients due to loss of sexual interest and confidence in the ability of having an erection rather than reduced ability of obtaining sexually induced erections. Average VIP content was 34.5AU in Group 1 and 39AU in Group 2 and this difference was not statistically significant. Chemical castration does not influence VIP immunostaining of human CC, suggesting that VIP is not an androgen-dependent neuromediator of penile erection and that it can be responsible for sexually induced erections in castrated patients.

    International Journal of Impotence Research (2005) 17, 23–26. doi:10.1038/sj.ijir.3901266
    Published online 4 November 2004
    __________________
    Diagnosed at age 73 Feb 2019 DRE indicates nodule PSA 2.8 Aug 2019 PSA 3.1 Urologist suggests biopsy in Oct Results of biopsy: 2 of 12 cores positive. Low volume T2b, intermediate risk, GS 3+4, PSA 3.10, prostate cancer, perineural invasion. Followed up with MRI to help decide between surgery and IMRT. MRI shows suspicious PIRADS 5 lesion measuring 2.cm in diameter, with associated left neurovascular bundle involvement. Started 6 month lupron series Feb 2020, 28 sessions of high dose IMRT Apr 15, 2020. Sexual functions okay except ejaculate has changed. Without libido it is an academic process that requires much focus. July 27 first measure of PSA and total testosterone. PSA: .13 ng/dl Total testosterone is less than 12 ng/dl.

     
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    Old 12-04-2020, 04:34 PM   #18
    SubDenis
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    Re: Surgical removal vs. EBRT

    Quote:
    Originally Posted by KPJ1 View Post
    I am 67, good health, my PSA has always been about 1.2 and this year is 1.4. My Dr. felt a hard spot with DRE, and sent me to urologist. I had MRI (pirads 4) and a fusion biopsy (Gleason 3+4=7), a bone scan and CT scan with no indication of spreading. Urologist is suggesting surgical removal, but says EBRT (40 treatments over 8 weeks) is another option. I am interested in hearing from those who have already made the surgery vs. EBRT decision, and any regrets you may have had with your decision. Especially interested in hearing of any after-effects from EBRT, and the downsides of EBRT.
    I had same pathology and chose HDRBT over surgery. I am 3 years post treatment, no side effects and psa is at Nadir of 0.4. I was 65 yo when I was treated.

     
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    Old 12-14-2020, 07:16 PM   #19
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    Re: Surgical removal vs. EBRT

    Here is my surgical path report:
    Prostate, right lateral base, core needle biopsy Part A
    Prostatic adenocarcinoma, Gleason 3+3=6 of 10, gg1, involving 6mm in a single needle core biopsy with a length of 8mm
    No definitive perineural or lymphovascular invasion is identified
    No definitive seminal vesicle invasion or extraprostatic extension identified

    Prostate, right lateral mid, core needle biopsy Part B
    Benign prostatic parenchyma

    Prostate, right lateral apex, core needle biopsy Part C
    Prostatic adenocarcinoma, Gleason 3+3=6 of 10, gg1, involving 2mm in a single needle core biopsy with a length of 9mm
    No definitive perineural or lymphovascular invasion is identified
    No definitive seminal vesicle invasion or extraprostatic extension identified

    Prostate, right base, core needle biopsy Part D
    Benign prostatic parenchyma

    Prostate, right mid, core needle biopsy Part E
    Atypical small acinar proliferation (ASAP)

    Prostate, right apex, core needle biopsy Part F
    Benign prostatic parenchyma

    Prostate, left base, core needle biopsy Part G
    Benign prostatic parenchyma based on histologic findings within outside immunostain only. No H&E stained slides available for review

    Prostate, left mid, core needle biopsy Part H
    Benign prostatic parenchyma

    Prostate, left apex, core needle biopsy Part I
    Prostatic adenocarcinoma, Gleason 3+3=6 of 10, gg1, involving 1mm in a single needle core biopsy with a length of 9mm
    No definitive perineural or lymphovascular invasion is identified
    No definitive seminal vesicle invasion or extraprostatic extension identified

    Prostate, left lateral base, core needle biopsy Part J
    Benign prostatic parenchyma

    Prostate, left lateral mid, core needle biopsy Part K
    Atypical small acinar proliferation

    Prostate, left lateral apex, core needle biopsy Part L
    Benign prostatic parenchyma

    Prostate, right anterior lesion #1, core needle biopsy Part M
    Prostatic adenocarcinoma, Gleason 3+4=7 of 10, gg2, involving 10mm in 3 of 3 core needle biopsies with an aggregate length of approximately 30mm
    No definitive perineural or lymphovascular invasion is identified
    No definitive seminal vesicle invasion or extraprostatic extension identified

    Prostate, right lateral lesion #2, core needle biopsy Part N
    Prostatic adenocarcinoma, Gleason 3+4=7 of 10, gg2, involving 7mm in 2 of 3 prostatic core needle biopsy fragments with an aggregate length of approximately 17mm
    No definitive perineural or lymphovascular invasion is identified
    No definitive seminal vesicle invasion or extraprostatic extension identified

    Prostate, left base lesion #3, core needle biopsy Part O
    Benign prostatic parenchyma

    Microscopic Description:
    Right mid Part E contains prostatic parenchyma. In the center of the biopsy specimen there are focal round to ovoid glands made up of glandular cells with foamy cytoplasm and basally oriented nuclei with inconspicuous nucleoli. The glands demonstrate poorly defined basal cells. No accompanying immunostain are available for review corresponding to this core biopsy specimen.

    Left lateral mid Part K contains a prostatic needle core biopsy. Within the center of the biopsy there are closely packed small prostatic glands with mildly enlarged vesicular nuclei, small dot like nucleoli, and poorly defined basal cells. Review of the accompanying immunostain demonstrates glands with prominent cytoplasmic staining for presumed AMACR and rare basil cells within the glandular population. The findings are felt to be suspicious but not diagnostic for prostatic adenocarcinoma.

    PSA:
    2014 1.1 age 61
    2016 1.44 age 63
    2017 1.05 age 64
    2018 1.37 age 65
    2019 1.37 age 66
    2020 1.39 age 67

     
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    Old 12-14-2020, 07:19 PM   #20
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    Re: Surgical removal vs. EBRT

    I posted my pathology report results above. I found much valuable material posted on this forum and thank everyone who provided advice and comments. After much thought, I have decided to go with IMRT, to be administered with a Varian Trilogy @ 70 over 28 days, no lupron. Fiducial markers will be placed at least 4+ days prior to beginning treatment. Appreciate any further comments on my situation and decision. It feels good to have made the decision and to get on with the treatment! I'll update again later to let you know how it goes.

     
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    Old 12-15-2020, 12:33 AM   #21
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    Re: Surgical removal vs. EBRT

    Had an inappropriate comment as I hadn't read far enough down the note.

    Had just read lines with the 3+3 diagnosis and commented that there is now some question as to whether 3 is actually a cancer as it does not leave the prostate or metastasize. Level 4 is more aggressive.
    __________________
    Diagnosed at age 73 Feb 2019 DRE indicates nodule PSA 2.8 Aug 2019 PSA 3.1 Urologist suggests biopsy in Oct Results of biopsy: 2 of 12 cores positive. Low volume T2b, intermediate risk, GS 3+4, PSA 3.10, prostate cancer, perineural invasion. Followed up with MRI to help decide between surgery and IMRT. MRI shows suspicious PIRADS 5 lesion measuring 2.cm in diameter, with associated left neurovascular bundle involvement. Started 6 month lupron series Feb 2020, 28 sessions of high dose IMRT Apr 15, 2020. Sexual functions okay except ejaculate has changed. Without libido it is an academic process that requires much focus. July 27 first measure of PSA and total testosterone. PSA: .13 ng/dl Total testosterone is less than 12 ng/dl.

     
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    Old 01-09-2021, 06:36 AM   #22
    KPJ1
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    Re: Surgical removal vs. EBRT

    Here's an update after my first week of radiation: I completed my first 5 IMRT treatments, 23 to go. No side effects experienced so far, the radiation is quick and painless. I spend only 10-15 minutes total getting each treatment, including setup. They do a blood test each Monday, and I meet with the radiation oncologist each Wednesday to discuss any side effects. After the radiation is complete, they will wait 6 months to do the first PSA test. So far so good.

     
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    Old 01-09-2021, 09:21 AM   #23
    Terry G
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    Re: Surgical removal vs. EBRT

    KPJ1...Don’t be surprised to have some urinary burning as treatment progresses. It’s a common side effect that typically resolves on its own. You may wish to proactively take an over the counter medication called AZO. It does make your urine a strange color; but, does seem to calm down your bladder and urinary tract that are feeling the effects of the radiation. Your urinary tract does go right through your prostate that’s being toasted by the radiation. I used AZO with good results and never did need to fill the script I had for Flowmax.
    __________________
    Rising PSA:
    11/13 1.95; 9/15 3.28; 10/16 5.94
    TRUS 1/17
    Bx: Three of twelve cores adenocarcinoma Gleason 6 (3+3) all on left side, no pni.
    DOB 7/21/47; good health; age 69 @ Dx
    Treated 6/17 SBRT @ Cleveland Clinic by Dr. Tendulkar
    Reduced ejaculate only side effect; everything works
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    PSA’s post.SBRT 1.1, 1.1, .9, 1.8, 2.7, 1.0, 0.3, 0.6, 0.8

     
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    Old 01-09-2021, 09:36 AM   #24
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    Re: Surgical removal vs. EBRT

    Thanks Terry G, the AZO might be a good suggestion if I get burning. I've already been taking flowmax for several years, but the AZO looks to be more for pain relief.

     
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    Old 01-09-2021, 11:41 AM   #25
    IADT3since2000
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    Re: Surgical removal vs. EBRT

    Quote:
    Originally Posted by KPJ1 View Post
    I posted my pathology report results above. ... After much thought, I have decided to go with IMRT, to be administered with a Varian Trilogy @ 70 over 28 days, no lupron. Fiducial markers will be placed at least 4+ days prior to beginning treatment. Appreciate any further comments on my situation and decision....
    Your choice strikes me as an excellent approach for your situation, considering your PSA, biopsy description and other data. You have a mild version of an intermediate risk case, as I understand it. While ADT (often Lupron) is typically given for four months to support radiation for intermediate risk cases, milder cases make using ADT more of a coin flip situation, and it makes sense to me to do the radiation without ADT in your situation.

    As you probably know by now, radiation injures both cancerous and healthy cells in the prostate. However, while cancerous cells do not recover from the radiation, healthy cells do, provided the radiation is not excessive, which it won't be with a competent provider that you almost surely have. This means that the urinary tract will be injured a bit, resulting in some symptoms during treatment and shortly thereafter, but healthy urinary tract cells will recover pretty quickly.

    Be sure to follow the recommended diet. Basically, it's an unhealthy long-term diet, but it is a good one for the duration of radiation. I did not do that out of lack of knowledge, somehow missing the word, sticking to my high-fiber, plant based Mediterranean diet, and I developed discomfort and bloating until the radiation team helped me correct course; that solved the problem almost immediately.

    Good luck!

    ….Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    21 years as a survivor. Doing well. Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low and stable at <0.01; apparently cured (Current PSA as of 12/2/2020). (Current T 93 12/2/2020.) Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs. Barely noticeable side effects from radiation; continuing low T, likely do to long use of ADT, but good energy and adequate strength. I have a lot of School of Hard Knocks knowledge, and have followed research, which has made me an empowered and savvy patient, but I have had no enrolled medical education. What I experienced is not a guarantee for all but shows what is possible.

    Last edited by IADT3since2000; 01-09-2021 at 11:45 AM. Reason: Added comment on diet right after posting.

     
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    Old 01-25-2021, 07:55 AM   #26
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    Re: Surgical removal vs. EBRT

    Radiation treatment update:

    Jan 16 end of second week, no noticeable side effects

    Jan 23 end of third week, no noticeable side effects

    15 treatments completed, 13 to go. I feel 100% normal. I do about 45 minutes cardio on the elliptical every day, the Dr. says this helps.

     
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    Old 02-21-2021, 08:35 AM   #27
    KPJ1
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    Re: Surgical removal vs. EBRT

    Update- I completed the 28 radiation treatments 10 days ago. No noticeable side effects so far, except for maybe slightly reduced bladder capacity after drinking a few liquids, and I feel the need to go now. I realize side effects could show up 2-3 years down the road, but none to speak of so far. I am happy with my choice of radiation over surgery. The radiologist/oncologist will see me for a checkup after 6 weeks, and the urologist will do a checkup after 6 months and begin the PSA monitoring.

     
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    Old 02-21-2021, 08:59 AM   #28
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    Re: Surgical removal vs. EBRT

    KP...Great news! Your urinary tract is irritated by the radiation effects but the heathy tissues will heal quickly while the cancer tissues will slowly die. My burning issues with urinating and ejaculation lasted 10-14 days. My advice now is to exercise more and enjoy life. The PSA’s to come maybe a little bumpy since it takes time for the cancer to die. Keep us posted on your progress. Terry
    __________________
    Rising PSA:
    11/13 1.95; 9/15 3.28; 10/16 5.94
    TRUS 1/17
    Bx: Three of twelve cores adenocarcinoma Gleason 6 (3+3) all on left side, no pni.
    DOB 7/21/47; good health; age 69 @ Dx
    Treated 6/17 SBRT @ Cleveland Clinic by Dr. Tendulkar
    Reduced ejaculate only side effect; everything works
    To view links or images in signatures your post count must be 10 or greater. You currently have 0 posts.

    PSA’s post.SBRT 1.1, 1.1, .9, 1.8, 2.7, 1.0, 0.3, 0.6, 0.8

     
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    Old 02-21-2021, 09:25 AM   #29
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    Re: Surgical removal vs. EBRT

    Quote:
    Originally Posted by GuyBMeredith View Post
    Had an inappropriate comment as I hadn't read far enough down the note.

    Had just read lines with the 3+3 diagnosis and commented that there is now some question as to whether 3 is actually a cancer as it does not leave the prostate or metastasize. Level 4 is more aggressive.

    While G 6 (3+3) cannot metastasize, it does sometimes grow locally out of the prostate in the form of EPE (extraprostatic extension). One study found this happens in about 4% of cases. But the real issue is that a biopsy that comes back as G6 tells you nothing about what going in the rest of the prostate. About one-third ofG6 men who elect surgery are upgraded to higher G scores when the whole prostate is examined.

    A biopsy score is the Gleason score of the highest score lesion seen. It is this score that basically determines treatment. I was a G 10 on biopsy with one G 10 (5+5) lesion and one G9 (4+5). If I had had any lower-grade lesions they would have been irrelevant. My score was downgraded to G9 (4+5) when the whole prostate was examined after surgery.

    Quote:
    Conclusions: It is not rare for pure Gleason score 6 prostate cancer to locally extend out of the prostate 3.9% focally and 2.4% nonfocally. In extremely rare cases Gleason score 6 can be associated with seminal vesicle invasion and yet not lymph node metastases. Our overall findings support the argument for continuing to use the term cancer for these tumors.
    From a 2018 study: https://www.auajournals.org/doi/10.1016/j.juro.2017.11.067

    Dr. J. Epstein has written convincingly about why we should still call G6 lesions cancer.


    Djin
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, 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
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, negative frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.037 (3 yr. 4 mo.)

     
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    Old 02-21-2021, 09:37 AM   #30
    KPJ1
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    Re: Surgical removal vs. EBRT

    Thanks DginTonic, actually I had a couple G7 (3+4) samples, it was out to the margin of the prostate on one side. But I was told no indication of spreading. I believe they did radiate the seminal vesicle as a precaution.

     
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