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  • What next?

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    Old 07-29-2021, 09:07 AM   #1
    windsorje
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    What next?

    In a nutshell:
    I was diagnosed with PC four years ago. The VA attributes my cancer to my service in Vietnam, where I most likely came in contact with "Agent Orange." The VA urologist told me early on that what I had was a very, very slow-growing cancer and he gave me my options, which included active surveillance. An MRI was scheduled and resulted in "No evidence of a clinically significant prostate cancer."
    Since my diagnosis, I have had my PSA tested every six months and then visit the VA for my follow-up. My PSA has gradually gone from 6.7 at the time of the biopsy to 11.3 recently, that's over a four-year period. Another MRI was ordered and this morning I got the results.

    FINDINGS: The examination is of good quality and shows interval development of 1.7 cm biconvex low T2 signal lesion of the right paramedian, anterior transitional zone at the mid gland level which exhibits positive gadolinium enhancement and patchy mild to moderate diffusion restriction. It was not visible on the previous examination. Most likely a clinically significant prostate cancer. A targeted biopsy is suggested. No other suspicious abnormalities are seen and there is no evidence of locally advanced disease. Multifocal areas of scarring of the peripheral zone are seen which are probably due to subacute to chronic inflammation. Mild BPH is present. The gland weight is 45 g. There is no evidence of lymphadenopathy. No pelvic osseous abnormality is seen to suggest malignancy. A left posterior iliac wing bone island is incidentally noted which is unchanged compared with 2018.

    IMPRESSION:

    1. 1.7 cm biconvex low T2 signal lesion of the right paramedian, far anterior transitional zone which is most likely a clinically significant prostate cancer. A targeted biopsy is suggested.

    2. There is no evidence of locally advanced disease.

    3. Mild to moderate BPH with a gland weight of 45 g.

    PI-RADS 5: Very high (clinically significant cancer is highly likely to be present).


    Now I am anxious to hear from urology for their opinion as to what's next.

     
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    Old 07-29-2021, 02:05 PM   #2
    DjinTonic
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    Re: What next?

    Hi Windsorje, and Wecome to the Forum! Even though a PIRAD-5 is at the top of the 1-5 scale for likelihood of being malignant, there are cases where a 5 does turn out to be benign. However, your PSA increase to >10 is worrisome, even though it's hard to know the contribution of the BPH.

    A biopsy is in order, as you probably known, since this has to be investigated -- a biopsy is the only way PCa can be diagnosed.

    My two suggestion are to

    (1) stay calm -- if it is clinically significant PCA you'll treat it like we all have, and continue on your merry way

    (2) I would ensure that the uro who will be doing you biopsy will be taking cores in all prostate zones, with extra cores in the MRI-identified target(s). This is in contrast to a target-only biopsy that goes after the identified targets only. The latter can miss significant cancer (one estimate I've seen is that this happen perhaps 7% of the time when random cores in the other zones are not done).

    Please keep us posted and ask all the questions you need to ask.

    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.)...0.020 (3 yr. 7 mo.)

     
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    windsorje (07-29-2021)
    Old 07-29-2021, 03:11 PM   #3
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    Re: What next?

    I addition to Djin’s advice, I would suggest that you ask if you can have a transperineal, rather than transrectal biopsy. That is because a transperineal biopsy, like the Precision Point system, can access the anterior area of the prostate, which is difficult for a transrectal biopsy to access.

    The MRI report describes the suspect area as being anterior.

     
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    Old 07-29-2021, 05:07 PM   #4
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    Re: What next?

    I wish you well and as suggested a fusion transperineal biopsy is the logical next step. And stay focused on what you know versus being caught in the fear of what it could be. Denis
    __________________
    65YO healthy man, PSA 5/17 4.6, MPMRI, 5/17 lesion. 13 core biopsy 3 positive 3+3 All cores less than 30% 8/17 - second opinion Yale (3+4) in one core, < 5%, decipher test shows intermediate risks. HDR BT completed 2/6/18. 5/3/18 3 month Post HDR BT PSA 1.3, 6 mo PSA 1.2. 1-year PSA 1.0, testosterone 475, 18 month PSA 0.4 Testosterone 524, 24 month PSA 0.4, 32 month PSA 0.4 Testosterone 391, 40 months PSA 0.3, Testosterone 630.

     
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    Old 07-29-2021, 06:10 PM   #5
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    Re: What next?

    Hi windsorje, and I'll add my welcome to the Board!

    You have already tapped good advice on the biopsy.

    Do you know much about prostate cancer? One important fact to know at this time is that this is a highly survivable disease for men in your situation. Even considering all comers, including men with very serious disease at diagnosis (which you did not have, survival at 15 years, compared to age-matched peers is around 94-96%, with many of us living for years beyond that. Dealing with prostate cancer is no cake walk for most of us, but modern approaches - usually radiation or surgery for those not eligible for active surveillance - are both highly effective and generally quite tolerable. There has been a lot of progress in prostate cancer management and treatment, and progress continues at a rapid clip.

    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, for some reason based on a less sensitive test on 7/20/2021 was <0.05, still apparently cured in my ninth year since radiation (PSA as of 12/2/2020 was <0.01). (T 93 as of 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.

     
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    windsorje (07-30-2021)
    Old 07-30-2021, 06:46 AM   #6
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    Re: What next?

    Your PSA is troubling and I'd attribute the bulk of it to cancer. Your prostate is not unusually large. Your PSA numbers should never have gotten this high without more aggressive investigation.

    You were diagnosed with prostate cancer four years ago, meaning you've already had a positive biopsy. What are the results and in the face of them why are you letting your PSA numbers get so high?

    Why wasn't a follow up biopsy performed a year later?

    Early detection and treatment is the key to successfully managing prostate cancer. The VA is hit and miss on this. You may want to consider moving your care to a cancer center of excellence. You now find yourself in a much more serious situation because of waiting. Waiting for what?

    Denial and delay are the two demons of cancer. And, no doctor can predict you have a slow growing cancer from a biopsy. They can only predict what they find. A biopsy samples a very small area of the gland. PC is multifocal, meaning it exists in many locations. It is very very rarely just one lesion unless caught early. And, it can be more than one grade of cancer.

    A quick Google search shows one small study with limited evidence suggests exposure to Agent Orange may lead to more aggressive prostate cancer. The VA website mentions this as well.

     
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    windsorje (07-30-2021)
    Old 08-12-2021, 10:35 AM   #7
    windsorje
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    Re: What next?

    I appreciate all the responses to my post.

    I have been scheduled for a biopsy on Nov. 2nd. The individual who scheduled the biopsy said that the procedure would be transrectal. I am assuming that I would have the option to request the transperineal biopsy. After some research, that is the way to go. I intend to inquire further about the option.

    The good news for now, I just got the results from a more recent lab indicating that my PSA has dropped to 10.3. That's back to the level I was at 8 months ago.

    I'll keep you posted on my progress.

     
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    Old 11-24-2021, 11:05 AM   #8
    windsorje
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    Re: What next?

    I have received the report from my latest biopsy on Nov. 3rd. I won't see my urologist until Jan., but the PA said the numbers "do not indicate an aggressive PC." Gleason 3+4 (Group 2) ??

    The report shows 2 sites:
    #1. right apex:
    - Prostatic adenocarcinoma, Gleason grade 3+4=7 (Grade group 2), measures 1.0 cm in greatest dimension and involving five of five cores (90%, 80%, 50%, 30%, greater than 5%)
    - Pattern 4 represents approximately 40% of the carcinoma.
    - Cribriform pattern4 is present.
    - Perineural invasion is present.

    #2 Left mid:
    - Focal high grade prostatic intraepithelial neoplasia.

     
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    Old 11-25-2021, 06:57 AM   #9
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    Re: What next?

    In my opinion, the PA is mistaken. A Gleason score of (3+4)=7 is only part of the risk calculation. The high percentages of core involvement, the cribriform morphology, and the perinureal invasion all increase your risk.

    Waiting until January is stressful, but I suggest that you do more research on risk and treatments. Best wishes to you.
    __________________
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    Seven biopsies from 2009 to 2021. Three were were positive with 5% Gleason(3+3) found.

     
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    Old 11-25-2021, 03:44 PM   #10
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    Re: What next?

    Howdy

    I'm also a vet with AO exposure and I get all my care through the VA. If you have not done so I would strongly suggest you sign up with MyHealthVet. Using the BlueButton reports you can you can get the actual notes, pathology reports ect..

    I find actually reading what is in the reports and notes is much more informative that relying on a resident or PA's opinion and it prepares me with questions when I do meet with the providers in person.

    It would seem the PA is interpreting your biopsy results as favorable risk intermediate. I am unfavorable risk intermediate. I've spent alot time researching the differences but if I hadn't signed up for MyHealthVet and had access to my actual reports my efforts in relying on only what I was told for me at least would have left me in the dark about a lot of what was in my records.

    If you have any problem signing up PM me..

     
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    Old 11-25-2021, 08:54 PM   #11
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    Re: What next?

    I share ASA’s concern regarding the volume of pattern 4 in your biopsy results. I encourage you to learn as much as possible about treatment options before your sit down in January. You have several radiation options as well as surgery. Each comes with the risks of unwanted and possibly life changing side effect. Although your urologist may know surgery he/she probably knows very little about your radiation options. This forum is a great place to ask questions and begin that learning process. I encourage every recently diagnosed guy to make an informed treatment decision as well as to seek out the best practitioner and treatment team available.
    __________________
    Rising PSA:
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    DOB 7/21/47; good health; age 69 @ Dx
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