Wednesday, September 21, 2016

Biopsy Result Shows Writing On The Wall - Maybe Limited Time To Act

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Horizontal -spatial view showing distribution of cancer regions and percentage of cells deemed malignant.

The grim-faced urologist entered the patient consultation room late yesterday morning as wifey and I stood up to greet him. Since I already suspected the worst (from an earlier telephone call) I wasn't totally shocked into insensibility when he handed me the summary sheet for the recent MRI fusion biopsy, e.g.

The worst part of the damned pathology report was the Gleason 7 score in one region (3 + 4) with 63 percent of the cells assigned malignant status. My temptation was to try to emphasize the benign regions and the lower (Gleason 6, or 3 + 3) score areas, e.g.
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But the urologist wasn't sharing any confidence for non-action. It was clear from these results as well as the associated Partin Table*,
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 I had little choice other than to act, or face a possible metastasis of the (currently) confined cancer in as little as 5-6 months. But to establish whether I had even that much time to act, the urologist suggested getting a genetic marker test, made on the biopsy cells - called Prolaris.  This test is designed to indicate whether the cells in that Gleason 7 region are very aggressive, or much less so. If the former, I will have to act much more rapidly.

When I asked how much time I'd have if I did nothing, he hedged, conceding no test could be a crystal ball. However, wifey, who worked for decades in the fields of radiotherapy treatment as well as software testing, warned me the last stages of the disease could be agonizing with bowel and bladder problems, bone fractures and pain that would be enough to make the strongest guy cry unless he was on a diet of opioid pain killers. (Which I hate, since I don't like taking anything more potent than a baby aspirin). So it appeared even Janice was taking the doc's side that I had no choice other than to treat the damned thing.

After fifteen minutes of discussing treatment options, side effects, the choices came down to two: 1) focal cryotherapy, or 2) salvage brachytherapy.  (1) is the "ice ball" treatment that is shown in two videos in the link above. (2) represents a repeat of the treatment I had in San Francisco four years ago but now done in two administrations, at much higher doses (36 Gy a week apart).

The urologist affirmed that he leaned more to (1) given my previous experience with brachy indicated the cancer was resistant to this treatment. That basically meant I might be "nuking" my prostate - including urethra and bowel, for nothing. (But I am still waiting for a full brochure or document discussing the full salvage treatment from UCSF).

I said earlier, with much bravado, I was prepared to do nothing. But that was delivered with the understanding (or assumption) I'd have maybe 7 quality years left. However, if doing nothing means dying in 1-2 years then it becomes a no go, a non option. I might be ready to toss in the towel at some point, but not that early.

If the focal cryotherapy is chosen we have in mind an expert in Denver, Dr. David Crawford, who is also at the forefront of 3D staged biopsy. That will necessitate a meeting with him to see if I qualify and also (likely) another 3D biopsy with full mapping - meaning that he'd take up to 150 core samples while I am knocked out under general anesthesia. Then, a month or so later I'd have the procedure done and stay over in a hotel until the Foley catheter can be removed (hopefully in under a week).

For now it's a watching and waiting game and the pathology slides also have to be reviewed by Dr. Hsu of UCSF. I am hoping on his review he will find that the Gleason 7 region is really a 6 and there are more benign areas than malignant.

But....that may be just wishful thinking.

* Partin Table:

A probability table showing outcomes expected just prior to treatment, assuming it is done in a reasonable time. A table shows the probabilities of the cancer remaining contained in the gland or getting out ("extraprostatic extension") including getting into lymph nodes. Bracketed values shown with it give the 95% confidence values.

See also (for more information on the 3D Staging biopsy and Focal Treatment):

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