Info wanted on hormone therapy

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matcha
New Member


Date Joined Mar 2010
Total Posts : 6
   Posted 3/13/2010 11:52 PM (GMT -6)   
Hello,
 
I was diagnosed last August at age 48 with Gleason 8, prostate cancer.  The biopsy results were 4 of 12 samples positive all Gleason 8(~1%, 10%, 15%, 40%).  My PSA was only 2.15.  The tumor was palpable on the left side.  I was also having quite a bit of trouble with urination.  A CT scan showed an enlarged lymph node(also left side) that tested positive using a CT guided needle biopsy.  A bone scan was negative.  I had the slides sent to John's Hopkins and they were also read at Vanderbilt confirming the diagnosis.  The LN biopsy was confirmed by Vanderbilt.
 
I did quite a bit of homework and saw at least 5 Dr's.  IMRT and surgery recommendations were about split.  I selected 3 months of hormone therapy (Lupron) followed by surgery.  The idea was to downstage and improve the chances of a successful surgery.  The surgeon worked hard on removing the lymph nodes and spared part of the nerve on my right side.  The surgery was done on December 1st.
 
I was shocked and amazed when the pathology results came back T0 N0.  My family and friends were praising God and celebrating the news.  I didn't know it was possible for HT to eliminate the tumors.  My Dr. said it was due to a "remarkable response" to the hormone therapy.  My first PSA following surgery was < .1 but the test was done at 4.5 months after the 4 month Lupron shot.  The Dr. said it would take about 6 months for the testosterone to rebound completely.
 
The recommendation from my surgeon was no more treatment!  He initially was leaning towards a year of hormone therapy but then changed.  I took the good news and ran but after a 3 month break I'm about to get another PSA test as well as another opinion.
 
One Dr. told me that the results put me in a favorable prognostic group.  I was hoping someone could point me to any information that would prove him right.  Or find someone that is in the same or a similar boat.  The only studies I could find show that neo-adjuvant hormone therapy with surgery doesn't improve long term results.  However there is mention that 4% got the same results as I had and I'm hoping that this group has a better outlook.  The report doesn't mention any specific follow up information on the 4%.
 
Thanks in advance for the help,
David

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 3/14/2010 12:09 AM (GMT -6)   
Hi matcha,
Welcome to the site. I am a chapter leader at UsTOO International and my predecessor had a very similar experience. He ran our group for 15 years after his diagnosis of Gleason 8. he had surgery, no local mets, no nodes, and he never relapsed. He retired last year when I took over the group. Great story and much hope ahead for you. Again, welcome to our website. I hope you hang around...

May peace always be with you...

Tony
www.caringbridge.org/visit/tonycrispino
Prostate Cancer Forum Co-Moderator


James C.
Veteran Member


Date Joined Aug 2007
Total Posts : 4463
   Posted 3/14/2010 8:26 AM (GMT -6)   
Welcome to the forum, I can't answer your question, but hope others here can give you better information.
James C. Age 62
Co-Moderator- Prostate Cancer Forum
Gonna Make Myself A Better Man: www.youtube.com/watch?v=a6cX61oNsRQ&feature=channel
4/07 PSA 7.6, referred to Urologist, recheck 6.7
7/07 Biopsy: 3 of 16 PCa, 5% involved, left lobe, GS 3/3=6
9/07 Nerve sparing open RRP 110gms.- Path Report: GS 3+3=6 Stg. pT2c, 110gms, margins clear
32 mts: PSA's: .04 each test since surgery, ED Continues-Bimix .3ml PRN or Trimix .15ml PRN


dkob131
Regular Member


Date Joined Apr 2008
Total Posts : 364
   Posted 3/14/2010 9:31 AM (GMT -6)   

Macha:  I had a Gleason 8 and did one shot of Lupron followed by surgery, at the post op pathology they couldn't get a Gleason score because the cancer had been ravaged so bad and I only had a small amount of cancer left in the capsule. I went for a year undetectable but had a reoccurence recently and did SRT, I'm also doing at least a year of HT, maybe more.  I'll take it 3 months at time after a  year.

After reading Dr. Meyers book, he seems to be a firm believer that HT actually does kill or help kill of cancer cells, I decided to throw the kitchen sink at the cancer and see where it goes.  

Did your surgeon mention having a problem removing the prostate because the Lupron had made it sticky or tough to remove ?

David    


 54 y.o.
 Diagnosed 4/10/08
 DRE Normal
 PSA-5.5
 Biopsy- 12 cores, 4 positive highest 4+4=8
 Bone scan, CT scan and Chest X-ray clear 4/16/08
 Urologist suggested surgery 4/16/08
 MRI on 4/24/08 clear no suggestion of lymph node   involvement.
 4/24/08 -Started on Lupron and Casodex preparing for HDRT and IMRT in late July.  This treatment will not preclude me from surgery if I change my mind.
Decide to have DaVinci surgery after another consult with surgeon.
6/19/08- DaVinci surgery at University of Washington.
6/25/08- Path report, clear margins, no noted extension
9/12/08- PSA <0.02 
12/05/08-PSA <0.02 Six months after surgery 
3/02/09-PSA <0.02 Nine months after surgery
5/02/09-PSA .10
8/17/09-PSA .21 Begin HT and set up for SRT to begin in 2 months.
 


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 3/14/2010 1:37 PM (GMT -6)   
Matcha,

I was at high risk for lymphnode PC with a psa of 40. I went to Holland for a combidex scan and part of the protocol was that there could be no HT prior to the scan because HT would reduce any PC in the lymphnode to undetectable levels. This does not mean that it would go away, just reduce it so it couldn't be discovered.
The best advice I can give is to get an opinion from a top prostate oncologist like Myers, Strum or Scholz. Most doctors treating PC, especially surgeons, don't understand the complexities of HT as this is a highly specialized field and response to HT is quite different depending on the type of PC you have. The most common protocol is to radiate the lymphnodes if they are found to be affected. I would ask why this was not done.
In some cases HT will kill all of the PC, but in most cases it just puts it into remission with an undetectable psa that begins to rise again.
JohnT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


matcha
New Member


Date Joined Mar 2010
Total Posts : 6
   Posted 3/14/2010 2:45 PM (GMT -6)   
David,

I was anxious to see what my gleason score would be after surgery but my Dr. told me that gleason scores are not assigned after hormone therapy. I don't remember exactly why though. My Dr. didn't say anything about having trouble with the removal. I do remember reading that cancerous tissue has a sticky feel and that most of the time open surgery is selected instead of robotic for situations where the cancer may be outside the prostate. The tactile feel helps identify the cancer. Several Dr.'s told me that most likely I would get open surgery for this reason but the Dr. I selected had a lot of experience with robotic surgery and he felt more comfortable going that route.

Matcha

matcha
New Member


Date Joined Mar 2010
Total Posts : 6
   Posted 3/15/2010 7:15 PM (GMT -6)   
Thanks to all for the welcome and information.  Before my surgery and pathology results I planned to be very agressive and was sure that I would be doing adjuvant radiation.  I think I was just so excited about the initial results and the recommendation for no further treatment I abandoned the strategy to "hit it with a hammer" like one Dr. advised.  So I guess I'll keep fighting by getting another opinion and gathering more information.
 
Thanks again,
Matcha

Diagnosis
   August 2009 - Age 48
   4/12 positive, Gleason 8
   1 enlarged(2.9 cm) lymph node tested positve
   Bone scan negative
   T2 N1 M0
   PSA 2.15
Treatment
   09/08/2009 - 4 month lupron shot
   12/01/2009 - Robotic Surgery with lymph node disection
   12/12/2009 - Catheter removed
   12/18/2009 - Aspirated lymphocelle
   12/28/2009 - JP Drain removed (in for 4 weeks)
Results
   12/08/2009 - Pathology report T0 N0 (No cancer found)
   01/11/2010 - PSA Undetectable


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 3/15/2010 8:14 PM (GMT -6)   
matcha,
I was stage 3b after surgery and we couldn't eliminate stage 4. So as a G4+3=7 we opted for radiation and hormone therapy as adjuvant therapies. If it was contained I would have stopped there and hoped for the best.

I am curious if you had that post-op LN biopsy re-evaluated at JHU as well. It is very strange to have a negative cancer diagnosis after surgery even with HT.

Tony
Prostate Cancer Forum Co-Moderator


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 3/15/2010 8:27 PM (GMT -6)   
Good question, how is the negative for cancer even possible post surgery in your case Matcha, when 1/3rd of your biopsy cores were cancer positive up to 40%.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/19 - Corr Surgery #4,  Caths #11 and #12  same time, 2/8-Cath #11 out - 21 days, 3/2- Cath #12 out - 41 days, 3/2- Corr Surgery #5, Caths #13 & #14 same time, 3/6 Cath #13 out - 4 days


matcha
New Member


Date Joined Mar 2010
Total Posts : 6
   Posted 3/17/2010 7:34 PM (GMT -6)   
Tony and Purgatory:  I did not get a second opinion on the pathology.  I do know that Vanderbilt spent more time than they usually do.  They performed extra "slices" looking for cancer.  It took 2 weeks for me to get the final results.
 
I pressed the Dr.'s for an explanation.  One of the younger ones said it wasn't possible.  My surgeon (who I believe is also an oncologist) is very well respected and was firm on his opinion that it was a remarkable response to HT.  He said that it happens sometimes but usually in patients that have a small amount of cancer and lower grades.  He said he has seen only 1 other case similar to mine so feel fortunate.
 
I asked the Dr. if it was a miracle and he said that he wasn't going to stand in the way of a miracle. :-)
 
Here's a link and excerpt to the only info I've been able to find that shows this is possible.
 
 
"Soloway et al conducted a randomized multicenter T2bN0M0 trial (1995)...... Upon pathologic examination, no evidence of tumor (pT0) was found in 6 (4%) patients treated with NAD." 
 
NAD = neoadjuvant androgen deprivation
 
My question of the day is can hormone therapy kill micrometastatic cells?
 
Matcha

Diagnosis
   August 2009 - Age 48
   4/12 positive, Gleason 8
   1 enlarged(2.9 cm) lymph node tested positve
   Bone scan negative
   T2 N1 M0
   PSA 2.15
Treatment
   09/08/2009 - 4 month lupron shot
   12/01/2009 - Robotic Surgery with lymph node disection
   12/12/2009 - Catheter removed
   12/18/2009 - Aspirated lymphocelle
   12/28/2009 - JP Drain removed (in for 4 weeks)
Results
   12/08/2009 - Pathology report T0 N0 (No cancer found)
   01/11/2010 - PSA Undetectable


Galileo
Veteran Member


Date Joined Nov 2008
Total Posts : 697
   Posted 3/17/2010 8:54 PM (GMT -6)   
Google around a bit and found these:

"Five (16%) of 31 patients had no residual cancer (pT0) after radical prostatectomy"
http://www.ncbi.nlm.nih.gov/pubmed/12168076

"Stage pT0 was diagnosed in 38 (16.7%) of 227 patients."
http://linkinghub.elsevier.com/retrieve/pii/S0090429503003510

"Of these 40 treated patients, one third showed clinical downstaging; one patient staged initially as T2/B was downstaged to PT0."
http://www3.interscience.wiley.com/journal/112722601/abstract?CRETRY=1&SRETRY=0

"Köllermann et al. from Berlin analyzed a group of 174 men who underwent prolonged androgen deprivation therapy and observed a pT0 in 36 of 174 men (21%). When comparing preoperative parameters, men with pT0 had better biopsy Gleason score and lower clinical stage compared to men with pT2–3 as expected. However when both groups were matched for Gleason score no difference in PSA free survival was observed. These findings indicate that even after conversion into pT0 after long-term neoadjuvant therapy, biochemical progression does occur."
http://www.europeanurology.com/article/S0302-2838%2803%2900423-8

"Reported incidence of no residual prostate cancer (i.e. pathological stage pT0) on radical prostatectomy ranges from 0.07 to 4.2%. The incidence is higher after neoadjuvant endocrine treatment." http://www.springerlink.com/content/3l25172278674815/

"None of patients with pathologic pT0 PC had clinical or biochemical progression during follow-up, except 3 patients with NHT (mean, 22 months; range, 2-105 months)...We need more time for follow-up to conclude whether the prognosis of pT0 PC is favorable."
http://synapse.koreamed.org/DOIx.php?id=10.4111/kju.2009.50.3.229

"We analyzed preoperative data, pathological results and followup of pT0 tumors after radical prostatectomy for prostate cancer diagnosed on previous positive biopsy....At 6 centers a total of 30 of 7,693 radical prostatectomy specimens were classified as pT0 despite prior biopsy proven prostate cancer....Followup comprised clinical examination and postoperative prostate specific antigen assay at 1 and 3 months, and every 6 months thereafter....After biopsy proven cancer pT0 prostate cancer is an unpredictable pathological finding. Despite its excellent prognosis it has medicolegal repercussions that justify DNA based tissue analysis. There is no evidence that finding focal cancer after extensive prostate resection changes patient prognosis and postoperative treatment." (This was about pT0 without neoadjuvant treatment, by the way) http://www.jurology.com/article/S0022-5347%2809%2902905-X/abstract
Galileo

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NX MX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 and thereafter <0.1
http://pcabefore50.blogspot.com

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