Hormone and radiation post robotic

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mr bill
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Date Joined Sep 2010
Total Posts : 683
   Posted 10/7/2010 8:28 AM (GMT -6)   
I am curious how long some have waited after RRP with a Gleason 9, Psa above 10 prior to surgery, to start adjunct therapy?  3 week PSA was .06. Euro surgeon says he would probably not start hormone till Psa was 10.00.  He is well written, published,knowledgeable (even if you have to drag it out of him) and seems to have done an excellent job with surgery.  But, 10.00... I dunno??
Age 66
BPH since 2000. at least three negative biopsies Erie. Uro did not prescribe finasteride
2007 acute urine retention photoselective vaporize Clev. Clinic
8-9-10 Aug PSA rose to 10.14 with finasteride positive biopsy Cleveland gleason 9, cat & bone scan negative
9-8-10 Robotic prostatectomy at Cleveland. Biopsy 9 nodes, 2 positive,seminal & vas deferens
PSA 3 week .06

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 10/7/2010 8:34 AM (GMT -6)   
you sure you didnt mean 1.0, not 10.0?

that is frightening if the 10.0 is correct.

you would not find a single US source that would even remotely agree, a 10.0 would be considered a run-away situation.

david in sc
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

mr bill
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Total Posts : 683
   Posted 10/7/2010 8:46 AM (GMT -6)   
You know, that was my question to him, I asked do you mean one-point-zero? He said no one-zero-point-zero. I agree it would be a real bomb!!! You can bet top dollar I will ask him again during next visit.  I think this guy has it together.  He is at the Cleveland Clinic.
Age 66
BPH since 2000. at least three negative biopsies Erie. Uro did not prescribe finasteride
2007 acute urine retention photoselective vaporize Clev. Clinic
8-9-10 Aug PSA rose to 10.14 with finasteride positive biopsy Cleveland gleason 9, cat & bone scan negative
9-8-10 Robotic prostatectomy at Cleveland. Biopsy 9 nodes, 2 positive,seminal & vas deferens
PSA 3 week .06

Fairwind
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Date Joined Jul 2010
Total Posts : 3637
   Posted 10/7/2010 8:53 AM (GMT -6)   
Your surgeon is in the Walsh School of Thinking...

Which is basically, "Why suffer the effects of HT any longer than you have to?? Studies have shown that survival time is the same whether you start HT early or late so take all the "good time" you can get....

The opposing view is more recent studies seem to show that adjunct HT and RT started as soon after surgery as possible improves outcomes even in high risk patients..

I asked my R-doc this: If my post surgery PSA drops to zero, why should I start any further treatment until and if my PSA begins to climb?? His answer was "With Gleason 9 the sooner you start followup treatment the better.." I asked How much better. His reply was 10-15% better.. I checked with a University cancer research center and they said the same thing, Gleason 9, doing all three gives you your best chance and the sooner the better..
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
age 61: 5.2
age 64: 7.5, DRE "Abnormal"
age 65: 8.5, " normal", biopsy, 12 core, negative...
age 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
age 67 4.5 DRE "normal"
age 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP performed Sept 3 2010, pos margin, one pos vesicle nodes neg

LV-TX
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Date Joined Jul 2008
Total Posts : 966
   Posted 10/7/2010 8:53 AM (GMT -6)   
Actually David....during my readings (which I guess at some point I need to start saving links) that HT typically isn't administered after surgery and SRT until the PSA is 10.0 Granted there are no set rules, but that seems to be the guideline depending on the velocity. If rapid then the HT begins sooner otherwise then waiting until later is appropriate. I believe Tony our moderator will go back on HT if his gets to 2.0. And Sonny won't go on HT for the first time until some time later and he is already above the 2.0 mark.

Crazy disease...it is all individual.
You are beating back cancer, so hold your head up with dignity

Les

Signature details in Sticky Post above - page 2

mr bill
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Date Joined Sep 2010
Total Posts : 683
   Posted 10/7/2010 8:59 AM (GMT -6)   
Now that you mention it I did say something to the effect that is how Dr. Walsh approaches treatment. He did ackowledge that. It was the high number that confused me more than I already am.  I just thought it was to long of a wait.
Age 66
BPH since 2000. at least three negative biopsies Erie. Uro did not prescribe finasteride
2007 acute urine retention photoselective vaporize Clev. Clinic
8-9-10 Aug PSA rose to 10.14 with finasteride positive biopsy Cleveland gleason 9, cat & bone scan negative
9-8-10 Robotic prostatectomy at Cleveland. Biopsy 9 nodes, 2 positive,seminal & vas deferens
PSA 3 week .06

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3637
   Posted 10/7/2010 9:48 AM (GMT -6)   
PSA 10.0 might not be that difficult to deal with..There are many case histories of men with PSA in the hundreds and thousands for whom HT is their primary treatment. Some of them have gone from PSA 2500 to undetectable in six months and stayed there for years..

Again, according to Walsh, it depends on what percentage of your PC is hormone dependent and what percentage is not...

Others seem to think PC cells BECOME hormone refractory over time. Walsh says no. He thinks there is a certain percentage of cells that are hormone independent right from the get-go. The smaller that percentage, the better (and longer) HT works...

John T
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Date Joined Nov 2008
Total Posts : 4188
   Posted 10/7/2010 10:13 AM (GMT -6)   
Why would anyone take a recommendation on HT from a surgeon. Would you go to a urologist if you had lung cancer? PC that has matastized is a different ball game from pc that is contained in the prostate. Surgeons understand the 1st and are usually clueless regarding the 2nd. I would never have an oncologist operate on me, nor would I ever have a surgeon give me HT. There are completely different skills and training involved; one is mechanical and the other is biological. Walsh is a surgeon, and most of his information about HT is 15 years old. If you want to learn about HT read Strum, Myers or Scholz and not Walsh.
Dr Strums rule #3 is find the best artist for the treatment you have chosen. This means that if you think you need HT then see an oncologist specializing in PC and not a surgeon.
With a gleason 9 and 2 lymphnodes positive you have matastized PC and any further treatment is well beyond your surgeon's skill level and training.
JohnT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

Fairwind
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Date Joined Jul 2010
Total Posts : 3637
   Posted 10/7/2010 11:08 AM (GMT -6)   
While Walsh is indeed a surgeon, one of the best, he also has the entire Johns-Hopkins brain trust standing behind him...But JohnT is right..At this point a Medical Oncologist will keep you alive longer than a surgeon especially if the Oncologist has some PC experience..

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 10/7/2010 12:12 PM (GMT -6)   
john, i think you just gave the best advice here.
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

John T
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Date Joined Nov 2008
Total Posts : 4188
   Posted 10/7/2010 1:02 PM (GMT -6)   
It's really simple common sense; would you rather have surgery from someone who read a book about robotic surgery or one that has done 3,000. The same holds true for advanced pc. You want a doctor that has treated 10,000 patients and has seen it all.
There are so many variations of advanced pc that even medical oncologists won't recognize them. A knowledgable oncologist will adjust treatments and meds according to how the PC is reacting to them.
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 10/7/2010 2:29 PM (GMT -6)   
you logic is perfect john. if, my srt fails, and i am in the next zone, there is nothing my beloved uro/surgeon can do for me, or even offer in the way of substantial advice. i would be seeking the very skilled medical oncologist that i had 11 years back, advanced pc was one of his specialties. my uro wouldnt presume to know anything about the radiation side of treatment, let alone advanced issues. however, i am glad he stuck with me through all the horrors i dealt with post srt, as they still directly effected my urinary system, even now.

david in sc
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

JohnK11
Regular Member


Date Joined Jan 2010
Total Posts : 25
   Posted 10/7/2010 2:47 PM (GMT -6)   
HT might advance HRPC !!!

There are some recent evidence that Hormone treatments itself might make the
HRPC (Hormone-resistant) more likely--sort of like overusing antibiotics making
Antibiotic resistant bacteria more prevalent. So, it may be that baring fast
doubling time, it might be more prudent for go back on Hormone treatment
at a higher level of PSA (perhaps 10).
While I was only Gleason 7 (4+3)--and that only in 1/12 cores, I was T3b, and my PSA
stayed at 7 before and after surgery (fast 2+ month doubling time then)--
At this moment, Hormone (Trelstar) is working--but I will go intermittent, and likely
only consider going back on Hormone after PSA rises to 2-5 level
(if doubling time remain 6+ months).

For those lucky ones that have PSA going to 0 after surgery/radiation, and who have
Gleason 8/9/10, it might be more prudent to start SRT ASAP and, after that, Hormone
treatment at reasonably low rising levels of PSA.

zufus
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Date Joined Dec 2008
Total Posts : 3149
   Posted 10/7/2010 4:51 PM (GMT -6)   
In Canada some docs believe psa of 20 is a magic level to add hormone therapy, some US docs are in the school of 10 to 15 range (arbitrary within it as to when to start). I got this from my radiation oncologist in a recent frank discussion on such, his words not mine.

I do believe Dr. Strum to be amongest the wisest docs ever on PCa issues(if you followed him over a few years you would get it), then some of the others Myers, Sartor, Scholz, Leibowitz, Lam, Volgelzang and some others. Considering your life and/or quality of life is  on the line, perhaps one should know those huge differences as John T had pointed out, that are really common sense.  Welcome to the twilight zone of PCa, makes fiction look believable.

John T
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Date Joined Nov 2008
Total Posts : 4188
   Posted 10/7/2010 5:18 PM (GMT -6)   
There is a common misconception that HT will actually fuel pc cell growth or make PC more hormone resistant. Again it depends on the varient of pc one has and the ratio of androgen dependent to androgen independent cells in the total cell population. HT will certaintly kill all dependent cells and leave only the independent cells to grow. Some of these cells will find a way to mutate and live without testosorone. The longer a cell lives the greater chance for mutation.
Strum and the other doctors Zufus mentioned all believe that starting HT at the earliest possible time will kill most of the cells before they have a chance to mutate. It is much easier to kill a low population of pc cells than a high population. This is a basic in oncology no matter what type of cancer you have. In no other type of cancer do you hear that starting chemo later rather than sooner is a good idea, yet this is exactly what many doctors suggesting by waiting until psa reaches 10 or 20 before starting HT are recommending. It just doesn't make any sense.
Intermittent HT is a different story, as time off gives the patient a better QOL and the body time to recover. Just because one would resume HT when psa reaches 10 doesn't mean that one should wait until psa reaches 10 before starting initial treatments. It's apples and oranges.
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

julios
Regular Member


Date Joined Jun 2010
Total Posts : 38
   Posted 10/7/2010 6:46 PM (GMT -6)   
Mr Bill

I'm in about the same boat as you. I know a PSA of 10 is about the time urologists do a biopsy for diagnosing CaP. But a PSA greater than 0.15 after RRP is considered failure. Cleveland Clinic is well known for great CaP specialists, but John T has it right. Get both a medical oncologist and a radiation oncologist from Cleveland. Get a second opinion from other med and rad oncologists.

I'm now 3 months post op and will be starting RT and ADT in two weeks. But my PSA post op is 0.50. You want to wait as long as the oncologists will let you, because the level of urinary and sexual function you have at the start of RT is about where it will remain for most men.

The sum of research I've read recently says there is still some debate on the advantage of adjuvant versus salvage therapy after RP, but there does seem to be an edge in favor of adjuvant (soon after RP, like between about 3 and 5 months), rather than waiting until biochemical failure. Since your PSA is already detectable but quit low, I suspect a good oncologist would tell you to get started sooner rather than later. If your functions have already recovered, there is no reason to wait. On the flip side, if there has been little progress of ED/urinary recovery since RP, there is little reason to wait. But if you are recovering at a good pace, get as much time as your oncogists will give you.

Best wishes

Julios
Age 52

At Diagnosis of PCa, had Gleason 9 and normal PSA

Radical Prostatectomy on July 7th, 2010 by Dr. Fagin using daVinci

25% to 50% nerves spared on left, 100% spared on right.

Continent from day one.

Pathology showed postive margins and extension beyond gland, including seminal vesicals and lymph nodes. Stage upgraded to T3b.

Jerry L.
Veteran Member


Date Joined Feb 2010
Total Posts : 3049
   Posted 10/19/2010 5:06 PM (GMT -6)   
I have this ongoing debate with myself whether I should begin HT even though currently my PSA is not detectable. I have seen those who have had surgery, radiation, and hormone therapy as well as those who have had only surgery and radiation like me. For T3b there are studies that show radiation soon after surgery has proven benefits, however I have not seen the same for adding hormone therapy to RP and RT. I am sure I don't have all the facts so anything that you guys can contribute to my ongoing debate with myself is appreciated.
Nov. 2009 Dx at Age 44
Dec. 2009 DaVinci Robotic Surgery
Jan. 2010 T3b, Gleason 9
Feb. 2010 ERBT

PSA History:
-----------------
Nov. 2009 4.03
Feb. 2010 <.05
May 2010 <.05
Aug. 2010 <.05

Geebra
Regular Member


Date Joined May 2009
Total Posts : 476
   Posted 10/19/2010 9:03 PM (GMT -6)   
I have a somewhat opposite problem. How long does one remain on the HT after a failed RRP and an SRT treatment? My Rad doc says three years, my Onc says one. Go figure. There is no research I could find on HT treatment in conjunction with SRT.
Father died from poorly differentiated PCa @ 78 - normal PSA and DRE
5 biopsies over 4 years negative while PSA going from 3.8 to 28
Dx Nov 2007, age 46, PSA 29, Gleason 4+4=8
Decided to participate in clinical trial at Duke - 6 rounds of chemo (Taxotere + Avastin)
PSA prior to treatment 1/8/2008 is 33.90, bounced on 1/31/2008 to 38.20, and down at the end of the treatment (4/24/2008) to 20.60
RRP at Duke (Dr. Moul) on 6/16/2008, Gleason downgraded 4+3=7, T3a N0MX, focal extraprostatic extension, two small positive margins
PSA undetectable for 8 months, then 2/6/2009 0.10, 4/26/2009 0.17, 5/22/2009 0.20, 6/11/2009 0.27
ADT (ongoing, duration TBD): Lupron started 6/22/2009
Salvage IMRT to prostate bed and pelvis - 72gy over 40 treatments finished 10/21/2009
PSA 6/25/2009 0.1, T=516, 7/23/2009 <0.05, T<10, 10/21/2009 <0.05, T<10

julios
Regular Member


Date Joined Jun 2010
Total Posts : 38
   Posted 10/20/2010 12:11 PM (GMT -6)   
Jerry L,

I start ADT next week, and RT soon after. I have a similar cancer as you. My understanding is that if RT is helpful, ADT will make it even more successful. But ask a medical oncologist, not your radiation oncologist.

Good luck
Age 52

At Diagnosis of PCa, had Gleason 9 and normal PSA

Radical Prostatectomy on July 7th, 2010 by Dr. Fagin using daVinci

25% to 50% nerves spared on left, 100% spared on right.

Continent from day one.

Pathology showed postive margins and extension beyond gland, including seminal vesicals and lymph nodes. Stage upgraded to T3b.

Jerry L.
Veteran Member


Date Joined Feb 2010
Total Posts : 3049
   Posted 10/20/2010 2:54 PM (GMT -6)   
Julios,

Thanks. I will get another med oncologist opinion. My current doctors have told me that there is no overwhelming evidence that adding HT increases odds. Do you or your doctors have any data supporting the use of HT early?

Also, how are we supposed to know if RT is helpful if HT is also used (which affect PSA)?

Thanks again,
Jerry
Nov. 2009 Dx at Age 44
Dec. 2009 DaVinci Robotic Surgery
Jan. 2010 T3b, Gleason 9
Feb. 2010 ERBT

PSA History:
-----------------
Nov. 2009 4.03
Feb. 2010 <.05
May 2010 <.05
Aug. 2010 <.05

howard l
Regular Member


Date Joined Aug 2010
Total Posts : 152
   Posted 10/20/2010 3:12 PM (GMT -6)   
 
 I started  adj radiation at .5 which actually got up to 1.5 by the time all the tests were completed. For radiation they like to see it under 2.0 but that varies among doctors. PSA 1 month into radiation was down to 1.0. PSA immidiately after radiation was .47. 3 months post radiation .24. You have time.
 
DX age 58
PSA 5.4
Gleason 5+4 = 9
City of Hope Clinical Trial (punch protocol). 6 sessions textore every 3 weeks + lupron
PSA .1
RP Oct 2009. Seminal Invasion positive margins. Lymphnods clear.
1 month PSA post op undetectable.
4 month PSA undetectable.
7 month PSA .5
Bone scan and CT scan negative. Prosticint scan mild activity in prostate bed.
EBRT May 2010. 39 sessions 70gy. On number 37.

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 10/20/2010 3:22 PM (GMT -6)   

Hi guys, it looks like this thread has been going on for a little while and I'm jumping in late, but I thought I would comment on the last few posts here regarding HT treatment (Jerry and Julios).  I don't have direct, first-hand knowledge on this, but in a separate thread, earlier today I posted a few links to some sites with relevant info.

I will re-post two of the links here:

The discussion reads:  "No large, randomized clinical trials have examined adding hormone therapy, also called Androgen Deprivation Therapy, to adjuvant or salvage radiation.  Choo reported on several small studies that showed benefit, including his own about 75 men who were treated with two years ADT after salvage radiation.  After median follow-up of 6.4 years, freedom from PSA relapse was 91.5% at 5 years and 78.6% at 7 years.  That is one of the highest success rates reported."

  • The Choo paper discussed on the PCRI site is here:  “Salvage Radiotherapy for Patients with PSA Relapse Following Radical Prostatectomy: Issues and Challenges”; discusses toxicity for both ART & SRT.  2010  http://e-crt.org/Synapse/Data/PDFData/0036CRT/crt-42-1.pdf     There is a section of interest in this paper titled, "Salvage Radiotherapy plus Androgen Ablation Therapy for PSA relapse."

 

I hope that this might be a little helpful...as it says, there is no random clinical trials proving out the HT + SRT approach, but some data indicates it improves cancer control outcomes.


Jerry L.
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Date Joined Feb 2010
Total Posts : 3049
   Posted 10/20/2010 6:05 PM (GMT -6)   
Thanks Casey59

compiler
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Date Joined Nov 2009
Total Posts : 7197
   Posted 10/20/2010 6:16 PM (GMT -6)   
Casey:
 
I will be seeing Dr. Hussein at Umich on Nov 1st. She is a top-notch medical oncologist specializing in PC. One of the reasons for this appointment is to get the latest information and map out a plan. HT/SRT combo is one of my questions.
 
I suspect the answer will be no HT, given my very low PSA.
 
In fact, I am hoping they do NOT do a PSA test for this appointment. My next one is scheduled for 12/21. I'll probably do that one 2 weeks later in time for my next appointment at Ford on 1/7/11.
 
I'm afraid if they do it on Nov. 1st. it will tell me for sure that the game is up (regarding BCR). I would prefer to be in ignorance for a few more months!
 
Mel
PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (PSAf: 24%), PCA3 =75 .
Biopsy 11/30/09. Gleason 4+3. Stage: T1C. Current Age: 64
Surgery: Dr. Menon @Ford Hospital, 1/26/10.
Pathology Report: G 4+3. Nodes: Clear. PNI: yes. SVI: No. EPE: yes. Pos. Margin: Yes-- focal-- 1 spot .5mm. 100% continent by 3/10. ED- in progress. First post-op PSA on 3/10/10-: 0.01. PSA on 6/21/10--0.02. 9/21/10--0.06

julios
Regular Member


Date Joined Jun 2010
Total Posts : 38
   Posted 10/20/2010 6:40 PM (GMT -6)   
Jerry

I don't have research at my finger tips but have read studies that convinced me HT, when combined with RT, improves success of RT. My uro, my rad oncol and my med oncol all strongly recommended HT with RT. RT is done at the prostate area to catch any micro cancer cells the surgery may have missed, or apparently did miss if you still have a detectable PSA. Besides helping the RT kill the cells, HT treats any cells that may exist beyond the pelvic area. My docs had me get an MRI and a contrasting CAT Scan after my operation to plan the RT. They found enlarged pelvic lymph nodes, so will now do a broader field of radiation (read: more good-tissue damage), and will also laser in on the enlarged LNs. They are having me do 2 months of HT first to shrink the LNs as much as possible first to minimize the RT dose.
Age 52

At Diagnosis of PCa, had Gleason 9 and normal PSA

Radical Prostatectomy on July 7th, 2010 by Dr. Fagin using daVinci

25% to 50% nerves spared on left, 100% spared on right.

Continent from day one.

Pathology showed postive margins and extension beyond gland, including seminal vesicals and lymph nodes. Stage upgraded to T3b.
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