best radiation for avoiding adt for unfav intermediate

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Manticore
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Date Joined Mar 2018
Total Posts : 17
   Posted 3/4/2018 7:01 PM (GMT -6)   
First time on list and recently joined member.

After two years of PCa favorable intermediate risk, I have moved into unfavorable intermediate risk category. My wife and I are looking for the radiation treatment which is most likely to avoid ADT. . . What is the most prudent radiation path without ADT? Surgery remains an option but RO and urologist have indicated something like a 67% chance of needing ART or SRT within a few years

One recommendation from my RO was for peripheral EBRT for 25 days followed by Brachy + 6 month ADT.

McLaughlin (RO U.Michigan) talks about Brachy LDR first and then EBRT in addition to get the dosage correct and also vessel sparing/mapping and very low drop in success without ADT??

Manticore

Tall Allen
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Date Joined Jul 2012
Total Posts : 10645
   Posted 3/4/2018 7:17 PM (GMT -6)   
Welcome Manticore-

You are right that brachy boost therapy probably doesn't need any ADT in unfavorable intermediate risk men:

/pcnrv.blogspot.com/2017/12/is-adt-still-needed-for-high-risk.html

(I don't think it matters much which you do first. But if you do brachy first, allow some time for the swelling to subside before iMRT)

Your other choices that don't need adjuvant ADT are SBRT monotherapy and HDR brachytherapy monotherapy. Both have reported excellent cure rates in intermediate risk men and may be less toxic than a brachy boost. U Michigan now offers SBRT. you'd have to go to Alvaro Martinez in Detroit for HDR BT.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Manticore
New Member


Date Joined Mar 2018
Total Posts : 17
   Posted 3/5/2018 9:29 PM (GMT -6)   
Thanks for the response and the information on the blog. I am trying to digest it.

The local RO offered IMRT only for the periphery of the prostate for 25 days and then Brachy HDR permanent, then ADT for 6 months.

I live in the triangle, NC area. UNC closest. Duke also close. Is there someone in this area you think of for radiation without adt?

If you could go anywhere in the country, who would you go to?
Manticore
___________________
2015 Dx. PSA 11 at 65. TRUS fusion: lesion along capsule—4 targets negative. 12 cores, one 7(3 + 4)
2016-17: 2 Consults with Klotz (Toronto)
12/2017 PSA 17, TPUS fusion biop. 4 Lesion cores: one 7(4 + 3), two 3 + 4s. two more 3 +4s in 12 cores. Prostate size: 34cc
Recent: consults wi R.Chen, Nielsen--UNC, Polascik, Klotz, P. McLaughlin. Awaiting PET scan results.
DRE's: normal

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10645
   Posted 3/5/2018 10:55 PM (GMT -6)   
Sorry- I'm got confused because you mentioned an RO at UMich. The RO I know of at Duke is Dr Lee:
/scholars.duke.edu/display/per0826072

I think they do all of the ones I mentioned at Duke - let me know if they do.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Manticore
New Member


Date Joined Mar 2018
Total Posts : 17
   Posted 3/8/2018 6:06 PM (GMT -6)   
I have an appointment in the next week with Dr. Lee. Thank you so much. I'll let you know if indeed they offer all the ones you mention.

A urosurgeon and a RO for PCa have told me that I have a 67%/70% probability of requiring Salvage or Adjuvant RT fairly soon (2-3 years) if I do Radical Prostatectomy. I would like to know where this probability is coming from, if it is simply the probability of unfavorable intermediate (my category) or something more specific to me. Do you know?

Another question (I hope it is ok to bundle them???). I read the profiles of Radiation Oncologists at Duke. One was an expert on clinical hyperthermia. It made me think of your article on using hyperthermia as a way to lower radiation dosage and have lower side effects. At the same time, I remember talking to a high volume surgeon who uses something called PROPEP during surgery. I asked about it and I think he answered that it gives an auditory signal if temperature gets too high with erectile nerves, and he also uses extra cool water for irrigation (of erectile nerves I think). I may be confusing things but I'm wondering if hyperthermia is contra-indicated in the area of the erectile nerves?

Duke also had a Radiation oncologist whose specialty was lowering radiation effects. Would it be kosher to just make an appointment with that doc also or should I decide on RO for the RT first and go through that person (e.g. Dr. Lee) to make the appointment with the lowering radiation effects specialist?

Thanks in advance. Manticore
2015 Dx. PSA 11 at 65. TRUS fusion: lesion along capsule—4 targets negative. 12 cores, one 7(3 + 4)
2016-17: 2 Consults with Klotz (Toronto)
12/2017 PSA 17, TPUS fusion biop. 4 Lesion cores: one 7(4 + 3), two 3 + 4s. two more 3 +4s in 12 cores. Prostate size: 34cc
Recent: consults wi R.Chen, Nielsen--UNC, Polascik, Klotz, P. McLaughlin. Awaiting PET scan results.
DRE's: normal

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10645
   Posted 3/8/2018 9:20 PM (GMT -6)   
Here's a nomogram so you can see the probability that men with your diagnosis will have the cancer wholly contained in the prostate:

/www.mskcc.org/nomograms/prostate/pre_op

I recall that Duke was experimenting with hyperthermia and will be interested to hear what they say about it. Both hyperthermia and hypothermia may work equally well in radiosensitizing the cancer. No, the nerves are not harmed by it, and its effects wear off after a few hours. Radiation doesn't harm nerves either. (btw-
I don't recommend reducing radiation dose if using hyperthermia - adequate dose is important and there's not enough clinical data on hyperthermia to support reducing dose. It may make the dose received more effective.) Cauterization used in surgery is very hot compared to the hyperthermia used with radiation.

I would talk to Dr Lee first - you can ask him what measures he takes to spare healthy tissue.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Manticore
New Member


Date Joined Mar 2018
Total Posts : 17
   Posted 3/14/2018 9:06 PM (GMT -6)   
From Nomogram?
PROBABILITY OF CANCER-SPECIFIC SURVIVAL AFTER RADICAL PROSTATECTOMY 10 YR99% 15 YR99%

Does that mean cancer-specific survival including a possible follow-up SRT or just after the RP? 99% survival just after RP only seems too high? Even with SRT afterwards if necessary, is survival really at 99% for the surgery first path?

PROGRESSION-FREE PROBABILITY AFTER RADICAL PROSTATECTOMY 5YR 35% 10 YR 23%
Does this mean the chance of having to do SRT is 65% in first 5 years and 77% in first 10 years?

Thanks, Manticore
2015 Dx. PSA 11 at 65. TRUS fusion: lesion along capsule—4 targets negative. 12 cores, one 7(3 + 4)
2016-17: 2 Consults with Klotz (Toronto)
12/2017 PSA 17, TPUS fusion biop. 4 Lesion cores: one 7(4 + 3), two 3 + 4s. two more 3 +4s in 12 cores. Prostate size: 34cc
Recent: consults wi R.Chen, Nielsen--UNC, Polascik, Klotz, P. McLaughlin. Awaiting PET scan results.
DRE's: normal

Manticore
New Member


Date Joined Mar 2018
Total Posts : 17
   Posted 3/14/2018 9:47 PM (GMT -6)   
Saw RO at Duke. I asked, "Is there a way to responsibly avoid ADT?" he replied, "for unfavorable intermediate like you, No." I started to whip out the chart from your piece: /pcnrv.blogspot.com/2017/12/is-adt-still-needed-for-high-risk.html, but then I thought better of it.

I did have a very good discussion with the RO about potency preservation in surgery vs. radiation, he thinks the differences are not significant. He also talked about McLaughlin and the care he puts into placement of seeds. And also the results McLaughlin gets in potency preservation. I don't think it was the RO's intention but I became more interested in McLaughlin's ldrbt with dosage escalation via EBRT even if I have to go live somewhere for 5 or 6 weeks. We never made it to SBRT. It was not his recommendation which was LDRBT + EBRT + ADT (4 months)

I did find it very easy to talk with the RO. He is the only Doc I've seen who seemed to really take in my bout with severe Peyronie's disease 10+ years ago, and the very satisfying outcome I had. That has been my model for this encounter with PCa so having him recognize the unusual result felt good. Most docs say nothing.

Where does it leave me? Right now, McLaughlin's LDRBT with dosage escalation with EBRT and peripheral treatment with vessel sparing seems the best I have found, even if I have to go there for 5 or 6 weeks.

I would like to know the 3 most experienced SBRT people in the country you would recommend for SBRT with unfavorable intermediate risk.

I also want to know more about HDR mono brachytherapy vs. combination brachytherapy or brachy boost? I want to know more about the toxicity risks there.

I am also still tracking if the LDRBT can be temporary. I get conflicting answers from RO's. I know the HDR is often temporary. I prefer the temporary. I've seen the graphs of higher dosage and more ablation of cancer but I wonder why the higher dosage wouldn't also carry more risk of toxicity?
2015 Dx. PSA 11 at 65. TRUS fusion: lesion along capsule—4 targets negative. 12 cores, one 7(3 + 4)
2016-17: 2 Consults with Klotz (Toronto)
12/2017 PSA 17, TPUS fusion biop. 4 Lesion cores: one 7(4 + 3), two 3 + 4s. two more 3 +4s in 12 cores. Prostate size: 34cc
Recent: consults wi R.Chen, Nielsen--UNC, Polascik, Klotz, P. McLaughlin. Awaiting PET scan results.
DRE's: normal

JNF
Veteran Member


Date Joined Dec 2010
Total Posts : 3886
   Posted 3/14/2018 10:14 PM (GMT -6)   
Why fear ADT?

Do what it takes to rid your self of cancer. Do too little now and you have to do much more later.

I had three years on ADT. not fun, but I worked and played every day and never had a problem. I was high risk and bound and determined to beat the cancer right up front. I certainly don’t yet know if that is the case, but I am now seven years undetectable after a high risk diagnosis.

The effects of ADT for a man are just about what we know our wife will go through naturally. So what is it so bad for so few of us????
PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.
PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10645
   Posted 3/15/2018 2:01 AM (GMT -6)   
"I would like to know the 3 most experienced SBRT people in the country you would recommend for SBRT with unfavorable intermediate risk. "

That would include the RO who first used it in 2003- Chris King at UCLA. Probably Alan Katz in Flushing has treated more people and been doing it longer than just about anybody but Dr King. For third - maybe Debra Freeman in Tampa - she started soon after Dr King.

"I also want to know more about HDR mono brachytherapy vs. combination brachytherapy or brachy boost? I want to know more about the toxicity risks there. "

HDR-BT monotherapy would have a lower toxicity profile than any combination therapy, of course.
/pcnrv.blogspot.com/2016/08/hdr-brachy-boost-and-monotherapy-for.html

"I am also still tracking if the LDRBT can be temporary. I get conflicting answers from RO's. I know the HDR is often temporary. I prefer the temporary. I've seen the graphs of higher dosage and more ablation of cancer but I wonder why the higher dosage wouldn't also carry more risk of toxicity?"

LDRBT (seeds) is ONLY permanent - once placed, they cannot be removed. HDRBT is ONLY temporary. HDR means high dose RATE, not higher dose. The nominal dose for seeds is usually about 145 Gy, while the nominal dose for HDR-BT monotherapy is about 45 Gy. But because of radiobiology, the biologically effective dose of HDRBT is much higher for cancer killing, while it is lower for healthy tissue toxicity.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

JNF
Veteran Member


Date Joined Dec 2010
Total Posts : 3886
   Posted 3/15/2018 6:02 AM (GMT -6)   
The best place to learn about brachytherapy and specifically High Dose Rate (HDR) is www.cetmc.com. This is the website of Dr. Jeffrey Demanes, the HDR pioneer. he has used it since 1981 for many cancers including PCa. He has also been the head of the department at the UCLA Medical Center.
PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.
PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta

Manticore
New Member


Date Joined Mar 2018
Total Posts : 17
   Posted 3/16/2018 3:39 PM (GMT -6)   
Dear JNF, thanks for the link to learn more about brachy and HDR and Dr. Demanes. Also thanks for the encouragement not to be overly fearful about ADT.

Let me say more about ADT. Sure there is some fear, but always I try to differentiate legitimate fear from irrational fear. If I am in a new city and I get lost and make a wrong turn and fear comes, it may be telling me quite legitimately to "watch out". .... or not.

So when I asked Tall Allen about ways to avoid ADT for my unfavorable intermediate risk category, I was delighted that he gave me 8 studies with 6 of them showing no effect from ADT meaning those methods were probably sound without ADT.

When I first looked into ADT, I was surprised to find how many things it affected and how many very slight risks it opens. Cardio, bone, cognition, mental health and more, not just threatening sexuality, are involved.

In dealing with disease, I like to take the generality of things and have it interact with me in particular. I have some vulnerability to osteoporosis and discomforting pain, I have some vulnerability to irritability. So for me in particular, ADT may not be such a wise way to go IF THERE ARE LEGITIMATE ways around it.

Also, in dealing with disease, I like to notice theoretical discrepancies which have not yet been integrated fully in the literature. So A. Morgenthaler's work has been pretty strong in challenging the notion that testosterone is a 'bad guy' in prostate cancer, 'like pouring gasoline on a fire.' That old concept sustains despite his empirical work challenging that. A new concept explaining why ADT helps but that testosterone is not at all bad, rather a basic building block of health it is, is yet to be fully fleshed out.

So when I see these places of insufficient theoretical integration, it is a signal to look for 'my way'. I ask myself, "Is there a responsible way to carve out a slightly different path here with ADT?"

It may turn out that my answer becomes no, like my recent RO appointment when I began with that same question. He answered with a flat out "No". If he had answered "No, there are some studies that indicate 'yes' but those studies aren't strong enough for me." I would have felt better.

These little places actually become a help for finding my personalized path in a place where there are many paths and many contradictory perspectives. Sometimes it feels like I am in a little boat in a stormy sea trying to find my way. But if I can sustain through that chaos, I can find pointers to my path. So this discussion list, and every response is helpful for sorting out my decision.
2015 Dx. PSA 11 at 65. TRUS fusion: lesion along capsule—4 targets negative. 12 cores, one 7(3 + 4)
2016-17: 2 Consults with Klotz (Toronto)
12/2017 PSA 17, TPUS fusion biop. 4 Lesion cores: one 7(4 + 3), two 3 + 4s. two more 3 +4s in 12 cores. Prostate size: 34cc
Recent: consults wi R.Chen, Nielsen--UNC, Polascik, Klotz, P. McLaughlin. Awaiting PET scan results.
DRE's: normal

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10645
   Posted 3/16/2018 4:06 PM (GMT -6)   
Manticore,

You may be interested in attending an online class on ADT. It says "Canada only" but they assure me that they will allow others in as space permits.

www.lifeonadt.com/

There are no theoretical discrepancies between Morgentaler and the use of ADT with radiation. In fact, the crux of his "saturation theory" is that while achieving castrate levels of testosterone helps with prostate cancer, adding more testosterone to already normal levels will have no effect on the cancer.

Also, be very careful of generalizing. There is definitely a benefit to adding 2 years of ADT to dose escalated IMRT for high risk cancer. The only questions are about how much it adds when extreme hypofractionation or brachy boost is used. My guess is that the main benefit is when there is occult cancer in the pelvic LNs - the radiation dose there is necessarily lower, so the addition of ADT to radiosensitize and kill off the remnants may be beneficial.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Manticore
New Member


Date Joined Mar 2018
Total Posts : 17
   Posted 3/25/2018 11:41 AM (GMT -6)   
Dear Tall Allen,
I am exploring SBRT further and have made contact with Freeman's office in Tampa. Thanks for that suggestion.

In terms of long-term rates (percentages) of biochemical recurrence-free survival (bRFS) how does SBRT do for Unfavorable Intermediate Risk--my category?

Thanks, Manticore
2015 Dx. PSA 11 at age 65. TRUS fusion: lesion along capsule—4 targets negative. 12 cores, one 7(3 + 4)
2016-17: 2 Consults with Klotz (Toronto)
12/2017 PSA 17, TPUS fusion biop. 4 Lesion cores: one 7(4 + 3), two 3 + 4s. two more 3 +4s in 12 cores. Prostate size: 34cc
Recent: consults wi R.Chen, Nielsen--UNC, Polascik, Klotz, P. McLaughlin. Awaiting PET scan results.
DRE's: normal

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10645
   Posted 3/25/2018 12:35 PM (GMT -6)   
I just answered that on another thread:

/www.healingwell.com/community/default.aspx?f=35&m=3994144&p=1
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Manticore
New Member


Date Joined Mar 2018
Total Posts : 17
   Posted 4/6/2018 3:53 PM (GMT -6)   
Dear Allen,
I am looking for a top HDR brachy RO. Someone suggested looking for a protege of Dr. Alvaro Martinez indicating that he was a top 3 researcher/practitioner for HDR and that there were a couple of very strong HDR RO's in their own right who had developed with Martinez. Would you know names of the strongest HDR docs at Beaumont Hospital besides Dr. Martinez?

Manticore
2015 Dx. PSA 11 at age 65. TRUS fusion: lesion along capsule—4 targets negative. 12 cores, one 7(3 + 4)
2016-17: 2 Consults with Klotz (Toronto)
12/2017 PSA 17, TPUS fusion biop. 4 Lesion cores: one 7(4 + 3), two 3 + 4s. two more 3 +4s in 12 cores. Prostate size: 34cc
Recent: consults wi R.Chen, Nielsen--UNC, Polascik, Klotz, P. McLaughlin. Awaiting PET scan results.
DRE's: normal

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10645
   Posted 4/6/2018 9:58 PM (GMT -6)   
The other one I know of is the one Martinez mentored - Michel Ghilezan, who is still at William Beaumont, I think. Dr. Demanes highly recommends him. Alvaro Martinez moved to 21st Century Oncology in Detroit.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Manticore
New Member


Date Joined Mar 2018
Total Posts : 17
   Posted 4/19/2018 12:53 PM (GMT -6)   
I have decided on SBRT. I've chosen a practitioner who specializes in that and whom I feel very confident in.

I am working on setting dates for the procedure and accomplishing the preliminaries. I am aware that I have a commitment to teach an important workshop in Germany about 3 months after the SBRT completes. I've also read that post-radiation effects are more intense in the first few months. Should I be concerned about the Germany trip? Would it better to take the earliest available SBRT time and have the full 3 months before I go or not important if I schedule the SBRT treatment a little later than the earliest possible?

I also have short trips--1.5 hour flight--which are NOT critical to work in the first month after the treatment so unsure whether to just wait and see or definitely cancel or???
2015 Dx. PSA 11 at age 65. TRUS fusion: lesion along capsule—4 targets negative. 12 cores, one 7(3 + 4)
2016-17: 2 Consults with Klotz (Toronto)
12/2017 PSA 17, TPUS fusion biop. 4 Lesion cores: one 7(4 + 3), two 3 + 4s. two more 3 +4s in 12 cores. Prostate size: 34cc
4/2018: PSA 15
Recent: consults wi R.Chen, Nielsen--UNC, Polascik, Klotz, P. McLaughlin, W.Lee, D. Freeman
DRE's: normal

19tarpon47
Regular Member


Date Joined Feb 2017
Total Posts : 185
   Posted 4/19/2018 1:09 PM (GMT -6)   
Manticore....I won't get into the technical information since the others you are conversing with are much more tecnically savvy than I am, but I will tell you that I finished SBRT with Dr. Debra Freeman last July and other than concern for the unknown, I could have done anything you mentioned (trips and teaching) immediately after the end of treatment. Everyone is different but search on here for other SBRT treatment sagas and you will see that the side effects are generally pretty minimal. If you have interest in specifics, feel free to ask or you can email me. Best of luck to you.

Skip
Dx Age 69 Jan 2017
Prostate at biopsy 27.3 g
BX, core needle biopsy, 3 of 12 cores positive G 3+4=7, L3 left apex 60%, L5 left lateral mid 50%, L6 left lateral apex 30%, and R3 right apex: Focal high-grade prostatic intraepithelial neoplasia
PSA: 01/17.....7.3
Completed SBRT Wednesday, July 26, 2017 at Cyberknife Center of Tampa with Dr. Debra Freeman
PSA: 10/17.....2.50
PSA:.02/18.....1.64

Tall Allen
Elite Member


Date Joined Jul 2012
Total Posts : 10645
   Posted 4/19/2018 2:38 PM (GMT -6)   
My SEs started about a week after treatment and lasted about 10 days. Think of it as a sunburn on the inside. They were mild and did not interfere at all with work or work outs.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

T.S. Eliot
Regular Member


Date Joined Jan 2018
Total Posts : 23
   Posted 4/20/2018 9:42 AM (GMT -6)   
Manticore - I finished my SBRT treatment exactly two weeks ago and I would reiterate what others have noted. Give yourself 10-14 days and you should be good to go with regard to the short term SE's.
DOB 11/1949, Age @ DX 68
DRE - enlarged but normal
PSA - 4.2 on 4/2016, 4.2 on 6/2017, 5.3 on 9/2017, 4.4 on 12/2017 (15% free)
MRI 8/2017 - 1 lesion, 8mm, PI-RAD 5, prostate volume 66mL
Biopsy 11-2017 - normal 12 core, 3 cores Gleason 3+4=7 (10% 4, 10% 4, 40% 4)
Biopsy 11-2017 - focused on MRI lesion, 5 of 5 cores 4+3=7, 55% 4, PI-RAD 4
Stage T1c, Intermediate Risk Category
SBRT 3/27/18 - 4/6/18
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