Adjuvant Radiation Therapry (ART) vs Early Salvage radiology

Just curious what are they considering radiating? Have you had a PSMA/PET showing any spread?

it would be the pelvic floor - from what i am gathering from comments - a broad strike of all remaining related tissues. Adjuvant means your risk factors are so high that they go in a radiate without a increase in PSA levels, typically in 6-8 months of a RP. Adjuvant it a recognition that its not if your are getting a recurrence, its when you are getting a recurrence. its a preemptive strike without evidence.

i understand that in lower risk situations, you wait for PSA increases, then get the PSMA/PET to identify the specific cancerous location(s). high risk cases ignore this standard technique - with the obvious downside that patients run the risk of potentially never needing it.

in my case i meet several of the high risk categories - Decipher of .93, Cribiform morphology, IDC-P, EPE. Sadly, I can say with pretty high probability that im gonna get it again.

Yes, the difference is pretty stark. I was also very surprised that the addition of ADT made no difference in these adjuvant cases.
Not sure if the same applies to salvage radiation, although the newest retrospective study says no ADT is indicated for patients with
PSA< 0.7
Mine was certainly less than that (0.18) but I never had a Decipher Test so I wasn’t taking any chances.

i havent read this one closely, but does it stratify the use of ADT for Cribiform pattern 1 and 2? Many studies dont. It appears Pattern 2 generally doesnt respond well to most drugs/hormones, whereas pattern 1 does in many cases. ps is cribiform pattern 1 the same as IDC-P- and pattern 2 the same as IDC-P+?)

Also, note that it appears abiraterone works better than docetaxel for IDC-P. The study does not discriminate between pattern 1 and pattern 2.

This info comes from this link, which is pretty current. https://www.mdpi.com/2072-6694/16/9/1650#:~:text=Emerging%20evidence%20underscores%20the%20association,risk%20stratification%20and%20therapeutic%20interventions.

This really is not good news. It’s good that you provided this information, however.

The following makes active surveillance a chancy situation

They found that IDC-P or cribriform patterns occur in 34.3% of men with a Gleason score of 6(3 + 3) at diagnosis following AS, and they hypothesized an underdetection of IDC-P or cribriform lesions upon diagnostic biopsy. Furthermore, they found that the findings from MRI were not predictive factors for the presence of IDC-P or cribriform patterns, suggesting that MRI was not adequate for the detection of these features. These findings seem to imply that in the setting of AS, repeat biopsies are necessary so that significant cancers are not overlooked, which cannot be detected via MRI alone.

Here is another scary part of that article about cribriform

Cribriform pattern 1 refers to benign (non-cancerous) growth that resembles a sieve but lacks the cellular atypia and invasive characteristics of cancer, while Cribriform pattern 2 describes the same cribriform (sieve-like) architectural pattern but with the presence of malignant (cancerous) cells, often with clear evidence of invasiveness or association with intraductal carcinoma of the prostate. While cribriform patterns 1 and 2 are not official Gleason or ISUP grading terms, the presence of a cribriform pattern in prostate tissue is significant because it is a recognized sign of high-grade prostate cancer and is associated with increased risk of recurrence and metastasis.

On the theory that sooner is bettet than later to act if there's even slightest evidence of micrometasis outside the prostate capsul if were you I'd follow your doc's advice
Ask the Doc about "extended field" radiation where they zap not only nodes blinking PSMA but those near them on the notion the micrometasis may be in them too. Google with an AI search on your question and you'll get a ton of info. Docs love informed patients

Good luck!!

I also had RP on 6/18 (at the Cleveland Clinic). My physical recovery has been near-perfect continence-wise and in terms of getting back to running - already up to 6 miles - and working out. No erections, but I am not sexually active so it's more of a curiosity at this point.

As you can see below, my post-op pathology was quite a bit worse than my T1C January Biopsy (Decipher 0.56), although the Gleason score didn't change. I asked the surgeon's office about a referral to a GU Oncologist, but they are adamant that I don't need to do anything as long as my PSA is undetectable. My first post-op PSA test is next month. Patience is not my strong suit but I haven't fallen into full-blown PSAnxiety yet.

FINAL DIAGNOSIS
A. Prostate, left base margin, biopsy:
- Benign fibromuscular and adipose tissue.
B. Prostate and seminal vesicles, radical prostatectomy:
- Prostatic adenocarcinoma, Gleason score 3+4=7 (Grade Group 2).
- Seminal vesicle invasion and extraprostatic extension are present (pT3b).
- Margins negative.
C. Lymph nodes, pelvic, regional resection:
- 15 lymph nodes, negative for neoplasm (0/15).
Radical Prostatectomy Morphology Summary
Unfavorable histology: Present (Less than 10%)
Large cribriform pattern 4: Present
Intraductal carcinoma: Atypical intraductal proliferation, suspicious

Thats a tough one.....Decipher is a little high, large cribiform, EPE, vescile invasion, but negative margins. lower grade.

Mine is little more clear cut. In your case, I would definitely get a Cleveland Clinic RO into the mix NOW. If you think about it, your surgeon is really done at this point. Any further treatment and recommendations will be at the hands of an experienced RO, not your surgeon. If anything, your surgeon and RO should be working as a team, which doesnt appear to be the case. In addition, I would not hesitate - if your are not confident - to get another opinion from another COE. My RO at Hopkins is Dr. Daniel Song, he is one of the most experienced at JH and I have received a couple of good recommendations. I am just starting out with him, but adjuvant is on the table.

The whole cribiform thing is kind of like the wild west. Not enough studies and proven diagnostics to make it a clear cut decision. From what I have researched, they large cribiform appears to be aggressive little bastards that are harder to kill. Sorry, get as much info as you can, but IMO, yours is a tough one and ultimately its your call. Good luck, brother.

I wish i had your luck with continence. It only been 2 months, but my progress is slow. I should buy stock in Depends. i should have looked harder for the experts in the newer fascia sparing techniques. more and more people seem to be getting out of the OR without serious continence issues. Tick mark for RP vs. RT.

Another complication is that I don't think I will be able to travel back to Cleveland (or to any other COE) for further treatment, if needed. Cleveland is 5.5 hours away and I don't own a Concorde so I can't skip on over for treatments during my lunch break. My insurance has an additional benefit that covered my airfare, lodging, and medical expenses for the RARP but my 9-day stay in Cleveland exhausted the per-incident benefit amount so traveling for 30-40 treatment days seems out of the question. Besides, even if they covered my expenses, it's unlikely my employer would let me work from "home" for that long and I don't have enough sick days to cover that duration.

I guess I could consult with a local RO while waiting for my PSA test next month.

It is possible to have the radiation treatment for your cancer done locally using the instructions from your far away provider. This is frequently done.

Ask the COE where they would accept the radiation being done, near where you live.