RARP vs RT plus ADT for Gleason 8 with cribiform and high Decipher

How is a PSMA expression measured? I know there is a scoring range used 0 - 3, zero being no and 3 being high.

You have a lot of high risk factors. If you go the radiation and ADT route to spare yourself the harsh and immediate side effects of an RP, you need to consider a stronger radiation treatment plan than 45 sessions of EBRT in order to get your lowest odds of recurrence. A stronger radiation plan would be 26 sessions of EBRT combined with one session of HDR Brachytherapy as a boost to the prostate. Your current medical services may not offer HDR Brachytherapy. Along with obtaining that option, getting the opinion of doctors from a cancer center of excellence would also be very beneficial for you. See my bio for more details.

When you mention that “… PET scan doesn’t have much diagnostic value given my very low PSMA expression.”
> what were the SUVmax scores from the PSMA PET scan?

The surgeon’s recommendation of “RARP….and perhaps have more flexibility of treatment upon recurrence” is standard recommendation for a surgeon and is very old-school and doesn’t consider modern treatment techniques. If there is local recurrence after initial radiation, choice of treatment would depend on the nature of the recurrence; there are other salvage options these days - focal therapy (e.g., cryo), brachytherapy, SBRT, and yes even re-radiation in some cases. (I personally know two guys who had their prostate recurrence re-treated with SBRT, because the recurrence was a single spot.) So, I wouldn’t let the old “no options if recurrence” philosophy change my initial treatment decision.

At 65y, with a localized, PSA of 7.976, Gleason 7(4+3), I had 28 sessions of proton radiation + 6 months of ADT (w/SpaceOAR Vue). PSA remained at 0.008 while the ADT was in my system, nadir was 0.198, now (almost 6 years later) PSA ranges from 0.31-0.55; most recent PSA was 0.314.

Regarding side-effects of ADT, with a robust resistance-training (or HIIT) exercise program, the side-effects are greatly minimized. When I was on ADT, I lifted weights, ran 5Ks, swam in the Senior Olympics, and more. Main side-effects were muscle atrophy, mild warm flashes, and loss of libido (but everything still worked).

For me, successful treatment and quality of life were equal priority. So, my RO and MO started from that baseline as we devised a treatment plan.

@stew80 Not sure about scoring range, but the background uptake in the prostate is SUV 2.1, and the uptake in the known lesion (PI RADS 5 lesion revealed by MRI and confirmed by biopsy) is only SUV 2.3. As a result, radiology report states "no marked prostate gland activity definitive for malignant neoplasia".

@stew80 Some centers normalize the SUVmax range to 0-3. I’ve seen some report SUVmax scores in the double-digits. I know one guy who had an SUVmax of 18.7; that was within the range that center chose to use.

Kind of like with PSA scores - some labs go to 1 significant digit, some to 2 significant digits, others to 3 significant digits. All are right; it just depends on what range they choose to use.

@klw23 Here’s how PSMA PET scan results are interpreted —>

As it turns out, PSMA (prostate specific membrane antigen) is not really “prostate specific.” There are other organs, tissues, and fluids that naturally express PSMA (without being cancerous) and will show as physiologic tracer uptake on a PSMA PET scan - particularly in the lacrimal (tear) and parotid (salivary) glands, blood, liver, spleen, pancreas, ganglia, and more, as well as the kidneys, ureters and the bladder (as the body tries to quickly excrete the radioligand that was injected).

“SUV” stands for “standard uptake value” and is a measure of radiotracer uptake that indicates how high grade the cancer is. The higher the SUVmax, the more advanced the cancer.

So, they use the PSMA SUVmax values of your blood (as the lowest level), liver (as the medium level), and parotid or the lacrimal glands (as the highest level) of SUVmax expression for comparison.

If a suspicious area (lesion) is expressing PSMA, and it has:
> a SUVmax score less than blood, then it’s not likely cancer, but instead just normal, background PSMA cellular expression;

> a SUVmax score greater than blood, but lower than liver, then it’s likely low-grade prostate cancer;

> a SUVmax score greater than liver, but lower than lacrimal/parotid glands, then it’s likely moderate-grade prostate cancer;

> a SUVmax score greater than parotid glands, then it’s likely high-grade prostate cancer;

As always, discuss all this with your doctor when you get your SUVmax scores from your PSMA PET scan report.

Dr. Johnson (of Mayo Clinic) talks about all this in his presentation, starting with the scans we’ve all heard about (MRI, bone, & CT scans), and then going into detail about PSMA PET scans: https://youtu.be/JoJomACA5UM

@wwsmith yes, definitely a lot of high risk factors which make getting the primary treatment right even more important. Thanks for the suggestion of a brachytherapy boost, I'll discuss that with the RO. The RO is with a center of excellence (Siteman Cancer Center in St. Louis) and they do offer brachytherapy.

@klw23 And remember, HDR brachytherapy is different from low dose brachytherapy that uses permanent seeds. HDR is used far more often in current times than low dose brachy. You can also use SBRT has a radiation boost to the prostate as well.

In Aug '24 I had PSA 14 and biopsy showed Gleason 3+4 cancer. Decipher of 0.90. Risk class unfavorable intermediate due to % cores positive. PET scan negative for bone and organs. RO suggested different RT's (2 I remember were implanting isotope shards in selected locations in prostate and one that inserted a "tube" to the prostate which was used to localize a much larger dose of radiation fewer times to kill the prostate). Don't know the terminology, but what I do know now is how ignorant I was going in. (I just found this forum; 18 months too late to get these invaluable experiences and viewpoints). Urologist recommended RARP. I chose surgery since I was told RT could be used in case of recurrence, while you couldn't do surgery after radiation. Side effects not bad; no erections (yet?) but no incontinence either. I leak if I'm not paying attention (rare), but no pads since 1st week after surgery. One thing I got with surgery was the prostate tissue and "eyes on" report of conditions around prostate. Things like: Seminal vesicle invasion (SVI) present, bilateral; cribiform glands present; extraprostatic extension present, nonfocal, R&Left posterior; margins negative for invasive carcinoma; and in my case 7 lymph nodes taken all of which were negative. I also was "gifted" with a Gleason downgrade to 4+3, and I got a pT3b and pN0 classification. Extra information although in my case, not great. I was at higher risk of a recurrence due to some of those factors and 18 months later a recurrence has occurred. I see a RO next week to discuss salvage rescue therapies with (no doubt) hormone therapies. I'm sure I'll be back here to discuss what my RO is offering. All in all, I don't regret the choice I made; just the outcome. 🙂 Good luck to you!

Ask about Proton Beam therapy instead of traditional radiation. I think most hospitals, if they have anything, only have traditional radiation which is NOT GOOD. After my first consult with the radiation oncologist at my large medical institution, he said I am not yet a candidate for radiation...if at all any time soon, but when I am, it will likely cause lifelong urinary incontinence." NO THANKS. But...I just found out that like most radiation oncology departments, my hospital does not yet have the new Proton Beam therapy modality.
The problem with traditional radiation therapy is that the radiation goes "to" and "through" the targeted tissue. That is why many men end up with scarred urethra, bladder problems and rectal problems. BUT...Proton beam therapy only goes "to" the targeted area to be treated. It does not go "through" and beyond to other areas causing the damage that traditional radiation does. I already know that I will ask for a referral to another local hospital (there are three) that already have Proton beam therapy if/when I need radiation in a few years. I think Proton Beam therapy will eventually replace traditional radiation therapy because it is so much better and doesn't cause the damage that traditional radiation therapy does.