Capsular Invasion

Capsular penetration Means that the cancer has penetrated the prostate wall. While you have had triple treatment it sounds like they have not addressed the real problem, your prostate. Have they talked to you about having your prostate removed or having radiation to obliterate it? If you don’t have something done to your prostate, it can continue to cause more cancer spread. This has been addressed more recently by doctors, where they’ve decided to do radiation or surgery, even though the cancer has gotten outside the prostate, because I can slow recurrence and spread.

You need to speak to your doctors and find out exactly where the capsular Penetration is occurring, and what do they recommend you do to prevent this from having your cancer spread further. If you’re not working with a center of excellence, you may not get the best answers. Consider getting a second opinion from outside the group that you’re working with now, Because they don’t seem to be supplying you with information that is important for you to use to make decisions.

I'll just back up Jeff here by mentioning that I did choose to get my prostrate radiated (with a high so-called "curative" dose) despite the fact that the cancer had already escaped to my spine. I also had the spine itself radiated, after most of the metastasised tumour was removed there surgically.

In his prostate-cancer book, Dr. Walsh (using simple terms for laypeople like me) explains that there's a belief among some oncologists that individual dormant cancer cells and micro-tumours don't survive as well if they don't have a larger tumour to support them — a "mothership," as he calls it, or the perhaps a "Death Star" if you're a Star Wars fan.

I had both of my "motherships" effectively destroyed, and while it's likely there are still individual cancer cells in my blood and bones that are too small to detect, they've kindly obliged by staying dormant since 2021. That doesn't prove anything, of course (it might be just the Orgovyx and Erleada doing the work), but one oncology resident told me he thought that might be helping that I had the surgery and extra radiation to my spine.

If those spots are around the capsule, it is still a fairly discreet area that can be addressed with radiation.
Depending on how you and the radiation oncologist feel about your overall condition, you can either do 5 visits of SBRT (cyberknife, meridian, etc) to hit ONLY those discreet areas, or do salvage radiation ((IMRT) which involves 25-39 visits of lower dosed radiation to hit the two areas that light up PLUS any that might be lurking but are not yet large enough to show up on the PSMA PET.
Remember, this PET is pretty good but does not show cancerous cells very clearly until your PSA is around .5 or higher.
You may want to discuss these two scenarios with your RO. Another thing they are doing more frequently now is high or low intensity brachytherapy (seeds) with or without SBRT.
This treatment, however, still does not take into account any metastases further out from the gland and capsule itself, such as pelvic lymph nodes. Best to you…

I'm very confident in my set of doctors at an elite center of excellence.

Note that I had an MRI of the area lit up by the most recent quarterly PET scan. I am nervously awaiting a follow-up meeting with the radiation oncologist recommended by my urologist.

What I'm curious about, while trying to gather background intel before the meeting, is whether the holes in the prostate wall (if there really is a "wall"), infer that cancer cells may be escaping to form more metastases. If so maybe I should do some sort of additional systemic treatment, such as more chemo, or maybe Pluvicto.

I'm also curious whether the recurrent cancer is the original version or so-called castration resistant. If it's the latter, then I'm hesitant to go back on Lupron. In my opinion the side effects from 13 months of Lupron were worse than the side effects of six sessions of Chemo and 26 sessions of radiation. How is the variant form identified without another biopsy? My PSA has stayed < 0.1 for several months of quarterly blood tests and scans.

You become castrate resistant when your PSA starts rising significantly after being on one of the ADT drugs, Like Lupron.

If it escapes the capsule, it causes cancer in other parts of the body. That’s when they do weeks of IMRT radiation on the prostate bed. If close enough they can do it when they do SBRT on the Prostate. Most commonly it attacks the lymph nodes when it gets out.

Hey Maccaulay, My bad - forgot you already had IMRT so I don’t believe you can have that again - it would have to be SBRT.
Apologies for any misinformation on my part!
Phil