Help-what treatment plan has anyone selected for Perineural invasion?

At age 72, I had RP for G 9. And required Salvage Treatment postop. Now undetectable PSA < .02
I would have surgery again.
Others have been satisfied/happy with RT and ADT.
I wanted a chance for a "cure" and hoped that all the cancer could be removed by surgery. All postop areas clear, but EPE foretold persistence/recurrence and I needed the salvage treatment.
Best wishes on your choice.

The perineural invasion is not your worry - it’s fairly common. It’s the high grade epithelium/ high Decipher Score risk that’s a concern.
Your age and overall health are VERY important in making your decision.
At 74, with some co-morbidities like brittle diabetes, hard to control HBP or advanced heart disease, radiation would be the better option.
However, if you are a fit and trim 74 with no other major health issues (uncontrolled by meds), surgery is a good choice because your type of cancer could return - no matter the initial treatment - and you could then do radiation/ADT to attempt a cure.
I just advised a friend NOT to have surgery at age 75 since his cancer is low grade, low Decipher and he has a lot of medical issues. Best,
Phil

As @heavyphil says PNI is not a big worry. I had PNI and 15 years later I’m still alive even though I have BRCA2 which prevents my system from correcting DNA errors.

I had a prostatectomy 15 years ago, But that was because my father had radiation and it didn’t work.

Both prostatectomy and radiation will eliminate your PNI problem.

You worry about “ high-grade prostatic intraepithelial neoplasia.” but it, Like your pirads 4 score, isn’t a big deal since it just means it could potentially lead to Prostate cancer. Surgery or radiation will eliminate issues related to those problems.

Yes, if you get surgery you can have radiation if it comes back. But at your age radiation may eliminate the cancer until something else kills you.

Don’t panic, Your cancer is very treatable.

I'd start ADT now and take a month to compare Proton with MRI guided SBRT. Many surgeons want two months of ADT prior to surgery. Have you spoken with a Surgical Oncologist. (Or two)

Yes, Jeff, you are quite correct about HGPIN - not even cancer. In my jumbled brain I meant the Gleason 8 in the two cores being the real concern, but the words “high grade” overwhelmed my thoughts. Appreciate the clarification!
Phil

Having an RP and follow up radiation 2 years later I have to wonder about the frequency percentage of left behind cells post-surgery and subsequent radiography to deal with it. Without investigation I suspect it is high. If I had to do it all over again, I would do a deep dive on rad vs RP. I hear of many that have to go back within two years for cells left behind. I know someone that is going with radiation for G9 for this reason and will be interested to see how it works out.

If both RP and radiation will eliminate why not just go with radiation?

After RP, I had "persistent " PSA of .19 and EPE.
Salvage Radiation Treatment to the whole prostate region (WPRT) and pelvic lymph nodes resluted in 18 mos of undetectable < .02 (so far).
With PSMA PET scan that was " clear", escaped cells are thought to reside locally to the prostate bed.

I think that the incidence of near term BCR is rough 25 - 30% ?

I wanted a chance at total removal and would opt for RP again. Just my choice.

Because in some cases, radiation will completely eliminate the cancer. It has a little bit wider margins than surgery I suspect, 4 to 5 mm of spread If you don’t use an MRIdian machine. Long-term results seemed to be similar, however.

I have a buddy with G9 going with radiation. Will be interested how it works out.