Newly diagnosed

I imagine your next step is the PSMA-PET and decipher reading for your biopsy. I wouldn’t necessarily rule out a prostatectomy. I know he states your age at 73. Unless you have health issues 73 is not an age that surgery is ruled out. Gleason 8 does typically call for ADT after radiation, the question today is for how long. Your RO recommendation is certainly good, but if your PET comes back negative, a surgery consultation is at least to be considered. I have heard certain cribriform patterns are not as susceptible to radiation. Your age is definitely reaching the cut off point for surgery, but after surgery you still have radiation in your back pocket. It is not definite you would need adjuvant radiation after surgery and ADT and there is a school of thought I don’t want double side effects. However, there is also the surgery and no radiation and ADT. I definitely think getting the further tests will help.

You do have some concerning things in this biopsy. You are a 4+4 Gleason 8 grade group 4. The lower Gleason scores are not really taken into account.

On top of that you have cribriform and intraductal, Two things that make it very aggressive along with the Gleason eight. One thing the doctor did not tell you is if the cribriform Was large versus small, meaning over .25 mm. This is really important because large cribriform Is much more aggressive than Small. You need to get ahold of the doctor and get an answer to this, you may need to have him talk to the pathologist. Hopefully the pathologist specializes in prostate cancer, A very important thing.

You might want to get a second opinion on your biopsy. A top doctor to do it is Dr. Epstein. In contact his office through this website to get a second opinion done. They do charge $500 sometimes insurance will cover it.
https://advanceduropathology.com/
There is a problem with treating both intraductal and cribriform as that there is no treatment that is definitive in eliminating it. Surgery was probably better than radiation for Cribriform. But radiation might be usable if you had SBRT radiation followed by multiple sessions of IMRT to the prostate bed and lymph nodes. You need to discuss this with both a urologist surgeon and a radiation oncologist to find out what may be better for you.

Thank you both, I failed to mention I have a PSMA PET scheduled for May 13. I will reach out to my Urologist to see if the cribriform is small or large, hopefully he can get an answer from the pathologist.

You might also ask for a decipher test, I found that interesting. Didn't like results, but good to know. Also, I had some genetic testing. One thing I might mention and pretty sure I am right, if you have radiation treatment first, they most likely would not do surgery at a later date. From what I understand, very few places do surgery after radiation.
When you get the PSMA PET I found it interesting to get the SUV reference scores for parotid glands, liver and blood. Then compare that to your prostate score. That helped me understand the prostate score better. I had to really ask a lot before they would give me these reference organ scores. Uptake > blood but less than liver is a low score 1. Greater than liver but less than parotid gland intermediate score 2. Uptake greater than parotid is high score 3.
Anyway, I wanted this information and found it useful, but sure had to ask a lot before they gave it to me. Others on here know much more than me, so they might give you much better advise.

@carlsbadguy Hi sorry for your news. I am 67 Gleason 4+3 with cribiform and idc. I had the prostatectomy at Mayo last August. I had biochemical recurrence at about 7 months and am scheduled to start salvage radiation and adt. I did recover from surgery completely except they had to remove a nerve bundle which disabled erections. Otherwise incontinence resolved at 2 months. I am not sure there is a wrong answer at this point to surgery or radiation. I figured I could give the surgery cure a try leaving the option for later radiation. Unfortunately that was needed.I will watch for you. This is a great place to learn and you can already see Jeff is a great guide. A couple others around here dealing with very similar situations so welcome to the group and sorry to meet you this way.

You mentioned that your Urologist took 12 cores, six from each side. This sounds like a random grid biopsy, although you mentioned that you had an MRI. Did the MRI identify any PIRADS lesions? Typically the biopsy will take a few extra cores from any identified lesions in addition to the random grid cores.

diverjer is correct in that most surgeons will not do surgery after radiation due to extreme technical difficulties with the radiated prostate in surgical removal. That being said he also correct that their are surgeons that have become highly skilled and proficient in being very successful in salvage surgery. The expertise in this procedure is also growing, typically at the major cancer hospitals.

@wheel1 Yes, the MRI showed one lesion PIRAD 5, all of the cancerous cores came from this lesion.

In addition, I would ask for decipher test. You want to look for gene mutations. Especially PTEN loss. That is often found in cases with IDC and cribiform.
The grid may help the doctor make a better informed decision.

@carlsbadguy Also, if radiation is considered as @jeffmarc has suggested, also ask about HDR brachytherapy - a ‘boost’ dose placed inside the prostate to blast the cribriform/IDC before proceeding with either SBRT or IMRT.
Importantly, get a Prostox test to see if radiation might adversely affect your bladder - everyone reacts differently.
Phil