Newly diagnosed

@carlsbadguy
Wow that shows how strange this prostate cancer is, I had a MRI first and it showed a PIRAD 5 lesion. Then the biopsy were done. I thought they would just biopsy the lesion. However, when I showed up they did 3 biopsy of the PIRAD 5 lesion and then 12 more, 6 each side. The PIRAD 5 lesion was just 3+3. They found 4+3 in other areas, 2 with cribiforms. So the MRI missed the real problem area.

@diverjer
You really hit it on the button. We’ve run into so many cases in this forum where people had positive cores outside of the spots where PIRADS lesions were found in the MRI.

It’s so important to get multiple spots biopsied.

@diverjer
As @wheel1 mentioned, Surgery is possible after radiation.

People who have radiation as their primary treatment have been told by doctors that surgery isn’t really an option if there’s a reoccurrence. Other options are not really mentioned..

This study shows that both salvage focal therapy (HIFU and cryotherapy) and salvage surgery were equally effective at extending the life of a patient that started off with radiation.

Those that had focal therapy had fewer perioperative complications.
https://jamanetwork.com/journals/jamaoncology/article-abstract/2844900
One other thing to consider is that it is likely that the BCR is due to a metastasis somewhere outside the prostate, So treating the prostate isn’t always necessary after a reoccurrence.

@wheel1 Yes, there are several surgeons in Urology at Mayo Rochester who are experts in surgery after radiation of the prostate. Thankfully, we have not had to use any of them, so I can't give recommendations of specific doctors. But I do know they exist there.

@diverjer
I still remember going in for my biopsy due to a PIRADS 4 lesion. 15 cores also, three from lesion and six random grid from each side. When I went in with the Urologist for results he asked if I wanted the good news or bad news first. I said good and he said the PIRADS 4 lesion was benign, now the bad news, the other random cores had two 6’s, (3+3), two favorable 7’s (3+4) and one 8 (4+4). Good thing once you go in they don’t stop with the PIRAD lesions.

You sound similar to my situation. I'm 68 but was diagnosed at 66. Gleason 9 with a number of the same adverse factors, including cribriform, multifocal, bladder neck invasion, perineural invasion and lymphatic invasion. Percentage of Gleason pattern 4: 60%. I had RP surgery 18 months ago, but my PSA started to rise after just 6 months. It didn't get above 0.04 but was trending in the wrong direction. I had a Lupron injection and 39 radiation treatments that ended in February. My PSA is now undetectable (< 0.01). It's been a long 21 months. I'm in a good place now but assume there is more work ahead. I'm in Phoenix.

I got the best understanding of my situation when I visited a different prostate cancer center to make sure they agreed with my treatment plan. More than what they said, it was the look on their face that told me my situation was more serious than I had realized. I think that and a strong support system have helped me get to this point.

Critical to know the location of the tumor(s). Example, if located center your decisions have more time. If located next to the colon wall, your decision time is a lot less if (and it will) the tumors metastasizes (spreads) into the colon wall. Many in this situation elect to have RP to eliminate chance. Of course when that happens you now have colon cancer that spreads at a rapid rate whereas prostate grows at tortoise speed.

Sorry to hear of your diagnosis.
Surgery vs radiation is a challenging choice for many.
At 72, I had RO for G 9 and I would choose RP again.
I favored a chance at complete removal and radiation as a backup.
Unfortunately, I did need SRT after RP due to persistent PSA post-op of .19
uPSA has been undetectable for over 2 years since.
May I suggest a 2d opinion at a center of excellence. There are excellent local community surgeons, however COEs have extensive treatment history with PCa and are worthwhile considerations.
Best wishes.

@lag Agree. When I was researching procedures, my Mayo Radiologist told me that you have probably heard from other providers that if you do radiation first, you cannot do surgery later. He then said we do it nearly everyday down here and very successfully. I ended up doing Tulsa, but have confidence that all other options are available later if needed.

Hello - I totally agree with what @jeff marc (Jeff Marchi) offers: "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." I totally agree that a radical prostatectomy is the better way to go.
I would add that while you have Intraductal carcinoma, it is still important to know and understand "which type" of Cribriform tissue that you have...and for a reason and outcome that I discovered quite unexpectedly when I did a little research to discover that there are about "eight" types of Cribriform tissue, two of which are nothing to worry about, AND that Cribriform tissue can exist as a "normal" microscopic feature in healthy prostate tissue in some men. In other words, you could have had Cribriform tissue all of your life, and when you got diagnosed with prostate cancer, with Cribriform tissue, that Cribriform tissue may have been there all along. Here is what happened with me:
I wanted to know more about Cribriform tissue, so I did an online search, and much to my surprise, I discovered the above mentioned fact that there are numerous types of Cribriform tissue, but...my post-RP surgical pathology report merely said: "Cribriform: Present". I called my urologist and asked him to have my slides pulled and re-read by the same pathologist so he could tell me what type of Cribriform tissue I have. Outcome: The pathologist modified his original surgical pathology report, correcting himself, that there was in fact NO Cribriform tissue in my prostate tissue"...per my urologist quoting the pathologist, he had made an overly conservative call and decided to say it was there, when upon re-examination, decided that he was wrong, and thus amended his own report. THAT did not instill much confidence in me as to the skill of the pathologist. So...It might be worth having your slides re-read, maybe by a different pathologist with the request to delineate "what type" of Cribriform tissue you have, because it may be "normal" Cribriform tissue.
As I mentioned above, two types are not problematic, while the others span a range of moderately problematic to ominous. It would be good to know, for peace of mind, what you have. I thoroughly believe in maximal understanding of everything about my cancer, so that when new decisions have to be made, I have "ALL" of the history and knowledge about "me" that I can possibly have. I fortunately did not have Intraductal Carcinoma, but I did have Extraprostatic Extension (EPE), left seminal vesicle invasion, and surgical margins which were only found after my prostate was removed and dissected. The left seminal vesicle invasion threw me into a more ominous pT3b category which my doctor told me, means that I have a 25-50% probability of the cancer returning "within" five years. I am hoping I will be in the 50-75% group where it does NOT recur. Good luck to you...keep us posted on your progress.