Possible Extracapsular Extension - How much influence on treatment(s)

1. Really not an easy question to answer. Where is the ECE? Is it near the nerves that need to be spared? In some cases, they can just spare one side and that will allow many people to get an erection. Your doctor is the one to get the answer to this question, They should know where it’s located, especially after having the PSMA PET scan.

2. It would require radiation after RP if they could not get clean margins. If they could get clean margins, then the radiation chance depends on your PSA over time. When the PSA hits .2 after an RP they want to do salvage radiation normally. You may never get there.

3. The decipher result of .48 tells you that you have a medium chance of having reoccurrence. It shows what the chance is in five or 10 years. That’s a lot more information than we can give you here.

4. In general a 3+3 should not be treated unless there are other advanced issues. The ECE is one. If you did pick active surveillance, you would probably want to get checked again in six months.

Here is a video with Dr. Laurence Klotz, one of the experts on active surveillance. He can give you answers as to why you would or would not be a good candidate for active surveillance.

A Gleason 3+3 (Grade Group 1) with extracapsular extension (ECE) (ECE) is considered more aggressive than typical low-risk 3+3 cancer, potentially elevating it to favorable intermediate-risk (Grade Group 2), meaning active surveillance (AS) needs careful evaluation due to increased risk of progression, though some low-risk ECE cases might still suit AS with intensive monitoring, requiring a discussion with your doctor about risks vs. benefits for treatment versus closer surveillance.

Wasn't there a post a while back that mentioned a newer study showing that when a patient has 5 or more positive 3+3 cores that active surveillance is not appropriate? Maybe someone remembers that thread and could post a link to it? And if you combine 5 positive 3+3 cores with an ECE then the situation is all the more dangerous, especially with an intermediate 0.48 Decipher score.

The 3+3 Gleason scores give some pause to treatment but not when considering that biopsies routinely do not reveal the actual maximum Gleason score. But if you want to avoid the harsh side effects of an RP and still have good odds that radiation kills everything (both in the prostate and outside to the extent of lymph nodes) with a minimum chance of recurrence, my lay opinion is that you would have to radiate the entire pelvic region with IMRT and hit the prostate with an SBRT or HDR brachytherapy boost.

Thanks Jeff,

I will watch the video. I have watched several of his videos. I have read Dr. Walsh's book.

MRI report: Lesion involving the left peripheral zone post lateral aspect mid gland and apex.

I meet back with Surgeon in February to discuss. City of Hope is also having their radiologist read my September 2025 MRI (performed at local hospital) for 2nd opinion on the possible extracapsular extension.

I appreciate all you do for the everyone. I have read alot of posts on this forum over the past 6 months. You are always so helpful.

Best Wishes

@wwsmith

Thanks. I am in agreement with it not being a standard 3+3.

Radiation Oncologist recommends HDR. She is comfortable with two doses of HDR.

I love the possibility of reduced side-effects of HDR vs RP. My concern is the possible return of cancer 5-10 years from now.

Thank you and best wishes.

@wwsmith
I actually posted about that information at one time. If 5 or more were found action was recommended, But there are extenuating factors.

It was discussed during one of the PCRI conferences.

I’ve heard further conferences at which it was not as emphatically recommended something be done immediately.

IMRT with HDR brachytherapy Is a real good way to fully treat the problem, Never seen SBRT being included in that kind of treatment. One person today already talked about the fact that they have multiple metastasis after having that done, so it’s not always the solution but it’s usually a great treatment.

@jeffmarc When I was working with doctors in the spring of 2024 at both MD Anderson (MDA) in Houston and Baylor Scott and White (BSW) in College Station, TX, I was offered a number of options for my 3+4 case (15% of 4) with 0.81 Decipher and two lesions (one Pirads 4 and one Pirads 5) broadly abutting the capsule but no evidence of ECE or cribriform or intraductal. There was also a third lesion (Pirads 4) that was not abutting the capsule. Because of the high Decipher score and two capsule abutting lesions, both RO's agreed that wide area pelvic radiation was needed in case any escape had happened even though my PSMA PET scan was clear outside the prostate. Both agreed that 26 IMRT sessions would be ideal for that and that my local BSW facility could provide that. Both RO's also agreed that my case deserved some radiation boost to the prostate as well as one year of ADT (actually the BSW RO wanted me to go two years on ADT!)

The main difference of opinion (besides the ADT time) was on the prostate radiation boost. The MDA RO gave me the choice of HDR Brachytherapy or SBRT. He explained that MDA was very big on SBRT in that there were even trials about to begin that would use SBRT in the same way that IMRT is used (low dose with broad targeting). Apparently, the SBRT machine is very flexible and programmable such that it can provide radiation in any way desired even though it's original design focused on high dosages at small targets. At that time I was a bit sad that my case was too early for the upcoming trials so IMRT was settled on for the greater pelvic region and I chose SBRT for the prostate boost. But when my BSW RO heard this, he flipped out and said that he would not do the IMRT on me if I was going to follow it with SBRT. He said SBRT is still too unproven and unsafe (might burn a hole in my rectum) and he did not want to be involved in a case where SBRT is used. It turned out that my MDA RO actually had a slight preference for HDR brachytherapy himself so he didn't seem to mind placating the BSW RO and advising me that HDR brachy was actually a bit safer than SBRT because the radiation is so contained in those 16 catheters they insert into the prostate.

So I ended up doing 26 sessions of IMRT and one HDR brachy session. But as the months passed, I looked into how those SBRT trials were going on trying to emulate IMRT and it was not good! There was so much radiation toxicity in some trials that they had to be aborted early. Apparently, they were trying to use slightly higher dosages than what IMRT does for wide area radiation so as to reduce the number of sessions. Because SBRT is so flexible there is no doubt that the doctors can ultimately figure out some optimal programming to emulate IMRT, but I did breathe a sigh of relief that I had just missed going into that trial!

@wwsmith

Thanks for sharing your experience and information.

Best Wishes

I had RARP at the Cleveland Clinic in June at age 50. Initial biopsy Gleason 7 (3 + 4), 6/12 cores, PSA 6.68, Stage T1C, and Decipher 0.56. Pre-op PSMA showed no metastasis to lymph nodes or bones.

My pre-op MRI showed EPE so the surgeon had a sample tested during my surgery to help ensure negative margins but he was still able to spare nerves on that side. CC calls the procedure "intraoperative diagnosis" but it's also called NeuroSafe or frozen section.

My surgical margins and 15 lymph nodes were negative but the post-op pathology revealed large Cribriform pattern (< 10%), and suspicious IDC, which changed my staging to pT3b. So far, my PSA has been undetectable on the first two post-op tests.

@psychometric

Very good info. I will discuss this surgery process on next Visit (in a month) with Urologist/surgeon.

I appreciate you sharing.

I had ECE with extensive G4+3 - which yours is not, thank goodness. However, surgery revealed a ‘tiny’ break in the capsule, but margins were negative.
Got 5 years out of that until the cancer recurred and I underwent 25 sessions of IMRT (many acronyms for this!) with 6 months ADT.
I was 64 at the time of surgery.
Yours is a difficult decision, for sure, because of its ambiguity: not a lot of bad cells, but right in a critical spot!
Your treatment decision depends a lot on your personality type. I am a worrier, a pessimist and I always expect a train🫣.
So I opted for surgery - even though 2 RO’s assured me that SBRT would be successful… and it turned out to be a good bet as I was able to hit it a second time with radiation.
I would have worried constantly that my options would be limited if the cancer returned, had I chosen radiation as primary treatment.
But remember, my case was a lot worse than yours and perhaps HDR/IMRT is all you’ll ever need.
But the real question is this: is your less than 10% G4/ECE gonna keep you up at night worrying if you don’t have surgery? Or is worrying about incontinence and ED gonna worry you more and prompt you to choose radiation with fingers crossed?
Ultimately, any treatment you choose will have a comparable success level. But it’s your COMFORT LEVEL with your decision that is most important! You gotta be 110% ALL IN on whatever you choose and never, never, EVER look back with woulda/shoulda… Hope I haven’t confused you even more, but this is a very confusing subject to begin with!😉
Phil