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

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

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 Hopefully, there was no escape before the RP was performed. A clear PSMA Pet scan and clear margins don't guarantee that no escape has already occurred. This post RP nomogram from MSK predicts the probability of remaining cancer recurrence-free at two, five, seven, and ten years following surgery. Using dynamic statistical formulas, this nomogram draws on data from more than 10,000 prostate cancer patients treated at MSK.
https://www.mskcc.org/nomograms/prostate/post_op

I had Pi-RADS 5 at my first MRI to confirm cancer with two tumors and possible ECE.
After a second opinion at Mayo Rochester it was changed to one tumor at Pi-RADS 4 with ECE.
After my biopsy the projected Gleason was 8 (4+4). My PSMA PET/CT showed no spread.
I had a robotic prostatectomy with nerve sparing. All margins, lymph nodes, etc. were clear. Some extra tissue around the prostate was removed. I have no idea how much but it didn't sound significant.
One benefit of surgery is being able to run a pathology report. Mine came back as Gleason 7 (4+3) vs 8. This can aid in the determination of follow-up treatments. I am having no radiation at this point and will be doing my first PSA test in 3 weeks.
I preferred to start with surgery and follow up with radiation if required since they could properly stage my cancer and any radiation follow up would be more targeted with fewer negative side effects. Be sure to read up on them if considering radiation as you can have incontinence (urinary and bowel) and ED as delayed side effects. My surgeon has over 20 years of robotic prostatectomy experience and was not overly concerned with my ECE as it seemed confined to the surface of my prostate. My radiologist was quite comfortable with a surgical choice and my proposed surgeon. My incontinence and ED recovery are proceeding as predicted. As everyone will tell you, it is a complicated choice to make and many variables to consider and the stories of everyone in this group will vary significantly. Best of luck.

@wwsmith

Thanks for the link to the post RP survey. Great info.

@charlesprestridge Be aware that MSK also has a similar nomogram for those seeking odds of recurrence before they have an RP as seen here https://www.mskcc.org/nomograms/prostate/pre_op

@psychometric Hopefully, there was no escape before the RP was performed. A clear PSMA Pet scan and clear margins don't guarantee that no escape has already occurred. This post RP nomogram from MSK predicts the probability of remaining cancer recurrence-free at two, five, seven, and ten years following surgery. Using dynamic statistical formulas, this nomogram draws on data from more than 10,000 prostate cancer patients treated at MSK.
https://www.mskcc.org/nomograms/prostate/post_op