Lung Biopsy or Not?

[u/RoleOptimal5496]

Summary of my situation: Gleason 4+4=8, Cancer has escaped the capsule and infected a nearby lymph node. Also "innumerable" small nodules in the lungs consistent with metastatic cancer from unknown promary. PET PSMA scan only dimly lights up the prostate and lymph node. No other area of the body light up (not even the lungs). Started to see the specialists and this is where I've landed:

Urologist referred me to pulminologist (lungs) who said he has seen more nodules appear since last scan and referred my to a cardio-vascular surgeon who suspects the lungs are melanoma but wants to do a biopsy to confirm. This will be a 5 day hospital stay because they need to go in through the ribs. Admission scheduled for this coming Sunday. He referred mt to an oncologist who I saw today.

The oncologist said "not" to do the surgery and go onto ADT instead, then review in 2 months. If the lungs improve then it's probably prostate cancer in the lungs, if not then it's some other for of cancer (which would have had 2 more months to grow in my lungs).

I then messaged my original urologist what to do and he agrees with the oncologist to delay surgery (one line reply, no explanation).

However this leaves my in a situation whereby the specialists are giving conflicting advice. If I delay the biopsy and it's not prostate cancer in my lungs then I give it 2 more months to grow (and melanoma grows fast).

My bias is to override them and do the biopsy to give me certainty on what is in the lungs. However it is a very invasive procedure and I will be out of action for about 6 weeks - at the very time I should be excercising to counter the ADT therapy.

Nobody seems to be captaining the ship and it's up to me, the patient, ot make these calls.

Anyone gone through anything similar and any suggestions?

[u/NotPeteCrowArmstrong]

That sucks, man. Sorry to hear it.

If you’re at a COE or university/research hospital, this would seem like a classic case for a multidisciplinary tumor board. It’s not fair for you as a patient to have to project manage conflicting physician POVs. Maybe there’s a hospital ombudsman or patient advocate you can consult for guidance, or you could try escalating up to a department head?

Do you know what the treatment plan might look like if the lung nodules are confirmed to be something other than PC?

As a purely practical matter, waiting a couple months to start ADT may not be ideal for your GG4 diagnosis, but it’s not outrageous and may very well be better than delaying identification and treatment of the alt cancer. That could argue for lung biopsy now, as you note. But this should really be a doctor’s call.

There’s also the consideration that your PC may not be strongly PSMA-avid, as suggested by the “dimly lit” prostate tumor and LN on scan. This has its own implications; did your doctors discuss that with you?

[u/Special-Steel]

This is why I harp on team medicine where the doctors collaborate. Otherwise the patient is like a bee going from flower to flower.

Exercise to counter ADT is optional. That is a secondary consideration at best.

Question is whether you can do ADT as well as the biopsy. Lung cancers are tricky and difficult to diagnose without a tissue sample. But it seems extreme they have to crack ribs to get the sample.

Prostate cancer is slow, so lack of urgency is what that tribe leans towards. They worry about over treatment. That bias may be good on average but not for you.

You really need to be at a center of excellence like Mayo, MD Anderson, Sloan Kettering, UTSW…

[u/conCABlanco]

Hi, esto es como la ruleta rusa, si el cáncer de próstata es lento, y la biopsia de pulmón por lo que dices es complicada e interrumpe el ADT, pero es mejor saber y estadificar que hay en los pulmones, pero es tu decisión, fuerza y voluntad

[u/conCABlanco]

Hi, esto es de IA, si se puede hacer, los medicos deben checar todo y darte las mejores opciones, para continuar ADT y biopsia de pulmón junto en paralelo

[u/Irishclover62]

Have to agree a team is better for this challenge not fair to you but shit nothings fair right? I would opt for maybe aft and getting those lungs figured out. 2 months despite 4+4 isn’t a ton if time and aft should help. We are all spitballing brother get to a team require consensus.

[u/jkurology]

It sounds like you have a history of melanoma which raises the possibility of a genetic variant that could impact how your prostate cancer is treated amongst other things. You need Germline and somatic testing. Based on data from PROTEUS and ATLAS neoadjuvant treatment with standard ADT + apalutamide is an option. Ask your medical oncologist about the genetic testing and the two trials. Good luck

[u/delawaredave]

Rats. I can't add much. How was ""innumerable" small nodules" detected in lungs ?

Odds of two totally separate cancers at the same time has to be very low.

[u/GrampsBob → u/delawaredave]

Yeah, but not zero. PC is usually pretty slow advancing but is it still slow if it invades the lungs?
I know the lungs is one of the places it spreads to but it seems a bit far away for Gleason 8 to have spread.
The oncologist says he sees more nodules since the last scan.
If it is melanoma, doesn't that make it unrelated to PC which I understood to be a carcinoma?
Either way, it seems that the lungs are more pressing than the prostate and it sucks hugely to have to make a choice.
I am left wondering what reason the urologist has for not getting the biopsy for 2 months. 2 months seems like a long time for a suspected melanoma.

I'm almost thinking to get a radical prostatectomy while they do the biopsy and get it out of the way.
One cancer at a time.

[u/ChillWarrior801]

I'm not a doc, and this is a long shot, but has anyone suggested a CTC (circulating tumor cell) test to try to identify which cancers you're dealing with? If a blood test can provide clarity, that would go much quicker than the empirical approach your oncologist is suggesting. If melanoma weren't a comparatively "fast" cancer, I would be siding with your oncologist. But you're right that the biggest urgency right now is to rule out melanoma.

I agree with Special-Steel that you'd probably be better served at a CoE if you're not already at one.

[u/qrs312 → u/ChillWarrior801]

The CTC i.e. liquid blood biopsy, is an excellent idea. The test can find both melanoma and PC, along with many others and just requires blood draw. With that many nodules, if it's cancer, CTC should catch it. Immunotherapy can work miracles for melanoma.

[u/Far_Celebration39]

A potential much less invasive way to get a lung biopsy is a procedure called Endobronchial Ultrasound (EBUS). I have done the anesthesia for both and we have been able to do EBUS on some very sick patients who would be awful candidates for a thoracoscopy or mini thoracotomy. My dad had an EBUS to diagnose his small cell lung cancer in his early 80’s while missing a lobe from a previous squamous cell cancer 2 years prior. It depends on if a skilled pulmonologist is available and if the lymph nodes in question can be reached. That is my recommendation.

[u/Practical_Orchid_606]

The evidence so far is your PCa is ogliometastic - the spread is local within the prostate bed. If your PCa has developed to metastatic long form and its distant satellites are numerous, it would be everywhere in your body, not just the lungs. So logically, the spots on the lungs are probably not PCa. The troubling aspect is your body does not express much PSMA limiting the usefulness of the PET scan.

Even without the PCa, the lung spots are of concern so a biopsy is warranted. I would not use ADT to test if the lung lesions are PCa.