MSK re-review of biopsy slides - worse

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Godfather
Regular Member


Date Joined Jan 2009
Total Posts : 64
   Posted 2/7/2009 6:50 AM (GMT -6)   
The hits just keep on coming.  In the hopes of getting a downgrade of my Gleason, I had my biopsy slides re-reviewed at Sloan-Kettering (Venice, FL is not exactly the healthcare capital of the world).  My reward is that my one 3+4=7 Gleason was changed to 4+3=7.  The other was confirmed at 4+3=7.  Anything else new?  Of course!  A nice little comment at the end of the report.... "Perineural invasion is present".
 
I'm still holding out hope for robotic RP, now more than ever.  In a few hours, I have a telephone consult with the newly elected Chief of Surgery of Urology at Sloan, James Eastham, MD (I'm glad my son was smart enough to marry a urologic nurse there).
 
Signature updated but not in the manner I had hoped for.
 
Tony
Age at diagnosis 61  5'8" 260 lbs.
Resides in SW Florida
12/07 PSA 2.6  12/08 PSA 4.0
Biopsy 1/09 - 6 of 8 nodes positive 
Left - 2 of 4 positive, 2% involved, 4+3=7 Gleason
Right - 4 of 4 positive, 40% involved, 4+3=7 Gleason
Perineual invasion is present 
DRE small nodule on right - Prostate 22.6 cc's
Hoping/planning da Vinci - searching for surgeon


divo
Veteran Member


Date Joined Jul 2008
Total Posts : 637
   Posted 2/7/2009 7:00 AM (GMT -6)   
Good luck Tony. Dr. Eastham is a fine man and a very talented one. He is only one of a handful of surgeons in the country that will do salvage surgery. You will be in fine hands with Dr. Eastham if you decide on surgery...I wish we had gone to him BEFORE the radiation. By the way, all of the nurses that we met in his office were really great.....I am sure that we met your daughter inlaw....we were in there so many times.......Diane
Husband Pete
dx Jan 2001 gleason 4 + 3 PSA 16.5
Seed implant and conformal radiation and Lupron from Jan 2001 to Jan2002
2005 Dec PSA began to rise from .5 to 8 within 6 months
Salvage surgery at MSK 9/06 Dr. Eastham
Fistula operation 2/07 MSK Dr. Wong
Many cystoscopies and ER visits with strictures
Catheter for one year....Catheter taken out Sept 07..
Total Incontinence since then....
PSA .52 3/08
AUS Operation at MSK Sept 8 2008 Dr. Sandhu
Activated Oct 28th Dr. Sandhu..MSK
Some difficulty with AUS arising Nov 10 2008
Meeting with Dr. Sandhu to discuss AUS problems and new PSA test Dec 11, 2008
PSA .6 12/08
AUS improving..only 2 pads a day and one at night
Complete hip replacement surgery Dr. Waters Gainesville, FL 1/9/09
Forging ahead to health!


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 2/7/2009 7:23 AM (GMT -6)   
Tony, I realzie that didnt flip the way you wanted or hoped, but still makes you a good candidate for surgery and it should still be contained. My best to you brother.

David in SC
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3
3rd Biopsy 9/8 Positive 7 of 7 cores pos, 40-90%, Gleason 7
Open RP surgery 11/14/8, Non-nerve sparing, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9/9
 
 


Godfather
Regular Member


Date Joined Jan 2009
Total Posts : 64
   Posted 2/7/2009 7:57 AM (GMT -6)   
Thanks to Diane and David.

Diane, during your long and difficult journey, have you and Pete developed a "Monday morning quarterback" preference of one treatment over the others?

Tony
Age at diagnosis 61  5'8" 260 lbs.
Resides in SW Florida
12/07 PSA 2.6  12/08 PSA 4.0
Biopsy 1/09 - 6 of 8 nodes positive 
Left - 2 of 4 positive, 2% involved, 4+3=7 Gleason
Right - 4 of 4 positive, 40% involved, 4+3=7 Gleason
Perineual invasion is present 
DRE small nodule on right - Prostate 22.6 cc's
Hoping/planning da Vinci - searching for surgeon


rob2
Veteran Member


Date Joined Apr 2008
Total Posts : 1131
   Posted 2/7/2009 8:43 AM (GMT -6)   
Good luck to you. My gleason biospy was a 3+4. After surgery, it was upgraded to a 4+4. As David says, you are still a candidate for surgery. Once you make the decision and have a plan you will feel better (at least I did). It is still very stressful but hang in there. Do your research and consult with the doctor's.
 
Age 48
occupation accountant
PSA increased from 2.6 to 3.5 in one year
biopsy march 2008 - cancer present gleason 7
decision - surgery (robotic)
surgery may 9, 2008 - houston, tx
pathology report -gleason 8
margins clear
9 month  PSA <.04 (low as the machine will go)
continent at 10 weeks (no pads!)
ED is still an issue


divo
Veteran Member


Date Joined Jul 2008
Total Posts : 637
   Posted 2/7/2009 3:28 PM (GMT -6)   
Well, Tony, There is no question that knowing what we do now, we would have had the surgery first...and gotten the cancer out. At that time it was contained, but because of Pete's 16 PSA and Gleason 4 + 3 ..the opinions we got from Moffitt and also Shands in Gainesville, suggested that Brachy and Radiation would be the way to go, They thought it might have escaped the capsule... If you remember it was just after Rudy Guiliani had the Brachy and Radiation....in 2001.. We decided that we would do the same thing, because everyone was talking it up..
The cancer had not escaped yet, even though the PSA was high ..The radiation and brachy did not get it all ..OR, as one doctor said....it could have been a completely new cancer that came later to the prostate. If we had taken the prostate out....it never would have returned...But, see, that is all behind us, and we try not to look at that....The one thing we do talk about is the salvage part...Pete should have gone on HT right then instead of the salvage surgery....There are people who have been on HT for 18 years....our doctor told us.... But everyone is different and treatments that are not good for someone can be wonderful for another... Good luck to you....Diane
Husband Pete
dx Jan 2001 gleason 4 + 3 PSA 16.5
Seed implant and conformal radiation and Lupron from Jan 2001 to Jan2002
2005 Dec PSA began to rise from .5 to 8 within 6 months
Salvage surgery at MSK 9/06 Dr. Eastham
Fistula operation 2/07 MSK Dr. Wong
Many cystoscopies and ER visits with strictures
Catheter for one year....Catheter taken out Sept 07..
Total Incontinence since then....
PSA .52 3/08
AUS Operation at MSK Sept 8 2008 Dr. Sandhu
Activated Oct 28th Dr. Sandhu..MSK
Some difficulty with AUS arising Nov 10 2008
Meeting with Dr. Sandhu to discuss AUS problems and new PSA test Dec 11, 2008
PSA .6 12/08
AUS improving..only 2 pads a day and one at night
Complete hip replacement surgery Dr. Waters Gainesville, FL 1/9/09
Forging ahead to health!


zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 2/7/2009 6:26 PM (GMT -6)   
Better assessment and knowledge leads to better choices and strategies to treat PCa, ok atleast in theory if you don't believe in that message. How many men got their slides reviewed and/or a 2nd or 3rd opinion on or on anything????
The value of a 2nd opinion should never be overlooked, but of course we all have that option of the whatever or darn the torpedos. Another thing about the value of a 2nd opinon, it shows the first opinion is not always correct and could be ruled either way in positive light or negative light (wouldn't you the patient like to have a better grasp of which is the truth and therefore the way), which for alot of patients changes the whole scenario or strategy on treatments, sometimes.
 


BillyMac
Veteran Member


Date Joined Feb 2008
Total Posts : 1858
   Posted 2/7/2009 9:45 PM (GMT -6)   
Godfather,
My initial biopsy resulted in 4+3=7 with no perineural invasion seen, following a PSA of 3.9. Post surgery pathology was 4+4=8 with extensive perineural invasion. Later while investigating the desirability of follow up radiation I had all the slides looked at again by a very highly regarded pathology lab attached to a cancer clinic. Post surgery pathology was downgraded to the initial 4+3=7 with a point of focal extension comprised of grade 3 cells (although this extension was mentioned in the first surgery pathology, there was no mention of the extension's cell grade). I guess the answer is "it all depends on who's looking at it". Perineural invasion is very common and probably present in most PCa cases. There have been a couple of posts about it which have tended to dismiss its significance.
Bill
1/05 PSA----2.9 3/06-----3.2 3/07-------4.1 5/07------3.9 All negative DREs
Aged 59 when diagnosed
Biopsy 6/07
4 of 10 cores positive for Adenocarcinoma-------bummer!
Core 1 <5%, core 2----50%, core 3----60%, core 4----50%
Biopsy Pathologist's comment:
Gleason 4+3=7 (80% grade 4) Stage T2c
Neither extracapsular nor perineural invasion is identified
CT scan and Bone scan show no evidence of metastases
Da Vinci RP Aug 10th 2007
Post-op pathology:
Positive for perineural invasion and 1 small focal extension
Negative at surgical margins, negative node and negative vesicle involvement
Some 4+4=8 identified ........upgraded to Gleason 8
PSA Oct 07 <0.1 undetectable
PSA Jan 08 <0.1 undetectable
PSA April 08 <0.001 undetectable (disregarded due to lab "misreporting")
PSA August 08 <0.001 undetectable (disregarded due to lab "misreporting")
Post-op pathology rechecked by new lab:
Gleason downgraded to 4+3=7
Focal extension comprised of grade 3 cells
PSA September 08 <0.01 (new lab)


Godfather
Regular Member


Date Joined Jan 2009
Total Posts : 64
   Posted 2/8/2009 6:50 AM (GMT -6)   
Diane:

Thank you for taking the time to write and for being so candid. My wife Kathy and I are so sorry that you and Pete are having to go through this. You are in our thoughts and prayers.

Tony
Age at diagnosis 61  5'8" 260 lbs.
Resides in SW Florida
12/07 PSA 2.6  12/08 PSA 4.0
Biopsy 1/09 - 6 of 8 nodes positive 
Left - 2 of 4 positive, 2% involved, 4+3=7 Gleason
Right - 4 of 4 positive, 40% involved, 4+3=7 Gleason
Perineual invasion is present 
DRE small nodule on right - Prostate 22.6 cc's
Hoping/planning da Vinci - searching for surgeon


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 2/8/2009 12:22 PM (GMT -6)   
Stay positive, Tony,
I am a 4+3 brother, and it was a mess at surgery, but we knew that was likely given my high PSA. It doesn't matter right now, but rather get after it. You can do quite well...

peace,

Tony
Age 46 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 15, 2007
Geason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (January 13, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


gpg
Regular Member


Date Joined Jan 2009
Total Posts : 180
   Posted 2/8/2009 12:44 PM (GMT -6)   
Hi Tony,

I also was sold on the robot and now think I made a real mistake. In my case the Dr. wasn't all that experienced but that is not what I am talking about.

It seems that it is routine with the robotic surgery to leave vas deferens, and seminal vessicles. With the possibility that your cancer is trying to get outside of the capsule I wonder that even in the hands of the best robotic guy you would not be better served by one of the best open anatomical guys who will take all of this other tissue and be able to touch and feel everything around the prostate.

Best wishes. Scott
Diagnosed @ 48yo 04/07
focal, low volume tumor gleason 6
RRP 07/30/07
Persistance of PSA
IMRT 11/07-01/08
Emerg, cysto obstructed bladder 01/08
Persistance of PSA
08/08 learned Dr. left significant amount of prostate
12/08 PCA3 negative
12/08 saturation biopsy 36 cores 24 having normal prostate tissue
12/08 referred whole to med malprac attorney


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 2/8/2009 1:24 PM (GMT -6)   
Scott, that was one of the selling points on me going with an open, was the ability to have more "parts" removed.
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3
3rd Biopsy 9/8 Positive 7 of 7 cores pos, 40-90%, Gleason 7
Open RP surgery 11/14/8, Non-nerve sparing, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9/9
 
 


sandstorm
Regular Member


Date Joined Dec 2008
Total Posts : 194
   Posted 2/8/2009 1:59 PM (GMT -6)   
Godfather,

Don't know if this helps or not but from Dr. Patrick Walsh's book:

Perineural invasion: a biopsy term meaning that prostate cancer has been found in the spaces around the nerves near the edge of the prostate. Because cancer that has penetrated the capsule can still be cured, perineural invasion has no long-term impact on a man's prognosis.

That sure sounded better to me. Hang in there.
Age at DX 57
5-18-07 PSA 7.7
5-06-08 PSA 4.6  8% free psa, but stable
10-23-08 PSA 5.65 4% free psa
11-04-08 biopsy
11-11-08 2 of 12 cores positive
Gleason 3+3  6  stage t1c / post-op 3+4  7  stage t2c
CT and Bone scan negative
Da Vinci RRP 01-09-09
Catheter removed 1-15-09
Pathology Report says it's gone!
First Post-op PSA due 2-17-09


livinadream
Veteran Member


Date Joined Apr 2008
Total Posts : 1382
   Posted 2/8/2009 3:57 PM (GMT -6)   

Tony, sorry to hear about the upgrade. The positive in this, using that term loosely, is that you are begining to get the full picture and once you have it all  you can formulate an attack plan. I like Tony from Vegas approach. Fire your torpedos now in the hopes of eradicating the demon. I pray all goes well for you my friend. Please keep us posted.

 

peace and love

dale


My PSA at diagnosis was 16.3
age 46 (current)
My gleason score from prostate was 4+5=9 and from the lymph nodes was 4+4=8
I had 44 IMRT's
Casodex
Currently on Lupron
I go to The Cancer Treatment Center of America
Married with two kids
latest PSA 5-27-08 0.11
PSA July 24th, 2008 is 0.04
PSA Dec 16th, 2008 is .06
Testosterone keeps rising, the current number is 156, up from 57 in May
cancer in 4 of 6 cores
92%
80%
37%
28%
 


BillyMac
Veteran Member


Date Joined Feb 2008
Total Posts : 1858
   Posted 2/8/2009 5:01 PM (GMT -6)   
gpg said...
Hi Tony,

.

It seems that it is routine with the robotic surgery to leave vas deferens, and seminal vessicles.

Best wishes. Scott


Scott,
I have never heard that before. It is my understanding that the seminal vesicles are always removed when undergoing prostatectomy as part of the procedure. There is no point to leaving them as they are virtually only a mixing chamber and there is nothing being produced to mix (other than the little tadpoles). The upper portion of the Vas Deferens are also removed as they are attached to the vesicles. The full length is obviously not removed as they go all the way to the testes.
Bill
1/05 PSA----2.9 3/06-----3.2 3/07-------4.1 5/07------3.9 All negative DREs
Aged 59 when diagnosed
Biopsy 6/07
4 of 10 cores positive for Adenocarcinoma-------bummer!
Core 1 <5%, core 2----50%, core 3----60%, core 4----50%
Biopsy Pathologist's comment:
Gleason 4+3=7 (80% grade 4) Stage T2c
Neither extracapsular nor perineural invasion is identified
CT scan and Bone scan show no evidence of metastases
Da Vinci RP Aug 10th 2007
Post-op pathology:
Positive for perineural invasion and 1 small focal extension
Negative at surgical margins, negative node and negative vesicle involvement
Some 4+4=8 identified ........upgraded to Gleason 8
PSA Oct 07 <0.1 undetectable
PSA Jan 08 <0.1 undetectable
PSA April 08 <0.001 undetectable (disregarded due to lab "misreporting")
PSA August 08 <0.001 undetectable (disregarded due to lab "misreporting")
Post-op pathology rechecked by new lab:
Gleason downgraded to 4+3=7
Focal extension comprised of grade 3 cells
PSA September 08 <0.01 (new lab)


gpg
Regular Member


Date Joined Jan 2009
Total Posts : 180
   Posted 2/8/2009 7:42 PM (GMT -6)   
BillyMac said...
gpg said...
Hi Tony,

.

It seems that it is routine with the robotic surgery to leave vas deferens, and seminal vessicles.

Best wishes. Scott


Scott,
I have never heard that before. It is my understanding that the seminal vesicles are always removed when undergoing prostatectomy as part of the procedure. There is no point to leaving them as they are virtually only a mixing chamber and there is nothing being produced to mix (other than the little tadpoles). The upper portion of the Vas Deferens are also removed as they are attached to the vesicles. The full length is obviously not removed as they go all the way to the testes.
Bill

Yeah, go figure, no one told me either.  The robotic guys do not do the same surgery that the open retro guys do.  Scott

Diagnosed @ 48yo 04/07
focal, low volume tumor gleason 6
RRP 07/30/07
Persistance of PSA
IMRT 11/07-01/08
Emerg, cysto obstructed bladder 01/08
Persistance of PSA
08/08 learned Dr. left significant amount of prostate
12/08 PCA3 negative
12/08 saturation biopsy 36 cores 24 having normal prostate tissue
12/08 referred whole to med malprac attorney


Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2457
   Posted 2/8/2009 7:51 PM (GMT -6)   
Tony,
Is is never a good news when the Gleason score is upgraded. As you can see in my bio, mine is already as high as you can get without a perfect 10. I'm having Robotic surgery tomorrow to have this monster removed and won't rest until I get my biopsy report and future PSA results. All I can hope for is for the cancer to be contained. Good luck to you.
Age: 67
5ft 10 inches 182 lbs
Retired in 2001 and living in Austin TX.
Dx 12/30/08
Scheduled for Robotic surgery on Feb 9th
Surgeon: Dr. Randy Fagin, Austin TX.
12 sections tested 2 with cancer
Left Medial Apex 4.0 mm. Gleason score 9 (4+5)
Left Lateral Apex. 2.0 mm Gleason score 8 (4+4)
Negative CT scan and bone scan done on 1/16
PSA 3.5

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