High Risk Info

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kcragman
Regular Member


Date Joined May 2008
Total Posts : 241
   Posted 8/25/2009 9:55 AM (GMT -6)   
My guy, Dr. Jason Engel with George Washington University in DC, has done hundreds (thousands?) of robotic assisted laparoscopic radical prostatectomies (RALPs). He runs a Fellowship at GWU and does a lot of writing and reporting of results. He has recently written a paper about his high-risk guys (including me). He gave me a copy.
 
His paper says RALP was approved by the FDA in 2001, and in 2008 there were 73,000 RALPs worldwide. Also, "There is a concern about the use of RALP due to lack of tactile feedback which would be particularly relevant for high-risk prostate cancer. Therefore, we evaluated the feasibility of RALP as primary, unimodal therapy in high-risk cancer patients." 
 
He considered high-risk to be PSA > 10, and/or Gleason >8 on final pathology report, and/or stage pT3. (All of these are "greater than or equal to.") He had 73 subjects (53 white, 18 black, 2 other), all of who had no previous medical treatment for prostate cancer. The mean age was 61 (range 52 to 74). They underwent "bilateral nerve sparing, non-salavge RALP by a single surgeon without adjuvant or neoadjuvant therapy of any kind."
 
He has tracked these guys for up to 85 months (average 23 months), and he reports that "biochemical recurrence free survival was 77%." Biochemical recurrance was defined as PSA >0.2. Average time to recurrance was 7.7 months. Recurrance was "significantly associated with (a) higher pathological Gleason score" but not pathological stage or preoperative PSA.
 
So what he is saying is that if you are a high-risk patient and have a RALP, you have a 77% of non-recurrance, at least thru 2 years. And it probably gets statistically better the further away from the 7-8 month average recurrance mark you get. Once again, these are just his stats - and in my opinion it is a pretty small sample.  
 
The sad part is, and my medical scientist wife supported him on this, that he can't get his paper published. Journals are run by editors. Editors have boards of doctors that review articles. If the editor likes your article, he will send it to doctors who will review it favorably. If the editor does not like your article, he sends it to doctors who will kill it. open surgeons hate these articles, and it actually takes business away from radiologists. (Adjuvant radiation is "pre-emptive" radiation given after surgery whether you need it or not. If he is saying "I have proof that you don't need adjuvant radiation" then it takes business away from radiologists.)
 
Of course, doctors write self-serving papers all the time (shocking!) and this paper is very pro-RALP. He said if nothing else, he will eventually post it on his website (http://www.dcurology.net/engel.html) and it might get published in the robotic surgery journal (whatever that name was).  He was frustrated that he wrote a paper some years ago trying to tell new surgeons how to be better robotic surgeons (everybody does not NEED to re-invent the wheel) and he had difficulty getting that published also.
 
Surgery is not the answer for everybody in every case. I just wanted to get this info out there. Hopefully other robotic surgeons are having the same results.
 
kcragman
Age: 53; 52 at DX
March 2006: PSA 2.5
Dec 2007: PSA taken for insurance application. I did not see the results until late
Jan '08 - after I was rejected. Their lab said PSA 4.5.
Feb 2008: PSA 3.7.
March 2008: Biopsy. Gleason 7 (4+3) 12 cores taken. 5 on the left side were
cancerous and the 6th was suspect.
May 5, 2008: Da Vinci robotic laparoscopy at GW Hospital, Washington DC.

Post op: Gleason 9 (4+5). 15% of prostate involved. Stage: pT3a. Negative margins. Lymph node and nerve samples taken, and appeared to be cancer free.

July 2008 - Aug 2009: PSA testing. Undetectable thru 15 months. 


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 8/25/2009 10:26 AM (GMT -6)   
kcrag,
I am with your wife on this. But what is missing is the same information on RRP patients. If a guy has stage 3 disease and/or > 8 Gleason after RRP, I doubt that there is much recognizable difference between the two procedures. If it is it's very small. High risk patients will have high risk results. For what the robot gives us in healingtime, it is great, but it isn't for everybody either. Some can't do it because of surgical history, size of the gland, or availablity. In those cases RRP can be equally effective.

Tony
 Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 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 (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2461
   Posted 8/25/2009 10:00 PM (GMT -6)   
kcrag,
I wish he had included how many of his patients had positive margins and what role did that play in the outcome.
Age: 67 at Dx on 12/30/08
PSA 9/05 1.15; 8/06 1.45; 12/07 2.41; 8/08 3.9; 11/08 3.5 free PSA 11%
2 cores out of 12 were positive Gleason (4+4) and (4+5)
Negative CT scan and bone scan done on 1/16
Robotic surgery performed 2/9/09 Dr Fagin, Austin TX
Pathology report:
Prostate weighed 57 grams size:5.2 x 5.0 x 4.9 cm
Posterior lateral lesions measuring 1.5 x 1.4 x 1.0 cm showing focal capsular penetration over a distance of 3mm.
Prostatic adenocarciroma accounts for approx. 10-20% of the hemisphere.
Gleason 4+4
both nerve bundles removed,
pT3a Nx Mx, Negative margins
seminal vesicles clean, lymph nodes: not dissected
continent after 4 months
8 weeks PSA test 4/7/09 result <0.1
5 months PSA test 7/9/09 result <0.1


kcragman
Regular Member


Date Joined May 2008
Total Posts : 241
   Posted 8/26/2009 9:47 AM (GMT -6)   
Ed C.

28 (38%) of his 73 high risk patients had positive margins. At the time of this paper (written in late 2008-early 2009) 10 had experienced recurrence, and 18 had not. He does not speak to positive margins as a significant recurrence marker. He only says that "...our 38% positive margin rate compares favorably to those reported for open RP in high-risk patients, which range from 38-56%." And then he gives the references.

Also, 42 patients had extracapsular extension. 15 experienced recurrence and 27 did not.

I hope this helps.

kcragman
Age: 53; 52 at DX
March 2006: PSA 2.5
Dec 2007: PSA taken for insurance application. I did not see the results until late
Jan '08 - after I was rejected. Their lab said PSA 4.5.
Feb 2008: PSA 3.7.
March 2008: Biopsy. Gleason 7 (4+3) 12 cores taken. 5 on the left side were
cancerous and the 6th was suspect.
May 5, 2008: Da Vinci robotic laparoscopy at GW Hospital, Washington DC.

Post op: Gleason 9 (4+5). 15% of prostate involved. Stage: pT3a. Negative margins. Lymph node and nerve samples taken, and appeared to be cancer free.

July 2008 - Aug 2009: PSA testing. Undetectable thru 15 months. 

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