what precludes surgery

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Veteran Member

Date Joined Nov 2009
Total Posts : 7187
   Posted 11/27/2009 11:16 AM (GMT -6)   
After one has a biopsy, there are results. So what kind of result takes surgery off the table as an option?
If there is extracapsular penetration, is that a deal breaker?
Or does it depend on the # cores?
Is Gleason 8 a deal breaker? What about Gleason 9 or 10?
PSA-- 3/08--2.90;  8/09--4.01; 11/09--4.19 (Free PSA 24%), this after 45 days on cipro!
History of BPH/prostatitis.
Awaiting results of my PCA-3 test which will determine whether a biopsy is in my immediate future. Just in: BAD NEWS: PCA-3 = 75.9! Cut-off is 35. Biopsy scheduled for 11/30

Veteran Member

Date Joined Oct 2006
Total Posts : 1210
   Posted 11/27/2009 11:43 AM (GMT -6)   

Hi Mel,

My Surgeon told me before the operation that if he finds that the cancer has spread to the lymph nodes he would stop the operation. So I guess if the cancer is so far advanced that it has spread to other parts of the body, an operation is probably pointless. Lukely, he completed the removal of my prostate.

All the best to you.

Born Sept 1936
PSA 7.9
-ve DRE
Gleason's Score 3+4=7, 2 of 8 positive
open RP 28 Nov 06 (nerve sparing), Post op staging T3a
Gleasons still 3+4=7
Seminal vesicles and lymph nodes clear
Catheter out 15 Dec 06, Dry since 11 Feb 07
All PSA tests in 2007 (4) <.04
PSA tests in 2008: Mar.=.04; Jun.=.05; Sept.=.08; 3 days before Rad Start=0.1
Salvage RT completed (33 sessions - 66 Grays) on the 19th Dec., 08.
PSA in Jan., 09, = 0.05; July 09, <0.04

Veteran Member

Date Joined Sep 2009
Total Posts : 3172
   Posted 11/27/2009 11:51 AM (GMT -6)   

Patients considering surgery among their treatment options should consult the Partin and Narayan Tables, Bluestein predictions and other predictive algorithms to get a sense of risk for extracapsular extension as well as lymph node involvement.

The Partin tables are probably the best known, and are compiled by analyzing thousands of pathology specimens removed at the time of radical prostatectomy (RP; surgery) to determine the probability of organ-confined disease, capsular penetration, seminal vesticle and lymph node involvement.  The Tables (and more info) can be found online at http://www.prostate-cancer.org/education/riskases/partin.html.

Partin Table inputs include PSA, Gleason score and clinical stage.  Of course, the Gleason score comes from the biopsy.  The PSA value should be the maximal PSA prior to any treatment.

Here’s the bottom line…if you know you have spread, then surgery makes no sense whatsoever because surgery only removes the prostate.  If you go forward anyhow, you will suffer the side effects of surgery AND will have not succeeded in removing the cancer (thereby requiring some secondary treatment, like radiation).  If you have known spread, radiation is probably a better first treatment because it also treats an area around the prostate.  The problem is that if you’re in a “gray zone” you won’t know if you have spread or not…thus the purpose of the Partin Tables, to give you an indication of your probabilities.

Number of cores simply refers to the number of biopsy samples taken, one by one, by the doctor.  Many consider this a needle in a haystack.  Dr Patrick Walsh has written that each sample is only 0.01% of a normal sized prostate.  The typical number of cores taken is 12, but since it’s a needle in a haystack, more is better.  Taking 20 cores is becoming more common as a result.  I encourage that you talk to your doctor about taking a maximum number.

John T
Veteran Member

Date Joined Nov 2008
Total Posts : 4171
   Posted 11/27/2009 12:24 PM (GMT -6)   
Biopsies are a poor indicator to use in eliminating surgery. Extra capuslar extension would eliminate surgery. Also what many do not know is that the location of the tumor plays a very important part in whether surgery will work or won't. If the tumor is near the seminal vescliles, is in the Apex near the edge or close to the bladder neck or in the transiton zone these are all probablimatic for surgery.
View Dr Bahn's presentation on Color Doppler at pcref.org and he has many examples of tumor locations that would not be good candidates for surgery. Anyone choosing surgery without knowing the precise location and volume of his tumor is taking a huge risk.

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.


Veteran Member

Date Joined Jul 2008
Total Posts : 981
   Posted 11/27/2009 12:31 PM (GMT -6)   
Seriously just WAIT until your biopsy and its results before you begin to panic again. Besides a normal biopsy still leaves much out. By far a 3D saturation biopsy would tell you much more.

Diagnosed 11/08/07 - Age: 58 - 3 of 12 @5%
Psa: 2.3 - 3+3=6 - Size: 34g -T-2-A
2/22/08 - 3D Mapping Saturation Biopsy - 1 of 45 @2% - Psa:2.1 - 3+3=6 - 28g after taking Avodart - Catheter for 1 day -Good Candidate for TFT(Targeted Focal Therapy) Cryosurgery(Ice Balls) - Clinical Research Study
4/22/08 - TFT performed at University of Colorado Medical Center - Catheter for 4 days - Slight soreness for 2 weeks but afterward life returns as normal
7/30/08 - Psa: .32
11/10/08 - Psa.62 - Not unexpected bounce after the 80% drop the quarter earlier. Along with urine flow readings, an acceptable amount left in bladder measured by sonic. Results warrant skipping third quarter tests, and to return April, 2009 for final biopsy scheduled to
complete clinical research study 
April 2009 12 of 12 Negative biopsy
10/12/09 - Psa .30

Post Edited (realziggy) : 11/27/2009 11:38:12 AM (GMT-7)

Regular Member

Date Joined Mar 2009
Total Posts : 260
   Posted 11/27/2009 1:37 PM (GMT -6)   
My brother recently had a positive biopsy. He came back with a Gleason of 4+4=8 several samples, two of which were 100%. His DRE was positive with a few small nodules found, and his PSA is 10. His urologist told him he was a high risk for surgery because of these factors and because of his age. He'll be 72 in Feb of next year.

The plan is radiation using IGRT (never heard of this) following the results of CT scan and bone scan.

Age 70, First ever PSA 7.8 taken June 2008, Biopsy July 2008, 10 of 12 cores positive, Gleason 3+3=6
da Vinci surgery December 10, 2008, catheter removed December 29 2008
St. Lukes Hospital, Bethlehem, Pa.
Dr. Frank Tamarkin
Prostate weight 73.0 grams, Gleason 3+3=6, stage pT3a
Tumor locations: right anterior apex, right posterior apex to mid
left anterior mid to base, left posterior apex to mid
extensive perineural invasion in right anterior apex, right and left posterior apex to mid
seminal vesicles negative
Four PSA tests undetectable, latest Oct 30

Elite Member

Date Joined Oct 2008
Total Posts : 25356
   Posted 11/27/2009 2:22 PM (GMT -6)   
You age, your weight, your current medical condition, and even your past medical history including previous surgeries could all rule out surgery.

I agree with realziggy, if you are going to have a biopsy, and you dont want to keep repeating them until they find gold, then a good satuation biopsy is the ticket.

But Mel, once again, you have jumped way over the fence and fretting about the unknown.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out  38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - began IMRT SRT - 39 sess/72 gys cath #8 33 days, 11/2- SP Cath #9 in place

Veteran Member

Date Joined Sep 2009
Total Posts : 3172
   Posted 11/27/2009 2:25 PM (GMT -6)   

As a demonstration, using pa69's brother's stats in the Partin tables, these predictions could be drawn:

  • organ confined:  13%
  • capsular penetration:  56%
  • seminal vesicle involvement:  16%
  • lymph node involvement:  13%

[I used the table for 6.1-10ng/mL, and stage T2c]

Using these tables, his urologist would have concluded that he was high risk for surgery...because of the low likelihood that the PC was organ confined.

Veteran Member

Date Joined Dec 2008
Total Posts : 3149
   Posted 11/27/2009 6:05 PM (GMT -6)   
Nothing has to be taken off the table with surgery, still done many times on uncureable patients. Generally (surgery) (PCa)if found in lympnodes which should have been sampled during surgery, and quickly analyzed, prior to gland removal, ..I have heard a surgeon say he did not sample them on lower Gleasons patients (6-7's), then if found the patient can be given the option to finish the surgery even if  PCa had spread...for the reason of "debulking" your overall tumor burden (in other words get rid of alot but not all your PCa) or sew you back up with gland intact and suggest hormone therapy, radiations, cryo, hifu, and other options for possible control.

No guarantees on cured PCa at any level (per se), not trying to scare anyone, but the truth of the matter is  usually not frankly given to patients and can be highly sugar coated. Failure rate is mentioned by Dr. Barken and others (long term 5-10 yrs.+) likely 25-30% or higher. Same can be said for other treatments or worse, alot of worse stats patients don't even go surgery or some docs will tell them 'you are not a reasonable candiated for successful surgery'. So the non-cured rate in radiation might and probably does look worse, but it also has a much worse patient base of high risk folks within it, which would skew a direct comparison.
With low stats and indolent PCa levels likely a patient could be cured or do fabulously well (there is maybe 70-75% cure rate with surgery overall, and likely much better numbers on the low or indolent presentations of PCa-90%-???). Not sugar coating anything, we take risks in treating and making decisions on PCa. Alot of imprecise data given to come up with imperfect Partin tables and nomograms, which are also an averages type basis thing...some higher and some lower. Missed biopsies possible, you can have multiple gleason scores within your gland(I have 3 different-7,8,9's)...so very possible to miss a higher one or others, you can have 12-14 variant types of PCa not easily identifiable even by experts, they don't all respond the same or play on a level field either. Thus it is a Jungle, sadly we get to try an navigate within it, even with all the impreciseness.
Not mentioning this to discourage any treatment or ones choices, but to open the curtains and make awareness of the whole situation, so when a possible doc guarantees a cure or such, then perhaps you can further your questions and find out what types of answers and frankness you are getting, which may indicate what type of person you are dealing with and overall truthfulness is in the situation.  The other option is not to care what is said to you and hope all is good, which is a choice and taken by enough people on any treatment type. Only you the patient has to walk the walk, live with whatever side effects and issues thereafter, alot of things are not told straight up or mentioned, alot of times it is what is not said that is telling information, too.  Anyway brother Compiler, don't rush into this and realize that PCa can take along time to get to where it is discovered in patients, you have time to analyze, study, compare, get opinions and postphone instant treatments in most cases....although how many docs will tell you that straight up????  Many are more than anxious to sign you up even on the spot, how do I know?.....get 8 opinions and see what you learn about the process end of it.

Post Edited (zufus) : 11/29/2009 5:46:11 AM (GMT-7)

Ed C. (Old67)
Veteran Member

Date Joined Jan 2009
Total Posts : 2457
   Posted 11/28/2009 5:34 PM (GMT -6)   
As you can see from my signature, I was diagnosed with Gleason 8 and 9. I opted for surgery. My final pathology was Gleason 8. So far I have had 3 PSA tests and 3 undetectable results. I'm hoping for the best but if it does rise then radiation is my second bullet.
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
8 months PSA test 10/9/09 result <0.1

Veteran Member

Date Joined Apr 2008
Total Posts : 1131
   Posted 11/28/2009 7:57 PM (GMT -6)   
I had a gleason 7 upgraded to 8 after surgery. I opted for surgery because that is what I wanted. Also, if the cancer comes back I can opt for radiation. sort getting 2 bites of the prostate. I have been very happy with my recovery. I still suffer from ED but I had cancer....
Age 49
occupation accountant
PSA increased from 2.6 to 3.5 in one year
biopsy march 2008 - cancer present gleason 7
Robotic Surgery May 9, 2008 - houston, tx
Pathology report -gleason 8, clear margins
12 month  PSA <.04 (low as the machine will go)
continent at 10 weeks (no pads!)
ED is still an issue but getting better

Veteran Member

Date Joined Apr 2008
Total Posts : 1131
   Posted 11/29/2009 9:08 AM (GMT -6)   
How old are you? Age might play a factor and overall health could be a factor as well.
Age 49
occupation accountant
PSA increased from 2.6 to 3.5 in one year
biopsy march 2008 - cancer present gleason 7
Robotic Surgery May 9, 2008 - houston, tx
Pathology report -gleason 8, clear margins
12 month  PSA <.04 (low as the machine will go)
continent at 10 weeks (no pads!)
ED is still an issue but getting better

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