Question re nomograms

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Zen9
Regular Member


Date Joined Oct 2009
Total Posts : 310
   Posted 12/21/2009 9:27 PM (GMT -6)   
Please help me think this through.

My post-op pathology report said I had four tumors (all contained). The largest was a 3 + 3. The second largest was a 4 + 3. The other two were very tiny and were 3 + 3.

M. D. Anderson told me only that I was 4 + 3 and should enter that on any post-op nomograms. I only found out about the four tumors, their sizes, and their Gleason scores when I paid the extra fee to get a copy of my path report.

You probably see where I am going with this ... if my four tumors were all one tumor, it would be a Gleason 3 + 4 because the majority of my malignant tissue was grade 3 and the rest was grade 4. [Let's put aside all issues about the subjectivity of Gleason scores and potential institutional incentives to report a 4 rather than a 3. Let's also put aside issues like the location of the tumors in the prostate.]

Why shouldn't I consider myself a 3 + 4, or actually an ex-3 + 4? It makes a big difference in terms of prognosis. Is there a fault in my logic?

And yes, I have asked this of my doctor (actually, his PA, since I can't get to my doctor) only to be told, "You're a 4 + 3, that's it."

Thanks in advance.

Zen9
No family history of PC.  PSA reading in 2000 was around 3.0 .  Annual PSA readings gradually rose; no one said anything to me until my PSA reached 4.0 in September 2007, at which point my internist advised me to see a urologist.   
Urologist advised a repeat PSA reading in six months = 4.0 .  Diagnosed May 2008 at age 56 as a result of 12 core biopsy.  Biopsy report by Bostwick Laboratories = Gleason 3 + 3. 
Interviewed two urologists - the one who did the biopsy and another - the latter had the biopsy slides re-examined = Gleason 3 + 3. 
Then went to M. D. Anderson Cancer Center in Houston in July 2008 and met with a urologist and a radiologist.  Biopsy slides re-examined yet again, this time by MDA's internal pathology department = Gleason 3 + 4.   
Chose da Vinci surgery over proton beam therapy; surgery performed at M. D. Anderson Cancer Center on August 15, 2008.  Post-operative pathology report = four tumors, carcinoma contained in prostate, clean (negative) margins, lymph nodes clear, seminal vesicles clear.  Gleason = 4 + 3. 
Minor temporary incontinence; current extent of ED uncertain due to lack of sexual partner; refused treatments for ED as being pointless under the circumstances. 
PSA readings: 
November 2008 = <0.1 ["undetectable"]
June 2009 = <0.1   
December 2009 = <0.1
 


geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 12/21/2009 9:39 PM (GMT -6)   
I guess that I would say that the nomograms are based on a particular way of interpreting the data -- that is, counting each tumor separately. I can't be sure, but I would guess that your idea has been tested and not found to be statistically as strong.
Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3+4=7
CAT scan, Bone scan 1/09 both negative.

Robotic surgery 03/03/09 Catheter Out 03/08/09
Pathology: Lymph nodes & Seminal vesicles negative
Margins positive, Capsular penetration extensive Gleason 4+3=7
6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.
10 weeks: no pad at night -- slight leakage day/1 pad.
3 mo. PSA 0.0 - now light pads
6 mo. PSA 0.00 -- 1 light pad/day


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 12/21/2009 9:39 PM (GMT -6)   
From what I have learned from my medical staff, whether you have 1,2,3, or even 4 seperate tumors like you have, the outcome is based on the worse of the mix, which in your case, is a 4+3. So that is why you would use it in the nomograms mentioned. The tenacity and unpredictable nature of the "4" cancer cells in the mix is the determining factor in your mix. Even though 3 of your 4, were Gleason 6, the one that is Gleason 7 will be the one that most effects your outcome.

This is based on my uro/surgeon's opinion and one of the three radiation oncologists I consulted with.

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
Post SRT PSA:
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 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 in place


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7211
   Posted 12/21/2009 9:46 PM (GMT -6)   

Let me take a shot at an answer. By DEFINITION, your Gleason score is the worst of all the individual Gleason scores. PERIOD. That's the definition.

 

Now, the nomographs are based on the experiences of thousands of people based on their Gleason scores and other inputs. If you want the nomograph to be accurate, you have to stick with the definitions used.

 

Mel


63 years old
PSA-- 3/08--2.90;  8/09--4.01; 11/09--4.19 (Free PSA 24%), this after 45 days on cipro! DREs have always been normal.  
History of BPH/prostatitis. PCA-3 test: 75.9 (bad news, guaranteeing I have to do....): Biopsy on 11/30/09. Result of biopsy:

5 out of 12 cores positive. Gleason 4+3. More specifically: 2 cores were 3+3 (one 5% and the other 30%) on one side. On the other side:2 cores are 4+3 (5%)--1 core 3+4 (30%) no peri-neural invasion. prostate is 45 grams. Stage: T1C

 Latest: Surgery with Dr. Menon at Ford Hospital, set for 1/25/10

 


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 12/21/2009 11:10 PM (GMT -6)   

This Gleason grading stuff is way above my paygrade.

However, in my own case, a Gleason 9 with and EPE still is a pretty good number, so I am not going to quibble over it being a 5 + 4 or a 4 + 5.

In your specific case, with clear margins, seminal vesicals, lymph nodes, etc., and a year of undetectables, aren't you getting caught up in a line of needless concern?  By all indications, your Gleason 3 +4 or 4 + 3 was totally removed in the surgical option.

Until you see a rise in PSA, I would say let the nomograms be darned.  You are in a great position to live to a ripe old age and die of some other malady. 

Goodlife

 


Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injections


Zen9
Regular Member


Date Joined Oct 2009
Total Posts : 310
   Posted 12/22/2009 10:13 AM (GMT -6)   

Thank you all.

Goodlife, I am not really worried about it, more curious than anything.  I assure you I do not spend my days running nomograms!

Compiler, your answer makes much sense.  If you're working a statistical (or any other kind of mathematical) algorithm, you must play by the rules for that algorithm if you want to get anything useful out of the exercise.

Zen9   


No family history of PC.  PSA reading in 2000 was around 3.0 .  Annual PSA readings gradually rose; no one said anything to me until my PSA reached 4.0 in September 2007, at which point my internist advised me to see a urologist.   
Urologist advised a repeat PSA reading in six months = 4.0 .  Diagnosed May 2008 at age 56 as a result of 12 core biopsy.  Biopsy report by Bostwick Laboratories = Gleason 3 + 3. 
Interviewed two urologists - the one who did the biopsy and another - the latter had the biopsy slides re-examined = Gleason 3 + 3. 
Then went to M. D. Anderson Cancer Center in Houston in July 2008 and met with a urologist and a radiologist.  Biopsy slides re-examined yet again, this time by MDA's internal pathology department = Gleason 3 + 4.   
Chose da Vinci surgery over proton beam therapy; surgery performed at M. D. Anderson Cancer Center on August 15, 2008.  Post-operative pathology report = four tumors, carcinoma contained in prostate, clean (negative) margins, lymph nodes clear, seminal vesicles clear.  Gleason = 4 + 3. 
Minor temporary incontinence; current extent of ED uncertain due to lack of sexual partner; refused treatments for ED as being pointless under the circumstances. 
PSA readings: 
November 2008 = <0.1 ["undetectable"]
June 2009 = <0.1   
December 2009 = <0.1
 


Worried Guy
Veteran Member


Date Joined Jul 2009
Total Posts : 3732
   Posted 12/22/2009 11:54 AM (GMT -6)   
I'd run it with the 4+3 ( worst case) and then the 3+4 (best case) and figure I was anywhere in between. You then have an option on how you will use the numbers. If you are dating an have to tell your partner something say it can be as good as.... If you are looking for sympathy from your kids then say it can be as bad as....
If you are using it for investment advice and are lending money, always go worst case. If you are asking for a loan, go best case.
Either way your PSA numbers look great.
Jeff
DX Age 56. First routine PSA test on April 8th: 17.8. Start 2 weeks of Cipro to rule out protatitis.
May PSA: 22.6, 3 weeks later: PSA: 23.2.
Biopsy 6/10/09: 7/12 scores positive, Gleason 6=3+3. Bone scan and C/T scan negative.
RP DaVinci -7/21/2009 @ Univ of Roch Medical Center
Left nerve gone, right partial spared.
Catheter removed - 7/31/2009 Pathology report received:
Gleason 3+4=7, Tumor size: 2.5 x 1.8 cm, location: both lobes and apex.
Extraprostatic extension present; Perineural invasion: present, extensive.
No Malignancy in Seminal Vesicle, vasa deferentia, lymph nodes 0/13
Prostate mass 56 grams. Pathologic Stage: pT3aN0MX
Post Surgery Status:
Potency - 12/11 5 months, Still no activity, zip. Using pump daily since 11/11. No effect with 20 mg of Cialis or 100 mg of Viagra. Shots next?
Incontinence - 8/20 4 full pads per day
.. 9/7 3-4 full pads per day (I'm going to try cutting down on fluids. Bad idea. I know.)
. 9/27 2 months: Still 3 pads per day.
11/14 4 months: Still 3 pads per day. 420ml/day, 91 um leak.
12/11 5 months: Still 3 pads per day. 400-450ml/day Experimenting with Nyquil for 10 days: Can sleep through the night but withdrawal is bad. Stopped 12/20.
Post Surgery PSA - 9/3 6 weeks - 0.05; 10/13 3 months - 0.04 undetectable.


Radical
Veteran Member


Date Joined Mar 2009
Total Posts : 739
   Posted 12/22/2009 3:25 PM (GMT -6)   
If you want to take this one step further, you can also calculate or ask the Doc about your  Gleason differencial, ie how much 4 or 3 do you have in that one foci.
As you can see I am a 60/40% guy, 60% grade 4 and 40% grade 3.  As far as I am concerned there is not alot of differnce between 4+3 and 3+4 when it is very close the the halfway mark,in percentages. And how good was the Pathologist that estimated the percentages under the microscope ? I gues what I am saying is, in my case I considerate it pretty much a line ball.  You may be in the same boat.
If it was more like 90% 4 and 10% 3, then I can acknowledge the difference.
Cheers ..........................Kev
Age 51yrs
6 out of 8 cores positive 3 X 60% / 3 X 10%
PSA 4 Gleason Score 3+4=7 Stage T1c
Robotic Surgery 24/12/08
Upgrade Gleason Score 4+3=7 Gleason Differential 60%/40%
Stage T2c Three small foci total volume <10%
Neg Margins and Nodes
Nil - Extraprostatic Extentions
Dry less than 1 week. ED- okay with Meds.
PSA at 12mths no change remains 0.03
"Everyday in Everyway I get better"


Radical
Veteran Member


Date Joined Mar 2009
Total Posts : 739
   Posted 12/22/2009 3:28 PM (GMT -6)   
Oh, forgot to mention, I to had 3 separate foci, 1 @ 3+3, 1 @ 4+3, and the final one @ 4+3, and thats the one they work with..............Thats Life.
Age 51yrs
6 out of 8 cores positive 3 X 60% / 3 X 10%
PSA 4 Gleason Score 3+4=7 Stage T1c
Robotic Surgery 24/12/08
Upgrade Gleason Score 4+3=7 Gleason Differential 60%/40%
Stage T2c Three small foci total volume <10%
Neg Margins and Nodes
Nil - Extraprostatic Extentions
Dry less than 1 week. ED- okay with Meds.
PSA at 12mths no change remains 0.03
"Everyday in Everyway I get better"


Zen9
Regular Member


Date Joined Oct 2009
Total Posts : 310
   Posted 12/22/2009 4:54 PM (GMT -6)   

NotHard,

That's a good point.  My path report doesn't give percentages. 

But as goodlife correctly says, in my case it's not worth the extra aggravation and expense to try to track down something that is of academic interest only.  My PSA will either start to rise or it won't.  If it does, whether I could construct a plausible argument that I was a 3 + 4 doesn't really matter.  If it doesn't, whether I could construct a plausible argument that I was a 3 + 4 doesn't really matter. 

Just a case of unquenchable curiousity, I guess.  rolleyes

Zen9


No family history of PC.  PSA reading in 2000 was around 3.0 .  Annual PSA readings gradually rose; no one said anything to me until my PSA reached 4.0 in September 2007, at which point my internist advised me to see a urologist.   
Urologist advised a repeat PSA reading in six months = 4.0 .  Diagnosed May 2008 at age 56 as a result of 12 core biopsy.  Biopsy report by Bostwick Laboratories = Gleason 3 + 3. 
Interviewed two urologists - the one who did the biopsy and another - the latter had the biopsy slides re-examined = Gleason 3 + 3. 
Then went to M. D. Anderson Cancer Center in Houston in July 2008 and met with a urologist and a radiologist.  Biopsy slides re-examined yet again, this time by MDA's internal pathology department = Gleason 3 + 4.   
Chose da Vinci surgery over proton beam therapy; surgery performed at M. D. Anderson Cancer Center on August 15, 2008.  Post-operative pathology report = four tumors, carcinoma contained in prostate, clean (negative) margins, lymph nodes clear, seminal vesicles clear.  Gleason = 4 + 3. 
Minor temporary incontinence; current extent of ED uncertain due to lack of sexual partner; refused treatments for ED as being pointless under the circumstances. 
PSA readings: 
November 2008 = <0.1 ["undetectable"]
June 2009 = <0.1   
December 2009 = <0.1
 


Radical
Veteran Member


Date Joined Mar 2009
Total Posts : 739
   Posted 12/22/2009 4:57 PM (GMT -6)   
Zen,
 
Yes I totally agree, there is no court of appeal here, you have got what you got, and I have got what I got, (actually we are very similar in stats), so far so good, lets keep those zero's rolling in.
 
Oh the gleason differencial, actually was on my path report, thats how I know about it.
 
Cheers....................Kev
Age 51yrs
6 out of 8 cores positive 3 X 60% / 3 X 10%
PSA 4 Gleason Score 3+4=7 Stage T1c
Robotic Surgery 24/12/08
Upgrade Gleason Score 4+3=7 Gleason Differential 60%/40%
Stage T2c Three small foci total volume <10%
Neg Margins and Nodes
Nil - Extraprostatic Extentions
Dry less than 1 week. ED- okay with Meds.
PSA at 12mths no change remains 0.03
"Everyday in Everyway I get better"


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4235
   Posted 12/22/2009 5:03 PM (GMT -6)   
Nomograms are only useful in predicting the total outcome of a population with given stats. They in no way predict the outcome of any individual or individual event. A wise prof once told me "On the average everyone in the world has one tit and one ball".
The gleason grade was built on a 90% accurracy rate, 90% of pathologists will agree on a grade. So right off you are imputing estimates.
There was a recent post in which nomograms showed higher doses of radiation lead to lower cure rates, and we all know that this is not likely.
They are useful in giving broad probabilities for an outcome.
JT

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.

JohnT


zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 12/22/2009 8:50 PM (GMT -6)   
Right with that idea John T, it is an averages thing...base your total decision on averages??? Not to mention you are basing your pathology numbers on what was found....they could have missed other spots that could be worse that are unknown. I am a beautiful example of having found 12 of 12 positive biopsies all 75-95% PCa...(full gland???maybe), guess what?? Found 2 sets of different Gleasons on like both sides, about equal in parameters. Found Gleason 7, 8, 9's I suppose it would have been possible they missed a Gleason 10 or 6 in the mix.
So, it is possible to have multiple Gleasons going on in your gland, it could go undetected depending upon biopsies findings and accuracy. ALso whom reviews your pathology...experts are ones you should be putting your faith into, maybe 8-10 of these docs are widely known. So after all that, you still are an averages thing....PCa is more insane as your try to make it definitive and sane in our analysis. I won't mention the 14 variant types of PCa, that sometime are never detected...and yeah that throws a fork into the road, some of those are aggressive in nature and less predictable or treatable. So is it complex??? Go figure.
Youth is wasted on the Young-(W.C. Fields)


Geebra
Regular Member


Date Joined May 2009
Total Posts : 476
   Posted 12/22/2009 9:05 PM (GMT -6)   
I totally agree with goodlife. But if you must think about this, think this way. If you only had one tumor, the one with G7, you would use the nomogram with that number. Now you add more cancer (granted, it's lower grade), it cannot make things any better, can it?

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4235
   Posted 12/22/2009 9:54 PM (GMT -6)   
The major things that influence outcome such as tumor volume and tumor location are not in the nomograms. these will influence your outcome more than the data input into the nomograms.
JT

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.

JohnT


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 12/22/2009 11:04 PM (GMT -6)   
Hey Zufus,

If you had a 6 and a 10, you would have a heck of a poker hand I think !

Goodlife
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injections

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