Another question about surgery - lymph nodes

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rob2
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Date Joined Apr 2008
Total Posts : 1132
   Posted 3/20/2010 8:27 AM (GMT -6)   
Hero asked about the doctor's success rate with surgical margins.  I have another question.  My doctor only removed one lymph node and see where others removed many to test for cancer.  Did any of you ask how many lymph nodes the doctor would remove.  Also, hindsight, shouldnew patients ask the doctor to remove more than one?
 
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
20 month  PSA <.04 (low as the machine will go)
continent at 10 weeks (no pads!)
ED is still an issue but getting better


Herophilus
Veteran Member


Date Joined Sep 2009
Total Posts : 664
   Posted 3/20/2010 8:42 AM (GMT -6)   

My doctor removed a total of 14 lymph nodes. He took 4 paraprostatic and 10 pelvic. However the same physician did my brothers surgery and a total of only 6 were taken all from the right pelvis (brother had right side prostate involvement). What I understand is that it really isn’t the easiest thing to do. I also understand that some folks have lymph edema of the lower extremities post surgery I assume from disrupting the lymph drainage system. So I guess that you can only take so much tissue. To answer your question Not only did I not ask about the surgical margin rate I did not even think to ask if lymph node harvesting would be a component of my surgery. I went in understanding the right side would be widely excised. I went in with the understanding that the surgeon would do all he could to “get it all” which actually is a way of saying trying to avoid any possibility of a positive margin. It worked for me but failed in my brother case. I mostly wanted to get discussion started with my original question because of the evidence that was in the two referenced articles. Thanks very much for your follow-up question. I’ll have another thing to ponder while I’m on my tractor this afternoon.

Hero


Age 51, PSA 08/31/2009= 6.8, DRE Neg.
Biopsy 9/24/09 =10 of 12 positive. Gleason 6. involving up to 75%
da Vinci at Wash U, Barnes on 11/02/09
Modified Pathology, Gleason 4 + 3 = 7. Gleason 7 present throughout Prostate.  Negative surgical margins
4 of 4 periprostatic Lymph Nodes Negative, 10 of 10 pelvic Lymph Nodes Negative. Seminal Vesicles tumor free. No prostate extension
Post-op PSA 12/10/2009, Undetectable
12/12/2009, Pad Free and Started jogging.


daveshan
Regular Member


Date Joined Jan 2010
Total Posts : 363
   Posted 3/20/2010 9:25 AM (GMT -6)   
I asked my Dr to do all she could to map the progress of my disease. She removed seminal vesicles and 9 lymph nodes. Didn't ask about the locations they were removed from.
Diagnosed 12-09 age 55
07-06 PSA 2.5
01-08 PSA 5.5 (PCP did not tell me of increase or schedule follow-up!!!!)
09-09 PSA 6.5 Sent for consult with Urologist
11-09 Consult, scheduled for biopsy, found out about PSA from '08 (yes I was pissed)
12-09 Biopsy, initial Gleason 9 (4+5) later reduced to 8 with tertiary 5, ain't much but I'll take it.
01-10 Bone Scan, "appears negative"
03-01-10 RRP by Dr Sejal Quale Durango CO, no naked eye evidence of spread, Vesicles and lymph nodes taken for microscopic exam.

03-16-10 Removal of cath' and pathology results of samples
4+4 with tertiary 5
Invasion of left Seminal vesicle
9 lymph nodes taken all negative
Tumor staging pT3b NO MX


John T
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Date Joined Nov 2008
Total Posts : 4269
   Posted 3/20/2010 12:37 PM (GMT -6)   
A study coming out of Germany and Holland last year found that there are two distinct paths prostate ca takes when spreading to the lymphnodes. Surgical removal only samples one of these paths so there is a 50%chance that lymph node PC will be detected by surgical removal. This is especially important if there is seminal vesicle involvement.
JohnT

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


tatt2man
Veteran Member


Date Joined Jan 2010
Total Posts : 2845
   Posted 3/20/2010 12:44 PM (GMT -6)   
ROB - with me a number of lymph nodes were removed and dissected - it appears it was on the basis of location near the positive margin and the coloring, condition of the nodes ( yellow grey) - and yes, as noted before, I was concerned with lymphedema ( note: weight is down from 255 to 245 ... only 45# to go..)
- I betcha never thought the prostate was as complex as all this before PCa... I learn something new each day!

hugs
BRONSON
.................
Age: 54 - gay - with spouse, Steve - 59
PSA: 04/2007- 1.68 - 08/2009 - 3.46 - 10/2009 - 3.86
Confirmation of Prostate Cancer: October 16, 2009 - 6 of 12 cancerous samples , Gleason 7 (4+3)
Doctor: Dr. Mohamed Elharram -Urologist / Surgeon - Peterborough Regional Health Centre
Radical Prostatectomy Operation: November 18, 2009 , home - November 21, 2009
Post Surgery Biopsy: pT3a- gleason 7 - extraprostatic extension - perineural invasion - prostate weight - 34.1gm -
ED Prescription: Jan 8/2010 - started daily 5mg cialis - girth back to normal -but not much length - will go for trimix in April when I see doc
Incontinence: 3-5 pads/1-2 clothes changes/day- finally seeing improvement - March 3, 2010 - week 14 after surgery -
location: Peteborough, Ontario, Canada
Post Surgery-PSA: to be announced - April 8, 2010
............


142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7084
   Posted 3/20/2010 1:07 PM (GMT -6)   
They took & examined 12 lymph nodes distributed on both sides from me - the small channels were involved, but the nodes were still clean.
There was no question, they just said that was what they would be doing.

Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2461
   Posted 3/20/2010 1:28 PM (GMT -6)   
My surgeon didn't remove any. When I asked him about it he said that they looked smooth and he didn't think it was necessary.
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 in circumference.
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
11.5 months test 1/21/10 result 0.004


livinadream
Veteran Member


Date Joined Apr 2008
Total Posts : 1382
   Posted 3/20/2010 3:08 PM (GMT -6)   
I had 13 removed and 2 on the left side tested positive and 1 on the right side. Since my surgery was aborted I have no idea where else my cancer may be but I am living large everyday so I guess ADT3 and radiation did the trick. Well for now anyway.

peace to all
dale
My PSA at diagnosis was 16.3
age 47 (current)

http://www.caringbridge.org/visit/dalechildress

My gleason score from prostate was 4+5=9 and from the lymph nodes (3 positive) 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 .016
PSA Mar 30th, 2009 is .02
PSA July 28th 2009 is .01
PSA OCt 15th 2009 is .11
PSA Jan 15th 2010 is .13

Testosterone keeps rising, the current number is 156, up from 57 in May

T level dropped to 37 Mar 30th, 2009
cancer in 4 of 6 cores
92%
80%
37%
28%


deer hunter
Regular Member


Date Joined Jan 2010
Total Posts : 250
   Posted 3/21/2010 7:18 AM (GMT -6)   
as far as lymps nodes go i think it is up to the dr. as to remove or not.i still think .there are several ways that PC can escape the prostate ,surgical margins ,seminal vessels , and perineural invasion [most drs. do not like to admit] and lymp nodes. that's my take ..on things .P>S> my lymps nodes could not be found at surgery so who knows dr. said he went as deep as he could on my right side to find them but could not.
DEERHUNTER
dx age 57 01/06 open RP 4/06 psa in 01/06 8.1  surgery path report Gleason 3+4=7 poorly differentiated  tumor was 90%involved in both lobes surgical margins postive. in the right apex and right radial margins tumor grade G3  perineural invasion present high grade of PIN found  T2c NX MX PSA 0706  .01 10/06 .02 01/07 .03 04/07 .04  06/07 .05  07/07 .08 07/07 bone scans pelvic ct neg. 08/07 proscintic scan neg.9/07 psa.10 net with rad onc. wanted to do SRT but i did not do it 10/07  saw a new dr at Emory University [my old dr urg. suggested second opinion ]  bone scans negs ct scans pelvics neg. biopies of the bladder and adrinal glands neg.another proscintic scan neg.12/07 Psa .11 clinial trial Emory injected with protons to try and find the cancer cells no luck 3/08 psa .17 06/08 psa .23 psa 09/08 psa .32 12/08 psa .39 3/09 psa .39 6/09 psa .43  meet with medical onc. he said  i might have waited to long to start SRT 7/09 psa .50  another bone scan ct scan all neg.MRI neg. meet rad. psa the last of 7/09was .55 onc. 7/09 started casdex 50mg 1 day for 30 days 2 shots of lupron started rad treament 10/09 40 treatments 75 gm 12 shots each time all aroud pelvic finished 12/09  psa .07 and psa 01/10.05 next dr visit 03/10 wait and see 3/10 psa.05


zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 3/21/2010 11:13 AM (GMT -6)   
As an observer of this phenomenon on patients and asking a surgeon doc at a seminar what he did for surgeries in general with an answer I could not believe, I would say "question everything and all the time" with PCa, based upon the lack of knowledge/errors of many uro-docs(whom are surgeons too) just on psa velocity, doubling time, biopsy issues,(errors like) prescribing Lupron before giving casodex especially to higher risk patients (because of 'flare' issues), and other less than definitive screenings and some not even running nomograms or Partin tables on patients(the mistakes, errors, lack of propriety)....perhaps you might reach a similar conclusion, do they know exactly what they are doing or are they doing harm either not knowingly or perhaps knowingly playing gineau pig with your lymphnode testings ?(how dark to mention). So, how good are they, as a layperson can you really know? You can think about it for yourselves. I know it is rough to contemplate, you see these variations herein add to them alot of guys never get sampled, what does Dr. Walsh probably say about sampling I would value his opinions as one the better experts in this field? (been long while since I read his book)  Surely someone here can quote him or his thoughts on this protocol...I thought all patients were supposed to get some type of lymphnode(s) sampled before removing the gland..that was the way I remember hearing it back in 2002-2003.

Post Edited (zufus) : 3/21/2010 10:17:01 AM (GMT-6)


brainsurgeon
Regular Member


Date Joined Jul 2009
Total Posts : 137
   Posted 3/21/2010 11:21 AM (GMT -6)   
Nodes in the pelvis are often buried in the fat on the pelvic floor. This makes them hard to evaluate unless they are removed. My doc took 14 out of me and said that was the hard part of the operation. He thinks it is important because he believes that even with no evident node involvement on CT, etc. There can be micro-metastases 15 % of the time. My lower extremity lymphedema is minimal. My legs didn't look that great pre-op either.
70 years old (1939) USA citizen
Prostatic carcinoma dxed June 2009 by PSA (7.0) and then Bx
PSAs yearly since 2001 ranged 1.52 to 7.0. Doubled from 3.5 to 7.0 in one year.
Neg. CT and Bone Scan
4 of 8 biopsies positive (all right side) Gleason Score 3+4=7
Robotic assisted total prostatectomy and node excision July 2009 in Luzern, Switzerland by Dr. A. Mattei in the Kantonsspital. New Gleason was 4+4=8
pT2c G3 pN0 (0/14 nodes +, Margins, etc. clear
Catheter out in 5 days (home in 3 days). No incontinence
Positional neurpraxia in hip and knee resolved 90+% in 5 months.
Potency: beginning tumescence??? at 3 weeks post-op. Still happens at 3 months PO. Nearly usable one month later. At 5 mo. with 100 mg Vitamin V, pretty good. Now beginning 5 mg Cialis daily.
3month PSA less than 0.01, 6 month PSA less than 0.01


142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7084
   Posted 3/21/2010 12:47 PM (GMT -6)   
Zufus,
To brutally summarize from a few pages in Walsh's book (June 2007, 2nd ed. p.273-276), he tells of the process of an early (extra) staging surgery for removal and testing of lymph nodes around the bladder, and how that is not done as much now, only for palpable tumors with Gleason 8 or higher.

He then says with a Gleason 8 or higher, the lymph nodes are very important. He says that "some surgeons no longer do the lymph node dissection at all, because finding positive lymph nodes is - fortunately - so rare these days." He adds "we continue to do lymph node dissections in all patients."

No statement made as to how many nodes are involved in a normal surgery.

rob2
Veteran Member


Date Joined Apr 2008
Total Posts : 1132
   Posted 3/21/2010 1:17 PM (GMT -6)   
142, thanks. I was a gleason 7 at biopsy and gleason 8 based on the pathology report. The doctor took 1 lymph node. One reason I went the surgery route was to test the nodes. The other reason, not based on medical knowledge, is I wanted the cancerous prostate out of me asap!
 
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
20 month  PSA <.04 (low as the machine will go)
continent at 10 weeks (no pads!)
ED is still an issue but getting better


zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 3/21/2010 2:12 PM (GMT -6)   
Interesting 142 (thanks for info) so we know a top guy like Dr. Walsh will sample for certainty(which is what I thought), how many might be based upon his overall assessment. So why are some patients not sampled at all, so are some patients getting a lesser protocol and treatment? (I think it is fair game for questioning). Thanks too, Brainsurgeon (the micro mets seems right on with what Dr. Barken has referred too), it seems like a wise statement maybe that percentage is correct, atleast he mentions such. Logically(my guessing of course.. the closest lymphnodes to the prostate(or first traveling spot) should be first in line as suspect if PCa escapes from lymph-system (not including perinural invasions-which is another means of escape), if that assumption is correct, then why are they not sampled on all patients and quick pathology done during surgery to assess if there PCa beyond the gland and if so...inform the patient as to it being a non-curative scenario..but still could be chosen and many do elect to have it removed to 'debulk' overall tumor burden on the patient even though non-curative, (which this protocol is done on some patients).

Just knowing this from these two examples, do you think patients should have alot more questions about the whole program???? Maybe another reason to get second opinions from leading surgeons for patients considering this modality and ask such questions to hear how they are answered or assessed, etc. Might make a big difference in ones outcomes, depending upon whom you had chosen, something to consider perhaps.


Youth is wasted on the Young-(W.C. Fields)

Post Edited (zufus) : 3/21/2010 1:16:58 PM (GMT-6)

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