Percentage of prostate tumors upgraded after prostatectomy

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Sunbird
Regular Member


Date Joined Apr 2008
Total Posts : 140
   Posted 4/28/2010 5:39 AM (GMT -6)   
Before prostatectomy,  my PCa was graded as a Gleason Six.  After surgery, my tumor was upgraded to a Gleason Seven.  Curious to how often this scenario occurs, I decided to google, "Percentage of prostate tumors upgraded after prostatectomy" and I found a number of links stating one third of tumors are upgraded after surgery.  I'd say this is an important consideration for newly diagnosed patients considering Active Surveillance or deciding to delay surgery.
1996, Age 48, Stage III Colon Ca, Colon Resection followed by 18 chemo treatments.
 
2000, Colon Ca Metastasis to upper left lung lobe.  Lung lobe surgically removed.  24 chemo treatments scheduled.  Took 1, declined the rest.
 
9/08 PSA is 2.8, 12/08 PSA is 4.56??  Chalk it up to prostatitis due to urinary retention after Nissen Fundo Surgery.  VA docs prescribe 30 days of Septra.  Prostate feels normal.  PSA hovers around 4.1.  VA docs want prostate biopsy but can't seem to get me into the schedule.  Continue through Spring and Fall of 2009 thinking I have prostatitis.  Bacteria cultures are always neg.  PSA drops to 3.1 10/09.
 
12/09 Prostate Biopsy performed
3 of 10 cores positive, 5%, 25%, & 35%, 3 + 3= Gleason Six with perineural invasion.
 
Doc wants CT Scan due to prior Colon Ca. Findings: "The seminal vesicles are irregular & there is nodularity in the periprostatic fat such that local extension cannot be excluded.  Shotty lymph nodes in both groin measuring 2.3 cm."
 
Doc wants Endo-rectal MRI (OUCH!) Findings: Mild central zone BPH, no discrete focus of carcinoma is identified, no evidience of invasion into the periprostatic fat or seminal vesicles.  Normal size iliac chain lymph nodes.
 
2/08/10 Open RP surgery.  Findings: Gleason Six upgraded to Seven.  3 + 4, Stage pT2c, Bilateral w/perineural invasion, No pos lymph nodes,  margins uninvolved, no extraprostatic extension, no seminal vesicle extension,  39 grams, blood loss 1200 ml (didn't want a transfusion & didn't get one) nerve bundles spared bilaterally.  current age-61


Steve n Dallas
Veteran Member


Date Joined Mar 2008
Total Posts : 4829
   Posted 4/28/2010 5:43 AM (GMT -6)   
Mine went up too. I'd venture to guess that more then 70% go up.
Age 55   - 5'11"   215lbs
Overall Heath Condition - Good
PSA - July 2007 & Jan 2008 -> 1.3
Biopsy - 03/04/08 -> Gleason 6 
06/25/08 - Da Vinci robotic laparoscopy
05/14/09  - 4th Quarter PSA -> less then .01
11/20/09 - 18 Month PSA -> less then .01
Surgeon - Keith A. Waguespack, M.D.


Sephie
Veteran Member


Date Joined Jun 2008
Total Posts : 1804
   Posted 4/28/2010 6:09 AM (GMT -6)   
Sun, our urologist told us it's very common for the Gleason score and/or stage to be upgraded after surgery. The biopsy is a sampling of tissue and is far from definitive. A surgical pathology report is the final word.

You will notice in discussions here about the pros and cons of surgery that this fact frequently is given as one of the "pros." Guys considering AS need to take this into consideration especially if they have a fairly high number of positive cores or a high percentage of cancer within a core.

Glad this was posted as a new thread as it is important to consider this fact when considering treatment options.
Husband diagnosed in 2/2008 at age 57 with stage T1c. Robotic surgery performed 3/2008. Stage upgraded to T3a (solitary focus of extraprostatic extension). Perineural tumor infiltration present. Apex margin, bladder neck and SVs negative. Final Gleason 3+4. PSA: 0.0 til July 2009. August 2009 - 0.1, September 0.3, October back to 0.0, December 0.0, March 2010 0.0. Next PSA in 6 months. Thank you God!


larch
Regular Member


Date Joined Apr 2010
Total Posts : 47
   Posted 4/28/2010 5:47 PM (GMT -6)   
There are stats from Hopkins that, if recalled correctly, 32% of Gleason scores go up on post-surgery pathology exam, and only 2-3% of the scores go down.

Check Hopkins, there are real stats and not just anecdotes on this topic.

The stats do, however, make the WW/AS call tougher with a Gleason 6 biopsy score, and should help those with Gleason 7 (3+4) biopsy scores realize that they need to act, and not sit and wait.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4226
   Posted 4/28/2010 6:20 PM (GMT -6)   
Clearly many gleason scores are upgraded after surgery because of the sampling inaccuries of a biopsy, but this should not affect the decision to go on AS. The criteria of AS is for small core, small % G6 only. There is a 30% chance of anyone going on AS to have a gleason stage progression or a psa doubling time that goes to less than 3 years. THIS ALSO MEANS THAT 70% NEVER PROGRESS AND THOSE THAT DO PROGRESS WHEN TREATED HAVE THE EXACT SAME CURE RATE AS IF TREATED IMMEDIATELY. These are the established facts period. The key to successful AS is to get another biopsy within a year and monitor psa at least every three months. Most all of the progressions occur within the 1st three years.
If you meet the criteria the choice is fairly simple:
1. Get treated immediately and have all the side affects that go along with treatment, which are not insignificant.
2. Wait and have a 70% chance of enjoying the rest of your life without side affects, and if signs of progresson show up get treated with the exact same results if you have done it immediately.
Gee, a 70% chance of no side affects and the same cure rate if treated later as if treated immediately vs all the treatment side affects right away and no 100% guarantee of cure. You make the decision.
The newly diagonosed patient needs factual information not fear or speculation.
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


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 4/28/2010 6:21 PM (GMT -6)   
It was said to me from the beginning, that at best, the pathology report of a prostate biopsy is but an estimate. Sephie's point of the number of positive cores and/or the percent of cancer in those cores is an important factor. A Gleason 7, any variety, has the potential of being a dangerous animal, and I couldn't imagine many uro/surgeons or oncologists telling someone that it's safe to wait with a "7".

Another factor to consider, is how much HGPIN (High Grade PIN) cells are found in the biopsy sample, as it can very well indicate a lot more cancer cells in possible formation. My own uro feels strongly about HGPIN, but with regular PIN cells, the potential danger is not considered as strong.

AS is still a good possibility if one meets the right criteria, no doubt. Many of us wish we had met those numbers. But we are talking of course, a Gleason 6, 1-3 cores max positive, with 1-10% cancer max, and no family history.

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, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, next one:  July
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 43 days, 1/19 - Corr Surgery #4,  Caths #11 and #12  same time, 2/8-Cath #11 out - 21 days, 3/2- Cath #12 out - 41 days, 3/2- Corr Surgery #5, 3/6 Cath #13 out - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 4/23 put in


twotall
Regular Member


Date Joined Nov 2009
Total Posts : 38
   Posted 4/28/2010 7:58 PM (GMT -6)   

I find this subject interesting as I was told for years that I had prostitatis instead of cancer.  A 12 core bio showed nothing and several months later an 18 core showed a "very small amount of gleason six" in one core (doctors quote).  Being a nervous sort I decided on surgery.  Post op showed that I had gleason 8 4+4 cancer in most of one side of the prostate that had not yet escaped the prostate (we hope).  Reading this forum and others is what convinced me to try the surgery.  It is not an easy call, each has to decide which path to take.  While I do have to deal with the side effects I am hopeful the cancer was caught in time.

Two Tall

 
 
age 59
2007 psa .6
Oct 2008 psa 9.4
Dec 2008 psa 11
Bio done 12 core, no cancer
July 2009 psa 16
Sept 2009 psa 20
All DRE were normal
Made appoinment at Mayo
Bio, 18 core 2 positive, gleason 3+3 =6
doctor said T2
Bone scan neg, CT neg, MRI with coil indicated cancer still in prostate
Robotic on 1/27/10
 
postop Pathology report:
prostite size 43g
adenocarcinoma involving left side from apex to base
nothing on right side
gleason up graded to 4+4=8
stage T2b no mo
largest area of cancer 1.4 cm in dia.
no involvement of periurethral glands
cancer does not extend into the posterior capsule
no extraprostatic extension and cancer does not extend to the external surface
distal and proximal periruethral margins are negative for cancer
high grade prostatic intraepithelial neoplasia found on both sides 
right and left side seminal vesicles are uninvolved
right and left pelvic nodes negative for cancer
PSA check every 3 months for 2 years
 
 
 
 


BB_Fan
Veteran Member


Date Joined Jan 2010
Total Posts : 1011
   Posted 4/28/2010 8:49 PM (GMT -6)   
I am also in the upgrade camp. Biopsy had my gleason at (3+4=7). Pathology upgraded it to 8. I can't understand how the biopsy could have been that far off. I can help but wonder it the 3.5 months that I waited for surgery thinking I was a 7 was the cause of my BCR.
Dx with PC Dec 2008 at 56, PSA 3.4, Biopsy: T1c, Geason 7 (3+4)

Robotic Surgery March 2009 Hartford Hospital, Dr Wagner
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes negitive
nerves spared, no negitive side effects of surgery

One night in hospital, back to work in 3 weeks

psa Junl 09 <.01
psa Oct 09 <.01
psa Jan 10 .07 re-test one week later .05
psa Mar 10 .28 re-test two weeks later .31


MrGimpy
Veteran Member


Date Joined Jul 2009
Total Posts : 504
   Posted 4/29/2010 1:36 AM (GMT -6)   
John,

Think of it this way, the Biopsy is from a small random sample that may or may not have actually hit the target of the most cancer related portion of ones prostate, thats why they take 12 or more samples

To perhaps put it in a better text, you go out for a T-Bone steak dinner and ask the waiter to just bring you a small random piece of any part of that steak. You could end up with a fatty piece or the filet piece, then when you actually get the steak handed to you the discovery is made that it is either representative of the sample or worse (fattier)
Stats:
Age: 52, PSA (2008)=1.9
Biopsy on 01/09/09, Gleason Score = 3+3
One (1) out of twelve (12) cores was positive, plus external nodule found
Surgery (Da Vinci, robotic prostatectomy): 4/7/09
Post Op Path 3+3
Removed Catheter: 04/19/09
100% bladder control - Pad free 7/09
PSA 7/09 undetectable, <0.01 - 3 months post-op
PSA 1/10 undetectable, <0.01 - 9 months post-op
Trimix provides 100% erectile function


English Alf
Veteran Member


Date Joined Oct 2009
Total Posts : 2215
   Posted 4/29/2010 3:02 AM (GMT -6)   
I was also upgraded
I went from 3+3 to 3+4

I heard it was about 30% of men got upgraded, but I'm pretty sure I heard that a while after I'd already opted for surgery.

Common sense told me that whatever treatment I opted for the certainty was that the cancer was going to get worse over time and I'd rather be in the position of having acted too soon than too late. (And as it is I already had seminal vesicle invasion, a biopsy was never going to find that either as I've heard sticking biopsy needles in the smeinal vesicles is not a good idea.)

This is another aspect of PCa, and the diagnosis thereof, that convinces me that there needs to be a major advance in the way biopsies are done as far as equipment and technique goes, such as using high quality imaging devices of some sort to allow all the sections of the gland to be sampled in a comprehensive manner that eliminates as much as possible of the hit and miss aspect.

yes it's only a sample but it needs to be a better sample.

If the Da Vinci equipment is the equivalent of a 16Gb memory stick, then the "gun" that did my biopsies looked like the equivalent of a Betamax tape - clumsy, old fashioned, inflexible (literally and metaphorically) and it was even beige! (The computer screen was so primitive it looked like the computer wasn't even up to running MS-dos)

For those of us who have been upgraded it's too late to do anything about it, but perhaps we should still all say something about this to our uros in the hope that it will encourage someone to improve things and make things better for other guys in the future. A lot rides on a biopsy, a h#ll of a lot, and it should be better than 70% accurate.

Alfred
Age at Dx 48 No Family history of Prostate Cancer
Married 25 years, and I cannot thank my wife enough for her support.
April 2009: PSA 8.6 DRE: negative. Tumour in 2 out of 12 cores. Gleason 3+3.
RALP (nerve-sparing) at AVL-NKI Hospital Amsterdam on 29th July 2009. Stay 1 night.
Partial erections on while catheter still in. Catheter out on 6th Aug 2009.
Dry at night after catheter came out
Post-op Gleason 3+4. Tumour mainly in left near neck of bladder.
Left Seminal Vesicle invaded, (=T3b!)
no perineraul invasion, no vascular invasion. clear margins,
Erection 100% on 15th Aug 2009, but lots of leaking
Stopped wearing pads on 21st Sept 2009
Pre-op style intercourse on 24th Oct 2009 !! No use of tablets, jabs, VED etc.
Nov 17th 2009 PSA = 0.1
Mar 17th 2010 PSA = 0.4!!! referred to radiation therapist


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4155
   Posted 4/29/2010 7:05 AM (GMT -6)   

Hi Guys:

Frankly the simplistic and anecdotal stories of specific patients whose Gleason scores are upgraded post-surgery are not particularly helpful to the patient who is considering AS.  Nor are broad statistics indicating the percentage of G scores that are updated.  As many of us have pointed out, PCa is a very patient specific disease and needs to be managed as such.  That is why each patient needs to get the very best possible pre-treatment advice that is available.

And, that is why that AS should not be managed by the garden variety urologist.  In the hands of an expert the patient can be provided with information on predictive factors that can help determine the risk of potential upgrade of their tumors.  These include things like PSA level, PSA velocity, number of samples, % cancer in each sample, expertise of the pathologist, etc. 

So, my advice to the prospective AS patient is simple:  Get an expert pathological reading (e.g. Epstein or Bostwick Labs) of your biopsy and deal with a physician who will give you the best possible staging and who knows the real ins and outs of dealing with AS.

Tudpock


Age 62, Gleason 3 + 4 = 7, T1C, PSA 4.2, 2 of 16 cores cancerous, 27cc
Brachytherapy December 9, 2008.  73 Iodine-125 seeds.  Procedure went great, catheter out before I went home, only minor discomfort.  Regular activities resumed, everything continues to function normally as of 4/10/10.  6 month PSA 1.4 and now 1 year PSA at 1.0.  My docs are "delighted"!

STW
Regular Member


Date Joined Jun 2009
Total Posts : 292
   Posted 4/29/2010 9:53 AM (GMT -6)   
Percentages are interesting and so are anecdotal stories. (For the record I went from 3+4 to 3+4 with tertiary 5) Even the professionals can only be a guide. One oncologist tells me the tertiary 5 cells are of no consequence; a urologist tells me that I should consider my Gleason score to be an 8. Dandy.

Real world says there is a 100% certainty that I had cancer. Most, maybe all, was cut out one year ago today. That there is a 90%, or 80%, or 70% chance that it is gone means little to me. They either got it or they didn't; there is 100% success or 100% failure.

I read that the mean time to biochemical failure for someone with my stats is 5 years. Again, interesting but of no help at all. In fact, knowing that is somewhat depressing unless you understand that those without biochemical failure would not be in the sample. That is where the professionals come in; they help you process and understand the conflicting information. However, I still don't know any more about where I'll be in four more years.

Any decisions are ours alone with no way of ever knowing if we made the correct one or not. There are no redos. Me? I know I made the right decision for me. Someone with the same medical information might have chosen differently. Again, the decision is there's. At no point in the process is there too much information just, possibly, more time needed for processing it.
Diagnosed at 54
PSA 8.7 Biopsy 1/7/09
4 of 6 cores positive, one at 90%
Gleason 3+4=7 Neg bone scan 1/15/09
One shot Lupron Depot 1/27/09 Tax Season
RP 4/29/09
Neg lymph nodes, postive seminal vesicle, 1 positive margin
Gleason 3+4=7 with tertiary 5 T3b
Catheter out at 2 weeks no nighttime incontinence Pad free week 5
PSA 6/6/09 <0.1; 9/10/09 <0.1; 3/11/10 <0.1


MrGimpy
Veteran Member


Date Joined Jul 2009
Total Posts : 504
   Posted 4/29/2010 10:48 AM (GMT -6)   
In many cases the Biopsy was performed a few if not many months prior to the removal of the Prostate Gland.

That being said, yet another possibility is that It is entirely possible that the cancer did grow during that time
Stats:
Age: 52, PSA (2008)=1.9
Biopsy on 01/09/09, Gleason Score = 3+3
One (1) out of twelve (12) cores was positive, plus external nodule found
Surgery (Da Vinci, robotic prostatectomy): 4/7/09
Post Op Path 3+3
Removed Catheter: 04/19/09
100% bladder control - Pad free 7/09
PSA 7/09 undetectable, <0.01 - 3 months post-op
PSA 1/10 undetectable, <0.01 - 9 months post-op
Trimix provides 100% erectile function


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4226
   Posted 4/29/2010 11:28 AM (GMT -6)   
Gimpy and others,
Upgraded Gleasons are about 30%; progressions on AS are about 30%. I don't think that this is a coindence. The vast majority of progressions I believe are due to initial biopsy error, not PC growth.
If knowing for certain didn't have a price I would be all for it.; but the price to know if you have an upgraded gleason is severe. 10% chance of severe incontinence, 70% chance of leaks after 2 years. Very high probability of ED and about a 90% chance of a somewhat reduced sex life and a major invasive surgery. If this added to survivability it might be worth it; but it doesn't.
Now that you found out your Gleason was upgraded what decision do you make, NONE, you just get psa tests every three months like everyone else and hope for the best. There is absolutely nothing you can do if your gleason is upgraded from a 6 to a 7.
Tud said if perfectly, get a doctor that is familiar with AS and if your initial biopsy was wrong it will be known within a year or 2 and you can be treated with the exact same cure rate. I know this is a difficult concept to grasp that the cure rates are the same if you delay treatment for a couple of years, but all of the data is consistant.
I myself would never go on AS without getting a color doppler ultrasound biopsy. It is non invasive and highly accurrate in spotting any cancers that are dangerous and can confirm an insignificant cancer. It can also be used as a baseline to identify any future progression.
In no way am I advocating that a G7 or a large volume G6 not be treated. But again a clinical pathology from surgery will result in more knowledge, but what do you do with that knowledge. Your psa will either remain stable or rise regardless of your clinical pathology. You make a decision on your psa rise not on the pathlogy, same as if on AS. In some cases as in a high volume G8 or G9 a clinical pathology can result in an immediate decision to do adjuvant radiation, but these cases are rare and not applicabible in G6 cancers.
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

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