PC profile - your thoughts

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An38
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Date Joined Mar 2010
Total Posts : 1152
   Posted 8/25/2010 6:24 PM (GMT -6)   
Hi all,

following the RP I now have much more information about my husband's pc and the picture is odd in some ways and I appreciate your thoughts.

Firstly his psa numbers are low but he has 3+4 cancer. I know this happens often enough.
But then his free psa %s were really very high so it is odd he has it at all.
Then the volume of his pc is low (0.2cc) but there is Gleason 4 in that small amount of cancer. And it is spread right through the prostate in 7 spots.

Knowing what I know post rp, it seems to me that this cancer is not doing the usual thing. From the papers that I read Gleason 7 cancer is usually associated with a higher volume than Gleason 6 and averages over 3ccs. Secondly the high free psa does not make sense to me as it too is associated with a low chance of cancer and especially high grade cancer.

I am trying to understand this and I am having difficulty. Your thoughts are very much appreciated.

An
Husband's age: 52. We live in Sydney Australia.
Family history:
Maternal grandfather died of prostate cancer at 72. Maternal uncle died of prostate cancer at 60. Because he is the third generation to be diagnosed he has hereditary PC.
PSA history:
Aug07 - 2.5|Feb08 - 1.7|Oct09 - 3.67 (free PSA ratio 27%)|Feb10 - 4.03 (free PSA ratio 31%) |Jun10 - 2.69
DRE normal
Biopsy 28/4/2010: results, negative for a diagnosis of PC however 3 focal ASAPs “ suspicious but not diagnostic for prostatic adenocarcinoma."
Review of biopsy by experienced pathologist, results,
1 out of 12 core diagnosed with 10% of Gleason score 3+3 cancer (left transitional)
1 out of 12 cores with ASAP (left apex), suspicious but not diagnostic of cancer

Nerve sparing RP on 20th August 2010 at St Vincent’s with Dr Stricker.
Post-op pathology
Final Gleason score: 3+4
Margin involvement: Nil
Extraprostatic extension: Nil
Multifocal, with involvement in the Peripheral, apex, fibro-muscular and transitional zones.

cooper360
Regular Member


Date Joined Jul 2010
Total Posts : 161
   Posted 8/25/2010 6:37 PM (GMT -6)   
I wouldn't have had surgery w/these numbers!!!

An38
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Date Joined Mar 2010
Total Posts : 1152
   Posted 8/25/2010 7:43 PM (GMT -6)   
Thanks Cooper for being so upbeat.
We are really pleased to have done the surgery now we know there is some Gleason 4 in there. Our tolarence for risk doesn't allow for living with high grade cancer no matter the quantity. The medical practitioners we have seen post-surgery have concurred and said we were very lucky to catch the Gleason 4 early.

My question is more about high free PSA and low volume cancer being incongruous with Gleason 4.

An

Post Edited (An38) : 8/25/2010 6:47:39 PM (GMT-6)


Geebra
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Date Joined May 2009
Total Posts : 476
   Posted 8/25/2010 8:40 PM (GMT -6)   
An,

What am I missing? The PSA is low, the free PSA is high is very consistent with low volume PCa.

Greg.

geezer99
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Date Joined Apr 2009
Total Posts : 990
   Posted 8/25/2010 9:09 PM (GMT -6)   
I think that these numbers seem reasonable -- and I think they tell you that you made a good choice to have it treated. Do you have an actual copy of the path report? If not, ask your doc for it. Remember that 3 + 4 means that the majority of the cells examined were 3. You want to look at the total amount of cancer found since a lot of 3 could explain the free PSA.

logoslidat
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Date Joined Sep 2009
Total Posts : 6075
   Posted 8/25/2010 10:22 PM (GMT -6)   
since your margins were not involved, someone correct me if I'm wrong, the statement about the gleason 4 spreading thru the prostate in 7 places, also given NO PROSTATIC EXTENSION, makes absolutly zero since. Also very few path reports will tell you what the gleason is that escaped. Did you in fact go over this report with the surgeon or anyone in the medical field. We are smart here, but your surgeon is the expert. The fact that some of your statements make no since , tells me you have been doing research, but not understanding the research you have done in a lot of regards. PS multifocal means the cancer is in more tnat one place in your prostate, not that it spread out of the prostate in thoses focal points. The focal points were inside your prostate. Your pathology report by the way is/was excellent. I assume cooper meant He wouldn't have treated it period, but we'll never know when He just drops a bomb and lets YOU figure out what "advice " He was giving in his eloquent post.
age 67 First psa 4/17/09 psa 8.3, 7/27/09 psa 8.1
8/12/09 biopsy 6 out of 12 pos 2-70%, rest <5% 3+3
10/19/09 open rrp U of Washington Medical Center, left bundle spared
10/30/09 catheter out. continent from the jump.
pathology- prostate confined, only thing positive was the report.everything else negative
9% of prostate affected. gleason 3+4, I suppose thats a negative
After reading pathology myself, gleason was 3+4 with tertiary 5, 2-3 foci, extensive PNI, That is a negative, but I am a positive !!
Ed an issue but keeping the blood flowing with the osbon pump
Dec 14,2009 psa 0.0 May 10 2010, psa 0.0

" Hypocrisy is vice's homage to Virtue " Francois de la Rochefoucauld, source courtesy of Tatt2

proscapt
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Date Joined Aug 2010
Total Posts : 644
   Posted 8/25/2010 11:04 PM (GMT -6)   
My situation was somewhat similar to your husband's. My PSA was only 3.6 when I sent in for biopsy but it still came back 3+4. Cancer was relatively small (3 cc / 7% ) when removed, though 10X as big as yours.

My urologist explained to me that cancer is often a multifocal disease, meaning that it often develops at several spots in the prostate independently and nearly simultaneously. It's not as if there is one starting cancer and everything that's cancerous came from this one starting point. So the idea that there's something strange about having multiple small points of grade 4 ca may not really be on target.

Given that it moved to a 4 quickly, consider yourselves lucky that you found it and got it out while it was still so small. The outlook is very favorable.

It was also a stroke of good fortune that it was found at all in the biopsy. Look at this way: For the entire cancer to be .2 cc that means the cancer (if a sphere) would have to be something like 7 mm in diameter, a little more than a quarter inch in diameter. Now, take that quarter inch mini-marble of cancer and imagine it broken into 7 little bits and then those bits stuck at random inside a prostate the size of a ping pong (table tennis) ball. It could easily have been missed by the 12 biopsy needles, and then you'd be in the situation of having a false negative biopsy (as many on this site have experienced) and then finding the cancer with a repeat biopsy 1-5 years later, but by then it's bigger and potentially higher grade. Lucky you!!!!

Retire1965
Regular Member


Date Joined Jul 2010
Total Posts : 38
   Posted 8/25/2010 11:04 PM (GMT -6)   
An,
 
I think you made a great choice.  You should consider yourself a role model to other PCA patients.
 
You faced an ambiguous situation and refused to allow any denial into your life.  You made a decision and didnt look back.  It absolutely turned out to be the right one.
 
It would not have been long before your husbands situation woud have been worse.
 
Retire1965

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7082
   Posted 8/25/2010 11:12 PM (GMT -6)   
I read 7 focal points of cancer within the prostate, not extra-prostatic extension. Gleason 3+4 has a 4 involved, which is what my Dr. says changes all the rules. As well, we are told a small spot of 4 is worse than a big volume of 3.

An, remember that Walsh tells us you can have a PSA of 2 and have extensive cancer, or have a high PSA and be simply afflicted with BPH. PSA is an indicator, not a guarantee.

Lastly, your decision was made, and the deed was done. Do not second-guess yourselves. It has no positive value.

My personal, non-physician opinion is that you have treated it, and you have a very high chance of being cured. But only a lifetime of 0 will tell that.

mspt98
Regular Member


Date Joined Dec 2008
Total Posts : 377
   Posted 8/25/2010 11:14 PM (GMT -6)   
An,
     I can't really tell you anything about your technical questions, but I too would have done what you guys did. My father died of colon cancer, mother of breast cancer both at early ages. Once I heard prostate cancer I had to act. And yes I know that prostate cancer is not the same as of either of these cancers. Anyway, psa's are all zeros (so far), 100% continent, use needle viagra (wife's phrase, not mine) for sex. Sometimes you just have to make a leap of faith on these questions.........

An38
Veteran Member


Date Joined Mar 2010
Total Posts : 1152
   Posted 8/26/2010 1:13 AM (GMT -6)   
Hello all,

Just a point of clarification, logoslidat - the margins were negative. The 7 focal points were in the prostate. I'm sorry if it was not clear.
Proscapt, you make a good point about PC being a multifocal disease so perhaps I shouldn't be so surprised about 7 different spots blooming with cancer at once. And procscapt you are right that we were extremely lucky to find cancer at all on the biopsy.

142, we are very happy with our decisions, I would just like this all the data I have on my husbands PC to make a little sense (blame it on me being an engineer). The RP last Friday has gone very well, my husbands catheter was taken out today, it looks like he is already continent and he had his first half erection this morning. We have a lot to be grateful for.

Greg, can you refer us to any articles or books that explain the connection between high free PSA and low volume cancer. I thought high free PSA related to having no cancer. Most websites relating to free psa look like this

http://www.psa-rising.com/prostatecancer/fpsa-flowchart.htm

Doctors tell people all the time not to have a biopsy because they have a high free PSA. This is based on the fact that a high PSA (over 25%) corresponds to a low risk of having cancer and furthermore people who have high free PSAs tend to have low grade cancers. Neither of these were true for us.

This coupled with the fact that we have such a low volume of cancer but with Gleason 4 in it makes me wonder if this is a particular subtype of PC with these particular characteristics.

An

Sephie
Veteran Member


Date Joined Jun 2008
Total Posts : 1804
   Posted 8/26/2010 7:39 AM (GMT -6)   
An, I applaud you for the knowledge you have accrued over a short period of time. I also applaud you and your husband for making a treatment choice and sticking by it regardless of what others may say. Based on the surgical path report, looks like surgery was the right choice.

Those Gleason 7s can be tricky little buggers. Your post mentions volume ... my husband's biopsy stated the largest of the 2 cores that were positive was 30%. I don't consider that large especially in light of the fact that 10 samples were taken, and only 1/5 of them showed cancerous cells. Yet, upon surgery, we found that one of those samples had broken through the prostate and invaded the capsule. Fortunately, his final Gleason remained unchanged at 3+4 but his stage moved up to T3a from a T1a at biopsy.

Keep asking those questions until you get answers. It aint' easy but I expect that you will find the answers you seek.

An38
Veteran Member


Date Joined Mar 2010
Total Posts : 1152
   Posted 8/26/2010 8:08 AM (GMT -6)   
Thanks Sephie. We are thankful that my husband's cancer has not invaded the capsule although I know your husbands PSA has stabalised back to zero (and I hope and pray it stays that way). I do know that if we weren't as pushy with the doctors as we were we still would be waiting for the next yearly PSA report as our primary care physician was reluctant to send someone with a PSA of less than 4 to a urologist. He chose to remain ignorant of the concept of PSA velocity and didn't find the rise from 1.8 to 3.6 in one year alarming. And the urologist was reluctant to do a biopsy with the free PSA value being so high but did it to humour us. Then he accepted the ASAP diagnosis without question and we didn't. I know that without asking questions we wouldn't be where we are today so I continue to do so.

Greg, I finally understand what you mean about the free PSA being high being completely consistant with low volume PC. It clicked just a little while ago. I saw the free PSA % as a switch, high for no cancer, low for cancer. But the PC being low volume would mean that the vast majority of the prostate emits free PSA as if it has no cancer. Low volume PC would not change the ratio much because the amount of free and bound PSA it emits would not be enough to change the ratio. Thank you so much for helping me through this part of the puzzle.

Thank you Retire. We just did what you are doing now, finding answers and helping others on the way.

An

Post Edited (An38) : 8/26/2010 7:22:21 AM (GMT-6)


60Michael
Veteran Member


Date Joined Jan 2009
Total Posts : 2243
   Posted 8/26/2010 8:59 AM (GMT -6)   
An,
Really cant answer your question but it sounds like the surgery went well, as is the recovery. Maybe the Dr can provide clarification on the questions that you have asked, but it is always good to have a plumber and an engineer and a mechanic in the family.
My best to both of you and keep us posted.
Michael

Woodworker
Regular Member


Date Joined Apr 2010
Total Posts : 90
   Posted 8/26/2010 10:44 AM (GMT -6)   

I am not sure what you mean by free PSA.  However, I had what I thought was a low PSA (2.7) and I still biopsied positive.  According to my doctor the issue

is how fast does it go up.

 

As you can tell from my signature the biopsy came back with only 2 cores of 12 @25% with a 3+4 Gleason.

 

Post operative biopsy indicated only 2% in 5 of 35 slides.  I was talking to my surgeon less than two hours ago.  He told me do not let the low numbers fool you.  The cancer was spread throughout the prostate.  He also indicated that the 4 in the Gleason score meant that you do not fool around with it. 

 

From what I have seen on this discussion group there have been a lot of Gleason scores go up after the post operative biopsy.

 

As one of you said, the PSA is only and indicator that says take a closer look.

 

I did get criticism from several sources for choosing surgery. The suggestions were radiation, wait and see, diet, prayer by itself, organic herbs.  All of this came from people at the church we go to.  The only two people that did not offer an opinion were Prostate Cancer themselves.

 


Age : 56
Diagnosed 3/29/2010
5mg Cialis daily
PSA 2.7; Gleasen (3+4) Biopsy 2 cores of 12 25% positive
DaVinci surgery 6/25/2010
Returned to work: 7/12/2010
Post Surgery
Final Biopsy report
5 slides of 35 were 2% positive for cancer
Clear Margins
Final Gleason (3+4)
Incontinence: None
ED: Still dead as a door knob
Still taking 5mg Cialis Daily

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 6075
   Posted 8/26/2010 10:46 AM (GMT -6)   
I re read your initial post and see where you said it was spread thru the prostate. I see now what you were saying. Spread thru out , or should I say thru in the prostate. Communication, seems so easy, but then........ I apologise for any scolding, you are very understanding of your research and I believe you absolutly made the right choice. I started with a 3+3, ended with 3+4, with some 5. This is the trouble with a lot of biopsies and my surgeon told me , in his experience most 3+3 are really 3+4 and aggressive treatment is warrented. You both did good. Hears wishing a nice recovery and do some walking. Don't hesitate to ask us questions about some bumps along the way. I'm 10 mos out and feel great, continent, yet ED is there and slowly recovering.
age 67 First psa 4/17/09 psa 8.3, 7/27/09 psa 8.1
8/12/09 biopsy 6 out of 12 pos 2-70%, rest <5% 3+3
10/19/09 open rrp U of Washington Medical Center, left bundle spared
10/30/09 catheter out. continent from the jump.
pathology- prostate confined, only thing positive was the report.everything else negative
9% of prostate affected. gleason 3+4, I suppose thats a negative
After reading pathology myself, gleason was 3+4 with tertiary 5, 2-3 foci, extensive PNI, That is a negative, but I am a positive !!
Ed an issue but keeping the blood flowing with the osbon pump
Dec 14,2009 psa 0.0 May 10 2010, psa 0.0

" Hypocrisy is vice's homage to Virtue " Francois de la Rochefoucauld, source courtesy of Tatt2

Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 8/26/2010 11:34 AM (GMT -6)   
An38 said...
I am trying to understand this and I am having difficulty. Your thoughts are very much appreciated.

An,

Here’s the important part to focus on…(looking forward at what will likely happen, not backward)...

Your husband’s case characteristics and relevant results are virtually the same as the most frequently occurring PC cases found today—low risk or lower-intermediate risk, found early, and surgically removed with no margins.

The best news is that it is highly unlikely that he (and the other guys in that most frequently occurring scenario) will ever have to deal with prostate cancer again in his lifetime.  Furthermore, if continence and sexual function were good before surgery, there is a strong statistical likelihood of full recovery in those areas by about the first of next year.

That’s news to celebrate!

Post Edited (Casey59) : 8/26/2010 10:43:06 AM (GMT-6)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 8/26/2010 11:59 AM (GMT -6)   
"Furthermore, if continence and sexual function were good before surgery, there is a strong statistical likelihood of full recovery in those areas by about the first of next year."

There is no way you can predict when someone's incontinence or ED issues will fully recover. Not even their doctors could make that statement
That's the trouble with using stats as a basis, when in reality, each person's recovery is so unique to their body and a host of other factors.

An, I hope that all matters in the recovery go well and in a timely manner.

David in SC
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

NEIrish
Regular Member


Date Joined Aug 2010
Total Posts : 245
   Posted 8/26/2010 12:05 PM (GMT -6)   
An,
Second guessing is brutal. It's why I and it seems so many others on this site say don't look back after making the decision. I found myself is the completely bizarre situation in the first post-surg psa reading apptmt. last wk when we had the prostate path report too of wanting to hear there was more cancer than was first found on the biopsy. The surgery and recovery is so difficult that I wanted more confirmation that my husband's decison had been the right one (I'd leaned more towards the AS option).Surgeon said it's a gender thing - the wives question and second guess a lot more than the guys. I think as each zero psa reading comes in (the 3 month intervals will fly by) it will relieve your mind. Happens with women with mammograms after cancer too - nervous for the subsequent year or 2 then time passes and as each "no change" comes in you relax. Keep asking your questions, but as Casey 59 just said - Celebrate!

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 8/26/2010 1:33 PM (GMT -6)   

Oops, did I imply that the likely positive result was guaranteed?  I didn’t mean to.  The correct wording (which I might have used) is that it is "likely."  Was that properly understood, An, from this sentence:  "Furthermore, if continence and sexual function were good before surgery, there is a strong statistical likelihood of full recovery in those areas by about the first of next year."?

One cannot look at the statistics and say “that’s exactly how my case will turn out”…it doesn’t work that way.  However, once you understand how statistics works, what you can say is this is how his case will “likely” turn out.

So, again, for a young man like your husband who went through a generally uneventful, prostatectomy with the typical (most frequently occurring) outcome that he had, if he didn’t have problems in these areas before, it is “likely” that he will essentially fully recover!  It’s no crystal ball, it’s no guarantee, and it’s not a “prediction”, but the likely odds are definitely in his favor!

Something to feel good about!

 

 


Post Edited (Casey59) : 8/26/2010 2:35:59 PM (GMT-6)


Retire1965
Regular Member


Date Joined Jul 2010
Total Posts : 38
   Posted 8/26/2010 8:41 PM (GMT -6)   
An,
 
I am very happy for you and your husband.  The initial recovery signs seem very positive.
 
Retire1965

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 8/26/2010 9:43 PM (GMT -6)   
An, just noticed you are from Oz. I've enjoyed a handful of trips there, mostly around the time of the Olympics. Did a bit of work at the Optus Headquarters which was on Miller Street in North Sydney, just off Pacific Highway...I hear they've relocated elsewhere.

Met a friend there who had an apartment on Milson's Point, sort of in the shadow of the bridge. Will never forget while grilling out on his patio at dusk the tens of thousands of bats that flew overhead. For probably 30 minutes there as a steady stream of them headed somewhere toward the bridge. It was bizarre.

I was there during a hale storm that I hear is still legendary locally...I was eating dinner at The Rocks when it happened. Grapefruit-sized hale. Most of the roofs in all of Sydney were damaged. I remember on my next trip there, house after house after house had blue tarps on their roof. If I remember, that would have been around 1999 or so.

Well, glad to see that your husband has received a good pathology. As I said earlier, he's got a great likelihood of excellent long-term outcomes.

best wishes...

An38
Veteran Member


Date Joined Mar 2010
Total Posts : 1152
   Posted 8/27/2010 9:42 PM (GMT -6)   
Hi Casey,

Yes, the storm of 99. It was a big one and some of those roofs were in tarps for years as roofing contractors were booked out. I was working late in downtown Sydney that day and I remember it very clearly.

I too worked in the Optus Headquarters on Miller Street not in 1999 but a few years ago. It's a small world! Optus have now moved out to a large technology park in a place called North Ryde, their "campus" is modelled on Google's campus.

An
Husband's age: 52. We live in Sydney Australia.
Family history:
Maternal grandfather died of prostate cancer at 72. Maternal uncle died of prostate cancer at 60. Because he is the third generation to be diagnosed he has hereditary PC.
PSA history:
Aug07 - 2.5|Feb08 - 1.7|Oct09 - 3.67 (free PSA ratio 27%)|Feb10 - 4.03 (free PSA ratio 31%) |Jun10 - 2.69
DRE normal
Biopsy 28/4/2010: results, negative for a diagnosis of PC however 3 focal ASAPs “ suspicious but not diagnostic for prostatic adenocarcinoma."
Review of biopsy by experienced pathologist, results,
1 out of 12 core diagnosed with 10% of Gleason score 3+3 cancer (left transitional)
1 out of 12 cores with ASAP (left apex), suspicious but not diagnostic of cancer

Nerve sparing RP on 20th August 2010 at St Vincent’s with Dr Stricker.
Post-op pathology
Final Gleason score: 3+4
Margin involvement: Nil
Extraprostatic extension: Nil
Multifocal, with involvement in the Peripheral, apex, fibro-muscular and transitional zones.
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