OK, Now I'm Worried

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Jazzman1
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Date Joined Sep 2010
Total Posts : 1160
   Posted 11/8/2010 4:55 PM (GMT -6)   
Had my RP last Tuesday, and I just got the pathology report. Here's some of what it says:

Gleason 3+4=7 (up from 6)
% of 4 and/or 5: 5%
% of 3: 95%

Apical involvement: Present on left side
Apical margin involvement: Negative for neoplasm, although the neoplasm is
close to the margin in the left apex. See other margins.

Margin: Positive for carcinoma in multiple foci. 2 mm of the
circumference is positive for carcinoma on the right side at 6 mm. Less
than 1 mm of the circumference is positive for carcinoma on the right side
at 9 mm and 15 mm.

Pathologic Stage: pT2c(+), pNX


If I'm reading this right, I gather we're talking about positive margins in three places. I seem to recall reading somewhere (Walsh's book?) that positive margins don't necessarily mean further treatment is necessary, and that sometimes there are no further problems. Also, what is pNX? Can anyone educate me on this? Do they usually wait and watch at this point, or is salvage therapy inevitable sometime soon?

Is it OK to freak out now?
Age 55

PSA:
8/09 2.69
7/10 4.00
8/10 4.11

Biopsy 8/10
Three of 14 cores positive: 10%, 60% & 80%
Stage T1C; Gleason 6

open radical prostatectomy at Cleveland Clinic 11/2/10

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 11/8/2010 5:17 PM (GMT -6)   
First of all, be thankful you elected surgery. It is still my primo argument for the benefits of surgery. Now you know what it is.

We have many guys on here who had positive margins and have had no problems. We have many guys who have had negative margins, and have had problems.

Of course, it is a potential for the PC to get out of the capsule and will merit a watchful eye. Depending on who you talk to, and what their specialty is, I would say many will recommend adjuvant radiation. Others will recommend a wait and see approach.

It is my personal opinion that first you need to get healed up and get your continence and ED under control.

Jonathon, we have seen worse pathology, and we have seen better. I would begin to research it, set up consults with an oncologist, and a radiation oncologist. Certainly Cleveland has many very good specialists. I don't think you need to act next week, but with the three open margins, you will need to consider some type of adjuvant treatment, or wait until PSA rises and then under go salvavge therapy.

You certainly are in a good place to ask questions here.
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 injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 6946
   Posted 11/8/2010 5:28 PM (GMT -6)   
The staging values mean (according to the charts from Cleveland Clinic and the organization which establishes the methodology):
 
T2c: the tumor is in both lobes
NX: cannot evaluate the regional lymph nodes
 
Because T3 means that there is a detectable spread through the capsule, it is good that you are a T2.
 
The NX - I get the impression that they did not take any lymph nodes. The path report should mention it if they did.
 
Yours is better than mine -

clocknut
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Date Joined Sep 2010
Total Posts : 2667
   Posted 11/8/2010 5:49 PM (GMT -6)   
How were you given your pathology results, Jazzman?  I hope they didn't just hand the report to you and send you on your way.  I don't know enough to say anything intelligent about your results, but I hope you have a doctor who will take the time to explain everything in detail.   Wish you all the best.

AJ 47 (Maryland)
Regular Member


Date Joined Aug 2010
Total Posts : 64
   Posted 11/8/2010 5:54 PM (GMT -6)   
Many people do very well with worse diagnoses. Just consider Michael Milliken for one:

"In January 1993, Milken received the results of a PSA test from a routine medical exam. Because prostate cancer is relatively rare for men in their 40s Milken's doctor didn't recommend the PSA test, he asked for it. The results came back with a level of 24 which is extremely high. Milken repeated the PSA test twice and a subsequent biopsy revealed advanced prostate cancer which had spread to his lymph nodes. At that time, doctors considered prostate cancer that advanced to indicate that a man had less than 2 years to live. Milken opted for prostatectomy but a subsequent test showed that the cancer had already spread to his lymph nodes. Milken started hormone therapy to shut down production of testosterone. Hormone therapy cut his PSA over the course of several months to zero. He also opted to have radiation therapy. Subsequent scans showed the swelling in his lymph nodes had disappeared. Milken's cancer was in remission and still was in 2004 when he was profiled in Fortune."

And he's still doing well today. You've got the right reading material to start with in Walsh's book. Your first post-op PSA will help you and your doctors understand better whether it's time to shoot the second bullet. Thankfully, the prostate and adjacent tissue are out. My path was worse than yours too with positive capsular extension. Did you ask your doctor what the "4/5" means? Is there a tertiary 5? I would ask to understand and perhaps have the pathology slides/tissue reread per prior discussions this week. I would also start reading about dietary changes that may aid in supressing cancer recurrence and aiding any additional RT you might consider. I'm no expert and am trying to learn about options too. We are all in this together. Don't freak.
Preoperative: PSA 1.5 to 3.2 in 11 months after 10 years of level psa. First 12 core biopsy on 2/10 negative in 11, atypical in 1. Second 13 core biopsy on 5/10 at Hopkins positive in 2 with Gleason 3+3 (focal). Robotic "Super VIP" Henry Ford on 8/10. Postoperative Gleason 3+4 (70%/30%). Focal ECE at right posteriolateral mid. Negative margins, lymphs, seminal vesicles. First PSA on 9/14

Jazzman1
Veteran Member


Date Joined Sep 2010
Total Posts : 1160
   Posted 11/8/2010 6:03 PM (GMT -6)   
Thanks for the information, commiseration and reassurances.

Clocknut: The Cleveland Clinic has an online resource called MyChart. It allows you to access your test results, among other things. I got an email saying I had new test results. I had asked my doc to release the report to MyChart, but he said he wouldn't because I might misinterpret it and be overconcerned or underconcerned. I didn't think he was going to release it, so it may have been some sort of snafu. I'll see him Thursday to get the catheter out, so I'm sure I'll hear his opinion then. Thanks for the good wishes.

142: That's very helpful; thank you. If T2 means there's no detectable spread through the capsule, what's it mean to have a positive margin? That point has confused me from the beginning. Are they saying there's cancer at the edge of the organ, but they have no evidence it's gone beyond the capsule? To answer your question, they did not take any lymph nodes. It was an open surgery and perhaps my doc felt that his tactile examination was sufficient.

Goodlife: You're the coolest, man. Thanks for the reassurance. You've been a huge help to me from the beginning. My initial, somewhat freaked out, impression is that you're right. Unless they insist I begin immediate therapy, I'd like to heal up, take a deep breath and see what the PSA scores look like.

And I agree; this is a great place to ask questions. People here are the coolest.
Age 55

PSA:
8/09 2.69 -- 7/10 4.00 -- 8/10 4.11

Biopsy 8/10
Three of 14 cores positive: 10%, 60% & 80%
Stage T1C; Gleason 6

open radical prostatectomy at Cleveland Clinic 11/2/10
Post-surgical pathology:
Gleason score 7 (3+4) extending to inked margin of excision.
- High-grade prostatic intraepithelial neoplasia
Positive margins in three foci
Stage T2c(+), pNX

Jazzman1
Veteran Member


Date Joined Sep 2010
Total Posts : 1160
   Posted 11/8/2010 6:09 PM (GMT -6)   
AJ 47:

I was wondering about the whole 4 and/or 5 thing myself. That's exactly the way they wrote it. I'll definitely ask on Thursday.

Thanks for the info on Milken. I knew he had PCa, but I didn't know all that. I'm generally not the freak out type, but I have to admit I hadn't prepared myself for this. I knew it was possible, but somehow it never seemed like a real possibility for me. Live and learn.
Age 55

PSA:
8/09 2.69 -- 7/10 4.00 -- 8/10 4.11

Biopsy 8/10
Three of 14 cores positive: 10%, 60% & 80%
Stage T1C; Gleason 6

open radical prostatectomy at Cleveland Clinic 11/2/10
Post-surgical pathology:
Gleason score 7 (3+4) extending to inked margin of excision.
- High-grade prostatic intraepithelial neoplasia
Positive margins in three foci
Stage T2c(+), pNX

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3741
   Posted 11/8/2010 6:25 PM (GMT -6)   
"Gleason 3+4=7 (up from 6)
% of 4 and/or 5: 5%
% of 3: 95%"

This is good news...the cancer that graded 4 & 5 only made up 5% of the total..95% of the cancer was 3, (Gleason 6)

Your next big moment comes in 6 or 8 weeks when you get the first post-op PSA results..If it drops to undetectable, they may not push to hard for adjunct radiation..There is a lot of controversy on this point..Some doctors are content to wait for a detectable PSA while others others push for adjunct radiation just as a matter of principal with positive margins..

You can move from the front half of Walsh's book to the back half with frightening speed..
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
age 61: 5.2
age 64: 7.5, DRE "Abnormal"
age 65: 8.5, " normal", biopsy, 12 core, negative...
age 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
age 67 4.5 DRE "normal"
age 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 11/8/2010 7:41 PM (GMT -6)   
I agree with Fairwind's post above, the good news is that 95% of the cancer found was type 3 cells, and only 5% type 4 - the more aggressive and unpredictible type. Positive margins are a funny thing, some have them, and never have recurrance. Some don't, yet have reccurance.

I was downgraded to a 3+4, with one tiny positive margin, and also T2C, and ended up with recurrance within 9 months of surgery, and then had to have SRT, so you never know. Presurgery, I had 7/7 positive cores, all Gleason 7, and a rapidly increasing PSA that hit 16+ before surgery, having tripled in the year before, so there are lots of factors at play with PC.

Good luck, now is the time to heal.

David
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 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 6946
   Posted 11/8/2010 7:57 PM (GMT -6)   
Jazz,
 
Here is the next line:
T2c: the tumor is in both lobes
T3:  the tumor has spread through the prostatic capsule (if only partially, it is still T2)
 
Now, I can't say what that qualification means. I am a T3, so it wasn't in scope for me. I had full blown EPE in multiple spots.
 
The problem with positive margins, as Walsh says in the book, is that you don't know if the cell they found on the margin was the last one cut in half, so dead, or if there were more. The optimist says it is half of the last one.

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3741
   Posted 11/8/2010 8:04 PM (GMT -6)   
Here is another twisted way to look at it..If your PSA moves up from undetectable or never becomes undetectable it is better to have positive margins than negative margins from a radiation oncologists point of view..

AJ 47 (Maryland)
Regular Member


Date Joined Aug 2010
Total Posts : 64
   Posted 11/8/2010 8:18 PM (GMT -6)   
I'm with you on the failure to prepare. I had two biopsies totalling 25 cores, two of which were Gleason 6 with less than 5% in each core positive. I was told by the best of the best, "take your time." And I did. 4 months later, I had the surgery, Dr. Menon did the Super Duper VIP, and I was up and walking in 4 hours. Things were really great and optimistic until I got the pathology (that was delivered by a PA) That day was the worst in my life, but now, with some help (yes counseling), I understand that we can't control what we can't and am trying to move on. It takes time and I'm not there yet, but as each day passes and things feel normal (no leakage post op but ED), we understand and reflect on what's important and what's not. This forum is great, but you have to keep it tightly boxed and dedicate a set amount of time to read and reflect. If you subsume yourself on this forum or in the research, you'll kill yourself way before the Pca does. Don't take me wrong, this is a great place with lots of good information, but once you're fairly certain you have what you need to make decisions, step back, do what you think is best, and enjoy what life is all about. This is what I'm learning now. You have legitimate questions to ask and future PSAs to worry about, but it's in G-d's hands to some extent but I know you'll do everything you can to improve your chances of cure. I believe in the diet, I believe in the exercise (despite a lazy past), and I believe in faith. If you consume yourself with the disease, you won't enjoy life's pleasures and will just be waiting for more bad news. Let the news come to you, don't bring it to yourself before it's time. This biopsy versus pathology discrepency is something maybe one day science will help us to solve. Don't second guess like I did on the delay in deciding what treatment to undergo. You are here and that's telling about how you went about deciding on a doctor, diagnosis, and treatment. We are all here to help. Things always have a way of working out.
Preoperative: PSA 1.5 to 3.2 in 11 months after 10 years of level psa. First 12 core biopsy on 2/10 negative in 11, atypical in 1. Second 13 core biopsy on 5/10 at Hopkins positive in 2 with Gleason 3+3 (focal). Robotic "Super VIP" Henry Ford on 8/10. Postoperative Gleason 3+4 (70%/30%). Focal ECE at right posteriolateral mid. Negative margins, lymphs, seminal vesicles. First PSA on 9/14

Jazzman1
Veteran Member


Date Joined Sep 2010
Total Posts : 1160
   Posted 11/9/2010 2:37 AM (GMT 0)   
Yeah, I like to think I'm pretty level-headed and rational, but you've got to wonder who is ever really ready for bad news like this. You arm yourself with all the facts you can gather, you read enough profiles to know that results are all over the map, and still you think somehow that the G6 you got after biopsy is something they can't take away from you. Again, live and learn.

I agree with Fairwind and Purgatory that having 95 percent of the cancer type 3 is a positive thing. We'll keep a good thought about that last cell being the one at the margin.
Age 55

PSA:
8/09 2.69 -- 7/10 4.00 -- 8/10 4.11

Biopsy 8/10
Three of 14 cores positive: 10%, 60% & 80%
Stage T1C; Gleason 6

open radical prostatectomy at Cleveland Clinic 11/2/10
Post-surgical pathology:
Gleason score 7 (3+4) extending to inked margin of excision.
- High-grade prostatic intraepithelial neoplasia
Positive margins in three foci
Stage T2c(+), pNX

Ricky2
Regular Member


Date Joined Dec 2009
Total Posts : 97
   Posted 11/8/2010 10:20 PM (GMT -6)   
My path report was similar to yours. My uro discouraged me from any further treatment. The best that I can determine is that with positive margins you have about a 60% chance of not having a reoccurrence. The Sloan Kettering nomogram is even more optimistic. With a GS of 3+4 and positive margins it shows only a 7 % chance in 10 years. With a lot of possible side effects from radiation, I am waiting for reoccurrence before I do anything and that is a good chance of never. Good luck to you.

Ricky2
Age 70
PSA 7/09- 6.1, retested 9/09-5.1.
Biopsy 9/09 4 of 12 positive.G3+4
RALP 10/09
Path Rep.G3+4 Margins slightly involved <.1mm to .25mm. Perineural invasion present, stage pT2c. Tumor 18%. Seminal Vesicle & nodes - clear. ED: use VED for therapy Trimex and quadmix don't give usable erection. hoping for implant someday.
3 PSA through 8/10 <.1

An38
Veteran Member


Date Joined Mar 2010
Total Posts : 1148
   Posted 11/9/2010 5:45 AM (GMT -6)   
Hi Jazzman,
 
The 5% of Gleason 4/5 although scary is good news, it's the best possible Gleason 7 cancer to have. See the link below, basically your cancer statistically would behave very much like a Gleason 6 cancer and very little like a Gleason 8:
 
 
I am no doctor so someone should correct me if I am wrong. pT2 means the cancer was contained within your prostate ie the pathologist could not see any evidence of extracapsular penetration. The + means that what they received had positive margins. So what I undertand is that the surgeon cut through your prostate (rather than around the capsule of the prostate) in certain spots and in a couple of areas he cut through areas of cancer leaving those areas of focally positive margins on the sample. It could be that the cancerous spot that he cut through was fully within bits of micellaneous tissue that are often also removed with the prostate. It could mean that the last cancer cells were on the edge of what the sample. Or it could mean that he cut through and left behind a bit of prostatic tissue. Although surgeons try to avoid the pT2+ scenario as far as possible sometimes there are good reason why they would cut through the prostate rather than around it - this sometimes happens when they are trying to save nerves for example.
 
I don't know if this helps you, I know this is a scary time but I think it is good to understand the pathology report so that you are ready for questions to your doctor.
 
Regards,
An
 

mr bill
Veteran Member


Date Joined Sep 2010
Total Posts : 688
   Posted 11/9/2010 6:38 AM (GMT -6)   
Jazzman,

My pathology was pretty nasty. However, my post PSA has been undectable for 3 wk and 6 wk. Radiation oncologist wanted to start adjunct with two shots HT during radiation. Then told me he would feel comfortable waiting till PSA went up a notch. Say from .03 to .04. AJ47 has a good outlook.

Mr. Bill
Age 66
BPH since 1996. at least three negative biopsies Erie. Uro did not prescribe finasteride
2007 acute urine retention photoselective vaporize Clev. Clinic
8-9-10 PSA rose to 10.14 with finasteride positive biopsy Cleveland gleason 9, cat & bone scan negative
9-8-10 Robotic prostatectomy at Cleveland. Biopsy 9 nodes, 2 positive,seminal & vas deferens
PSA 3 wk .06, 6 wk <.03

Jazzman1
Veteran Member


Date Joined Sep 2010
Total Posts : 1160
   Posted 11/9/2010 8:58 AM (GMT -6)   
Thanks for the dose of perspective.

I agree; AJ 47 has a great perspective. It's the perspective to have.

It also sounds like nothing's cast in stone just yet regarding my future, which is good to hear. I can live with ambiguity, but I always crave information until I understand what I'm up against.

Thanks for info on the Sloan Kettering nomogram, Ricky. The big piece of information I don't have yet is the post-surgical PSA. If that's undetectable, I may be in good shape. I also don't have any pathology on the lymph nodes, which may or may not matter.

An38, thanks for some interesting information I wouldn't have known about. I'll definitely speak with the doc about that when I see him on Thursday.
Age 55

PSA:
8/09 2.69 -- 7/10 4.00 -- 8/10 4.11

Biopsy 8/10
Three of 14 cores positive: 10%, 60% & 80%
Stage T1C; Gleason 6

open radical prostatectomy at Cleveland Clinic 11/2/10
Post-surgical pathology:
Gleason score 7 (3+4) extending to inked margin of excision.
- High-grade prostatic intraepithelial neoplasia
Positive margins in three foci
Stage T2c(+), pNX
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