Shocked at Post Op Pathology Report

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halbert
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Date Joined Dec 2014
Total Posts : 3110
   Posted 9/3/2017 3:16 PM (GMT -7)   
AZ Guy, at this point, your only action is to heal from the surgery and get your strength back. They can't do anything for a while--a couple of months at least. At that point, the decision of what (and when) to do additional treatment will be determined by your PSA and other tests that may be indicated.

Yes, it sucks that you got a nasty upgrade. It may be that you're one of the lucky ones that will still get to non-detectable and stay there. Or maybe not. No one can really say today how it will play out. That sucks too, but it is what it is.

Eat well, keep walking, heal. And, try to relax and wait it out.
Age at Diagnosis: 56
RALP on 2/17/15, BJC St. Louis, Dr. Figenshau
58.5g, G3+4, 20%, 4 quadrants involved
PSA 3/10/15: 0.10
5/18/15: <.04
8/24/15: <.04
11/30/15: <.04
2/29/16: <0.04
8/30/16: <0.04
2/15/17: <0.006
8/22/17: <0.006
My Story: www.healingwell.com/community/default.aspx?f=35&m=3300024

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8824
   Posted 9/3/2017 3:34 PM (GMT -7)   
Small size/focal and low grade at the margin are mitigating factors.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Brook58
New Member


Date Joined Sep 2017
Total Posts : 6
   Posted 9/5/2017 6:33 AM (GMT -7)   
AZ Guy
My surgeon started talking about adjuvant radiation at my post-op consult. However my pathology was T3bM0.

R-0.009
New Member


Date Joined Aug 2017
Total Posts : 14
   Posted 9/5/2017 5:08 PM (GMT -7)   
I had one small, one millimetre, surgical margin. I have since seen one scientific paper which found no difference in outcome for a single very small positive margin versus no margin at all. (Of course next week another paper may come out saying the opposite). But it seems to be agreed that lots of positive margins or a large positive margin is less desirable than no positive margin at all. So, you could ask for more details about the magnitude of the positive margins. That said, no one is ever completely out of the woods. A few people with negligible cancer suffer recurrence. Others in which cancer had spread to lymph nodes and seminal vesicles never see recurrence. It seems to be an issue of the probabilities of recurrence increasing with greater spread. But nothing seems to be 100% in either direction.

If you really want to get a better handle on your status, in a few months have an ultrasensitive PSA test done. It seems that recurrence is very rare if that number comes out below 0.003. Some studies have found that below 0.05 has a large proportion of benign prognoses. Mine was 0.009, which seems to be associated with a 15% risk of recurrence within five years. But again, different studies done on different groups of patients come out with differing results.

Obviously, the less the cancer seems to have spread the better the outlook. And bear in mind the following: After PSA rises again above 0.2 (if it ever does) on average it takes 8 to 10 years before metastasis can be detected in bone. And after that, people live on average about five more years. This is why, while 60% of men in their 70s HAVE prostate cancer - although the vast majority never know about it - only ~3% of men die from it, simply because, at that age, they die from something else first. It is MUCH MUCH better to have prostate cancer than almost any other type of cancer.

Hope this helps clarify a bit.
Age at diagnosis=74; PSA=6.8 // Biopsy: 4+3; 2% // Pathology: 3+4; 8%; both sides; one 1 mm positive margin // fully continent in 30 days; but ED still at 10 months // US-PSA @ 10 months (Aug '17)=0.009 // SFSG!

R-0.009
New Member


Date Joined Aug 2017
Total Posts : 14
   Posted 9/5/2017 6:16 PM (GMT -7)   
Hi AZ guy: My previous post was, of course, addressed to you. So is this one. You might want to take a look at some of the data here:

https://seer.cancer.gov/statfacts/html/prost.html

There is no more authoritative source than the above. It is the US National Institutes of Health department responsible for cancer - The National Cancer Institute. First of all note that of people diagnosed with prostate cancer 98.6% live at least five years. In addition, note in the table further down that page, that while it is estmated that in 2017 161,360 people will be diagnosed with the disease, 26,730 will die from it. Think about what this means: only 16.6% of people who are diagnosed with it will die from it. That percentage is almost identical to that for breast cancer.

There is a lot more data there that will be of interest. But the main message is that for most people the prospects are surprisingly encouraging.

With best wishes,

R-0.009.
Age at diagnosis=74; PSA=6.8 // Biopsy: 4+3; 2% // Pathology: 3+4; 8%; both sides; one 1 mm positive margin // fully continent in 30 days; but ED still at 10 months // US-PSA @ 10 months (Aug '17)=0.009 // SFSG!

prostate begone
Regular Member


Date Joined Sep 2017
Total Posts : 45
   Posted 10/10/2017 4:22 PM (GMT -7)   
"In addition, note in the table further down that page, that while it is estmated that in 2017 161,360 people will be diagnosed with the disease, 26,730 will die from it. Think about what this means: only 16.6% of people who are diagnosed with it will die from it."

I know I'm a little late coming to this thread, but I wanted to put a more positive spin on the above. Mortality rates per 1,000 are dropping for prostate cancer. It is being diagnosed earlier, and treatment is getting better. Most of the 26,730 dying from PC this year were diagnosed 5, 10, or 15 years ago, if not more. The percentage of the 161,360 diagnosed this year who die from PC will be much lower.

PC is so slow (even high grade PC), and treatment is evolving so fast, that the studies and statistics cannot keep up with developments. Just remember, no matter what statistic you are looking at, things are better now.
62 yrs
PSA: 2/4/15: 3.5;
1/21/16: 3.8
2/13/17: 5.1
3/27/17: 5.45
3/27/17: 5.5
4/17/17: 2 of 16 pos., 15 and 4 percent. GS 8.
Bone Scan clear.
Robotic RP May 24, 2017, NYU Hospital, Samir Taneja M.D.
Margins clear, SV and LN negative, Focal EPE, GS 4+5
Prostate 44.6 grams, tumor 5% of prostate
1 pad a day after about 3 weeks. ED near total.
7/26/17 PSA <.01
9/7/17 .01
10/7/17 .01

WeightLoss
Regular Member


Date Joined Feb 2017
Total Posts : 36
   Posted 10/11/2017 6:30 AM (GMT -7)   
Tall Allen said...
You didn't have the kind of MRI that is used to detect high grade cancer for active surveillance. But if you were headed for surgery anyway, you wouldn't need one.

Ask your pathologist for the size and grade at the margin - it might turn out later to be useful.


Allen, Although his report was rather brief and didn't say "mp MRI" he did seem to have one though. As you know, a mp MRI consists of T2WI, DWI, DCE and MRSI done in sequence. As it was a 3T machine, there was no need for an endorectal coil.

From his report:

"The normally hyperintense peripheral zone is heterogeneous with nonspecific multifocal areas of intermediate to low signal." seems to indicate T2WI

"There is no restricted diffusion" seems to indicate DWI

".... or washout type contrast kinetics" seems to indicate DCE

There is no indication MRSI was done but I think that is optional in a mp MRI. Also, he had a pretty big tumor of 1.2cm. That is hardly a spot.
Dx Age 55 Dec '16, PSA 4.313
MP MRI Jan '17: PR 5, Bn Scan -ve
Jan '17 MRI Fs BX 4 of 12 +ve G7 (3+4)
RALP Feb 2, 2017
Path: tumor 1.75x1.8x1.8 G7 (3+4), PT2c ECE, Margins, LN, SV all -ve
uPSA:
Mar-May 2017: 0.029-0.059(Siemens); <0.008(Abbott); <0.03(NCCS); < 0.01(Bck Coulter)
Jun-Aug 2017: <0.02(Bck Coulter, Quest); <0.006(Roche, Labcorp); 0.04(Siemens) <0.008 (Abbott) <0.03 (NCCS)

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8824
   Posted 10/11/2017 10:40 AM (GMT -7)   
Weightloss- I think you are right. The normal MRI is T1 or T2 which, as you say would account for only the first statement. They are often done with and without contrast. But "restricted diffusion" is probably from a DWI. You are right that MRS is seldom done as part of mpMRIs. The lesson is that even the best mpMRIs will sometimes have false negatives for high grade cancer, and that TRUS biopsies often miss significant cancer. IMHO, AS candidates should always have a confirmatory biopsy within a year of the first biopsy, template mapping if they can get it, before "officially" being on AS. mpMRI alone without a biopsy is not reliable enough to confirm candidacy.

What I was referring to when I wrote "Small size/focal and low grade at the margin are mitigating factors." was in direct response to the OPs question: "Does anyone know whether there are mitigating factors for positive margins?" The comment had nothing to do with the tumor size.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

AZ Guy
Regular Member


Date Joined Feb 2017
Total Posts : 39
   Posted 10/16/2017 12:35 PM (GMT -7)   
I was able to use Best Doctors again as a service through my Employer. They did their own pathology at Mass General in Boston. They state the Gleason is 3+4 vs the 4+3 at the original post-op pathology. Mass General also states that the tumor involved <10% of the Prostate. The positive margin is confirmed. So it still comes down to watching the PSA and doing SRT if required.
Age 49
DX 2/17: G6 2/12 cores <5% in each; one lobe
PSA 6.6 (doubling actual 3.3 due to Finasteride use)
RALP 8/17
pT2c R1
Gleason 7 (4+3)
Margin Positive
-ECE; -SVI; +PI

R-0.009
New Member


Date Joined Aug 2017
Total Posts : 14
   Posted 10/16/2017 4:41 PM (GMT -7)   
Hi AZ Guy:

Your case seems very similar to mine, just age is different. I suggest an ultrasensitive PSA test periodically. My recent result - nine months after surgery - came in at 0.009. That is a little ambiguous as I still have not been able to determine if that means "undetectable" meaning less than 0.01 (which is how some test assays work), or if it means "the test measures below 0.009 and yours was calculated to be 0.009, specifically." If/when I get a response to my inquiries I will post, jftr.
Age at diagnosis=74; PSA=6.8; %fPSA=7.5 (OUCH!) // Biopsy: 4+3; 2% // Surgery Oct 2016: pathology: 3+4; 8%; both sides; one 1 mm positive margin // fully continent in 30 days; but ED still at 10 months // usPSA Aug 2017=0.009 // SFSG!

BillyBob@388
Veteran Member


Date Joined Mar 2014
Total Posts : 2601
   Posted 10/16/2017 6:57 PM (GMT -7)   
halbert said...
AZ guy, I, also, had a post surgery upgrade...not as much as you (I went from G6 on one side to G3+4 in all 4 quadrants). The key for you is to recuperate from the surgery and see what your PSA is in 3 months. Seriously, 3 months. Your doc may do a PSA at 6 weeks, but it's not definitive till 3 months. In the meantime, walk, eat well, do your kegals, and get back in shape.


Halbet, did you change labs between 8/30/16 and <0.04 and 2/15/17: <0.006? Of course, I realize <.04 could also be < .006, but that is possibly a huge drop, depending on whet the actual <.04 was, which could have been .03(or of course much lower). Or maybe your doc or other lab simply got new machines. But man, that is a low #!

AZ Guy, lets face it, we are dealing with possibly microscopic cancer cells(unless the needle got lucky and happened to stick right into the middle of a mass/tumor), and it is not difficult to miss a bunch of higher Gleason cells. We are probably lucky that they manage to more often than not hit the bad areas with our highest Gleason, or even hit a cancerous spot at all. Some of us are down graded, but not a few of us are up graded. The Bx is just a crap shoot, ore or less. On the bright side, one reason(certainly not the only) a bunch of us decide to have the surgery is to get that path report, just in case of a situation like yours exists. You and I both got news we didn't want, but at least we know. Hang in there Brother!
PSA 10.9 ~112013
Bx on 112013 at age ~65yrs, with 5 of 12 pos with one G9(5+4), 1 PNI, T2B.
RALP with lymph nodes at Vanderbilt 021914. (nodes clear, SV+, G9 down graded to 4+5, cut wide, but 1 tiny foci right at the edge of margin ) Pros. 106.7 gms!
At 15 months, not wearing a pad most days, mostly dry
PSA <.01 on 6/14 and all until 9/15 = .01, still .01 9/16, .02 on 3/17,6/17,10/17

halbert
Veteran Member


Date Joined Dec 2014
Total Posts : 3110
   Posted 10/17/2017 3:30 AM (GMT -7)   
BillyBob, yes I changed labs. I moved from east-central Illinois, where my PSA's were done at the Uro's office, to the Philly area, where I'm going with Labcorp.

AZGuy, keep on hangin on, brother. How's the rest of recovery going?
Age at Diagnosis: 56
RALP on 2/17/15, BJC St. Louis, Dr. Figenshau
58.5g, G3+4, 20%, 4 quadrants involved
PSA 3/10/15: 0.10
5/18/15: <.04
8/24/15: <.04
11/30/15: <.04
2/29/16: <0.04
8/30/16: <0.04
2/15/17: <0.006
8/22/17: <0.006
My Story: www.healingwell.com/community/default.aspx?f=35&m=3300024

AZ Guy
Regular Member


Date Joined Feb 2017
Total Posts : 39
   Posted 10/17/2017 7:00 AM (GMT -7)   
Thanks for asking halbert- my recovery has been great really. I do get a dribble surprise now and then and it serves mostly as a reminder that I'm still in recovery. No ED. I'm taking Cialis every third day but think I will go to once a week. I do get Climacturia but think its getting better. I need to be sure to go to the bathroom sitting down, not standing, prior to sex. That seems to better empty the bladder.
Age 49
DX 2/17: G6 2/12 cores <5% in each; one lobe
PSA 6.6 (doubling actual 3.3 due to Finasteride use)
RALP 8/17
pT2c R1
Gleason 7 (4+3)
Margin Positive
-ECE; -SVI; +PI

AZ Guy
Regular Member


Date Joined Feb 2017
Total Posts : 39
   Posted 11/3/2017 10:25 AM (GMT -7)   
Got my first PSA test post-RP yesterday. At nine weeks out it is 0.4.

So spent the better part of the evening feeling sorry for myself. It was hard to tell the wife but with the positive margins its not the biggest surprise in the world. I have an appointment scheduled with Mayo Clinic RO for Wednesday next week. Appointment with my surgeon is scheduled for the end of this month but I suppose its time to say goodbye to him. My recovery has been excellent as I have no ED and seem to have my continence back (just seems like the bladder volume is less than before). At Mayo Clinic we'll go through my case and I've seen a great list of questions on this site to ask about. I think I'm good to go with SRT as soon as it makes sense. Looks like the battle continues....
Age 49
DX 2/17: G6 2/12 cores <5% in each; one lobe
PSA 6.6 (doubling actual 3.3 due to Finasteride use)
RALP 8/17
pT2c R1
Gleason 7 (4+3) (Revised to 3+4 by Mass General)
Margin Positive
-ECE; -SVI; +PI
Tumor <10% of gland
PSA .4 10/17

InTheShop
Veteran Member


Date Joined Jan 2012
Total Posts : 7927
   Posted 11/3/2017 10:46 AM (GMT -7)   
Sorry to hear about the PSA - not what you wanted. Likely they can start SRT almost anytime. Maybe give another month or so for healing. Even if you decide to start SRT, it can take a few weeks to get things setup before they start treatment.

and you'll want at least one more PSA test to confirm the .4 result.

Hang in there, you still have fight left.
Andrew
I'll be in the shop.
Age 57, 52 at DX
PSA:
4.2 10/11, 1.9 6/12, 1.2 12/12, 1.0 5/13, .6 11/13,
.7 5/14, .5 10/14, .5 4/15, .3 10/15, .3 4/16, .4 10/16, .4 5/17, .3 10/17
G 3+4
Stage T1C
2 out of 14 cores positive
Treatment IGRT - 2/2012
My latest blog post

Michael_T
Veteran Member


Date Joined Sep 2012
Total Posts : 2512
   Posted 11/3/2017 11:15 AM (GMT -7)   
Sorry about that news, but as you said it wasn't necessarily surprising. The good news is that SRT should have an excellent chance of killing off any stray cells in the area. And anecdotally, there's been several stories here of SRT guys that have sailed through it. I'm sure if you post about getting ready for that, they'll give you lots of good feedback.

And great news on the ED and continence front!
Age 56, Diagnosed at 51
PSA 9.6, Gleason: 9 (5+4), three 7s (3+4)
Chose triple play of HDR brachy, IMRT and HT (Casodex, Lupron and Zytiga)
Completed HT (18 months) in April 2014
3/17: T = 167, PSA = 0.13

Skypilot56
Regular Member


Date Joined Mar 2017
Total Posts : 206
   Posted 11/4/2017 6:36 AM (GMT -7)   
Here's hoping your next psa check will be non detectable! At the mayo in MN the RO wanted to wait at least 6 months before starting SRT for healing but we started with Lupron and then in 2 months will start SRT.

Larry
Male 61 DX @ 60
Father had PC
2002. Psa. .08 Enlarged Prostrate
2014. Psa. 3.8
2016. Psa. 19
3-08-17 RP Mayo Clinic Mn
Path Report: Gleason 9, pt3b, Seminal vessels and one nerve removed, negative margins, 35 lymph nodes removed no cancer, Prostrate 45 grams
4-20-17 Incarcerated Umbilical Hernia
6-13-17 1st psa check 0.13
7-19-17 psa 0.12 MRI clear
10-11-17 psa 0.16
10-12-17 Lupron started

Pratoman
Veteran Member


Date Joined Nov 2012
Total Posts : 4922
   Posted 11/4/2017 6:49 AM (GMT -7)   
AZ, are you sure that wasn't .04, rather than .4?
Even with the positive margin, .4 seems like an unlikely post op number considering your Gleason go (3+4) and a pre-op PSA of only 6.6.
Dx Age 64 Nov 2014, 4.3
BX 3 of 12 cores positive original pathologyG6, G6, G8 (3+5)
downgraded to 3+3=6 by tDr Epstein, JH
RALP with Dr Ash Tewari Jan 6, 2015
Post surgical pathology – G7 (3+4), ECE, Margivns, LN, SV all negative
PSA @ 6 weeks 2/15, .<02, remained <0.02 until January 2017, .02, repeat Feb 2017, still .02. May 2017-.033, August 2017- .033
Decipher test, low risk, .37 score

garyi
Regular Member


Date Joined Jun 2017
Total Posts : 244
   Posted 11/4/2017 7:18 AM (GMT -7)   
Prato.....you may recall that my pre-op PSA was 2.3; my Gleason was 3+4; and my sixteen week post-op PSA is .42

So, unfortunately AZ is most likely correct.
70 years old @ Dx, LUTS for 7 years
PSA's never over 3.0
Ulcerative Colitis since 1973
TURP 2/16, G3+4 discovered,
3T MRI fusion guided biopsy 6/16
14 cores; G 3+3, one G3+4, Grade T1b
Second 3T MRI 1/17
RALP 7/17 Dr. Gonzaglo The Univ of Miami
G3+4 Organ confined
pT2c pNO pMn/a
Mostly Dry
10 week PSA .32
12 week PSA .40
14 week PSA .42
It's called Persistent PSA
Decipher & DCFPyL PET Scan

Pratoman
Veteran Member


Date Joined Nov 2012
Total Posts : 4922
   Posted 11/4/2017 7:39 AM (GMT -7)   
You're right Gary, thanks for correcting me.

Still, as Andrew stated, a confirmatory retest is in order. I got a result of 3.8 at 9 months, turned out to be an error and retest was <.02.

Not trying to give you false hope AZ, but wait for the retest.
Dx Age 64 Nov 2014, 4.3
BX 3 of 12 cores positive original pathologyG6, G6, G8 (3+5)
downgraded to 3+3=6 by tDr Epstein, JH
RALP with Dr Ash Tewari Jan 6, 2015
Post surgical pathology – G7 (3+4), ECE, Margivns, LN, SV all negative
PSA @ 6 weeks 2/15, .<02, remained <0.02 until January 2017, .02, repeat Feb 2017, still .02. May 2017-.033, August 2017- .033
Decipher test, low risk, .37 score

garyi
Regular Member


Date Joined Jun 2017
Total Posts : 244
   Posted 11/4/2017 7:57 AM (GMT -7)   
Yep Prato, a fast confirmatory PSA is a fine suggestion.

BTW, you are starting to grow a mustache in support of Movember, aren't you?
70 years old @ Dx, LUTS for 7 years
PSA's never over 3.0
Ulcerative Colitis since 1973
TURP 2/16, G3+4 discovered,
3T MRI fusion guided biopsy 6/16
14 cores; G 3+3, one G3+4, Grade T1b
Second 3T MRI 1/17
RALP 7/17 Dr. Gonzaglo The Univ of Miami
G3+4 Organ confined
pT2c pNO pMn/a
Mostly Dry
10 week PSA .32
12 week PSA .40
14 week PSA .42
It's called Persistent PSA
Decipher & DCFPyL PET Scan

Pratoman
Veteran Member


Date Joined Nov 2012
Total Posts : 4922
   Posted 11/4/2017 8:05 AM (GMT -7)   
Actually, I decided, I've done so in the past, also ran a 5k to honor Movember, with my daughter.
But this year, I've been growing my hair out (back to my "yout(h)", and it might look pretty unprofessional with a fuzzy stache. Normally I wouldn't care, but I've got a ton of client appointments in the next few weeks, that I need to get done in advance of heading down your way for the winter.

I haven't shaved yet this month, so I'll see what it looks like on Monday, maybe I'll trim it , if it looks ok, I'll go for it.
Dx Age 64 Nov 2014, 4.3
BX 3 of 12 cores positive original pathologyG6, G6, G8 (3+5)
downgraded to 3+3=6 by tDr Epstein, JH
RALP with Dr Ash Tewari Jan 6, 2015
Post surgical pathology – G7 (3+4), ECE, Margivns, LN, SV all negative
PSA @ 6 weeks 2/15, .<02, remained <0.02 until January 2017, .02, repeat Feb 2017, still .02. May 2017-.033, August 2017- .033
Decipher test, low risk, .37 score

garyi
Regular Member


Date Joined Jun 2017
Total Posts : 244
   Posted 11/4/2017 8:19 AM (GMT -7)   
Good man! Call me when you escape the NY winter.
70 years old @ Dx, LUTS for 7 years
PSA's never over 3.0
Ulcerative Colitis since 1973
TURP 2/16, G3+4 discovered,
3T MRI fusion guided biopsy 6/16
14 cores; G 3+3, one G3+4, Grade T1b
Second 3T MRI 1/17
RALP 7/17 Dr. Gonzaglo The Univ of Miami
G3+4 Organ confined
pT2c pNO pMn/a
Mostly Dry
10 week PSA .32
12 week PSA .40
14 week PSA .42
It's called Persistent PSA
Decipher & DCFPyL PET Scan

George_
Regular Member


Date Joined Apr 2016
Total Posts : 408
   Posted 11/4/2017 8:30 AM (GMT -7)   
Pratoman said...
AZ, are you sure that wasn't .04, rather than .4?
I think you are right. AZ should ask for a printed lab report to verify the PSA value.

The surgeon apparently did a nerve-sparing operation and so there is some benign tissue left which will cause a detectable PSA value. A value of 0.04 is no need to worry.

George

George_
Regular Member


Date Joined Apr 2016
Total Posts : 408
   Posted 11/4/2017 10:52 AM (GMT -7)   
AZ Guy said...
I am wondering if I blew it by waiting six months to consider my options and have the surgery

This study indicates that it makes no difference whether you wait three months or six months to start with surgery after diagnosis.

George
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