My decision and path report

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jmadrid
Regular Member


Date Joined Sep 2017
Total Posts : 39
   Posted 11/28/2017 4:20 AM (GMT -7)   
A couple of months ago I was asking for advice here on treatment options. I consulted two RO (HDBR and cyberknive) and a urologist/surgeon. Finally I decided to have surgery based in the surgeon experience (more than a thousand of manual LRPs, actually some of my friends were his patients) despite his personality, total lack of empaty and communication. I also were not happy with the idea to having an additional tretment for my enlarged prostate and with the lack of precise information, no pathological report, no early warning of recurrence, if I have chosen the radiation way. On the other hand I considered that maybe radiation was more effective in the case ECE was present, MRI showed some contacts with the capsule, but any choice have an uncertainty component.
Surgery was mostly uneventful, some pain (kind of spams or gas or both) that completely vanished after 12 hours. I still have occasional spams after urinating, but they are not too bad. The main incisions developed a couple of light seromas that I hope will heal by themselves. I have mild incontinence only when standing up or walking, but the pads get now 60% less in weight than the day the catheter was removed (200/500 g. per day).
Today I have got the pathological report. Contrary to what I thought most probable, it clearly remarks that there is not ECE and margins are clean (organ confined). But... it shows a big jump in grade from 3+3 to 5+3. Therefore, I think I made the right decision on my treatment (just by chance). I went to the mskcc nomogram and it predicts a specific survival of 99% in 15 years and a BRS of 60% in 10 years,which it does not seem too bad. Of course I understand this is based in a mskcc cohort and it is plain statistics. I would greatly appreciate your expert opinion about what can expect. First PSA in February.
67 years old.
PSA: 2008:2.8; 2012-2016: 4.5-5.5.
May, July 2017: 6.1, 7.6
mpMRI, July 2017: PIRAD5 5.
Dx August 2017,Gleason 3+3, 2 cores, left 5%, right 3%, greatest tumor length: 3.5 mm., left.
Prostate ebout 100 g. DRE +.
Manual LRP, november 6, 2017.
Pathological report: G 5+3. Clean margins, not other features.

Post Edited (jmadrid) : 11/28/2017 5:16:04 AM (GMT-7)


halbert
Veteran Member


Date Joined Dec 2014
Total Posts : 3141
   Posted 11/28/2017 5:07 AM (GMT -7)   
j,

Glad to hear you're having an uneventful recovery, and that your continence is where it is. That's all good. The pathology report is a surprise with the upgrade, and I'm with you on the value of actually knowing where you're at.

The important thing now is to get healed, get your strength back. You might be surprised at how long it actually takes to get back to 100%. I went back to work after 3 weeks--and regretted it. It was probably at least 3 months before I was 'mostly' back, and at least 6 months before I really felt physically able to do what I needed to do.

At 3 months, your ultrasensitive PSA should be non-detectable. With that 5+3, it will need watching for a long time. Some will say that if you're not non-detect, that you should immediately go into ART, regardless of how close, others will say that there is an actual trigger value of 0.02 or 0.03 or some other number. It might be wise to at least be ready to talk to your surgeon at that 3 month visit about what he thinks the trigger should be...and to get a referral to a RO for your back pocket as it were.
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

ddyss
Regular Member


Date Joined Apr 2017
Total Posts : 144
   Posted 11/28/2017 5:24 AM (GMT -7)   
Welcome to the other side. Your large prostrate size does reduce your chance of BCR.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3102877/[url]

"In agreement with previous reports (20, 21), we showed that men with smaller prostates were at a significantly higher risk of BCR. The reason for this remains unknown; however, many potential explanations exist. First, it has been suggested that men with smaller prostates may have lower levels of testosterone, which has been shown to correlate with more aggressive prostate cancer (22). Second, men with larger prostates had their tumors detected earlier because of PSA-driven biopsies resulting from PSA elevation from an enlarged gland. This lead-time bias would be expected to result in better outcomes (23). As shown in Table 1, the extra-prostatic group had a higher PSA than the organ-confined group. The PSA range was 3.7-95.8 ng/mL. Thus, a PSA-driven biopsy group that had a large portion of benign tissue is difficult to be included. Third, a tumor within a small prostate has to migrate a lesser distance to escape the prostatic capsule, as demonstrated by Yadav et al. (24), who showed that decreased prostate volume is a predictor of extra-prostatic extension. It is likely that a combination of these factors leads to a greater chance of BCR after treatment for men with smaller prostate volume. The most important finding in our study was obtained from the analysis of prostate volume stratified by pathologic T stage. Our data showed that prostate volume was not prognostic in the pT3 group."
DX@ 48 Yrs PSA 03/15 4.45 DRE: Firm Right Base
04/18 Biopsy Right: Base 4+3, Middle 3+4, Apex: HPIN
Left 6 cores : -ve
5/20 MRI: Pirads 5, ECE:+ve
RALP 05/26 Mt. Sinai Miami - Dr. A. Bhandari
Path:
Gleason downgraded to 3+4 !! Stage T2C
Prostrate Size: 49grams Tumor:20%
LN/SV/ECE: -ve PNI: +ve
Cath Removed : 6/1
Full continence: 7/4
PSA History :
7/7 <0.1
10/2 <0.006

jmadrid
Regular Member


Date Joined Sep 2017
Total Posts : 39
   Posted 11/28/2017 6:27 AM (GMT -7)   
Halbert and ddyss, thank you for your useful answers.
I have an important doubt: in the mskcc nomograms both G 5+3 and 3+ 5 grades show significantly better outcomes than G 4 + 4 for the OC case. Trying to confirm this I found an article signed by d'Amico and others claiming that G 5+ 3/ 3+5 actually show significantly higher specific mortality than 4 + 4. Right now I am confused, are the mskcc differences an artifact of the calculation software or there is any evidence to trust them?
67 years old.
PSA: 2008:2.8; 2012-2016: 4.5-5.5.
May, July 2017: 6.1, 7.6
mpMRI, July 2017: PIRAD5 5.
Dx August 2017,Gleason 3+3, 2 cores, left 5%, right 3%.
Prostate about 100 g. DRE +.
Manual LRP, november 6, 2017.
Pathological report: less than 20% involved. G 5+3. Clean margins, not other features.

John_TX
Veteran Member


Date Joined Jan 2015
Total Posts : 900
   Posted 11/28/2017 6:53 AM (GMT -7)   
jmadrid said...
...Today I have got the pathological report. Contrary to what I thought most probable, it clearly remarks that there is not ECE and margins are clean (organ confined). But... it shows a big jump in grade from 3+3 to 5+3. Therefore, I think I made the right decision on my treatment (just by chance). ....

And that's the advantage (so to speak) of surgery and a path report, you have a definite grading of the cancer from the excised tissue.
DX - 1-13-2015 (age 66) -- PSA 4.02 (9-16-2014) to 4.38 (12-5-2014)
RALP on March 2, 2015
G6 to G7(3+4) to G7(4+3)
Stage pT3aN1
10/2017 PSA < 0.1
7/31/2015 HT - six month's injection of Lupron
ART 11/2015, 33 sessions

Pratoman
Veteran Member


Date Joined Nov 2012
Total Posts : 4980
   Posted 11/28/2017 7:12 AM (GMT -7)   
Jmadrid, glad you got the surgery behind you, here's hoping that's the last of it. Obviously, as others have said, that 5+3 beats close watching. That is quite a jump, unfortunately, and it makes me wonder whether it might be worth sending the surgical slides for a second opinion.
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, Margins, 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 November .046
Decipher test, low risk, .37 score

Michael_T
Veteran Member


Date Joined Sep 2012
Total Posts : 2540
   Posted 11/28/2017 7:46 AM (GMT -7)   
The G 5+3 is a very atypical reading and I wonder if it's worth getting some confirmation on that. I believe you're in Spain, so not sure what your options are. But if one of the goals of surgery was to have the definitive pathology, I would consider following up on that.

Congrats on making it through and I wish you continued success with the healing!
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

Gemlin
Veteran Member


Date Joined Jul 2015
Total Posts : 620
   Posted 11/28/2017 9:09 AM (GMT -7)   
jmadrid, sorry about the upgrade to 5 + 3.
This article put 5+3 at the same risk level as Gleason score 9!
Gleason score 5 + 3 = 8 prostate cancer: much more like Gleason score 9?
It is therefore even more important that you carefully monitor your PSA with the ultra sensitive PSA test.
Since PSA half life is 3-4 days you can expect to be undetectable at 6 - 8 weeks.

jmadrid
Regular Member


Date Joined Sep 2017
Total Posts : 39
   Posted 11/28/2017 9:45 AM (GMT -7)   
Thank you again for your well informed answers.
Yes, it is difficult to have a second opinion on a pathological report here in Spain. I understand 5+3 is very atypical. The report took three weeks to come, I wonder if they made some kind of verification. I took a look of the pathologist name in the internet and he seems to be a big name here (what does not warranty much).
My idea is to say goodbye to my urologist/surgeon, he did a good job avoiding margins but I do not like his clinical protocols. I have got a prescription for a simple PSA plus free PSA (???) analysis. It was given by his assistant, he was not today present. I will go to an oncology center for closer monitoring and advice.
67 years old.
PSA: 2008:2.8; 2012-2016: 4.5-5.5.
May, July 2017: 6.1, 7.6
mpMRI, July 2017: PIRAD5 5.
Dx August 2017,Gleason 3+3, 2 cores, left 5%, right 3%.
Prostate about 100 g. DRE +.
Manual LRP, november 6, 2017.
Pathological report: less than 20% involved. G 5+3. Clean margins, not other features.

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8951
   Posted 11/28/2017 10:59 AM (GMT -7)   
jmadrid-

I'm glad the surgery went well. Your incontinence seems to be resolving quickly. I hope you have begun penile rehab already.

That is a huge difference from GS3+3 to 5+3. With hindsight, it is rare that a GS 3+3 would show up with a PIRADS 5 unless it is very big. But we can only deal with the information we have. That puts you in a risk category that NCCN considers to be "very high risk." There's no point in second guessing your treatment decision now. You made a very reasonable decision based on the information you had. Hopefully, you will be among the 60% that did not have a recurrence, and not the 40% who did.

Your 3-month PSA will tell you a lot. It should be an ultrasensitive PSA, not a conventional PSA. Percent free PSA is absolutely useless to you now - that's only useful in deciding whether to biopsy - that ship has sailed.

Please let us know.
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

jmadrid
Regular Member


Date Joined Sep 2017
Total Posts : 39
   Posted 11/28/2017 11:10 AM (GMT -7)   
Thank you TA,
I want to believe now that staging is more important than grading.
I revised the MSKCC nomogram (graphic). They assign many points to the G4 secondary pattern. This explains why 5+3 gives a better outcome than 4+4.
But probably the publications I have already read are right and 5+3 is more risky than 4+4.
I will try to find a good oncologist and wait for the results of a good PSA analysis in a couple of months.
According to what I know now, I guess that trusting in just a single primary radiation treatment for my case in the belief that grade was low would have been risky. Since tumor was organ confined I guess I made the right option.
67 years old.
PSA: 2008:2.8; 2012-2016: 4.5-5.5.
May, July 2017: 6.1, 7.6
mpMRI, July 2017: PIRAD5 5.
Dx August 2017,Gleason 3+3, 2 cores, left 5%, right 3%.
Prostate about 100 g. DRE +.
Manual LRP, november 6, 2017.
Pathological report: less than 20% involved. G 5+3. Clean margins, not other features.

Post Edited (jmadrid) : 11/28/2017 11:21:17 AM (GMT-7)


Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8951
   Posted 11/28/2017 11:56 AM (GMT -7)   
SBRT and HDR-BT monotherapy have been used in clinical trials to treat high risk cases, as yours turned out to be. So far, the results look very good. Of course, if you knew then what you know now, you would have explored brachy boost therapy. Hindsight is 20/20. As I said, I think you made a very reasonable decision based on what you knew at the time, and your decision-making process was exemplary. That's the best that any of us can hope to do.
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

hrpufnstuf
Regular Member


Date Joined Mar 2012
Total Posts : 312
   Posted 11/28/2017 2:46 PM (GMT -7)   
I agree with others concerning the big change in your Gleason rating. It's not uncommon to hear of changes in Gleason scores following surgery. However, most who change report incremental changes such as 3+3 to 3+4 or to 4+3. A change like yours from 3+3 to 5+3 I think is very unusual. I can't imagine that the post surgical pathology is from the same tumor as the one found in your biopsy. My guess is the pathologist examined multiple sites as would be routine and one of the samples revealed far worse cancer tissue than the biopsy. To believe that the surgery pathologist simply disagreed with the biopsy pathologist is unimaginable. Whatever the reason I urge you to get a second opinion.
Age 69 DX 06/14 1 of 24 cores positive, 5% involved, (3+4), psa 6.2
2nd opinion from JH (3+3)
3rd opinion from UFPTI (3+4)
mpMRI Duke: 50% chance of SV spread
SV fusion biopsy Duke 10/2014 negative
proton at UFPTI 11/14-01/15
PSA:
06/14 6.2 (at diagnosis)
11/14 11.19
01/15 6.62
07/15 2.50
01/16 1.28
07/16 2.56 (bounce)
01/17 .75

jmadrid
Regular Member


Date Joined Sep 2017
Total Posts : 39
   Posted 11/30/2017 1:39 AM (GMT -7)   
The pathological report describes in detail features that I think they correspond to G5, in my totally inexpert opinion.
Now I realize that a primary G5 pattern is of big concern. According to a couple of articles, the 5 year specific survival is about 85% in 5 years and about 60-75 in 10 year which is not so much for PCa. Playing with the nomograms I can see that chances increase significantly for organ contained cases. I also read an older publication showing much better survival rates for high-risk organ confined cases.
In any case, my first estimations from the mskcc nomogram, for instance a 99% specific survival in 15 years, are clearly wrong. Also, the biochemical survival was grossly overestimated. With a G 4+4 and my other pathological data, the same monogram gives just a 50% in 10 years but I know now that 5+3 gives poorer outcomes.
Also, I understand that every case is different and, in a more general context, nothing can warranty us to be alive and safe in 5 or 10 years, not even at the end of this day or this week.
Thank you for all your very valuable opinions.
67 years old.
PSA: 2008:2.8; 2012-2016: 4.5-5.5.
May, July 2017: 6.1, 7.6
mpMRI, July 2017: PIRAD5 5.
Dx August 2017,Gleason 3+3, 2 cores, left 5%, right 3%.
Prostate about 100 g. DRE +.
Manual LRP, november 6, 2017.
Pathological report: less than 20% involved. G 5+3. Clean margins, not other features.
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